Gynecologic Oncology Practice Questions

Q: Which of the following is NOT used for carcinoma cervix screening?

CT and MRI. **Explanation:** The primary goal of **screening** is to detect pre-invasive lesions (CIN) or early-stage cancer in asymptomatic individuals. Screening tools must be cost-effective, accessible, and highly sensitive. **Why CT and MRI are the correct answer:** CT and MRI are **imaging modalities used for staging and treatment planning** once a diagnosis of cervical cancer has already been confirmed. According to the FIGO staging (revised 2018), imaging is used to assess tumor size, parametrial involvement, and lymph node status. They are never used as screening tools due to high costs, lack of specificity for pre-invasive lesions, and low cost-benefit ratio for the general population. **Analysis of other options:** * **Pap Smear (Exfoliative Cytology):** The traditional gold standard for screening. It involves collecting cells from the transformation zone to identify dysplastic changes. * **Liquid-based Cytology (LBC):** An improvement over conventional Pap smears. It reduces unsatisfactory samples by filtering out blood and mucus and allows for reflex HPV testing from the same vial. * **Colposcopy:** While often used as a diagnostic tool following an abnormal Pap smear, it is considered a secondary screening/triage method to identify the most suspicious areas for biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of cervical cancer:** Squamous cell carcinoma. * **Primary Screening (WHO guidelines):** HPV DNA testing is now preferred over cytology where available. * **Screening Age:** Usually starts at age 25–30 and continues until 65. * **VIA (Visual Inspection with Acetic Acid):** A low-cost screening alternative in resource-limited settings (positive result = opaque white areas).

Q: A 62-year-old woman presents with postmenopausal bleeding 13 years after menopause. She has a history of hypertension and type 2 diabetes mellitus. An endometrial biopsy reveals grade I endometrial adenocarcinoma. What is the most appropriate next step in management?

Hysterectomy. **Explanation:** The patient presents with classic risk factors for **Type I Endometrial Adenocarcinoma**, including postmenopausal status, hypertension, and diabetes mellitus (part of the metabolic syndrome). Once a diagnosis of endometrial adenocarcinoma is confirmed via biopsy, the standard of care and the definitive next step in management is surgical staging. **Why Hysterectomy is correct:** The primary treatment for clinical Stage I endometrial cancer is **Total Extraperitoneal Hysterectomy (TAH) with Bilateral Salpingo-Oophorectomy (BSO)**. In postmenopausal women, removing the ovaries is crucial as they are a source of estrogen and a potential site for metastasis. Surgical staging also typically includes pelvic and para-aortic lymphadenectomy or sentinel lymph node mapping to determine the need for adjuvant therapy. **Why incorrect options are wrong:** * **Chemotherapy (A):** This is reserved for advanced-stage disease (Stage III or IV) or recurrent cases; it is not the primary treatment for localized Grade I adenocarcinoma. * **Cone biopsy (B):** This is a diagnostic and therapeutic procedure for cervical intraepithelial neoplasia (CIN) or early cervical cancer, not endometrial cancer. * **Dilatation and curettage (C):** While D&C is a diagnostic tool used if an endometrial biopsy is inconclusive, it is not a treatment. Since the diagnosis is already confirmed as adenocarcinoma, we proceed directly to definitive surgery. **NEET-PG High-Yield Pearls:** * **Most common symptom:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma (Type I), which is estrogen-dependent. * **Risk Factors:** Obesity, Nulliparity, Early menarche/Late menopause, PCOS, and Tamoxifen use. * **Investigation of choice:** Transvaginal Ultrasound (TVS) is the initial screening (Endometrial thickness >4mm in PMB is significant), but **Endometrial Biopsy** is the gold standard for diagnosis.

Q: Which of the following is FALSE regarding a hydatidiform mole?

