Practice questions III answers, female genital tract
Practice questions III answers, female genital tract
Pathology of Ovary A
© Jun Wang, MD, PhD
1. B. A single ovarian cyst lined by benign follicular cells is a follicular cyst. Endometrioid cyst (endometrioma, chocolate cyst) is ovarian endometriosis, typical has benign endometrial glands and stroma, as well as hemorrhagic changes. Luteal cyst is lined by luteinized granulosa cells and theca cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei. Mucinous cystadenoma is usually multilocular with thick fluid contents, and lined by columnar benign mucinous cells. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia.
2. C. Ovarian cyst in young woman, lined by benign cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei, and central hemorrhagic changes is likely a luteal cyst. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation. Serous cystadenocarcinoma has cords and nests of markedly atypical cells, some form papillary architecture, but should not have mucin production.
4. E. Endometriosis may carry the same molecular abnormalities as endometrial hyperplasia and endometrioid endometrial adenocarcinoma, that is commonly associated with mutations of PTEN and MSI genes. Abnormalities of BRCA, p53 are likely seen in high grade serous carcinoma. CDKN2A (p16) is more commonly seen in mucinous cystadenocarcinoma and endocervical adenocarcinoma. KRAS mutation is more commonly seen in mucinous cystadenocarcinoma and low-grade serous carcinoma.
5. A. Presentation of elevated androgen effects (hirsutism, etc) in an overweight young woman is suggestive of polycystic ovary disease or stromal hyperthecosis. Ovarian finding of multiple follicular cysts is consistent with polycystic ovary disease, the most common cause of anovulatory infertility. Indeed, diabetes is also a feature of polycystic ovary disease. Luteal phase insufficiency usually does not have signs of abnormal androgen metabolism. Pelvic inflammatory disease is usually caused by infection and has relevant history.
6. C. Ovarian cystic changes seen in polycystic ovary disease are follicular cysts. Luteal cyst is lined by luteinized granulosa cells and theca cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei. Mucinous cystadenoma is usually multilocular with thick fluid contents, and lined by columnar benign mucinous cells. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia. Simple cyst, also called inclusion cyst, is a small ovarian cyst lined by single layer of flat to cuboidal cells.
7. A. Polycystic ovary disease is a disorder of abnormal metabolism of androgen and estrogen, and has overproduction of androgen. It has elevated LH, but FSH can be normal or low. Estrogen levels in patients with polycystic ovary disease are usually not elevated. Metaplasia of endometrial type tissue is probably associated with some cases of endometriosis.
8. B. Polycystic ovary disease is associated with endometrial hyperplasia and endometrial endometrioid adenocarcinoma. Clear cell carcinoma of ovary is associated with endometriosis and ovarian endometrioid adenocarcinoma.
9. B. Polycystic ovary disease has elevated androgen and LH, but FSH can be normal or low. Glucose intolerance in polycystic ovary disease is most likely caused by insulin resistance, not deficiency. Some recent studies demonstrate polycystic ovary disease may be a risk factor for autoimmune disorder of thyroid and subsequent hypothyroidism.
10. D. Signs of virilization in women can be resulted from polycystic ovary disease, stromal hyperthecosis or androgen producing ovarian tumor, such as Sertoli-Leydig cell tumor. Uniform ovarian enlargement in an older woman with signs of androgen overproduction is most consistent with stromal hyperthecosis. Polycystic ovary disease is usually seen in reproductive age and has multiple ovarian follicular cysts. Sertoli-Leydig cell tumor is commonly seen in young woman and has discrete ovarian mass. Brenner’s tumor and fibroma usually do not have abnormal hormone production. Granulosa cell tumor and thecoma usually have elevated estrogen levels. All four have discrete ovarian mass.
11. E. Unilocular ovarian cyst lined by single layer of flat or cuboidal cells without cytological atypia is consistent with serous cystadenoma. Although not common, hemorrhage may occur in serous cystadenoma. Endometrioid adenocarcinoma has irregular complex endometrioid type glands lined by atypical cells. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation. Serous cystadenocarcinoma has cords and nests of markedly atypical cells, some form papillary architecture, but should not have mucin production.
