Practice questions II answers, female genital tract

Practice questions II answers, female genital tract

Pathology of uterus

© Jun Wang, MD, PhD

1. D. This patient presents with symptoms, signs and laboratory findings of acute inflammation. With the history of recent abortion, and tenderness on cervical movement, it is most likely acute endometritis, characterized by neutrophilic infiltrate of endometrium. Increased endometrial glands with budding and branching is seen in complex endometrial hyperplasia. Increase of irregular endometrial glands with glandular fusion and cytological atypia is seen in endometrioid endometrial adenocarcinoma. Increase of simple tubular endometrial glands is seen in simple endometrial hyperplasia. Normal proliferative endometrium would not cause symptoms of acute inflammation.

2. B. Presence of plasma cells in endometrium in an otherwise healthy patient is highly suggestive of chronic endometritis. Other conditions listed have changes of the number or morphology of endometrial glands, but usually do not cause plasmacytic endometrium infiltration.

3. A. History of dysmenorrhea may be suggestive of endometriosis, and biopsy finding of benign endometrial glands and stroma, as well as hemorrhagic changes at a location outside uterine cavity confirms the diagnosis. Hemangioma has proliferation of vessels, not endometrial tissue. Metastatic endocervical adenocarcinoma and endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia. Metastatic serous carcinoma usually have nests or cord of markedly atypical cells.

4. E. Endometriosis may carry the same molecular abnormalities as endometrial hyperplasia and endometrioid endometrial adenocarcinoma, a type I malignancy, that is commonly associated with mutations of PTEN and MSI genes. Abnormalities of E-cadherin, Her2, p53 and p16 are more likely seen in type II endometrial carcinomas, including serous carcinoma and clear cell carcinoma. Higher level of p16 can also be seen in endocervical adenocarcinoma.

5. A. Benign endometrial glands and stroma, as well as hemorrhagic changes in myometrium is consistent with adenomyosis. Endometrial stroma nodule is a well-circumscribed endometrial lesion composed of endometrial stroma like tissue (small round to oval nuclei) only. Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia. Leiomyoma has benign spindle cells with cigar-shaped nuclei without significant atypia. Leiomyosarcoma has marked atypia, brisk mitosis and necrosis. Both are smooth muscle neoplasms without glandular components.

6. B. Polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels is most likely endometrial polyp. Endometrial hyperplasia has increased endometrial glands, with (complex) or without (simple) architectural complexity. Hemangioma has proliferation of vessels, not endometrial tissue. Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia.

7. E. Increase of simple tubular endometrial glands without budding and complex branching is seen in simple endometrial hyperplasia. Increased endometrial glands with budding and branching are seen in complex endometrial hyperplasia. Endometrial atrophy has thin endometrial with inactive tubular endometrial glands. Endometrial polyp is a polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels. Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia.

8. A. Nulliparous status and obesity are suggestive of higher level/period of estrogen effects on endometrium and other organs. Crowded endometrial glands with budding and branching are seen in complex endometrial hyperplasia. Dysfunctional uterine bleeding is a clinical term with pathological findings of endometrial glandular and stromal development dyssynchrony. Endometrial polyp is a polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels.  Endometritis has inflammatory changes, but not glandular proliferation. Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia.

9. C. Endometrial hyperplasia and endometrioid endometrial adenocarcinoma are associated with estrogen effects. Atrophic endometrium is usually seen in the background of patient with serous carcinoma. Human papillomavirus infection causes cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas. Chronic endometritis and progesterone are not associated with endometrial neoplasms.

10. E. See discussion in question 4.

11. C. Glandular fusion is consistent with endometrioid endometrial adenocarcinoma, that commonly has benign squamous metaplasia. Endometrial atrophy has thin endometrial with inactive tubular endometrial glands. Complex endometrial hyperplasia have complex glandular architecture, but all glands are separated by various amount of stroma. Leiomyoma is myometrial smooth muscle tumor with benign spindle cells with cigar-shaped nuclei without significant atypia. Metastatic colon cancer has mucinous glands and usually do not have squamous metaplasia. Serous carcinoma usually have papillary growth, and nests or cord of markedly atypical cells, without glandular differentiation.

12. C. See discussion in question 4.

13. D. Obesity are suggestive of higher level of estrogen effects on endometrium and other organs, and is a risk factor for endometrioid endometrial adenocarcinoma.

14. D. Papillary endometrial growth with markedly atypical cells is consistent with serous carcinoma. Endometrial atrophy has thin endometrial with inactive tubular endometrial glands. Endometrial hyperplasia has increased endometrial glands, with (complex) or without (simple) architectural complexity, but not papillary growth. Metastatic lung adenocarcinoma is positive for TTF1.

15. E. Serous endometrial carcinoma is estrogen independent and usually arise in atrophic endometrium. Polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels is most likely endometrial polyp.  Thick endometrium with complex glands, lined by atypical cells, with focal squamous metaplasia is usually seen in endometrioid endometrial adenocarcinoma. Thick endometrium with tortuous glands lined by cuboidal to columnar cells without atypia, luminal secretion, and edematous endometrial stroma is characteristic for normal secretory phase endometrium. Thin endometrium with regular tubular glands lined by cuboidal cells with focal mitotic activity is consistent with normal early proliferative phase endometrium.

16. B. Serous endometrial carcinoma is associated with p53 abnormality or previous radiation therapy. EGFR mutation is seen in adenocarcinoma of lung. Prolonged estrogen effects are associated with endometrial hyperplasia and endometrioid endometrial adenocarcinoma.

17. B. Endometrial growth of atypical glandular cells with clear cytoplasm is likely clear cell carcinoma. Endometrial atrophy has thin endometrial with inactive tubular endometrial glands. Endometrial hyperplasia has increased endometrial glands, with (complex) or without (simple) architectural complexity, but not clear cells. Endometrial polyp is a polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels.  Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia, but not clear or hobnail cells.

18. D. Malignant mixed mullerian tumor is a biphasic tumor with malignant epithelial and stromal components. Metastatic ductal carcinoma to endometrium is extremely rare. It has feature of ductal carcinoma and the stroma is benign. Endometrial hyperplasia has increased endometrial glands, with (complex) or without (simple) architectural complexity, but not clear cells. Endometrial polyp is a polypoid growth with dilated glands with flat to cuboidal glandular cells, fibrotic stroma and thick-walled vessels.  Endometrioid endometrial adenocarcinoma have features of adenocarcinoma, such as irregular glandular formation with cytological atypia, but not clear or hobnail cells.

19. D. Well-circumscribe spindle cell tumor with cigar-shaped nuclei, without cytological atypia is most consistent with leiomyoma (leiomyomata if multiple). Adenomyosis is benign endometrial glands and stroma, as well as hemorrhagic changes in myometrium. Endometrial hyperplasia has increased endometrial glands, with (complex) or without (simple) architectural complexity, but not clear cells. Endometrial stroma tumor has endometrial stroma like tissue (small round to oval nuclei) with (endometrial stromal sarcoma) or without (endometrial stromal nodule) invasion. Leiomyosarcoma has marked atypia, brisk mitosis and necrosis.

20. A. In a patient with irregular uterine bleeding due to subendometrial leiomyoma, the cause of possible anemia is likely to be chronic bleeding. Folate deficiency, iron deficieny, hemoglobinopathy and vitamin 12 deficiency usually have abnormal red cell morphology.

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