Practice questions II, female genital tract
Practice questions II, female genital tract
Pathology of uterus
© Jun Wang, MD, PhD
1. A
25-year-old woman presents with lower abdominal pain associated with fever and
chills for 1 day. She had a spontaneous abortion 3 days ago. Her past medical
history is otherwise unremarkable. Per physical examination, she appears to be
acutely ill with slightly tender lower abdomen. Speculum examination reveals
small amount of purulent exudate pooled in the vaginal vault. Bimanual
examination reveals extreme tenderness on cervical movement. No mass is noted. No
other abnormality is noted. Laboratory test results include a white cell count
at 17 x 109/L (normal 4.7-10.5 x 109/L) with 85% mature neutrophils and 5%
bands. Toxic granulation is seen. No other abnormality is noted. What is the
most likely finding in her endometrium?
A. Increase
of endometrial glands with budding and branching
B. Increase
of irregular endometrial glands with glandular fusion and cytological atypia
C. Increase
of simple tubular endometrial glands
D.
Neutrophilic infiltrate of endometrium with focal microabscess formation
E. Normal
proliferative endometrium
2. A
35-year-old woman presents with irregular vaginal bleeding for 6 months. She
denies other symptoms. Her past medical history is unremarkable. Endometrial
biopsy reveals scattered tubular proliferative type glands in a stroma with
lymphocytic and plasmacytic infiltration. No tubular budding or branching, or
cytological atypia is noted. What is the most likely cause of her
presentations?
A. Abnormal
estrogen effects
B. Chronic
endometritis
C. Complex
endometrial hyperplasia
D.
Endometrioid adenocarcinoma
E. Simple
endometrial hyperplasia
3. Use this case for the next two questions.
A 37-year-old nulliparous woman presents with progressive abdominal pain for 6
years, sometimes associated with urinary frequency. She has a history of
cervical adenocarcinoma in situ 10 years ago, that was treated with cone
biopsy. She has a history of menorrhagia and dysmenorrhea for 10 years. Her
past history is otherwise unremarkable. Physical examination reveal a slightly
distended abdomen. No evidence of hepatomegaly or splenomegaly is noted.
Sonographic examination reveals small amount of ascites. Laparoscopic
examination reveal multiple red nodules measuring up to 1.1 cm in greatest
dimension at the peritoneum covering posterior urinary bladder and lateral
pelvic walls. Biopsy of these nodules reveal tubular glands lined by cuboidal
epithelial cells in a background of endometrial type stroma. Hemorrhagic
changes are seen. No glandular irregularity or cytological atypia are noted.
What is the most likely diagnosis?
A.
Endometriosis
B.
Hemangioma
C. Metastatic
endocervical adenocarcinoma
D.
Metastatic endometrial adenocarcinoma
E.
Metastatic endometrial serous carcinoma
4. A
37-year-old nulliparous woman presents with progressive abdominal pain for 6
years, sometimes associated with urinary frequency. She has a history of
cervical adenocarcinoma in situ 10 years ago, that was treated with cone
biopsy. She has a history of menorrhagia and dysmenorrhea for 10 years. Her
past history is otherwise unremarkable. Physical examination reveal a slightly
distended abdomen. No evidence of hepatomegaly or splenomegaly is noted.
Sonographic examination reveals small amount of ascites. Laparoscopic
examination reveal multiple red nodules measuring up to 1.1 cm in greatest
dimension at the peritoneum covering posterior urinary bladder and lateral
pelvic walls. Biopsy of these nodules reveal tubular glands lined by cuboidal
epithelial cells in a background of endometrial type stroma. Hemorrhagic
changes are seen. No glandular irregularity or cytological atypia are noted.
What molecular abnormality is likely to be seen in these lesions?
A. E-cadherin
B. Her2
C. p16
D. p53
E. PTEN
5. A
42-year-old G2P2 woman presents with pelvic pain for 6 months. She denies
history of irregular vaginal bleeding, vaginal discharge or weight loss. She
has a history of dysmenorrhea for 10 years. Physical examination is
unremarkable except pallor skin. Sonographic examination reveals an enlarged
globular uterus. A hysterectomy was performed and reveal a uterus with spongy
nodular areas in the myometrium. Microscopically, these areas contains benign
appearing tubular glands lined by cuboidal epithelial cells in a background of
endometrial type stroma. Hemorrhagic changes are seen. No glandular
irregularity or cytological atypia are noted. The endometrium is unremarkable.
