Practice questions IV, female genital tract

Practice questions IV, female genital tract

Pathology of ovary B

© Jun Wang, MD, PhD

1. Use this case for the next five questions. A 51-year-old woman presents with vague left lower abdominal pain for 2 months. She denies other symptoms. She has a history of endometriosis that was treated with oral contraceptives. She has multiple squamous cell carcinoma of skin during the past ten years and was treated with local resection. She smokes cigarette 1 pack a day for 25 years and drinks 1 glass of wine per day for 20 years. Physical examination reveals a firm mass at her left adnexa. Image studies reveals a 3.5 cm solid and cystic mass at her left ovary and a 1.2 cm cystic lesion at her right ovary. Bilateral oophorectomy was performed. Microscopically, the right ovarian lesion has tubular gland lined by benign appearing columnar cells with no mucin production. There are signs of old hemorrhage but no cytological atypia is noted. The left ovarian mass has complex glands lined by markedly atypical cells. Focally there are nest of benign appearing squamoid cells. Necrosis is focally seen. What is the diagnosis of her left ovarian lesion?

A. Clear cell carcinoma

B. Endometrioid adenocarcinoma

C. Endometriosis

D. Metastatic squamous cell carcinoma

E. Mucinous cystadenocarcinoma

2. A 51-year-old woman presents with vague left lower abdominal pain for 2 months. She denies other symptoms. She has a history of endometriosis that was treated with oral contraceptives. She has multiple squamous cell carcinoma of skin during the past ten years and was treated with local resection. She smokes cigarette 1 pack a day for 25 years and drinks 1 glass of wine per day for 20 years. Physical examination reveals a firm mass at her left adnexa. Image studies reveals a 3.5 cm solid and cystic mass at her left ovary and a 1.2 cm cystic lesion at her right ovary. Bilateral oophorectomy was performed. Microscopically, the right ovarian lesion has tubular gland lined by benign appearing columnar cells with no mucin production. There are signs of old hemorrhage but no cytological atypia is noted. The left ovarian mass has complex glands lined by markedly atypical cells. Focally there are nest of benign appearing squamoid cells. Necrosis is focally seen. What is the diagnosis of her right ovarian lesion?

A. Clear cell carcinoma

B. Endometrioid adenocarcinoma

C. Endometriosis

D. Metastatic squamous cell carcinoma

E. Mucinous cystadenocarcinoma

3. A 51-year-old woman presents with vague left lower abdominal pain for 2 months. She denies other symptoms. She has a history of endometriosis that was treated with oral contraceptives. She has multiple squamous cell carcinoma of skin during the past ten years and was treated with local resection. She smokes cigarette 1 pack a day for 25 years and drinks 1 glass of wine per day for 20 years. Physical examination reveals a firm mass at her left adnexa. Image studies reveals a 3.5 cm solid and cystic mass at her left ovary and a 1.2 cm cystic lesion at her right ovary. Bilateral oophorectomy was performed. Microscopically, the right ovarian lesion has tubular gland lined by cuboidal cells in an endometrioid stroma. There are signs of old hemorrhage but no cytological atypia is noted. the left ovarian mass has complex glands lined by markedly atypical cells. Focally there are nest of benign appearing squamoid cells. Necrosis is focally seen. What is the most significant factor in her history that is associated with her left ovary lesion?

A. Alcohol usage

B. Cigarette smoking

C. Endometriosis

D. Skin squamous cell carcinoma

4. A 51-year-old woman presents with vague left lower abdominal pain for 2 months. She denies other symptoms. She has a history of endometriosis that was treated with oral contraceptives. She has multiple squamous cell carcinoma of skin during the past ten years and was treated with local resection. She smokes cigarette 1 pack a day for 25 years and drinks 1 glass of wine per day for 20 years. Physical examination reveals a firm mass at her left adnexa. Image studies reveals a 3.5 cm solid and cystic mass at her left ovary and a 1.2 cm cystic lesion at her right ovary. Bilateral oophorectomy was performed. Microscopically, the right ovarian lesion has tubular gland lined by cuboidal cells in an endometrioid stroma. There are signs of old hemorrhage but no cytological atypia is noted. the left ovarian mass has complex glands lined by markedly atypical cells. Focally there are nest of benign appearing squamoid cells. Necrosis is focally seen. What is the most significant factor in her history that is associated with her left ovary lesion?

