Gynecologic Oncology Practice Questions

Q: A 20-year-old woman presents with rapid onset hirsutism and a pelvic mass. What is the likely cause?

Sex cord-stromal tumor of the ovary. ### Explanation **Correct Answer: A. Sex cord-stromal tumor of the ovary** The key clinical markers in this case are **rapid onset virilization** (hirsutism) and the presence of a **pelvic mass**. In a young woman, this combination is a classic presentation for a virilizing sex cord-stromal tumor, most commonly a **Sertoli-Leydig cell tumor**. These tumors produce high levels of testosterone, leading to sudden defeminization followed by masculinization. **Why other options are incorrect:** * **B. Polycystic Ovarian Syndrome (PCOS):** While PCOS is a common cause of hirsutism, it typically presents with a **gradual onset** starting at puberty and is associated with bilateral "necklace" appearance of follicles, not a large, discrete pelvic mass. * **C. Congenital Adrenal Hyperplasia (CAH):** This is a systemic enzymatic deficiency (usually 21-hydroxylase). While it causes virilization, it presents with bilateral adrenal hyperplasia rather than a palpable pelvic mass. * **D. Large simple ovarian cyst:** Simple cysts are usually functional (follicular or luteal) and do not possess the endocrine machinery to produce androgens; they are typically asymptomatic or cause pressure symptoms. **Clinical Pearls for NEET-PG:** * **Sertoli-Leydig Cell Tumor:** The most common virilizing ovarian tumor. Look for elevated **Testosterone** levels (>200 ng/dL). * **Reinke Crystals:** Pathognomonic histological finding in Leydig cell tumors. * **Rule of Thumb:** Rapid onset virilization + Pelvic mass = Ovarian origin (Sertoli-Leydig). Rapid onset virilization + No pelvic mass = Adrenal origin (check DHEAS). * **Tumor Marker:** Inhibin is often elevated in sex cord-stromal tumors (especially Granulosa cell tumors).

Q: What is the most common type of ovarian tumor?

Cystadenoma. **Explanation:** Ovarian tumors are classified based on their tissue of origin: Surface Epithelial, Germ Cell, Sex Cord-Stromal, and Metastatic. **Surface epithelial tumors** are the most common category, accounting for approximately 60–70% of all ovarian neoplasms. **Why Cystadenoma is correct:** Cystadenomas (specifically Serous and Mucinous) are benign surface epithelial tumors. In clinical practice, **benign tumors** are far more common than malignant ones (80% vs. 20%). Among all ovarian neoplasms, the **Serous Cystadenoma** is the single most common type. **Analysis of Incorrect Options:** * **A. Dermoid (Mature Cystic Teratoma):** This is a germ cell tumor. While it is the most common ovarian tumor in **young women (ages 20–30)**, it is less frequent than epithelial cystadenomas when considering all age groups. * **C. Fibroma:** This is a sex cord-stromal tumor. It is the most common solid benign tumor of the ovary but is relatively rare compared to epithelial cysts. It is classically associated with Meigs’ Syndrome. * **D. Cystadenocarcinoma:** This is the malignant counterpart of cystadenomas. While Serous Cystadenocarcinoma is the most common **malignant** ovarian tumor, benign cystadenomas occur much more frequently in the general population. **NEET-PG High-Yield Pearls:** * **Most common ovarian neoplasm overall:** Serous Cystadenoma. * **Most common malignant ovarian tumor:** Serous Cystadenocarcinoma. * **Most common tumor in children/adolescents:** Germ cell tumors (specifically Dermoid). * **Most common bilateral ovarian tumor:** Serous Cystadenoma/Carcinoma (Krukenberg is also frequently bilateral but is metastatic). * **Psammoma bodies** are a characteristic histological finding in Serous tumors.

Q: What is the investigation of choice in a 55-year-old postmenopausal woman presenting with postmenopausal bleeding?

Fractional curettage. **Explanation:** In a postmenopausal woman presenting with bleeding, the primary clinical objective is to rule out **Endometrial Carcinoma**, which is present in approximately 10% of such cases. **Why Fractional Curettage is the Correct Choice:** Fractional curettage is traditionally considered the "gold standard" investigation of choice for postmenopausal bleeding. It involves two steps: first, sampling the endocervical canal, and second, the endometrium. This allows the clinician to differentiate between primary endometrial cancer and cervical cancer extending upwards. Histopathological examination of the tissue obtained provides a definitive diagnosis, which is mandatory before planning management. **Analysis of Incorrect Options:** * **A. Pap smear:** This is a screening tool for cervical cancer, not a diagnostic tool for endometrial pathology. While it may occasionally show glandular cells, it has very low sensitivity for detecting endometrial cancer. * **C. Transvaginal Ultrasound (TVS):** TVS is an excellent initial **screening** tool. An endometrial thickness (ET) of ≤4 mm has a high negative predictive value. However, if the ET is >4 mm or if bleeding persists, a tissue diagnosis (like fractional curettage or Pipelle biopsy) is required for a definitive diagnosis. * **D. CA-125:** This is a tumor marker primarily used for monitoring epithelial ovarian cancer. It is neither sensitive nor specific for diagnosing postmenopausal bleeding. **NEET-PG High-Yield Pearls:** * **Most common cause** of postmenopausal bleeding: **Senile Atrophic Vaginitis**. * **Most common malignancy** presenting as postmenopausal bleeding: **Endometrial Carcinoma**. * **Investigation of choice (Gold Standard):** Fractional Curettage (or Hysteroscopy-guided biopsy). * **First-line screening tool:** Transvaginal Ultrasound (Cut-off for biopsy: ET >4 mm).

