Gynecologic Oncology Practice Questions

Q: Prophylactic chemotherapy is indicated after evacuation of hydatidiform mole in all cases EXCEPT:

Nulliparous patient. **Explanation:** The management of Hydatidiform Mole (HM) primarily involves suction evacuation followed by serial hCG monitoring. **Prophylactic chemotherapy** is not routinely recommended for all patients because 80% of cases resolve spontaneously, and chemotherapy carries risks of toxicity and drug resistance. **Why "Nulliparous patient" is the correct answer:** Parity (being nulliparous or multiparous) is not a clinical indicator for chemotherapy. The decision to initiate treatment is based on the risk of malignant transformation (Gestational Trophoblastic Neoplasia - GTN), not the patient's reproductive history. In fact, for older patients who have completed their family, a prophylactic hysterectomy may be considered, but nulliparity itself is never an indication for chemotherapy. **Analysis of Incorrect Options (Indications for Chemotherapy):** * **Options A & B (hCG levels):** According to FIGO criteria, chemotherapy is indicated if hCG levels plateau (stay within ±10% over 3 weeks) or rise (increase >10% over 2 consecutive weeks). A high titre of 40,000 IU/L at 6 weeks or a significant rise to 24,000 IU/L at 10 weeks suggests persistent disease or malignant transformation into Choriocarcinoma or Invasive Mole. * **Option C (Metastasis):** The presence of any clinical or radiological evidence of metastasis (commonly to lungs or vagina) automatically classifies the condition as GTN, requiring immediate chemotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** Used for GTN to decide between single-agent (Methotrexate) or multi-agent (EMA-CO) chemotherapy. * **Follow-up Protocol:** hCG is monitored weekly until three consecutive negatives (<5 mIU/mL), then monthly for 6 months. * **Contraception:** Essential during the follow-up period (OCPs are preferred) to avoid confusing a new pregnancy with rising hCG from a relapse. * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%).

Q: Which one of the following tumors involving the female genital tract has the worst prognosis?

Serous cystadenocarcinoma of the ovary in a 45-year-old. **Explanation:** The prognosis of gynecologic tumors depends on their biological behavior, chemosensitivity, and stage at presentation. **Serous cystadenocarcinoma** is the most common type of epithelial ovarian cancer (EOC). It has the worst prognosis among the options because it is typically diagnosed at an advanced stage (Stage III or IV) due to its "silent" progression and rapid intraperitoneal spread. Unlike germ cell tumors, it has a high recurrence rate and lower long-term survival. **Analysis of Options:** * **Dysgerminoma (Option A):** These are highly radiosensitive and chemosensitive germ cell tumors. Even in advanced stages, the cure rate is excellent (>90%), making it one of the most treatable ovarian malignancies. * **Uterine Choriocarcinoma (Option B):** While highly aggressive and prone to early hematogenous metastasis (to lungs), gestational choriocarcinoma is exquisitely sensitive to chemotherapy (e.g., Methotrexate). It is considered a "curable" cancer even in the presence of metastasis. * **Granulosa Cell Tumor (Option C):** These are "low-grade" sex cord-stromal tumors. They have an indolent course, are usually diagnosed at Stage I, and have a very high 10-year survival rate, though they require long-term follow-up due to late recurrences. **Clinical Pearls for NEET-PG:** * **Most common ovarian malignancy:** Serous cystadenocarcinoma. * **Tumor Marker for Serous Ca:** CA-125 (used for monitoring, not screening). * **Psammoma bodies:** Characteristic histological finding in Serous cystadenocarcinoma. * **Call-Exner bodies:** Pathognomonic for Granulosa cell tumors (Inhibin is the marker). * **LDH:** The characteristic marker for Dysgerminoma.

Q: Brachytherapy is used in which of the following conditions?