A. BRCA1

B. CTNNB1

C. Her2

D. KRAS

E. p53

5. A 51-year-old woman presents with vague left lower abdominal pain for 2 months. She denies other symptoms. She has a history of endometriosis that was treated with oral contraceptives. She has multiple squamous cell carcinoma of skin during the past ten years and was treated with local resection. She smokes cigarette 1 pack a day for 25 years and drinks 1 glass of wine per day for 20 years. Physical examination reveals a firm mass at her left adnexa. Image studies reveals a 3.5 cm solid and cystic mass at her left ovary and a 1.2 cm cystic lesion at her right ovary. Bilateral oophorectomy was performed. Microscopically, the right ovarian lesion has tubular gland lined by cuboidal cells in an endometrioid stroma. There are signs of old hemorrhage but no cytological atypia is noted. the left ovarian mass has complex glands lined by markedly atypical cells. Focally there are nest of benign appearing squamous cells. Necrosis is focally seen.

Two month later, she develops abnormal vaginal bleeding. Sonographic examination reveals a thickened endometrium. What is likely to cause her vaginal bleeding?

A. Endometrial atrophy

B. Endometrial endometrioid adenocarcinoma

C. Endometrial polyp

D. Endometrial serous carcinoma

E. Subendometrial leiomyoma

6. A 52-year-old woman presents with lower abdominal progressive dull aching pain for 6 months. She does not have other symptoms associated with the pain. She has history of endometriosis, ischemic heart disease and diabetes. Physical examination reveals a firm mass in the left pelvic area. Image studies reveal a 16 cm left ovarian mass with cystic and solid areas. The mass was removed. Microscopically it has complex cystic structure lined by markedly atypical cells with clear cytoplasm. Necrosis is focally seen. What is the diagnosis?

A. Clear cell carcinoma

B. Endometrioid adenocarcinoma

C. Endometriosis

D. Mucinous cystadenocarcinoma

E. Serous cystadenocarcinoma

7. Use this case for the next two questions. A 55-year-old woman presents with vague lower abdomen discomfort for 6 months. She has a history of renal pelvis urothelial carcinoma 2 years ago, that was treated with nephrectomy. Physical examination reveals a firm mass at her left pelvic area. No significant abnormality is seen in her laboratory test results. Image studies reveal a 4.5 cm cystic mass at her left ovary. Left oophorectomy was performed. Microscopically the cystic lesion is covered by columnar cells with basally located small round nuclei. No necrosis is noted. In the background ovarian stroma, small nest of benign appearing transitional type cells are seen. What is the diagnosis of the cystic lesion?

A. Endometrioid adenocarcinoma

B. Mucinous cystadenocarcinoma

C. Mucinous cystadenoma

D. Serous cystadenocarcinoma

E. Serous cystadenoma

8. A 55-year-old woman presents with vague lower abdomen discomfort for 6 months. She has a history of renal pelvis urothelial carcinoma 2 years ago, that was treated with nephrectomy. Physical examination reveals a firm mass at her left pelvic area. No significant abnormality is seen in her laboratory test results. Image studies reveal a 4.5 cm cystic mass at her left ovary. Left oophorectomy was performed. Microscopically the cystic lesion is covered by columnar cells with basally located small round nuclei. No necrosis is noted. In the background ovarian stroma, small nest of benign appearing transitional type cells are seen. What is the diagnosis of the background ovarian lesion?

