Reproductive Pathology — MCQs

Reproductive Pathology Indian Medical PG Practice Questions and MCQs

Question 161: A hysterectomy specimen from a 38-year-old woman shows the following gross appearance. What is the most likely diagnosis?

A. Endometrial Carcinoma
B. Leiomyoma Uterus (Correct Answer)
C. Leiomyosarcoma
D. Mixed Mullerian Tumor

Explanation: ***Leiomyoma Uterus*** - **Well-circumscribed** nodular masses with a **whorled, white-grey appearance** and **pseudocapsule** are characteristic of leiomyomas on gross examination. - Common in **reproductive-age women** (like this 38-year-old), representing the most frequent **benign smooth muscle tumor** of the uterus. *Endometrial Carcinoma* - Typically presents as a **friable, hemorrhagic mass** arising from the **endometrial cavity**, not as circumscribed nodules in the myometrium. - More common in **postmenopausal women** and would show **irregular, soft tissue** rather than the firm, whorled appearance of leiomyomas. *Leiomyosarcoma* - Shows **irregular borders**, **areas of necrosis**, and **hemorrhage** on gross examination, unlike the well-demarcated appearance described. - Typically presents as a **large, soft mass** with **fish-flesh appearance** and lacks the characteristic whorled pattern of benign leiomyomas. *Mixed Mullerian Tumor* - Presents as a **large, polypoid mass** protruding into the **endometrial cavity** with **necrotic and hemorrhagic areas**. - Primarily occurs in **elderly postmenopausal women** (mean age 60-70 years) and shows **heterogeneous appearance** rather than circumscribed nodules.

Question 162: Which of the following is not a sex cord-stromal tumor?

A. Granulosa cell tumor
B. Leydig cell tumor
C. Yolk sac tumor (Correct Answer)
D. Sertoli cell tumor

Explanation: ### Explanation The classification of ovarian and testicular tumors is based on the cell of origin. This question tests your ability to distinguish between **Sex Cord-Stromal Tumors** and **Germ Cell Tumors** [2]. **Why Yolk Sac Tumor is the correct answer:** The **Yolk Sac Tumor** (also known as Endodermal Sinus Tumor) is a **Germ Cell Tumor**, not a sex cord-stromal tumor [1], [2]. It originates from the primitive germ cells that normally differentiate into the yolk sac [1]. It is characterized by the production of **Alpha-Fetoprotein (AFP)** and the presence of pathognomonic **Schiller-Duval bodies** (glomeruloid-like structures) on histology. **Why the other options are incorrect:** Sex cord-stromal tumors arise from the connective tissue (stroma) and specialized cells of the gonads [3]. * **Granulosa cell tumor:** Arises from the sex cords; it is the most common estrogen-producing ovarian tumor, often associated with Call-Exner bodies [3]. Elevated levels of inhibin may be useful for identifying these tumors [4]. * **Sertoli and Leydig cell tumors:** These are sex cord-stromal tumors that can occur in both males and females (where they often cause virilization due to androgen production). **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Markers:** Yolk Sac Tumor = **AFP** [1]; Choriocarcinoma = **hCG** [2]; Dysgerminoma/Seminoma = **LDH**. * **Schiller-Duval Bodies:** Central vessel surrounded by tumor cells in a space lined by tumor cells (resembling a primitive glomerulus). * **Reinke Crystals:** Pathognomonic cytoplasmic inclusions found in **Leydig cell tumors**. * **Call-Exner Bodies:** Small fluid-filled spaces between granulosa cells, seen in **Granulosa cell tumors**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 979-980. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1035-1036. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 481-482. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1036-1037.

Question 163: According to the Bethesda System, in 'LSIL' histologic changes are observed in which part of the cervix?

