Gynecologic Oncology Practice Questions

Q: Which of the following is a risk factor for the development of Choriocarcinoma?

Onset following term gestation. **Explanation:** Choriocarcinoma is a highly malignant form of Gestational Trophoblastic Neoplasia (GTN). The correct answer is **B. Onset following term gestation.** **1. Why Option B is Correct:** While choriocarcinoma most commonly follows a hydatidiform mole (50% of cases), it can also occur after abortions (25%), ectopic pregnancies (5%), or **term gestations (20%)**. Crucially, choriocarcinoma that develops after a term pregnancy carries a **worse prognosis** and is considered a significant risk factor for high-risk disease according to the FIGO/WHO scoring system. This is because it often presents later, may be overlooked initially, and is biologically more aggressive than post-molar GTN. **2. Why Other Options are Incorrect:** * **Option A (Lung Metastasis):** Lung metastasis is a common site of spread for choriocarcinoma, but it is categorized as a **low-risk** metastatic site in the FIGO scoring system (Score 0). In contrast, metastases to the liver or brain are high-risk factors. * **Option C (b-hCG 100,000 mIU/mL** is the threshold for a higher risk score. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** A score of **≥ 7** indicates High-Risk GTN, usually requiring multi-agent chemotherapy (EMA-CO regimen). * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Characteristic Histology:** Absence of chorionic villi; presence of sheets of anaplastic syncytiotrophoblasts and cytotrophoblasts with extensive hemorrhage and necrosis. * **The "Great Imitator":** Choriocarcinoma is known for its tendency to bleed; always consider it in a reproductive-age woman with unexplained hemoptysis or stroke.

Q: Good prognosis in gestational trophoblastic disease is seen with which organ metastasis?

Lung. **Explanation:** Gestational Trophoblastic Neoplasia (GTN) is unique among malignancies because it is highly chemosensitive, even in the presence of distant metastases. The prognosis is determined using the **WHO Modified FIGO Staging and Risk Factor Scoring System**. **Why Lung is the Correct Answer:** The **lungs** are the most common site of metastasis in GTN (occurring in approximately 80% of metastatic cases). According to the FIGO scoring system, the site of metastasis significantly impacts the prognosis score. Metastasis to the **lungs** is assigned a score of **0**, indicating the lowest risk and the best prognosis. Patients with isolated lung involvement often achieve nearly 100% remission with appropriate chemotherapy (e.g., Methotrexate or EMA-CO). **Analysis of Incorrect Options:** * **Kidney (Option B):** Renal involvement is assigned a score of **2**. It represents a higher tumor burden than lung involvement and carries a moderate risk. * **Liver (Option A) and Brain (Option C):** These are considered **high-risk sites**. Metastasis to the liver or brain is assigned a score of **4** (the highest possible for a single site). These patients have a significantly poorer prognosis, higher rates of chemoresistance, and often require multi-modal therapy including radiation or surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Commonest site of metastasis:** Lung (80%), followed by the Vagina (30%). * **Low-risk GTN (Score 0-6):** Usually treated with single-agent chemotherapy (Methotrexate). * **High-risk GTN (Score ≥7):** Requires multi-agent chemotherapy (EMA-CO regimen). * **Choriocarcinoma** is the most common histological type to metastasize hematogenously. * **Vaginal metastasis** typically presents as highly vascular, "blue-domed" nodules; biopsy should be avoided due to the risk of torrential hemorrhage.

Q: Which one of the following is not a complication of cervical cone biopsy?

Spread of the cancer. **Explanation:** Cervical cone biopsy (conization) is both a diagnostic and a therapeutic procedure used to manage cervical intraepithelial neoplasia (CIN) and early-stage cervical cancer. **Why "Spread of the cancer" is the correct answer:** Cervical conization involves the surgical removal of a cone-shaped wedge of the cervix. Unlike some other biopsies (like fine-needle aspiration of certain malignant tumors), a cone biopsy does not cause the "seeding" or mechanical spread of cancer cells to adjacent tissues. In fact, conization is the definitive treatment for Stage IA1 microinvasive cervical carcinoma, as it aims to remove the entire lesion with clear margins. **Analysis of Incorrect Options:** * **Bleeding:** This is the **most common** acute complication. It can occur intraoperatively or as secondary hemorrhage (usually 7–14 days later) when the surgical scab or sutures slough off. * **Cervical Stenosis:** A common long-term complication where the cervical canal narrows due to scarring. This can lead to dysmenorrhea, hematometra, or difficulty in future obstetric procedures and cytological sampling. * **Sepsis:** As with any surgical procedure involving a non-sterile field like the vagina, postoperative infection (cervicitis or pelvic inflammatory disease) leading to sepsis is a recognized, though less common, risk. **High-Yield Clinical Pearls for NEET-PG:** * **Obstetric Complications:** Conization increases the risk of **cervical insufficiency** (leading to mid-trimester miscarriages) and **preterm pre-labor rupture of membranes (PPROM)** in future pregnancies. * **Indications:** Performed when there is a discrepancy between cytology and biopsy, an unsatisfactory colposcopy, or suspicion of microinvasion. * **Cold Knife vs. LEEP:** Cold knife conization provides the best margins for pathology but has a higher risk of bleeding compared to the Loop Electrosurgical Excision Procedure (LEEP).

