Gynecologic Oncology Practice Questions

Q: Which of the following would be the earliest symptom of Ca cervix?

Postcoital bleeding. **Explanation:** **1. Why Postcoital Bleeding is Correct:** Carcinoma of the cervix typically originates at the **Transformation Zone**. As the malignant cells proliferate, they create a friable, vascularized lesion on the ectocervix. Because these neoplastic blood vessels are fragile and lack a proper basement membrane, minor mechanical trauma—specifically during sexual intercourse—causes them to rupture. Therefore, **postcoital bleeding** is classically regarded as the earliest and most specific clinical symptom of cervical cancer in sexually active women. **2. Analysis of Incorrect Options:** * **Pain (Option A):** This is a **late feature** of Ca cervix. Pain typically signifies advanced disease (Stage IIIB or IV), indicating involvement of the pelvic side walls, nerve plexus compression, or hydronephrosis. * **Metrorrhagia (Option C):** While intermenstrual bleeding occurs as the tumor grows and undergoes spontaneous surface necrosis, it usually follows the initial phase of contact bleeding (postcoital). * **Menorrhagia (Option D):** Heavy menstrual bleeding is rarely a primary symptom of cervical cancer. It is more characteristic of uterine pathologies like fibroids, adenomyosis, or endometrial hyperplasia. **3. Clinical Pearls for NEET-PG:** * **Most common symptom:** Abnormal vaginal bleeding (often intermenstrual or postcoital). * **Most common sign:** A growth or ulcer on the cervix that bleeds on touch (friable). * **Screening Gold Standard:** Pap smear (cytology) is for screening; however, the **confirmatory diagnosis** is always via **Colposcopy-directed biopsy**. * **Triad of advanced Ca Cervix:** Unilateral leg edema, sciatic pain, and hydronephrosis (indicates pelvic wall involvement). * **Note:** In postmenopausal women, the earliest symptom may present as a foul-smelling serosanguinous discharge.

Q: Endometrial cancer is associated with all EXCEPT:

Dysgerminoma. **Explanation:** The core concept behind the development of **Type I Endometrial Carcinoma** (the most common variety) is **unopposed estrogen stimulation**. To answer this question, one must identify which condition does *not* contribute to an increased estrogenic state. * **Why Dysgerminoma is the correct answer:** Dysgerminoma is a germ cell tumor of the ovary, typically seen in young women. It is **hormonally inert** (it does not produce estrogen). While it may produce LDH or occasionally hCG (if syncytiotrophoblast cells are present), it has no association with endometrial proliferation or cancer. * **Why the other options are associated:** * **Granulosa Cell Tumor:** This is a sex cord-stromal tumor that **secretes high levels of estrogen**. This chronic estrogenic exposure leads to endometrial hyperplasia and, in approximately 5–15% of cases, progresses to endometrial carcinoma. * **Endometrial Hyperplasia:** Specifically "Atypical Hyperplasia" (Endometrial Intraepithelial Neoplasia) is the direct **precursor lesion** for Type I endometrial cancer due to prolonged estrogenic stimulation. * **Fibromyoma (Leiomyoma):** While not a precursor, fibroids are frequently **co-associated** with endometrial cancer because both are estrogen-dependent conditions. They often coexist in patients with obesity, nulliparity, or polycystic ovary syndrome (PCOS). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Obesity (peripheral conversion of androstenedione to estrone), Lynch Syndrome (HNPCC), Tamoxifen use, and Nulliparity. * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs), smoking (decreases estrogen levels, though harmful otherwise), and multiparity. * **Most common subtype:** Endometrioid adenocarcinoma. * **Investigation of choice:** Fractional Curettage or Pipelle Biopsy (Gold Standard for diagnosis).

Q: Recurrence of gestational trophoblastic tumor can be associated with all except?

