Gynecologic Oncology Practice Questions

Q: What is the treatment of choice for sarcoma of the uterus?

Total hysterectomy with bilateral salpingoophorectomy. **Explanation:** The treatment of choice for uterine sarcoma is **Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH + BSO)**. Uterine sarcomas (such as Leiomyosarcoma, Endometrial Stromal Sarcoma, and Adenosarcoma) are aggressive mesenchymal tumors. Unlike epithelial endometrial cancers, sarcomas primarily spread via the hematogenous route and direct local extension. Surgical removal of the primary tumor and potential sites of spread (the ovaries) is the cornerstone of management. * **Why Option B is correct:** TAH + BSO is the standard staging and therapeutic procedure. Removing the ovaries is crucial because many uterine sarcomas (especially Endometrial Stromal Sarcomas) are hormone-sensitive, and residual estrogen can promote recurrence. * **Why Option A is incorrect:** Total hysterectomy alone is insufficient because it leaves the ovaries intact, increasing the risk of recurrence due to hormonal influence or occult metastasis. * **Why Options C & D are incorrect:** Uterine sarcomas are generally **radioresistant**. While radiotherapy may be used for local pelvic control in advanced stages, it is never the primary treatment of choice. Surgery must always precede adjuvant therapies. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Leiomyosarcoma (LMS) is the most frequent histological subtype. * **Diagnosis:** Often suspected when a "fibroid" grows rapidly in a postmenopausal woman. * **Staging:** Uterine sarcomas are staged using the **FIGO staging system** (similar to endometrial carcinoma). * **Prognosis:** Generally poor compared to endometrial adenocarcinoma; the most important prognostic factor is the **mitotic index** and stage at presentation. * **Note on Lymphadenectomy:** Unlike endometrial cancer, routine lymphadenectomy is controversial in sarcomas (especially LMS) as nodal involvement is relatively rare (<5%).

Q: Which of the following presentations of vulvar cancer has the poorest prognosis?

Positive pelvic lymph nodes. **Explanation:** The prognosis of vulvar cancer is most significantly determined by the status of the regional lymph nodes. Vulvar cancer typically spreads in a predictable, stepwise fashion: first to the **inguino-femoral (superficial and deep) lymph nodes**, and subsequently to the **pelvic (iliac) lymph nodes**. **Why C is Correct:** The presence of **positive pelvic lymph nodes** indicates advanced lymphatic dissemination (Stage IVB). While positive inguino-femoral nodes are the most important *initial* prognostic factor, once the disease reaches the pelvic nodes, the 5-year survival rate drops drastically (often below 20%). Pelvic node involvement signifies that the cancer has bypassed the primary regional filters, representing a systemic risk and the poorest prognosis among the given options. **Why Other Options are Incorrect:** * **A & D (Large tumor size/Vaginal involvement):** These factors influence the T-stage (local extent). While a larger tumor or involvement of adjacent structures like the lower vagina increases the risk of nodal spread, they do not carry as grave a prognosis as confirmed nodal metastasis. * **B (Positive inguino-femoral nodes):** This is the most common prognostic factor identified, but it represents an earlier stage of lymphatic spread compared to pelvic node involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (SCC). * **Most important prognostic factor:** Lymph node status (specifically the number and extent of nodal involvement). * **Sentinel Lymph Node Biopsy (SLNB):** Indicated in Stage T1b/T2 tumors (<4cm) with clinically negative nodes. * **Cloquet’s Node:** The highest deep inguinal node; if positive, it often necessitates pelvic lymphadenectomy as it is the gateway to the pelvic nodes.

Q: What is the investigation of choice to detect a hydatiform mole?

Ultrasound (USG). **Explanation:** **Ultrasound (USG)** is the investigation of choice (Gold Standard) for diagnosing a hydatidiform mole. In a **complete mole**, the characteristic USG finding is a **"Snowstorm appearance,"** which represents multiple hydropic villi (vesicles) and the absence of a fetus or gestational sac. In a **partial mole**, USG typically reveals a thickened placenta with cystic spaces ("Swiss cheese appearance") and a potentially growth-restricted fetus. **Why other options are incorrect:** * **X-ray Abdomen:** Historically used to look for fetal skeletal parts (absent in complete moles), it is now obsolete due to radiation risks and the superior resolution of USG. * **Serum hCG level:** While hCG levels are characteristically very high in molar pregnancies (often >100,000 mIU/mL), this is not diagnostic. High hCG can also occur in multiple gestations or normal pregnancies. It is, however, the investigation of choice for **follow-up** and monitoring for gestational trophoblastic neoplasia (GTN). * **Gravindex:** This is an older, qualitative immunological urine pregnancy test. It only confirms pregnancy but cannot differentiate between a normal and a molar pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Vaginal bleeding (painless). * **Clinical sign:** "Size > Date" (Uterus is larger than the period of amenorrhea) and "Doughy feel" on palpation. * **Ovarian finding:** Bilateral **Theca Lutein Cysts** (due to high hCG levels). * **Definitive Diagnosis:** Histopathological examination (HPE) after suction evacuation. * **Treatment:** Suction and Evacuation is the treatment of choice.