Q: Which of the following statements about squamous cell carcinoma of the cervix is false?

CT scan is mandatory for staging.. **Explanation:** **1. Why Option B is the correct (False) statement:** The staging of Cervical Cancer is primarily **clinical**, according to the **FIGO (International Federation of Gynecology and Obstetrics) classification**. While the 2018 FIGO update allows the use of imaging (MRI, CT, or PET-CT) and pathology to assign the stage where available, they are **not mandatory**. In resource-limited settings, staging can still be performed using clinical examination (under anesthesia), colposcopy, biopsy, cystoscopy, and proctosigmoidoscopy. Therefore, a CT scan is a helpful tool but not a mandatory requirement for staging. **2. Analysis of other options:** * **Option A:** The **Transformation Zone (Squamocolumnar Junction)** is the most metabolically active area of the cervix where columnar epithelium undergoes metaplasia into squamous epithelium. This is the site where HPV integration and neoplastic changes most frequently occur. * **Option C:** **Postcoital bleeding** is the most characteristic clinical presentation of cervical cancer. Other symptoms include intermenstrual bleeding and foul-smelling vaginal discharge. * **Option D:** **HPV 16 and 18** are "high-risk" genotypes responsible for approximately 70% of all cervical cancer cases globally. HPV 16 is most commonly associated with squamous cell carcinoma, while HPV 18 is more frequently linked to adenocarcinoma. **Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (80-85%). * **FIGO 2018 Update:** Imaging and surgical findings can now be used to stage the disease (unlike the older 2009 purely clinical staging). * **Stage IIB:** The presence of parametrial involvement; this is the threshold where management shifts from surgery (Wertheim’s Hysterectomy) to **Concurrent Chemoradiotherapy (CCRT)**. * **Screening:** The primary screening tool is the Pap smear or HPV DNA testing.

Q: A perimenopausal lady with well-differentiated adenocarcinoma of the uterus has more than half myometrial invasion, vaginal metastasis, and inguinal lymph node metastasis. What is the stage of this patient?

Stage IVB. ### Explanation The staging of endometrial carcinoma is based on the **FIGO (2023/2009) surgical staging system**. This patient has three key findings: deep myometrial invasion (>50%), vaginal metastasis, and inguinal lymph node metastasis. **Why Stage IVB is Correct:** The defining feature for this patient’s stage is the **inguinal lymph node metastasis**. According to FIGO staging: * **Stage IVB** includes distant metastasis, which encompasses spread to intra-abdominal lymph nodes (other than para-aortic/pelvic), **inguinal lymph nodes**, lung, liver, or bone. Even though she has local spread (vagina), the presence of distant nodal involvement automatically upgrades her to IVB. **Analysis of Incorrect Options:** * **Stage IIIB:** This involves spread to the **vagina** and/or parametrium. While this patient has vaginal metastasis, the presence of inguinal node involvement (distant spread) makes this stage too low. * **Stage IIIC:** This stage is reserved for metastasis to the **pelvic (IIIC1)** or **para-aortic (IIIC2)** lymph nodes. Inguinal nodes are considered "distant" rather than "regional" in endometrial cancer. * **Stage IVA:** This involves tumor invasion of the **bladder mucosa** and/or **rectal mucosa**. There is no mention of transmural organ involvement in this case. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Lungs. * **Lymphatic spread:** Usually follows a predictable pattern (Pelvic → Para-aortic). Inguinal node involvement is rare and signifies advanced disease. * **Myometrial invasion:** <50% is Stage IA; ≥50% is Stage IB. * **Staging Method:** Endometrial cancer is **surgically staged**, unlike cervical cancer which was historically clinically staged (though FIGO 2018 now allows imaging/pathology for cervix too).

Q: All of the following are indications for a Pap smear except?