A. Brenner tumor

B. Inclusion cyst

C. Metastatic urothelial carcinoma

D. Mucinous cystadenocarcinoma

E. Serous cystadenocarcinoma, low grade

9. Use this case for the next two questions. A 78-year-old woman presents with fatigue and vague low abdomen discomfort for 3 months. Her past history is unremarkable. Physical examination reveals a firm left adnexa mass. Sonographic examination reveals a 5 cm left ovarian mass with cystic and solid areas. Left oophorectomy is performed. Microscopically, the cystic portion of the mass is lined by columna cells with basally located enlarged hyperchromic nuclei. No significant atypia is seen. The solid portion has irregular cords of atypical transitional type cells infiltrating a fibrotic stroma. What is the diagnosis for the cystic lesion?

A. Endometrioid adenocarcinoma

B. Mucinous cystadenocarcinoma

C. Mucinous cystadenoma

D. Serous cystadenocarcinoma

E. Serous cystadenoma

10. A 78-year-old woman presents with fatigue and vague low abdomen discomfort for 3 months. Her past history is unremarkable. Physical examination reveals a firm left adnexa mass. Sonographic examination reveals a 5 cm left ovarian mass with cystic and solid areas. Left oophorectomy is performed. Microscopically, the cystic portion of the mass is lined by columnar cells with basally located enlarged hyperchromic nuclei. No significant atypia is seen. The solid portion has irregular cords of atypical transitional type cells infiltrating a fibrotic stroma. What is the diagnosis for the solid lesion?

A. Endometrioid adenocarcinoma

B. Malignant Brenner tumor

C. Mucinous cystadenocarcinoma

D. Serous cystadenocarcinoma

E. Sertoli-Leydig cell tumor

11. A 21-year-old woman presents with increased abdominal girth for 3 months. She has a history of irregular menses for two years. Her past medical history is otherwise unremarkable. Physical examination reveals a soft mass at her left adnexa. Her laboratory tests results are within normal range. Urine pregnancy test is negative. Sonographic examination reveals a cystic mass at her left ovary. The mass was removed and the cystic lesion contains grease material, hairs and tooth. Microscopically, no immature tissue is noted. What is the diagnosis?

A. Ectopic pregnancy

B. Immature teratoma

C. Mature teratoma

D. Mucinous cystadenoma

E. Serous cystadenoma

12. A 25-year-old woman presents with shaking, sweating, palpitation and a 15 pound weight loss in 2 months. She has had irregular vaginal bleeding for 6 months. Her past medical history is unremarkable, except thyroid follicular adenoma 7 years ago, that was treated with partial thyroidectomy. Physical examination reveal no abnormality of her thyroid. Bimanual examination reveals a firm mass at her left adnexa. Laboratory tests results include a free T4 at 52 ng/dL (normal 0.7-1.9 ng/dL) and a TSH < 5 microIU/ml (normal 9-30 microIU/ml). Sonographic examination reveal a 1.5 cm solid mass at her left ovary. The mass was removed. Microscopically it has round to oval spaced containing eosinophilic homogenous material and lined by cuboidal cells. No cytological atypia is noted. What is the diagnosis?

A. Metastatic thyroid follicular carcinoma

B. Mucinous cystadenoma

C. Mucinous borderline tumor

D. Serous cystadenoma

E. Struma ovarii

13. Use this case for the next two questions. A 12-year-old girl presents with progressive abdominal distension for a year. Her past medical history is unremarkable. Physical examination reveals a large firm mass at her left lower abdomen. Image studies reveal a 15 cm left adnexa mass. The mass is removed and grossly it has a cystic cut surface with necrosis and hemorrhage. Microscopically it is composed primarily of loosely cohesive immature cells, some surrounding a central thin-walled blood vessel, with loose connection to other surrounding tumor cells. Vaguely formed space are seen between these two groups of cells with similar morphology. No multinucleated cells are seen. What is most likely diagnosis?

