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

Answers

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