Practice questions I answers, female reproductive tract

Practice questions Ia answers, female genital tract

Pathology of vulva, vagina and cervix

© Jun Wang, MD, PhD

1. D. Multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei are characteristic for herpes infection. Candida infection usually has fungal hyphae. Decidualization of cervix is characterized by decidual cells with abundant pale granular cytoplasm, but no abnormal nuclear morphology. Human papillomavirus infection will cause cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas. Depending on grade, these lesion usually have enlarged hyperchromic nuclei with irregular nuclear membrane, with various amount of cytoplasm.

2. C. Maternal genital tract herpes infection is a risk factor for neonatal herpes.

3. D. Pruritic pink skin nodules with eosinophilic homogenous cytoplasmic inclusion is consistent with molluscum contagiosum. It is caused by molluscum contagiosum virus. Herpes infection of skin is painful and microscopically it is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei. Human papillomavirus infection causes cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas. Depending on grade, these lesion usually have enlarged hyperchromic nuclei with irregular nuclear membrane, with various amount of cytoplasm. Trichomonas infection causes trichomoniasis.

4. A. Vaginal pruritis/burning sensation with sticky white vaginal discharge is highly suggestive of candidiasis, as confirmed by identification of fungal hyphae. Diabetes is a risk factor for many infections, including fungal infection. Condyloma is characterized by koilocyte with enlarged dark nuclei and wrinkled nuclear membrane, and well-demarcated halo. Lichen sclerosus presents with genital area pruritis and is characterized by atrophic features including flat atropic epidermis and hyalinized fibrosis in superficial dermis. Squamous intraepithelial neoplasia is associated with human papillomavirus infection and usually has enlarged hyperchromic nuclei with irregular nuclear membrane, with various amount of cytoplasm. Trichomoniasis is caused by Trichomonas vaginalis, a parasite that can be seen on wet mount as pear-shaped motile oval, or round cyanophilic protozoa.

5. B. Papillary growth with koilocytes is consistent with condyloma. Chronic cervicitis has nonspecific chronic inflammation and minimal epithelial changes. Herpes infection of skin is painful and microscopically it is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei. High grade cervical intraepithelial neoplasia is defined by dysplastic change involving upper third of epithelium, characterized by high nuclear/cytoplasm ratio, large hyperchromic nuclei with wrinkled nuclear membrane. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls.

6. C. Cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas are associated with human papillomavirus. Chlamydia and gonorrhea infections usually have non specific inflammation, and is usually diagnosed by molecular tests. Herpes infection is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei. Trichomonas vaginalis can be seen on wet mount as pear-shaped motile oval, or round cyanophilic protozoa.

7. E. Genital pruritis with yellow malodorous vaginal discharge is highly suggestive of Trichomoniasis. Also see discussion in question 6.

8. A. Thin vaginal discharge with fishy odor is suggestive of bacterial vaginosis, caused by Gardnerella vaginalis, characterized by clue cells. Also see discussion in question 6.

9. A. Cyst lined by squamous epithelium at vulva is most likely a Bartholin cyst. Condyloma has koilocytes. Lichen sclerosus is characterized by atrophic features including flat atropic epidermis and hyalinized fibrosis in superficial dermis. Paget disease has pale cells in epidermis. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls.

10. D. Pelvic adhesion and inflammation as a result of pelvic inflammatory disease may cause infertility. Other conditions usually have presentation of endocrine abnormality such as dysfunctional uterine bleeding or enlarged uterus.

11. B. Lichen sclerosus has atrophic features including flat atropic epidermis and hyalinized fibrosis in superficial dermis. Infectious vaginitis has abnormal vaginal discharge and evidence of microorganisms. Metastatic adenocarcinoma of endometrium has features of original tumor, such as irregular glandular structure and cytological atypia, etc. Paget disease has pale cells in epidermis. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls.

12. E. Lichen sclerosus is benign non-infection lesion and a risk factor for squamous cell carcinoma.

13. D. Clusters or single atypical pale cells in epidermis is suggestive of either Paget disease or melanoma. Paget disease is positive for cytokeratin and negative for S-100. Melanoma is positive for S-100 but negative for cytokeratin. Candidiasis has non specific inflammation and fungal hyphae. Lichen sclerosus has atrophic features including flat atropic epidermis and hyalinized fibrosis in superficial dermis. Trichomoniasis has malodorous vaginal discharge and the parasite can be seen on wet mount as pear-shaped motile oval, or round cyanophilic protozoa.

