PA29.2-10 | Female Genital Tract — Graded Quiz

A 38-year-old woman with polycystic ovary syndrome (PCOS) and a BMI of 34 presents with irregular, heavy menstrual bleeding for 18 months. She is nulliparous and has never taken oral contraceptives. Transvaginal ultrasound shows endometrial thickness of 18 mm. Endometrial biopsy shows markedly crowded glands with a gland:stroma ratio >3:1, back-to-back architecture, intraluminal epithelial tufting, nuclear stratification, and rounded nuclei with prominent nucleoli. No stromal invasion is identified. What is the MOST appropriate classification and the most critical management decision at this point?

A 68-year-old thin, non-diabetic woman with no history of exogenous estrogen use presents with one episode of postmenopausal bleeding. Endometrial biopsy shows a serous papillary carcinoma. CA-125 is 185 U/mL. Peritoneal washings are positive for malignant cells. Hysterectomy + bilateral salpingo-oophorectomy shows a 0.4 cm tumour confined to an endometrial polyp with no myometrial invasion. What is the MOST accurate characterisation of stage and prognosis?

A 34-year-old nulliparous woman presents with 6 months of secondary dysmenorrhoea and deep dyspareunia. Laparoscopy reveals a right ovarian 'chocolate cyst' (4 cm), powder-burn lesions in the pouch of Douglas, and dense filmy adhesions fixing the uterus in retroversion. A biopsy from the posterior broad ligament shows endometrial glands and stroma with haemosiderin-laden macrophages. CA-125 is 78 U/mL. She wishes to conceive. Which statement BEST characterises the RISK of malignancy in this setting?

A 42-year-old multiparous woman with a 10-year history of heavy menstrual bleeding undergoes hysterectomy. The uterus weighs 360 g (normal ~70 g). Cut surface of the myometrium shows irregular, haemorrhagic, soft foci scattered throughout the posterior wall, without a discrete capsule. The endometrium is intact. Microscopically, endometrial glands and stroma are identified within the myometrium at multiple foci more than 2.5 mm below the endomyometrial junction, surrounded by hypertrophied smooth muscle. No mitoses or cytological atypia. CA-125 is normal. What is the MOST specific clinical predictor that distinguishes this from uterine leiomyomas preoperatively?

A 55-year-old woman presents with a 6 cm bilateral complex ovarian mass found on routine pelvic ultrasound. She is otherwise asymptomatic. CA-125 = 850 U/mL. CT shows omental caking, ascites, and bilateral pleural effusions. Histology from an omental biopsy shows high-grade carcinoma with psammoma bodies and complex papillary architecture. TP53 is mutated; BRCA1 is mutated. Which statement about the ORIGIN and CLINICAL implications of this tumour is MOST accurate?

A 19-year-old woman presents with a solid left ovarian mass. Serum AFP = 3,400 ng/mL; β-hCG = normal; LDH = elevated. Histology shows a solid tumour with interlocking cords of primitive germ cells around a central hyalinised fibrovascular core, forming papillary structures. PAS stain shows a bright red rim around the central core. IHC: AFP+, Gleason-staining positive for AFP on the papillary structures. What is the MOST complete diagnosis including the name of the pathognomonic structure?

A 50-year-old woman is admitted for evaluation of abdominal distension. She had a left salpingo-oophorectomy 2 years ago for a 'benign cystic ovarian mass' with 'abundant mucinous material.' Now, re-exploration reveals massive gelatinous material filling the peritoneal cavity with mucoid implants on the omentum and bowel serosa. Repeat appendix biopsy is non-contributory. Review of the original left ovary shows a multilocular mucinous cystadenoma without atypia. What MOST accurately explains this clinical scenario?

A 25-year-old woman is found to have a 3 cm solid right ovarian mass at routine scan. Serum LDH and PLAP are mildly elevated; AFP and β-hCG are normal. Histology shows solid nests of large cells with clear cytoplasm and central nuclei separated by fibrous septa containing a brisk lymphocytic infiltrate. PAS shows intracytoplasmic glycogen. No Schiller-Duval bodies are seen. IHC: OCT4+, CD117+, D2-40+, SALL4+, AFP negative. Five percent of cells have microfoci with syncytiotrophoblastic giant cells. What is the ONE most important treatment implication of this diagnosis?

A 28-year-old woman has a uterine evacuation for a suspected molar pregnancy. Products of conception are sent for histology. The pathologist identifies: (i) Enlarged villi with central cisterns (cavities); (ii) Some villi with irregular, scalloped outlines; (iii) A few recognisable fetal blood vessels in some villi; (iv) Trophoblastic hyperplasia focally, predominantly syncytiotrophoblast only; (v) p57 immunostaining POSITIVE in villous stromal cells and cytotrophoblast. Karyotype is 69,XXY. What is the MOST accurate diagnosis and its malignant potential compared to the alternative molar diagnosis?

A 24-year-old woman presents with vaginal bleeding 8 weeks after an uneventful term delivery. β-hCG is 28,000 mIU/mL. MRI shows a 2.2 cm vascular uterine mass invading through the myometrium. Histology from a curettage specimen shows mononuclear intermediate trophoblastic cells infiltrating individually through the myometrium between smooth muscle fibres with minimal necrosis. The β-hCG is only mildly elevated relative to the tumour size. Inhibin A is strongly positive; hPL (human placental lactogen) is strongly positive. Multinucleated syncytiotrophoblast and chorionic villi are ABSENT. What is the MOST likely diagnosis and the critical therapeutic implication that distinguishes it from choriocarcinoma?

A 52-year-old woman presents with a 7 cm solid right ovarian mass. Serum estradiol is markedly elevated; FSH is suppressed. She has endometrial hyperplasia on biopsy. Histology of the ovarian mass shows polygonal cells with abundant pale cytoplasm arranged in nests and microfollicular structures, with characteristic 'coffee-bean' nuclei (grooved, oval nuclei). Call-Exner bodies are identified. What additional finding would MOST likely be present on further investigation, and which marker best confirms this diagnosis?

A 44-year-old woman presents with cervical discharge, pelvic pain, and cervical motion tenderness. A cervical smear shows short, cylindrical, intracellular Gram-negative diplococci within neutrophils. She is treated with dual antibiotics. Three months later she is asymptomatic but presents for infertility evaluation. Hysterosalpingography shows bilateral tubal occlusion. What is the MOST accurate pathological explanation for her infertility?