Stage Ib Ca cervix. **Explanation:** **1. Why Stage Ib Ca Cervix is Correct:** Brachytherapy (internal radiation) is a cornerstone in the management of cervical cancer. For **Stage Ib Ca Cervix**, the standard treatment is either a Radical Hysterectomy with pelvic lymphadenectomy or **Definitive Radiotherapy**. Radiotherapy for cervical cancer typically involves a combination of External Beam Radiation Therapy (EBRT) and **Brachytherapy**. Brachytherapy allows for the delivery of a high dose of radiation directly to the tumor (the cervix) while sparing adjacent critical organs like the bladder and rectum, utilizing the inverse square law. **2. Why the other options are incorrect:** * **Ovarian Ca:** The primary treatment is cytoreductive surgery followed by systemic chemotherapy (Paclitaxel + Carboplatin). Brachytherapy is not used because ovarian cancer tends to spread throughout the peritoneal cavity, requiring systemic rather than localized internal radiation. * **Stage IV Ca Vagina:** While brachytherapy is used in early-stage vaginal cancer, Stage IV involves distant metastasis or extension into the bladder/rectal mucosa. Treatment at this stage is usually palliative EBRT or chemotherapy; the disease is too extensive for localized brachytherapy to be effective as a primary modality. * **Stage II Fallopian Tube Ca:** Similar to ovarian cancer, fallopian tube cancers are managed with staging surgery and systemic chemotherapy due to their pattern of intraperitoneal spread. **Clinical Pearls for NEET-PG:** * **Manchester System:** Used in cervical brachytherapy to define **Point A** (2cm superior to the external os and 2cm lateral to the uterine canal) and **Point B** (3cm lateral to Point A). * **Most common isotope used:** Iridium-192 (High Dose Rate) or Cesium-137 (Low Dose Rate). * **Stockholm and Paris systems** are other historical methods of cervical brachytherapy application.

Q: In colposcopy, which of the following is NOT visualized?

Upper two-thirds of the endocervix. **Explanation:** The correct answer is **A. Upper two-thirds of the endocervix**. Colposcopy is a diagnostic procedure used to visualize the cervix, vagina, and vulva under magnification. Its primary limitation is that it is a **surface-viewing tool**. While it can visualize the ectocervix and the lower part of the endocervical canal (depending on the visibility of the Transformation Zone), it cannot see deep into the endocervical canal. The upper two-thirds of the endocervix are anatomically "blind" to the colposcope; lesions located here require an endocervical curettage (ECC) or conization for evaluation. **Analysis of Options:** * **Cervical carcinoma in situ (B) and Cervical dysplasia (D):** These are the primary indications for colposcopy. The procedure identifies abnormal vascular patterns (punctations, mosaicism) and acetowhite epithelium associated with these conditions, provided they are located on the visible ectocervix or the distal endocervix. * **Cervical polyp (C):** Since polyps usually protrude from the external os or are attached to the visible portion of the cervix, they are easily visualized during colposcopy. **High-Yield Clinical Pearls for NEET-PG:** * **Satisfactory Colposcopy:** Defined as the ability to visualize the **entire Squamocolumnar Junction (SCJ)** and the margins of any visible lesion. * **Unsatisfactory Colposcopy:** Occurs if the SCJ is recessed into the endocervical canal (common in postmenopausal women). In such cases, the "upper" limits of the lesion cannot be seen. * **Reagents used:** 3–5% Acetic acid (highlights acetowhite areas) and Lugol’s Iodine (Schiller’s test; mature squamous cells stain mahogany brown, while dysplastic cells remain unstained/yellow). * **Indications for ECC:** Performed during colposcopy if the SCJ is not fully visualized or if the lesion extends into the canal.

Q: Which of the following is NOT a common recurrence or metastatic site of malignancy following pelvic surgery?

Carcinoma of the ovary - Lung. **Explanation:** The correct answer is **B (Carcinoma of the ovary - Lung)** because epithelial ovarian cancer primarily spreads via **exfoliation and intraperitoneal seeding**. The most common site of metastasis/recurrence is the **peritoneum and omentum** (forming an "omental cake"). While hematogenous spread to the lungs can occur in advanced Stage IV disease, it is not considered a "common" or characteristic primary recurrence site compared to the other options listed. **Analysis of Incorrect Options:** * **A. Carcinoma of the cervix:** Recurrence typically occurs locally in the **central pelvis** (vaginal vault/stump) or along the **lateral pelvic wall**, often leading to ureteral obstruction and uremia (the most common cause of death). * **C. Chorionepithelioma (Choriocarcinoma):** This is a highly vascular tumor with a predilection for hematogenous spread. The **vagina** (specifically the suburethral anterior wall) is a classic site for "blue-domed" metastatic nodules. * **D. Carcinoma of the body of the uterus:** Following a total hysterectomy for endometrial cancer, the **vaginal vault** is the most frequent site of isolated local recurrence. **NEET-PG High-Yield Pearls:** * **Choriocarcinoma:** Most common site of metastasis is the **Lung** (80%), followed by the **Vagina** (30%). * **Cervical Cancer:** Spreads primarily by direct extension and lymphatics. The "Triad of Death" in advanced cases includes uremia, infection, and hemorrhage. * **Ovarian Cancer:** The "Seed and Soil" hypothesis applies here; cancer cells "wash" through the peritoneal fluid and implant on the diaphragm and paracolic gutters.