Menorrhagia. **Explanation:** The **Pap smear** is a screening tool used primarily for the early detection of cervical pre-cancer (Cervical Intraepithelial Neoplasia) and cervical cancer. It is not a diagnostic tool for abnormal uterine bleeding. **Why Menorrhagia is the Correct Answer:** Menorrhagia (heavy menstrual bleeding) is a symptom related to the uterine cavity, myometrium, or hormonal axis (e.g., fibroids, adenomyosis, or endometrial hyperplasia). The primary investigation for menorrhagia is a **Transvaginal Ultrasound (TVS)** or an **Endometrial Biopsy**, not a Pap smear, which only samples cells from the ectocervix and transformation zone. **Analysis of Other Options:** * **Age 20 years or older:** According to most guidelines (including ACOG and FOGSI), screening typically begins at age 21, regardless of sexual debut. Therefore, being in this age bracket is a standard indication. * **Pregnant female:** Pregnancy is not a contraindication for a Pap smear. If a woman is due for her routine screening, it can be safely performed during the first prenatal visit. * **Sexually active female:** Since Human Papillomavirus (HPV) is the primary causative agent for cervical cancer and is sexually transmitted, sexual activity is the most significant risk factor necessitating screening. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Age:** Start at 21 years. (Note: Screening <21 is avoided as HPV infections in teens are usually transient). * **Frequency:** Age 21–29 (Cytology every 3 years); Age 30–65 (Co-testing with Cytology + HPV DNA every 5 years is preferred). * **Discontinuation:** At age 65 if previous screenings were consistently negative. * **Post-Hysterectomy:** If the uterus was removed for benign reasons and there is no history of CIN 2/3, Pap smears can be discontinued.

Q: Which of the following is a feminizing ovarian tumor?

Granulosa cell tumor. **Explanation:** **1. Why Granulosa Cell Tumor is Correct:** Granulosa cell tumors (GCT) are the most common type of **Sex Cord-Stromal Tumors**. They are clinically significant because they are **estrogen-secreting (feminizing)**. The granulosa cells convert androgens into estrogens via the enzyme aromatase. * **In children:** This leads to precocious puberty. * **In reproductive age:** It causes irregular bleeding or menorrhagia. * **In postmenopausal women:** It presents as postmenopausal bleeding due to endometrial hyperplasia or even endometrial carcinoma (seen in 5% of cases). **2. Why Other Options are Incorrect:** * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are **virilizing (masculinizing)** tumors. they secrete testosterone, leading to hirsutism, clitoromegaly, and voice deepening. * **Hilus Cell Tumor:** A subset of Leydig cell tumors that occur in the ovarian hilum. They are typically small but highly potent **androgen-secreting** tumors, causing rapid virilization in postmenopausal women. * **Gynandroblastoma:** An extremely rare tumor containing both feminizing (Granulosa) and masculinizing (Sertoli-Leydig) components. While it can have mixed effects, it is not primarily classified as a feminizing tumor like GCT. **3. High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** **Inhibin (Inhibin B)** is the most specific marker used for diagnosis and monitoring recurrence. * **Histopathology:** Pathognomonic **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Risk:** Always perform an endometrial biopsy in GCT patients to rule out concurrent endometrial malignancy due to chronic estrogen exposure.

Q: A 40-year-old female presents with a clinically detected pelvic mass. Which of the following investigations should NOT be performed?

Laparoscopy. **Explanation:** The primary goal in evaluating a clinically detected pelvic mass is to differentiate between benign and malignant pathology and determine the organ of origin using non-invasive methods first. **Why Laparoscopy is the correct answer (NOT performed):** Laparoscopy is an invasive surgical procedure. In the context of a suspected ovarian or pelvic malignancy, performing a laparoscopy (or any percutaneous biopsy) is contraindicated if there is a risk of rupturing a cystic mass. If the mass is malignant, rupture can lead to **"spillage" of malignant cells** into the peritoneal cavity, upstaging the cancer (e.g., from FIGO Stage IA to IC) and significantly worsening the prognosis. Therefore, it is not a primary investigation for a newly detected mass. **Analysis of Incorrect Options:** * **Ultrasound (USG):** This is the **investigation of choice (IOC)** and the first-line imaging modality. It helps determine the size, consistency (cystic/solid), and origin of the mass. * **CT Scan:** Useful for evaluating the extent of the disease, detecting lymphadenopathy, and checking for metastasis or involvement of other pelvic organs (e.g., omentum, bowel). * **Pap Smear:** A routine part of the workup for any pelvic mass to rule out cervical pathology as a primary or co-existing condition. **NEET-PG High-Yield Pearls:** * **First-line investigation for pelvic mass:** Transvaginal Ultrasound (TVUS). * **Gold Standard for staging ovarian cancer:** Exploratory Laparotomy (not laparoscopy). * **Tumor Marker:** CA-125 is the most common marker for epithelial ovarian tumors, but it is non-specific in premenopausal women. * **Rule of Thumb:** Never biopsy a suspected ovarian mass; always perform a formal staging laparotomy if malignancy is suspected to avoid upstaging the disease.

