Gynecologic Oncology Practice Questions

Q: Which of the following is NOT an indication for radiotherapy in carcinoma of the endometrium?

Enlarged uterine cavity. **Explanation:** In endometrial carcinoma, the decision to administer adjuvant radiotherapy (RT) is based on the risk of recurrence, which is determined by surgical-pathological staging. **Why "Enlarged uterine cavity" is the correct answer:** An enlarged uterine cavity is a clinical or radiological finding often associated with the bulk of the tumor or associated leiomyomas. However, it is **not** an independent prognostic factor or a recognized indication for adjuvant radiotherapy in current FIGO guidelines. Management is dictated by the depth of invasion and histological characteristics, not the size of the uterus itself. **Analysis of Incorrect Options (Indications for RT):** * **Deep Myometrial Involvement (Option B):** Invasion of more than 50% of the myometrium (Stage IB) significantly increases the risk of lymph node metastasis and local recurrence, making it a standard indication for RT. * **Poor Differentiation (Option D):** Grade 3 (G3) tumors are biologically aggressive. High-grade histology, even with superficial invasion, often warrants adjuvant treatment (Brachytherapy or External Beam RT). * **Pelvic Node Involvement (Option A):** Positive nodes (Stage IIIC1) indicate regional spread. These patients require External Beam Radiotherapy (EBRT) often combined with chemotherapy to control pelvic disease. **Clinical Pearls for NEET-PG:** * **Standard Treatment:** The primary treatment for endometrial cancer is **Extrafascial Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH+BSO)** with pelvic/para-aortic lymphadenectomy. * **Risk Stratification:** Adjuvant RT is indicated for "High-Intermediate Risk" factors, often remembered by the **GOG-99 criteria**: Age >60, Grade 2 or 3, presence of Lymphovascular Space Invasion (LVSI), and Deep myometrial invasion. * **Type II Endometrial CA:** Serous and Clear Cell carcinomas are high-risk regardless of stage and almost always require adjuvant therapy.

Q: A postmenopausal woman who is obese, hypertensive, and diabetic presents with postmenopausal bleeding. What is the most probable cause?

Endometrial cancer. ### Explanation **Correct Option: B. Endometrial cancer** The clinical presentation described—**postmenopausal bleeding (PMB)** in a patient with the "Corpus Uteri Cancer Syndrome" triad (**Obesity, Hypertension, and Diabetes**) — is a classic textbook scenario for **Endometrial Carcinoma**. The underlying pathophysiology involves **unopposed estrogen**. Obesity leads to increased peripheral conversion of androstenedione to estrone in adipose tissue. Chronic exposure to estrogen without the counter-effect of progesterone causes endometrial hyperplasia, which can progress to malignancy. In any postmenopausal woman presenting with vaginal bleeding, endometrial cancer must be ruled out first via endometrial biopsy or transvaginal ultrasound (TVS). **Why other options are incorrect:** * **A. Malignant ovarian tumor:** While some functional ovarian tumors (like Granulosa cell tumors) can secrete estrogen and cause PMB, they typically present with an adnexal mass and are less common than primary endometrial pathology in this demographic. * **C. Endocervical cancer:** While it can cause bleeding, it is more frequently associated with post-coital bleeding and is not specifically linked to the metabolic triad of obesity and diabetes. * **D. Brenner tumor:** This is a rare, usually benign fibroepithelial ovarian tumor. While it can occasionally be hormonally active, it is a much less probable cause of PMB compared to endometrial cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (however, malignancy must be excluded first). * **Risk Factors:** Nulliparity, early menarche, late menopause, PCOS, and Tamoxifen use. * **Investigation of Choice:** Endometrial Biopsy (Pipelle biopsy) is the gold standard. * **TVS Cut-off:** An endometrial thickness (ET) of **>4 mm** in a postmenopausal woman warrants further evaluation.

Q: The vulval carcinoma commonly metastasizes to which group of lymph nodes?