Q: A 55-year-old woman is diagnosed with Stage II-III cervical cancer, considered locally advanced. What is the recommended management?

Radiotherapy plus chemotherapy. **Explanation:** The management of cervical cancer is primarily determined by the FIGO stage. For **Locally Advanced Cervical Cancer (LACC)**, which includes stages **IB3, IIA2, and Stage IIB to IVA**, the standard of care is **Concurrent Chemoradiotherapy (CCRT)**. 1. **Why Option B is Correct:** In locally advanced stages (like Stage II-III), the tumor has either reached a size >4cm or has spread beyond the cervix to the parametrium or pelvic wall. Surgery in these cases is associated with high morbidity and a high risk of positive margins. Clinical trials have proven that adding chemotherapy (specifically **Cisplatin**) to radiotherapy acts as a radiosensitizer, significantly improving overall survival and reducing recurrence compared to radiation alone. 2. **Why Options A, C, and D are Incorrect:** * **Option A:** Surgery (Radical Hysterectomy) is generally reserved for early-stage disease (Stage IA to IIA1). Combining surgery with post-operative radiation increases complications without improving survival in LACC. * **Option C:** Chemotherapy alone is not curative for cervical cancer; it is used for palliation in Stage IVB (metastatic disease). * **Option D:** The HPV vaccine is a preventive measure (primary prevention) and has no therapeutic role in treating established cervical cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Drug:** Cisplatin is the most common radiosensitizer used in CCRT. * **Stage IIB:** Defined by **Parametrial involvement** (but not reaching the pelvic wall). This is the most common stage where surgery is abandoned in favor of radiotherapy. * **Investigation of Choice for Staging:** MRI is the preferred imaging modality to assess local tumor extent and parametrial involvement. * **Radiotherapy Components:** CCRT typically involves a combination of External Beam Radiation Therapy (EBRT) and Brachytherapy.

Q: Cryosurgery is used in the treatment of cervical intraepithelial neoplasia. In which of the following conditions is cryosurgery NOT appropriate?

Cervical intraepithelial neoplasia-3 (CIN-3).. **Explanation:** Cryosurgery is an ablative technique used for treating Cervical Intraepithelial Neoplasia (CIN). Its success depends on the ability to freeze the entire transformation zone (TZ) and the lesion to a specific depth. **Why Option C is the correct answer:** Cryosurgery is generally **not recommended for CIN-3**. High-grade lesions (CIN-3) have a higher risk of harboring occult invasive carcinoma or extending deep into the endocervical crypts. Because cryosurgery is an ablative method, it does not provide a tissue specimen for histopathological verification of margins or to rule out invasion. For CIN-3, excisional procedures like LEEP (Loop Electrosurgical Excision Procedure) or Cold Knife Conization are preferred. **Analysis of Incorrect Options:** * **Option A:** Cryosurgery is ideal when the **TZ is entirely on the ectocervix** (Type 1 TZ). If the TZ extends into the endocervical canal, the cryoprobe cannot reach the upper limits, leading to treatment failure. * **Option B:** A **smooth cervical surface** ensures uniform contact between the cryoprobe and the tissue. Deep crevices or irregular contours prevent adequate freezing of the entire lesion. * **Option D:** Cryosurgery is most effective for **small lesions** (limited to <2 quadrants). Large lesions covering more than 75% of the cervix have a higher failure rate with ablation. **Clinical Pearls for NEET-PG:** * **Prerequisites for Cryosurgery:** Negative endocervical curettage (ECC), no evidence of malignancy, and a correlation between cytology and colposcopy. * **Technique:** The "Freeze-Thaw-Freeze" technique is used (3 mins freeze, 5 mins thaw, 3 mins freeze). * **Side Effect:** Patients often experience a profuse, watery vaginal discharge for 2–4 weeks post-procedure. * **Refrigerant:** Nitrous oxide ($N_2O$) or Carbon dioxide ($CO_2$) are commonly used.

Q: What is the co-test in cervical cancer screening?

