Upper Genital Tract Benign and Malignant Conditions

1. A 44-year-old multiparous obese woman complains of abnormal vaginal bleeding of 5 months’ duration. Pelvic examination demonstrates a small, anteverted uterus and a normal-appearing cervix. No adnexal masses are present. A serum pregnancy test is negative, and a cervical Papanicolaou (Pap) smear is normal. Prolactin and thyroid-stimulating hormone (TSH) levels are normal. Which of the following is the most efficient next step in the evaluation of this patient?

2. A 44-year-old multiparous obese woman complains of abnormal vaginal bleeding of 5 months’ duration. Pelvic examination demonstrates a small, anteverted uterus and a normal-appearing cervix. No adnexal masses are present. A serum pregnancy test is negative, and a cervical Papanicolaou (Pap) smear is normal. Prolactin and thyroid-stimulating hormone (TSH) levels are normal. Tissue sampling in this patient reveals endometrial hyperplasia. What is the most common symptom associated with this condition?

3. A 44-year-old multiparous obese woman complains of abnormal vaginal bleeding of 5 months’ duration. Pelvic examination demonstrates a small, anteverted uterus and a normal-appearing cervix. No adnexal masses are present. A serum pregnancy test is negative, and a cervical Papanicolaou (Pap) smear is normal. Prolactin and thyroid-stimulating hormone (TSH) levels are normal. Which of the following factors is protective against endometrial hyperplasias?

4. A 49-year-old woman experiences irregular vaginal bleeding of 3 months’ duration. You perform an endometrial biopsy, which obtains copious tissue with a velvety, lobulated texture. The pathologist report shows proliferation of glandular and stromal elements with dilated endometrial glands, consistent with simple hyperplasia. Cytologic atypia is absent. Which of the following is the best way to advise the patient?

5. A 48-year-old woman is referred to you for irregular vaginal bleeding of 6 months’ duration. Her referring physician removed tissue protruding through the cervix 3 months ago. Microscopic examination of the tissue shows a mass with cystic hyperplasia and a central vascular channel surrounded on three sides by epithelium. The vaginal bleeding has continued. Which of the following is the best way to advise the patient?

6. A 58-year-old woman on combined estrogen and progesterone hormone replacement has postmenopausal bleeding. You obtain a pelvic ultrasound that shows an endometrial stripe thickness of 12 mm. Which of the following is most correct?

7. An internist calls you for consultation regarding a 55-year-old postmenopausal woman with some vaginal spotting. On examination, a small, round, bright red mass was noted to protrude through the cervical os. It bled during the Pap smear. The Pap smear result was normal. You should advise the internist to do which of the following?

8. A 44-year-old female biochemist has complex hyperplasia without atypia on endometrial biopsy. You prescribe 40-mg megestrol acetate daily. She inquires about the mechanism of action and regression rate. Which of the following explanations is most correct?

9. A 45-year-old woman complains of pelvic pressure and abnormal uterine bleeding. Ultrasound reveals an enlarged uterus with an intramural 4 cm mass. Which of the following is the most common uterine neoplasm?

10. During a presentation to a group on women’s health a discussion of gynecologic/reproductive cancers including their etiology risk, factors, and normal clinical course is presented. Which of the following types of cancer is the leading cause of gynecologic/reproductive cancer death in women?

11. A 69-year-old postmenopausal woman is being admitted for surgical treatment of endometrial cancer. She has no health insurance and would like to know which is the most important preoperative screening test to look for metastasis?

12. A 58-year-old woman develops postmenopausal bleeding. An endometrial biopsy shows adenocarcinoma. She undergoes a total abdominal hysterectomy with pelvic lymph node sampling. The final pathology shows tumor extending from the uterus into the cervix but no other invasion (see Figure 22–1). Lymph nodes were negative for metastasis. The cancer is classified as which stage?

Figure 22–1.

