Gynecologic Oncology Practice Questions

Q: Which cancer is most commonly associated with increased estrogen levels?

Breast. ***Breast*** - Many breast cancers, particularly **estrogen receptor-positive (ER+)** tumors, are fueled by **estrogen**. - Prolonged exposure to high estrogen levels, such as early menarche, late menopause, or obesity, is a known risk factor for breast cancer. *Ovarian* - While estrogen does play a role in ovarian function, the link between **increased estrogen levels** and ovarian cancer risk, while present, is **less direct and less significant** than for breast cancer. - Ovarian cancer is associated with other risk factors like **nulliparity**, **endometriosis**, and certain genetic mutations. *GTN* - **Gestational trophoblastic neoplasia (GTN)** is an abnormal proliferation of trophoblastic tissue, commonly occurring after pregnancy. - Its development is primarily linked to **abnormal fertilization**, not directly to independently increased estrogen levels. *Cervix* - **Cervical cancer** is overwhelmingly caused by **persistent human papillomavirus (HPV) infection**. - While hormonal factors can influence HPV progression, increased estrogen levels are **not considered a primary cause** or strongly associated risk factor for cervical cancer.

Q: A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?

Endometrial biopsy. ***Endometrial biopsy*** - Post-menopausal **vaginal bleeding** or spotting, especially with an **endometrial thickness of ≥ 4-5 mm** on ultrasound, is highly suspicious for endometrial hyperplasia or carcinoma and warrants an endometrial biopsy for definitive diagnosis. - An endometrial biopsy is crucial to rule out endometrial malignancy, as this is the primary concern in such presentations. *CA 125 levels* - **CA 125** is primarily used as a tumor marker for **ovarian cancer** surveillance and response to treatment, not for initial diagnosis of post-menopausal bleeding or endometrial pathology. - Elevated CA 125 can be found in various benign conditions as well and is not specific enough to guide the initial management of post-menopausal bleeding without tissue sampling. *Paps smear and follow up* - A **Pap smear** screens for **cervical abnormalities** and **cervical cancer**, not endometrial pathology. - While it's part of routine gynecological care, it will not address the investigation of post-menopausal bleeding originating from the uterus. *Myomectomy* - **Myomectomy** is a surgical procedure to remove **uterine fibroids**, typically when they are causing symptoms like heavy menstrual bleeding or pressure. - In a post-menopausal woman with spotting, the intramural fibroid may or may not be directly responsible, and the priority is to exclude **endometrial cancer** before considering fibroid-specific interventions.

Q: Early age at first sexual intercourse is a risk factor for

Carcinoma cervix. ***Carcinoma cervix*** - **Early age of sexual debut** is a significant risk factor for cervical cancer due to increased exposure time to **human papillomavirus (HPV)**, the primary cause. - The immature transformation zone of the cervix in younger individuals is more vulnerable to HPV infection and subsequent dysplastic changes. *Carcinoma vagina* - While HPV can cause vaginal cancer, the association with **early sexual debut** is less direct and less prominent compared to cervical cancer. - Risk factors often include a history of **cervical cancer** or **cervical intraepithelial neoplasia (CIN)**. *Carcinoma ovary* - Ovarian cancer is primarily linked to **genetic factors** (e.g., BRCA mutations), **nulliparity**, and **endometriosis**. - There is no established link between **age of sexual debut** and the risk of ovarian cancer. *Carcinoma vulva* - Vulvar cancer is also associated with **HPV infection**, but its primary risk factors often include **lichen sclerosus**, **chronic irritation**, and **immunodeficiency**. - The link to **early sexual debut** is less strong compared to cervical cancer, which is almost exclusively HPV-driven and highly sensitive to infection duration.

Q: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :

Malignancy of the endometrium. ***Malignancy of the endometrium*** - **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases. - **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure. *Malignancy of the vulva* - Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding. - While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding. *Malignancy of the cervix* - Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding. - Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population. *Malignancy of the ovary* - Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain. - **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.

