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Rubins/Robbins breast path
Terms in this set (210)
A 21-year-old woman delivered a normal term infant a week ago and is now nursing the infant. She now notes a lump in her right axilla that has increased in size over the past week. On physical examination there is a rubbery, mobile, 1.5-cm mass beneath the skin at the right anterior axillary line. The mass is excised and the microscopic appearance is shown in the figure. Which of the following hormones most likely pro- duced the greatest effect upon this tissue?
A 24-year-old woman is breastfeeding 3 weeks after giving birth to a normal term infant. She notices fissures in the skin around her left nipple. Over the next 3 days, a 5-cm region near the nipple becomes erythematous and tender. Pu- rulent exudate from a small abscess drains through a fissure. Which of the following organisms is most likely to be cultured from the exudate?
A 30-year-old woman sustained a traumatic blow to her right breast. Initially, there was a 3-cm contusion beneath the skin that resolved within 3 weeks, but she then felt a firm, painless lump that persisted below the site of the bruise 1 month later. What is the most likely diagnosis for this lump?
A study of mammographic findings on women of reproductive years is performed. The study identifies mam- mograms showing 1- to 5-cm cysts with focal microcalcifi- cations and surrounding densities. Subsequent fine-needle aspiration yielded turbid fluid with few cells. Which of the following microscopic changes is most likely to be present in these lesions?
A 27-year-old woman feels a lump in her right breast. She has normal menstrual cycles, she is G3, P3, and her last child was born 5 years ago. On examination a 2-cm, irregular, firm area is palpated beneath the lateral edge of the areola. This lumpy area is not painful and is movable. There are no lesions of the overlying skin and no axillary lymphadenop- athy. A biopsy specimen shows microscopic evidence of an increased number of dilated ducts surrounded by fibrous connective tissue. Fluid-filled ducts with apocrine metaplasia also are present. What is the most likely diagnosis?
A 47-year-old woman has a routine health examination. There are no remarkable findings except for a barely palpable mass in the right breast. A mammogram shows an irregular, 1.5-cm area of density with scattered microcalcifications in the upper outer quadrant. A biopsy specimen from this area is ob- tained and microscopically shows ductal hyperplasia. Which of the following is the most appropriate option for follow-up of this patient?
continued screening for breast cancer
A 34-year-old woman has noticed a bloody discharge from the nipple of her left breast for the past 3 days. On physi- cal examination, the skin of the breasts appears normal, and no masses are palpable. There is no axillary lymphadenopa- thy. She has regular menstrual cycles and is using oral contra- ceptives. Excisional biopsy is most likely to show which of the following lesions in her left breast?
A 57-year-old man has developed bilateral breast en- largement over the past 2 years. On physical examination, the enlargement is symmetric and is not painful to palpation. There are no masses. He is not obese and is not taking any medications. Which of the following underlying conditions best accounts for his findings?
A 58-year-old woman sees her naturopathic health care provider for a routine health examination. There are no remarkable findings on physical examination. A screening mammogram shows a 0.5-cm irregular area of increased density with scattered microcalcifications in the upper outer quadrant of the left breast. Excisional biopsy shows atypical lobular hyperplasia. She has been on postmenopausal estrogen- progesterone therapy for the past 10 years. She has smoked 1 pack of cigarettes per day for the past 35 years. Which of the following is the most significant risk factor for the development of lobular carcinoma in patients with such lesions?
atypical cytologic changes
A 25-year-old Jewish woman sees her physician after finding a lump in her right breast. On physical examination, a 2-cm, firm, nonmovable mass is palpated in the upper outer quadrant. No overlying skin lesions and no axillary lymphadenopathy are present. The figure shows an excisional biopsy specimen. The family history indicates that the patient's mother, maternal aunt, and maternal grandmother have had similar lesions. Her 18-year-old sister has asked a physician to determine whether she is genetically at risk of developing a similar disease. A mutated gene encoding for which of the following is most likely to be found in her sister?
A clinical study is performed on postmenopausal wom- en living in Paris, France, who are between the ages of 45 and 70 years. All have been diagnosed with infiltrating ductal car- cinoma positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for HER2 expression, which has been confirmed by biopsy and microscopic examination of tis- sue. None has the BRCA1 or BRCA2 mutation. Which of the following is most likely to indicate the highest relative risk of developing the carcinomas seen in this group of women?
first-degree relative with breast cancer
A 54-year-old woman feels a lump in her left breast. On examination there is a firm, irregular mass in the lower outer quadrant. A mammogram shows a 2-cm density with focal microcalcifications. Excisional biopsy shows intraductal and invasive carcinoma. Immunohistochemical staining is negative for estrogen receptor (ER). FISH analysis (green = HER2; red = chromosome 17 centromere) shows the findings in the figure. When combined with doxorubicin, which of the following drugs is most likely to be useful in treating this patient?
A 66-year-old nulliparous woman received hormone re- placement therapy for 7 years following menopause at age 53 years. Her BMI is 33. She now undergoes screening mammog- raphy, and an irregular mass is identified in the right breast. An excisional biopsy yields a 1.5-cm mass that microscopically has invasive cells that are positive for estrogen receptor but negative for HER2, with low proliferation markers and mutated PIK3CA gene. Following surgical removal of the mass, which of the fol- lowing clinical courses will most likely occur over the next year?
very low likelihood of recurrence
A 63-year-old woman has a screening mammogram that shows an irregular density with microcalcifications. On physi- cal examination, there are no lesions of the overlying skin, and there is no axillary lymphadenopathy. An excisional biopsy specimen shows no mass on sectioning. Microscopic examina- tion shows the findings in the figure. What is the most likely diagnosis?
ductal carcinoma in situ
A 48-year-old woman has noticed a red, scaly area of skin on her left breast that has grown slightly larger over the past 4 months. On physical examination, there is a 1-cm area of eczematous skin adjacent to the areola. The figure shows the microscopic appearance of the skin biopsy specimen. What is the most likely diagnosis?
A 54-year-old woman noticed a lump in her right breast. On examination, she has an ill-defined, 1-cm mass in the upper outer quadrant. The mass is cystic on ultrasound. An excision is done, and microscopically the mass shows predominantly fibrocystic changes, but the lesion shown in the figure also is present. Fine-needle aspirates of both breasts reveal additional foci of similar cells. Which of the following breast lesions is most likely to produce these findings?
lobular carcinoma in situ
A 49-year-old woman felt a lump in her left breast 1 week ago. On examination, a firm, irregular mass is palpable in the upper outer quadrant of her left breast. There are no overlying skin lesions. The gross appearance of the excisional biopsy specimen is shown in the figure. Which of the follow- ing additional findings is she most likely to have on physical examination?
A 57-year-old woman has felt a lump in her left breast for 4 months. She has had new onset headaches associated with nau- sea for the past month. Her physician palpates a firm but irregu- lar 2-cm mass in her left breast. CT imaging of her brain shows leptomeningeal enhancement. A lumpectomy with axillary node sampling is performed. Immunohistochemical staining of these cells shows absence of E-cadherin and HER2, but presence of es- trogen receptor (ER) and progesterone receptor (PR). An H and E stained section is shown in the figure. No nodal metastases are present. Which of the following is the most likely diagnosis?
A 39-year-old woman has noticed an enlarging mass in her left breast for the past 2 years. The physician palpates a 4-cm firm mass. Following biopsy, a simple mastectomy is performed with axillary lymph node sampling. On gross sec- tioning, the mass has a soft, tan, fleshy surface. Histologically, the mass is composed of large cells with vesicular nuclei and prominent nucleoli. There is a marked lymphocytic infiltrate within the tumor, and the tumor has a discrete, noninfiltrative border. No axillary node metastases are present. The tumor cells are triple negative, for HER2, estrogen receptor (ER), and progesterone receptor (PR). What is the most likely diagnosis?
An epidemiologic study is conducted with male subjects who have been diagnosed with breast carcinoma. Their demo- graphic data, medical histories, family histories, and labora- tory data are examined to identify factors that increase the risk of cancer. Which of the following factors is most likely to be as- sociated with the greatest number of male breast carcinomas?
A study of women with breast carcinoma is done to de- termine the presence and amount of estrogen receptor (ER) and progesterone receptor (PR) in the carcinoma cells. Large amounts of ER and PR are found in the carcinoma cells of some patients. These receptors are not present in the cells of other patients. The patients with positivity for ER and PR are likely to exhibit which of the following traits?
higher response to therapy
A 26-year-old woman has felt a breast lump for the past month and is worried because she has a family history of early onset and bilateral breast cancers. On physical examination, there is a firm, 2-cm mass in the upper outer quadrant of her left breast. A biopsy is done, and the specimen microscopically shows carcinoma. Genetic analysis shows that she is a carrier of the BRCA1 gene mutation, as are her mother and sister. Which of the following histologic types of breast carcinoma has the highest incidence in families such as hers?
A 79-year-old, previously healthy woman feels a lump in her right breast. The physician palpates a 2-cm firm mass in the upper outer quadrant. Nontender right axillary lymphade- nopathy is present. A lumpectomy with axillary lymph node dissection is performed. Microscopic examination shows that the mass is an infiltrating ductal carcinoma. Two of 10 axillary nodes contain metastases. Flow cytometry on the carcinoma cells shows a small aneuploid peak and high S-phase. Immu- nohistochemical tests show that the tumor cells are positive for estrogen and progesterone receptor (ER/PR), negative for HER2/neu expression, and positive for cathepsin D expression. What is the most important prognostic factor for this patient?
presence of lymph node metastases
A study of gene expression profiling involving breast bi- opsies showing invasive carcinoma of no specific type (NST) is performed. A subset of these cases, comprising about 15% of all cases, has the following characteristics: estrogen receptor (ER) and progesterone receptor (PR) negative, HER2/neu nega- tive, basal keratin positive, flow cytometry showing aneuploi- dy and high proliferation rate, and association with BRCA1 mutations. Which of the following therapies is most likely to be effective in women with this subset of NST breast cancer?
