Gynecologic Oncology Practice Questions

Q: Most common gestational trophoblastic disease following hydatidiform mole is?

Invasive mole. **Explanation:** Gestational Trophoblastic Disease (GTD) encompasses a spectrum of tumors arising from the placenta. When these conditions become malignant or persist after a pregnancy, they are termed **Gestational Trophoblastic Neoplasia (GTN)**. **1. Why Invasive Mole is Correct:** The most common form of GTN following a hydatidiform mole is an **Invasive Mole** (accounting for approximately 70–80% of cases). It is characterized by the presence of hydropic villi that invade the myometrium. It occurs almost exclusively after a molar pregnancy (more commonly after a complete mole than a partial mole). **2. Why Incorrect Options are Wrong:** * **Choriocarcinoma:** While it is the most aggressive form of GTN, it is less common than an invasive mole following a hydatidiform mole. Notably, choriocarcinoma can follow *any* type of pregnancy (abortion, ectopic, or term birth), whereas invasive moles are specific to post-molar sequences. * **Placental Site Trophoblastic Tumor (PSTT):** This is a rare variant arising from intermediate trophoblasts. It typically follows a term pregnancy and is characterized by low hCG levels and relative resistance to chemotherapy. * **Placental Nodule:** This is generally a benign, incidental finding representing a remnant of a previous pregnancy and does not signify malignant transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Risk of GTN:** After a Complete Hydatidiform Mole, the risk of developing GTN is **15–20%**, whereas after a Partial Mole, it is only **0.5–5%**. * **Diagnosis:** The most important tool for diagnosing post-molar GTN is the **plateau or rise of serial β-hCG levels**. * **Treatment:** Most cases of Invasive Mole are highly sensitive to chemotherapy (Methotrexate is the first-line agent for low-risk cases). * **Metastasis:** The most common site of metastasis for GTN is the **Lungs**, followed by the Vagina.

Q: Postmenopausal bleeding is associated with all of the following except:

Cervical intraepithelial neoplasia (CIN). **Explanation:** Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring after 12 months of amenorrhea in a woman of menopausal age. It is a "red flag" symptom that must always be investigated to rule out malignancy. **Why CIN is the correct answer:** **Cervical Intraepithelial Neoplasia (CIN)** is a pre-invasive, asymptomatic condition. By definition, the neoplastic cells are confined to the epithelium and have not breached the basement membrane. Therefore, CIN does not cause spontaneous bleeding or tissue friability significant enough to manifest as postmenopausal bleeding. It is typically detected via screening (Pap smear) rather than clinical symptoms. **Analysis of incorrect options:** * **Carcinoma of Cervix:** This is a common cause of PMB in developing countries. Invasive growth leads to surface ulceration and friability of the cervical tissue, resulting in intermenstrual, post-coital, or postmenopausal bleeding. * **Carcinoma of Ovary:** While less common than endometrial causes, certain ovarian tumors (especially Estrogen-secreting Germ Cell or Sex Cord-Stromal tumors like Granulosa cell tumors) can cause endometrial hyperplasia, leading to PMB. * **Endometrial Carcinoma:** This is the most critical diagnosis to exclude in any case of PMB. Approximately 10% of women with PMB will be diagnosed with endometrial cancer. **NEET-PG High-Yield Pearls:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (followed by endometrial polyps and atrophy). * **Most serious cause of PMB:** Endometrial Carcinoma. * **First-line investigation for PMB:** Transvaginal Ultrasound (TVUS). An **endometrial thickness (ET) ≤ 4 mm** has a high negative predictive value for malignancy. * **Gold Standard investigation:** Endometrial biopsy (Pipelle or D&C).

Q: Follow-up of low-risk gestational trophoblastic neoplasia (GTN) is done for how long?

12 months. ### Explanation **1. Why 12 months is the correct answer:** Gestational Trophoblastic Neoplasia (GTN) is highly sensitive to chemotherapy, but there is a risk of recurrence, most of which occurs within the first year after achieving remission. For **low-risk GTN** (FIGO Score 0-6), the standard protocol involves monitoring serum **beta-hCG levels** until they normalize (usually three consecutive weekly normal values). Once normalization is achieved, follow-up continues for **12 months**. During this period, hCG is monitored monthly to ensure early detection of relapse. **2. Why the other options are incorrect:** * **3 months (A) & 6 months (B):** These durations are insufficient. While the risk of relapse drops significantly after 6 months, the standard of care remains 12 months to capture late recurrences and ensure a sustained remission before allowing a subsequent pregnancy. * **24 months (D):** This is generally reserved for **high-risk GTN** (FIGO Score ≥7) or patients with placental site trophoblastic tumors (PSTT). High-risk cases have a higher relapse rate and require more prolonged surveillance (often 12–24 months). **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Contraception:** Reliable contraception (preferably **Combined Oral Contraceptive Pills**) is mandatory during the entire 12-month follow-up period to prevent pregnancy, which would confound hCG monitoring. * **FIGO Scoring:** Low-risk GTN is defined by a FIGO score of **0–6**; the primary treatment is single-agent chemotherapy (usually **Methotrexate** or Actinomycin-D). * **Remission Definition:** Remission is defined as three consecutive weekly normal hCG levels. * **Follow-up Schedule:** Monthly hCG for 12 months (Low-risk); Monthly hCG for 24 months (High-risk). * **Post-Molar Pregnancy Follow-up:** Note the difference—follow-up for a simple **Hydatidiform Mole** (not yet GTN) is usually 6 months after the first normal hCG.

