Gynecologic Oncology Practice Questions

Q: What is the recommended initial management for atypical hyperplasia?

Hysterectomy. **Explanation:** **Atypical Hyperplasia (AH)**, also known as Endometrioid Intraepithelial Neoplasia (EIN), is a premalignant condition with a high risk of progressing to or harboring coexistent malignancy. **Why Hysterectomy is the Correct Answer:** The definitive management for atypical hyperplasia is **Total Hysterectomy** (usually with bilateral salpingo-oophorectomy in postmenopausal women). This is because approximately **40% of women** diagnosed with AH on a biopsy are found to have a concurrent, undiagnosed endometrial carcinoma in the final hysterectomy specimen. Surgery eliminates the risk of progression and provides a definitive diagnosis. **Why Other Options are Incorrect:** * **Options A & B (Cyclical/Continuous Progestogens):** While progestogens can reverse hyperplasia without atypia, they are not the first-line treatment for atypical hyperplasia due to the high failure rate and the risk of underlying malignancy. * **Option C (LNG-IUS/Mirena):** The LNG-IUS is highly effective for *non-atypical* hyperplasia. In atypical cases, it is only reserved for patients who strongly desire **fertility preservation** or those who are **medically unfit** for surgery. It is not the "recommended initial management" for the general population. **NEET-PG High-Yield Pearls:** * **Risk of Malignancy:** Hyperplasia *without* atypia has a <3% risk of progression; Hyperplasia *with* atypia has a ~29-40% risk. * **Fertility Sparing:** If a patient with AH desires pregnancy, management involves high-dose oral progestogens or LNG-IUS with mandatory endometrial sampling every 3 months. * **Postmenopausal Bleeding:** Always the first symptom to rule out endometrial hyperplasia/carcinoma. * **Gold Standard Diagnosis:** Endometrial biopsy or D&C (Dilatation and Curettage).

Q: Which of the following lymph nodes are typically NOT involved in cervical cancer?

Femoral lymph nodes. **Explanation:** The lymphatic drainage of the cervix follows a predictable, stepwise pattern through the pelvic and abdominal lymphatics. Understanding this hierarchy is crucial for staging and surgical management in cervical cancer. **Why Femoral Lymph Nodes are the Correct Answer:** Femoral (superficial inguinal) lymph nodes primarily drain the **vulva, lower third of the vagina, and the skin of the perineum**. They are not part of the primary or secondary lymphatic drainage pathway for the cervix. Involvement of femoral nodes in cervical cancer would be highly atypical and would only occur in cases of massive retrograde lymphatic blockage or direct extension to the lower vagina. **Analysis of Incorrect Options:** * **Obturator Lymph Nodes:** These are considered the **primary (sentinel) nodes** for cervical cancer. They are usually the first group to be involved. * **Hypogastric (Internal Iliac) Lymph Nodes:** Along with the external iliac nodes, these form the primary drainage group for the cervix. * **Para-aortic Lymph Nodes:** These represent the **secondary drainage** pathway. Cancer spreads from the pelvic nodes (common iliac) to the para-aortic nodes. Involvement of these nodes signifies Stage IIIC2 disease in the FIGO 2018 classification. **NEET-PG High-Yield Pearls:** * **Most common site of lymph node metastasis:** Obturator nodes. * **Order of Spread:** Obturator → External/Internal Iliac → Common Iliac → Para-aortic. * **FIGO 2018 Update:** The presence of lymph node metastasis now classifies the disease as **Stage IIIC** (IIIC1 for pelvic nodes, IIIC2 for para-aortic nodes). * **Ureters:** The most common cause of death in cervical cancer is uremia due to ureteric obstruction by local spread or lymphadenopathy.

Q: Which of the following ovarian tumors cause masculinization?