A. Basal one-third (Correct Answer)
B. Basal half to two-thirds
C. Whole thickness except superficial layers
D. Whole thickness

Explanation: ### Explanation The Bethesda System for reporting cervical cytology categorizes squamous intraepithelial lesions into two groups: **LSIL** (Low-grade Squamous Intraepithelial Lesion) and **HSIL** (High-grade Squamous Intraepithelial Lesion). This classification correlates with the histological Cervical Intraepithelial Neoplasia (CIN) grading system [1]. **1. Why Option A is Correct:** **LSIL** corresponds histologically to **CIN I**. In CIN I, cellular atypia (increased N:C ratio, hyperchromasia) and mitotic figures are confined to the **basal one-third** of the cervical epithelium [1]. The upper layers show maturation, although they often exhibit **koilocytotic atypia** (clear halos and shrunken nuclei), which is the hallmark of HPV infection [4]. **2. Analysis of Incorrect Options:** * **Option B (Basal half to two-thirds):** This describes **CIN II**, which falls under the category of **HSIL** in the Bethesda System. Atypia extends beyond the lower third but does not involve the full thickness [1]. * **Option C (Whole thickness except superficial layers):** This describes **CIN III**, also categorized as **HSIL** [3]. Atypia involves the majority of the epithelium, but a thin layer of maturation remains at the surface. * **Option D (Whole thickness):** This describes **Carcinoma in situ (CIS)**, the most severe form of CIN III/HSIL, where maturation is completely absent from the basement membrane to the surface [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **LSIL (CIN I):** High rate of spontaneous regression (approx. 60%); usually associated with low-risk HPV (6, 11) or transient high-risk HPV [1]. * **HSIL (CIN II/III):** Lower regression rate; strongly associated with persistent high-risk HPV (16, 18) and requires aggressive management (LEEP/Conization). * **Koilocytes:** Pathognomonic for HPV; seen primarily in the superficial layers of LSIL [4]. * **Key Marker:** **p16** immunohistochemistry is a surrogate marker for high-risk HPV and is typically diffuse/strong in HSIL [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1008-1010. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1007-1008. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 467-468. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 466-467.

Question 164: Biopsy from a testicular mass following orchidectomy showed sheets of uniform cells containing abundant clear cytoplasm with prominent nucleus. Which is the histopathological diagnosis?

A. Embryonal Carcinoma
B. Lymphoma
C. Seminoma (Correct Answer)
D. Teratoma

Explanation: ### **Explanation** **Correct Option: C. Seminoma** Seminoma is the most common germ cell tumor of the testis [1]. The classic histopathological hallmark is the presence of **sheets or nests of uniform, large, polygonal cells** separated by thin fibrous septa [1]. These cells possess **abundant clear cytoplasm** (due to high glycogen content) and a large, central, **prominent nucleolus** [1]. A key diagnostic feature often seen is the infiltration of the fibrous septa by small lymphocytes. **Why other options are incorrect:** * **A. Embryonal Carcinoma:** Characterized by pleomorphic, primitive-looking cells arranged in alveolar, tubular, or papillary patterns [1]. Unlike the "uniform" cells of seminoma, these cells are highly malignant-looking with indistinct cell borders (syncytial growth). * **B. Lymphoma:** Usually seen in older men (>60 years). Histology shows diffuse infiltration of malignant lymphoid cells (typically Diffuse Large B-cell Lymphoma) rather than clear-cell sheets. * **C. Teratoma:** Composed of tissues derived from more than one germ layer (ectoderm, mesoderm, endoderm), such as cartilage, muscle, or neural tissue [2]. It does not present as a uniform sheet of clear cells. **High-Yield Pearls for NEET-PG:** * **Tumor Marker:** Seminomas are typically associated with elevated **hCG** (in 10-15% of cases) but **never** elevated Alpha-fetoprotein (AFP) [1]. If AFP is high, it indicates a non-seminomatous component (e.g., Yolk Sac Tumor). * **Radiosensitivity:** Seminomas are highly radiosensitive and have an excellent prognosis. * **Fried-Egg Appearance:** The clear cytoplasm and central nucleus are often described as having a "fried-egg" appearance. * **IHC Marker:** Positive for **OCT3/4, NANOG, and CD117 (c-KIT)** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 979-980. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 982-983.

Question 165: What is the origin of cancer cells in a Krukenberg tumour?