13. A patient has just been diagnosed with endometrial cancer by endometrial biopsy. During her counseling regarding the disease, staging, management, and prognosis the patient is told that most endometrial cancers are diagnosed as which of the following stages

14. A healthy 65-year-old woman is seen for postmenopausal bleeding. The pelvic examination is normal. A fractional D&C demonstrates adenocarcinoma of the endometrium. Histologically, endometrial glands are confluent without solid areas of tumor cells. The endocervical curettage shows normal endocervical cells. The cervical Pap smear and other preoperative investigations are normal. Which of the following statements most likely reflects this patient’s endometrial carcinoma stage or treatment.

15. A healthy 65-year-old woman is seen for postmenopausal bleeding. The pelvic examination is normal. A fractional D&C demonstrates adenocarcinoma of the endometrium. Histologically, endometrial glands are confluent without solid areas of tumor cells. The endocervical curettage shows normal endocervical cells. The cervical Pap smear and other preoperative investigations are normal. Exploratory laparotomy is negative for metastatic disease. The uterus is opened in the operating room and found to have tumor invasion into the myometrium. Histologic examination of the uterus confirms tumor invasion beyond the inner half of the myometrium. Peritoneal washings and pelvic and paraaortic nodes are negative for malignancy. What should you advise this patient?

16. A healthy 65-year-old woman is seen for postmenopausal bleeding. The pelvic examination is normal. A fractional D&C demonstrates adenocarcinoma of the endometrium. Histologically, endometrial glands are confluent without solid areas of tumor cells. The endocervical curettage shows normal endocervical cells. The cervical Pap smear and other preoperative investigations are normal. This patient underwent postoperative radiation. During radiation therapy she develops nausea,anorexia, diarrhea, and mild abdominal pain. Which of the following is the most likely diagnosis?

17. A pulmonary nodule is discovered on the chest radiogram of a healthy 82-year-old woman. Four years ago, she was treated for endometrial adenocarcinoma. Excision of the nodule shows moderately differentiated endometrial adenocarcinoma-containing progesterone receptors. There is no other evidence of metastatic disease. What should you advise this patient?

18. A 52-year-old patient undergoes a hysterectomy for a rapidly growing uterine mass. At surgery the frozen biopsy is reported as a sarcoma. What is the most common uterine sarcoma?

19. A 55-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a rapidly enlarging pelvic mass. A frozen section is sent, although the pathologist tells you he cannot distinguish leiomyosarcomas very well on frozen section. Nonetheless, the specimen looks very suspicious. You still have her abdomen open in the operating room. Which of the following statements describes the optimal next step in the evaluation and management for this patient?

20. A 40-year-old woman is found on pelvic examination to have an enlarged uterus. Ultrasound reveals a well-circumscribed intramural mass consistent with the leiomyoma. The patient asks: what is the incidence of sarcomatous degeneration in a uterine leiomyoma?

21. Which of the following is a factor predisposing to the development of malignant mixed müllerian tumors?

22. A 38-year-old nulliparous woman presents requesting a bilateral salpingo-oophorectomy. Her mother died of ovarian cancer at the age 64, and her sister at the age 48. There is no family history of other cancers. You advise her that her risk of developing ovarian cancer is what percentage?

23. The same patient gets on the Internet and returns asking about the hereditary types of epithelial ovarian cancer. Which of the following statements is true?

24. A 56-year-old healthy woman develops vague complaints and presents to her primary care physician. Which of the following accurately describes symptoms that could be associated with a diagnosis of ovarian cancer?

25. Which of the following is a cornerstone for detection of ovarian neoplasia?

26. Ovarian neoplasms most commonly arise from which of the following cell lines?

27. Which of the following postmenopausal women is most protected from ovarian epithelial carcinoma?

28. Which of the following statements accurately reflects the natural history of ovarian epithelial carcinoma?

29. A 35-year-old woman desiring fertility undergoes exploratory laparotomy for a 12-cm pelvic mass. At surgery, a large, lobulated, right ovarian mass is observed. It has a smooth external capsule and a bluishgray appearance. The uterus, fallopian tubes, and left ovary appear normal. Abdominal exploration is negative for metastatic disease. A right salpingo-oophorectomy is performed. The tumor is opened intraoperatively and found to be divided by septa into lobules. Frozen section of the tumor shows a mucinous cystadenoma of low malignant potential.One would base the remainder of the surgical intervention at this time on which of the following statements regarding mucinous cystadenoma of low malignant potential?