Q: A 56-year-old female presents with abdominal pain and a 4 cm bilateral ovarian mass with increased vascularity on ultrasound. What is the next best step in management?

Surgical intervention. **Explanation:** The patient is a **postmenopausal female** (56 years old) presenting with a symptomatic, **bilateral ovarian mass** showing **increased vascularity**. In postmenopausal women, any adnexal mass is considered malignant until proven otherwise. The presence of bilateral involvement and increased Doppler vascularity are high-risk features (RMI - Risk of Malignancy Index) that necessitate definitive surgical management. * **Why Surgical Intervention is Correct:** The primary goal in postmenopausal ovarian masses is to rule out malignancy. Surgical exploration (usually via laparotomy or laparoscopy) allows for staging and histological diagnosis. Fine-needle aspiration is contraindicated due to the risk of "seeding" the peritoneum if the mass is malignant. * **Why Option A is Wrong:** Ultrasound-guided aspiration is strictly avoided in suspected ovarian cancer because it can rupture the capsule, upstaging a localized tumor (Stage IA to IC) and worsening the prognosis. * **Why Option B is Wrong:** Observation is only appropriate for small (<5 cm), simple, unilocular, asymptomatic cysts in postmenopausal women with normal CA-125 levels. This patient is symptomatic with high-risk ultrasound features. * **Why Option D is Wrong:** OCPs are used to suppress functional cysts in reproductive-age women. They have no role in treating postmenopausal masses, which are never functional. **High-Yield Clinical Pearls for NEET-PG:** * **Postmenopausal Palpable Ovary Syndrome:** Any palpable ovary in a postmenopausal woman is abnormal and requires investigation. * **Malignancy Risk:** Bilaterality, solid components, ascites, and high vascularity (low resistance index on Doppler) are strong predictors of malignancy. * **Management Gold Standard:** The definitive management for a suspicious postmenopausal adnexal mass is **Total Abdominal Hysterectomy (TAH) + Bilateral Salpingo-Oophorectomy (BSO)** with surgical staging.

Q: Unsatisfactory colposcopy refers to failure to visualize which of the following?

Transformation zone. **Explanation:** Colposcopy is the gold standard investigation for evaluating abnormal cervical cytology (Pap smear). The primary goal of colposcopy is to examine the **Transformation Zone (TZ)**, which is the area between the original squamous epithelium and the columnar epithelium. **Why the Transformation Zone is the Correct Answer:** The Transformation Zone is the site where over 90% of cervical neoplasias (CIN) and cancers originate. A colposcopy is labeled **"Unsatisfactory"** if the entire squamocolumnar junction (SCJ) and the full extent of any lesion cannot be visualized. This often occurs in postmenopausal women or those with previous cervical surgery where the SCJ recedes into the endocervical canal. If the TZ is not fully seen, a diagnostic excisional procedure (like LEEP or Cold Knife Conization) may be required to rule out occult malignancy. **Why Other Options are Incorrect:** * **Fallopian tubes:** These are internal pelvic structures and are not visible via colposcopy, which focuses on the lower genital tract. * **Ectocervix:** While the ectocervix is examined during colposcopy, failure to see it is rare; the "unsatisfactory" label specifically pertains to the inability to see the "active" junctional area. * **Fornices:** These are the recesses of the vagina surrounding the cervix. While they are inspected, they are not the defining criteria for a satisfactory colposcopic exam. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Colposcopy:** Persistent LSIL, HSIL, or ASC-H on Pap smear, and positive HPV 16/18. * **Reagents used:** 3–5% **Acetic acid** (turns dysplastic cells "acetowhite") and **Lugol’s Iodine** (Schiller’s test; normal cells turn mahogany brown, while abnormal cells remain pale/yellow). * **Green Filter:** Used during colposcopy to highlight abnormal vascular patterns like punctations and mosaicism.

Q: Molar pregnancy is diagnosed best by?

Ultrasound. **Explanation:** **Ultrasound (USG)** is the gold standard and the investigation of choice for diagnosing molar pregnancy. In a complete hydatidiform mole, the characteristic finding is a **"Snowstorm appearance,"** which represents multiple hydropic villi and the absence of fetal parts. In a partial mole, USG reveals focal cystic changes in the placenta and an increased transverse diameter of the gestational sac. **Why other options are incorrect:** * **Clinical Examination:** While a patient may present with classic signs like "size greater than dates," vaginal bleeding (grape-like vesicles), and absence of fetal heart sounds, these are non-specific and can mimic multiple gestations or uterine fibroids. * **Serum beta-hCG:** While hCG levels are characteristically very high (often >100,000 mIU/mL) in molar pregnancies, a single high value is not diagnostic. High hCG can also be seen in multiple pregnancies or incorrect dating. Its primary role is in **monitoring and follow-up** to detect gestational trophoblastic neoplasia (GTN), rather than initial diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Snowstorm Appearance:** Pathognomonic USG finding for complete mole. * **Theca Lutein Cysts:** Often seen on USG (bilateral, multilocular) due to extreme hCG stimulation. * **Karyotype:** Complete mole is 46,XX (diploid, paternal origin); Partial mole is 69,XXX/XXY (triploid). * **Treatment:** Suction and evacuation is the treatment of choice regardless of uterine size.