A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the past 2 months. On physical examination, the 7-cm area of ery- thematous skin is tender with a rough, firm surface resembling an orange peel. There is swelling of the right breast, nipple retraction, and right axillary nontender lymphadenopathy. Excisional biopsy of skin and breast is most likely to show which of the following lesions?
infiltrating ductal carcinoma
A 26-year-old woman has noticed a lump in her right breast for the past year. A 2-cm, firm, circumscribed, mov- able mass is palpated in the lower outer quadrant. The figure shows the excised mass (A) and the mammogram (B). What is the most likely diagnosis?
A 27-year-old woman in the third trimester of her third pregnancy discovers a lump in her left breast. On physical ex- amination, a 2-cm, discrete, freely movable mass beneath the nipple is palpable. After the birth of a term infant, the mass appears to decrease in size. The infant is breastfed without dif- ficulty. What is the most likely diagnosis?
A 24-year-old woman notes a lump in her right breast for the past month. She is concerned because her sister was di- agnosed with a poorly differentiated "triple negative" breast cancer at age 31. Ultrasonography of the breast shows a solid mass. Fine needle aspiration is attempted but no diagnostic cells are obtained. Mammography is performed and there is a single 1-cm density with small clustered calcifications in the right breast but no lesions of the opposite breast. Which of the following is the best course of action for this patient?
biopsy to obtain tissue from the lesion
A 48-year-old woman has felt a poorly defined lump in her right breast for the past year. On examination, she has a nontender, firm, 6-cm mass in the upper inner quadrant of her right breast. There are no lesions of the overlying skin and no axillary lymphadenopathy. A biopsy is performed, and mi- croscopic examination of the specimen shows the findings in the figure. The mass is excised with a wide margin, but recurs 1 year later. After further excision, the lesion does not recur. What is the most likely diagnosis?
A 30-year-old woman suffers traumatic injury to her breast while playing soccer. Physical examination reveals a 3-cm area of ecchymosis on the left breast. Two weeks later, the patient palpates a firm lump beneath the area where the bruise had been located. Which of the following is the most likely patho- logic diagnosis?
A 50-year-old woman presents with a mass in her left breast that she first detected 6 months earlier. A firm 4-cm mass is palpated on breast examination. Excisional biopsy reveals malignant cuboidal cells that form gland-like structures and solid nests, surrounded by dense collagenous stroma. Which of the following terms best describes the adaptive response of this patient's normal breast tissue to the tumor?
A 54-year-old woman complains of bloody discharge from her left nipple. Physical examination reveals a 0.5-cm nod- ule in the subareolar breast tissue, which is surgically excised. Histologic examination (shown in the image) reveals cuboidal and myoepithelial cell-lined vascular connective tissue cores, which project into the lumen of a major lactiferous duct. Which of the following is the appropriate diagnosis?
A 53-year-old woman discovers a lump in her breast and physical examination confirms a mass in the lower, outer quadrant of the left breast. Mammography demonstrates an ill-defined, stellate density measuring 1 cm. Needle aspiration reveals malignant ductal epithelial cells. A modified radical mastectomy is performed. The surgical specimen reveals a firm irregular mass (arrows). Which of the following cellular markers would be the most useful to evaluate before consider- ing therapeutic options for this patient?
A 35-year-old nulliparous woman complains that her breasts are swollen and nodular upon palpation. A mammogram discloses foci of calcification in both breasts. A breast biopsy reveals cystic duct dilation and ductal epithelial hyperplasia without atypia (shown in the image). What is the appropriate diagnosis?
A 24-year-old woman delivers a 3.5-kg baby and begins breastfeeding her infant. The patient presents 2 weeks later with a fever of 38°C (101°F). Physical examination shows no abnormal vaginal discharge or evidence of pelvic pain but does reveal redness on the lower side of the left breast. The patient stops nursing the infant temporarily, but the symptoms per- sist, and the entire breast becomes swollen and painful. What is the most likely diagnosis?
A 35-year-old woman consults her family physician because of painful swelling of her breasts, particularly as she approaches the end of her menstrual cycle. On self-examination she recently felt a tender nodule in the right breast. Physical examination reveals an irregular nodularity of both breasts with diffuse tenderness. Examination of the axilla is negative. A mammogram demonstrates irregular areas of density in the lower, outer quadrants of both breasts. Which of the following histopathologic features is considered to be a risk factor for the development of carcinoma in this patient?
A 60-year-old man presents with painless, bilateral enlarge- ment of both breasts. The patient has a history of nodular prostatic hyperplasia and is taking medication for hypercho- lesterolemia. Physical examination reveals no discrete breast masses or axillary lymph node enlargement. Which of the fol- lowing is the most likely underlying cause of breast enlarge- ment in this patient?
A 30-year-old woman presents with nipple discharge of 3 weeks in duration. Physical examination reveals a white dis- charge from both nipples. The patient has not menstruated for the past 4 months, and she is not pregnant. The breasts are firm and nontender. A cytologic smear of the discharge shows no evidence of acute or chronic inflammatory cells. Which of the following is the most likely cause of galactorrhea in this patient?
A woman consults her physician because of painful swelling of her breasts. Physical examination reveals nodularity of both breasts. Mammography shows irregular areas of increased density in the lower, outer quadrants of both breasts. A breast biopsy reveals increased fibrous stoma, cystic dilation of the terminal ducts, and varying degrees of apocrine metaplasia. This patient's condition is most commonly seen in which of the following groups?
women of reproductive age
A 22-year-old woman presents with a painless nodule in the lower outer aspect of her right breast that she has had for 2 months. The nodule appears to be freely movable, sharply demarcated from the surrounding parenchyma, and firm. A mammogram demonstrates a circumscribed, homogeneous density. A biopsy of the breast mass is shown in the image. Which of the following best estimates the risk of subsequent invasive breast cancer developing in this patient?
risk is doubled
A 20-year-old woman asks for your advice regarding her risk of developing breast cancer. Her mother, maternal aunt, and maternal grandmother all developed breast cancer. She would like to know if she has a genetic predisposition. Laboratory tests for mutations in which of the following genes would be most likely to answer your patient's question?
A 26-year-old woman presents with a breast mass that was detected on self-examination 1 week earlier. Mammography reveals a round, sharply demarcated 1-cm nodule in the right breast (shown in the image). Biopsy of the breast mass shows neoplastic epithelial ductal structures situated within a fibro- myxoid stroma. The patient refuses further treatment and informs you that she wishes to become pregnant. Which of the following is the most likely effect of pregnancy on this breast lesion?
Upon self-examination, a 53-year-old woman discovers a lump in her left breast. Physical examination reveals a palpa- ble lump about 1 cm in diameter in the outer quadrant of the left breast. No palpable lymph nodes are found in the axilla. Mammography reveals an ill-defined, stellate density measur- ing 1 cm in the left breast. Fine-needle aspiration of the mass discloses malignant epithelial cells. A partial mastectomy is performed and shows invasive ductal adenocarcinoma. Which of the following is the most important prognostic factor for this patient?
status of the axillary lymph nodes
A mammogram of a 52-year-old woman demonstrates calcifi- cations in her left breast. No axillary lymph node enlargement is detected on physical examination. An excisional biopsy is shown in the image. If this patient foregoes further treatment, which of the following best estimates her risk of developing invasive carcinoma in this breast over the next 20 years?
A 54-year-old woman presents with a mass in her right breast that she first palpated 5 days before. A breast biopsy reveals malignant cells, and a mastectomy is performed. Immuno- histochemical staining is performed for HER2/neu (shown in the image). Which of the following genetic mechanisms best accounts for the intensity of staining in this specimen?
A 45-year-old woman discovers a solitary, freely movable mass in her right breast on self-examination, which is confirmed on physical examination. Mammography demonstrates focal calcification, with a linear configuration in the region of the breast mass. A breast biopsy (shown in the image) reveals large, pleomorphic epithelial cells confined to dilated ducts, with central zones of necrosis. What is the appropriate patho- logic diagnosis?
ductal carcinoma in situ, comedocarcinoma type
A 50-year-old woman has been aware of a mass in her left breast for the past 6 months. A 4-cm mass is palpated on examination. The mass is hard, tender, and fixed to the overly- ing skin. A lumpectomy is performed. The surgical specimen is firm, has poorly defined margins, and cuts with a gritty sen- sation. The cut surface is gray, opaque, and slightly depressed. Streaks of gray connective tissue extend into the surround- ing fibroadipose tissue. The tumor histology is shown in the image. Which of the following risk factors has the strongest association with this patient's tumor?
A 58-year-old woman presents with an irregular nodularity that has developed in her right breast over the past 3 months. Mammography demonstrates irregular densities in both breasts. A needle biopsy of one breast lesion is shown. An excisional biopsy of the contralateral breast shows similar his- tology. Which of the following is the most likely pathologic diagnosis?
lobular carcinoma in situ
A 22-year-old woman nursing her newborn develops a tender erythematous area around the nipple of her left breast. On physical examination, a purulent exudate is observed to drain from an open fissure. Culture of this exudate will most likely grow which of the following microorganisms?
