Practice questions III, female genital tract
Practice questions III, female genital tract
Pathology of ovary A
© Jun Wang, MD, PhD
1. A 43-year-old woman presents with vague
left lower abdomen discomfort for 3 days. She does not have fever, weight loss,
vaginal bleeding or discharge. She has a history of cervical condyloma and
chlamydial urethritis 10 years ago. Her past medical history is otherwise
unremarkable. She has multiple family members in her maternal side diagnosed
with breast, ovarian and endometrial carcinoma. Pelvic sonographic examination
reveals a 5 cm cystic mass at her left ovary. An excisional biopsy was
performed and the lesion is a unilocular cyst with smooth lining.
Microscopically it has a fibrous wall covered by multiple layers of loosely
cohesive cells with moderate amount of cytoplasm and small round dark nuclei.
What is the diagnosis?
A. Endometrial cyst
B. Follicular cyst
C. Luteal cyst
D. Mucinous cystadenoma
E. Serous cystadenoma
2. A 28-year-old woman presents with cramping
right lower abdominal pain for 4 hours and dizziness for 1 hour. She does not
have fever or urinary symptoms. She is at 18th day of her cycle. She has a
history of peritoneal endometriosis. Her past history is otherwise
unremarkable. Physical examination reveal a pulse of 110 and blood pressure at
95/60 mmHg. Her abdomen is soft without rigidity or guarding. Laboratory tests
revealed a hemoglobin at 8.5 g/dL (normal 12-16 g/dL). All other results are
within normal range. Sonographic examination reveals a 5 cm mass at her right
ovary. There are signs of pelvic fluid collection. Her uterus and left ovary
are unremarkable. Laparoscopic examination reveals a ruptured hemorrhagic right
ovary cyst and hemoperitoneum. The cyst was removed and microscopically, it is
composed of sheets of intermediate to large cells with abundant eosinophilic
cytoplasm and round to oval nuclei with vesicular chromatin. Central
hemorrhagic changes are seen. No glandular components nor necrosis are noted.
What is the diagnosis?
A. Endometrioid cyst
B. Follicular cyst
C. Luteal cyst
D. Mucinous cystadenocarcinoma
E. Serous cystadenocarcinoma
3. Use
this case for the next two questions. A 22-year-old woman presents with
left lower abdomen pain for 2 days. She does not have fever or urinary tract
abnormalities. She has a history of dysmenorrhea for 2 years. The family
history is significant for multiple family members with early onset of ovarian,
endometrial and breast cancers. Physical examination reveals a soft left adnexa
mass. Biopsy of the mass reveals proliferative type endometrial type glands and
stroma without significant architectural or cytological atypia. Old hemorrhagic
changes are seen. What is the diagnosis?
A. Endometrioid adenocarcinoma
B. Endometrioid cyst
C. Inclusion cyst
D. Luteal cyst
E. Mucinous cystadenocarcinoma
4. A 22-year-old woman presents with left
lower abdomen pain for 2 days. She does not have fever or urinary tract
abnormalities. She has a history of dysmenorrhea for 2 years. The family
history is significant for multiple family members with early onset of ovarian,
endometrial and breast cancers. Physical examination reveals a soft left adnexa
mass. Biopsy of the mass reveals proliferative type endometrial type glands and
stroma without significant architectural or cytological atypia. Old hemorrhagic
changes are seen. Abnormality of what gene is likely to be associated with this
lesion?
A. BRCA 1
B. KRAS
C. p16
D. p53
E. PTEN
5. Use
this case for the next five questions. A 33-year-old woman presents for
evaluation of infertility. She has a history of impaired glucose intolerance
and irregular menstrual periods. Her past history is otherwise unremarkable.
Physical examination reveals an overweight hirsute woman with a body mass index
of 35.5 (normal 18.5 to 24.9). No other abnormality is noted. Sonographic examination
reveals enlarged ovaries containing a few cystic lesions, up to 1.2 cm in
greatest dimension. Biopsy of the ovaries reveals cysts with clear contents.
