Practice questions I gyn path

Practice questions Ia, female genital tract

Pathology of vulva, vagina and cervix

© Jun Wang, MD, PhD

1. Use this case for the next two questions. A 22-year-old woman presents with watery vaginal discharge for 2 weeks. She is in her third trimester of pregnancy. She has a history of type I diabetes since age 14, and gonorrheal urethritis 2 years ago. She is sexually active and has been living with her most recent partner for a month. Physical examination reveals no lesion in the anogenial area. Colposcopic examination reveals a 0.8 cm ulcer at the cervix with contact bleeding. Biopsy of the ulcer reveals diffuse neutrophilic infiltrate with scattered atypical squamoid multinucleated cells with ground glass appearing nuclear inclusion. The peripheral of these nuclei are much darker than the central portion. The nuclear membrane is smooth although slightly irregular. What is most likely causing these changes?

A. Candida infection

B. Decidualization

C. Gonorrhea infection

D. Herpes infection

E. Human papillomavirus infection

2. A 22-year-old woman presents with watery vaginal discharge for 2 weeks. She is in her third trimester of pregnancy. She has a history of type I diabetes since age 14, and gonorrheal urethritis 2 years ago. She is sexually active and has been living with her most recent partner for a month. Physical examination reveals no lesion in the anogenital area. Colposcopic examination reveals a 0.8 cm ulcer at the cervix with contact bleeding. Biopsy of the ulcer reveals diffuse neutrophilic infiltrate with scattered atypical squamoid multinucleated cells with ground glass appearing nuclear inclusion. The peripheral of these nuclei are much darker than the central portion. The nuclear membrane is smooth although slightly irregular. What is most likely risk to her new baby?

A. Congenital heart disease

B. Congenital human immunodeficiency virus infection

C. Neonatal Herpes

D. Neonatal human papilloma virus infection

E. Primary immunodeficiency

3. A 34-year-old woman presents with pruritic skin lesion of her lower abdomen and genital area. Her past history is unremarkable. Physical examination reveals multiple pink nodules, primarily at the lower abdomen. Biopsy of these lesions reveal thickened epidermis with many superficial cells containing pink homogenous cytoplasmic inclusion. No significant nuclear atypia is noted. What is the cause of these changes?

A. Candida infection

B. Herpes infection

C. Human papillomavirus infection

D. Molluscum contagiosum virus infection

E. Trichomonas infection

4. A 15-year-old female presents with genital pruritis and "sticky-white" vaginal discharge for a week. She denies other symptoms. She has a history of type I diabetes. Physical examinations reveal erythematous changes of vaginal wall as well as white thick discharges. Pap test reveals clusters of elongated branching microorganisms. The squamous cells have abundant cytoplasm and slightly enlarged nuclei with smooth nuclear membrane. Scattered neutrophils are seen. What is the most likely diagnosis?

A. Candidiasis

B. Condyloma

C. Lichen sclerosis

D. Squamous cell neoplasia

E. Trichomoniasis

5. Use this case for the next two questions. A 21-year-old woman presents for colposcopic examination due to abnormal pap test results. Her past history is unremarkable. She is currently sexual active with multiple partners. Colposcopic examination reveal a 0.2 cm growth at the anterior lip of her cervical os. The lesion has a cauliflower appearance. Biopsy reveal a growth with finger like project of a fibrovascular core, covered by atypical squamous cells. These cells have slightly enlarged hyperchromic nuclei and sharply demarcated perinuclear cytoplasmic vacuole. No other abnormalities are seen. What is the most likely diagnosis?

A. Chronic cervicitis

B. Condyloma

C. Herpes

D. High grade squamous intraepithelial neoplasm

E. Squamous cell carcinoma

6. A 21-year-old woman presents for colposcopic examination due to abnormal pap test results. Her past history is unremarkable. She is currently sexual active with multiple partners. Colposcopic examination reveal a 0.2 cm growth at the anterior lip of her cervical os. The lesion has a cauliflower appearance. Biopsy reveal a growth with finger like project of a fibrovascular core, covered by atypical squamous cells. These cells have slightly enlarged hyperchromic nuclei and sharply demarcated perinuclear cytoplasmic vacuole. No other abnormalities are seen. What is the cause of these changes?