A. Choriocarcinoma

B. Endometrioid adenocarcinoma

C. Granulosa cell tumor

D. Mucinous adenocarcinoma

E. Yolk sac tumor

14. A 12-year-old girl presents with progressive abdominal distension for a year. Her past medical history is unremarkable. Physical examination reveals a large firm mass at her left lower abdomen. Image studies reveal a 15 cm left adnexa mass. The mass is removed and grossly it has a cystic cut surface with necrosis and hemorrhage. Microscopically it is composed primarily of loosely cohesive immature cells, some surrounding a central thin-walled blood vessel, with loose connection to other surrounding tumor cells. Vaguely formed space are seen between these two groups of cells with similar morphology. No multinucleated cells are seen. What serum marker is likely to be elevated?

A. AFP

B. CEA

C. hCG

D. HE4

E. PLAP

15. A 25-year-old woman presents with right lower abdominal pain for a week. She does not have fever, urinary symptoms or change of bowel habit. Physical examination reveals a soft abdomen without rigidity or guarding. Bimanual exam reveals a firm right adnexa lesion. Sonographic examination reveals a 7.5 cm right ovarian mass, possible cystic. The mass was removed. Grossly it has extensive hemorrhagic changes. Microscopically, it have many atypical multinucleated cells. These cells are positive for hCG, but negative for cytokeratin. What is the diagnosis?

A. Choriocarcinoma

B. Endometrioid adenocarcinoma

C. Endometriosis

D. Mucinous adenocarcinoma

E. Yolk sac tumor

16. Use this case for the next two questions. A 25-year-old woman presents with right lower abdomen pain with nausea for 2 weeks. She does not have fever, urinary symptoms or change of bowel habit. She has a history of ectopic pregnancy at age 21. Physical examination reveals a firm right adnexa mass. The uterus and left adnexa are unremarkable. Urine hCG test is positive. Sonographic examination reveals a 12 cm solid right ovarian mass. No fetus is seen in uterine cavity. The mass is removed. Grossly it is light brownish nodular mass with focal hemorrhagic changes. Microscopically it is composed of large cells with well defined cell borders, clear cytoplasm and centrally located nuclei. What is most likely the diagnosis?

A. Choriocarcinoma

B. Dysgerminoma

C. Fibroma

D. Thecoma

E. Yolk sac tumor

17. A 25-year-old woman presents with right lower abdomen pain with nausea for 2 weeks. She does not have fever, urinary symptoms or change of bowel habit. She has a history of ectopic pregnancy at age 21. Physical examination reveals a firm right adnexa mass. The uterus and left adnexa are unremarkable. Urine hCG test is positive. Sonographic examination reveals a 12 cm solid right ovarian mass. No fetus is seen in uterine cavity. The mass is removed. Grossly it is light brownish nodular mass with focal hemorrhagic changes. Microscopically it is composed of large cells with well defined cell borders, clear cytoplasm and centrally located nuclei. What serum marker is likely to be elevated?

A. CA19.9

B. CA125

C. CEA

D. HE4

E. LDH

18. Use this case for the next four questions. A 28-year-old woman presents with irregular uterine bleeding. Her past history is unremarkable. Physical examination reveal a left adnexa mass. Sonographic examination reveals a 5.5 cm solid left ovarian mass. The endometrium is thickened. No discrete uterine tumor is noted. Left oophorectomy is performed and the mass has a grey to yellow cut surfaces with many small cysts. Microscopically, the mass has cords and nests of small cells with mild atypia. Some cells form a thyroid follicular-like structure filled with eosinophilic amorphous material. What is the diagnosis?

A. Brenner tumor

B. Granulosa cell tumor

C. Mucinous cystadenoma

D. Struma ovarii

E. Yolk sac tumor

19. A 28-year-old woman presents with irregular uterine bleeding. Her past history is unremarkable. Physical examination reveal a left adnexa mass. Sonographic examination reveals a 5.5 cm solid left ovarian mass. The endometrium is thickened. No discrete uterine tumor is noted. Left oophorectomy is performed and the mass has a grey to yellow cut surfaces with many small cysts. Microscopically, the mass has cords and nests of small cells with mild atypia. Some cells form a thyroid follicular-like structure filled with eosinophilic amorphous material. Abnormality of what gene is likely associated with these findings?