Plateau of hCG. ### Explanation The diagnosis of **Gestational Trophoblastic Neoplasia (GTN)** or recurrence is based on specific FIGO criteria regarding Beta-hCG levels. **Why "Plateau of hCG" is the correct answer:** A **plateau of hCG** (defined as four values within ±10% over three weeks) is a diagnostic criterion for the **initial diagnosis** of GTN following a molar pregnancy, not a sign of **recurrence**. Recurrence refers to the reappearance of disease after hCG levels have already normalized (<5 mIU/mL) for a period. In cases of recurrence, hCG levels will **rise** again rather than plateau. **Analysis of Incorrect Options:** * **Enlarged Uterus:** Recurrence often involves the growth of trophoblastic tissue within the myometrium (Choriocarcinoma or Invasive Mole), leading to asymmetrical uterine enlargement and irregular vaginal bleeding. * **Persistent Lutein Cysts:** High levels of hCG (produced by the recurring tumor) cause hyperstimulation of the ovaries, leading to the formation or persistence of **Theca Lutein cysts**. * **Sub-urethral Nodule:** Choriocarcinoma is highly vascular and spreads hematogenously. The **vagina** (specifically the sub-urethral area) is a common site for metastatic deposits, appearing as bluish, friable nodules that bleed easily. **Clinical Pearls for NEET-PG:** * **FIGO Criteria for GTN:** 1. hCG plateau for 3 weeks. 2. hCG rise (>10%) for 2 weeks. 3. Histological diagnosis of choriocarcinoma. 4. Persistent hCG 6 months after molar evacuation. * **Most common site of metastasis:** Lungs (80%), followed by the Vagina (30%). * **Treatment:** GTN is highly chemosensitive. Low-risk cases (WHO score ≤6) are treated with **Methotrexate**, while high-risk cases (score ≥7) require **EMA-CO** regimen.

Q: Which is the commonest malignancy of the ovary?

Serous type. **Explanation:** Ovarian tumors are classified based on their tissue of origin into Epithelial, Germ Cell, and Sex Cord-Stromal tumors. **Surface Epithelial-Stromal tumors** are the most common category, accounting for approximately 90% of all ovarian malignancies. **Why Serous type is correct:** Among epithelial tumors, the **Serous type** is the most frequent. It accounts for about 50–60% of all epithelial ovarian cancers. These tumors are often bilateral and are frequently diagnosed at an advanced stage. They are histologically characterized by the presence of **Psammoma bodies** (concentric calcifications). **Why other options are incorrect:** * **Mucinous type:** These are the second most common epithelial tumors (approx. 10–15%). They are typically large, multiloculated, and less likely to be bilateral compared to serous tumors. * **Dermoid cyst (Mature Cystic Teratoma):** This is a Germ Cell tumor. While it is the **most common benign ovarian tumor** in young women, it is rarely malignant (only 1–2% undergo malignant transformation, usually to Squamous Cell Carcinoma). * **Granulosa cell tumor:** This is a Sex Cord-Stromal tumor. It is much rarer than epithelial tumors and is known for producing estrogen, often leading to endometrial hyperplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian tumor overall:** Dermoid cyst (Benign). * **Most common malignant ovarian tumor:** Serous cystadenocarcinoma. * **Most common Germ Cell tumor:** Dermoid cyst. * **Most common malignant Germ Cell tumor:** Dysgerminoma. * **Tumor Marker:** CA-125 is the primary marker for epithelial ovarian tumors (especially serous).

Q: Which of the following is a serum marker for ovarian carcinoma?

CA-125. **Explanation:** **Correct Option: A. CA-125** Cancer Antigen 125 (CA-125) is the most widely used serum tumor marker for **epithelial ovarian cancer**, particularly the serous subtype. It is a high-molecular-weight glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, and peritoneum). While it is used for monitoring treatment response and detecting recurrence, its utility as a screening tool is limited due to low sensitivity in early stages and low specificity in premenopausal women. **Incorrect Options:** * **B. Fibronectin:** This is a glycoprotein involved in cell adhesion. In obstetrics, **Fetal Fibronectin (fFN)** is used as a biochemical marker to predict the risk of preterm labor, not ovarian malignancy. * **C. Acid Phosphatase:** Historically used as a marker for **prostate cancer** (specifically Prostatic Acid Phosphatase), though it has largely been replaced by PSA. * **D. PSA (Prostate-Specific Antigen):** This is the gold-standard screening and monitoring marker for **prostate adenocarcinoma**. **High-Yield Clinical Pearls for NEET-PG:** * **Specificity:** CA-125 can be elevated in benign conditions like endometriosis, PID, pregnancy, and fibroids, making it less specific in younger patients. * **Germ Cell Tumors (GCT):** Remember specific markers for GCTs: * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP). * **Dysgerminoma:** LDH (and sometimes hCG). * **Choriocarcinoma:** beta-hCG. * **Granulosa Cell Tumor:** Inhibin B. * **Meigs Syndrome:** Characterized by the triad of benign ovarian fibroma, ascites, and pleural effusion; CA-125 can be elevated here despite the tumor being benign.