Q: A 42-year-old female with P3+0+0+3 is found to have carcinoma in situ. What is the best treatment?

Hysterectomy. **Explanation:** **1. Why Hysterectomy is the Correct Answer:** Carcinoma in situ (CIS) of the cervix is synonymous with **CIN 3**. The management of CIN 3 depends primarily on the patient’s age and desire for future fertility. In this case, the patient is 42 years old and has completed her family (P3+0+0+3). For women who have **completed their family**, a **Total Abdominal Hysterectomy (TAH)** is the definitive treatment of choice as it eliminates the risk of recurrence and progression to invasive cancer. **2. Why Other Options are Incorrect:** * **Wertheim’s Hysterectomy (Radical Hysterectomy):** This is indicated for invasive cervical cancer (Stage IA2 to IIA). Since CIS is a pre-invasive lesion (Stage 0) that does not involve the stroma or lymph nodes, radical surgery is overtreatment. * **Conization:** This is a fertility-sparing procedure. While it is the treatment of choice for younger patients or those desiring more children, it carries a small risk of recurrence. In a 42-year-old with completed family, hysterectomy is preferred for its definitive nature. * **Wait and Watch:** CIS/CIN 3 is a high-grade premalignant lesion with a high risk of progression to invasive squamous cell carcinoma. Observation is contraindicated; active intervention is mandatory. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Colposcopy-directed biopsy. * **Treatment of Choice (Fertility desired):** Cervical Conization or LEEP (Large Loop Excision of the Transformation Zone). * **Treatment of Choice (Family completed):** Extrafascial (Simple) Hysterectomy. * **Microinvasive Carcinoma (Stage IA1):** If <3mm invasion and no LVSI, the treatment remains the same as CIS (Hysterectomy or Cone biopsy).

Question 1

A 42-year-old woman presents with menometrorrhagia for the past 2 months. She has no history of prior irregular menstrual bleeding and has not yet reached menopause. Physical examination reveals no vaginal or cervical lesions and a normal-sized uterus, but there is a right adnexal mass. An abdominal ultrasound scan shows a 7-cm solid right adnexal mass. Endometrial biopsy shows hyperplastic endometrium without cellular atypia. What is the most likely lesion underlying her menstrual abnormalities?

Accepted Answer

Granulosa-theca cell tumor

Answer

Corpus luteum cyst

Answer

Endometrioma

Answer

Mature cystic teratoma

Question 2

Which of the following is a risk factor for the development of Choriocarcinoma?

Accepted Answer

Onset following term gestation

Answer

Presence of Lung metastasis

Answer

b-hCG level < 40,000 mIU/mL

Answer

None of the above

Question 3

Good prognosis in gestational trophoblastic disease is seen with which organ metastasis?

Accepted Answer

Lung

Answer

Liver

Answer

Kidney

Answer

Brain

Question 4

Which one of the following is not a complication of cervical cone biopsy?

Accepted Answer

Spread of the cancer

Answer

Bleeding

Answer

Cervical stenosis

Answer

Sepsis

Question 5

Which of the following statements about squamous cell carcinoma of the cervix is false?

Accepted Answer

CT scan is mandatory for staging.

Answer

Common at the squamocolumnar junction.

Answer

Postcoital bleeding is a common symptom.

Answer

HPV 16 and 18 are associated with a high risk of carcinogenesis.

Question 6

A perimenopausal lady with well-differentiated adenocarcinoma of the uterus has more than half myometrial invasion, vaginal metastasis, and inguinal lymph node metastasis. What is the stage of this patient?

Accepted Answer

Stage IVB

Answer

Stage IIIB

Answer

Stage IIIC

Answer

Stage IVA

Question 7

All of the following are indications for a Pap smear except?

Accepted Answer

Menorrhagia

Answer

Age 20 years or older

Answer

Pregnant female

Answer

Sexually active female

Question 8

Which of the following is a feminizing ovarian tumor?

Accepted Answer

Granulosa cell tumor

Answer

Arrhenoblastoma

Answer

Hilus cell tumor

Answer

Gynandroblastoma

Question 9

A 40-year-old female presents with a clinically detected pelvic mass. Which of the following investigations should NOT be performed?

Accepted Answer

Laparoscopy

Answer

CT scan

Answer

Pap smear

Answer

Ultrasound (USG)

Question 10

A 42-year-old female with P3+0+0+3 is found to have carcinoma in situ. What is the best treatment?

Accepted Answer

Hysterectomy

Answer

Wertheim's hysterectomy

Answer

Conization

Answer

Wait and watch

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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