Gynecologic Oncology Practice Questions

Q: A 57-year-old woman presents with chronic pelvic pain, urinary frequency, constipation, dyspareunia, and bloating. Physical examination reveals a large pelvic mass. Ultrasound shows a multiloculated cystic mass involving the right adnexa. Which serum tumor marker is most appropriate to screen for ovarian cancer prior to surgery?

CA-125. **Explanation:** The clinical presentation of a postmenopausal woman (57 years old) with a large, multiloculated cystic pelvic mass and symptoms of mass effect (urinary frequency, constipation, bloating) is highly suspicious for **Epithelial Ovarian Cancer (EOC)**. **Why CA-125 is the correct answer:** **Cancer Antigen 125 (CA-125)** is the most widely used tumor marker for epithelial ovarian tumors, particularly the serous subtype. While it lacks specificity in premenopausal women (due to elevation in endometriosis, PID, or pregnancy), it is highly significant in postmenopausal women for the evaluation of adnexal masses. It is used for preoperative assessment, monitoring treatment response, and detecting recurrence. **Analysis of Incorrect Options:** * **A. Adrenocorticotropic hormone (ACTH):** This is a marker for pituitary function or ectopic ACTH syndrome (often associated with Small Cell Lung Cancer), not ovarian malignancies. * **C. Galactosyltransferase:** While studied in research contexts for various malignancies, it is not a standard clinical marker for ovarian cancer screening or diagnosis. * **D. S-100:** This is a marker primarily used for **Melanoma**, neural tumors, and certain sarcomas. It has no role in the routine workup of epithelial ovarian cancer. **NEET-PG High-Yield Pearls:** * **Most common EOC:** Serous Cystadenocarcinoma. * **Tumor Markers by Type:** * **Dysgerminoma:** LDH (most specific), hCG. * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP). * **Granulosa Cell Tumor:** Inhibin B. * **Choriocarcinoma:** beta-hCG. * **RMI (Risk of Malignancy Index):** Uses CA-125 levels, Ultrasound features, and Menopausal status to predict the likelihood of malignancy.

Q: A 38-year-old woman presents with painless post-coital bleeding. She had a cone biopsy for carcinoma in situ five years ago. Her last smear was three months ago, following this. Her last period was six weeks ago. What is the most probable diagnosis?

Carcinoma of cervix. **Explanation:** The clinical presentation of **painless post-coital bleeding** in a woman with a history of cervical intraepithelial neoplasia (CIN/Carcinoma in situ) is a classic "red flag" for **Cervical Carcinoma**. 1. **Why Option A is correct:** Post-coital bleeding is the most common presenting symptom of cervical cancer. This patient has a significant risk factor: a history of carcinoma in situ treated with a cone biopsy. Despite the procedure, she remains at higher risk for recurrence or progression to invasive disease. The fact that her last smear was only three months ago does not rule out malignancy, as cytology has a known false-negative rate, and invasive lesions can sometimes be missed if they are endocervical or rapidly progressing. 2. **Why the other options are incorrect:** * **Ectopic Pregnancy:** While she is six weeks post-LMP, ectopic pregnancy typically presents with abdominal pain and vaginal spotting/bleeding, not specifically post-coital bleeding. * **Endometrial Carcinoma:** This usually presents as post-menopausal bleeding. In a 38-year-old, it is rare unless there are specific risk factors like PCOS, obesity, or Lynch syndrome. * **Uterine Fibroids:** These typically present with heavy menstrual bleeding (menorrhagia) or pelvic pressure, rather than contact (post-coital) bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of Cervical Cancer:** Post-coital bleeding. * **Most common histological type:** Squamous cell carcinoma (80-85%). * **Screening:** PAP smear is a screening tool, but the definitive diagnosis of cervical cancer is always made via **Biopsy**. * **Risk Factors:** Early age at first intercourse, multiple sexual partners, and persistent high-risk HPV infection (Types 16 and 18).

Q: A 45-year-old postmenopausal woman presents with vaginal bleeding. Transvaginal ultrasound reveals an endometrial thickness of 8.0 mm. What is the next step in management?