Q: Systemic metastasis is commonest in which of the following gynecologic malignancies?

Choriocarcinoma. **Explanation:** The correct answer is **Choriocarcinoma**. This is because choriocarcinoma is a highly malignant, germ-cell-derived tumor characterized by early and extensive **hematogenous spread** (blood-borne metastasis). Unlike most other gynecologic cancers that spread primarily through direct extension or the lymphatic system, choriocarcinoma lacks an intrinsic stroma and directly invades blood vessels, leading to rapid systemic dissemination. **Why the other options are incorrect:** * **Ovarian Carcinoma:** Primarily spreads via **exfoliation** and intraperitoneal seeding (transcoelomic spread). While it can spread lymphatically, systemic (extra-abdominal) metastasis usually occurs late in the disease. * **Endometrial Carcinoma:** Most commonly spreads by **direct extension** to the myometrium and cervix, or via lymphatics. Systemic hematogenous spread is less common and typically occurs in high-grade variants. * **Carcinoma of the Cervix:** Predominantly spreads by **direct local invasion** into the parametrium and vagina, followed by predictable **lymphatic spread** to pelvic and para-aortic nodes. Hematogenous spread is a late-stage event. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** For choriocarcinoma, the **lungs** are the most common site (80%), followed by the vagina (30%), liver, and brain. * **Characteristic Sign:** "Cannon-ball" opacities on a chest X-ray are classic for pulmonary metastasis from choriocarcinoma. * **Tumor Marker:** Serum **beta-hCG** is the highly sensitive marker used for diagnosis, monitoring, and follow-up. * **Treatment:** It is one of the most chemo-sensitive tumors; even with systemic metastasis, the cure rate is high using the EMA-CO regimen.

Question 1

What is the treatment of choice for sarcoma of the uterus?

Accepted Answer

Total hysterectomy with bilateral salpingoophorectomy

Answer

Total hysterectomy

Answer

Radiotherapy

Answer

Bilateral salpingoophorectomy followed by radiotherapy

Question 2

Which of the following presentations of vulvar cancer has the poorest prognosis?

Accepted Answer

Positive pelvic lymph nodes

Answer

Large tumor size

Answer

Positive inguino-femoral lymph nodes

Answer

Involvement of the lower one-third of the vagina

Question 3

All of the following are true about Meig's syndrome except?

Accepted Answer

Ascites is caused due to lymphatic dysplasia

Answer

Seen with ovarian fibroma

Answer

Pleural effusion and ascites are seen in patients with Meig's syndrome

Answer

Ascites and pleural effusion do not require treatment

Question 4

A young lady presents with mild cervical erosion and a Pap smear shows dysplasia. What is the next step in management?

Accepted Answer

Colposcopy

Answer

Antibiotics

Answer

Cryosurgery

Answer

Conization

Question 5

What is the investigation of choice to detect a hydatiform mole?

Accepted Answer

Ultrasound (USG)

Answer

X-ray abdomen

Answer

Serum hCG level

Answer

Gravindex

Question 6

A 56-year-old female presents with abdominal pain and a 4 cm bilateral ovarian mass with increased vascularity on ultrasound. What is the next best step in management?

Accepted Answer

Surgical intervention

Answer

Ultrasound-guided ovarian aspiration

Answer

Observation and serial ultrasound

Answer

Oral contraceptive pills for three cycles

Question 7

Unsatisfactory colposcopy refers to failure to visualize which of the following?

Accepted Answer

Transformation zone

Answer

Fallopian tubes

Answer

Ectocervix

Answer

Fornices

Question 8

Molar pregnancy is diagnosed best by?

Accepted Answer

Ultrasound

Answer

Clinical examination

Answer

b hCG

Answer

None of the above

Question 9

What is the best management for a 26-year-old woman diagnosed with ovarian carcinoma and Grade I histology?

Accepted Answer

Unilateral oophorectomy and follow-up

Answer

Unilateral oophorectomy with chemotherapy

Answer

Bilateral oophorectomy

Answer

Hysterectomy and bilateral oophorectomy

Question 10

Systemic metastasis is commonest in which of the following gynecologic malignancies?

Accepted Answer

Choriocarcinoma

Answer

Ovarian Carcinoma

Answer

Endometrial Carcinoma

Answer

Carcinoma of the cervix

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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