A 52-year-old woman presents with a 3-month history of a palpable breast mass. Physical examination confirms a 1-cm nodule in the upper outer quadrant of the right breast. A biopsy reveals small cuboidal cells, with round nuclei and prominent nucleoli. The cells are arranged in single cell col- umns, between strands of connective tissue (shown in the image). Which of the following is the appropriate diagnosis?
invasive lobular carcinoma
A 58-year-old woman has a screening mammography and is found to have a 4-cm circumscribed mass, without calcifica- tions, in her left breast. An excisional biopsy shows solid nests and sheets of highly pleomorphic cells, with many mitotic fig- ures, surrounded by a dense infiltrate of lymphocytes. Which of the following is the most likely diagnosis?
A 45-year-old woman presents with an oozing, reddish patch on her left nipple (patient shown in the image). The patient has a history of skin rashes and food allergies and believes this condition is due to an allergic reaction to her bra. Cyto- logic examination of fluid oozing from the skin lesion reveals neoplastic cells. Excisional biopsy shows large clear malignant cells in the epidermis of the areola. Which of the following is the most likely diagnosis?
A 60-year-old woman presents with a large breast mass that she first detected 3 months ago. Mammography reveals a well- circumscribed mass measuring 8 cm in diameter. A breast biopsy shows loose fibroconnective tissue with a sarcomatous stroma, abundant mitoses, and nodules and ridges lined by cuboidal epithelial cells. Which of the following is the appro- priate diagnosis?
A 65-year-old woman presents with a palpable breast mass that she palpated 1 month earlier. Physical examination reveals a soft, jelly-like tumor measuring 5 cm in diameter. Histologic examination of a breast biopsy is shown in the image. What is the appropriate diagnosis?
A 55-year-old man presents with a solitary breast mass and biopsy reveals malignant cells. Immunohistochemical staining experiments show that the tumor cells are positive for HER2/ neu and cytokeratins 4 and 11 and negative for estrogen receptors. What is the most likely diagnosis?
invasive ductal carcinoma
A 55-year-old man presents with a solitary breast mass and biopsy reveals malignant cells. Immunohistochemical staining experiments show that the tumor cells are positive for HER2/ neu and cytokeratins 4 and 11 and negative for estrogen receptors. What gene likely plays a role in this case?
A 36-year-old woman presents with infertility. She complains of having had dull pelvic pain for 9 months, which is accen- tuated during menstruation. Physical examination and endo- crinologic studies are normal. Laparoscopy reveals multiple, small hemorrhagic lesions over the surface of both ovaries and fallopian tubes and abundant pelvic scarring. Which of the following is the most likely diagnosis?
A 58-year-old woman complains of recent swelling in her vagina. There is a past medical history of prenatal exposure to diethylstilbestrol. Physical examination reveals a 3-cm firm mass in the anterior wall of the upper vagina. Biopsy of the vaginal mass will most likely show which of the following pathologic findings?
clear cell adenocarcinoma
A 60-year-old woman presents with a 3-week history of a pain- ful genital lesion and bleeding. Physical examination reveals an exophytic, ulcerated 1-cm polypoid mass near the external end of the urethra. What is the most likely diagnosis?
A 30-year-old woman presents with a 5-month history of increasing abdominal girth and pelvic discomfort. Imaging studies reveal a mass replacing the left ovary. A multilocular tumor filled with thick, viscous fluid is removed (shown in the image). Tumor spaces are lined by mucinous, columnar epithelial cells, showing no evidence of atypia. There are no
papillary structures and no evidence of stromal invasion. Which of the following is the appropriate pathologic diagnosis?
Mutinous cystadenomas most closely resembles which of the following patterns of müllerian-type differentiation?
mucosa of the endocervix
A 19-year-old student presents to the university health ser- vice with lower abdominal pain and a painful swollen right knee. She denies any trauma to the knee. Pelvic examination is exquisitely painful and reveals an ill-defined thickening in the right and left adnexae. A vaginal discharge is noted. The patient is febrile (38.7°C/103°F). Examination of her right knee reveals an enlarged, tender, and warm joint. The WBC count is 18,500/μL (normal = 4,000 to 11,000/μL). If untreated, which of the following would be the most likely complication in this patient?
A 59-year-old woman presents with a 2-year history of vul- var itching and burning. Physical examination reveals a red, moist lesion of the labium major. Biopsy reveals clusters of pale vacuolated cells within the epidermis that stain posi- tively for periodic acid-Schiff (PAS) and carcinoembryonic antigen (CEA). Which of the following is the most likely diagnosis?
extramammary paget disease
A 52-year-old woman with hypothyroidism presents with a 2-year history of vulvar itching and painful intercourse. Physi- cal examination reveals vulval white plaques, atrophic skin, and a parchment-like appearance. Biopsy of the lesion (shown in the image)demonstrates hyperkeratosis, loss of rete ridges, and a homogeneous, acellular zone in the upper dermis. This patient's vulvar dermatitis is most commonly associated with which of the following underlying conditions?
A 29-year-old woman is evaluated for an abnormal cervical Pap smear. Colposcopy reveals condyloma acuminatum of the exocervix. A biopsy of the cervix is shown in the image. PCR amplification of this biopsy specimen will most likely demonstrate evidence of which of the following infectious agents?
A 31-year-old Haitian woman is evaluated for infertility. Pel- vic examination shows a markedly enlarged vulva, inguinal lymph node enlargement, and rectal stricture. Biopsy of an inguinal lymph node reveals necrotizing granulomas, neutro- philic infiltrates, and inclusion bodies within macrophages. Which of the following is the most likely etiology of infertility in this patient?
A 35-year-old woman in Africa presents with fever, chills, and malaise. She further complains of a painful genital sore. She had sexual intercourse 5 days previously. Physical examina- tion reveals vesiculopustular lesions on the labium major and cervix. There is bilateral inguinal lymphadenopathy. A lymph node biopsy reveals granulomatous inflammation. Which of the following is the most likely etiology of this constellation of signs and symptoms?
A routine cervical Pap smear taken during a gynecologic examination of a 31-year-old woman shows numerous, loosely arranged cells with high nuclear-to-cytoplasmic ratio. Colpos- copy shows white epithelium, punctation, and a mosaic pat- tern in the transformation zone (shown in the image). Which of the following is the most likely diagnosis?
dysplasia of the cervix
A 36-year-old woman is evaluated for an abnormal Pap smear. A cervical biopsy shows atypical squamous cells throughout the entire thickness of the epithelium, with no evidence of epi- thelial maturation (shown in the image). The basal membrane appears intact. What is the appropriate diagnosis?
severe dysplasia CIN-3
A 35-year-old woman presents with a 6-week history of vaginal discharge, which is occasionally blood tinged. Pelvic examination reveals a 2-cm pedunculated, lobulated, and smooth cervical growth; it is excised. Histologic examina- tion of the specimen would most likely reveal which of the following?
A 28-year-old woman, who is 28 weeks pregnant, presents with vaginal bleeding. She does not have a history of uterine contractions. Pelvic examination reveals bright red blood in the endocervical canal. An ulcerated exophytic mass is identi- fied on the left side of the cervix. There is no evidence of direct tumor extension into the parametrium. The pelvic lymph nodes are slightly enlarged, raising the possibility of nodal involvement by the tumor. A Caesarian section is performed, followed by a radical hysterectomy. The cervix is shown in the image. Which of the following is the best prognostic indicator of survival in this patient?
Diagnosis of stage IV cervical cancer if untreated, which of the following will be the most likely cause of death in the patient described?
A 50-year-old nulliparous woman with a history of diabetes complains that her menstrual blood flow is more abundant than usual. During the last two menstrual cycles, she noticed spotting throughout the entire cycle. The patient is obese (BMI = 32 kg/m2), and her blood pressure is 160/100 mm Hg. An ultrasound examination reveals a thickened endometrial stripe with a polypoid mass in the uterine fundus. The patient undergoes a hysterectomy. The uterus is opened to reveal a partially necrotic mass (shown in the image). A biopsy of the mass shows moderately differentiated adenocarcinoma. Which of the following represents the most likely precursor of this patient's malignant disease?
Neoplastic cells obtained from a patient with endometrial adenocarcinoma would most likely show loss of function of which of the following cell cycle control proteins?
A 45-year-old obese woman (BMI = 32 kg/m2) with a history of diabetes and poorly controlled hypertension complains of increased menstrual blood flow of 3 months in duration. An endometrial biopsy is shown in the image. Which of the fol- lowing most likely accounts for the pathogenesis of endometrial hyperplasia in this patient?
excess estrogen stimulation
A 33-year-old woman with a history of menorrhagia presents with a 6-month history of increasing fatigue. A CBC reveals a hypochromic, microcytic anemia (hemoglobin = 8 g/dL). Bimanual pelvic examination reveals an enlarged uterus with multiple, irregular masses. A hysterectomy is performed, and a sharply circumscribed fleshy tumor is found within the uterine wall (shown in the image). Which of the following is the most likely cause of vaginal bleeding and anemia in this patient?
A 52-year-old woman presents with chronic pelvic discomfort. A CT scan of the pelvis shows a 10-cm, well-circumscribed uterine mass. A hysterectomy is performed. On gross exami- nation, the mass is soft with areas of necrosis and irregular borders extending into the myometrium. Histologic examina- tion demonstrates large zones of necrosis surrounded by a rim of disorganized spindle cells that display numerous mitoses. Immunohistochemical staining for smooth muscle actin is positive. Which of the following is the most likely diagnosis?