A. Chlamydia trachomatis

B. Herpes simplex virus

C. Human papillomavirus

D. Neisseria gonorrhoeae

E. Trichomonas vaginalis

7. A 35-year-old woman presents with vulvar itching and smelly yellow vaginal discharge for 1 week. Her past medical history is unremarkable. She is sexually active with two partner in the last two months. She denies history of sexually transmitted disease. Physical examination is unremarkable. Speculum exam reveals moderate amount of yellow frothy malodorous vaginal discharge. No erosion, bleeding or abnormal growth is seen. Saline wet mount reveals many motile microorganism with anterior flagella. No clue cells are seen. What is the cause of her presentation?

A. Chlamydia trachomatis

B. Herpes simplex viruse

C. Human papillomavirus

D. Neisseria gonorrhoeae

E. Trichomonas vaginalis

8. A 17-year-old female presents with vaginal burning and thin vaginal discharge with a fishy odor for 2 weeks. The odor became stronger after intercourse. Her past medical history is unremarkable. She is sexually active with several partners. Speculum exam reveals moderate amount of thin, grayish vaginal discharge. No erosion, bleeding or abnormal growth is seen. Saline wet mount reveals many squamous cells covered by coccobacilli. KOH mount reveals no fungal elements, but produces a strong fishy odor. What is the cause of her presentation?

A. Gardnerella vaginalis

B. Herpes simplex viruse

C. Human papillomavirus

D. Neisseria gonorrhoeae

E. Trichomonas vaginalis

9. A 65-year-old woman presents with painless swelling of right labia for 2 years. Her past medical history is unremarkable. Physical examination reveals a 5 cm soft mass at right labia majora. No regional lymphadenopathy is noted. The mass is removed and microscopically it is a cyst lined by squamous cells without significant atypia. What is the most likely diagnosis?

A. Bartholin cyst

B. Condyloma

C. Lichen sclerosis

D. Paget disease

E. Squamous cell carcinoma

10. A 25-year-old woman presents with infertility for 2 years. She denies abnormal vaginal bleeding or discharge. She has a history of gonorrheal urethritis 5 years ago that was treated with antibiotics. She has chronic lower abdominal pain for 3 years. Her past history including menstrual history are otherwise unremarkable. Fertility tests of her husband are within normal range. Physical and speculum exam are unremarkable. Bimanual exam reveals uterine and adnexal tenderness, and pain with cervical motion. What is the most likely cause of her infertility?

A. Abnormal ovarian function

B. Abnormal pituitary function

C. Endometrial hyperplasia

D. Pelvic adhesion and inflammation

E. Uterine tumor

11. Use this case for the next two questions. A 65-year-old woman presents with vulvar pruritus, burning and dysuria for one year. She was treated with vaginal estrogen cream, but no relief is achieved. She has a history of endometrial endometrioid adenocarcinoma at age of 48, that was treated with hysterectomy and bilateral oophrectomy. She is not sexually active and her past medical history is unremarkable. Physical examination reveals flat atrophic appearing skin of her labia majora. Several small erosions are seen near urethral opening. No abnormal discharge or mass are noted. Biopsy of the skin reveal thin epidermis without rete ridges. The dermis appears to be fibrotic. No cytological atypia is seen. What is the diagnosis?

A. Infectious vaginitis

B. Lichen sclerosus

C. Metastatic endometrial adenocarcinoma

D. Paget disease

E. Squamous cell carcinoma

12. A 65-year-old woman presents with vulvar pruritus, burning and dysuria for one year. She was treated with vaginal estrogen cream, but no relief is achieved. She has a history of endometrial endometrioid adenocarcinoma at age of 48, that was treated with hysterectomy and bilateral oophrectomy. She is not sexually active and her past medical history is unremarkable. Physical examination reveals flat atrophic appearing skin of her labia majora. Several small erosions are seen near urethral opening. No abnormal discharge or mass are noted. Biopsy of the skin reveal thin epidermis with loss of rete ridges. The dermis appears to be fibrotic. No cytological atypia is seen. What is likely to occur if she is not treated?

