Gynecologic Oncology Practice Questions

Q: A woman in the late menstrual phase presents with an ovarian mass. Her Pap smear shows predominantly superficial cells stained orange (see image). What is the most likely ovarian tumor?

Granulosa cell tumor. ***Granulosa cell tumor*** - The predominance of **superficial cells** with an orange (eosinophilic) stain in a Pap smear indicates unopposed **estrogen effect**. - **Granulosa cell tumors** are sex cord-stromal tumors of the ovary that characteristically secrete estrogen, leading to such changes. *Serous cystadenoma* - This is a common **epithelial ovarian tumor** that is typically benign and does not produce hormones. - It would not cause an estrogenic effect on the Pap smear. *Mucinous cystadenoma* - Another common **epithelial ovarian tumor**, usually benign, which is not associated with hormone production. - It would not lead to the observed estrogen-mediated changes in the cervical cytology. *Fibroma* - An **ovarian fibroma** is a benign stromal tumor that does not typically produce hormones. - While some rare stromal tumors can be hormonally active (e.g., thecofibromas), a standard fibroma would not cause significant estrogenic effects on the Pap smear.

Q: Which one of the following is an indication for knife conisation? 1. Treatment of Nabothian follicle 2. Diagnosis and directed biopsy of cervix when punch biopsy is inadequate 3. Unsatisfactory colposcopy (transformation zone not fully visible) 4. Negative endocervical curettage Select the correct answer using the code given below:

2 and 3 only. ***2 and 3 only*** - **Knife conisation** (cold-knife conization) is a surgical procedure that removes a **cone-shaped piece of tissue** from the cervix for both diagnostic and therapeutic purposes. - **Statement 2 is correct**: Conisation is indicated for diagnosis and obtaining adequate tissue when punch biopsy is inadequate or when there is discrepancy between cytology, colposcopy, and histology. - **Statement 3 is correct**: Unsatisfactory colposcopy (when the transformation zone cannot be fully visualized) is a key indication for diagnostic conisation. *1, 2 and 3* - This option incorrectly includes treatment of **Nabothian follicles**. Nabothian cysts are benign retention cysts that are asymptomatic and require **no treatment**. They are not an indication for conisation. *1 and 4* - Both statements are **incorrect**. Nabothian follicles do not require treatment, and a **negative endocervical curettage (ECC)** is not an indication for conisation. In fact, a **positive ECC** (showing dysplasia) would be an indication. *1 and 3 only* - This option incorrectly includes **Nabothian follicle treatment**, which is not an indication for conisation as these are benign cysts requiring no intervention.

Q: Bilateral total salpingectomy is a recommended surgical procedure to reduce the risk of :

Epithelial ovarian cancer. ***Epithelial ovarian cancer*** - Many high-grade serous ovarian cancers, the most common and aggressive type, are now believed to originate in the **distal fallopian tube** (specifically the fimbriae). - Removing the fallopian tubes significantly reduces the risk of these cancers, especially in women at **high genetic risk** (e.g., BRCA1/2 mutations) or undergoing hysterectomy for benign indications. *Uterine cancer* - Uterine cancer primarily affects the **endometrium** (lining of the uterus) or the **myometrium** (muscle wall). - Bilateral salpingectomy, which involves removing the fallopian tubes, does not directly influence the risk of uterine cancer. *Fallopian tube cancer* - While bilateral salpingectomy removes the fallopian tubes, the primary goal for risk reduction associated with these tubes is for **epithelial ovarian cancer**, not primary fallopian tube cancer itself. - Primary fallopian tube cancer is extremely rare, and often shares similar histopathological features and biological behavior with high-grade serous ovarian cancer. *Peritoneal cancer* - Peritoneal cancer can arise from the lining of the abdominal cavity, often with a similar histology to **serous ovarian cancer**. - While there might be some overlap in the pathogenesis, the strongest evidence for risk reduction with salpingectomy specifically targets the origin of **epithelial ovarian cancer** from the fallopian tube, rather than direct primary peritoneal cancer risk.