Q: What is the management for stage IIB cancer of the cervix?

Radiotherapy with combination with chemotherapy. **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**. Stage IIB is defined as carcinoma that has extended beyond the uterus to the **parametrium**, but not reaching the pelvic side wall. **1. Why Option B is Correct:** For **locally advanced cervical cancer (LACC)**, which includes stages **IIB to IVA**, the standard of care is **Concurrent Chemoradiotherapy (CCRT)**. * **Radiotherapy** consists of External Beam Radiation Therapy (EBRT) followed by Brachytherapy. * **Chemotherapy** (typically weekly **Cisplatin**) acts as a radiosensitizer, enhancing the lethal effects of radiation on tumor cells. Large clinical trials have proven that CCRT significantly improves overall survival compared to radiation alone. **2. Why Other Options are Incorrect:** * **Option A (Radiotherapy alone):** While radiation is the primary modality, using it without chemotherapy is suboptimal and no longer the gold standard for Stage IIB. * **Option C (Chemotherapy alone):** Chemotherapy is used as a primary treatment only in Stage IVB (metastatic disease) for palliation; it cannot cure Stage IIB in isolation. * **Option D (Hysterectomy):** Surgery (Wertheim’s Radical Hysterectomy) is generally reserved for **early-stage disease (up to Stage IIA1)**. In Stage IIB, the involvement of the parametrium makes it difficult to achieve clear surgical margins, and primary surgery followed by adjuvant radiation significantly increases morbidity. **High-Yield Clinical Pearls for NEET-PG:** * **Cut-off for Surgery:** Stage IIA1 (size ≤ 4cm, no parametrial involvement). * **Most Common Histology:** Squamous Cell Carcinoma. * **Drug of Choice for Radiosensitization:** Cisplatin. * **Stage IIB Definition:** Parametrial involvement present (diagnosed via per-rectal examination).

Q: What is the diagnosis based on the ultrasound findings of an early pregnancy?

Complete mole. ***Complete mole*** - Shows the classic **"snowstorm"** or **"Swiss cheese"** appearance on ultrasound due to multiple **cystic spaces** representing hydropic villi. - **No fetal parts** or **fetal heart activity** are visualized, and **beta-hCG levels** are markedly elevated (>100,000 mIU/mL). *Partial mole* - Ultrasound shows **mixed echogenic pattern** with **focal cystic changes** and **fetal parts** may be present. - Associated with **triploid karyotype** (69,XXX or 69,XXY) and **lower beta-hCG levels** compared to complete mole. *Invasive mole* - **Cannot be diagnosed** by ultrasound alone as it appears similar to complete mole initially. - Diagnosis requires **histopathological evidence** of **myometrial invasion** and **persistently elevated beta-hCG** after evacuation. *Choriocarcinoma* - Ultrasound shows **heterogeneous mass** with **areas of hemorrhage** and **necrosis**, not the classic snowstorm pattern. - Develops after **any type of pregnancy** and shows **rapid metastatic spread** with **very high beta-hCG levels**.

Q: A 60-year-old lady is diagnosed with carcinoma of the endometrium with involvement of more than 50% of the myometrium and vagina. The carcinoma has not involved pelvic and para-aortic lymph nodes, and peritoneal cytology is positive. What is the stage of her malignancy?

Stage IIIb. **Explanation:** The staging of endometrial carcinoma is based on the **FIGO Staging System (Revised 2023/2009)**. In this clinical scenario, the key finding is the involvement of the **vagina**, which automatically classifies the malignancy as **Stage IIIb**. 1. **Why Stage IIIb is correct:** According to FIGO staging, Stage III denotes local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Tumor involves serosa or adnexa. * **Stage IIIb:** Tumor involves the **vagina** and/or parametrium. * Since this patient has vaginal involvement, she is classified as Stage IIIb, regardless of the myometrial invasion depth or positive peritoneal cytology (which is no longer used to upstage disease in the 2009/2023 criteria but is noted). 2. **Why other options are incorrect:** * **Stage Ib:** This involves invasion of $\geq$ 50% of the myometrium but is strictly confined to the **corpus uteri**. The presence of vaginal spread excludes Stage I. * **Stage IIIc:** This stage is reserved for metastasis to the **pelvic (IIIc1) or para-aortic (IIIc2) lymph nodes**. The question explicitly states these nodes are not involved. * **Stage IVa:** This represents advanced spread to the **bladder or bowel mucosa**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma. * **Staging Method:** Endometrial cancer is **surgically staged** (unlike cervical cancer, which was historically clinically staged). * **Peritoneal Cytology:** While recorded, positive cytology alone does not change the FIGO stage; however, vaginal or parametrial involvement (IIIb) is a significant prognostic indicator.