Superficial inguinal group of lymph nodes. **Explanation:** The lymphatic drainage of the vulva follows a predictable, stepwise anatomical pattern. The primary site of metastasis for vulval carcinoma is the **Superficial Inguinal group of lymph nodes**. 1. **Why Option D is Correct:** The vulva (excluding the clitoris) drains first into the superficial inguinal nodes, located in the subcutaneous tissue just below the inguinal ligament. From here, the drainage proceeds to the deep inguinal nodes (including the Node of Cloquet) and subsequently to the external iliac nodes. This "sentinel" role makes the superficial inguinal nodes the most common and earliest site of clinical metastasis. 2. **Why Other Options are Incorrect:** * **External Iliac (C):** These are secondary nodes. Cancer reaches them only after passing through the inguinal chain. * **Internal Iliac (B):** These nodes primarily drain pelvic viscera like the upper vagina and cervix, not the vulva. * **Para-aortic (A):** These are distant nodes involved in late-stage spread or primary drainage of the ovaries and uterine fundus. **High-Yield Clinical Pearls for NEET-PG:** * **Way’s Rule:** Vulval cancer spreads in a stepwise fashion; it rarely skips the inguinal nodes to reach the iliac nodes. * **Contralateral Spread:** Because of the midline nature of the vulva, tumors near the midline can drain to **bilateral** inguinal nodes. * **The Node of Cloquet:** This is the highest deep inguinal node; if it is negative, the pelvic nodes are usually negative. * **Staging:** The most important prognostic factor in vulval cancer is the **status of the inguinal lymph nodes**.

Question 1

Which of the following is NOT an indication for radiotherapy in carcinoma of the endometrium?

Accepted Answer

Enlarged uterine cavity

Answer

Pelvic node involvement

Answer

Deep myometrial involvement

Answer

Poor differentiation

Question 2

A postmenopausal woman who is obese, hypertensive, and diabetic presents with postmenopausal bleeding. What is the most probable cause?

Accepted Answer

Endometrial cancer

Answer

Malignant ovarian tumor

Answer

Endocervical cancer

Answer

Brenner tumor

Question 3

Carcinoma of the endometrium involving the uterine cavity more than 10 cm long with early myometrial involvement is classified as which stage?

Accepted Answer

Stage Ib

Answer

Stage Ia

Answer

Stage IIa

Answer

Stage IIb

Question 4

What is the management of CIN III?

Accepted Answer

LEEP conization

Answer

Cervical biopsy

Answer

Hysterectomy

Answer

Cone biopsy

Question 5

The vulval carcinoma commonly metastasizes to which group of lymph nodes?

Accepted Answer

Superficial inguinal group of lymph nodes

Answer

Para-aortic group of lymph nodes

Answer

Internal iliac group of lymph nodes

Answer

External iliac group of lymph nodes

Question 6

A 45-year-old woman has a negative Pap smear with positive endocervical curettage. What is the next step in management?

Accepted Answer

Wertheim's hysterectomy

Answer

Colposcopy

Answer

Vaginal hysterectomy

Answer

Conization

Question 7

A 60-year-old woman presents with a distended abdomen and postmenopausal bleeding. Imaging reveals bilateral complex ovarian masses with a CA-125 value of 1500. Intraoperatively, bilateral ovarian masses with surface involvement and ascites are noted, with no evidence of pelvic or extrapelvic tumor extension or lymph node involvement. A comprehensive surgical staging is planned. What is the most appropriate management?

Accepted Answer

Surgical staging with hysterectomy and bilateral salpingo-oophorectomy, followed by adjuvant chemotherapy

Answer

Maximal cytoreductive surgery

Answer

Hysterectomy and bilateral salpingo-oophorectomy

Answer

Bilateral salpingo-oophorectomy followed by adjuvant chemoradiation

Question 8

A 34-year-old woman with a history of high-grade squamous intraepithelial lesion (HSIL), confirmed as cervical intraepithelial neoplasia (CIN) III on colposcopy and biopsy, undergoes conization which reveals a focus of microinvasion at the squamocolumnar junction. What is the most appropriate next step in management?

Accepted Answer

No further therapy required

Answer

Bone scan to evaluate for metastatic disease

Answer

Radiation therapy

Answer

Pelvic exenteration

Question 9

A patient presents with a unilateral ovarian tumor and ascites positive for malignant cells. Laparotomy reveals no other structures are involved. What is the stage of her disease?

Accepted Answer

Stage I a

Answer

Stage III a

Answer

Stage III b

Answer

Stage III c

Question 10

A 33-year-old nulliparous female patient presents with irregular vaginal bleeding. Examination reveals a papillary lesion on the cervix. Biopsy and staging reveal stage IB1 cervical cancer. The patient desires fertility. What management would you recommend?

Accepted Answer

Radical trachelectomy and pelvic lymph node dissection.

Answer

Cervical conization alone.

Answer

Cervical conization and pelvic lymph node dissection.

Answer

Radical trachelectomy alone.

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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