A. Ascending infection to peritoneal cavity

B. Deep invasion

C. Distant metastasis

D. Sepsis

E. Squamous cell carcinoma development

13. A 59-year-old woman presents with vulva pruritus for three months. She has history of type II diabetes for 15 years, oral candidiasis 1 year ago, and multiple melanoma of chest, arms since age 45. She denies any other significant medical history. Physical examination reveals a wide erythematous rash involving both labia. No erosion or ulceration is noted. Biopsy of her labia reveals slightly thickened epidermis with parakeratosis and scattered cells with pale cytoplasm and slightly atypical hyperchromic nuclei. Per immunohistochemistry, these pale cells are positive for cytokeratin and negative for S-100. What is the most likely diagnosis?

A. Candidiasis

B. Lichen sclerosus

C. Metastatic melanoma

D. Paget disease

E. Trichomoniasis

14. Use this case for the next two questions. A 1-year-old girl presents with intermittent vaginal bleeding for 3 months. She was born full term without complications. Physical examination reveals normal development. A 1.3 cm mass is seen in the distal portion of her vagina. The mass have a lobulated surface. Ulceration is focally seen. Biopsy of the mass reveal sheets of small undifferentiated cells underneath normal squamous mucosa. Per immunuhistochemistry, these cells are positive for vimentin, but negative for cytokeratin, CD45 and synaptophysin. What additional protein is most likely to be expressed by these cells?

A. CD3

B. CD20

C. Desmin

D. EBV antigen

E. S100

15. A 1-year-old girl presents with intermittent vaginal bleeding for 3 months. She was born full term without complications. Physical examination reveals normal development. A 1.3 cm mass is seen in the distal portion of her vagina. The mass have a lobulated surface. Ulceration is focally seen. Biopsy of the mass reveal sheets of small undifferentiated cells underneath normal squamous mucosa. Per immunuhistochemistry, these cells are positive for vimentin, but negative for cytokeratin, CD45, CD99 and synaptophysin. What is the diagnosis?

A. Burkitt lymphoma

B. Ewing sarcoma

C. Sarcoma botryoides

D. Small cell carcinoma

E. Small lymphocytic lymphoma

16. A 25-year-old woman presents for colposcopic examination due to abnormal pap test results. Her past medical history is unremarkable. She is sexually active with multiple partners. Colposcopic examination reveals a 0.7 cm growth at the posterior lip of her cervical os. Biopsy of the growth reveal finger like projects with fibrovascular core and squamous epithelium. The squamous cells have abundant cytoplasm and appear to maintain normal polarity. Some cells in the superficial portion have slightly enlarged hyperchromic nuclei and sharply demarcated cytoplasmic clear vacuoles. What is the most likely diagnosis?

A. Cervical adenocarcinoma in situ

B. Condyloma

C. High grade squamous intraepithelial lesion

D. Sarcoma botryoides

E. Squamous cell carcinoma

17. Use this case for the next four questions. A 34-year-old woman presents with abnormal pap test results. She has a history of infectious mononucleosis at age 18. She is an intravenous drug user and has been HIV positive for 10 years. She is sexually active with multiple sexual partners. She does not smoke cigarette but drinks wines 2 glasses per day. She has several aunt at the maternal side with breast cancers and ovarian cancers. Physical and colposcopic examination are unremarkable. Multiple cervical biopsies were taken. One of the biopsies reveal full thickness squamous cell atypia, characterized by increased nuclear/cytoplasmic ratio, enlarged hyperchromic nuclei with irregular nuclear membrane. A few mitosis are seen at the upper third levels. No evidence of invasion is noted. What is the diagnosis?