Q: A post-menopausal woman presents with a 4-year history of itching over the labia majora, with minimal relief from topical medications. Examination reveals an indurated lesion on the right labia with palpable inguinal lymph nodes. What is the most appropriate management?

Biopsy. ### Explanation The clinical presentation of a post-menopausal woman with chronic, refractory vulvar pruritus (itching) and an indurated lesion is highly suspicious for **Vulvar Carcinoma**. **1. Why Biopsy is the Correct Answer:** In any post-menopausal woman presenting with a chronic vulvar lesion, especially one that is indurated, ulcerated, or non-responsive to medical therapy, the gold standard and mandatory first step is a **wedge biopsy** or **Punch biopsy**. This is essential to rule out malignancy (Squamous Cell Carcinoma) or its precursors (Vulvar Intraepithelial Neoplasia - VIN). The presence of palpable inguinal lymph nodes further increases the suspicion of metastatic spread, making histological confirmation the priority before planning definitive surgical management (like radical vulvectomy and lymphadenectomy). **2. Why Other Options are Incorrect:** * **Options A & B:** Topical steroids (Beclomethasone) or estrogens are used for benign conditions like Lichen Sclerosus or Atrophic Vaginitis. However, using them without a diagnosis in the presence of an indurated lesion delays the diagnosis of cancer. * **Option C:** While lymphadenopathy can be inflammatory, "watchful waiting" with antibiotics is inappropriate when a suspicious primary lesion is present. Malignancy must be ruled out first. **3. Clinical Pearls for NEET-PG:** * **Most common type:** Squamous Cell Carcinoma (SCC) is the most common histological type of vulvar cancer. * **Risk Factors:** HPV (16, 18) in younger patients; Lichen Sclerosus in elderly patients. * **Lymphatic Spread:** Vulvar cancer spreads primarily via lymphatics to the **Inguinal-Femoral nodes** (Sentinel nodes). * **Rule of Thumb:** Any vulvar "wart" or "ulcer" in a post-menopausal woman that does not heal within 2 weeks of conservative treatment must be biopsied.

Q: Which of the following does not secrete a hormone?

Dysgerminoma. **Explanation:** The correct answer is **Dysgerminoma**. In gynecologic oncology, ovarian tumors are often classified by their ability to produce hormones (functioning tumors) or their lack thereof (non-functioning tumors). **1. Why Dysgerminoma is the correct answer:** Dysgerminoma is a germ cell tumor that is histologically identical to the male seminoma. It is considered a **non-functioning tumor** because it does not inherently secrete hormones. While it is a classic marker for **LDH (Lactate Dehydrogenase)**, it does not produce estrogen or androgens. Note: In rare cases, if it contains syncytiotrophoblastic giant cells, it may secrete low levels of hCG, but it is fundamentally categorized as non-hormonal. **2. Why the other options are incorrect:** * **Granulosa Cell Tumor:** A sex cord-stromal tumor known for secreting high levels of **Estrogen**. It often presents with precocious puberty in children or postmenopausal bleeding in adults. Inhibin B is its specific tumor marker. * **Theca Cell Tumor (Thecoma):** Also a sex cord-stromal tumor, these are almost always benign and are highly associated with **Estrogen** production, often leading to endometrial hyperplasia. * **Hilus Cell Tumor:** A subtype of Sertoli-Leydig cell tumors (pure Leydig cell tumor). These are potent secretors of **Androgens** (testosterone), leading to rapid virilization and hirsutism. Reinke crystals are a pathognomonic histological finding. **NEET-PG High-Yield Pearls:** * **Dysgerminoma:** Most common malignant germ cell tumor in pregnancy and Turner syndrome (gonadal dysgenesis). Highly radiosensitive. * **Tumor Markers:** Dysgerminoma (LDH), Yolk Sac Tumor (AFP), Choriocarcinoma (hCG), Granulosa Cell Tumor (Inhibin). * **Call-Exner Bodies:** Pathognomonic for Granulosa Cell Tumors.

Q: In cervical cancer, surgery is limited to patients with which stage?

