Gynecologic Oncology Practice Questions

Q: Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)? 1. Low serum β-hCG 2. Composed mainly of cytotrophoblast 3. Highly responsive to chemo radiation 4. Confined to endometrium without myometrial invasion

1. Low serum β-hCG. ***Low serum β-hCG*** - **PSTT** originates from intermediate trophoblasts, which produce **human placental lactogen (hPL)** rather than **β-hCG**, leading to relatively low serum β-hCG levels. - This low **β-hCG** is a key differentiator from other gestational trophoblastic neoplasms like **choriocarcinoma**. *Confined to endometrium without myometrial invasion* - **PSTT** is known for its **local invasiveness** and frequently invades into the **myometrium**, and may even penetrate the serosa. - Its infiltrative growth pattern can lead to **uterine rupture** and significant **hemorrhage**. *Composed mainly of cytotrophoblast* - **PSTT** is primarily composed of **intermediate trophoblasts**, not cytotrophoblasts. - These intermediate trophoblasts are characterized by their **mononuclear appearance** and distinctive immunohistochemical staining pattern, including positivity for **hPL** and **cytokeratin**. *Highly responsive to chemo radiation* - PSTT is **not highly responsive** to chemotherapy; it often exhibits **chemoresistance**, especially in advanced stages. - Because of its chemoresistance, **surgery** (hysterectomy) is the primary treatment for localized disease, and systemic therapy options are more challenging.

Q: Serum level of CA 125 is raised in which of the following conditions?

All of the options. ***All of the options*** - **CA 125** levels can be elevated in various gynecological conditions, both malignant and benign. - While most recognized for its role in **epithelial ovarian cancer**, it is not exclusively specific to this condition. *Epithelial ovarian cancer* - **CA 125** is a commonly used tumor marker for **epithelial ovarian cancer**, playing a role in its diagnosis, monitoring, and recurrence detection. - While elevated in a high percentage of advanced ovarian cancers, it can also be normal in early-stage disease. *Pelvic inflammatory disease* - **Inflammation** of the pelvic organs, such as in **Pelvic Inflammatory Disease (PID)**, can cause an increase in **CA 125** levels. - The elevation is typically due to the irritation of the peritoneal surface or the presence of inflammatory exudates. *Endometriosis* - **Endometriosis**, a condition where endometrial-like tissue grows outside the uterus, is a well-known cause of elevated **CA 125**. - The level of **CA 125** often correlates with the severity and extent of the endometrial implants.

Q: Which of the following is the most widely used screening test for cervical cancer?

Pap test. ***Pap test*** - The **Pap test** (Papanicolaou test) is the most widely used and effective screening test for cervical cancer globally. - It involves collecting cells from the **cervix** to detect **precancerous** and cancerous changes early. *Endocervical curettage* - **Endocervical curettage** is a diagnostic procedure used to obtain tissue samples from the endocervical canal, typically performed after an abnormal Pap test. - It is a **biopsy procedure**, not a primary screening test for general populations. *Visual inspections with acetic acid* - **Visual inspection with acetic acid (VIA)** is a lower-cost screening method used in resource-limited settings. - It involves applying acetic acid to the cervix and observing for **acetowhite changes**, but its sensitivity and specificity are not as high as the Pap test. *HPV DNA test* - The **HPV DNA test** detects high-risk types of human papillomavirus, which are responsible for most cervical cancers. - While it's increasingly used, especially in conjunction with the Pap test (co-testing) or as primary screening in some settings, the **Pap test** remains the most **widely established** and utilized primary screening method.

Q: The most appropriate management of a 32 weeks pregnant lady with carcinoma cervix stage IIb is.