A. Cervical adenocarcinoma in situ

B. Chronic cervicitis with reactive atypia

C. Condyloma

D. High grade cervical intraepithelial neoplasia

E. Squamous cell carcinoma

18. A 34-year-old woman presents with abnormal pap test results. She has a history of infectious mononucleosis at age 18. She is an intravenous drug user and has been HIV positive for 10 years. She is sexually active with multiple sexual partners. She does not smoke cigarette but drinks wines 2 glasses per day. She has several aunt at the maternal side with breast cancers and ovarian cancers. Physical and colposcopic examination are unremarkable. Multiple cervical biopsies were taken. One of the biopsies reveal full thickness squamous cell atypia, characterized by increased nuclear/cytoplasmic ratio, enlarged hyperchromic nuclei with irregular nuclear membrane. A few mitosis are seen at the upper third levels. No evidence of invasion is noted. What is the most important risk factor in her history that is associated with her findings?

A. Alcohol usage

B. Family history of gynecological cancers

C. History of infectious mononucleosis

D. Multiple sexual partners

E. Status of HIV infection

19. A 34-year-old woman presents with abnormal pap test results. She has a history of infectious mononucleosis at age 18. She is an intravenous drug user and has been HIV positive for 10 years. She is sexually active with multiple sexual partners. She does not smoke cigarette but drinks wines 2 glasses per day. She has several aunt at the maternal side with breast cancers and ovarian cancers. Physical and colposcopic examination are unremarkable. Multiple cervical biopsies were taken. One of the biopsies reveal full thickness squamous cell atypia, characterized by increased nuclear/cytoplasmic ratio, enlarged hyperchromic nuclei with irregular nuclear membrane. A few mitosis are seen at the upper third levels. No evidence of invasion is noted. What is the most like associated with her findings?

A. Genetic abnormality of BRCA gene

B. EB virus

C. Human herpes virus

D. Human immunodeficiency virus

E. Human papilloma virus

20. A 34-year-old woman presents with abnormal pap test results. She has a history of infectious mononucleosis at age 18. She is an intravenous drug user and has been HIV positive for 10 years. She is sexually active with multiple sexual partners. She does not smoke cigarette but drinks wines 2 glasses per day. She has several aunt at the maternal side with breast cancers and ovarian cancers. Physical and colposcopic examination are unremarkable. Multiple cervical biopsies were taken. One of the biopsies reveal full thickness squamous cell atypia, characterized by increased nuclear/cytoplasmic ratio, enlarged hyperchromic nuclei with irregular nuclear membrane. A few mitosis are seen at the upper third levels. No evidence of invasion is noted. What additional stain pattern of the epithelium is expected?

A. Diffuse reactivity to Herpes virus antigen

B. Diffuse reactivity to p16

C. Diffuse reactivity to p53

D. Focal reactivity of EBV antigen

E. Fungal hyphae in superficial layer

21. A 29-year-old woman presents for colposcopic examination due to abnormal Pap test results and positive concurrent HPV test. She has a history of cervical condyloma 5 years ago, and endometriosis for 10 years. No significant gross abnormalities are noted. Biopsies were performed at 12, 3, 6 and 9 o'clock position. Microscopically the squamous epithelium is unremarkable. The endocervical glands have normal architecture and lined by cells with elongated hyperchromic nuclei. Nuclear overlapping is noted. There is no evidence of invasion. No endometrial type stroma or hemorrhage is noted. What is the diagnosis?

A. Condyloma

B. Endocervical adenocarcinoma in situ

C. Endometriosis

D. Invasive endocervical adenocarcinoma

E. Squamous cell carcinoma

22. Use this case for the next four questions. A 59-year-old woman presents with intermittent dry cough, 15 lb weight loss and watery malodorous vaginal discharge for 2 months. She has a history of pulmonary adenocarcinoma 10 years ago that was treated with surgery and chemotherapy. She is not currently sexually active and has not seen a physician for 5 years. She used to smoke cigarette 1 pack a day for 25 years, but quitted 10 years ago. She denies alcohol usage. Speculum examination reveals a 2.5 cm exocervical exophytic mass with focal ulceration. Chest CT reveal multiple nodules at the peripheral of lungs. Biopsy of the growth reveals irregular nests of atypical cells with marked pleomorphism, abundant cytoplasm, and necrosis. Intercellular bridges are seen. What is most likely the diagnosis?

