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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