Cesarean delivery followed by chemoradiation. ***Cesarean delivery followed by chemoradiation*** - For **stage IIb carcinoma cervix** at 32 weeks gestation, **cesarean delivery** is the safest option to deliver the baby while avoiding trauma to the tumor and potential dissemination. - Subsequently, **chemoradiation** is the standard treatment for stage IIb cervical cancer, ensuring optimal maternal oncologic outcome. *Observation and follow-up* - This approach is **inappropriate** for stage IIb cervical cancer in pregnancy, as it delays definitive treatment and allows for disease progression. - Such an aggressive cancer requires **prompt intervention** for the best maternal prognosis. *Chemo-radiation followed by labour induction and vaginal delivery* - **Chemoradiation during pregnancy** is harmful to the fetus, especially beyond the first trimester. - A **vaginal delivery** in the presence of cervical cancer carries a high risk of hemorrhage and tumor dissemination, making it contraindicated. *Labour induction, vaginal delivery followed by radio-therapy* - **Labour induction and vaginal delivery** are contraindicated due to risks of hemorrhage, tumor spread, and potential obstruction from the tumor. - While radiotherapy would follow, the mode of delivery poses significant risks to the mother.

Q: A 25 year old patient who has had an abortion four months ago has come with the history of profuse vaginal bleeding. On examination uterus is bulky, both the ovaries are enlarged, pregnancy test is positive. What is the probable clinical diagnosis ?

Choriocarcinoma. ***Choriocarcinoma*** - The combination of a history of **recent abortion** (four months prior), **profuse vaginal bleeding**, a **bulky uterus**, **enlarged ovaries**, and a positive **pregnancy test** strongly suggests choriocarcinoma. The enlarged ovaries are often due to **theca-lutein cysts** formed in response to very high hCG levels produced by the tumor. - Choriocarcinoma is a highly aggressive form of **gestational trophoblastic neoplasia** that typically arises after a molar pregnancy, abortion, or term pregnancy, and it secretes high levels of **hCG**, which accounts for the positive pregnancy test. *Ectopic pregnancy* - While an ectopic pregnancy can present with vaginal bleeding and a positive pregnancy test, it is unlikely to cause a **bulky uterus** or **bilateral enlarged ovaries**. - Symptoms usually appear earlier in pregnancy, and the hCG levels would typically not be as high as to cause theca-lutein cysts or persist four months post-abortion with profuse bleeding without rupture. *Incomplete abortion* - An incomplete abortion could cause vaginal bleeding and a bulky uterus, but it would typically occur much sooner after the abortion event (not four months later) and is generally associated with a declining or low plateau of hCG, not persistently high levels causing enlarged ovaries. - Retained products of conception would be the primary cause of bleeding, not a rapidly growing tumor with systemic effects. *Malignant ovarian tumor* - While a malignant ovarian tumor can cause an **enlarged ovary** (or ovaries) and vaginal bleeding, it would not result in a **positive pregnancy test** unless it was a very rare hCG-producing germ cell tumor, and even then, its presentation with a bulky uterus post-abortion is not typical. - The clinical picture here, particularly the positive pregnancy test and bulky uterus, points more specifically towards a **trophoblastic disease**.

Q: A 60-year-old woman is diagnosed with genital malignancy. On physical examination she is found to have the enlargement of superficial inguinal lymph nodes. The most likely organ involved is

Vulva. ***Vulva (Correct Answer)*** - The **vulva** drains primarily to the **superficial inguinal lymph nodes**, making its malignancy the most likely cause of their enlargement. - Unlike deeper pelvic organs, vulvar cancer metastases travel directly to these easily palpable nodes. - This is a key anatomical principle: **external genitalia → superficial inguinal nodes**. *Adnexa (Incorrect)* - Malignancies of the **adnexa** (ovaries, fallopian tubes) typically metastasize via the **para-aortic or pelvic lymph nodes**, not the superficial inguinal nodes. - These follow the ovarian vessels along the infundibulopelvic ligament. - Distant inguinal node involvement would indicate advanced disease, but initial spread is not to these nodes. *Cervix (Incorrect)* - Cervical cancer primarily metastasizes to the **pelvic lymph nodes** (e.g., obturator, internal iliac, external iliac), with superficial inguinal nodes rarely involved unless there is extensive local spread. - The lymphatic drainage of the cervix is distinct from that of the external genitalia. *Uterus (Incorrect)* - Uterine cancer (endometrial or uterine body) typically spreads to the **pelvic** and **para-aortic lymph nodes**, following the ovarian and uterine vessels. - Like cervical cancer, superficial inguinal lymph node involvement is uncommon and usually a sign of very advanced or unusual spread.

