Gynecologic Oncology Practice Questions

Q: A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

Paracervical or parametrial nodes. ***Paracervical or parametrial nodes*** - Carcinoma of the **cervix** typically spreads initially to the **paracervical** and **parametrial nodes**, which are the first lymphatic drainage sites. - These nodes are located **adjacent to the cervix** and within the **parametrium**, representing the primary regional lymph node stations. - Early involvement of these nodes is crucial for **staging** and determining treatment approach. *Para-aortic nodes* - The para-aortic nodes are involved in **advanced disease** representing tertiary lymphatic spread. - Metastasis to these nodes indicates **spread beyond regional nodes** and significantly impacts prognosis and treatment planning. - They become involved **after** the pelvic lymph nodes (paracervical, parametrial, and iliac nodes) have been compromised. *External iliac nodes* - The external iliac nodes are part of the **primary pelvic lymphatic drainage** but are typically involved **after** the immediate paracervical and parametrial nodes. - They represent the **next step in regional spread** once the closest nodes are affected. - These are still considered regional nodes important for staging purposes. *Common iliac nodes* - The common iliac nodes are **secondary lymphatic drainage sites** for cervical cancer, receiving lymph from the external and internal iliac nodes. - Involvement of these nodes indicates **more advanced regional disease** and suggests spread has progressed through the primary pelvic nodes. - They are located at the **bifurcation of the aorta** and represent a higher level of nodal involvement.

Q: Which ovarian tumor is likely to involve the opposite ovary by metastasis?

Dysgerminoma. **Dysgerminoma** - **Dysgerminomas** are ovarian germ cell tumors that have a strong propensity for **lymphatic spread** and can frequently involve the contralateral ovary via micrometastases. - They are typically **highly radiosensitive** and respond well to chemotherapy, even in advanced stages with bilateral involvement. *Granulosa cell tumor* - **Granulosa cell tumors** are sex cord-stromal tumors known for producing **estrogen**, leading to endometrial hyperplasia or postmenopausal bleeding. - While they can recur, bilateral involvement is uncommon, and metastasis usually occurs later in the disease course, primarily to nearby structures. *Endodermal tumor* - **Endodermal sinus tumors** (yolk sac tumors) are aggressive germ cell tumors characterized by elevated **alpha-fetoprotein (AFP)**. - These tumors typically spread rapidly via peritoneal dissemination and lymphatics but are less likely to involve the contralateral ovary directly via metastasis compared to dysgerminomas. *Gynandroblastoma* - **Gynandroblastomas** are very rare sex cord-stromal tumors that contain features of both granulosa cell and Sertoli-Leydig cell tumors. - They are generally considered **low-grade malignancies** and do not typically metastasize to the opposite ovary, with local spread being more common if at all.

Q: A lady undergoes radical hysterectomy for suspected stage Ib cancer cervix. Histopathology reveals cancer extension to the lower part of the uterine body with positive surgical margins. What is the next step of management?

Chemoradiation. ***Correct Option: Chemoradiation*** - **Positive surgical margins** after radical hysterectomy represent a **high-risk feature** requiring adjuvant concurrent chemoradiation. - According to **GOG 109 trial** and **NCCN/ESGO guidelines**, high-risk features (positive surgical margins, parametrial involvement, or positive pelvic lymph nodes) mandate **concurrent chemoradiation** (external beam radiotherapy + cisplatin-based chemotherapy). - **Cisplatin-based chemoradiation** improves local control and overall survival compared to radiotherapy alone in high-risk post-operative cervical cancer. - The combination provides both local control (radiation) and systemic treatment (chemotherapy) to address micrometastatic disease. *Incorrect Option: Radiotherapy* - Radiotherapy alone is used for **intermediate-risk features** (large tumor size >4 cm, deep stromal invasion, lymphovascular space invasion) without positive margins or nodal involvement. - In this case with **positive surgical margins**, radiotherapy alone is insufficient and would miss the survival benefit provided by concurrent chemotherapy. - The presence of positive margins elevates this to high-risk category requiring combined modality treatment. *Incorrect Option: Chemotherapy* - Chemotherapy alone (without radiation) is not standard adjuvant treatment after radical hysterectomy. - Systemic chemotherapy as a single modality is reserved for recurrent or metastatic disease. - The standard in high-risk post-operative cases is **concurrent** chemoradiation, not sequential therapy. *Incorrect Option: Follow-up* - Follow-up alone is contraindicated with **positive surgical margins**, which indicate residual microscopic disease. - Without adjuvant treatment, the risk of local recurrence and distant metastasis is unacceptably high. - Active intervention with chemoradiation is essential to improve disease-free and overall survival.