What is the most likely diagnosis?
A.
Adenomyosis
B.
Endometrial stromal nodule
C. Invasive
endometrioid adenocarcinoma
D. Leiomyoma
E.
Leiomyosarcoma
6. A
57-year-old woman presents with irregular vaginal bleeding for 4 months. Her
past medical history is unremarkable. Physical examination reveals no
significant abnormality. Sonographic examination reveals a 1.5 cm exophytic
growth in the uterine cavity. Endometrial biopsy reveals a polypoid lesion with
fibrotic stroma and a few scattered tubular glands lined by flat to cuboidal
epithelium. Some glands are dilated. Clusters of thick-walled blood vessels are
focally seen. There is no evidence of glandular crowding, budding, branching or
cytological atypia. What is the most likely diagnosis?
A. Complex
endometrial hyperplasia
B.
Endometrial polyp
C.
Endometrioid adenocarcinoma
D.
Hemangioma
E. Simple endometrial
hyperplasia
7. A
63-year-old woman presents with vaginal spotting. She denies history of vaginal
discharge. She has been using estrogen replacement for 11 years. Her past
history is otherwise unremarkable. Physical examination reveal no significant
abnormalities. Sonographic examination reveals thickened endometrium. No discrete
mass is identified. Endometrial biopsy reveals increase of tubular glands lined
by normal appearing epithelial cells. Focally the glands appear to be crowded,
but no glandular budding or branching is seen. What is the most likely
diagnosis?
A. Complex
endometrial hyperplasia
B.
Endometrial atrophy
C.
Endometrial polyp
D.
Endometrioid adenocarcinoma
E. Simple
endometrial hyperplasia
8. Use this case for the next three questions.
A 48-year-old nulliparous overweight woman (body mass index 37.2) presents with
vaginal spotting for 3 months. She denies other symptoms. She has a history of
polycystic ovarian disease. Physical examination reveals no significant
abnormality. Sonographic examination reveal thickening of endometrium without
discrete mass. Endometrial biopsy reveals crowded irregular glands with budding
and branching lined by epithelial cells containing nuclei with various size and
shape. No glandular fusion, squamous metaplasia or necrosis is noted. What is
the most likely diagnosis?
A. Complex
endometrial hyperplasia
B.
Dysfunctional uterine bleeding
C.
Endometrial polyp
D.
Endometritis
E. Well
differentiated endometrioid adenocarcinoma
9. A
48-year-old nulliparous overweight woman (body mass index 37.2) presents with
vaginal spotting for 3 months. She denies other symptoms. She has a history of
polycystic ovarian disease. Physical examination reveals no significant abnormality.
Sonographic examination reveal thickening of endometrium without discrete mass.
Endometrial biopsy reveals crowded irregular glands with budding and branching
lined by epithelial cells containing nuclei with various size and shape. No
glandular fusion, squamous metaplasia or necrosis is noted. What is most likely
associated with her endometrial changes?
A. Atrophic
changes
B. Chronic
inflammation
C. Estrogen
effects
D. Human
papilloma virus
E.
Progesterone effects
10. A
48-year-old nulliparous overweight woman (body mass index 37.2) presents with
vaginal spotting for 3 months. She denies other symptoms. She has a history of
polycystic ovarian disease. Physical examination reveals no significant
abnormality. Sonographic examination reveal thickening of endometrium without
discrete mass. Endometrial biopsy reveals crowded irregular glands with budding
and branching lined by epithelial cells containing nuclei with various size and
shape. No glandular fusion, squamous metaplasia or necrosis is noted.
Abnormality of what gene is most likely associated with these changes?
A.
E-cadherin
B. Her2
C. p16
D. p53
E. PTEN
11. Use this case for the next three questions.
A 69-year-old woman presents with uterine bleeding for 3 months. She has a
history of stage I colon adenocarcinoma 10 years ago that was treated with
colectomy. She does not smoke cigarette but has been drinking wine two glasses
a day for the last 15 years. She is overweight with a BMI of 35.5. Physical examination
reveals normal size uterus. Sonographic examination reveals slightly thickened
endometrium, and a few well-demarcated nodule within myometrium. No other
abnormalities are noted. Endometrial biopsy reveals crowded complex glands with
focal solid area and squamous metaplasia. These glands are lined by cells with
nuclei that are markedly variable in size, shape and chromatin pattern.
Necrosis and atypical mitosis are seen. What is the most likely cause of her
uterine bleeding?