12. D. Presence of solid area raise the concern of malignancy. An ovarian cancer with atypical polygonal cells with papillary architecture is most likely serous cystadenocarcinoma. Since the nuclei are relative uniform, meaning lack of marked pleomorphism, it is like a low grade serous cystadenocarcinoma. Borderline serous tumor and serous cystadenoma do not invade. Endometrioid adenocarcinoma has irregular complex endometrioid type glands lined by atypical cells. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation.
13. B. Serous cystadenocarcinoma usually has elevated levels of CA125. AFP is elevated in yolk sac tumor and hepatocellular carcinoma. Elevated CEA may be associated with malignancies, such as ovarian mucinous adenocarcinoma. Elevated PLAP may be seen in dysgerminoma. Elevation of inhibin is seen in ovarian sex cord-stroma tumors and dysgerminoma.
14. B. BRAF mutation can be seen in serous cystadenocarcinoma. ARID1A and PTEN mutations are commonly seen in endometriosis and endometrioid adenocarcinoma. BRCA and p53 abnormalities are usually associated with high-grade serous cystadenocarcinoma.
15. E. High grade ovarian tumor with positive reactivity to WT1 is most consistent with high-grade serous cystadenocarcinoma. Borderline serous tumor do not have marked cytological atypia. Endometrioid adenocarcinoma is negative for WT1. Adenocarcinoma of lung is most likely positive for TTF1. Ovarian mucinous adenocarcinoma is usually positive for CA19.9.
16. D. High-grade serous cystadenocarcinoma is commonly positive for p53. AFP is expressed in yolk sac tumor and hepatocellular carcinoma. CEA is positive in various tumors, such as ovarian mucinous adenocarcinoma. Trophoblast diseases, including complete mole, partial mole and choriocarcinoma, or germ cell tumor trophoblast components, express hCG. PTEN is commonly associated with endometriosis and endometrioid adenocarcinoma.
17. C. HE4 may be elevated in serous cystadenocarcinoma and endometrioid adenocarcinoma. Elevated CEA may be associated with malignancies, such as ovarian mucinous adenocarcinoma. Trophoblast diseases, including complete mole, partial mole and choriocarcinoma, or germ cell tumor trophoblast components, may have elevated hCG. Elevation of inhibin is seen in ovarian sex cord-stroma tumors and dysgerminoma. LDH may be elevated in dysgerminoma.
18. A. WT1 positive papillary growth without marked cytological atypia and invasion is likely a borderline serous tumor. Mucinous adenocarcinoma is positive for CEA. Pelvic inflammatory disease does not tumor growth. Serous cystadenocarcinoma usually is invasive. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia, but no papillary growth with cytological atypia.
19. E. Borderline tumor should be staged as malignancy. For a young patient, hysterectomy is not recommended.
20. D. Ovarian cyst lined by benign mucinous cells, either intestinal type or endocervical type, is a mucinous cystadenoma. Mucinous adenocarcinoma, borderline mucinous tumor and endocervical adenocarcinoma have cytological atypia. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia, but no papillary growth with cytological atypia.
21. A. A mucinous lesion with papillary growth lined by moderately atypical cells without invasion is likely a borderline mucinous tumor. Serous tumors have cells without mucin production, and usually do not have elevated CEA and CA19.9. Mucinous adenomadoes not have enlarged hyperchromic nuclei.
22. C. An invasive ovarian tumor with positive reactivity to CA19.9 but negative for CA125 and WT1 is most likely mucinous adenocarcinoma. Borderline or benign tumors do not invade. Serous cystadenocarcinoma usually is positive for WT1 and CA125.
23. B. See discussion in question 17.
Pathology of Ovary A
© Jun Wang, MD, PhD
1. B. A single ovarian cyst lined by benign follicular cells is a follicular cyst. Endometrioid cyst (endometrioma, chocolate cyst) is ovarian endometriosis, typical has benign endometrial glands and stroma, as well as hemorrhagic changes. Luteal cyst is lined by luteinized granulosa cells and theca cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei. Mucinous cystadenoma is usually multilocular with thick fluid contents, and lined by columnar benign mucinous cells. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia.