A 50-year-old woman complains of having intermenstrual bleeding for 4 months. A Pap smear is normal. An ultra- sound examination shows a mass in the endometrial cavity. The patient elects to undergo a hysterectomy. A large polyp is found upon opening the endometrial cavity (shown in the image). Histologic examination of this polyp will most likely show which of the following pathologic findings?
endometrial glands and fibrous stroma
A 40-year-old woman presents with a 5-year history of dys- menorrhea. Physical examination and endocrine studies are normal. A hysterectomy is performed. Histologic examination of the uterine wall reveals areas of extensive adenomyosis. Which of the following best describes this patient's uterine pathology?
displacement of endometrial glands and storm
A 60-year-old women presents with a 2-week history of uter- ine bleeding. Gynecologic examination reveals an enlarged uterus. The hysterectomy specimen shows a large polypoid mass involving the endometrium and myometrium. Histologic examination reveals malignant glands and malignant stromal elements, including striated muscle and cartilage. What is the appropriate diagnosis?
A 25-year-old woman is referred to the gynecologist for treat- ment of infertility. The patient is obese (BMI = 32 kg/m2) and has pronounced facial hair. She states that she has always had irregular menstrual periods. On gynecologic examination, both ovaries are found to be symmetrically enlarged. This patient's ovaries would likely show which of the following pathologic findings? endocrine studies on this woman would show?
high levels of luteinizing hormone
A 50-year-old woman who has a family history of breast can- cer presents with a 6-month history of increasing abdomi- nal girth. On close questioning, she volunteers a history of vague abdominal pain dating back 1 year. She has no chil- dren and has never been pregnant. Bimanual pelvic exami- nation reveals a 10-cm right adnexal mass. Percussion of the
abdomen indicates ascites. Aspiration cytology of the ascites fluid reveals malignant papillary structures with psammoma bodies. A mutation in which of the following genes is most likely associated with this patient's malignant disease?
Psammoma bodies are derived from what kind of ovarian cells/tissue?
A 50-year-old woman presents with a 1-month history of intermittent vaginal bleeding. A Pap smear is normal. Pel- vic examination reveals a left adnexal mass. A uterine curet- tage shows complex endometrial hyperplasia without atypia. A CT scan of the abdomen reveals a 5-cm mass replacing the left ovary. The patient undergoes hysterectomy and bilateral salpingo-oophorectomy. Histologic examination of the ovar- ian mass is shown in the image. Which of the following is the appropriate pathologic diagnosis?
Granulosa cell tumor
A 40-year-old woman presents with 6 months of increasing abdominal girth. Gynecologic examination reveals large bilateral ovarian masses. The patient undergoes bilateral oophorectomy. The pathology report reads "Krukenberg tumor," and the histo- pathologic findings are shown in the image. Which of the fol- lowing tests would likely provide the highest diagnostic yield?
A 15-year-old girl presents with left lower abdominal pain. She has noted recent enlargement of her breasts. Her last men- strual period was 10 weeks ago. She denies having had sex- ual intercourse. Serum levels of hCG are markedly elevated. Which of the following is the most likely diagnosis?
A 20-year-old woman presents with increasing abdominal girth of 3 months in duration. Physical examination reveals ascites. A pelvic examination discloses a right ovarian mass. A 7-cm ovarian mass is removed at surgery. The histologic appearance of this ovarian neoplasm (shown in the image) most closely resembles which of the following malignant neo- plasms seen in males?
A 60-year-old woman presents with a 1-year history of vul- var itching, bleeding, and inflammation. Physical examina- tion reveals a 1-cm exophytic mass on the labium major. Biopsy of the mass is shown in the image. These neoplastic cells would most likely express which of the following tumor markers?
A 22-year-old woman presents to the emergency room with a 2-hour history of acute abdominal pain and vaginal bleed- ing. Her vital signs are normal. Physical examination reveals blood oozing from the vaginal opening. Laparotomy shows an enlarged right fallopian tube with hemorrhage and rup- ture. What is the most likely cause of hemorrhage in this patient?
A 25-year-old woman in the last trimester of her first preg- nancy presents for a routine obstetric evaluation. Her blood pressure is 160/100 mm Hg, and her pulse is 75 per minute. Physical examination shows pitting edema of the extremi- ties. Urinalysis demonstrates 3+ proteinuria. Which of the following is the most dangerous complication of preeclampsia in this patient?
disseminated intravascular coagulation
A 17-year-old woman presents to her gynecologist with a 5-day history of vaginal bleeding. A home pregnancy test had been positive 1 week previously. This morning, the patient passed tissue with the appearance of small grapes. An ultra- sound shows a dilated endometrial cavity but no evidence of a fetus. Endometrial evacuation of the uterus by suction curet- tage reveals grapelike clusters, with individual units measur- ing up to 5 mm in diameter (shown in the image). Cytogenetic examination of this tissue will most likely demonstrate which of the following genetic patterns?
A 41-year-old immigrant woman from Asia presents for prenatal care. Her uterus is significantly larger than expected, and her serum hCG level is much higher than expected for her due date. No fetus is found on ultrasound examination. The abnormal placenta is removed. One month later, this patient presents to the emergency room with abdominal pain. Explor- atory laparotomy reveals rupture of the posterior uterine fundus with grape-like tissue extruding from the defect. Two liters of blood are present in the abdominal cavity. Histologic examination of the uterine mass is shown in the image. The arrows point to syncytial cells. Which of the following is the most likely diagnosis?
A 34-year-old woman in the third trimester of her second pregnancy presents with a 1-week history of vaginal bleeding. The patient subsequently gives birth to a healthy female at 35 weeks of gestation. Immediately after delivery, the patient begins to hemorrhage transvaginally. The bleeding cannot be controlled, and the patient undergoes emergency hysterec- tomy. Examination of the hysterectomy specimen reveals pen- etration of chorionic villi deep into the myometrium, causing failure of the placental tissue to fully separate from the uterine wall. Which of the following best describes the uteroplacental abnormality seen in this patient?
A 30-year-old pregnant woman asks for information regarding mechanisms of sex determination during development. You explain that the Y chromosome determines male phenotype and that specific genital organs are inhibited from developing by hormones secreted by the developing testes. For example, müllerian-inhibiting substance released by Sertoli cells causes the involution of which of the following urogenital organs?
A 33-year-old woman presents after 3 weeks of a painful genital lesion. Physical examination reveals a tender, erythematous, submucosal lesion of the labium minor (shown in the image). Which of the following is the most likely diagnosis?
bartholin gland cyst
A 22-year-old woman presents to the emergency room with an 8-hour history of high fever, vomiting, diarrhea, and night sweats. Her temperature on admission is 38.7°C (103°F), blood pressure 100/60 mm Hg, and respirations 24 per min- ute. She has a diffuse desquamative erythematous rash. Upon pelvic examination, the patient is found to be menstruating, and a tampon is in place. A purulent exudate is found within the vagina, which is cultured and grows Staphylococcus aureus. The hemoglobin is 12 g/dL, and the platelet count is 40,000/μL. Which of the following represents the most com- mon life-threatening complication of this patient's systemic disorder?
disseminated intravascular coagulation
A 35-year-old woman complains of vaginal discomfort for 2 weeks. Physical examination reveals a scanty vaginal dis- charge. The fluid develops a "fishy" odor after treatment with 10% potassium hydroxide. A Pap smear taken during the pel- vic examination shows squamous cells covered by coccobacilli ("clue" cells). Which of the following is the most likely etiol- ogy of vaginal discomfort in this patient?
A 56-year-old woman presents with a 3-month history of vagi- nal bleeding. A cervical Pap smear reveals malignant, glandu- lar epithelial cells. This patient most likely has a neoplasm originating in which of the following anatomic locations?
A 20-year-old woman presents for a complete physical exami- nation. During the pelvic examination, a 5-cm cystic mass is found in the region of the right ovary. Radiographs show focal calcifications in the mass. The tumor is removed, and the sur- gical specimen is shown in the image. Which of the following is the most likely diagnosis?
A 43-year-old woman presents with a 6-month history of increasing abdominal girth. On physical examination, there is pronounced ascites. Pelvic examination reveals a left adnexal mass. A 6-cm ovarian tumor is removed. The tumor is solid and white. Histologically, it is composed of cells resembling normal ovarian stroma surrounded by collagen fibers. Which of the following is the appropriate diagnosis?
A 25-year-old woman presents with a 6-month history of increasing facial hair, deepened voice, and amenorrhea. Physical examination confirms virilization. A CT scan reveals a left ovarian mass. The tumor is surgically removed. It mea- sures 10 cm in diameter and has a yellowish-tan appearance on cross section. The tumor is malignant and consists of two distinct cell populations. Some cells form solid nests, whereas others are arranged in trabecular and gland-like structures. Which of the following is the appropriate diagnosis?
Sertoli-Leydig cell tumor
A 25-year-old woman presents with a 6-month history of breast enlargement and menstrual irregularities. An endome- trial biopsy 3 months previously showed complex hyperplasia without atypia. A CT scan of the pelvis reveals a left ovarian mass, which is subsequently removed. The surgical specimen is solid and yellow, and measures 8 cm in diameter. Histo- logically, it is composed of lipid-laden theca cells. Following removal of this neoplasm, a marked decrease in serum levels of which of the following hormones would be expected in this patient?
A 34-year-old woman presents with increasing abdominal girth of 3 months in duration. Physical examination reveals a left ovarian mass and mild ascites. The ovarian mass is removed, and the pathology report states "yolk sac carcinoma." Which of the following provides the best serologic marker to monitor
the course of disease in this patient after surgery?