Q: A 35-year-old woman presents with complaints of profuse vaginal bleeding. She also has a history of abortion 4 months ago. On examination, the uterus is soft and bulky, both ovaries are enlarged and cystic, and the pregnancy test is positive. The probable diagnosis is

Persistent trophoblastic disease. ***Persistent trophoblastic disease*** - The history of **abortion 4 months ago** followed by **profuse vaginal bleeding**, a **positive pregnancy test**, and a **bulky uterus** strongly suggests persistent trophoblastic disease (PTD). - The presence of **bilaterally enlarged cystic ovaries** (theca-lutein cysts) is also characteristic, resulting from ovarian stimulation by persistently high levels of hCG. *Malignant ovarian tumour* - While it can cause vaginal bleeding, a **positive pregnancy test** and the finding of a **bulky uterus** are generally not primary features of most ovarian malignancies. - Ovarian tumours are less likely to present with the rapid development of bilateral, **cystic enlargement** associated with a recent pregnancy and persistent hCG. *Incomplete abortion* - While it causes **vaginal bleeding** and a **bulky uterus**, it typically occurs much more acutely and closer to the time of the abortion itself, not four months later. - An incomplete abortion would usually result in a **negative or rapidly declining pregnancy test** due to the absence of viable trophoblastic tissue. *Dysfunctional uterine bleeding* - This diagnosis usually implies bleeding without a clear organic cause and would not be associated with a **positive pregnancy test** or **enlarged, cystic ovaries**. - DUB is a diagnosis of exclusion after other causes, including **gestational** trophoblastic disease, have been ruled out.

Q: A 35-year-old woman who has completed her family shows a positive Pap smear (Cervical intraepithelial neoplasia III (CIN III)). What is to be done next?

Simple hysterectomy. ***Simple hysterectomy*** - **Simple (total) hysterectomy** is the **definitive treatment of choice** for **CIN III** in a woman who has **completed her family**. - It removes the **entire uterus and cervix**, eliminating the risk of **recurrence or progression** to invasive cancer. - This provides a **permanent cure** without the need for long-term surveillance required after excisional procedures. - Preferred over conisation in this scenario as **fertility preservation is not needed**. *Conisation* - **Conisation** (cone biopsy) is an excisional procedure that removes a cone-shaped piece of cervical tissue and is the **treatment of choice for CIN III when fertility preservation is desired**. - While it can be both diagnostic and therapeutic, it has a **10-15% recurrence rate** and requires **lifelong cervical surveillance**. - In a patient who has **completed her family**, a more definitive treatment (hysterectomy) is preferred over conisation. *Wertheim's hysterectomy* - **Wertheim's hysterectomy** (radical hysterectomy with pelvic lymphadenectomy) is indicated for **invasive cervical cancer** (Stage IA2-IIA). - **CIN III is a pre-invasive lesion**, not invasive cancer, making this procedure unnecessarily radical and associated with significant morbidity. - This would only be considered if invasion is confirmed on histopathology. *Cryotherapy* - **Cryotherapy** is an **ablative treatment** that destroys abnormal cervical tissue by freezing. - It is suitable for **CIN I or CIN II** with small lesions but is **inadequate for CIN III** due to: - Higher risk of **residual disease** (cannot assess depth of involvement) - **No histological specimen** obtained for margin assessment - Higher recurrence rates compared to excisional procedures

Q: The risk of progression to endometrial cancer from simple hyperplasia without atypia is