Can be diagnosed very early by ultrasonography. In a hydatidiform mole, the characteristic ultrasonographic appearance—the **"snowstorm" or "honeycomb" pattern**—is caused by the hydropic swelling of chorionic villi. However, this classic feature typically develops only after the **first trimester (usually >10–12 weeks)**. In very early pregnancy, a molar pregnancy often lacks these diagnostic features and is frequently misdiagnosed as a missed abortion or a simple gestational sac. Therefore, it cannot be reliably diagnosed "very early" by ultrasound. **Analysis of other options:** * **Option A (True):** A **Partial Mole** is classically caused by **triploidy (69, XXX or 69, XXY)**, resulting from the fertilization of a normal ovum by two sperm (dispermy). * **Option C (True):** Many patients with molar pregnancies are asymptomatic or present with vaginal bleeding, leading to a clinical diagnosis of **missed or incomplete abortion**. The diagnosis of a mole is often only made after histopathological examination of the products of conception. * **Option D (True):** This refers specifically to **Partial Moles**, which have a low risk (approx. 1–5%) of progressing to persistent gestational trophoblastic disease (GTD) compared to Complete Moles (15–20%). **NEET-PG High-Yield Pearls:** * **Complete Mole:** 46, XX (diploid); "Snowstorm" appearance; No fetal parts; High hCG; 20% risk of malignancy. * **Partial Mole:** 69, XXY (triploid); Fetal parts present; Lower hCG; <5% risk of malignancy. * **Gold Standard Diagnosis:** Histopathology (p57 immunostaining is negative in complete moles). * **Management:** Suction evacuation followed by weekly hCG monitoring until three consecutive negative results.

Q: Sarcoma botryoides is most commonly seen in which age group?

Children under 2 years. **Explanation:** **Sarcoma botryoides** (Embryonal Rhabdomyosarcoma) is a highly malignant tumor derived from primitive mesenchymal cells. It is the most common vaginal tumor found in infants and children. 1. **Why Option B is Correct:** The peak incidence of Sarcoma botryoides occurs in children **under the age of 2 years**, with over 90% of cases diagnosed before age 5. It typically originates in the **anterior vaginal wall** (near the cervix) in young children, whereas in older girls or adolescents, it more commonly arises from the cervix itself. 2. **Why Other Options are Incorrect:** * **A (Neonates):** While it can occur shortly after birth, it is not the most common age group compared to the broader "under 2 years" category. * **C & D (Adults/Post-menopausal):** Vaginal malignancies in adults are predominantly **Squamous Cell Carcinomas** (linked to HPV) or **Adenocarcinomas** (historically linked to DES exposure). Sarcoma botryoides is extremely rare in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Gross Appearance:** Classically presents as a **"bunch of grapes"** (polyps) protruding from the vagina. * **Clinical Presentation:** Often presents as blood-stained vaginal discharge or a visible mass at the introitus. * **Histology:** Characterized by the **Cambium layer** (a dense subepithelial layer of spindle-shaped tumor cells) and the presence of **rhabdomyoblasts** (strap or tadpole cells) with cytoplasmic cross-striations. * **Immunohistochemistry (IHC):** Positive for **Desmin**, Myogenin, and Myo-D1. * **Treatment:** Multimodal approach involving surgery (local excision) and chemotherapy (VAC regimen: Vincristine, Actinomycin-D, Cyclophosphamide).

Q: What is the commonest presentation of hydatidiform mole?

Bleeding. **Explanation:** Hydatidiform mole (molar pregnancy) is a gestational trophoblastic disease characterized by the abnormal proliferation of trophoblastic tissue. **Why Bleeding is the Correct Answer:** Vaginal bleeding is the **most common clinical presentation**, occurring in approximately 85–95% of cases. It typically occurs in the first trimester (around 6–16 weeks). The bleeding results from the separation of the molar vesicles from the decidua. It is often described as "prune juice" discharge—a dark brown discharge caused by the liquefaction of intrauterine clots. **Analysis of Incorrect Options:** * **A. Hyperemesis gravidarum:** While common due to abnormally high levels of hCG, it occurs in only about 25–30% of patients. It is a classic sign but not the *most* common. * **C. Pre-eclampsia:** Development of hypertension and proteinuria in the first or early second trimester (before 20 weeks) is a diagnostic hallmark of molar pregnancy, but it occurs in only about 10–25% of cases. * **D. Choriocarcinoma:** This is a potential malignant sequela of a hydatidiform mole (seen in ~15–20% of complete moles), not a presenting symptom of the mole itself. **NEET-PG High-Yield Pearls:** * **Most common sign:** Vaginal bleeding. * **Most common symptom:** Nausea and vomiting (Hyperemesis). * **Uterine size:** In a complete mole, the uterus is often "larger than dates" (in ~50% of cases) and has a "doughy" feel. * **USG Gold Standard:** "Snowstorm appearance" (due to multiple hydropic villi). * **Theca Lutein Cysts:** Occur in 25–40% of cases due to high hCG levels; they usually regress after evacuation.