Q: A 20-year-old female presents with a 6x6x6 cm ovarian mass, ultrasonography of which reveals solid structures. Her serum biomarkers, including AFP, β-hCG, and CA 125, are normal, but serum alkaline phosphatase is elevated. The most likely diagnosis is:

Dysgerminoma. ***Dysgerminoma*** - Dysgerminomas are **germ cell tumors** that characteristically present as **solid ovarian masses** in young women, which matches this presentation. - They typically have **normal AFP and β-hCG levels**, as seen in this patient. - The classic tumor marker for dysgerminoma is **elevated LDH (lactate dehydrogenase)**, not alkaline phosphatase. - Despite the atypical elevated alkaline phosphatase, the solid mass with normal germ cell markers makes dysgerminoma the most likely diagnosis among the given options. *Endodermal sinus tumor* - This germ cell tumor is characterized by significantly **elevated serum alpha-fetoprotein (AFP)**, which is normal in this patient. - While it can present as a solid ovarian mass, the **normal AFP level essentially rules out** this diagnosis. *Malignant teratoma* - Malignant (immature) teratomas typically show **elevated AFP** and sometimes **β-hCG**, neither of which are elevated here. - The normal tumor markers make this diagnosis unlikely. *Mucinous cystadenocarcinoma* - Mucinous tumors are **epithelial ovarian cancers** that typically present as **cystic or multiloculated masses**, not predominantly solid structures. - They are associated with elevated **CA 125** (which is normal here) and sometimes CA 19-9. - The solid appearance on ultrasound argues strongly against this diagnosis.

Q: All of the following ovarian tumors usually occur bilaterally, except:

Dermoid cyst. ***Dermoid cyst*** - Dermoid cysts (mature cystic teratomas) are typically **unilateral** in about 85-90% of cases, with only 10-15% being bilateral. - They arise from **totipotential germ cells** and are benign tumors containing mature tissues like hair, teeth, or bone. - This is the **most common ovarian tumor** with predominantly unilateral presentation. *Metastatic mass* - Ovarian metastases, particularly from **gastrointestinal primaries (Krukenberg tumors)** and breast cancer, frequently involve both ovaries in **70-80% of cases**. - The bilateral presentation is due to **transcoelomic spread** or lymphatic/hematogenous dissemination. *Dysgerminoma* - While individual dysgerminomas may present unilaterally at diagnosis, they have a **significant propensity for bilateral involvement** when considering: - **Microscopic involvement** of the contralateral ovary (occult disease) - **Synchronous** bilateral disease in 10-15% of cases - Association with **gonadal dysgenesis** where bilateral gonadoblastomas may give rise to dysgerminomas - Among malignant germ cell tumors, dysgerminoma has the **highest rate of bilaterality**. *Adenoma of ovary* - Epithelial ovarian tumors, particularly **serous cystadenomas**, present bilaterally in approximately **20% of cases**. - **Mucinous cystadenomas** are less frequently bilateral (5%), but serous tumors show notable bilateral tendency. - The term "adenoma" here likely refers to benign epithelial neoplasms with bilateral potential.

Q: Ball's operation is indicated for which of the following conditions?