1%. ***1%*** - The risk of **simple endometrial hyperplasia without atypia** progressing to endometrial cancer is very low, typically cited as less than 1%. - This low risk is why conservative management and surveillance are often sufficient for this type of hyperplasia. *8-10%* - This percentage is more indicative of the risk of progression for **complex endometrial hyperplasia without atypia**, which has a higher propensity for malignant transformation. - Simple hyperplasia without atypia carries a much lower risk due to its less abnormal glandular architecture and lack of cytologic atypia. *25-30%* - This value represents the risk of progression for **atypical endometrial hyperplasia (endometrial intraepithelial neoplasia)**, which is considered a precursor lesion to endometrial cancer. - The presence of **cytological atypia** significantly increases the risk of malignant transformation. *3-5%* - This risk range is typically associated with **complex endometrial hyperplasia without atypia**, which is higher than simple hyperplasia but considerably lower than atypical hyperplasia. - While it has abnormal architectural features, the absence of **cellular atypia** keeps the risk below that of atypical lesions.

Question 1

Which of the following is INCORRECT regarding endometrial cancer?

1. Persistent progesterone stimulation is an important etiology.
2. It is more common in white population.
3. HNPCC (Hereditary Nonpolyposis Colorectal Cancer) syndrome is a high risk factor.
4. Adenocarcinoma is the commonest histopathology.

Accepted Answer

1. Persistent progesterone stimulation is an important etiology.

Answer

2. It is more common in white population.

Answer

3. HNPCC (Hereditary Nonpolyposis Colorectal Cancer) syndrome is a high risk factor.

Answer

4. Adenocarcinoma is the commonest histopathology.

Question 2

Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)?

1. Low serum β-hCG
2. Composed mainly of cytotrophoblast
3. Highly responsive to chemo radiation
4. Confined to endometrium without myometrial invasion

Accepted Answer

1. Low serum β-hCG

Answer

4. Confined to endometrium without myometrial invasion

Answer

2. Composed mainly of cytotrophoblast

Answer

3. Highly responsive to chemo radiation

Question 3

Serum level of CA 125 is raised in which of the following conditions?

Accepted Answer

All of the options

Answer

Epithelial ovarian cancer

Answer

Pelvic inflammatory disease

Answer

Endometriosis

Question 4

Which of the following is the most widely used screening test for cervical cancer?

Accepted Answer

Pap test

Answer

Visual inspections with acetic acid

Answer

HPV DNA test

Answer

Endocervical curettage

Question 5

The most appropriate management of a 32 weeks pregnant lady with carcinoma cervix stage IIb is.

Accepted Answer

Cesarean delivery followed by chemoradiation

Answer

Observation and follow-up

Answer

Chemo-radiation followed by labour induction and vaginal delivery

Answer

Labour induction, vaginal delivery followed by radio-therapy

Question 6

A 25 year old patient who has had an abortion four months ago has come with the history of profuse vaginal bleeding. On examination uterus is bulky, both the ovaries are enlarged, pregnancy test is positive. What is the probable clinical diagnosis ?

Accepted Answer

Choriocarcinoma

Answer

Ectopic pregnancy

Answer

Incomplete abortion

Answer

Malignant ovarian tumor

Question 7

A 60-year-old woman is diagnosed with genital malignancy. On physical examination she is found to have the enlargement of superficial inguinal lymph nodes. The most likely organ involved is

Accepted Answer

Vulva

Answer

Adnexa

Answer

Cervix

Answer

Uterus

Question 8

A 35-year-old woman presents with complaints of profuse vaginal bleeding. She also has a history of abortion 4 months ago. On examination, the uterus is soft and bulky, both ovaries are enlarged and cystic, and the pregnancy test is positive. The probable diagnosis is

Accepted Answer

Persistent trophoblastic disease

Answer

Malignant ovarian tumour

Answer

Incomplete abortion

Answer

Dysfunctional uterine bleeding

Question 9

A 35-year-old woman who has completed her family shows a positive Pap smear (Cervical intraepithelial neoplasia III (CIN III)). What is to be done next?

Accepted Answer

Simple hysterectomy

Answer

Wertheim's hysterectomy

Answer

Cryotherapy

Answer

Conisation

Question 10

The risk of progression to endometrial cancer from simple hyperplasia without atypia is

Accepted Answer

1%

Answer

8-10%

Answer

25-30%

Answer

3-5%

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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