A. BRCA1

B. CTNNB1

C. DICER

D. FOXL2

E. PTEN

20. A 28-year-old woman presents with irregular uterine bleeding. Her past history is unremarkable. Physical examination reveal a left adnexa mass. Sonographic examination reveals a 5.5 cm solid left ovarian mass. The endometrium is thickened. No discrete uterine tumor is noted. Left oophorectomy is performed and the mass has a grey to yellow cut surfaces with many small cysts. Microscopically, the mass has cords and nests of small cells with mild atypia. Some cells form a thyroid follicular-like structure filled with eosinophilic amorphous material. What is likely the cause of her uterine bleeding?

A. Elevated androgen

B. Elevated estrogen

C. Endometrial polyp

D. Insufficiency of LH

E. Insufficiency of progesterone

21. A 28-year-old woman presents with irregular uterine bleeding. Her past history is unremarkable. Physical examination reveal a left adnexa mass. Sonographic examination reveals a 5.5 cm solid left ovarian mass. The endometrium is thickened. No discrete uterine tumor is noted. Left oophorectomy is performed and the mass has a grey to yellow cut surfaces with many small cysts. Microscopically, the mass has cords and nests of small cells with mild atypia. Some cells form a thyroid follicular-like structure filled with eosinophilic amorphous material. What serum marker is likely to be elevated?

A. CA19.9

B. CA125

C. CEA

D. HE4

E. Inhibin

22. A 23-year-old woman presents with irregular uterine bleeding, increased facial hair, hoarseness of voice for 6 months. Her past medical history is otherwise unremarkable. Physical examination reveals a firm mass at her left adnexa. Laboratory test results include a testosterone at 32.5 ng/ml (normal 0.2-1.2 mg/ml). Other test results including CA125, CA19.9, AFP and hCG are within normal range. Image studies a 3.5 cm well circumscribed solid mass at her left ovary. Her right ovary, fallopian tubes, uterus and both adrenal glands are unremarkable. Left oophorectomy is performed. Grossly this mass is lobulated with yellow cut surfaces. Microscopically the tumor has well formed tubular structured lined by small cuboidal cells, in a background of sheets of intermediate sized cells with small dark round to oval nuclei and eosinophilic granular cytoplasm. What is the diagnosis?

A. Brenner tumor

B. Endometriosis

C. Mucinous cystadenoma

D. Sertoli-Leydig cell tumor

E. Yolk sac tumor

23. A 69-year-old woman presents with shortness of breath for 3 days. She has had progressive abdominal distension for 6 months. Her past medical history is unremarkable. Physical examination reveal a large lower abdominal mass extending to umbilicus. The abdomen is soft without rigidity or guarding, but has a dull percussive sound. Image studies reveals a 19 cm solid left adnexa mass, with signs of ascites and pleural effusion. Left oophorectomy is performed. The mass is firm with white cut surface. No necrosis or hemorrhage is seen. Microscopically it is composed of packed benign appearing spindle cells. Collagen bundles are seen in the background. These cells are positive for vimentin but negative for S100 and desmin. What is the diagnosis?

A. Leiomyoma

B. Meigs syndrome

C. Peritoneal carcinomatosis

D. Thecoma

E. Serous carcinoma

24. A 71-year-old woman present with vague left lower abdomen discomfort for 3 months. She has a history of adenocarcinoma of stomach and was treated with surgery and chemotherapy. Physical examination reveals a firm left adnexa mass. There is no evidence of ascites. Image studies reveals a 15 cm solid left ovarian mass. Her right ovary, bilateral fallopian tubes and uterus are unremarkable. Left oophorectomy is performed. The mass has a golden-yellow cut surface. There is no evidence of hemorrhage or necrosis. Microscopically, the mass is composed of mildly atypical spindle cells with pale cytoplasm containing many small vacuoles. What is the diagnosis?

A. Hyperthecosis

B. Leiomyoma

C. Metastatic gastric adenocarcinoma

D. Sertoli-Leydig cell tumor

E. Thecoma

Answers

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