A 20-year-old woman presents to her gynecologist with a 3-day history of vaginal bleeding. An ultrasound shows a dilated endometrial cavity. Evacuation of the uterus by suction curettage reveals grapelike clusters and fetal parts. Cytogenetic examination of this tissue will most likely demonstrate which of the following genetic patterns?
A 55-year-old nulliparous woman presents for a physical examination. The patient is obese (BMI = 33 kg/m2) and has mild, adult-onset diabetes. Compared with multiparous women, this patient is at increased risk of developing a neo- plasm in which of the following anatomic locations?
A 14-year-old boy presents with 3 months of lethargy, headaches, and muscle weakness. His parents note that he drinks water excessively. His vital signs are normal. A 24-hour urine collection shows polyuria. The fasting blood sugar is normal. An X-ray film of the brain reveals suprasellar calcifi- cation. An autopsy specimen of a similar case is shown in the image. Which of the following neoplasms is the most likely cause of polyuria in this patient?
A 60-year-old man with small cell carcinoma of the lung is rushed to the emergency room in a coma after suffering a clonic-tonic seizure. The patient's temperature is 37°C (98.6°F), blood pressure 100/50 mm Hg, and pulse 88 per minute. Lab- oratory studies show a serum sodium of 103 mmol/L, normal serum levels of BUN and creatinine, and a dilute but otherwise normal urine. A CT scan of the head is normal. Which of the following is the most likely cause of seizures in this patient?
syndrome of inappropriate ADH secretion
A 60-year-old woman with small cell carcinoma of the lung notes rounding of her face, upper truncal obesity, and muscle weakness. Physical examination reveals thin, wrinkled skin, abdominal striae, and multiple purpuric skin lesions. The patient's blood pressure is 175/95 mm Hg. Laboratory studies will likely show elevated serum levels of which of the follow- ing hormones?
A 21-year-old woman experiences abruptio placentae with severe bleeding during the delivery of a term fetus. Five months later, she presents with profound lethargy, pallor, mus- cle weakness, failure of lactation, and amenorrhea. Which of the following pathologic findings is expected in this patient?
infarction of the pituitary
A 25-year-old man presents with 3 months of polyuria and increased thirst. The patient suffered trauma to the base of the skull in a motorcycle accident 4 months ago. A 24-hour urine collection shows polyuria but no evidence of hematu- ria, glucosuria, or proteinuria. The pathogenesis of polyuria in this patient is most likely caused by a lesion in which of the following areas of the brain?
A 30-year-old woman complains of headache, visual distur- bances, deepening of the voice, and generalized weakness. She reports amenorrhea for the past year and states that she recently required a larger shoe size. Laboratory studies show impaired glucose tolerance. What other procedure would be useful for establishing your diagnosis?
MRI of the sella turcica
A 35-year-old woman with a history of schizophrenia com- plains of headaches, visual disturbances, and irregular menses for 9 months. On physical examination the breasts are firm and tender. MRI shows enlargement of the anterior pituitary (arrow). Which of the following is the most likely cause of pituitary enlargement in this patient?
A 55-year-old man complains of severe muscle weakness and drooping eyelids. He states that his symptoms worsen with repetitive movements but then resolve after a short rest. A chest X-ray reveals an anterior mediastinal mass. A biopsy of this mass would most likely reveal which of the following pathologic changes?
A 45-year-old woman complains of tingling in her hands and feet, 24 hours after surgery to remove a thyroid follicular carcinoma. Her symptoms rapidly progress to severe muscle cramps, laryngeal stridor, and convulsions. Which of the fol- lowing laboratory findings would be expected in this patient prior to treatment?
decreased serum calcium and decreased PTH
A 55-year-old woman presents with a large anterior neck mass (patient shown in the image). She also complains of dysphagia
and hoarseness. Physical examination reveals inspiratory stridor. Laboratory evaluation of this patient would most likely demonstrate which of the following?
A 48-year-old man presents with recurrent headaches and arthritic pain in his knees of 9 months in duration. He notes that his hat size has recently increased. He also states that he suffers from erectile dysfunction. His past medical history is significant for kidney stones 2 years ago. Physical examination reveals a blood pressure of 170/100 mm Hg. The patient is observed to have coarse facial features and a goiter. Urinalysis reveals glu- cosuria and hypercalciuria. Which of the following is the most likely explanation for this patient's clinical presentation?
excess growth hormone secretion
A 48-year-old man presents with recurrent headaches and arthritic pain in his knees of 9 months in duration. He notes that his hat size has recently increased. He also states that he suffers from erectile dysfunction. His past medical history is significant for kidney stones 2 years ago. Physical examination reveals a blood pressure of 170/100 mm Hg. The patient is observed to have coarse facial features and a goiter. Urinalysis reveals glu- cosuria and hypercalciuria. Why does this patient suffer from erectile dysfunction?
excess prolactin secretion by the pituitary
Physical examination of a neonate shows peculiar genitalia (shown in the image). Cytogenetic studies reveal a 46, XX karyotype. Laboratory studies will most likely reveal a defi- ciency of which of the following?
A 7-week-old infant develops severe dehydration and hypoten- sion and expires. The kidneys and adrenal glands at autopsy are shown in the image. Hypovolemic shock in this infant was most likely caused by inadequate synthesis of which of the following hormones?
A 6-month-old girl with Wiskott-Aldrich syndrome is brought to the emergency room shortly after spiking a fever of 38.7°C (103°F). The infant has a history of chronic respiratory infec- tions, gastrointestinal infections, petechiae, and eczema. This infant likely has which of the following associated birth defects?
hypoplasia of thymus
A female neonate with DiGeorge syndrome develops severe muscle cramps and convulsions soon after birth. Which of the following is the cause of convulsions in this neonate?
DiGeorge causes parathyroid agenesis, and what other condition would be presented?
A 15-year-old boy with Albright hereditary osteodystrophy is rushed to the emergency room with severe muscle cramps and convulsions. The child has a history of mental retarda- tion. Laboratory studies reveal hypocalcemia and elevated blood levels of PTH. Which of the following distinguishes this patient's endocrinopathy from hypoparathyroidism seen in DiGeorge syndrome?
end organ unresponsiveness to PTH
A 50-year-old woman presents with acute right flank pain of 72 hours in duration. Physical examination is unremarkable. Her temperature is 37°C (98.6°F), blood pressure 140/85 mm Hg, and pulse 85 per minute. A CBC is normal. Urinalysis reveals hematuria and urine cultures are negative. Imaging studies show stones in the right renal pelvis and ureter. This patient's condition may be associated with which of the fol- lowing endocrine disorders?
Laboratory evaluation of the patient described in Question 20 shows markedly elevated serum levels of calcium and PTH. A CT scan of the neck reveals a 3-cm mass on the posterior surface of the right lobe of the thyroid gland. External and cross-sectional views of the surgical specimen are shown in the image. Microscopic examination of this neck mass would most likely reveal a benign neoplasm derived from which of the following cells?
A 72-year-old woman with a long history of diabetes type 2 presents with abdominal pain. Physical examination reveals neuromuscular weakness and hypertension. Laboratory stud- ies show markedly elevated levels of serum calcium and PTH. A surgical exploration of the patient's neck demonstrates four symmetrically enlarged parathyroid glands. This patient's endocrinopathy may be caused by which of the following underlying disorders?
A 20-year-old woman with Hirschsprung disease presents with acute leg pain. The patient had a glioma resected 3 years ago. An X-ray film of the leg reveals a fracture of the left tibia. Laboratory studies show elevated serum levels of calcium and PTH. A CT scan of the patient's neck demonstrates a solitary parathyroid mass. Two years later, the patient presents with hypertension, and a CT scan of the abdomen displays a 4-cm mass in the right adrenal. Genetic studies conducted on this patient would likely reveal germline mutations in which of the following protooncogenes?
A 40-year-old woman with a history of hyperparathyroidism presents with a 2-month history of burning epigastric pain. The pain can be relieved with antacids or food. The patient also reports a recent history of tarry stools. She denies tak- ing aspirin or NSAIDs. Laboratory studies show a microcytic, hypochromic anemia (hemoglobin = 8.5 g/dL). Gastroscopy reveals a bleeding mucosal defect in the antrum. Which of the following best characterizes the pathogenesis of epigastric pain in this patient?
increased secretion of gastrin
The parents of a 4-week-old girl complain that their baby is apathetic and sluggish. On physical examination, the child's abdomen is large and exhibits an umbilical hernia. The skin is pale and cold, and the temperature is 35°C (95°F). Which of the following provides a plausible explanation for the signs and symptoms of this child?
A 55-year-old man who is on dialysis because of end-stage renal disease complains of pain in his jaw and left arm for 6 months. An X-ray of the left arm reveals multiple, small bone cysts and pathologic fractures. What is the appropriate diag- nosis for this patient's bone lesions?
osteitis fibrosa cystica
A 46-year-old woman complains of increasing fatigue and mus- cle weakness over the past 6 months. She reports an inability to concentrate at work and speaks with a husky voice. The patient denies drug or alcohol abuse. Physical examination reveals cold and clammy skin, coarse and brittle hair, boggy face with puffy eyelids, and peripheral edema. There is no evidence of goiter or exophthalmos. Laboratory studies show reduced serum levels of T3 and T4. Which of the following is the most likely under- lying cause of these signs and symptoms?
A 65-year-old woman with a history of multinodular goi- ter complains of increasing nervousness, insomnia, and heart palpitations. She has lost 9 kg (20 lb) over the past 6 months. Physical examination reveals a diffusely enlarged thyroid. There is no evidence of exophthalmos. Laboratory studies show elevated serum levels of T3 and T4. Serologic tests for antithyroid antibodies are negative. Which of the following is an important complication of this patient's endocrinopathy?