Q: Which of the following is NOT true about borderline ovarian tumors?

They have a high rate of recurrence following surgery.. **Explanation:** Borderline Ovarian Tumors (BOTs), also known as "Tumors of Low Malignant Potential" (LMP), occupy an intermediate position between benign cystadenomas and invasive carcinomas. **Why Option B is the correct answer (False statement):** Contrary to invasive ovarian cancer, borderline tumors have an **excellent prognosis** and a **low rate of recurrence**. Most patients (approx. 75%) are diagnosed at Stage I. Even in cases of recurrence, the tumors usually remain borderline in histology rather than transforming into invasive carcinoma. The 10-year survival rate for Stage I BOTs is nearly 95-99%. **Analysis of other options:** * **Option A:** It is a standard epidemiological fact that approximately **10–15%** of all epithelial ovarian tumors are classified as borderline. * **Option C:** Histologically, these tumors are **well-differentiated**. They exhibit epithelial proliferation and nuclear atypia (stratification, pleomorphism) but lack the aggressive features of high-grade malignancies. * **Option D:** The hallmark histological feature that distinguishes a borderline tumor from a malignant one is the **absence of destructive stromal invasion** (they do not breach the basement membrane). **Clinical Pearls for NEET-PG:** * **Age Group:** BOTs typically occur in younger women (mean age 40–45 years) compared to invasive ovarian cancer. * **Management:** Fertility-sparing surgery (unilateral salpingo-oophorectomy or cystectomy) is the treatment of choice for young patients. * **CA-125:** May be elevated but is less specific than in invasive types. * **Most Common Type:** Serous borderline tumors are the most frequent, followed by mucinous. * **Psammoma bodies:** Frequently seen in serous borderline tumors.

Q: What is the percentage of complete moles that progress to persistent Gestational Trophoblastic Neoplasia (GTN)?

15-20%. **Explanation:** Gestational Trophoblastic Neoplasia (GTN) refers to the malignant subset of gestational trophoblastic diseases. The risk of malignant transformation is significantly higher in complete hydatidiform moles compared to partial moles. **Why 15-20% is correct:** In a **Complete Hydatidiform Mole (CHM)**, there is a total absence of fetal tissue and a 46,XX or 46,XY diploid karyotype (entirely paternal). Due to the higher proliferation of trophoblastic tissue, approximately **15-20%** of patients with a complete mole will develop persistent GTN (most commonly invasive mole, and less frequently, choriocarcinoma). **Analysis of Incorrect Options:** * **A, B, and C (1-12%):** These percentages are too low for complete moles. However, it is important to note that for **Partial Hydatidiform Moles (PHM)**, the risk of progression to GTN is much lower, typically cited as **1-5%**. Options A and B would be more representative of the risk associated with partial moles. **High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** Complete Mole is 46,XX (90%) or 46,XY (10%); Partial Mole is Triploid (69,XXX or 69,XXY). * **Risk Factors for Malignancy in CHM:** Pre-evacuation hCG >100,000 mIU/mL, excessive uterine size for dates, and large theca lutein cysts (>6 cm). * **Follow-up:** Post-evacuation, weekly β-hCG levels are monitored until three consecutive normal values are obtained, then monthly for 6 months. * **Diagnosis of GTN:** Based on FIGO criteria—hCG plateau (4 values over 3 weeks), hCG rise (3 values over 2 weeks), or histological diagnosis of choriocarcinoma.

Q: Carcinoma of the cervix stage IA1 is defined by which of the following depth of invasion?

Less than 3 mm depth of stromal invasion. **Explanation:** The staging of Cervical Cancer is based on the **FIGO (International Federation of Gynecology and Obstetrics) classification**. Stage I is defined as carcinoma strictly confined to the cervix. Stage IA represents **microscopically diagnosed** invasive carcinoma, where the lesion is not visible to the naked eye. * **Stage IA1:** Defined as measured stromal invasion **less than 3.0 mm** in depth. * **Stage IA2:** Defined as measured stromal invasion **between 3.0 mm and less than 5.0 mm** in depth. **Why the other options are incorrect:** * **Option B & D:** The "7 mm" horizontal spread criterion was removed in the **2018 FIGO update**. Previously, Stage IA required a lateral extent of <7 mm, but current staging relies solely on the **depth of invasion**. * **Option C:** Invasion greater than 3 mm (but less than 5 mm) would categorize the disease as **Stage IA2**. If the invasion exceeds 5 mm, it is classified as Stage IB. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Stage IA1 and IA2 are diagnosed via **microscopy** (usually through a cone biopsy or LEEP), not clinical examination. * **Management:** For Stage IA1 without lymphovascular space invasion (LVSI), **Extra-fascial Hysterectomy** (Type A) or even **Conization** (if fertility preservation is desired) is sufficient. * **Lymphovascular Space Invasion (LVSI):** The presence of LVSI does not change the FIGO stage but significantly influences the choice of surgical radicality. * **Stage IB1:** Now defined as invasion ≥ 5 mm depth and < 2 cm in greatest dimension.