Q: Prophylactic oophorectomy is recommended in high risk women with which of the following ? 1. Carrying BRCA1 or BRCA2 genes 2. Family history of breast, colon, ovarian cancer 3. Patients having tubo-ovarian abscess Select the correct answer using the code given below :

1 and 2 only. ***1 and 2 only*** - Prophylactic oophorectomy is strongly recommended for women carrying **BRCA1 or BRCA2 genes** due to a significantly increased lifetime risk of developing ovarian and breast cancer. - A strong **family history of breast, colon, or ovarian cancer**, especially in multiple first-degree relatives or at early ages, indicates a higher genetic predisposition that warrants consideration for prophylactic oophorectomy. *1, 2 and 3* - While carrying BRCA1/2 genes and a significant family history are indications, a **tubo-ovarian abscess (TOA)** is an infectious condition that requires antibiotic treatment and possibly surgical drainage, not a prophylactic oophorectomy for cancer risk reduction. - Prophylactic oophorectomy is performed to reduce cancer risk in genetically predisposed individuals, which is unrelated to the management of an acute infectious process like TOA. *2 and 3 only* - This option incorrectly excludes **BRCA1 or BRCA2 gene carriers**, who are among the highest-risk group for ovarian and breast cancer, making prophylactic oophorectomy a crucial primary prevention strategy. - The inclusion of **tubo-ovarian abscess** as an indication for prophylactic oophorectomy is incorrect, as TOA is an inflammatory condition, not a genetic predisposition to cancer. *1 and 3 only* - This option incorrectly includes **tubo-ovarian abscess (TOA)** as a reason for prophylactic oophorectomy; TOA is an infection requiring specific medical or surgical treatment, not risk-reducing surgery for cancer. - This option incorrectly excludes a **strong family history of breast, colon, or ovarian cancer** as a separate indication for prophylactic oophorectomy, especially when genetic testing might not have identified a specific mutation but a high familial risk remains.

Q: Which of the following are indications of cold knife conization? 1. Inconsistent findings between colposcopy, cytology and directed biopsy 2. Persistent CIN-1 lesion in women willing for future fertility 3. Carcinoma in situ 4. Unsatisfactory colposcopic finding where the entire margin of lesion is not visible Select the correct answer using the code given below.

1, 3 and 4. ***1, 3 and 4*** - **Inconsistent findings** between colposcopy, cytology, and directed biopsy necessitate a conization to obtain a more definitive diagnosis and rule out higher-grade lesions or early invasion. - **Carcinoma in situ (CIS)**, also known as CIN 3, requires excisional treatment such as cold knife conization to remove the entire lesion and provide a complete pathological assessment of the margins, which is crucial for determining further management. - An **unsatisfactory colposcopic finding**, particularly when the entire transformation zone and thus the margins of the lesion are not visible, indicates that the full extent of the abnormality cannot be adequately assessed. Cold knife conization allows for removal of the entire endocervical canal for comprehensive evaluation. *2, 3 and 4* - This option is incorrect because **persistent CIN-1 lesions**, especially in women desiring future fertility, are often managed with observation and repeat cytology/colposcopy rather than excisional biopsy, due to the high rate of spontaneous regression and the potential for conization to affect cervical competence. *1, 2 and 3* - This option is incorrect as it includes **persistent CIN-1 lesions** as an indication for cold knife conization, which is generally not the primary management strategy due to the typically benign course of CIN-1. *1, 2 and 4* - This option is incorrect because **persistent CIN-1 lesions** are not a standard indication for cold knife conization, particularly when future fertility is a concern.

Q: Which one of the following drugs is most effective in the treatment of gestational trophoblastic neoplasia?