A 40-year-old woman complains of chronic constipation and anovulatory cycles for the last 8 months. Her vital signs are normal. Physical examination reveals peripheral edema and a firm, diffusely enlarged thyroid gland. Serum levels of T3 and T4 are abnormally low. A thyroid biopsy is shown in the image. What is the appropriate diagnosis?
A 52-year-old woman complains of swelling in the anterior portion of her neck, which she first noticed 6 months ago. Except for some discomfort during swallowing, the patient does not report any significant symptoms. Physical exami- nation reveals a symmetrically enlarged thyroid. A thyroid biopsy is shown in the image. Which of the following is the most likely diagnosis?
A 32-year-old woman presents with a solitary, nontender, firm nodule on the left side of her neck. Thyroid function tests are within normal limits. A fine-needle biopsy reveals malignant cells. The tumor is excised and examined by light microscopy (shown in the image). What is the appropriate pathologic diagnosis?
A 43-year-old woman complains of low-grade fever and has a 3-day history of pain in her neck. Physical examination reveals a slightly enlarged thyroid. A CBC is normal. A biopsy of the thyroid reveals granulomatous inflammation and the presence of giant cells (shown in the image). What is the appropriate diagnosis?
subacute (deQuervain) thyroiditis
A 33-year-old woman complains of swelling in the anterior portion of her neck, which she first noticed 8 months ago. Except for some discomfort during swallowing and hoarse- ness, the patient does not report any symptoms. Physical examination reveals a stony, hard thyroid gland that is adher- ent to other neck structures. A thyroid biopsy is shown in the image. The pathologist reports that the thyroid parenchyma is replaced by dense, hyalinized fibrous tissue and a chronic inflammatory infiltrate. What is the appropriate diagnosis?
A 29-year-old woman complains of nervousness and muscle weakness of 6 months in duration. She is intolerant of heat and sweats excessively. She has lost 9 kg (20 lb) pounds over the past 6 months, despite increased caloric intake. She frequently finds her heart racing and can feel it pounding in her chest. She also states that she has missed several menstrual periods over the past few months. Physical examination reveals warm and moist skin and bulging eyes (exophthalmos). Laboratory studies will likely reveal which of the following endocrine abnormalities in this patient?
anti-TSH receptor antibodies
A thyroid biopsy obtained from a patient with anti-TSH receptor antibodies is best described by what pathological findings?
follicular hyperplasia with scalloping of colloid
A 33-year-old woman presents with a swelling in her neck, which she first noticed 2 months ago. Physical examination reveals a solitary, nontender nodule of the thyroid gland mea- suring 2 cm in diameter. Thyroid function tests are within normal limits. The nodule does not accumulate 125Iodine on thyroid scintiscan. A biopsy of the nodule is shown in the image. Which of the following is the most likely diagnosis?
A 36-year-old woman presents with swelling in her neck that she first noticed 3 months ago. She also complains of inter- mittent watery diarrhea over the same time period. Physical examination reveals a nontender nodule in the left lobe of the thyroid. The patient's mother died of thyroid cancer 8 years ago. The thyroid nodule is found to be "cold" by radioiodine scintiscan. A needle biopsy of the nodule reveals malignant cells and homogeneous eosinophilic material (shown in the image). Laboratory studies would likely show elevated blood levels of which of the following hormones in this patient?
The tumor in the patient described in Question 38 is removed, and a section stained with Congo red reveals birefringent amy- loid stroma. Genetic studies show that this patient has a famil- ial cancer syndrome. In addition to hyperparathyroidism, the patient is advised that she is at risk of developing which of the following neoplastic diseases?
A 45-year-old man presents with swelling in the anterior por- tion of his neck. Physical examination reveals an enlarged nodular thyroid. Thyroid function tests are within normal limits. A thyroid scintiscan shows a dominant "hot" nodule. A biopsy of this nodule reveals neoplastic cells with evidence of vascular and capsular invasion (shown in the image). X-rays demonstrate distant bony metastases. What is the most likely diagnosis?
A 4-year-old girl is brought to the pediatric clinic by her mother who reports that her daughter has decreased appetite, lethargy, and an enlarging belly. Physical examination reveals a large, firm, irregular, nontender mass in the child's abdomen. A CT-guided biopsy reveals neoplastic "small blue cells." The child's malignant neoplasm is removed and the surgical speci- men is shown in the image. Which of the following laboratory tests would be useful in monitoring this patient for recurrence of disease?
urinary vanillylmandelic acidN-myc amplification
A 45-year-old man with a recent history of bizarre behavior is seen by a psychiatrist, who recommends evaluation of his endocrine status. On physical examination, the patient appears moderately obese (BMI = 31 kg/m2), with mild hypertension, facial acne, fat accumulation in the supraclavicular fossae, and a protuberant abdomen. Laboratory studies demonstrate a neutrophilic leukocytosis, with a decrease in the percentage of lymphocytes and an absence of eosinophils. The hematocrit and hemoglobin are normal. There is a mild hypokalemia and mild metabolic alkalosis. The fasting serum glucose is within the reference range, but on a 2-hour glucose tolerance test, both the 60- and 120-minute samples had glucose concen- trations greater than 200 mg/dL. Laboratory studies show free urinary cortisol of 156 mg per 24 hours (normal = 10 to 100 mg per 24 hours). Which of the following questions would be of most help in establishing a diagnosis?
are you receiving corticosteroids for some other disease?
A 42-year-old woman presents with amenorrhea and emo- tional disturbances. You note upper truncal obesity and sus- pect Cushing syndrome. Laboratory studies reveal elevated serum levels of corticosteroids that can be lowered by admin- istration of dexamethasone. Which of the following is the most likely cause of hypercortisolism in this patient?
A 40-year-old woman with a history of diabetes complains of recent changes in her bodily appearance. A photograph of the patient is shown in the image. Laboratory studies reveal elevated serum corticosteroids and low serum corticotropin. Administration of dexamethasone does not lower serum levels of corticosteroids. This patient most likely has a tumor that originates in which of the following anatomic locations?
adrenal cortex, zona fasiculata
A 46-year-old woman with severe asthma presents with increasing weight and back pain for 9 months. The patient is taking corticosteroids for her asthma. An X-ray of the verte- brae will likely reveal which of the following pathologic findings?
A 40-year-old man complains of nausea, vomiting, diarrhea, and cramping abdominal pain. His temperature is 38°C (101°F), blood pressure 90/60 mm Hg, and pulse rate 90 per minute. On physical examination, the patient appears dehy- drated, with sunken eyeballs, dry tongue, and poor skin tur- gor. Hyperpigmentation is noted in the palmar creases and the gingival margins. Laboratory results include fasting serum glucose of 62 mg/dL (normal = 70 to 115 mg/dL), BUN of 27 mg/dL (normal = 11 to 23 mg/dL), Na of 122 mEq/L (normal = 136 to 145 mEq/L), and K of 6.5 mEq/L (normal = 3.5 to 5.0 mEq/L). Which of the following is the most likely cause of this patient's symptoms?
A 50-year-old man complains of muscle weakness and dizziness of 3 months in duration. His blood pressure is 185/100 mm Hg. Laboratory studies show hypernatremia and hypokalemia. Endocrine studies reveal elevated serum aldos- terone and low renin and angiotensin. BUN is 24 mg/dL, and creatinine is 1.2 mg/dL. Endocrinologic studies rule out Cush- ing syndrome. Which of the following is the most likely cause of hypertension in this patient?
A 34-year-old man complains of sudden attacks of dizziness, blurred vision, and excruciating headaches of 4 months in duration. During one of these attacks, his blood pressure was 180/120 mm Hg. The patient's father had been treated for thyroid cancer about 15 years ago. Laboratory studies show normal serum levels of aldosterone, renin, and angiotensin. A 24-hour urinalysis reveals increased metanephrines. Epi- sodic hypertension in this patient is most likely caused by a tumor in which of the following endocrine organs?
A 55-year-old man from China presents with a 3-month history of scales on his skin. Physical examination reveals numerous scaly, pigmented plaques, which rub off easily. Biopsy of a plaque shows anastomosing cords of mature and stratified squamous epithelium, associated with small keratin cysts. This patient may have which of the following underlying conditions?
An 18-year-old woman notes that one of her moles has increased in size and become darker. The patient has a family history of melanoma, and she is seen by her dermatologist regularly to "follow her moles." Physical examination reveals numerous, 5 to 10 mm, darkly pigmented, variegated lesions distributed primarily on her trunk but also involving non-sun-exposed skin. This patient may harbor a germline mutation in a gene that regulates which of the following proteins?
An 80-year-old farmer presents with a 1-cm, red, slightly raised plaque on his face. A biopsy of the lesion shows cytologic atypia and dyskeratosis limited to the basal layers of the stratum spon- giosum, as well as hyperkeratosis and parakeratosis. This lesion is a precursor for which of the following dermatologic diseases?
Squamous cell carcinoma
A 45-year-old man presents with painful, purple nodules on the dorsal surface of his left hand that he first noticed 9 months ago. A biopsy (shown in the image) discloses a poorly demar- cated lesion composed of atypical spindle-shaped neoplastic cells and extravasated red cells. Similar lesions are found in the lymph nodes and liver. Which of the following viruses is associated with the pathogenesis of these skin lesions?
A 36-year-old woman presents with a pigmented lesion on the posterior aspect of her left calf (shown in the image). An excisional biopsy demonstrates a superficial spreading type of mel- anoma. Which of the following histologic features has the most important prognostic value in your evaluation of this patient?