These cysts are lined by multiple layers of cells with small to moderate amount
of cytoplasm and small dark round nuclei. No cytological atypia is noted. What
is the most likely cause of her infertility?
A. Failure of ovulation
B. Hyperglycemia
C. Hyperlipidemia
D. Luteal phase insufficiency
E. Pelvic inflammatory disease
6. A 33-year-old woman presents for
evaluation of infertility. She has a history of impaired glucose intolerance
and irregular menstrual periods. Her past history is otherwise unremarkable.
Physical examination reveals an overweight hirsute woman with a body mass index
of 35.5 (normal 18.5 to 24.9). No other abnormality is noted. Sonographic
examination reveals enlarged ovaries containing a few cystic lesions, up to 1.2
cm in greatest dimension. Biopsy of the ovaries reveals cysts with clear
contents. These cysts are lined by multiple layers of cells with small to
moderate amount of cytoplasm and small dark round nuclei. No cytological atypia
is noted. What is the diagnosis?
A. Luteal cyst
B. Mucinous cystadenoma
C. Polycystic ovary disease
D. Serous cystadenoma
E. Simple cysts
7. A 33-year-old woman presents for
evaluation of infertility. She has a history of impaired glucose intolerance
and irregular menstrual periods. Her past history is otherwise unremarkable.
Physical examination reveals an overweight hirsute woman with a body mass index
of 35.5 (normal 18.5 to 24.9). No other abnormality is noted. Sonographic
examination reveals enlarged ovaries containing a few cystic lesions, up to 1.2
cm in greatest dimension. Biopsy of the ovaries reveals cysts with clear
contents. These cysts are lined by multiple layers of cells with small to
moderate amount of cytoplasm and small dark round nuclei. No cytological atypia
is noted. What is the most likely associated with her ovarian changes?
A. Androgen overproduction
B. Estrogen excess
C. FSH excess
D. Lack of LH surge
E. Metaplasia to endometrial type tissue
8. A 33-year-old woman presents for
evaluation of infertility. She has a history of impaired glucose intolerance
and irregular menstrual periods. Her past history is otherwise unremarkable.
Physical examination reveals an overweight hirsute woman with a body mass index
of 35.5 (normal 18.5 to 24.9). No other abnormality is noted. Sonographic
examination reveals enlarged ovaries containing a few cystic lesions, up to 1.2
cm in greatest dimension. Biopsy of the ovaries reveals cysts with clear
contents. These cysts are lined by multiple layers of cells with small to
moderate amount of cytoplasm and small dark round nuclei. No cytological atypia
is noted. What risk is the most likely elevated with her ovarian changes?
A. Endometrial atrophy
B. Endometrial hyperplasia
C. Endometriosis
D. Ovarian clear cell carcinoma
E. Ovarian endometrioid adenocarcinoma
9. A 33-year-old woman presents for
evaluation of infertility. She has a history of impaired glucose intolerance
and irregular menstrual periods. Her past history is otherwise unremarkable.
Physical examination reveals an overweight hirsute woman with a body mass index
of 35.5 (normal 18.5 to 24.9). No other abnormality is noted. Sonographic
examination reveals enlarged ovaries containing a few cystic lesions, up to 1.2
cm in greatest dimension. Biopsy of the ovaries reveals cysts with clear
contents. These cysts are lined by multiple layers of cells with small to moderate
amount of cytoplasm and small dark round nuclei. No cytological atypia is
noted. What abnormal laboratory test result is most likely to be found?
A. Elevated FSH
B. Elevated testosterone
C. Elevated thyroxine
D. Reduced insulin
E. Reduced LH
10. A 65-year-old woman presents with vaginal
bleeding, progressive hirsutism and acne for 6 months. She has a history of
type II diabetes and hypertension. Her past medical history is unremarkable.
Physical examination reveals overweight with a BMI of 32 (normal 18.5 to 24.9).