2. C. Ovarian cyst in young woman, lined by benign cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei, and central hemorrhagic changes is likely a luteal cyst. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation. Serous cystadenocarcinoma has cords and nests of markedly atypical cells, some form papillary architecture, but should not have mucin production.
3. B. History of dysmenorrhea raise the
concern of endometriosis. Endometrioid cyst (endometrioma, chocolate cyst) is
ovarian endometriosis,
typically has benign endometrial glands and stroma, as well as hemorrhagic
changes. Endometrioid
adenocarcinoma has irregular complex endometrioid type glands lined
by atypical cells. An inclusion
cyst is a small ovarian cyst lined by single layer of flat to
cuboidal cells. Luteal
cyst is lined by luteinized granulosa cells and theca cells with
abundant eosinophilic granular cytoplasm and small round to oval nuclei. Mucinous
cystadenocarcinoma has markedly atypical cells with mucinous
differentiation.
4. E. Endometriosis may carry the same molecular abnormalities as endometrial hyperplasia and endometrioid endometrial adenocarcinoma, that is commonly associated with mutations of PTEN and MSI genes. Abnormalities of BRCA, p53 are likely seen in high grade serous carcinoma. CDKN2A (p16) is more commonly seen in mucinous cystadenocarcinoma and endocervical adenocarcinoma. KRAS mutation is more commonly seen in mucinous cystadenocarcinoma and low-grade serous carcinoma.
5. A. Presentation of elevated androgen effects (hirsutism, etc) in an overweight young woman is suggestive of polycystic ovary disease or stromal hyperthecosis. Ovarian finding of multiple follicular cysts is consistent with polycystic ovary disease, the most common cause of anovulatory infertility. Indeed, diabetes is also a feature of polycystic ovary disease. Luteal phase insufficiency usually does not have signs of abnormal androgen metabolism. Pelvic inflammatory disease is usually caused by infection and has relevant history.
6. C. Ovarian cystic changes seen in polycystic ovary disease are follicular cysts. Luteal cyst is lined by luteinized granulosa cells and theca cells with abundant eosinophilic granular cytoplasm and small round to oval nuclei. Mucinous cystadenoma is usually multilocular with thick fluid contents, and lined by columnar benign mucinous cells. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia. Simple cyst, also called inclusion cyst, is a small ovarian cyst lined by single layer of flat to cuboidal cells.
7. A. Polycystic ovary disease is a disorder of abnormal metabolism of androgen and estrogen, and has overproduction of androgen. It has elevated LH, but FSH can be normal or low. Estrogen levels in patients with polycystic ovary disease are usually not elevated. Metaplasia of endometrial type tissue is probably associated with some cases of endometriosis.
8. B. Polycystic ovary disease is associated with endometrial hyperplasia and endometrial endometrioid adenocarcinoma. Clear cell carcinoma of ovary is associated with endometriosis and ovarian endometrioid adenocarcinoma.
9. B. Polycystic ovary disease has elevated androgen and LH, but FSH can be normal or low. Glucose intolerance in polycystic ovary disease is most likely caused by insulin resistance, not deficiency. Some recent studies demonstrate polycystic ovary disease may be a risk factor for autoimmune disorder of thyroid and subsequent hypothyroidism.
10. D. Signs of virilization in women can be resulted from polycystic ovary disease, stromal hyperthecosis or androgen producing ovarian tumor, such as Sertoli-Leydig cell tumor. Uniform ovarian enlargement in an older woman with signs of androgen overproduction is most consistent with stromal hyperthecosis. Polycystic ovary disease is usually seen in reproductive age and has multiple ovarian follicular cysts. Sertoli-Leydig cell tumor is commonly seen in young woman and has discrete ovarian mass. Brenner’s tumor and fibroma usually do not have abnormal hormone production. Granulosa cell tumor and thecoma usually have elevated estrogen levels. All four have discrete ovarian mass.