Q: In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Type - II. ***Type - II*** - In a **Type II hysterectomy** (modified radical hysterectomy), the **uterine vessels** are ligated at the level of the **ureter** to ensure wider margins when excising the paracervical tissue. - This approach aims to resect the **medial portion of the cardinal and uterosacral ligaments**, along with the parametrial tissue, necessitating a more lateral ligation point. *Type - I* - **Type I hysterectomy** (simple or extrafascial hysterectomy) involves ligating the **uterine vessels** closer to the uterus, **medial to the ureter**, at the level of the internal os. - This type of hysterectomy is performed for benign conditions and does not require extensive paracervical tissue removal. *Type - IV* - **Type IV hysterectomy** (radical hysterectomy) involves an even wider dissection than Type III, extending to the **hypogastric vessels**, which is well beyond the ureter. - This procedure removes more of the **lateral parametrium and paravaginal tissue**, along with the superior vesical artery. *Type - III* - **Type III hysterectomy** (radical hysterectomy) involves ligating the **uterine vessels at their origin** from the internal iliac artery, which is significantly lateral to the ureter. - This extensive dissection is performed for invasive cervical cancer, requiring removal of the **entire cardinal and uterosacral ligaments** along with wide parametrial and paravaginal tissue.

Q: Which among the following is not a premalignant lesion of vulva?

Bacterial Vaginosis. ***Bacterial Vaginosis*** - This is a common **vaginal infection** caused by an imbalance of normal vaginal bacteria, characterized by specific symptoms like increased discharge and odor. - Bacterial vaginosis is not considered a premalignant lesion and does not increase the risk of developing vulvar cancer. *Paget's disease* - This is a rare form of intraepithelial adenocarcinoma that can occur on the vulva, presenting as a red, itchy, scaly rash. - While it is a **carcinoma in situ**, it has the potential to become invasive, thus considered a premalignant or pre-invasive condition. *Bowen's disease* - This is a form of **squamous cell carcinoma in situ (SCCIS)**, typically appearing as a slow-growing, red, scaly patch on the skin. - It is considered a premalignant lesion because it can progress to invasive squamous cell carcinoma if left untreated. *Lichen Sclerosus* - This is a chronic inflammatory skin condition primarily affecting the anogenital region, leading to thinning, whitening, and scarring of the skin. - Although it is a benign condition, individuals with vulvar lichen sclerosus have an increased risk (3-5%) of developing **vulvar squamous cell carcinoma**, making it a premalignant condition.

Q: Possible conversion to choriocarcinoma after hydatidiform mole is denoted by all of the following, except:

Sub urethral nodule. ***Sub urethral nodule*** - A **suburethral nodule** is a sign of **metastatic choriocarcinoma**, indicating the disease has already converted and spread. - The question asks for signs indicating a *possible conversion* to choriocarcinoma, not an established metastatic disease. *More Theca lutein cysts* - **Theca lutein cysts** result from overstimulation of the ovaries by high levels of **hCG**, which is elevated in both hydatidiform mole and choriocarcinoma. - An increase in these cysts suggests persistent trophoblastic activity, raising suspicion for transition to choriocarcinoma. *Increase uterus size* - An **enlarging uterus** post-evacuation of a hydatidiform mole can indicate persistent trophoblastic tissue or the development of choriocarcinoma. - This suggests continued growth and abnormal proliferation of trophoblastic cells. *Rising hCG* - **Persistently rising or plateauing hCG levels** after evacuation of a hydatidiform mole are the most critical indicator of persistent gestational trophoblastic disease (GTD), including potential conversion to choriocarcinoma. - Serial hCG monitoring is essential for surveillance following a molar pregnancy to detect malignant transformation.

