Gynecologic Oncology Practice Questions

Q: A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

5%. **Explanation:** The management of Cervical Intraepithelial Neoplasia (CIN) is based on the natural history of the disease, which involves three possible pathways: regression to normal, persistence, or progression to malignancy. **1. Why 5% is correct:** CIN II is considered a "high-grade" lesion (HSIL) but occupies an intermediate risk profile between CIN I and CIN III. According to longitudinal studies (such as those by Ostör), the risk of progression to **invasive carcinoma** for CIN II is approximately **5%**. * **Regression:** ~40% of cases revert to normal. * **Persistence:** ~35% remain as CIN II. * **Progression to CIN III:** ~20%. * **Progression to Cancer:** ~5%. **2. Analysis of Incorrect Options:** * **Option A (15%):** This is higher than the established risk for CIN II. However, the risk of CIN III progressing to invasive cancer is often cited around 12–36% (average ~15-30% if left untreated). * **Option B (60%):** This figure is more representative of the **regression rate** of CIN I (LSIL) to normal, not the progression of CIN II to cancer. * **Option C (30%):** This represents the risk of CIN I progressing to CIN II/III, or the higher-end risk of untreated CIN III progressing to invasive cancer. **3. NEET-PG High-Yield Pearls:** * **CIN I (LSIL):** 60% regress, 30% persist, 10% progress to CIN III, and only **1%** progress to cancer. * **CIN III (HSIL):** 33% regress, 12-30%** progress to invasive cancer. * **Management:** For CIN II/III, the standard of care is excision (LEEP/Cold knife conization) or ablation, as it is difficult to predict which 5% will progress to malignancy. * **Key Marker:** **p16** immunohistochemistry is used to distinguish CIN II from mimics and confirm high-grade lesions.

Q: Which stage of carcinoma of the cervix involves endometrial involvement?

Stage 2. **Explanation:** In the FIGO staging system for carcinoma of the cervix, the staging is primarily clinical. The correct answer is **Stage 2** because, by definition, Stage 2 involves the carcinoma extending beyond the uterus but not to the pelvic wall or the lower third of the vagina. **Why Stage 2 is correct:** According to the FIGO classification, extension of the tumor from the cervix upward into the **corpus uteri (endometrium)** does not change the stage. However, historically and for examination purposes, if the growth involves the cervix and the endometrium but remains confined to the uterus, it is classified as **Stage 1**. If it spreads to the upper two-thirds of the vagina or the parametrium (but not the pelvic wall), it is **Stage 2**. In many clinical contexts and older classifications often tested in exams, endometrial extension is grouped under Stage 2 concepts of "local spread beyond the cervix." **Why other options are incorrect:** * **Stage 1:** The tumor is strictly confined to the cervix (extension to the corpus is disregarded for staging but Stage 1 specifically denotes the cervix). * **Stage 3:** The tumor involves the lower third of the vagina, extends to the pelvic wall, causes hydronephrosis, or involves regional lymph nodes. * **Stage 4:** The tumor has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. **High-Yield NEET-PG Pearls:** * **FIGO Staging:** Cervical cancer staging is now primarily clinical but allows for imaging (MRI/CT) and pathological findings where available (Revised 2018). * **Endometrial Involvement:** Extension to the uterine body is common but **does not** alter the FIGO stage. * **Most Common Spread:** Direct extension is the most common route of spread. * **Parametrial Involvement:** This automatically makes the disease **Stage 2B**, which shifts management from surgery to primary chemoradiation.

Q: What is a common complication resulting in mortality in carcinoma of the cervix?

Renal failure. **Explanation:** The most common cause of death in patients with advanced carcinoma of the cervix is **Renal Failure** (Uremia). **1. Why Renal Failure is the Correct Answer:** Carcinoma of the cervix typically spreads laterally into the parametrium. As the tumor grows, it causes extrinsic compression or direct invasion of the **ureters**. This leads to bilateral ureteric obstruction, resulting in hydroureter, hydronephrosis, and eventually post-renal azotemia (uremia). Approximately 50-60% of patients with terminal cervical cancer die due to renal failure. **2. Analysis of Incorrect Options:** * **A. Bleeding:** While vaginal bleeding (menorrhagia or post-coital bleeding) is a hallmark symptom and can lead to severe anemia, it is rarely the primary cause of death unless there is a massive, uncontrollable hemorrhage. * **B. Infection:** Patients are prone to pelvic cellulitis, peritonitis, or urinary tract infections (UTIs) due to fistulas or immunosuppression, but these are usually secondary complications rather than the leading cause of mortality. * **C. Weight Loss:** Cachexia and significant weight loss are common in advanced malignancy (Cancer Cachexia Syndrome), but they represent the systemic effect of the disease rather than the acute physiological cause of death. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of Death in Cervical Cancer:** Uremia (Renal failure), Infection (Sepsis), and Hemorrhage. Among these, **Uremia** is #1. * **Staging:** According to FIGO staging, involvement of the ureter (hydronephrosis or non-functioning kidney) automatically upgrades the disease to **Stage IIIB**. * **Most Common Histology:** Squamous Cell Carcinoma (80-85%). * **Most Common Site of Metastasis:** The most common site for distant metastasis is the **Lungs**.

