Here’s a little quiz on female reproductive (and breast) pathology. Answers and explanations are posted at the bottom.

1. A 32-year-old woman had a firm nodule palpable on her uterus three years ago noted on a routine physical examination. The nodule has slowly increased in size and is now about twice the size it was when first discovered. She is asymptomatic. Which of the following does this patient most likely have?
A. Adenocarcinoma
B. Leiomyosarcoma
C. Rhabdomyosarcoma
D. Leiomyoma


2. A 36-year-old woman finds a lump in her right breast. Her physician notes a 4 cm firm, irregular, fixed mass in the upper outer quadrant of her right breast. A fine needle aspiration is performed, and the findings are consistent with infiltrating ductal carcinoma. The mass is removed, and a sentinel lymph node dissection is performed. Which of the following findings will best predict a better prognosis for the patient?
A. The patient has concurrent ductal carcinoma in situ in the same breast
B. The sentinel node is negative for tumor
C. The patient has a sister who had a similar type of breast cancer
D. The tumor has a high grade


3. Prognostic factors in invasive breast carcinoma include all of the following EXCEPT:
A. Tumor size
B. Type of carcinoma (ductal, inflammatory, etc.)
C. Location of primary tumor within breast
D. Lymph node involvement by tumor
E. Grade of tumor


4. All of the following are true regarding fibroadenoma EXCEPT:
A. It is the most common benign tumor of the female breast
B. More common in younger women
C. May enlarge late in the menstrual cycle and during pregnancy
D. Is an important risk factor for breast carcinoma
E. Usually presents as a solitary, moveable mass.


5. Which of the following neoplasms is derived from all three germ layers?
A. Carcinoma
B. Teratoma
C. Sarcoma
D. Apudoma


6. All of the following are true of endometrial carcinoma EXCEPT:
A. Most cases occur in postmenopausal women
B. it is caused by prolonged stimulation of the endometrium by progesterone
C. It is preceded by endometrial hyperplasia in most cases
D. It can metastasize via lymphatic and/or hematogenous routes
E. The most important prognostic factor is the stage of the tumor


7. All of the following are true of squamous cell carcinoma of the cervix EXCEPT:
A. It is preceded by squamous cell dysplasia in most cases
B. It is caused by human papillomavirus (HPV)
C. Early age at first intercourse is a risk factor
D. Most cases occur in women over 65
E. The Pap smear is an important screening test


8. Which of the following is true regarding ovarian neoplasms?
A. Most are malignant
B. They usually present while still small (<1 cm)
C. They may interfere with fertility
D. They are very rare
E. Most arise from germ cells


Answers and explanations

1. D. Explanation: The nodule grew slowly, and the patient is asymptomatic. Malignant tumors (A – C) would be more likely to grow quickly and produce nasty symptoms.

2. B. Explanation: Prognosis in breast cancer is determined primarily on the stage of the tumor (how far it has spread) – so a negative sentinel node is a good prognostic sign. Concurrent ductal carcinoma in situ (DCIS) would tend to make the prognosis a bit worse – because DCIS is a precursor to invasive carcinoma. A family history would tend to worsen the prognosis (familial breast cancer tends to be more aggressive than the sporadic type). The grade of a tumor also has a bearing on prognosis – higher grade tumors tend to be more aggressive (carry a worse prognosis).

3. C. Explanation: Staging (which involves the size of the tumor (T), the presence of lymph node metastases (N) and distant metastases (M)) is very important in prognosis. The grade of the tumor (which is determined by looking under the microscope and seeing how differentiated the tumor is, and how mitotically active it is) is also important (but a little less so than staging). Some variants of breast carcinoma (like inflammatory breast carcinoma) have a particularly bad prognosis – so this information is important too. It doesn’t really matter where the tumor is in the breast.

4. D. Explanation: A, B, and E are pretty self-explanatory. C is correct because sometimes fibroadenomas (and leiomyomas, for that matter) seem to respond to hormonal stimulation. D is incorrect – fibroadenomas are completely benign and do not turn into (or predispose the patient towards) carcinoma.

5. B. Teratomas can happen in men or women. Tissues from all three germ layers (endoderm, mesoderm and ectoderm) must be present in order to call a tumor a teratoma. You remember what carcinomas and sarcomas are (malignancies of epithelial and mesenchymal origin, respectively). Apudomas are endocrine tumors that arise in APUD cells (neural crest cells that make hormones like secretin and cholecystokinin; APUD stands for amine precursor uptake and decarboxylation). Such tumors can be found in the ampulla of Vater, pancreas and prostate.

6. B. Explanation: A and D are pretty self-explanatory. B is incorrect because it is not stimulated by progesterone, but estrogen (tricky, I know). C is correct; most cases do arise in a background of endometrial hyperplasia. However, remember that hyperplasia in and of itself is not pre-neoplastic (there are many, many cases of hyperplasia that never go on to become carcinoma). E is correct; the depth of invasion (and presence or absence of metastases) – which is basically the stage of the tumor – is the most important factor in prognosis.

7. D. HPV is the causative agent of carcinoma of the cervix (or at least, it’s the most important causative agent – there may be additional factors, like smoking, which play a role). So anything that increases one’s risk of acquiring the virus – such as an early age at first intercourse – will increase the risk of carcinoma. Squamous cell carcinoma is preceded by dysplasia in the cervical epithelium (high-grade dysplasia carries the greatest risk of turning into invasive carcinoma; low-grade dysplasia may revert to normal). The Pap smear is great because it can detect these dysplastic changes well before carcinoma develops, allowing for early intervention and prevention of carcinoma. D is incorrect; most cases occur in younger women.

8. C. Ovarian neoplasms are pretty common (so D is wrong). Most are benign (so A is wrong) and arise from the surface epithelium of the ovary (so E is wrong). They often grow to great proportions before presenting with symptoms (because the ovary is really just a tiny thing floating out there in the peritoneal space – so a tumor of the ovary can get pretty big before you’d notice that anything was wrong). C is correct – any time you mess with the ovary (whether it’s a benign tumor, a malignant tumor, or endometriosis), you can impact fertility.