A. Atrophy
B. Complex endometrial
hyperplasia
C.
Endometrioid adenocarcinoma
D. Leiomyoma
E.
Metastatic colon cancer
F. Serous
carcinoma
12. A
69-year-old woman presents with uterine bleeding for 3 months. She has a
history of stage I colon adenocarcinoma 10 years ago that was treated with
colectomy. She does not smoke cigarette but has been drinking wine two glasses
a day for the last 15 years. She is overweight with a BMI of 35.5. Physical
examination reveals normal size uterus. Sonographic examination reveals
slightly thickened endometrium, and a few well-demarcated nodule within
myometrium. No other abnormalities are noted. Endometrial biopsy reveals
crowded complex glands with focal solid area and squamous metaplasia. These
glands are lined by cells with nuclei that are markedly variable in size, shape
and chromatin pattern. Necrosis and atypical mitosis are seen. Thorough work up reveals no evidence of abnormality involving other sites. Abnormality of
what gene/genes is likely to be associated with her endometrial changes?
A.
E-cadherin
B. Her2
C.
Microsatellite instability genes
D. p16
E. p53
13. A
69-year-old woman presents with uterine bleeding for 3 months. She has a
history of stage I colon adenocarcinoma 10 years ago that was treated with
colectomy. She does not smoke cigarette but has been drinking wine two glasses
a day for the last 15 years. She is overweight with a BMI of 35.5. Physical
examination reveals normal size uterus. Sonographic examination reveals
slightly thickened endometrium, and a few well-demarcated nodule within
myometrium. No other abnormalities are noted. Endometrial biopsy reveals
crowded complex glands with focal solid area and squamous metaplasia. These
glands are lined by cells with nuclei that are markedly variable in size, shape
and chromatin pattern. Necrosis and atypical mitosis are seen. For this
patient, what is the most significant risk factor for her endometrial changes?
A. Alcohol
usage
B. History
of colon cancer
C.
Myometrial tumors
D. Obesity
E.
Post-menopausal status
14. Use this case for the next three questions.
A 71-year-old woman presents with intermittent dry cough and vaginal bleeding
for 6 months. She denies history of fever or chest/abdominal pain. She has lost
20 pound weight unintentionally in the last 3 months. She has a history of
adenocarcinoma of lung 15 years ago that was treated with surgery and
chemotherapy. Physical examination reveals no significant abnormalities. Chest
CT reveals 2 nodules at the peripheral of her lower lobe of right lung.
Sonographic examination reveals a focal bulging area of her posterior
endometrium. The uterus is small without myometrium lesions. Endometrial biopsy
of the bulging area reveal finger like projects lined by markedly atypical
cells. Focally there are solid area, calcification, and necrosis. CT guided
biopsy of the lung nodule reveals similar findings. Per immunohistochemistry,
these cells are positive for cytokeratin but negative for TTF1. What is the most likely cause of her vaginal
bleeding?
A.
Endometrial atrophy
B. Complex
endometrial hyperplasia
C.
Metastatic adenocarcinoma of lung to endometrium
D. Serous
endometrial carcinoma
E. Simple
endometrial hyperplasia
15. A
71-year-old woman presents with intermittent dry cough and vaginal bleeding for
6 months. She denies history of fever or chest/abdominal pain. She has lost 20
pound weight unintentionally in the last 3 months. She has a history of
adenocarcinoma of lung 15 years ago that was treated with surgery and
chemotherapy. Physical examination reveals no significant abnormalities. Chest
CT reveals 2 nodules at the peripheral of her lower lobe of right lung.
Sonographic examination reveals a focal bulging area of her posterior
endometrium. The uterus is small without myometrium lesions. Endometrial biopsy
of the bulging area reveal finger like projects lined by markedly atypical
cells. Focally there are solid area, calcification, and necrosis. CT guided
biopsy of the lung nodule reveals similar findings. Per immunohistochemistry,
these cells are positive for cytokeratin but negative for TTF1. What is most
likely to be found in the rest of endometrium?
A. Polypoid
endometrium with cystically dilated glands and fibrous stroma containing
clusters of thick-walled vessels
B. Thick
endometrium with complex glands, lined by atypical cells, with focal squamous
metaplasia
C. Thick
endometrium with tortuous glands lined by cuboidal to columnar cells without
atypia, luminal secretion, and edematous endometrial stroma
D. Thin
endometrium with regular tubular glands lined by cuboidal cells with focal
mitotic activity
E. Thin
endometrium with scant inactive endometrial glands
16. A
71-year-old woman presents with intermittent dry cough and vaginal bleeding for
6 months. She denies history of fever or chest/abdominal pain. She has lost 20
pound weight unintentionally in the last 3 months. She has a history of
adenocarcinoma of lung 15 years ago that was treated with surgery and
chemotherapy. Physical examination reveals no significant abnormalities. Chest
CT reveals 2 nodules at the peripheral of her lower lobe of right lung.
