1) Which one of the following endometrial lesions is associated with the highest risk of developing endometrial carcinoma?
A. Chronic endometritis
B. Complex hyperplasia with atypia
C. Complex hyperplasia without atypia
D. Simple hyperplasia
E. Squamous metaplasia
The correct answer is B. In general, any condition characterized by excessive estrogenic stimulation is associated with some degree of endometrial hyperplasia and increased risk of endometrial cancer. Endometrial hyperplasia is a histologic precursor of endometrial adenocarcinoma.The most severe changes are present in complex hyperplasia with atypia. Disorganization and crowding of glands, high mitotic activity, and nuclear atypia characterize this change. 25% of women with this form of hyperplasia develop adenocarcinoma.
2) a 36 year old gravid female notes vaginal bleeding. Ultrasound reveals small grape-like cystic structures witout evidence of a developing embryo. A diagnosis of complete hydatidiform mole is made at the hospital. Further analysis is most likely to reveal that:
A. hCG levels are markedly increased
B. serum levels of alpha fetoprotein are elevated
C. the genotype of the mole is 46,XX and is completely paternal is origin
D. the genotype of the mole is triploid
E. two or more sperm fertilized the ovum
The most correct answer is C. A complete hydatidiform mole is characterized by elevated hCG and grape like cystic structures filling the uterus with no detectable embryo on ultrasound. The genotype of a complete hydatidiform mole is purely paternal, caused by fertilization of an egg that has lost its chromosomes. Hydatidiform mole is associated with increasing maternal age, and may be a precursor to choriocarcinoma.
hCG levels are increased relative to normal values for dates, rathar than decreased, in a molar pregnancy (choice A).
Alpha fetoprotein (choice B) is a marker for endodermal yolk sac tumors, embryonal tumors in men, and hepatocellular carcinoma. It is made by the fetus, hence not detectable in a complete hydatidiform mole.
Triploidy and even tetraploidy are characteristics of partial moles (choice D). Partial moles are thought to be due to fertilization of an egg with two different sperm, one with an X and one with a Y chromosome, typically leading to triploidy.
Two or more sperm may fertilize an ovum, leading to a triploid fetus and a partial mole (choice E).
3) A 37 year old woman complains to her gynecologist of discomfort during intercourse and placement of a tampon. Physical examination demonstrates flocculent swelling below the skin of the posterolateral part of one labium majora. Which of the following is the most likely diagnosis?
A. Bartholin's gland cyst
B. Condylomata acuminatum
C. Lichen sclerosis
D. Vestibular adenitis
E. Vulvar squamous hyperplasia
The correct answer is A. This is a Bartholin's gland cyst, which is a relatively common lesion occurring when Bartholin's duct becomes obstructed, typically a sequela to a previous infection. The cysts can enlarge to 3 to 5 cm in diameter.They are lined by either transitional or metaplastic squamous epithelium. Treatment is by excision or marsupialization (permanent opening).
Condylomata acuminatum (choice B) usually produces a papillary lesion (venreal wart).
Lichen sclerosis (choice C) usually produces gray, parchment-like thinned epidermis.
Vestibular adenitis (choice D) usually produces an exquisitely tender posterior introitus with focal ulcerations.
Vulvar squamous hyperplasia (choice E) usually produces a white plaque.
4) A 39 year old woman has cyclical premenstrual pain. Her breasts have a "lumpy bumpy" texture on palpation. A biopsy is performed. The histopathologic features include small cysts lined by epithelial cells with apocrine metaplasia, calcium deposits, areas of fibrosis, increased number of acini (adenosis), and foci of florid hyperplasia of ductal epithelium. Which of these changes increase the risk of breast cancer?
B. Apocrine metaplasia
C. Calcium deposits
E. Epithelial hyperplasia
The correct answer is E. Fibrocystic changes usually come to clinical attention by causing pain (often cyclical, in premenstrual phase), palpable lumps, or mammographic densities and calcifications. A "lumpy-bumpy" texture is caused by cysts and fibrosis. Epithelial hyperplasia is defined as an increase in the number of epithelial cell layers in the ductal epithelium. Florid epithelial hyperplasia leads to an increased risk of developing carcinoma, especially is these is associated cellular atypia (atypical ductal hyperplasia).
Adenosis (choice A) refers to an increase in the number of acini and can be observed in fibrocystic changes as well as in other breast conditions, such as sclerosing adenosis.
Apocrine metaplasia (choice B) describes a benign change of breast epithelial cells that come to resemble the apocrine epithelium of sweat glands.
Calcium deposition (choice C) is a nonspecific finding that mar occur in a number of both benign and malignant breast change, including fibrocystic changes, ductal carcinoma in situ, and invasive carcinoma. Calcification is not clinically significant except for its diagnostic value.
Cysts (choice D) are frequent in fibrocystic changes and result from dilatation of ducts. A classic gross description is that of blue-dome cysts, which appear brown to blue because of their turbid fluid content.
5) An 83 year old female has a biopsy of an ulcerated nipple lesion that is interpreted as Paget's disease. A biopsy of the underlying breast tissue will most likely show which of the following?
A. Acute mastitis
B. Ductal carcinoma in situ
C. Intraductal papilloma
D. Invasive lobular carcinoma
E. Normal breast tissue
The correct answer is B. Paget's disease of the breast is a form of ductal carcinoma in which neoplastic cells involve the squamous epithelium of the skin by direct extension through the lactiferous ducts.
Acute mastitis (choice A) is a disease of nursing women in which bacteria (S. aureus) gain entry to the breast tissue via cracks in the traumatized nipple. It is characterized by acute inflammation and tissue necrosis.
Intraductal papilloma (choice C), a papillary mass arising within the ducts, usually presents as a single subareolar tumor that may produce a bloody or serous nipple discharge.
Invasive lobular carcinoma (choice D) is a tumor of the terminal ductules of the breast. It presents as a poorly circumscribed, rubbery breast mass. Lobular carcinoma does not produce Paget's disease.
Paget's disease of the breast always reflects underlying ductal cancer. This is in marked distinction from extramammary Paget's disease, which may arise without an identifiable malignancy (choice E).