Depth of dermal invasion
A 3-year-old child has numerous small, white scales covering the extensor surfaces of the extremities, trunk, and face (shown in the image). The child's mother and grandmother have the same condition. Biopsy of lesional skin shows hyperkeratosis and a thin stratum granulosum. Which of the following is the most likely diagnosis?
A 25-year-old man presents with a 1-month history of fatigue, mild fever, and an erythematous scaling rash. His major con- cern is related to the scaling plaques distributed on his knees, buttocks, elbows, scalp, and feet. He also notes some joint pain and swelling, primarily involving the small bones of his fingers. Physical examination reveals erythematous plaques with adherent silvery scales that induce punctate bleeding points when removed. Biopsy of lesional skin would most likely show an accumulation of which of the following cells in the epidermis?
Examination of a 2-day-old neonate reveals numerous blisters on the trunk and extremities. Skin biopsy discloses separation of the basal layer of the epidermis from its basement membrane and is devoid of inflammatory cells. No antibody deposits are identified by immunofluorescence microscopy. Which of the following is the most likely diagnosis?
A 25-year-old man complains of eruptions of blisters on his scalp and inner surface of the groin and in his mouth. The blisters rupture easily and leave large crusted areas. Histologically, the lesions show separation of the stratum spinosum from the basal layer. The results of direct immunofluorescence microscopy for IgG are shown. Which of the following proteins is targeted by IgG autoantibody in the skin of this patient?
A 70-year-old woman presents with facial discoloration. The patient is observed to have a flat, pigmented lesion on the atrophic, sun-damaged skin (shown in the image). Which of the following is the most likely diagnosis?
Lentigo maligna melanoma
A 12-year-old girl presents for a routine physical examination. The patient has numerous freckles over her upper trunk and face. Which of the following terms best describes the morphologic appearance of her freckles?
A 40-year-old woman complains that the skin on her fingers feels stiff. The skin of her face appears tense, and radial furrows are evident around the mouth. A skin biopsy shows loss of dermal appendages and abundant collagen bundles aligned parallel to an atrophic epidermis. Which of the following clinical symptoms is commonly seen in patients with this dermatologic condition?
A 14-year-old boy presents with a 6-month history of erythematous papules on his face. Physical examination reveals numerous "blackheads" over the forehead and cheeks. Which of the following bacteria is associated with the development of these lesions?
A 30-year-old man presents with flat-topped papules that have appeared gradually on the flexor surfaces of his wrists. White streaks and patches are also found on the buccal mucosa of the patient's mouth. Histologically, the lesions showed hyperkeratosis, thickening of the stratum granulosum, and a band- like infiltrate of lymphocytes and macrophages in the upper dermis, disrupting the basal layer of the epidermis. Lymphocytes were mostly of the CD4+ immunophenotype. Which of the following is the appropriate diagnosis?
A 66-year-old woman presents with a 5-year history of erythematous, scaly patches on her buttocks. Physical examination reveals plaques with telangiectases, atrophy, and pigmentation. Biopsy of lesional skin shows that the epidermis and papillary dermis are expanded by an extensive infiltrate of atypical lymphocytes. These infiltrating lymphocytes most likely express which of the following "cluster of differentiation" cell surface markers?
A 30-year-old woman with chronic hepatitis B presents with numerous red skin lesions that she has had for 5 days. Physical examination reveals multiple, purpuric, 2- to 4-mm papules on the skin (shown in the image). The papules did not blanch under pressure. Biopsy of lesional skin shows necrotizing leukocytoclastic venulitis. Immunofluorescence studies disclose immune complex deposition in vascular walls. Which of the following is the most likely diagnosis?
A 20-year-old man presents to his family physician for treatment of itching after exposure to poison ivy. The patient's hands and arms appeared red and were covered with oozing blisters and crusts (shown in the image). Which of the following represents the most important step in the pathogenesis of sensitization phase of injury in this patient?
Migration of Langerhan's cells to dermal lymphatics
A 60-year-old former lifeguard presents with several small, pearly nodules on the back of her neck. A biopsy of one of the nodules (shown in the image) reveals buds of atypical, deeply basophilic keratinocytes extending from the overlying epidermis into the papillary dermis. Which of the following is the appropriate diagnosis?
Basal cell carcinoma
A 10-year-old girl presents with multiple papules on the back of her hand that bleed easily. Histologic examination of a lesion reveals squamous epithelial-lined fronds with fibrovascular cores (shown in the image). Which of the following viruses is most likely responsible for the development of these skin lesions?
Human papilloma virus
A 28-year-old woman presents with a 2-day history of dome- shaped erythematous nodules appearing on her skin. She recently had a urinary tract infection for which she was treated with trimethoprim sulfamethoxazole (Bactrim). Biopsy discloses focal hemorrhage, neutrophilic infiltrates in the subcutaneous fibrous tissue septa, and giant cells at the interface between the septa and the adipose fat tissue. No infectious agents are identified. Which of the following is the most likely diagnosis?
A 65-year-old woman complains of having an itchy rash for the past few months. She said the lesions first appeared as red swollen plaques on her abdomen and flexor aspect of her forearms. Physical examination reveals urticarial plaques, as well as large bullae on her abdomen and thighs (shown in the image). A skin biopsy shows a positive direct immunofluorescence test for IgG anti-basement membrane antibody. Which of the following is the appropriate diagnosis?
15-year-old girl complains of itchy skin lesions of 6 months in duration. Physical examination reveals numerous wheal-like lesions with small vesicles over her elbows and knees. A skin biopsy demonstrates inflammation in the tips of the dermal papillae and subepidermal vesicles. Which of the following histopathologic findings would provide the best evidence to support a diagnosis of dermatitis herpetiformis in this patient?
IgA deposits in dermal papillae
A 17-year-old woman is brought to the physician by her parents because "she has been acting strangely" for a couple of days. Over the past 3 months, she has experienced malaise, joint pain, weight loss, and sporadic fever. The patient appears agitated, with a temperature of 38°C (101°F). Other physical findings include malar rash, erythematous-pink plaques with telangiectatic vessels, oral ulcers, and nonblanching purpuric papules on her legs. Laboratory studies show elevated levels of BUN and creatinine. The anti-double-stranded DNA antibody test is positive. Biopsy of sun-damaged lesional skin would most likely show which of the following histopathologic findings in this patient?
Granular distribution of immune complexes in the basement membrane zone
For the past decade, a 29-year-old man has had waxing and waning of the lesions shown in the figure. The scalp, lumbosacral region, and glans penis also are affected. For the past 2 years, he has had chronic arthritis in the hips and knees. Which of the following physical findings would most likely be present in this patient?
Damage to the nails
An epidemiologic study is conducted to identify factors that increase the risk of skin cancer. The study documents subjects reported to tumor registries with a diagnosis of malignant melanoma and the incidence of melanoma worldwide over the past 25 years. Demographic information is collected. Analysis of the data is most likely to show the greatest increase in incidence of malignant melanoma in which of the following locations?
A 64-year-old man has noted changes in the texture and color of skin in his armpit and groin over the past 3 months. On physical examination, there is thickened, darkly pigmented skin in the axillae and flexural areas of the neck and groin. These areas are neither painful nor pruritic. A punch biopsy specimen of axillary skin shows undulating epidermal acanthosis with hyperkeratosis and basal layer hyperpigmentation. Which of the following underlying diseases is most likely to be present in this patient?
A 51-year-old man noticed a change in the skin lesion on the upper, outer area of his right arm, shown in the figure. The lesion has enlarged during the past month. Physical examination yields no other remarkable findings. Which of the following occupations is this man most likely to have had earlier in life?
A 35-year-old man has had an outbreak of pruritic lesions over the extensor surfaces of the elbows and knees during the past month. He has a history of malabsorption that requires him to eat a special diet, but he has had no previous skin problems. On physical examination, the lesions are 0.4- to 0.7-cm vesicles. A 3-mm punch biopsy of one of the lesions over the elbow is performed. Microscopic examination of the biopsy specimen shows accumulation of neutrophils at the tips of dermal papillae and formation of small blisters owing to separation at the dermoepidermal junction. Immunofluorescence studies performed on this specimen show granular deposits of IgA localized to tips of dermal papillae. Laboratory studies show serum antigliadin antibodies. What is the most likely diagnosis?
Over the course of 1 week, a 6-year-old boy develops 1- to 2-cm erythematous macules and 0.5- to 1-cm pustules on his face. During the next 2 days, some of the pustules break, forming shallow erosions covered by a honey-colored crust. New lesions form around the crust. The boy's 40-year-old uncle develops similar lesions after visiting for 1 week during the child's illness. Removal of the crusts from the boy's face is followed by healing within 1 week. The uncle does not seek medical care, and additional pustules form at the periphery of the crusts. Which of the following conditions most likely explains these findings?
A 50-year-old woman has been bothered by a discolored area of skin on her forehead that has not faded during the past 3 years. On physical examination, there is a 0.8-cm red, rough-surfaced lesion on the right forehead above the eyebrow. A biopsy specimen examined microscopically shows basal cell hyperplasia. Some of the basal cells show nuclear atypia associated with marked hyperkeratosis and parakeratosis with thinning of the epidermis. The upper dermal collagen and elastic fibers show homogenization with elastosis. What is the most appropriate advice to give this patient?