Q: What is the investigation of choice for cervical neoplasm?

Cone biopsy. **Explanation:** The "Investigation of Choice" (IOC) for cervical neoplasm refers to the **Gold Standard** method required for a definitive diagnosis and staging. 1. **Why Cone Biopsy is Correct:** While a punch biopsy can diagnose invasive cancer, a **Cone Biopsy** (Cold knife conization or LEEP) is the definitive investigation. It provides a large tissue specimen that allows the pathologist to evaluate the entire transformation zone, the depth of stromal invasion, and the presence of lymphovascular space invasion (LVSI). It is both diagnostic and, in cases of microinvasive carcinoma (Stage IA1), therapeutic. 2. **Why Other Options are Incorrect:** * **Pap Smear:** This is a **screening tool**, not a diagnostic one. It identifies cytological abnormalities but cannot confirm the stage or depth of invasion. * **Speculoscopy & Cervicography:** These are adjunct visual screening methods used to enhance the detection of lesions. They lack the histological precision required for a definitive diagnosis of neoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Test of Choice:** Pap Smear (Liquid-based cytology is preferred). * **Best Screening Strategy:** Co-testing (Pap smear + HPV DNA testing) every 5 years for women aged 30–65. * **Initial Investigation for Abnormal Pap:** Colposcopy-directed biopsy. * **IOC for Microinvasive Carcinoma:** Cone Biopsy (to rule out deeper invasion). * **Staging:** Cervical cancer is staged **Clinically** (FIGO staging), though the 2018 update allows for imaging (MRI/CT) and pathological findings where available.

Question 1

A 40-year-old woman has CIN 2. What is the next step in management?

Accepted Answer

Colposcopy

Answer

Cryotherapy

Answer

Conization

Answer

Hysterectomy

Question 2

Which of the following would be the earliest symptom of Ca cervix?

Accepted Answer

Postcoital bleeding

Answer

Pain

Answer

Metrorrhagia

Answer

Menorrhagia

Question 3

Endometrial cancer is associated with all EXCEPT:

Accepted Answer

Dysgerminoma

Answer

Fibromyoma

Answer

Endometrial hyperplasia

Answer

Granulosa cell tumor

Question 4

Recurrence of gestational trophoblastic tumor can be associated with all except?

Accepted Answer

Plateau of hCG

Answer

Enlarged uterus

Answer

Persistent lutein cysts in ovaries

Answer

Sub urethral nodule

Question 5

Which is the commonest malignancy of the ovary?

Accepted Answer

Serous type

Answer

Mucinous type

Answer

Dermoid cyst

Answer

Granulosa cell tumor

Question 6

Which of the following is a serum marker for ovarian carcinoma?

Accepted Answer

CA-125

Answer

Fibronectin

Answer

Acid Phosphatase

Answer

PSA

Question 7

What is the management for stage IIB cancer of the cervix?

Accepted Answer

Radiotherapy with combination with chemotherapy

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Hysterectomy

Question 8

What is the diagnosis based on the ultrasound findings of an early pregnancy?

Accepted Answer

Complete mole

Answer

Partial mole

Answer

Invasive mole

Answer

Choriocarcinoma

Question 9

A 60-year-old lady is diagnosed with carcinoma of the endometrium with involvement of more than 50% of the myometrium and vagina. The carcinoma has not involved pelvic and para-aortic lymph nodes, and peritoneal cytology is positive. What is the stage of her malignancy?

Accepted Answer

Stage IIIb

Answer

Stage Ib

Answer

Stage IIIc

Answer

Stage IVa

Question 10

What is the investigation of choice for cervical neoplasm?

Accepted Answer

Cone biopsy

Answer

Speculoscopy

Answer

Pap smear

Answer

Cervicography

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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