HPV and PAP smear. ***HPV and PAP smear*** - **Co-testing** is the simultaneous use of the **hrHPV DNA test** (to detect oncogenic virus presence) and the **Papanicolaou (PAP) smear** (to detect cytological abnormalities). - This combination provides the highest sensitivity for detecting high-grade cervical intraepithelial neoplasia (**CIN 2/3**) and is recommended for screening women aged 30-65 years in many guidelines. *Pap smear and VIA* - **Visual Inspection with Acetic acid (VIA)** is typically used as a primary screening method in settings where laboratory infrastructure for cytology or HPV testing is limited, not as a standard co-test. - The combination of **PAP smear** (cytology) and **HPV testing** (molecular) offers a superior and more risk-stratified approach than combining cytology with simple visual inspection. *HPV and VIA* - This combination lacks the necessary **specificity** provided by the PAP smear, as VIA relies on subjective visual assessment of acetowhite changes rather than objective cytological classification. - Standard screening protocols often require detailed cytological results (e.g., **ASCUS, LSIL, HSIL**) from the PAP smear to guide subsequent triage and management decisions when HPV is positive. *PAP smear and colposcopy* - **Colposcopy** is a **diagnostic and evaluation procedure** performed *after* an abnormal screening result (e.g., abnormal PAP or positive HPV), not a screening test to be paired with the PAP smear. - Colposcopy allows for directed biopsy and is crucial for definitive diagnosis and staging of **cervical intraepithelial neoplasia (CIN)**.

Question 1

Prophylactic chemotherapy is indicated after evacuation of hydatidiform mole in all cases EXCEPT:

Accepted Answer

Nulliparous patient

Answer

Initial level of urine hCG is 40,000 IU/L after 6 weeks of evacuation

Answer

Increase in hCG titre to 24,000 IU/L after 10 weeks of evacuation

Answer

Presence of metastasis

Question 2

Which one of the following tumors involving the female genital tract has the worst prognosis?

Accepted Answer

Serous cystadenocarcinoma of the ovary in a 45-year-old

Answer

Dysgerminoma in a 35-year-old

Answer

Uterine choriocarcinoma in a 25-year-old with a recent history of molar pregnancy

Answer

Granulosa cell tumor in a 40-year-old

Question 3

Brachytherapy is used in which of the following conditions?

Accepted Answer

Stage Ib Ca cervix

Answer

Ovarian Ca

Answer

Stage IV Ca vagina

Answer

Stage II fallopian tube Ca

Question 4

In colposcopy, which of the following is NOT visualized?

Accepted Answer

Upper two-thirds of the endocervix

Answer

Cervical carcinoma in situ

Answer

Cervical polyp

Answer

Cervical dysplasia

Question 5

Which of the following is NOT a common recurrence or metastatic site of malignancy following pelvic surgery?

Accepted Answer

Carcinoma of the ovary - Lung

Answer

Carcinoma of the cervix - Lateral pelvic wall and central pelvis

Answer

Chorionepithelioma - Suburethral anterior vaginal wall

Answer

Carcinoma of the body of the uterus - Vault of the vagina

Question 6

What is the treatment for a patient with a 20-week size uterus and a vesicular mole?

Accepted Answer

Suction evacuation

Answer

Induction of labor

Answer

Methotrexate

Answer

Hysterotomy

Question 7

Which of the following is a true statement regarding sarcoma botryoides?

Accepted Answer

Involvement of the vagina

Answer

Grape-like growth is seen

Answer

Common in the aged

Answer

Malignant

Question 8

A 55-year-old woman is diagnosed with Stage II-III cervical cancer, considered locally advanced. What is the recommended management?

Accepted Answer

Radiotherapy plus chemotherapy

Answer

Surgery plus chemotherapy

Answer

Chemotherapy alone

Answer

Radiotherapy plus HPV vaccine

Question 9

Cryosurgery is used in the treatment of cervical intraepithelial neoplasia. In which of the following conditions is cryosurgery NOT appropriate?

Accepted Answer

Cervical intraepithelial neoplasia-3 (CIN-3).

Answer

Transformation zone lying entirely on the ectocervix.

Answer

Smooth cervical surface without deep crevices.

Answer

CIN limited to two quadrants of the cervix.

Question 10

What is the co-test in cervical cancer screening?

Accepted Answer

HPV and PAP smear

Answer

PAP smear and colposcopy

Answer

HPV and VIA

Answer

Pap smear and VIA

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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