Stage I to IIA. **Explanation:** In cervical cancer management, the primary treatment modality is determined by the clinical stage. Surgery is generally reserved for **early-stage disease (Stage I to IIA)**, where the tumor is confined to the cervix or the upper two-thirds of the vagina without involving the parametrium. **1. Why Stage I to IIA is correct:** At these stages, the disease is surgically resectable. Procedures like Radical Hysterectomy (Wertheim’s Hysterectomy) with pelvic lymphadenectomy can achieve clear margins and provide excellent survival rates. Once the cancer reaches **Stage IIB**, it involves the **parametrium**. Surgical clearance of the parametrium is difficult and often results in positive margins; therefore, these patients are better managed with Concurrent Chemoradiotherapy (CCRT). **2. Why other options are incorrect:** * **Stage IIB (Option B):** This stage marks the beginning of "locally advanced" disease. Parametrial involvement makes surgery technically challenging and increases morbidity without improving survival compared to radiotherapy. * **Stage IIIA/IIIB (Options C & D):** These stages involve the lower third of the vagina (IIIA) or extension to the pelvic wall/hydronephrosis (IIIB). These are strictly managed with radiotherapy as surgery is not curative. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Surgery:** Type III Radical Hysterectomy (Meigs' operation) is the classic choice for Stage IB1 and IIA1. * **Fertility Sparing:** Radical Trachelectomy can be considered for Stage IA2 to IB1 in patients wishing to preserve fertility. * **Treatment of Choice for IIB to IVA:** Concurrent Chemoradiotherapy (Cisplatin-based) is the gold standard. * **Stage IVB:** Managed with palliative chemotherapy. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (post-renal failure).

Q: Which of the following statements about partial mole is false?

Can be reliably diagnosed by ultrasound in early gestation. **Explanation:** The correct answer is **D**. Unlike complete hydatidiform moles, which show a classic "snowstorm appearance" on ultrasound, **partial moles are difficult to diagnose reliably via ultrasound**, especially in early gestation. They often mimic a missed or incomplete abortion. Ultrasound may only show a thickened placenta with some cystic spaces or an increased gestational sac diameter, making histopathological examination the gold standard for diagnosis. **Analysis of Options:** * **Option A (True):** Partial moles are almost always **triploid (69, XXX or 69, XXY)**, resulting from the fertilization of a normal ovum by two sperm (dispermy). * **Option B (True):** The risk of persistent Gestational Trophoblastic Neoplasia (GTN) after a partial mole is very low (**<1-5%**), compared to 15-20% after a complete mole. Choriocarcinoma following a partial mole is extremely rare. * **Option C (True):** Most partial moles present clinically as a **missed or incomplete abortion**. Patients often undergo evacuation for a non-viable pregnancy, and the diagnosis of a partial mole is an incidental finding on pathology. **NEET-PG High-Yield Pearls:** * **Karyotype:** Complete Mole = 46,XX (Diploids); Partial Mole = 69,XXX/XXY (Triploid). * **Fetal Tissue:** Present in Partial Mole; Absent in Complete Mole. * **p57 Expression:** Partial moles are **p57 positive** (maternal DNA present), whereas complete moles are **p57 negative** (no maternal DNA). * **hCG Levels:** Markedly elevated in complete moles; only mildly elevated or normal in partial moles.

Question 1

Most common gestational trophoblastic disease following hydatidiform mole is?

Accepted Answer

Invasive mole

Answer

Choriocarcinoma

Answer

Placental site trophoblastic tumor

Answer

Placental nodule

Question 2

Postmenopausal bleeding is associated with all of the following except:

Accepted Answer

Cervical intraepithelial neoplasia (CIN)

Answer

Carcinoma of cervix

Answer

Carcinoma of ovary

Answer

Endometrial carcinoma

Question 3

Follow-up of low-risk gestational trophoblastic neoplasia (GTN) is done for how long?

Accepted Answer

12 months

Answer

3 months

Answer

6 months

Answer

24 months

Question 4

A post-menopausal woman presents with a 4-year history of itching over the labia majora, with minimal relief from topical medications. Examination reveals an indurated lesion on the right labia with palpable inguinal lymph nodes. What is the most appropriate management?

Accepted Answer

Biopsy

Answer

Topical beclomethasone

Answer

Topical estrogen with antibiotic

Answer

Amoxicillin with clavulanic acid and follow up for lymph node status

Question 5

A patient with a history of ovarian cancer is undergoing follow-up. Her CA125 level is elevated. What is the next best step in management?

Accepted Answer

PET scan

Answer

CT scan

Answer

MRI scan

Answer

Clinical examination and serial monitoring of CA125 levels

Question 6

Pap smear of a 45-year-old female shows CIN grade III. Which of the following is the next step in management?

Accepted Answer

Colposcopy directed biopsy

Answer

Punch biopsy

Answer

Large loop excision

Answer

Cone biopsy

Question 7

Which of the following does not secrete a hormone?

Accepted Answer

Dysgerminoma

Answer

Granulosa cell tumor

Answer

Hilus cell tumor

Answer

Theca cell tumor

Question 8

A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management?

Accepted Answer

Unilateral salpingo-oophorectomy

Answer

Serial Ca-125 measurement and follow-up

Answer

Hysterectomy and bilateral salpingo-oophorectomy

Answer

Radiotherapy

Question 9

In cervical cancer, surgery is limited to patients with which stage?

Accepted Answer

Stage I to IIA

Answer

Stage I to IIB

Answer

Stage I to IIIA

Answer

Stage I to IIIB

Question 10

Which of the following statements about partial mole is false?

Accepted Answer

Can be reliably diagnosed by ultrasound in early gestation

Answer

Usually associated with triploidy

Answer

Rarely causes persistent gestational trophoblastic neoplasia

Answer

Usually presents as missed abortions

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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