Q: All of the following are known risk factors for the development of ovarian carcinoma except?

Use of oral contraceptives. ### Explanation The development of epithelial ovarian carcinoma is closely linked to the **"Incessant Ovulation Theory."** This theory suggests that repeated trauma to the ovarian surface epithelium during ovulation, followed by inflammatory repair processes, increases the risk of malignant transformation. **Why "Use of Oral Contraceptives" is the correct answer:** Oral Contraceptive Pills (OCPs) are **protective** against ovarian cancer, not a risk factor. By suppressing ovulation, OCPs provide "rest" to the ovarian epithelium. Using OCPs for 5 years reduces the lifetime risk of ovarian cancer by approximately 50%. This protective effect persists for up to 15–20 years after discontinuation. **Analysis of Incorrect Options:** * **Family History:** A first-degree relative with ovarian cancer significantly increases risk. About 10–15% of cases have a hereditary component. * **Use of Clomiphene:** Clomiphene citrate is an ovulation-inducing agent. Prolonged use (usually >12 cycles), especially in women who do not achieve pregnancy, is associated with an increased risk due to "super-ovulation." * **BRCA-1 Positive:** This is the strongest genetic risk factor. BRCA-1 mutation carriers have a 40–50% lifetime risk of developing ovarian cancer (compared to 1.3% in the general population). **NEET-PG High-Yield Pearls:** * **Protective Factors:** OCPs, Pregnancy (Multiparity), Breastfeeding, and Tubal Ligation/Salpingectomy (prevents migration of precursors from the fallopian tube). * **Risk Factors:** Nulliparity, Early menarche, Late menopause, Endometriosis (linked to Clear cell and Endometrioid types), and Lynch Syndrome (HNPCC). * **Most Common Type:** Serous cystadenocarcinoma is the most common epithelial ovarian malignancy.

Question 1

A 20-year-old woman presents with rapid onset hirsutism and a pelvic mass. What is the likely cause?

Accepted Answer

Sex cord-stromal tumor of the ovary

Answer

Polycystic ovarian syndrome

Answer

Congenital adrenal hyperplasia

Answer

Large simple ovarian cyst

Question 2

What is the most common type of ovarian tumor?

Accepted Answer

Cystadenoma

Answer

Dermoid

Answer

Fibroma

Answer

Cystadenocarcinoma

Question 3

What is the investigation of choice in a 55-year-old postmenopausal woman presenting with postmenopausal bleeding?

Accepted Answer

Fractional curettage

Answer

Pap smear

Answer

Transvaginal ultrasound

Answer

CA-125

Question 4

A 65-year-old lady presents with a single episode of postmenopausal bleeding. What is the next step in management?

Accepted Answer

Fractional curettage

Answer

Pap smear

Answer

Hysterectomy immediately

Answer

Endometrial biopsy

Question 5

Which of the following is NOT true about borderline ovarian tumors?

Accepted Answer

They have a high rate of recurrence following surgery.

Answer

Approximately 10% of epithelial tumors of the ovary are classified as borderline tumors.

Answer

They are well-differentiated tumors.

Answer

They do not invade the basement membrane.

Question 6

What is the percentage of complete moles that progress to persistent Gestational Trophoblastic Neoplasia (GTN)?

Accepted Answer

15-20%

Answer

1-4%

Answer

4-8%

Answer

8-12%

Question 7

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

Serial Ca-125 measurement and follow-up

Answer

Hysterectomy and bilateral salpingo-oophorectomy

Answer

Hysterectomy with radiotherapy

Answer

Radiotherapy

Question 8

Carcinoma of the cervix stage IA1 is defined by which of the following depth of invasion?

Accepted Answer

Less than 3 mm depth of stromal invasion

Answer

Less than 7 mm depth of stromal invasion

Answer

Greater than 3 mm depth of stromal invasion

Answer

Greater than 7 mm depth of stromal invasion

Question 9

All of the following are known risk factors for the development of ovarian carcinoma except?

Accepted Answer

Use of oral contraceptives

Answer

Family history of ovarian carcinoma

Answer

Use of Clomiphene

Answer

BRCA-1 positive individual

Question 10

Suburethral metastasis is seen in which of the following?

Accepted Answer

Carcinoma endometrium

Answer

Carcinoma cervix

Answer

Choriocarcinoma

Answer

Vaginal carcinoma

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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