A. Ovarian carcinoma
B. Gastric carcinoma (Correct Answer)
C. Duodenal carcinoma
D. Pancreatic carcinoma

Explanation: **Explanation:** A **Krukenberg tumour** refers to a metastatic signet-ring cell carcinoma of the ovary. The hallmark of this pathology is the presence of mucin-secreting "signet-ring" cells infiltrating the ovarian stroma, typically presenting as bilateral, solid ovarian masses. **Why Gastric Carcinoma is correct:** The most common primary site for a Krukenberg tumour is the **stomach** (specifically the diffuse type of gastric adenocarcinoma). Malignant cells spread to the ovaries most commonly via **retrograde lymphatic dissemination**, though transcoelomic (peritoneal) seeding is also a recognized pathway. **Why other options are incorrect:** * **Ovarian carcinoma:** This refers to a primary malignancy arising from the ovary itself (e.g., Serous cystadenocarcinoma). By definition, a Krukenberg tumour is a *metastatic* lesion, not a primary one. * **Duodenal/Pancreatic carcinoma:** While these GI malignancies can occasionally metastasize to the ovary, they are significantly less common causes and do not typically present with the classic signet-ring morphology associated with the Krukenberg definition. **High-Yield NEET-PG Pearls:** 1. **Bilateralism:** Approximately 80% of Krukenberg tumours are bilateral. 2. **Microscopy:** Look for **Signet-ring cells** (nucleus pushed to the periphery by a large mucin vacuole) and a dense, reactive fibroblastic stroma (sarcomatoid reaction). 3. **Primary Sites:** Stomach (>70%) is #1, followed by the colon, breast (lobular carcinoma), and appendix [1]. 4. **Clinical Sign:** Often presents as a palpable pelvic mass in a patient with a history of dyspepsia or weight loss. 5. **Stain:** Mucin can be highlighted using **PAS (Periodic Acid-Schiff)** or **Mucicarmine** stains. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 478-480.

Question 166: What is true about the histology of infiltrating lobular breast carcinoma?

A. Single file pattern (Correct Answer)
B. Pleomorphic cells in sheets
C. Cribriform pattern
D. Pinwheel pattern

Explanation: **Explanation:** Infiltrating Lobular Carcinoma (ILC) is the second most common type of invasive breast cancer. The hallmark histological feature of ILC is the **"Single File Pattern"** (also known as Indian filing) [1]. **1. Why "Single File Pattern" is correct:** The defining molecular defect in ILC is the **loss of E-cadherin expression** (due to mutations in the *CDH1* gene). E-cadherin is a cell-surface adhesion molecule; its absence causes tumor cells to lose cohesion. Consequently, instead of forming solid nests or ducts, the dyscohesive, small, monomorphic cells invade the stroma individually or in linear, single-cell rows [1]. These cells often surround normal ducts in a "targetoid" or concentric fashion [1]. **2. Analysis of Incorrect Options:** * **B. Pleomorphic cells in sheets:** This is characteristic of **Invasive Carcinoma of No Special Type (NST)**, formerly known as Invasive Ductal Carcinoma. ILC cells are typically small and uniform (monomorphic), not pleomorphic [1]. * **C. Cribriform pattern:** This "sieve-like" appearance with punched-out spaces is characteristic of **Adenoid Cystic Carcinoma** or the cribriform subtype of ductal carcinoma in situ (DCIS). * **D. Pinwheel pattern:** Also known as a "storiform" pattern, this is typically seen in mesenchymal tumors like **Dermatofibrosarcoma Protuberans (DFSP)** or Fibrous Histiocytomas, not ILC. **High-Yield Clinical Pearls for NEET-PG:** * **Bilateral & Multicentric:** ILC has a higher tendency to be bilateral and multicentric compared to ductal carcinoma [1]. * **Metastasis:** ILC has a unique metastatic profile, often spreading to the **peritoneum, GI tract, ovaries, and leptomeninges.** * **Signet Ring Cells:** A variant of ILC may show signet ring morphology (intracytoplasmic mucin displacing the nucleus) [1]. * **E-cadherin:** Negative staining for E-cadherin is the gold standard IHC marker to differentiate ILC from ductal carcinoma. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 454-455.

Question 167: What condition presents the maximum risk of invasive breast carcinoma?