Q: What is the primary treatment for Stage IB cervical cancer?

Surgery. **Explanation:** The primary treatment for **Stage IB cervical cancer** (specifically IB1 and IB2) is **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** with bilateral pelvic lymphadenectomy. In early-stage cervical cancer (Stage IA2 to IB2), surgery is preferred over radiotherapy in young, fit patients because it preserves ovarian function, maintains vaginal elasticity, and avoids the long-term sequelae of radiation. **Analysis of Options:** * **A. Surgery (Correct):** For Stage IB, a Radical Hysterectomy is the gold standard. It involves the removal of the uterus, cervix, parametrium, and the upper 1/3rd of the vagina, along with pelvic lymph nodes. * **B. Chemotherapy:** Chemotherapy is never used as a standalone primary treatment for cervical cancer. It is used as a "radiosensitizer" (Cisplatin) during Concurrent Chemoradiotherapy (CCRT) for advanced stages. * **C. Radiotherapy:** While radiotherapy has equal efficacy to surgery in Stage IB, it is generally reserved for patients who are medically unfit for surgery or have bulky tumors (Stage IB3). It becomes the primary treatment of choice from Stage IIB onwards. * **D. Cryotherapy:** This is an ablative procedure used only for pre-cancerous lesions (CIN) or Stage IA1 (if no LVSI), not for invasive Stage IB cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Simple Hysterectomy (or Conization if fertility is desired). * **Stage IB1 to IIA1:** Radical Hysterectomy is the treatment of choice. * **Stage IIB onwards:** Concurrent Chemoradiotherapy (CCRT) is the standard of care. * **Fertility Preservation:** In Stage IB1, if the lesion is <2cm, a **Radical Trachelectomy** can be considered. * **Most common cause of death** in cervical cancer: Uremia due to bilateral ureteric obstruction.

Q: A patient with carcinoma of the cervix has involvement of the parametrium and the lower one-third of the vagina. On per rectal examination, there is no free space. What is the clinical stage of this cancer?

Stage IIb. ### Explanation The clinical staging of cervical cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) classification**. Staging is primarily clinical, based on physical examination (including per rectal exam), colposcopy, and basic imaging. **Why Stage IIIb is the correct answer:** The patient presents with two key clinical findings: 1. **Involvement of the lower one-third of the vagina:** This automatically classifies the cancer as at least **Stage IIIa**. 2. **No free space on per rectal (PR) examination:** This is a classic clinical description indicating that the tumor has extended to the **pelvic sidewall**. According to FIGO staging, any tumor that involves the pelvic sidewall and/or causes hydronephrosis/non-functioning kidney is classified as **Stage IIIb**. In staging, we always assign the **highest (most advanced) stage** identified. **Analysis of Incorrect Options:** * **Stage IIa:** Involves the upper two-thirds of the vagina without parametrial involvement. * **Stage IIb:** Involves the parametrium but **not** up to the pelvic sidewall (there would still be "free space" on PR exam). * **Stage IIIa:** Involves the lower one-third of the vagina but **does not** extend to the pelvic sidewall. Since this patient has no free space on PR exam, she is upstaged to IIIb. **High-Yield Clinical Pearls for NEET-PG:** * **Parametrial involvement:** Stage IIb. * **Lower 1/3 of vagina:** Stage IIIa. * **Pelvic sidewall involvement/Hydronephrosis:** Stage IIIb. * **Bullous edema of bladder mucosa:** This does **not** constitute Stage IVa; there must be biopsy-proven involvement of the bladder or rectal mucosa. * **Management:** Stages I to IIa2 can be treated surgically (Radical Hysterectomy), whereas Stage IIb to IVa are treated with **Concurrent Chemoradiotherapy (CCRT)**.