No other significant abnormalities are noted. Laboratory tests results include
a testosterone at 172 ng/dL (normal <70 ng/dL). Her FSH, LH,
dehydroepiandrosterone sulphate (DHEA-S) and cortisol are within normal range.
Pelvic sonographic examination reveals bilateral ovarian enlargement. No
discrete mass is noted. Bilateral oophorectomy is performed. Both ovaries are
enlarged and firm. Microscopically there are nests of spindles cells with
eosinophilic cytoplasm and small round nuclei. No cytological atypia is seen.
What is the diagnosis?
A. Brenner’s tumor
B. Fibroma
C. Granulosa cell tumor
D. Stromal hyperthecosis
E. Thecoma
11. An 18-year-old woman presented with
sudden onset of right lower abdominal pain for 2 hours. The pain is severe and sharp,
associated with emesis. She does not have fever, urinary symptoms or diarrhea.
She has a history of dysmenorrhea, but denies other abnormalities. She is not
sexually active. Per physical examination, her vital signs are within normal
range. Her abdomen is soft without rigidity or guarding. Her laboratory results
are unremarkable. Sonographic examination reveal a 15 cm cystic mass at right
pelvic region. The mass is removed and grossly it is unilocular hemorrhagic
cyst with smooth lining and necrotic appearance. Microscopically the cyst is
lined by flat to cuboidal cells. No atypia is seen. Normal ovarian stroma is
focally seen. What is the diagnosis?
A. Endometriosis
B. Endometrioid adenocarcinoma
C. Mucinous cystadenocarcinoma
D. Serous cystadenocarcinoma
E. Serous cystadenoma
12.
Use this case for the next three questions. A 78-year-old woman presents
with progressive abdominal distension for 6 months. She has a history of
adenocarcinoma of left lung 10 years ago that was treated with surgery and chemotherapy.
Her past medical history is otherwise unremarkable. Sonographic examination
reveals a 10 cm right ovarian mass with both cystic and solid areas. Ascites is
noted. The mass is removed and grossly it has both cystic and solid areas.
Microscopically the solid area has sheets of moderately atypical cells invading
into stroma. These cells are polygonal with relatively uniform nuclei. Focally
there are papillary architecture covered by flat to cuboid epithelial cells.
What is the diagnosis?
A. Borderline serous tumor
B. Endometrioid adenocarcinoma
C. Mucinous cystadenocarcinoma
D. Serous cystadenocarcinoma, low grade
E. Serous cystadenoma
13. A 78-year-old woman presents with
progressive abdominal distension for 6 months. She has a history of adenocarcinoma
of left lung 10 years ago that was treated with surgery. Her past medical
history is otherwise unremarkable. Sonographic examination reveals a 10 cm
right ovarian mass with both cystic and solid areas. Ascites is noted. The mass
is removed and grossly it has both cystic and solid areas. Microscopically the
solid area has sheets of moderately atypical cells invading into stroma. These
cells are polygonal with relatively uniform nuclei. Focally there are papillary
architecture covered by flat to cuboid epithelial cells. What serum marker is
likely to be elevated?
A. AFP
B. CA125
C. CEA
D. Inhibin
E. PLAP
14. A 78-year-old woman presents with
progressive abdominal distension for 6 months. She has a history of
adenocarcinoma of left lung 10 years ago that was treated with surgery. Her
past medical history is otherwise unremarkable. Sonographic examination reveals
a 10 cm right ovarian mass with both cystic and solid areas. Ascites is noted.
The mass is removed and grossly it has both cystic and solid areas. Microscopically
the solid area has sheets of moderately atypical cells invading into stroma.
These cells are polygonal with relatively uniform nuclei. Focally there are
papillary architecture covered by flat to cuboid epithelial cells. Abnormality
of what gene is most likely associated with these findings?