Vulvar cancer (Ca. Vulva). ***Vulvar cancer (Ca. Vulva)*** - **Ball's operation** (radical vulvectomy) is a surgical procedure specifically designed for the treatment of **vulvar cancer**. - It involves the **wide excision of the vulva** along with lymphadenectomy to remove cancerous tissue and prevent spread. *Cervical cancer (Ca. Cx)* - Treatment for cervical cancer typically involves procedures like **cone biopsy**, **hysterectomy**, or **radical trachelectomy**, often combined with radiation and chemotherapy. - Ball's operation is not indicated for cervical cancer, as it targets the external genitalia. *Ovarian cancer (Ca. Ovary)* - Ovarian cancer is primarily managed through **surgical debulking**, which includes **hysterectomy**, **bilateral salpingo-oophorectomy**, and omentectomy. - This type of cancer requires intra-abdominal surgery, distinct from procedures for external genital cancers. *Fallopian tube cancer (Ca. Fallopian tube)* - Treatment for fallopian tube cancer also involves intra-abdominal surgery, typically **salpingectomy** (removal of the fallopian tube) and often **hysterectomy** and **oophorectomy**. - Ball's operation is not relevant for this internal gynecologic malignancy.

Q: What is the stage of ovarian cancer with liver parenchymal metastasis and bilateral ovarian mass?

Stage IV. ***Stage IV*** - **Liver parenchymal metastasis** is considered **distant metastasis (M1)**, automatically classifying ovarian cancer as **Stage IVB** according to FIGO staging. - While **bilateral ovarian masses** might be present in earlier stages, the presence of **parenchymal liver or splenic metastasis** defines Stage IV disease. - Liver capsule surface involvement alone (without parenchymal invasion) would be Stage III as peritoneal spread. *Stage I* - Stage I ovarian cancer is confined to **one or both ovaries/fallopian tubes** only. - No evidence of tumor outside the ovaries, no peritoneal disease, and no nodal involvement. *Stage II* - Stage II involves tumor growth **beyond the ovaries/fallopian tubes** but confined to the **pelvis**. - No distant metastasis or lymph node involvement. *Stage III* - Stage III involves cancer spread **outside the pelvis** to the peritoneum or **retroperitoneal lymph nodes**. - Includes **peritoneal implants** (including liver/spleen capsule surface), but specifically excludes parenchymal liver or spleen metastasis.

Q: Ca vulva of the anterior part will spread primarily to which of the following lymph nodes?

Inguinal. ***Inguinal*** - Carcinoma of the vulva, particularly the anterior part, primarily metastasizes to the **inguinal lymph nodes** (both superficial and deep inguinal nodes). - The lymphatic drainage pathway: vulva → superficial inguinal nodes → deep inguinal nodes → external iliac nodes. - **Superficial inguinal nodes** lie above the inguinal ligament and are the first-line drainage. - The anterior vulva (especially the clitoris) may have bilateral drainage, making sentinel lymph node mapping important. *Obturator* - **Obturator lymph nodes** are pelvic nodes that primarily drain the cervix, bladder, and medial thigh. - These nodes are NOT part of the primary drainage pathway for vulvar cancer. - Involvement would indicate advanced disease with secondary pelvic spread. *Femoral* - The **deep inguinal (femoral) nodes** are part of the inguinal lymphatic chain and lie along the femoral vessels medial to the femoral vein. - While these nodes DO receive vulvar drainage, they are considered part of the broader "inguinal node group." - The term **"inguinal"** is preferred in clinical practice as it encompasses both superficial and deep (femoral) components of the primary drainage pathway. *Para-aortic* - **Para-aortic lymph nodes** drain the ovaries, uterine fundus, kidneys, and testis. - These nodes are NOT involved in primary vulvar drainage. - Para-aortic involvement in vulvar cancer indicates distant metastasis and advanced stage disease.

Q: An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?