Methotrexate. ***Methotrexate*** - **Methotrexate** is the most commonly used first-line chemotherapy for **low-risk gestational trophoblastic neoplasia (GTN)**, with cure rates exceeding 90% as a single agent. - It works by inhibiting **dihydrofolate reductase**, thereby blocking DNA synthesis and cell proliferation in rapidly dividing trophoblastic cells. - Administered as a single agent in various regimens (weekly IM, 5-day course, or 8-day alternating with folinic acid). *Actinomycin D* - **Actinomycin D** is an equally effective alternative first-line agent for low-risk GTN with similar cure rates to methotrexate. - However, the question asks for the "most effective," and both drugs have comparable efficacy; methotrexate is often preferred initially due to its favorable side effect profile and ease of administration. - Actinomycin D is frequently used when methotrexate resistance develops or as part of combination therapy for high-risk disease. *Cisplatin* - **Cisplatin** is a platinum-based chemotherapy drug reserved for **high-risk or resistant GTN**, typically as part of multi-drug regimens like EMA-CO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, Vincristine). - While effective in combination therapy, it is not used as first-line monotherapy for GTN. *Gemcitabine* - **Gemcitabine** is an antimetabolite used in various cancers but is **not a standard drug** for GTN treatment. - It may be considered for **refractory or resistant cases** as part of salvage therapy, but is not part of standard first-line or second-line protocols for GTN.

Q: Which of the following are favourable factors in prognosis of ovarian malignancy? 1. Older age group 2. Well-differentiated tumour 3. Smaller tumour volume 4. Younger age group Select the correct answer using the code given below.

2, 3 and 4. ***2, 3 and 4*** - **Well-differentiated tumours** indicate less aggressive cell growth and a better prognosis due to their similarity to normal tissue and slower metastatic potential. - **Smaller tumour volume** implies less disease burden, making the cancer more amenable to treatment and reducing the likelihood of widespread metastasis. - **Younger age group** is often associated with better overall health, greater tolerance to aggressive treatments, and a more robust immune response, contributing to a better prognosis in ovarian cancer. *1, 3 and 4* - **Younger age group**, **well-differentiated tumour**, and **smaller tumour volume** are indeed favorable prognostic factors. - However, **older age group** is generally associated with a poorer prognosis in ovarian malignancy due to increased comorbidities and decreased tolerance to aggressive therapies. *1, 2 and 4* - While **well-differentiated tumours** and **younger age group** are favorable, **older age group** is typically a poor prognostic indicator. - This option incorrectly includes older age as a favorable factor and omits **smaller tumour volume**, which is a significant positive prognosticator. *1, 2 and 3* - This option incorrectly lists **older age group** as a favorable factor, which usually indicates a poorer prognosis. - It also includes **well-differentiated tumour** and **smaller tumour volume**, which are indeed favorable, but is flawed by the inclusion of older age.

Q: Which one of the following is correct regarding choriocarcinoma?

Vaginal bleeding is the commonest presenting symptom. ***Vaginal bleeding is the commonest presenting symptom*** - **Vaginal bleeding** (often irregular or persistent) is the most frequent symptom of choriocarcinoma, especially when it arises after a hydatidiform mole or pregnancy. - This bleeding can be accompanied by symptoms related to distant metastases, highlighting the aggressive nature of the disease. *About 20-30% of patients with molar pregnancies develop choriocarcinoma* - The risk of developing choriocarcinoma after a **hydatidiform mole** is much lower than 20-30%; it's estimated to be around 2-3% after a complete mole and less than 0.5% after a partial mole. - The majority of molar pregnancies resolve spontaneously without progressing to choriocarcinoma. *Highly resistant tumour to chemotherapy* - Choriocarcinoma is notably one of the most **chemosensitive solid tumors** and generally responds very well to chemotherapy, even in advanced stages. - This high sensitivity to chemotherapy is a key characteristic that distinguishes it from many other cancers. *Primary site of involvement is fallopian tube* - The primary site of choriocarcinoma is usually the **uterus**, developing from gestational trophoblastic tissue. - While it can metastasize widely, the fallopian tube is not its primary site of involvement.

Q: Which surgery is most likely to disturb the paracervical nerve plexus resulting in atonicity of the bladder?