A. ARID1A
B. BRAF
C. BRCA1
D. p53
E. PTEN
15. Use
this case for the next three questions. A 71-year-old woman presents with
shortness of breath for 2 hours. She has had progressive abdominal distension
for 1 month. Her significant past medical history include adenocarcinoma of
right lung 5 years ago that was treated with surgery and chemotherapy. Physical
examination is positive for large amount of ascites. Image studies reveals
bilateral ovarian masses. Biopsy of the masses reveals sheets of markedly
atypical cells with pleomorphic nuclei and atypical mitosis. Per
immunohistochemistry, these cells are positive for cytokeratin, WT1 but
negative for CA19.9 and TTF1. What is the diagnosis?
A. Borderline serous tumor
B. Endometrioid adenocarcinoma
C. Metastatic adenocarcinoma of lung
D. Mucinous adenocarcinoma of ovary
E. Serous adenocarcinoma of ovary
16. A 71-year-old woman presents with
shortness of breath for 2 hours. She has had progressive abdominal distension
for 1 month. Her significant past medical history include adenocarcinoma of
right lung 5 years ago that was treated with surgery and chemotherapy. Physical
examination is positive for large amount of ascites. Image studies reveals
bilateral ovarian masses. Biopsy of the masses reveals sheets of markedly
atypical cells with pleomorphic nuclei and atypical mitosis. Per
immunohistochemistry, these cells are positive for cytokeratin, WT1 but
negative for CA19.9 and TTF1. What additional marker is likely to be positive
in these cells?
A. AFP
B. CEA
C. hCG
D. p53
E. PTEN
17. A 71-year-old woman presents with
shortness of breath for 2 hours. She has had progressive abdominal distension
for 1 month. Her significant past medical history include adenocarcinoma of
right lung 5 years ago that was treated with surgery and chemotherapy. Physical
examination is positive for large amount of ascites. Image studies reveals
bilateral ovarian masses. Biopsy of the masses reveals sheets of markedly
atypical cells with pleomorphic nuclei and atypical mitosis. Per
immunohistochemistry, these cells are positive for cytokeratin, WT1 but
negative for CA19.9 and TTF1. What additional serum marker is likely to be
elevated?
A. CEA
B. hCG
C. HE4
D. Inhibin
E. LDH
18. Use
this case for the next two questions. A 25-year-old woman presents with
vague lower abdomen discomfort and slowly progressive abdomen distension for 6
months. Her past medical history is unremarkable except gonorrheal urethritis
at age of 18. Physical examination reveals sign of ascites that is confirmed by
image studies. A 2.5 cm solid mass is identified at left ovary. Laboratory test
reveals a CA125 at 170 U/ml (normal < 35 U/ml). Her AFP, CA19.9, and hCG are
all within normal range. Laparotomy was performed and the mass was removed.
During the surgery, multiple peritoneal nodules are noted and biopsied.
Microscopically, this cystic ovarian mass has papillary fronds covered by
moderately atypical cells. No destructive invasion is seen. These cells are
positive for WT1 and CA125, but negative for CEA. The peritoneal nodules have
same morphology as the ovarian mass. What is the diagnosis?
A. Borderline serous tumor
B. Mucinous adenocarcinoma of ovary
C. Pelvic inflammatory disease
D. Serous cystadenoma
E. Serous adenocarcinoma of ovary
19. A 25-year-old woman presents with vague
lower abdomen discomfort and slowly progressive abdomen distension for 6
months. Her past medical history is unremarkable except gonorrheal urethritis
at age of 18. Physical examination reveals sign of ascites that is confirmed by
image studies. A 2.5 cm solid mass is identified at left ovary. Laboratory test
reveals a CA125 at 170 U/ml (normal < 35 U/ml). Her AFP, CA19.9, and hCG are
all within normal range. Laparotomy was performed and the mass was removed.
During the surgery, multiple peritoneal nodules are noted and biopsied.
Microscopically, this cystic ovarian mass has papillary fronds covered by
moderately atypical cells. No destructive invasion is seen. These cells are
positive for WT1 and CA125, but negative for CEA. The peritoneal nodules have
same morphology as the ovarian mass. What is the next step of management?