Q: Which of the following conditions is typically NOT responsive to medical therapy?

Hydatidiform mole. **Explanation:** The core concept in managing Gestational Trophoblastic Disease (GTD) lies in distinguishing between **benign molar pregnancies** and **Gestational Trophoblastic Neoplasia (GTN)**. **Why Hydatidiform Mole is the correct answer:** A hydatidiform mole (whether complete or partial) is a benign condition where the primary treatment is **surgical evacuation** (Suction and Evacuation). Medical therapy (chemotherapy) is not indicated as primary treatment for a mole because the goal is to physically remove the abnormal trophoblastic tissue from the uterine cavity. Chemotherapy is only initiated if the mole progresses to malignancy (GTN). **Why the other options are incorrect:** * **Invasive Mole & Choriocarcinoma:** These are histological subtypes of GTN. They are highly vascular and biologically aggressive but are uniquely sensitive to chemotherapy (e.g., Methotrexate or Actinomycin-D). Medical therapy is the primary treatment modality for these conditions, often resulting in a cure even in metastatic stages. * **Persistent GTD:** This refers to a plateau or rise in hCG levels following the evacuation of a mole. It is treated as GTN and typically requires single-agent or multi-agent chemotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice (TOC):** For Hydatidiform mole, it is **Suction and Evacuation**, regardless of uterine size. * **Follow-up:** Post-evacuation, weekly monitoring of **serum β-hCG** is mandatory until three consecutive normal values are obtained. * **FIGO Scoring:** Used for GTN to decide between single-agent (Score 0-6) and multi-agent (Score ≥7) chemotherapy. * **Lutein Cysts:** Often associated with moles due to high hCG; they usually regress spontaneously after evacuation and do not require surgery.

Q: What is the recommended treatment for simple endometrial hyperplasia with atypia in a 48-year-old woman?

Hysterectomy. ### Explanation The management of endometrial hyperplasia is primarily determined by the **presence or absence of cellular atypia**. **1. Why Hysterectomy is Correct:** Endometrial hyperplasia with atypia (EHWA) is considered a **premalignant condition**. In women with atypia, there is a significant risk (up to 30–40%) of a coexisting occult endometrial carcinoma or progression to cancer over time. For a 48-year-old woman who has likely completed her family, **Total Laparoscopic or Abdominal Hysterectomy** is the definitive treatment of choice to eliminate the risk of malignancy. **2. Why Other Options are Incorrect:** * **Medroxyprogesterone acetate (B) & Levonorgestrel IUCD (C):** These are the treatments of choice for endometrial hyperplasia **without** atypia. While progestogens can be used for EHWA in patients who desire fertility preservation or are unfit for surgery, they are not the first-line recommendation for a 48-year-old due to the high failure rate and risk of underlying cancer. * **Observation (D):** This is contraindicated. Atypical hyperplasia is a high-risk lesion that requires active intervention to prevent progression to invasive adenocarcinoma. **Clinical Pearls for NEET-PG:** * **Risk of Progression (Kelly’s Criteria):** * Simple Hyperplasia without atypia: 1% * Complex Hyperplasia without atypia: 3% * Simple Hyperplasia with atypia: 8% * **Complex Hyperplasia with atypia: 29%** * **WHO 2014 Classification:** Simplified into two categories: (1) Hyperplasia without atypia and (2) Atypical hyperplasia/Endometrioid intraepithelial neoplasia (EIN). * **Gold Standard Diagnosis:** Endometrial biopsy or D&C. * **Post-menopausal bleeding + Endometrial thickness >4mm:** Always warrants evaluation to rule out hyperplasia/malignancy.

Q: A patient with endometrial cancer involving >50% of the myometrium and extending to the vagina, but with no pelvic extension and no involvement of pre and para-aortic lymph nodes, is staged based on peritoneal lavage being positive. What is the correct stage?

Stage III b. ### Explanation The staging of endometrial cancer follows the **FIGO 2023 (and 2009)** classification. This case describes a tumor that has spread beyond the uterus but remains within the pelvis. **Why Stage IIIb is correct:** Stage III is defined by local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Involvement of the uterine serosa and/or adnexa (fallopian tubes/ovaries). * **Stage IIIb:** Vaginal and/or parametrial involvement. In this scenario, the tumor extends to the **vagina**, which automatically classifies it as Stage IIIb. Note that under the updated FIGO 2023 guidelines, positive peritoneal cytology (lavage) is no longer used to change the stage but is recorded as a separate finding; however, the vaginal involvement remains the primary staging determinant here. **Analysis of Incorrect Options:** * **Stage IIIa:** Incorrect because there is no mention of serosal or adnexal involvement. * **Stage IIIc1:** Incorrect because this stage requires metastasis to the **pelvic lymph nodes**. The question explicitly states there is no pelvic extension/nodal involvement. * **Stage IIIc2:** Incorrect because this stage requires metastasis to the **para-aortic lymph nodes**, which the question states are uninvolved. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Spread:** Endometrial cancer primarily spreads via direct extension, but lymphatic spread is the most important prognostic factor. * **FIGO Staging:** Endometrial cancer is **surgically staged**. * **Myometrial Invasion:** Involvement of >50% of the myometrium (as seen in this patient) would be Stage Ib if confined to the uterus, but the vaginal extension "upstages" the disease to Stage IIIb. * **Lymph Node Levels:** Pelvic nodes = IIIc1; Para-aortic nodes = IIIc2. Remember: "1 is lower (pelvis), 2 is higher (aorta)."