30. A 35-year-old woman desiring fertility undergoes exploratory laparotomy for a 12-cm pelvic mass. At surgery, a large, lobulated, right ovarian mass is observed. It has a smooth external capsule and a bluishgray appearance. The uterus, fallopian tubes, and left ovary appear normal. Abdominal exploration is negative for metastatic disease. A right salpingo-oophorectomy is performed. The tumor is opened intraoperatively and found to be divided by septa into lobules. Frozen section of the tumor shows a mucinous cystadenoma of low malignant potential. Two days after surgery, you receive the pathology report of the ovarian tumor. It is a mucinous cystadenoma of low malignant potential mixed with well-differentiated carcinoma. The tumor has not invaded the ovarian capsule, lymphatics, or mesovarium. Omental and retroperitoneal lymph node biopsies and peritoneal washings are negative for tumor cells. How do you advise this patient?

31. A 54-year-old healthy woman comes for an annual examination. Her last menstrual period (LMP) was 4 years ago. The physical examination is normal. Pelvic examination shows vaginal atrophy and a small, mobile uterus. The right ovary is 2.5 x 4.5 cm in diameter. The left ovary is nonpalpable. Vaginal ultrasonography shows that the right ovary is similar in size to that of a premenopausal ovary. What should you advise this patient?

32. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL).Which of the following statements reflects CA-125?

33. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL).  Which of the following is the most likely diagnosis?

34. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). Her surgical treatment should do which of the following?

35. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexalmass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries,urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination andgastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). Exploratory laparotomy shows a tumor involving the right ovary. The left ovary appears normal.Several tumor implants are present on the peritoneal surfaces of small bowel and omentum. Biopsies of the peritoneal implants and ovarian tumor show moderately differentiated serous cystadenocarcinoma. There are no distant metastases, and the liver appears normal (see Figure 22–2). What is the initial intraoperative assessment of stage of the tumor?

Figure 22–2.

36. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). The primary tumor and all metastases are surgically removed. You meet with the patient postoperatively to discuss her prognosis. How do you advise this patient?

37. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). You are called to the operating room by the general surgeons at a local children’s hosp ital. A 4-yearold girl with acute abdominal pain was thought to have appendicitis; instead, she has a large right ovary. What is the most likely diagnosis?

38. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). An 18-year-old woman with a history of pelvic inflammatory disease (PID) undergoes a laparoscopic ovarian cystectomy for a 5-cm ovarian mass containing a tooth. The contents of the cyst spill during removal and contain thick sebaceous material and hair. Copious irrigation was used to remove this material. She is noted to have marked bowel adhesions in the pelvis, which require dissection to reach the ovarian cyst. Four days postoperatively she returns to the emergency department with a temperature of 101.1°F, abdominal pain, nausea, and vomiting. White blood cell (WBC) count is 15.0. What is the most likely diagnosis?

39.  A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). An 11-year-old girl presents with abdominal pain, and a right 5-cm solid ovarian mass is found. The alpha-fetoprotein level is elevated. In which of the following ways should you counsel the girl and parents?

40. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). A 10-year-old girl presents with abdominal pain. During the emergency department workup, an adnexal mass is found. You suspect a germ cell tumor. In preoperative discussion, her parents are told that the most common germ cell tumor is which of the following?

41. A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL). A 19-year-old woman with an ovarian mass is thought to have a dermoid or teratoma based on ultrasound findings and gross examination at removal by laparoscopy. At her postoperative visit the pathology returns with the finding of an immature teratoma. Which of the following statements reflects current knowledge about immature teratomas?