Endometrial cancer. ***Endometrial cancer*** - This patient has multiple risk factors for **endometrial cancer**, including **obesity**, **diabetes**, **hypertension**, and being in the **perimenopausal** age group (49 years old). - Her symptoms of heavy menstrual bleeding with delayed and irregular cycles are classic presentations of **endometrial hyperplasia** or **endometrial cancer**, warranting prompt investigation. *Cancer cervix* - While cervical cancer is a concern, its typical presentation often involves **post-coital bleeding** or **intermenstrual bleeding**, rather than heavy and irregular cycles, making other causes more likely in this specific scenario. - Risk factors for cervical cancer include **HPV infection**, early age of first intercourse, multiple sexual partners, and smoking, which are not mentioned here. *Fibroid uterus* - **Fibroids** can cause heavy menstrual bleeding, but the delayed and irregular cycles, combined with the patient's strong metabolic risk factors, make endometrial pathology a more urgent concern. - Fibroids are **benign tumors** and do not carry the same immediate malignancy risk as the presenting symptoms suggest for this patient profile. *Polycystic ovaries* - **PCOS** often presents with irregular or absent menstruation and infertility, usually in younger women, and is associated with obesity and insulin resistance. - While PCOS can lead to chronic anovulation and increased risk of **endometrial hyperplasia**, a 49-year-old with acute changes in bleeding pattern and metabolic syndrome points more directly to the need to rule out established endometrial malignancy.

Question 1

A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

Accepted Answer

Paracervical or parametrial nodes

Answer

Para-aortic nodes

Answer

External iliac node

Answer

Common iliac nodes

Question 2

Which ovarian tumor is likely to involve the opposite ovary by metastasis?

Accepted Answer

Dysgerminoma

Answer

Granulosa cell tumor

Answer

Gynandroblastoma

Answer

Endodermal tumor

Question 3

A lady undergoes radical hysterectomy for suspected stage Ib cancer cervix. Histopathology reveals cancer extension to the lower part of the uterine body with positive surgical margins. What is the next step of management?

Accepted Answer

Chemoradiation

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Follow-up

Question 4

A 20-year-old female presents with a 6x6x6 cm ovarian mass, ultrasonography of which reveals solid structures. Her serum biomarkers, including AFP, β-hCG, and CA 125, are normal, but serum alkaline phosphatase is elevated. The most likely diagnosis is:

Accepted Answer

Dysgerminoma

Answer

Endodermal sinus tumor

Answer

Malignant teratoma

Answer

Mucinous cystadenocarcinoma

Question 5

All of the following ovarian tumors usually occur bilaterally, except:

Accepted Answer

Dermoid cyst

Answer

Metastatic mass

Answer

Dysgerminoma

Answer

Adenoma of ovary

Question 6

Ball's operation is indicated for which of the following conditions?

Accepted Answer

Vulvar cancer (Ca. Vulva)

Answer

Cervical cancer (Ca. Cx)

Answer

Ovarian cancer (Ca. Ovary)

Answer

Fallopian tube cancer (Ca. Fallopian tube)

Question 7

What is the stage of ovarian cancer with liver parenchymal metastasis and bilateral ovarian mass?

Accepted Answer

Stage IV

Answer

Stage I

Answer

Stage II

Answer

Stage III

Question 8

Ca vulva of the anterior part will spread primarily to which of the following lymph nodes?

Accepted Answer

Inguinal

Answer

Obturator

Answer

Femoral

Answer

Para-aortic

Question 9

Which of the following statements about carcinoma of the vulva is correct?

Accepted Answer

Commonly seen after menopause and associated with viral predisposition.

Answer

Spreads to iliac nodes.

Answer

Spreads to superficial inguinal nodes and is treated with radiotherapy.

Answer

All of the options.

Question 10

An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?

Accepted Answer

Endometrial cancer

Answer

Cancer cervix

Answer

Fibroid uterus

Answer

Polycystic ovaries

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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