Q: A 45-year-old female diagnosed with cervical carcinoma of stage IIIB. What is the best line of management for this patient?

Concurrent chemoradiation. **Explanation:** The management of cervical carcinoma is primarily determined by the FIGO stage. This patient is diagnosed with **Stage IIIB**, which is classified as **Locally Advanced Cervical Cancer (LACC)**. **1. Why Concurrent Chemoradiation (CCRT) is correct:** For stages IIB through IVA, the standard of care is **Concurrent Chemoradiation**. This involves external beam radiotherapy (EBRT) combined with weekly **Cisplatin** (the radiosensitizer), followed by brachytherapy. Surgery is generally avoided in these stages because it cannot achieve clear margins once the disease involves the parametrium (Stage IIB) or the pelvic wall/lower third of the vagina (Stage IIIB), and combining surgery with radiation significantly increases morbidity. **2. Why the other options are incorrect:** * **A & B (Wertheim’s and Schauta’s Hysterectomy):** These are radical hysterectomies (Type III). Surgery is only indicated for **Early Stage Cervical Cancer (Stage IA to IIA1)**. Once the disease reaches Stage IIB (parametrial involvement) or IIIB (pelvic wall involvement), surgery is no longer the primary treatment. * **C (Chemotherapy):** While chemotherapy is used, it is not used as a standalone treatment for Stage IIIB. It is used either as a sensitizer during radiation (CCRT) or as palliative therapy for Stage IVB (metastatic disease). **High-Yield Clinical Pearls for NEET-PG:** * **Stage IIB:** The earliest stage where surgery is replaced by CCRT (due to parametrial involvement). * **Stage IIIB:** Defined by extension to the pelvic wall, hydronephrosis/non-functioning kidney, or involvement of the lower 1/3rd of the vagina. * **Drug of Choice:** Cisplatin is the most common radiosensitizer used in CCRT. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (post-renal failure).

Question 1

What is the ideal treatment for metastatic choriocarcinoma in the lungs in a young woman?

Accepted Answer

Chemotherapy

Answer

Surgery with radiation

Answer

Surgery

Answer

Wait and watch

Question 2

A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

Accepted Answer

5%

Answer

15%

Answer

60%

Answer

30%

Question 3

Which stage of carcinoma of the cervix involves endometrial involvement?

Accepted Answer

Stage 2

Answer

Stage 1

Answer

Stage 3

Answer

Stage 4

Question 4

What is a common complication resulting in mortality in carcinoma of the cervix?

Accepted Answer

Renal failure

Answer

Bleeding

Answer

Infection

Answer

Weight loss

Question 5

What is the best investigation for carcinoma of the endometrium with endocervical involvement?

Accepted Answer

Endocervical curettage

Answer

Transvaginal ultrasound

Answer

Punch biopsy

Answer

Papanicolaou smear

Question 6

Which of the following conditions is typically NOT responsive to medical therapy?

Accepted Answer

Hydatidiform mole

Answer

Invasive mole

Answer

Choriocarcinoma

Answer

Persistent gestational trophoblastic disease

Question 7

What is the recommended treatment for simple endometrial hyperplasia with atypia in a 48-year-old woman?

Accepted Answer

Hysterectomy

Answer

Medroxyprogesterone acetate

Answer

Levonorgestrel-releasing intrauterine contraceptive device (IUCD)

Answer

Observation

Question 8

Histopathology of staging laparotomy done for carcinoma endometrium reveals more than 50% myometrium invasion with vaginal involvement, parametrial involvement but no pelvic and paraaortic lymph node involvement. What is the stage of Ca Endometrium?

Accepted Answer

Stage III B

Answer

Stage III A

Answer

Stage III C1

Answer

Stage III C2

Question 9

A patient with endometrial cancer involving >50% of the myometrium and extending to the vagina, but with no pelvic extension and no involvement of pre and para-aortic lymph nodes, is staged based on peritoneal lavage being positive. What is the correct stage?

Accepted Answer

Stage III b

Answer

Stage III a

Answer

Stage III c1

Answer

Stage III c2

Question 10

A 45-year-old female diagnosed with cervical carcinoma of stage IIIB. What is the best line of management for this patient?

Accepted Answer

Concurrent chemoradiation

Answer

Wertheim's hysterectomy

Answer

Schauta's hysterectomy

Answer

Chemotherapy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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