A. Complex fibroadenoma
B. Sclerosing adenosis
C. Intraductal papilloma
D. Atypical ductal hyperplasia (Correct Answer)

Explanation: The risk of developing invasive breast carcinoma is categorized based on the histological features of benign breast lesions. This classification is a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** **D. Atypical Ductal Hyperplasia (ADH):** This condition falls under the category of **Proliferative Breast Disease with Atypia**. ADH involves a clonal proliferation of cells that histologically resemble low-grade ductal carcinoma in situ (DCIS) but are limited in extent (occupying <2 mm or <2 duct spaces) [1]. It carries a **moderate risk (4 to 5-fold increase)** of developing invasive carcinoma in either breast. If a patient also has a first-degree family history of breast cancer, this risk can increase up to 10-fold. ### **Analysis of Incorrect Options** * **A. Complex Fibroadenoma:** These are fibroadenomas containing cysts (>3mm), sclerosing adenosis, or epithelial calcifications. They carry a **slight risk (1.5 to 2-fold)**. * **B. Sclerosing Adenosis:** This is a **Proliferative Disease without Atypia**. It involves an increased number of acini that are compressed and distorted by central stroma [1]. It carries a **slight risk (1.5 to 2-fold)**. * **C. Intraductal Papilloma:** Small duct papillomas are also classified as **Proliferative Disease without Atypia**, carrying a **slight risk (1.5 to 2-fold)** [1]. ### **NEET-PG Clinical Pearls** * **No Increased Risk (1x):** Fibrocystic changes (without hyperplasia), mild hyperplasia, simple fibroadenoma, and duct ectasia. * **Slight Risk (1.5–2x):** Moderate/florid hyperplasia (without atypia), sclerosing adenosis, and complex fibroadenoma. * **Moderate Risk (4–5x):** Atypical Ductal Hyperplasia (ADH) and Atypical Lobular Hyperplasia (ALH). * **High Risk (8–10x):** Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS). * **Note:** Most cancers following ADH/ALH occur in the **ipsilateral** breast, but the risk is increased for **both** breasts. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1052-1056.

Question 168: What is the most common age group for leiomyosarcoma?

A. 20 - 40 years
B. 30 - 50 years
C. 40 - 60 years (Correct Answer)
D. 50 - 70 years

Explanation: **Explanation:** **Leiomyosarcoma (LMS)** is a malignant neoplasm arising from the smooth muscle cells of the myometrium. Unlike benign leiomyomas (fibroids), which are common in women of reproductive age, leiomyosarcomas are rare and typically occur in a significantly older demographic. **1. Why 40–60 years is correct:** The peak incidence of leiomyosarcoma is in the **perimenopausal and postmenopausal** periods. Most epidemiological data and standard pathology textbooks (like Robbins) place the peak age range between **40 and 60 years**, with a median age of approximately 55. This timing is a critical diagnostic clue: a "fibroid" that rapidly increases in size after menopause should be treated with high suspicion for malignancy. **2. Why other options are incorrect:** * **20–40 years (Option A):** This is the peak age for benign leiomyomas. LMS is exceedingly rare in women under 40. * **30–50 years (Option B):** While there is some overlap, this range is too young for the peak incidence of a sar-coma, which generally follows a "late-onset" pattern. * **50–70 years (Option D):** While many cases do occur in the 6th and 7th decades, the statistical peak begins earlier (at age 40), making 40–60 the more accurate clinical bracket for the "most common" group. **High-Yield NEET-PG Pearls:** * **De Novo Origin:** Leiomyosarcomas arise **de novo** from myometrial precursor cells; they almost never arise from pre-existing benign leiomyomas. * **Diagnostic Triad:** Diagnosis is based on three histological criteria: **1. Nuclear atypia, 2. High mitotic index (>10 per 10 HPF), and 3. Coagulative tumor cell necrosis.** [1] * **Clinical Sign:** Rapid enlargement of a uterine mass in a postmenopausal woman is the classic presentation. * **Metastasis:** Hematogenous spread is common, most frequently to the **lungs**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1024-1025.

Question 169: Gleason's classification is used for which of the following conditions?