Q: In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Serum hCG. ***Serum hCG*** - **Human chorionic gonadotropin (hCG)** is produced by the trophoblastic tissue, which is overproliferated in molar pregnancies. - Monitoring **serial hCG levels** post-evacuation is the **gold standard** for detecting persistent trophoblastic disease or malignant transformation. - A rise or plateau in hCG levels indicates inadequate treatment or recurrence, requiring chemotherapy. - **Clinical protocol**: Weekly hCG monitoring until three consecutive negative results, then monthly for 6 months (FIGO guidelines). *Serum CA-125* - **CA-125** is primarily a marker for ovarian cancer and certain benign gynecologic conditions like endometriosis. - It is not a reliable marker for monitoring the response to treatment in **molar pregnancies**. *Serum estriol* - **Estriol** is a hormone produced by the placenta and fetal adrenal gland, primarily used to monitor fetal well-being during pregnancy. - It has no role in the diagnosis or monitoring of **molar pregnancies**. *Serum AFP* - **Alpha-fetoprotein (AFP)** is a tumor marker for certain germ cell tumors, liver cancer, and is also used in prenatal screening for neural tube defects. - It is not associated with the pathogenesis or monitoring of **molar pregnancies**.

Q: Which is the least invasive and effective option for high-grade squamous intraepithelial lesion (HSIL) on Pap smear?

LEEP. ***LEEP*** - **LEEP (Loop Electrosurgical Excision Procedure)** is a highly effective treatment for HSIL, offering both diagnostic and therapeutic benefits. - It involves using a thin, electrified wire loop to remove the abnormal tissue, and it is considered less invasive than a cold knife cone biopsy while maintaining high efficacy. *Laser ablation* - **Laser ablation** destroys abnormal tissue but does not provide a specimen for histological examination, which is crucial for confirming the diagnosis and ensuring clear margins in HSIL. - While minimally invasive, its effectiveness for HSIL treatment is generally considered lower than LEEP due to the lack of a histological specimen and potential for incomplete eradication. *Cone biopsy* - **Cold knife cone biopsy** is highly effective but more invasive than LEEP, carrying a higher risk of complications such as bleeding, infection, and cervical incompetence. - It involves surgical removal of a larger cone-shaped piece of tissue, often requiring general anesthesia. *Cryotherapy* - **Cryotherapy** involves freezing and destroying abnormal cells; however, it is primarily recommended for **low-grade squamous intraepithelial lesions (LSIL)**. - It is generally considered less effective for HSIL compared to excisional procedures like LEEP, as it also does not provide a specimen for histological evaluation.

Question 1

Which cancer is most commonly associated with increased estrogen levels?

Accepted Answer

Breast

Answer

Ovarian

Answer

GTN

Answer

Cervix

Question 2

A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?

Accepted Answer

Endometrial biopsy

Answer

CA 125 levels

Answer

Paps smear and follow up

Answer

Myomectomy

Question 3

Early age at first sexual intercourse is a risk factor for

Accepted Answer

Carcinoma cervix

Answer

Carcinoma vagina

Answer

Carcinoma ovary

Answer

Carcinoma vulva

Question 4

A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :

Accepted Answer

Malignancy of the endometrium

Answer

Malignancy of the vulva

Answer

Malignancy of the cervix

Answer

Malignancy of the ovary

Question 5

In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Accepted Answer

Type - II

Answer

Type - I

Answer

Type - IV

Answer

Type - III

Question 6

Which among the following is not a premalignant lesion of vulva?

Accepted Answer

Bacterial Vaginosis

Answer

Paget's disease

Answer

Bowen's disease

Answer

Lichen Sclerosus

Question 7

Possible conversion to choriocarcinoma after hydatidiform mole is denoted by all of the following, except:

Accepted Answer

Sub urethral nodule

Answer

More Theca lutein cysts

Answer

Increase uterus size

Answer

Rising hCG

Question 8

In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Accepted Answer

Serum hCG

Answer

Serum CA-125

Answer

Serum estriol

Answer

Serum AFP

Question 9

Which drug is most appropriate for reducing risk of ovarian cancer in a BRCA1 positive woman not planning for children?

Accepted Answer

Oral contraceptive pills

Answer

Gonadotropin-releasing hormone

Answer

Tamoxifen

Answer

Progesterone IUD

Question 10

Which is the least invasive and effective option for high-grade squamous intraepithelial lesion (HSIL) on Pap smear?

Accepted Answer

LEEP

Answer

Laser ablation

Answer

Cone biopsy

Answer

Cryotherapy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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