Histopathological examination of curettage. **Explanation:** The primary concern in a postmenopausal woman presenting with vaginal bleeding (PMB) is excluding **Endometrial Carcinoma**. **Why Option C is Correct:** In postmenopausal women, the gold standard for evaluating abnormal uterine bleeding is a tissue diagnosis. While Transvaginal Ultrasound (TVUS) is an excellent screening tool, an **endometrial thickness (ET) of >4 mm** in a symptomatic postmenopausal woman is considered abnormal and carries a significant risk for malignancy or hyperplasia. Since this patient has an ET of 8.0 mm, a **histopathological examination** (via endometrial biopsy or fractional curettage) is mandatory to rule out cancer. **Why Other Options are Incorrect:** * **Option A (Hysterectomy):** This is a definitive surgical treatment, not a diagnostic step. It is only indicated after a confirmed diagnosis of malignancy or failed medical management of benign conditions. * **Option B (Progesterone therapy):** Hormonal therapy is used to treat endometrial hyperplasia without atypia. It should never be started empirically without first obtaining a tissue diagnosis. * **Option D (Follow-up sonography):** Delaying diagnosis in the presence of a thickened endometrium and active bleeding is inappropriate and risks missing an early-stage malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Cut-off values:** In PMB, an ET **≤4 mm** has a high negative predictive value (>99%) for endometrial cancer. If ET is >4 mm, biopsy is mandatory. * **Asymptomatic postmenopausal women:** If there is no bleeding, the threshold for biopsy is generally higher (typically **>8–11 mm**), though this is controversial. * **Most common cause of PMB:** Senile/Atrophic vaginitis (however, malignancy must be ruled out first). * **Risk Factors:** Obesity, Nulliparity, Early menarche/Late menopause, and Tamoxifen use.

Q: A patient presents with bilateral ovarian carcinoma with a breech in the capsular wall, ascites, peritoneal metastasis, and positive cytology. What is the stage of the carcinoma?

Stage Ic. **Explanation:** The staging of ovarian carcinoma follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification. This case describes a tumor limited to the ovaries (Stage I) but with specific features that upgrade it to **Stage Ic**. **Why Stage Ic is correct:** Stage I is defined as growth limited to the ovaries or fallopian tubes. It is subdivided into: * **Ia:** One ovary/tube involved, capsule intact, no tumor on surface, negative washings. * **Ib:** Both ovaries/tubes involved, capsule intact, no tumor on surface, negative washings. * **Ic:** Tumor limited to one or both ovaries/tubes **PLUS** any of the following: * **Ic1:** Surgical spill. * **Ic2:** Capsule ruptured before surgery (breech in the wall) or tumor on surface. * **Ic3:** Malignant cells in the ascites or peritoneal washings (positive cytology). Since the patient has a capsular breech and positive cytology, it fits the criteria for Stage Ic. **Why other options are incorrect:** * **Stage II:** Involves pelvic extension (uterus, tubes, bladder, or rectum) below the pelvic brim. * **Stage III:** Involves spread to the peritoneum outside the pelvis and/or metastasis to retroperitoneal lymph nodes. (Note: While the question mentions "peritoneal metastasis," in the context of Stage I/II, this usually refers to microscopic seeding or washings; gross extrapelvic peritoneal spread would be Stage III). * **Stage IV:** Distant metastasis (e.g., pleural effusion with positive cytology, parenchymal liver/spleen metastasis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Most ovarian cancers are diagnosed at **Stage III**. * **Prognostic Factor:** Positive peritoneal cytology (Ic3) is a significant poor prognostic indicator in early-stage disease. * **CA-125:** While useful for monitoring epithelial tumors, it is not used for staging; staging is strictly **surgical-pathological**.

Q: A patient with carcinoma of the ovary presents with a left supraclavicular lymph node. What is the clinical stage of this cancer?

Stage IV. **Explanation:** The clinical staging of Ovarian Cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**. **Why Stage IV is correct:** Stage IV represents **distant metastasis** (excluding peritoneal metastases). According to the FIGO 2014 classification, Stage IV is subdivided into: * **Stage IV-A:** Pleural effusion with positive cytology. * **Stage IV-B:** Parenchymal metastases (liver/spleen) and **extra-abdominal lymph node involvement**. A **left supraclavicular lymph node** (also known as Virchow’s node) is located outside the abdominal cavity; therefore, its involvement signifies distant hematogenous or lymphatic spread, classifying the disease as **Stage IV-B**. **Why other options are incorrect:** * **Stage I:** Growth is limited strictly to the ovaries or fallopian tubes. * **Stage II:** Growth involves one or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer. * **Stage III:** Growth involves one or both ovaries with cytologically/histologically confirmed spread to the peritoneum **outside the pelvis** and/or metastasis to the **retroperitoneal (pelvic/paraaortic) lymph nodes**. Since supraclavicular nodes are extra-abdominal, they exceed Stage III criteria. **High-Yield Clinical Pearls for NEET-PG:** * **Most common mode of spread:** Seeding/Exfoliation into the peritoneal cavity (Transcoelomic). * **Most common site of distant metastasis:** Pleura (presents as malignant pleural effusion). * **Lymphatic drainage:** Primary drainage is via the infundibulopelvic ligament to the **paraaortic lymph nodes**. * **Sister Mary Joseph’s Nodule:** Metastasis to the umbilicus, also indicative of advanced disease.

Q: Which of the following gynaecological cancers is unusual in young women?