A. Chemotherapy
B. Follow up with serum CEA testing
C. Radiation therapy
D. Total hysterectomy and bilateral
oophorectomy
E. Tumor staging
20. A 59-year-old woman presents with vague
abdominal pain for 3 months. She has progressive abdominal distension for 5
years. She has a history of endocervical adenocarcinoma in situ 30 years ago
that was treated with conization. Physical examination reveal a distended tense
abdomen and diminished bowel sound. Laboratory tests results including CA125,
HE4, CEA and CA19.9 are within normal range. CT scan reveals a 30 cm ovarian
mass. The mass was removed and grossly it is a multilocular cystic growth with
smooth outer surface and thick clear contents. No necrosis is identified.
Microscopically, these cysts have a fibrous capsule, covered by cells similar
to benign endocervical glandular cells. No cytological atypia is noted. What is
the diagnosis?
A. Borderline mucinous tumor
B. Metastatic endocervical adenocarcinoma
C. Mucinous cystadenocarcinoma
D. Mucinous cystadenoma
E. Serous cystadenoma
21. A 25-year-old woman presents with vague
lower abdomen discomfort and progress abdominal distension for 4 months. Her
past medical history is unremarkable except dysmenorrhea for 4 years. Physical
examination reveal a firm mass in right pelvic area. Signs of ascites are
noted. Laboratory tests reveals a CEA at 57 ng/ml (normal < 3 ng/ml) and
CA19.9 at 570 U/ml (normal < 37 U/ml). CA125, hCG, AFP, inhibin and PLAP are
within normal range. The mass is removed. Grossly, this 15 cm multilocular mass
has a smooth external surface. Microscopically, it has complex papillary growth
on the cystic surfaces. The cysts and these papillary growth are covered by
columnar cells with enlarged hyperchromic nuclei located at the basal half of
the cells. No evidence of invasion is seen. What is the diagnosis?
A. Borderline mucinous tumor
B. Borderline serous tumor
C. Mucinous cystadenoma
D. Serous cystadenocarcinoma
E. Serous cystadenoma
22. Use
this case for the next two questions. A 55-year-old presents with rapid
increase of abdominal girth for a year. She has a history of type 2 diabetes,
hyperlipidemia and hypertension. Her past medical history is otherwise
unremarkable. Physical examination reveals a tense, distended abdomen with
dullness to percussion. Laboratory examination reveals a CA19.9 at 650 U/ml
(normal < 37 U/ml). Her CA125, estrogen, testosterone and cortisol levels
are within normal range. Image studies reveal 17 cm left ovarian mass and large
amount of ascites. Laparotomy is performed and the mass is removed. During
surgery, a few solid nodules are noted at omentum and pelvic peritoneum, and
are biopsied. Microscopically, the ovarian mass has cords of markedly atypical
cells infiltrating fibrotic stroma. The cells are positive for CA19.9, but
negative for WT1 and CA125. The peritoneal and omentum nodules have similar
features. What is the diagnosis?
A. Borderline mucinous tumor
B. Borderline serous tumor
C. Mucinous cystadenocarcinoma
D. Serous cystadenocarcinoma
E. Serous cystadenoma
23. A 55-year-old presents with rapid
increase of abdominal girth for a year. She has a history of type 2 diabetes,
hyperlipidemia and hypertension. Her past medical history is otherwise
unremarkable. Physical examination reveals a tense, distended abdomen with
dullness to percussion. Laboratory examination reveals a CA19.9 at 650 U/ml
(normal < 37 U/ml). Her CA125, estrogen, testosterone and cortisol levels
are within normal range. Image studies reveal 17 cm left ovarian mass and large
amount of ascites. Laparotomy is performed and the mass is removed. During
surgery, a few solid nodules are noted at omentum and pelvic peritoneum, and
are biopsied. Microscopically, the ovarian mass has cords of markedly atypical
cells infiltrating fibrotic stroma. The cells are positive for CA19.9, but
negative for WT1 and CA125. The peritoneal and omentum nodules have similar
features. What serum marker is likely to be elevated?
A. AFP
B. CEA
C. hCG
D. HE4
E. Inhibin
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