Sonographic examination reveals a focal bulging area of her posterior
endometrium. The uterus is small without myometrium lesions. Endometrial biopsy
of the bulging area reveal finger like projects lined by markedly atypical
cells. Focally there are solid area, calcification, and necrosis. CT guided
biopsy of the lung nodule reveals similar findings. Per immunohistochemistry,
these cells are positive for cytokeratin but negative for TTF1. What is the
most likely associated with her presentations?
A. EGFR
mutation
B. p53
mutation
C. Previous
history of adenocarcinoma of lung
D. Previous
history of chemotherapy
E. Prolonged
estrogen effects
17. A
66-year-old woman presents with intermittent vaginal bleeding for 3 months. She
denies vaginal discharge, abdominal pain or urinary symptoms. She has a history
of endometrial polyp 7 years ago. Her past medical history is otherwise
unremarkable. Physical examination is unremarkable. Pelvic sonographic
examination reveal a normal-sized uterus with a polypoid growth at her anterior
endometrium. Biopsy of the polypoid growth reveals nests of atypical cells with
clear cytoplasm. Glandular formation is focally seen. What is the most likely
diagnosis?
A. Atrophy
B. Clear
cell carcinoma
C. Complex
endometrial hyperplasia
D.
Endometrial polyp
E. Well
differentiated endometrioid adenocarcinoma
18. A
72-year-old woman presents with fatigue, vague lower abdominal pain and
intermittent vaginal bleeding for 3 months. She denies history of vaginal
discharge or weight changes. She has a history of invasive ductal carcinoma of
left breast 15 years ago that was treated with surgery and radiation therapy.
Her past medical history is otherwise unremarkable. Physical examination
reveals no significant abnormalities. Sonographic examination reveals a 5 cm
endometrial mass. Biopsy of the mass reveals hypercellular stroma with marked
cytological atypia, brisk mitosis and foci of necrosis. There are scattered
irregular glands lined by markedly atypical epithelial cells. What is the most
likely diagnosis?
A. Complex
endometrial hyperplasia
B.
Endometrial polyp
C.
Endometrioid adenocarcinoma
D. Malignant
mixed mullerian tumor
E.
Metastatic ductal carcinoma
19. Use this case for the next two questions.
A 47-year-old woman presents with fatigue, vague lower abdomen pain and
irregular uterine bleeding for 5 months. She denies abnormal urinary symptoms
and bowel movement. She has a history of endometriosis that was treated with
oral contraceptives. Physical examination reveals an enlarged uterus with
nodular appearance. Laboratory examination reveals a hemoglobin at 8.5g/dL
(normal 12-16 g/dL). No other abnormalities are noted. A hysterectomy was
performed and reveal multiple well-circumscribed myometrial and subendometrial
round to oval firm nodules, up to 5.6 cm in diameter. Microscopically these
nodules are composed of well-organized spindle cells with cigar-shaped nuclei.
No cytological atypia or necrosis are noted. What is the diagnosis?
A.
Adenomyosis
B.
Endometrial hyperplasia
C.
Endometrial stromal tumor
D.
Leiomyomata
E.
Leiomyosarcoma
20. A
47-year-old woman presents with fatigue, vague lower abdomen pain and irregular
uterine bleeding for 5 months. She denies abnormal urinary symptoms and bowel
movement. She has a history of endometriosis that was treated with oral
contraceptives. Physical examination reveals an enlarged uterus with nodular
appearance. Laboratory examination reveals a hemoglobin at 8.5g/dL (normal
12-16 g/dL). No other abnormalities are noted. A hysterectomy was performed and
reveal multiple well-circumscribed myometrial and subendometrial round to oval
firm nodules, up to 5.6 cm in diameter. Microscopically these nodules are
composed of well-organized spindle cells with cigar-shaped nuclei. No
cytological atypia or necrosis are noted. What is the cause of her anemia?
A. Chronic
blood loss
B. Folate
deficiency
C.
Hemoglobinopathy
D. Iron deficiency
E. Vitamin
B12 deficiency
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