Radical hysterectomy. ***Radical hysterectomy*** - This procedure involves extensive dissection around the cervix and upper vagina, increasing the risk of **damage to the paracervical nerve plexus** (Frankenhäuser's plexus). - Damage to this autonomic plexus, which supplies the bladder, can lead to **atonicity** and urinary retention postoperatively due to disrupted innervation. *Simple hysterectomy* - A simple hysterectomy removes the uterus but preserves the parametrial tissues and hence the **paracervical nerve plexus**, minimizing the risk of bladder denervation. - While temporary bladder dysfunction can occur due to local trauma, long-term atonicity is less likely compared to radical procedures. *Myomectomy* - Myomectomy involves the surgical removal of uterine fibroids (myomas) while **preserving the uterus**. - This procedure generally involves minimal dissection in the vicinity of the paracervical nerve plexus, making bladder atonicity an uncommon complication. *Vaginal hysterectomy* - A vaginal hysterectomy removes the uterus through the vagina, with dissection primarily involving the uterosacral and cardinal ligaments. - Although there is some manipulation near the plexus, the **extent of dissection is typically less** than a radical hysterectomy, leading to a lower risk of complete denervation and atonicity.

Question 1

All are true about the procedure being performed except: (Recent Neet Pattern 2016-17)

Accepted Answer

Procedure to be done after bimanual examination

Answer

Cusco speculum introduced without lubrication

Answer

Ayre spatula

Answer

Scraping material fixed over slide using 95% ether and alcohol

Question 2

A woman in the late menstrual phase presents with an ovarian mass. Her Pap smear shows predominantly superficial cells stained orange (see image). What is the most likely ovarian tumor?

Accepted Answer

Granulosa cell tumor

Answer

Serous cystadenoma

Answer

Mucinous cystadenoma

Answer

Fibroma

Question 3

Which one of the following is an indication for knife conisation?

1. Treatment of Nabothian follicle
2. Diagnosis and directed biopsy of cervix when punch biopsy is inadequate
3. Unsatisfactory colposcopy (transformation zone not fully visible)
4. Negative endocervical curettage

Select the correct answer using the code given below:

Accepted Answer

2 and 3 only

Answer

1 and 4

Answer

1, 2 and 3

Answer

1 and 3 only

Question 4

Bilateral total salpingectomy is a recommended surgical procedure to reduce the risk of :

Accepted Answer

Epithelial ovarian cancer

Answer

Uterine cancer

Answer

Fallopian tube cancer

Answer

Peritoneal cancer

Question 5

Prophylactic oophorectomy is recommended in high risk women with which of the following ?

1. Carrying BRCA1 or BRCA2 genes 
2. Family history of breast, colon, ovarian cancer 
3. Patients having tubo-ovarian abscess

Select the correct answer using the code given below :

Accepted Answer

1 and 2 only

Answer

1, 2 and 3

Answer

2 and 3 only

Answer

1 and 3 only

Question 6

Which of the following are indications of cold knife conization?

1. Inconsistent findings between colposcopy, cytology and directed biopsy
2. Persistent CIN-1 lesion in women willing for future fertility
3. Carcinoma in situ
4. Unsatisfactory colposcopic finding where the entire margin of lesion is not visible

Select the correct answer using the code given below.

Accepted Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Answer

1, 2 and 4

Question 7

Which one of the following drugs is most effective in the treatment of gestational trophoblastic neoplasia?

Accepted Answer

Methotrexate

Answer

Actinomycin D

Answer

Cisplatin

Answer

Gemcitabine

Question 8

Which of the following are favourable factors in prognosis of ovarian malignancy?

1. Older age group
2. Well-differentiated tumour
3. Smaller tumour volume
4. Younger age group
Select the correct answer using the code given below.

Accepted Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

1, 2 and 3

Question 9

Which one of the following is correct regarding choriocarcinoma?

Accepted Answer

Vaginal bleeding is the commonest presenting symptom

Answer

About 20-30% of patients with molar pregnancies develop choriocarcinoma

Answer

Highly resistant tumour to chemotherapy

Answer

Primary site of involvement is fallopian tube

Question 10

Which surgery is most likely to disturb the paracervical nerve plexus resulting in atonicity of the bladder?

Accepted Answer

Radical hysterectomy

Answer

Simple hysterectomy

Answer

Myomectomy

Answer

Vaginal hysterectomy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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