A. Carcinoma of the breast
B. Carcinoma of the prostate (Correct Answer)
C. Carcinoma of the pancreas
D. Carcinoma of the rectum

Explanation: **Explanation:** **Gleason’s Grading System** is the gold standard for determining the prognosis of **Prostate Adenocarcinoma** (Option B) [1]. Unlike many other grading systems that rely on cellular atypia, the Gleason system is based entirely on the **architectural patterns** of the tumor cells [1]. ### Why Option B is Correct: The Gleason system assigns a grade from 1 to 5 based on the degree of glandular differentiation [1]. * **Grade 1:** Well-defined, uniform, small glands (most differentiated). * **Grade 5:** Lack of gland formation, showing sheets of cells or nests (least differentiated). The **Gleason Score** is calculated by adding the primary (most dominant) pattern and the secondary (second most dominant) pattern (e.g., 3+4=7) [2]. A higher score indicates a more aggressive tumor and a poorer prognosis [2]. ### Why Other Options are Incorrect: * **Option A (Breast):** Uses the **Nottingham Grading System** (Modified Bloom-Richardson), which evaluates tubule formation, nuclear pleomorphism, and mitotic count. * **Option C (Pancreas):** Graded based on the degree of glandular differentiation and mucin production, but does not use a specific eponymous system like Gleason. * **Option D (Rectum):** Colorectal cancers are typically graded as well, moderately, or poorly differentiated based on the percentage of gland formation (WHO criteria). ### High-Yield Clinical Pearls for NEET-PG: * **ISUP Grade Groups:** Modern pathology now groups Gleason scores into 5 Grade Groups (1 to 5) to better predict clinical outcomes (e.g., Gleason ≤6 is Grade Group 1). * **Prostate Biopsy vs. Prostatectomy:** In a biopsy, if only one pattern is seen, it is doubled (e.g., 3+3=6). If three patterns are seen, the most common and the *highest* grade are added. * **PSA Correlation:** Higher Gleason scores generally correlate with higher serum PSA levels and a greater risk of extraprostatic extension [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 990-992. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 993-994.

Question 170: Which among the following are testicular tumor markers?

A. b-hCG, AFP, and LDH are true markers, while CA-125 and CEA are false. (Correct Answer)
B. b-hCG, AFP, and LDH are false markers, while CA-125 and CEA are true.
C. b-hCG, AFP, and CEA are false markers, while LDH and CA-125 are true.
D. b-hCG, AFP, and CEA are true markers, while LDH and CA-125 are false.

Explanation: In testicular germ cell tumors (GCTs), serum tumor markers are essential for diagnosis, staging, prognosis, and monitoring treatment response. [1] **Why Option A is Correct:** The three primary markers for testicular GCTs are: 1. **Alpha-fetoprotein (AFP):** Produced by yolk sac elements. It is **never** elevated in pure seminomas; its elevation in a suspected seminoma indicates a non-seminomatous component. 2. **beta-hCG:** Produced by syncytiotrophoblasts. [1] It is elevated in all choriocarcinomas and approximately 15% of seminomas. [2] 3. **Lactate Dehydrogenase (LDH):** A less specific marker that reflects the overall tumor burden, growth rate, and degree of tissue proliferation. **CA-125** is primarily a marker for ovarian cancer, and **CEA** (Carcinoembryonic Antigen) is associated with colorectal and GI malignancies; neither is used in the standard evaluation of testicular tumors. **Analysis of Incorrect Options:** * **Options B & C:** These incorrectly categorize the established markers (AFP, hCG, LDH) as false. * **Option D:** Incorrectly includes CEA as a true marker for testicular cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Pure Seminoma:** May show elevated hCG but **never** elevated AFP. * **Yolk Sac Tumor:** Characterized by high AFP and the presence of Schiller-Duval bodies. * **Choriocarcinoma:** Characterized by very high hCG and early hematogenous spread. [1] * **Prognostic Value:** LDH is the most useful marker for assessing the total mass of the tumor. * **Post-Orchidectomy:** Persistence of markers suggests metastatic disease or incomplete resection. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, p. 982. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 512-513.

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Diseases of Male Genital Tract

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Testicular Tumors

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Prostate Pathology

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Diseases of Female Genital Tract

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Cervical Pathology and Neoplasia

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Endometrial Pathology

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Ovarian Diseases and Tumors

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Gestational Trophoblastic Disease

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Placental Pathology

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Sexually Transmitted Infections

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