42. A 26-year-old nulliparous woman is seen in the emergency department for acute abdominal pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 120 bpm; and temperature, afebrile. Abdominal examination shows right lower quadrant tenderness with rebound. Pelvic examination demonstrates a painful 10-cm right adnexal mass. A serum pregnancy test is negative. A hematocrit is 24% (normal, 35–45%). Exploratory laparotomy confirms a hemoperitoneum. A smooth right ovarian tumor is bleeding from its ruptured capsule. Inspection of the uterus, fallopian tubes, and left ovary is normal. A right salpingo-oophorectomy is performed. Frozen section of the tumor shows primitive germ cells with intervening connective tissue infiltrated by lymphocytes. The tumor is most likely which of the following?

43. A 26-year-old nulliparous woman is seen in the emergency department for acute abdominal pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 120 bpm; and temperature, afebrile. Abdominal examination shows right lower quadrant tenderness with rebound. Pelvic examination demonstrates a painful 10-cm right adnexal mass. A serum pregnancy test is negative. A hematocrit is 24% (normal, 35–45%). Exploratory laparotomy confirms a hemoperitoneum. A smooth right ovarian tumor is bleeding from its ruptured capsule. Inspection of the uterus, fallopian tubes, and left ovary is normal. A right salpingo-oophorectomy is performed. Frozen section of the tumor shows primitive germ cells with intervening connective tissue infiltrated by lymphocytes.. Which of the following statements reflects current understanding about the above tumor?

44. An 18-year-old woman with primary amenorrhea complains of a right inguinal mass. Physical examination demonstrates a normal-appearing female. Bilateral breast development is present. Axillary and pubic hair are sparse. The vulva appears normal, but the vagina ends in a blind pouch. The uterus is nonpalpable by rectal examination. The right inguinal mass is most likely which of the following?

45. An 18-year-old woman with primary amenorrhea complains of a right inguinal mass. Physical examination demonstrates a normal-appearing female. Bilateral breast development is present. Axillary and pubic hair are sparse. The vulva appears normal, but the vagina ends in a blind pouch. The uterus is nonpalpable by rectal examination.Which of the following tumors is most likely to occur in the right inguinal mass?

46. Malignant changes occur in what percentage of streak ovaries when a Y chromosome is present?

47. A 5-year-old girl experiences early breast development. She is taller than her peers. Her mother has noticed blood at the girl’s introitus. Serum gonadotropin levels are low and are unchanged after intravenous administration of gonadotropin-releasing hormone (GnRH). Which of the following is the most likely diagnosis?

48. A 48-year-old woman is taken to surgery for a solid pelvic mass of 6×7 cm and marked ascites. At laparotomy the adnexa is removed and sent for frozen section examination. The report returns as metastic adenocarcinoma to the ovary. Although uncommon, metastatic tumors to the ovary most often originate from which of the following?

49. A hormonally active neoplasm is likely to cause clinical signs through the hormonal effect that would prompt earlier evaluation and hence diagnosis. Which one of the following tumors is likely to be found primarily based on physical size and location of the neoplasm?

50. An 18-year-old G1P0 patient presents with vaginal bleeding at 10 weeks estimated gestational age. She has not received any prenatal care. You find the uterine size more consistent with 12–14 weeks and no fetal heart tones are found. Ultrasound is consistent with a molar pregnancy. Which of the following accurately reflects current knowledge regarding gestational trophoblastic disease?

51. An 18-year-old G1P0 patient presents with vaginal bleeding at 10 weeks estimated gestational age. She has not received any prenatal care. You find the uterine size more consistent with 12–14 weeks and no fetal heart tones are found. Ultrasound is consistent with a molar pregnancy. Pathology returns as choriocarcinoma. During counseling of the patient regarding the disease, treatment and prognosis, which of the following statements is accurate?

52. Tumors grow exponentially due to which of the following?

53. Which of the following does the stem cell theory state?

54. As a general rule, drugs used in multiagent chemotherapeutic regimens should be which of the following?

55. A 43-year-old woman has stage III epithelial ovarian carcinoma. She had surgical debulking and has received five courses of carboplatin and paclitaxel. She is now due for her sixth course. She comes to clinic complaining of fatigue and myalgias. She has a temperature of 101.3°F. On examination, you find no obvious source of the fever. WBC count is 1,000/mm3 (normal 4, 500 to 11,000/mm3). Your next course of action is to do which of the following?