Gynandroblastoma and Arrhenoblastoma. **Explanation:** The correct answer is **A: Gynandroblastoma and Arrhenoblastoma**. **1. Why Option A is Correct:** Masculinization (virilization) in ovarian tumors is caused by the excessive production of androgens (primarily testosterone). * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** This is the most common virilizing ovarian tumor. It contains Leydig cells that secrete testosterone, leading to hirsutism, clitoromegaly, and deepening of the voice. * **Gynandroblastoma:** This is an extremely rare sex cord-stromal tumor that contains both male (Sertoli-Leydig) and female (Granulosa-Theca) cell components. Because it contains androgen-secreting elements, it frequently causes masculinization. **2. Why Other Options are Incorrect:** * **Gonadoblastoma (Options C & D):** While gonadoblastomas occur in dysgenetic gonads (like in Swyer syndrome) and are associated with a Y chromosome, the tumor itself is usually **hormonally inert**. Any virilization seen in these patients is typically due to the underlying gonadal dysgenesis or the presence of a co-existing malignant germ cell tumor (like a Dysgerminoma), rather than the gonadoblastoma itself producing androgens. * **Option B:** This is incomplete as it omits Arrhenoblastoma, the classic cause of virilization. **NEET-PG High-Yield Pearls:** * **Most common virilizing tumor:** Sertoli-Leydig Cell Tumor (Arrhenoblastoma). * **Tumor Marker:** Sertoli-Leydig tumors often show elevated **Testosterone** levels with low/normal DHEAS (DHEAS is an adrenal marker). * **Reinke’s Crystals:** Pathognomonic histological finding in **Hilus cell tumors** (another rare virilizing tumor). * **Meigs’ Syndrome:** Triad of Benign Ovarian Fibroma, Ascites, and Pleural Effusion.

Q: A woman presents with vomiting and vaginal bleeding. Further investigation reveals a trophoblastic disease that has invaded the myometrium. Histopathology shows evidence of chorionic villi. What is your diagnosis?

Invasive mole. ### Explanation The correct diagnosis is **Invasive Mole** (also known as Chorioadenoma Destruens). **1. Why the correct answer is right:** The diagnosis of Gestational Trophoblastic Disease (GTD) depends on two key histopathological features: the presence of **chorionic villi** and the **depth of tissue invasion**. An invasive mole is characterized by the presence of hydropic chorionic villi that have invaded deep into the **myometrium** or its blood vessels. The clinical presentation of vaginal bleeding and vomiting (due to high hCG levels) is typical of molar pregnancies. **2. Why the incorrect options are wrong:** * **Benign Complete/Incomplete Mole:** While these also show chorionic villi, they are confined to the uterine cavity and do **not** invade the myometrium. * **Choriocarcinoma:** This is a highly malignant tumor. The pathognomonic feature that distinguishes it from an invasive mole is the **absence of chorionic villi**. It consists purely of sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts with extensive hemorrhage and necrosis. **3. NEET-PG High-Yield Pearls:** * **Gold Standard for Diagnosis:** Histopathology is definitive. If you see "Villi + Myometrial Invasion," it is an **Invasive Mole**. If you see "No Villi + Myometrial Invasion," it is **Choriocarcinoma**. * **Most Common Site of Metastasis:** For both invasive moles and choriocarcinoma, the **lungs** are the most common site of distant spread (often presenting as "cannonball" opacities on X-ray). * **Treatment:** Both are highly sensitive to chemotherapy (Methotrexate is the first-line agent for low-risk cases). * **Follow-up:** Serial monitoring of **serum β-hCG** levels is essential to ensure complete remission.

Q: All of the following statements are true for melanoma of the vulva EXCEPT?

The most common site is the labia majora.. **Explanation:** Vulvar melanoma is a rare but aggressive malignancy, accounting for approximately 5–10% of all vulvar cancers. **Why Option B is the Correct Answer (The Exception):** The most common site for vulvar melanoma is the **clitoris or the labia minora**, not the labia majora. Unlike squamous cell carcinoma (SCC) of the vulva, which frequently involves the labia majora, melanomas have a predilection for the mucosal surfaces and midline structures of the vulva. **Analysis of Other Options:** * **Option A:** Squamous cell carcinoma is the most common vulvar cancer (approx. 90%), making **melanoma the second most common** primary vulvar malignancy. * **Option C:** While many arise de novo, vulvar melanomas can develop from pre-existing **junctional nevi**. Any pigmented lesion on the vulva in a postmenopausal woman should be viewed with suspicion and biopsied. * **Option D:** It has a **poor prognosis** compared to SCC. This is due to its high propensity for early hematogenous and lymphatic spread. The most important prognostic factor is the depth of invasion (Breslow’s thickness). **High-Yield Clinical Pearls for NEET-PG:** * **Staging:** Unlike SCC, which uses FIGO staging, vulvar melanoma is often staged using the **AJM/TNM system** (similar to cutaneous melanoma) or the **Breslow/Clark scale**. * **Appearance:** Often presents as a pigmented, raised, or ulcerated lesion (ABCDE criteria apply). * **Treatment:** Radical local excision with adequate margins (1–2 cm) is the primary treatment. Routine radical vulvectomy is no longer the standard. * **Sentinel Lymph Node Biopsy (SLNB):** Recommended for lesions >1 mm in thickness to assess nodal status.

Q: A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. What is your diagnosis?