Cancer vulva. **Explanation:** **Cancer of the vulva** is primarily a disease of elderly, postmenopausal women. The peak incidence occurs in the **7th and 8th decades of life** (average age 65–70 years). The most common histological type, Keratinizing Squamous Cell Carcinoma, is typically associated with lichen sclerosus and chronic inflammatory conditions seen in older age groups. While HPV-related vulvar intraepithelial neoplasia (VIN) can occur in younger women, progression to invasive cancer in this demographic remains rare compared to other gynecological malignancies. **Analysis of Incorrect Options:** * **Cancer Ovary:** While common in older women, specific types like **Germ Cell Tumors** (e.g., Dysgerminoma, Yolk sac tumor) are most prevalent in adolescents and women in their 20s. * **Cancer Cervix:** This is the most common gynecological cancer in many developing regions and frequently affects women in their **30s and 40s** due to early exposure to HPV. * **Choriocarcinoma:** This is a gestational trophoblastic neoplasia that occurs during the **reproductive years**, following a molar pregnancy, abortion, or normal term delivery. It is virtually unseen after menopause. **Clinical Pearls for NEET-PG:** * **Most common site for Vulvar Cancer:** Labia majora (anterior two-thirds). * **Most common histology:** Squamous cell carcinoma (90%). * **Lymphatic Spread:** Vulvar cancer spreads primarily via the lymphatics to the **Inguinal nodes** (Sentinel node) first, then to Femoral and Iliac nodes. * **Younger patients:** When vulvar cancer does occur in young women, it is almost always associated with **High-risk HPV (16, 18)** and smoking.

Question 1

A 57-year-old woman presents with chronic pelvic pain, urinary frequency, constipation, dyspareunia, and bloating. Physical examination reveals a large pelvic mass. Ultrasound shows a multiloculated cystic mass involving the right adnexa. Which serum tumor marker is most appropriate to screen for ovarian cancer prior to surgery?

Accepted Answer

CA-125

Answer

Adrenocorticotropic hormone

Answer

Galactosyltransferase

Answer

S-100

Question 2

Ultrasound of a 36 year old gravida reveals small grape-like cystic structures without evidence of a developing embryo. What is the most likely diagnosis?

Accepted Answer

The genotype of the mole is 46XXX and is completely paternal in origin.

Answer

The genotype of the mole is triploid.

Answer

hCG levels are markedly decreased.

Answer

Serum levels of alpha-fetoprotein are elevated.

Question 3

A 56-year-old woman presents with a 3-month history of vaginal bleeding. A cervical Pap smear reveals malignant, glandular epithelial cells. This patient most likely has a neoplasm originating in which of the following anatomic locations?

Accepted Answer

Cervix

Answer

Endometrium

Answer

Ovary

Answer

Vagina

Question 4

A 38-year-old woman presents with painless post-coital bleeding. She had a cone biopsy for carcinoma in situ five years ago. Her last smear was three months ago, following this. Her last period was six weeks ago. What is the most probable diagnosis?

Accepted Answer

Carcinoma of cervix

Answer

Ectopic pregnancy

Answer

Endometrial carcinoma

Answer

Uterine fibroids

Question 5

A 50-year-old woman underwent debulking surgery for advanced epithelial ovarian cancer. What standard adjuvant therapy is recommended for this patient?

Accepted Answer

Paclitaxel and carboplatin for six cycles

Answer

Paclitaxel and carboplatin for six cycles and radiotherapy

Answer

Paclitaxel for six cycles and radiotherapy

Answer

Radiotherapy alone

Question 6

A 45-year-old postmenopausal woman presents with vaginal bleeding. Transvaginal ultrasound reveals an endometrial thickness of 8.0 mm. What is the next step in management?

Accepted Answer

Histopathological examination of curettage

Answer

Hysterectomy

Answer

Progesterone therapy

Answer

Follow-up sonography

Question 7

A patient presents with bilateral ovarian carcinoma with a breech in the capsular wall, ascites, peritoneal metastasis, and positive cytology. What is the stage of the carcinoma?

Accepted Answer

Stage Ic

Answer

Stage IIc

Answer

Stage IIIc

Answer

Stage IVc

Question 8

A patient with carcinoma of the ovary presents with a left supraclavicular lymph node. What is the clinical stage of this cancer?

Accepted Answer

Stage IV

Answer

Stage III

Answer

Stage II

Answer

Stage I

Question 9

Which of the following gynaecological cancers is unusual in young women?

Accepted Answer

Cancer vulva

Answer

Cancer ovary

Answer

Cancer cervix

Answer

Choriocarcinoma

Question 10

A 54-year-old woman undergoes a laparotomy for a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered with a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. What is the most appropriate intraoperative course of action?

Accepted Answer

Omentectomy, total abdominal hysterectomy, and bilateral salpingo oophorectomy

Answer

Excision of the omental metastasis and ovarian cystectomy

Answer

Omentectomy and ovarian cystectomy

Answer

Excision of the omental metastasis and unilateral oophorectomy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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