A. Cervical adenocarcinoma

B. Cervical condyloma

C. Cervical squamous cell carcinoma

D. Metastatic small cell carcinoma of lung

E. Trichomoniasis

23. A 59-year-old woman presents with intermittent dry cough, 15 lb weight loss and watery malodorous vaginal discharge for 2 months. She has a history of pulmonary adenocarcinoma 10 years ago that was treated with surgery and chemotherapy. She is not currently sexually active and has not seen a physician for 5 years. She used to smoke cigarette 1 pack a day for 25 years, but quitted 10 years ago. She denies alcohol usage. Speculum examination reveals a 2.5 cm exocervical exophytic mass with focal ulceration. Chest CT reveal multiple nodules at the peripheral of lungs. Biopsy of the growth reveals irregular nests of atypical cells with marked pleomorphism, abundant cytoplasm, and necrosis. Intercellular bridges are seen. What is the most likely finding of her lung lesions?

A. Adenocarcinoma of lung

B. Bronchopneumonia

C. Mesothelioma

D. Metastatic squamous cell carcinoma

E. Pneumonia

24. A 59-year-old woman presents with intermittent dry cough, 15 lb weight loss and watery malodorous vaginal discharge for 2 months. She has a history of pulmonary adenocarcinoma 10 years ago that was treated with surgery and chemotherapy. She is not currently sexually active and has not seen a physician for 5 years. She used to smoke cigarette 1 pack a day for 25 years, but quitted 10 years ago. She denies alcohol usage. Speculum examination reveals a 2.5 cm exocervical exophytic mass with focal ulceration. Chest CT reveal multiple nodules at the peripheral of lungs. Biopsy of the growth reveals irregular nests of atypical cells with marked pleomorphism, abundant cytoplasm, and necrosis. Intercellular bridges are seen. What is the most likely associated with her cervical lesion?

A. Cigarette smoking

B. Estrogen effects

C. EGFR mutation

D. Human papilloma virus

E. Trichomonas vaginalis

25. A 59-year-old woman presents with intermittent dry cough, 15 lb weight loss and watery malodorous vaginal discharge for 2 months. She has a history of pulmonary adenocarcinoma 10 years ago that was treated with surgery and chemotherapy. She is not currently sexually active and has not seen a physician for 5 years. She used to smoke cigarrete 1 pack a day for 25 years, but quitted 10 years ago. She denies alcohol usage. Speculum examination reveals a 2.5 cm exocervical exophytic mass with focal ulceration. Chest CT reveal multiple nodules at the peripheral of lungs. Biopsy of the growth reveals irregular nests of atypical cells with marked pleomorphism, abundant cytoplasm, and necrosis. Intercellular bridges are seen. What molecular pathway is most likely associated with the pathogenesis of her cervical lesion?

A. Activation of EGFR by mutation

B. Activation of Rb by E7

C. Inactivation of telomerase by mutation

D. Increased degradation of p53 by E6

E. Loss of function of PTEN

26. A 38-year-old woman presents with intermittent post-coital vaginal bleeding for 3 months. She denies history of abnormal vaginal sensation or discharge. She has a history of high grade cervical intraepithelial neoplasm 6 years ago that was treated with cone resection. She was diagnosed as polycystic ovarian disease at age 21. Her past medical history is otherwise unremarkable. Physical examination is unremarkable. Speculum examination reveal a 1.3 cm exophytic mass protruding out of cervical os. Biopsy of the lesion reveal irregular nests of atypical cells. Focally there are glandular appearing growth. These cells have enlarged hyperchromic nuclei with irregular nuclear shape and size. No intercellular bridges are seen. Per immunohistochemistry, these cells have diffuse strong reactivity to p16, but negative for p53. What is the most likely diagnosis?

A. Endocervical adenocarcinoma in situ

B. Endometrial serous carcinoma

C. Endometrioid adenocarcinoma

D. Invasive endocervical adenocarcinoma

E. Squamous cell carcinoma

Answers

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