Microinvasive cancer. **Explanation:** The diagnosis is **Microinvasive Squamous Cell Carcinoma (Stage IA1)**. According to the FIGO staging for cervical cancer, Stage IA1 is defined as invasive carcinoma that can be identified only by microscopy, with a maximum depth of invasion **≤ 3 mm**. In this case, the tumor invades only **1 mm** beyond the basement membrane, and the absence of lymphovascular space invasion (LVSI) and clear margins on the cone biopsy confirm this diagnosis. Microinvasive cancer represents a transition point where the malignant cells have breached the basement membrane but have a very low risk of pelvic lymph node metastasis (<1%). **Analysis of Incorrect Options:** * **Option A (Carcinoma of low malignant potential):** This term is typically used for borderline ovarian tumors, not cervical pathology. * **Option C (ASC-US):** This is a cytological category from a Pap smear indicating cells that do not look normal but do not meet the criteria for a definitive lesion. It is a precursor finding, not a histological diagnosis of invasion. * **Option D (Carcinoma in situ):** Also known as CIN III, this refers to full-thickness dysplasia where the basement membrane is **intact**. Once the basement membrane is breached (as the 1 mm invasion indicates here), it is no longer "in situ" but "invasive." **Clinical Pearls for NEET-PG:** * **FIGO Stage IA1:** Invasion ≤ 3 mm depth. Treatment of choice is **Extra-fascial Hysterectomy** (Type A). If the patient desires fertility, a **Cold Knife Conization** with clear margins is sufficient. * **FIGO Stage IA2:** Invasion > 3 mm to ≤ 5 mm. Requires Modified Radical Hysterectomy (Type B) with pelvic lymphadenectomy. * The most important prognostic factor in early-stage cervical cancer is **lymphovascular space invasion (LVSI)**.

Question 1

Which of the following pre-malignant conditions of the vulva presents with a "cake icing effect"?

Accepted Answer

Paget's disease of vulva

Answer

Vulvar intraepithelial neoplasia

Answer

Lichen sclerosis

Answer

Leukoplakia

Question 2

What is the recommended initial management for atypical hyperplasia?

Accepted Answer

Hysterectomy

Answer

Cyclical progestogens

Answer

Continuous progestogens

Answer

Levonorgestrel-releasing intrauterine system (MIRENA)

Question 3

All of the following are recommendations for screening of Lynch syndrome in women with endometrial cancer except?

Accepted Answer

Endometrial cancer before 60 years of age

Answer

Evidence of microsatellite instability

Answer

DNA mismatch repair protein loss

Answer

First or second-degree relative with known DNA mismatch repair gene mutation

Question 4

Which of the following lymph nodes are typically NOT involved in cervical cancer?

Accepted Answer

Femoral lymph nodes

Answer

Para-aortic lymph nodes

Answer

Obturator lymph nodes

Answer

Hypogastric lymph nodes

Question 5

Which of the following ovarian tumors cause masculinization?

Accepted Answer

Gynandroblastoma and Arrhenoblastoma

Answer

Gynandroblastoma

Answer

Arrhenoblastoma and Gonadoblastoma

Answer

Gynandroblastoma, Arrhenoblastoma, and Gonadoblastoma

Question 6

A woman presents with vomiting and vaginal bleeding. Further investigation reveals a trophoblastic disease that has invaded the myometrium. Histopathology shows evidence of chorionic villi. What is your diagnosis?

Accepted Answer

Invasive mole

Answer

Benign complete mole

Answer

Benign incomplete mole

Answer

Choriocarcinoma

Question 7

All of the following statements are true for melanoma of the vulva EXCEPT?

Accepted Answer

The most common site is the labia majora.

Answer

It is the second most common vulvar cancer.

Answer

It may arise from a junctional nevus.

Answer

It has a poor prognosis.

Question 8

What is the indication for adjuvant radiotherapy in endometrial cancer?

Accepted Answer

Cervical involvement, lymph node involvement, and carcinoma in situ

Answer

Lymph node involvement and carcinoma in situ

Answer

Cervical involvement, carcinoma in situ, and papillary serous tumor

Answer

Lymph node involvement, papillary serous tumor, and estrogen receptor positive

Question 9

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. What is your diagnosis?

Accepted Answer

Microinvasive cancer

Answer

Carcinoma of low malignant potential

Answer

Atypical squamous cells of undetermined significance

Answer

Carcinoma in situ

Question 10

Endocervical curettage shows malignant cells in a 40-year-old lady. What is the next line of management?

Accepted Answer

Cone biopsy

Answer

Pap smear

Answer

Colposcopy

Answer

Repeat procedure and if positive, hysterectomy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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