11. E. Unilocular ovarian cyst lined by single layer of flat or cuboidal cells without cytological atypia is consistent with serous cystadenoma. Although not common, hemorrhage may occur in serous cystadenoma. Endometrioid adenocarcinoma has irregular complex endometrioid type glands lined by atypical cells. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation. Serous cystadenocarcinoma has cords and nests of markedly atypical cells, some form papillary architecture, but should not have mucin production.
12. D. Presence of solid area raise the concern of malignancy. An ovarian cancer with atypical polygonal cells with papillary architecture is most likely serous cystadenocarcinoma. Since the nuclei are relative uniform, meaning lack of marked pleomorphism, it is like a low grade serous cystadenocarcinoma. Borderline serous tumor and serous cystadenoma do not invade. Endometrioid adenocarcinoma has irregular complex endometrioid type glands lined by atypical cells. Mucinous cystadenocarcinoma has markedly atypical cells with mucinous differentiation.
13. B. Serous cystadenocarcinoma usually has elevated levels of CA125. AFP is elevated in yolk sac tumor and hepatocellular carcinoma. Elevated CEA may be associated with malignancies, such as ovarian mucinous adenocarcinoma. Elevated PLAP may be seen in dysgerminoma. Elevation of inhibin is seen in ovarian sex cord-stroma tumors and dysgerminoma.
14. B. BRAF mutation can be seen in serous cystadenocarcinoma. ARID1A and PTEN mutations are commonly seen in endometriosis and endometrioid adenocarcinoma. BRCA and p53 abnormalities are usually associated with high-grade serous cystadenocarcinoma.
15. E. High grade ovarian tumor with positive reactivity to WT1 is most consistent with high-grade serous cystadenocarcinoma. Borderline serous tumor do not have marked cytological atypia. Endometrioid adenocarcinoma is negative for WT1. Adenocarcinoma of lung is most likely positive for TTF1. Ovarian mucinous adenocarcinoma is usually positive for CA19.9.
16. D. High-grade serous cystadenocarcinoma is commonly positive for p53. AFP is expressed in yolk sac tumor and hepatocellular carcinoma. CEA is positive in various tumors, such as ovarian mucinous adenocarcinoma. Trophoblast diseases, including complete mole, partial mole and choriocarcinoma, or germ cell tumor trophoblast components, express hCG. PTEN is commonly associated with endometriosis and endometrioid adenocarcinoma.
17. C. HE4 may be elevated in serous cystadenocarcinoma and endometrioid adenocarcinoma. Elevated CEA may be associated with malignancies, such as ovarian mucinous adenocarcinoma. Trophoblast diseases, including complete mole, partial mole and choriocarcinoma, or germ cell tumor trophoblast components, may have elevated hCG. Elevation of inhibin is seen in ovarian sex cord-stroma tumors and dysgerminoma. LDH may be elevated in dysgerminoma.
18. A. WT1 positive papillary growth without marked cytological atypia and invasion is likely a borderline serous tumor. Mucinous adenocarcinoma is positive for CEA. Pelvic inflammatory disease does not tumor growth. Serous cystadenocarcinoma usually is invasive. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia, but no papillary growth with cytological atypia.
19. E. Borderline tumor should be staged as malignancy. For a young patient, hysterectomy is not recommended.
20. D. Ovarian cyst lined by benign mucinous cells, either intestinal type or endocervical type, is a mucinous cystadenoma. Mucinous adenocarcinoma, borderline mucinous tumor and endocervical adenocarcinoma have cytological atypia. Serous cystadenoma is commonly unilocular with thin clear fluid and lined by single layer of flat to cuboidal cells with cilia, but no papillary growth with cytological atypia.
21. A. A mucinous lesion with papillary growth lined by moderately atypical cells without invasion is likely a borderline mucinous tumor. Serous tumors have cells without mucin production, and usually do not have elevated CEA and CA19.9. Mucinous adenomadoes not have enlarged hyperchromic nuclei.
22. C. An invasive ovarian tumor with positive reactivity to CA19.9 but negative for CA125 and WT1 is most likely mucinous adenocarcinoma. Borderline or benign tumors do not invade. Serous cystadenocarcinoma usually is positive for WT1 and CA125.
23. B. See discussion in question 17.
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