14. C. Small undifferentiated tumor cells with normal epithelium seen in a vaginal tumor in young patient is compatible with sarcoma botryoides, a type of embryonal rhabdomyosarcoma. It is positive for desmin. CD3 is a T cell marker, CD20 is a B cell marker. EBV antigen is expressed in EBV associated lesions, such as Burkitt lymphoma and nasopharyngeal carcinoma. S100 is expressed in cells with neuronal or melanocytic differentiation.

15. C. Burkitt lymphoma and chronic lymphocytic leukemia/Small lymphocytic lymphoma are positive for CD45. Ewing sarcoma is positive for CD99. Small cell carcinoma is positive for cytokeratin and synaptophysin. Also see discussion in question 14.

16. B. Papillary growth with koilocytes is consistent with condyloma. Endocervical adenocarcinoma in situ has normal glandular architecture but the glandular cells have elongated hyperchromic nuclei. High-grade cervical intraepithelial neoplasia is defined by dysplastic change involving upper third of epithelium, characterized by high nuclear/cytoplasm ratio, large hyperchromic nuclei with wrinkled nuclear membrane. Sarcoma botryoides has small undifferentiated tumor cells underneath normal epithelium. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls.

17. D. Full thickness squamous dysplasia as characterized by high nuclear/cytoplasm ratio, large hyperchromic nuclei with wrinkled nuclear membrane is consistent with high-grade cervical intraepithelial neoplasia. See discussion in question 16.

18. D. High-grade cervical intraepithelial neoplasia is associated with HPV infection and multiple sexual partners is a risk factor, as other sexually transmitted diseases.

19. E. High-grade cervical intraepithelial neoplasia is associated with HPV infection. BRCA mutation is associated with multiple cancers, including those from ovary and breast. EB virus is associated with various malignancies, including Burkitt lymphoma and nasopharyngeal carcinoma. HHV8 is associated with Kaposi sarcoma and primary effusion lymphoma. However, HSV and HIV are likely not directly associated with cancers.

20. B. HPV associated High-grade cervical intraepithelial neoplasia and squamous carcinoma are usually strongly positive for p16. Fungal hyphae is seen in fungal infections, including candidiasis. Also see discussion in question 19.

21. B. Normal glandular architecture lined by glandular cells with elongated hyperchromic nuclei is consistent with endocervical adenocarcinoma in situ. Condyloma is characterized by koilocyte with enlarged dark nuclei and wrinkled nuclear membrane, and well-demarcated halo. Endometriosis is characterized by benign endometrial glands, stroma and signs of hemorrhage at a location outside uterine cavity. Cervical carcinomas have signs of invasion.

22. C. Irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls are seen in squamous carcinoma. Cervical adecarcinoma has irregular glands lined by atypical cells. Condyloma is non-invasive and has koilocyte with enlarged dark nuclei and wrinkled nuclear membrane, and well-demarcated halo. Small cell carcinoma has sheets of cells with scant cytoplasm. Trichomoniasis has malodorous vaginal discharge and parasite seen on wet mount, but not cytological atypia.

23. D. Multiple nodules at periphery of lungs in a patient with invasive carcinoma is most likely metastatic tumor to lungs.

24. D. Although cigarette smoking is an independent risk factor, cervical cancers are predominantly associated with HPV. Estrogen effects are associated with adenocarcinoma of endometrium and breast. EGFR mutation is seen in various cancers, especially adenocarcinoma of lung. Trichomoniasis has no known risk for malignancy.

25. D. HPV cause cancers through two viral components, E6 through promote p53 degradation or activation of telomerase; and E7 through Rb inhibition. Activating mutation of EGFR is seen in adenocarcinoma of lung. PTEN mutation is seen in various cancers, including adenocarcinoma of endometrium and breast.

26. D. Invasive cervical cancer with glandular differentiation is an invasive endocervical adenocarcinoma, usually HPV associated, with positive p16 expression. Endocervical adenocarcinoma in situ has normal glandular architecture but the glandular cells have elongated hyperchromic nuclei. Endometrial serous carcinoma usually does not have glandular differentiation and is positive for p53. Endometrioid endometrial adenocarcinoma has weak p16 reactivity. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellularbridges and/or squamous pearls.

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