Question 41
A 33-year-old woman has been on oral contraceptives for a year. She has noted vaginal bleeding for the past 5 weeks. The bleeding is not severe, but it occurs nearly every day. On pelvic examination, there is a 0.7 cm polypoid mass noted to extend outward from the endocervical region. The ectocervix appears normal. The uterus is normal in size. The adnexa have no palpable masses. A biopsy of this lesion is performed. Which of the following pathologic findings is most likely to be found on microscopic examination of this lesion?
A Endocervical adenocarcinoma
B Clear cell adenocarcinoma
C Microglandular hyperplasia
D Sarcoma botryoides
E Endocervical polyp
F Follicular cervicitis
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(C) CORRECT. This lesion occurs secondary to oral contraceptive use (those containing progestagens) and must be distinguished from adenocarcinoma histologically.
(A) Incorrect. This is an uncommon lesion that is unlikely to be present at this age.
(B) Incorrect. This unusual lesion is more likely to occur in the vagina of women who were exposed to diethylstilbestrol in utero when their mothers took this drug.
(D) Incorrect. This rare tumor, a form of embryonal rhabdomyosarcoma, is seen in the vagina of young girls.
(E) Incorrect. Endocervical polyps occur in about 2 to 5% of women but is not specifically related to oral contraceptive use.
(F) Incorrect. Follicular cervicitis appears grossly as erythema and irregular surface features of the cervix, but not a mass.
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Question 42
A 48-year-old woman has noted a small amount of irregular vaginal bleeding for the past 2 months. She has a pelvic examination that reveals no cervical lesions, and a Pap smear that shows no abnormal cells. Next, an endometrial biopsy is performed, and there is microscopic evidence for endometrial hyperplasia. An abdominal ultrasound reveals a solid right ovarian mass. Which of the following neoplasms is this woman is most likely to have?
A Mature cystic teratoma
B Choriocarcinoma
C Sertoli-Leydig cell tumor
D Fibrothecoma
E Krukenberg tumor
F Cystadenocarcinoma
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(D) CORRECT. Fibrothecomas and granulosa cell tumors can be estrogen producing. The excessive estrogen drives endometrial hyperplasia, which can progress to atypical adenomatous hyperplasia, which can progress to carcinoma.
(A) Incorrect. Struma ovarii is the most common variant of a 'dermoid' that secretes significant amounts of a hormone. Such benign teratomas are invariably cystic, usually filled with hair and sebum from a prominent ectodermal component.
(B) Incorrect. However, theca-lutein cysts of the ovary may occur with molar pregnancy.
(C) Incorrect. However, Sertoli-Leydig cell tumor can produce virilizing symptoms.
(E) Incorrect. This tumor represents a metastatic adenocarcinoma (usually from a gastric primary).
(F) Incorrect. Though cystadenocarcinoma is one of the more common ovarian neoplasms, it is not likely to be a source of steroid hormone secretion. Cystadenocarcinomas are likely to be cystic and not solid.
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Question 43
A 49-year-old perimenopausal woman has had vaginal bleeding for the past 6 months. On physical examination she has an enlarged, nodular uterus. A hysterectomy is performed. The surgeon notes several 0.2 to 1 cm translucent, smooth-surfaced, thin-walled, fluid-filled cysts near the fimbriated end of the right fallopian tube. Which of the following is the most likely diagnosis for these cysts?
A Gartner duct cysts
B Krukenberg tumors
C Parovarian cysts
D Pelvic inflammatory disease
E Mucinous cystadenomas
F Fibrocystic disease
G Omphalomesenteric duct cyst
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(C) CORRECT. Also called paratubal cysts, these are common incidental findings. They are embryologic remnants of the wolffian duct. They are not related to neoplasia. This woman had leiomyomas of the uterus which led to the hysterectomy.
(A) Incorrect. Such cysts are found in the anterolateral vaginal wall. They are derived from embryologic wolffian duct rests.
(B) Incorrect. These are metastatic adenocarcinomas, typically from the stomach.
(D) Incorrect. PID leads to inflammation with fibrosis, which may result in tubo-ovarian abscess.
(E) Incorrect. These are usually solitary large bulky tumors of the ovary.
(F) Incorrect. Fibrocystic disease (or fibrocystic changes) is a diagnosis applied to the breast.
(G) Incorrect. A remnant of the embryologic omphalomesenteric duct may be found from umbilicus to small bowel; the most common remnant is a Meckel diverticulum.
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Question 44
A 36-year-old woman has had episodes of lower abdominal and pelvic pain for the past 10 years. A bimanual pelvic examination reveals no abnormalities. A Pap smear is negative. She has an abdominal ultrasound scan that reveals no abnormalities. Finally, she undergoes laparoscopy, and her physician notes the presence of several 0.2 to 0.5 cm brown lesions located over the serosal surfaces of the uterus, fallopian tubes, and appendix. These lesions are excised. Which of the following microscopic findings is most likely to be present in these lesions?
A Endometrial glands and stroma
B Mesothelioma
C Metastatic carcinoma
D Small capillary proliferation
E Caseating granulomas
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(A) CORRECT. Pain is a major feature of endometriosis. The foci of endometriosis are most often found on serosal surfaces in the pelvis, but can be found in other locations such as the surface of the bowel.
(B) Incorrect. Endometriosis does not undergo malignant transformation and it is not associated with mesothelial lesions.
(C) Incorrect. Endometriosis (which has glands) is a benign process and not neoplastic.
(D) Incorrect. Though hemangiomas can be found at a variety of lcoations and can be multiple, they are not typically associated with pain.
(E) Incorrect. Granulomatous inflammation of the pelvis is uncommon; it is unlikely to be hemorrhagic.
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Question 45
A 47-year-old woman has noted a pressure sensation, but no pain, in her pelvic region for the past 5 months. On physical examination there is a right adnexal mass. An ultrasound scan shows a 10 cm fluid-filled cystic mass in the right ovary. A fine needle aspirate of the mass is performed and cytologic examination of clear fluid aspirated from the mass reveals clusters of malignant epithelial cells surrounding psammoma bodies. Which of the following neoplasms is she most likely to have?
A Endometrial adenocarcinoma
B Ovarian serous cystadenocarcinoma
C Mesothelioma
D Ovarian mature cystic teratoma
E Adenocarcinoma of fallopian tube
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(B) CORRECT. Ovarian carcinomas are often associated with ascites, because they seed throughout the peritoneal cavity. Psammoma body formation is common to malignant serous tumors of the ovary.
(A) Incorrect. Cells from such a carcinoma are usually shed into the endometrial cavity and psammoma body formation does not occur.
(C) Incorrect. Though clusters of mesothelioma cells might be difficult to distinguish from adenocarcinoma, mesotheliomas are quite rare and they do not make psammoma bodies.
(D) Incorrect. A mature cystic teratoma would not have malignant elements.
(E) Incorrect. An adenocarcinoma at this site is extremely rare.
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