Q: What is the chemotherapeutic agent of choice for concurrent chemoradiation in carcinoma cervix?

Cisplatin. **Explanation:** **Cisplatin** is the gold standard and the chemotherapeutic agent of choice for concurrent chemoradiation (CCRT) in locally advanced carcinoma cervix (Stages IB3 to IVA). The underlying medical concept is **radiosensitization**: Cisplatin inhibits the repair of DNA damage caused by ionizing radiation, thereby enhancing the lethal effect of radiotherapy on tumor cells. Large-scale clinical trials (GOG) have demonstrated that Cisplatin-based CCRT significantly improves both overall survival and progression-free survival compared to radiation alone. **Analysis of Incorrect Options:** * **A. Paclitaxel:** While used in the management of metastatic or recurrent cervical cancer (often in combination with Cisplatin/Carboplatin), it is not the primary agent for concurrent sensitization in the definitive setting. * **B. Hydroxyurea:** Historically, this was the first agent used for CCRT. However, it was replaced by Cisplatin because Cisplatin showed superior efficacy and a more manageable toxicity profile in landmark trials. * **C. 5-Fluorouracil (5-FU):** 5-FU has radiosensitizing properties and was previously used in combination with Cisplatin. However, single-agent Cisplatin is now preferred due to its proven efficacy and lower risk of gastrointestinal toxicity compared to multi-drug regimens. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** Cisplatin is typically administered weekly at a dose of **40 mg/m²** during the course of external beam radiotherapy. * **Prerequisite:** Before starting Cisplatin, always check the patient's **renal function (Serum Creatinine)** and ensure adequate hydration, as it is nephrotoxic. * **Treatment of Choice:** For Stage IIB (Parametrial involvement) and above, CCRT is the treatment of choice, not surgery.

Question 1

Which of the following is NOT used for carcinoma cervix screening?

Accepted Answer

CT and MRI

Answer

Pap smear

Answer

Liquid-based cytology

Answer

Colposcopy

Question 2

A 62-year-old woman presents with postmenopausal bleeding 13 years after menopause. She has a history of hypertension and type 2 diabetes mellitus. An endometrial biopsy reveals grade I endometrial adenocarcinoma. What is the most appropriate next step in management?

Accepted Answer

Hysterectomy

Answer

Chemotherapy

Answer

Cone biopsy

Answer

Dilatation and curettage

Question 3

Nulliparity and late menopause are risk factors for which of the following group of diseases?

Accepted Answer

Endometrial cancer and breast cancer

Answer

Cervical cancer and endometrial hyperplasia

Answer

Ovarian cancer and endometrial polyp

Answer

Vulvar cancer and endometrial cancer

Question 4

Which of the following is a protective factor for ovarian cancer?

Accepted Answer

Bilateral Tubectomy

Answer

Nulliparity

Answer

Dysgenetic gonads

Answer

Worker of asbestos industry

Question 5

Which of the following is FALSE regarding a hydatidiform mole?

Accepted Answer

Can be diagnosed very early by ultrasonography

Answer

Caused by triploidy

Answer

Can present as a missed abortion

Answer

Rarely causes persistent gestational trophoblastic disease

Question 6

Sarcoma botryoides is most commonly seen in which age group?

Accepted Answer

Children under 2 years

Answer

Neonates

Answer

Adults

Answer

Post-menopausal women

Question 7

What is the commonest presentation of hydatidiform mole?

Accepted Answer

Bleeding

Answer

Hyperemesis gravidarum

Answer

Pre-eclampsia

Answer

Choriocarcinoma

Question 8

What is the primary treatment for Stage IB cervical cancer?

Accepted Answer

Surgery

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Cryotherapy

Question 9

A patient with carcinoma of the cervix has involvement of the parametrium and the lower one-third of the vagina. On per rectal examination, there is no free space. What is the clinical stage of this cancer?

Accepted Answer

Stage IIb

Answer

Stage IIa

Answer

Stage IIIa

Answer

Stage IIIb

Question 10

What is the chemotherapeutic agent of choice for concurrent chemoradiation in carcinoma cervix?

Accepted Answer

Cisplatin

Answer

Paclitaxel

Answer

Hydroxyurea

Answer

5-Fluorouracil

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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