Practice questions Ib answers, female genital tract

Practice questions Ib answers, female genital tract
Pathology of vulva, vagina and cervix

© Jun Wang, MD, PhD


1. A. Thick white vaginal discharges are suggestive of candida infection, that can be confirmed by wet mount preparation with identification of fungal pseudo hyphae, as seen in this case. Chlamydia trachomatis is probably the most common type of STD. However, there is no specific morphological changes for chlamydia infection. Gonorrhea usually has purulent discharges with Gram negative diplococci, but not pseudohyphae. Herpes infection is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei, with marked neutrophilic infiltration. Human papillomavirus infection will cause cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas, with presence of koilocyte, or neoplastic glandular or squamous cells, but not pseudohyphae.

2. D. Yellow-green malodorous vaginal discharge is suggestive of trichomoniasis, that can be confirmed by identification of motile pear-shaped protozoa on saline wet mount. Anti-cardiolipin antibody is a screening test for syphilis. Cervical biopsy is usually used for tissue abnormalities, but not trichomoniasis, when the parasites are outside the cervical tissue. Gram stain of discharge can be used for bacterial infection, such as gonorrhea. Whiff test is defined by production of fishy odor upon addition of KOH to vaginal discharge. It is positive for bacterial vaginosis.

3. E. See discussion of question 2. This is a Giemsa stain, which highlighted a few pear-shaped protozoa.

4. A. The wet mount reveals two squamous cells coated with coccobacilli, consistent with bacterial vaginosis, a condition associated with elevated vaginal pH. Fungal pseudohyphae are seen in candida vaginitis. Gram-negative diplococci are suggestive of gonorrhea. Motile protozoa is seen in trichomoniasis. Squamous cells with large hyperchromatic irregular nuclei are consistent with cervical intraepithelial neoplasia.

5. A. See discussions for questions 1 and 4.

6. D. See discussions of questions 1 and 2.

7. D. These are two koilocytes, characterized by well-demarcated perinuclear halo, with enlarged hyperchromic nuclei or double nuclei, a sign consistent with condyloma caused by human papillomavirus. Candida albican has pseudohyphae. There are no specific morphological changes for chlamydia trachomatis infection. Herpes infection is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei, with marked neutrophilic infiltration. Trichomoniasis has motile pear-shaped protozoa

8. B. See discussions of question 7. Cervical carcinomas has marked dysplastic cells, either glandular or squamous.

9. D. See discussion of question 7.

10. B. See discussion of question 7.

11. D. This case is characterized by full thickness dysplasia of squamous epithelium, with focal glandular involvement. These features are consistent with cervical intraepithelial neoplasia
Grade III. It is equivalent to squamous cell carcinoma in situ, that is associated with human papillomavirus infection. In histology, usually other infections are characterized by various degree of inflammation, but not cellular dysplasia.

12. B. Full thickness dysplasia of squamous epithelium is consistent with cervical intraepithelial neoplasia Grade III.  Condyloma is characterized enlarged dark nuclei and wrinkled nuclear membrane, and well-demarcated halo. Dysplasia may be seen in a background of condyloma, that need to be reported accordingly. Endocervical adenocarcinoma has irregular glands lined by atypical glandular cells invading into stroma. Endocervical adenocarcinoma in situ has normal glandular architecture but the glandular cells have elongated hyperchromic nuclei. Squamous cell carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellular bridges and/or squamous pearls.

13. E. All cervical intraepithelial neoplasia is a risk factor for subsequent squamous cell carcinoma, especially high grade, including CIN II and III. Ectopic pregnancy and pelvic inflammatory disease are usually associated with infection. Endometrioid endometrial adenocarcinoma may be associated with estrogen effects, PTEN mutation, Lynch syndrome, but not human papillomavirus or cervical intraepithelial neoplasia. Regression most commonly occurs with low grade, but NOT high grade cervical intraepithelial neoplasia.

14. D. Pruritic pink  nodules with eosinophilic homogenous cytoplasmic inclusion is consistent with molluscum contagiosum. It is caused by molluscum contagiosum virus. Herpes infection is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei, with marked neutrophilic infiltration. Human papillomavirus infection causes cervical intraepithelial neoplasia, endocervical adenocarcinoma in situ, and most of cervical carcinomas. Klebsiella granulomatis causes granuloma inguinale. Treponema pallidum causes syphilis.

15. C. See discussion of question 14. Chancroid is caused by Haemophilus ducreyi.

16. E. Atrophic features with flat atrophic epidermis and hyalinized fibrosis in superficial dermis is consistent with lichen sclerosus. It is a risk factor for squamous cell carcinoma.

17. C. Atrophic features with flat atrophic epidermis and hyalinized fibrosis in superficial dermis is consistent with lichen sclerosus. Condyloma is characterized enlarged dark nuclei and wrinkled nuclear membrane, and well-demarcated halo. Dermatophytosis usually has neutrophilic infiltration with fungal hyphae identified by special stains. Paget disease has scattered pale cells in epidermis. Squamous carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellular bridges and/or squamous pearls.

18. D. Normal glandular architecture lined by glandular cells with elongated hyperchromic nuclei is consistent with endocervical adenocarcinoma in situ. It is associated with human papillomavirus infection. Actinomycete is a filamentous anaerobic bacteria that commonly seen in women with intrauterine device. Histologically, actinomycetes are basophilic filamentous microorganism in clusters. Candida infection is characterized by identification of fungal pseudo hyphae. Gardnerella vaginalis is associated with bacterial vaginosis. Neisseria gonorrhoeae causes gonorrhea. All these bacterial or fungal infections are associated with cervicitis, but not dysplasia.

19. D. Normal glandular architecture lined by glandular cells with elongated hyperchromic nuclei is consistent with endocervical adenocarcinoma in situ. Cervical intraepithelial neoplasia Grade III has full thickness dysplasia of squamous epithelium. Chronic cervicitis has nonspecific chronic inflammation and minimal epithelial changes. Endocervical adenocarcinoma has irregular glands lined by atypical glandular cells invading into stroma. Squamous cell carcinoma has irregular nests or cords of atypical cells with squamous differentiation, such as intercellular bridges and/or squamous pearls.

20. D. Irregular glands lined by atypical glandular cells invading into endocervical stroma is characteristic endocervical adenocarcinoma. It is associated with human papillomavirus infection. Estrogen effect is associated with endometrioid endometrial adenocarcinoma. P53 mutation is commonly seen in high grade endometrioid endometrial adenocarcinoma, serous carcinoma, and other high grade tumors. It is usually absent in usual type endocervical adenocarcinoma. Herpes virus may cause cervicitis, but not dysplasia or malignant tumors.

21. B. See discussion of question 19. Endometrioid endometrial adenocarcinoma may involve endocervix, but not for this patient, since the tumor is confined to cervix without additional abnormalities.

22. D. This tumor has atypical cells with intercellular bridges and squamous pearls, consistent with well differentiated squamous cell carcinoma. It is most likely associated with human papillomavirus. There are no specific morphological changes for chlamydia trachomatis infection, beside nonspecific inflammation. Estrogen effect is associated with endometrioid endometrial adenocarcinoma. Herpes infection is characterized by multinucleation, chromatin margining with ground glass appearing nuclei, as well as molding of nuclei, with marked neutrophilic infiltration. P53 mutation is commonly seen in high grade endometrioid endometrial adenocarcinoma, serous carcinoma, and other high grade tumors.

22. E. See discussion of question 19. Endometrioid endometrial adenocarcinoma, like other adenocarcinomas, has irregular glands lined by atypical glandular cells invading into stroma.

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