Wear a hat outdoors
A 10-year-old girl is brought to the physician by her mother because multiple excoriations have appeared on the skin of her hands over the past week. The child reports that she scratches her hands because they itch. Physical examination shows several 0.2- to 0.6-cm linear streaks in the interdigital regions. Treatment with a topical lindane lotion resolves the condition. Which of the following organisms is most likely responsible for these findings?
A 35-year-old man has noted a bump on his upper trunk for the past 6 weeks. On physical examination, there is a solitary, 0.4-cm, flesh-colored nodule on the upper trunk. The dome-shaped lesion is umbilicated, and a curdlike material can be expressed from the center. This material is smeared on a slide, and Giemsa stain shows many pink, homogeneous, cytoplasmic inclusions. The lesion regresses over the next 2 months. Which of the following infectious agents most likely produced this lesion?
Many skin disorders give rise to vesicles or bullae (blisters) in the skin. The location of the bulla often aids in the diagnosis. What disorder is most likely to produce the type of blister that is schematically illustrated in the figure?
A 39-year-old woman has a nodule on her back that has become larger over the past 2 months. On physical examination, there is a 2.1-cm pigmented lesion with irregular borders and an irregular brown-to-black color. An excisional biopsy with wide margins is performed, and microscopic examination of the biopsy specimen shows a malignant melanoma composed of epithelioid cells that extends 2 mm down to the reticular dermis. There is a band of lymphocytes beneath the melanoma. Which of the following statements is most appropriate to make to this patient regarding these findings?
The prognosis is poor
A 39-year-old woman goes to her dentist for a routine checkup. The dentist notes that she has 0.2- to 1.5-cm scattered, white, reticulated areas on the buccal mucosa. The woman says that these lesions have been present for 1 year. She also has some 0.3-cm purple, pruritic papules on each elbow. A biopsy specimen of a skin lesion shows a bandlike infiltrate of lymphocytes at the dermal-epidermal junction and degeneration of basal keratinocytes. What is the best advice to give this patient regarding these lesions?
These lesions will probably resolve over time
A 22-year-old man and other members of his racquetball club have noticed more itching of their feet in the past 2 months. On physical examination, the man has diffuse, erythematous, scaling skin lesions between the toes of both feet. There are no other remarkable findings. These findings are most likely the result of infection with which of the following organisms?
Over the past 20 years, a 75-year-old man has noticed slowly enlarging lesions, similar to those shown in the figure, on his trunk. One of the lesions is excised, and microscopic examination shows sheets of lightly pigmented basaloid cells that surround keratin-filled cysts. This lesion is sharply demarcated from the surrounding epidermis. What is the most likely diagnosis?
A 30-year-old man is known for his large appetite. At a luncheon meeting, he notices that all the cookies contain nuts, which the other diners have ordered knowing that he would not eat them because he would develop blotchy erythematous, slightly edematous, pruritic plaques on his skin. These plaques would form and then fade within 2 hours. If the man eats the cookies, which of the following sensitized cells would release a mediator that produces these skin lesions?
A 17-year-old girl has hundreds of skin lesions on her body that have been forming since childhood. On physical examination, 0.4- to 1.7-cm, macular to slightly raised, plaquelike, dark brown pigmented lesions are present on sun- exposed and non-sun-exposed areas of skin. The lesions have irregular contours, and there is variability in pigmentation. She says that her 15-year-old brother has similar lesions. Which of the following molecular changes are most likely to be present in the DNA from this patient?
Deletion of the p16/INK4A (CDNK2) gene
A 60-year-old man has noted the appearance of a nodule on his ear during the past month. On physical examination, there is a 1.2-cm, flesh-colored, dome-shaped nodule on his right ear lobe. The nodule has a central keratin-filled crater surrounded by proliferating epithelium. The lesion regresses and disappears within 1 month. What is the most appropriate diagnosis of this lesion?
A 68-year-old man visits the physician because of a slowly enlarging nodule on his right eyelid. On physical examination, there is a 0.3-cm pearly nodule on the upper eyelid near the lateral limbus of the right eye. The lesion is excised, but multiple frozen sections are made during the surgery to minimize the extent of the resection and preserve the eyelid. The microscopic appearance of the lesion is shown at low magnification in the figure. What is the most likely diagnosis?
Basal cell carcinoma
A 5-year-old girl is brought to the physician by her parents for a routine health checkup. On physical examination, she has scattered 1- to 3-mm, light brown macules on her face, trunk, and extremities. The parents state that these macules become more numerous in the summer months, but fade over the winter. The lesions do not itch, bleed, or hurt. What is the most likely diagnosis?
A 19-year-old man has facial and upper back lesions that have waxed and waned for the past 6 years. On physical examination, there are 0.3- to 0.9-cm comedones, erythematous papules, nodules, and pustules most numerous on the lower face and posterior upper trunk. Other family members have been affected by this condition at a similar age. The lesions worsen during a 5-day cruise to the Caribbean. Which of the following organisms is most likely to play a key role in the pathogenesis of these lesions?
A 53-year-old man with idiopathic dilated cardiomyopathy underwent orthotopic heart transplantation. During the next 5 years, he had two episodes of minimal cellular rejection, which were adequately treated by an increase in immunosuppressive therapy. He has developed multiple skin lesions on the face and upper trunk over the past 6 months. On physical examination, the lesions are similar to the lesion shown in the figure. Some of the larger lesions have ulcerated. A biopsy specimen is most likely to identify which of the following lesions?
Squamous cell carcinoma
A 39-year-old woman comes to her physician because she has developed vesicular skin lesions over the past week. On physical examination, she has multiple, 0.2- to 1-cm vesicles and bullae on the skin of her scalp, in both axillae, in the groin, and on the knees. Many lesions appear to have ruptured, and a shallow erosion with a dried crust of serum remains. A biopsy specimen of an axillary lesion examined microscopically shows epidermal acantholysis and formation of an intraepidermal blister. The basal cell layer is intact. Which of the following additional tests is most likely to explain the pathogenesis of the patient's disease?
Immunofluorescent staining of skin with anti-IgG
For the past 3 days, a 25-year-old man known to be infected with HIV has had increasing fever, cough, and dyspnea, which has culminated in acute respiratory failure. On admission to the hospital, his temperature is 37.8°C. On physical examination, there are no significant findings. He undergoes a bronchoalveolar lavage that yields Pneumocystis jiroveci by direct fluorescent antigen testing. Within 1 week after initiation of therapy, he develops "target lesions" composed of red macules with a pale, vesicular center. The 2- to 5-cm lesions are distributed symmetrically over the upper arms and chest. Which of the following drugs is most likely to be implicated in the development of these lesions?
A 28-year-old man has noticed slowly enlarging lesions on his hands for the past 3 years. On physical examination, the lesions appear similar to those shown in the figure. There are no other remarkable findings. The lesions have not changed in color, do not itch or bleed, and are not associated with pain. What is the most likely diagnosis?
A 32-year-old woman has noticed depigmented areas on her trunk that have waxed and waned for several months. She says that they do not itch or bleed, and are not painful. Physical examination shows variably sized, 0.3- to 1.2-cm macules over her upper trunk. The macules are lighter colored than the surrounding skin and have a fine, peripheral scale. Infection with which of the following organisms is most likely to produce these findings?
After being hospitalized 1 week for treatment of an upper respiratory infection complicated by pneumonia, a 43-year-old woman develops a rash on her trunk and extremities. On physical examination, the 2- to 4-mm lesions are red, papulovesicular, oozing, and crusted. The lesions begin to disappear after she is discharged from the hospital 1 week later. What is the most likely pathogenesis of these lesions?
A 30-year-old man with a history of Crohn disease has noted the appearance of a painful red nodule on his left lower leg during the past week. On physical examination, his temperature is 37.3°C. There is a 0.4-cm, dark red nodule that is very tender to palpation and has a surrounding 5-cm diameter area of paler red skin. Over the next 3 weeks, this lesion resolves, but another develops on the opposite calf. A skin biopsy of the second lesion is done, and microscopic examination shows a dermal mixed inflammatory infiltrate with neutrophils, round cells, and giant cells with pronounced edema. These lesions resolve without scarring, but more lesions develop during the next year. What is the most likely diagnosis?
A 31-year-old man comes to his physician because of a bump on the skin of the lower abdomen that has enlarged over the past 4 years and has become more painful in the past week. On physical examination, there is a subcutaneous, movable, soft nodule at the belt line anteriorly that elicits pain with pressure. The overlying skin is intact. The patient states that the nodule began hurting about 1 day after he vigorously squeezed it. The lesion is excised and does not recur. Which of the following is the most likely diagnosis of this lesion?
Epidermal inclusion cyst
A 9-year-old girl is brought to the physician by her parents because she has been scratching a group of small bumps on the skin of her forearm for the past month. On physical examination, there are five 0.4- to 0.9-cm, small, flat to slightly papular, pale brown lesions on the volar surface. The lesions become more pruritic with swelling and erythema when rubbed. A biopsy specimen of one of the lesions examined microscopically shows an upper dermal infiltrate of large cells with abundant pink cytoplasm that stains an intense purple color with toluidine blue. Which of the following cell types is most likely to form these lesions?
A 50-year-old man notes several small, baglike lesions that have appeared on the skin in front of his armpits over the past 2 years. On physical examination, five small, soft papules in the anterior axillary line are covered by wrinkled skin and attached to the skin surface by a thin pedicle. They are 0.5 to 0.8 cm in length and about 0.3 cm in diameter. One lesion has undergone torsion and is more erythematous and painful to touch than the others. What is the most likely diagnosis?
A 10-year-old girl is brought to the physician by her parents because of an earache. On physical examination, the physician notices a flat, uniformly brown, 2-cm skin lesion, just above the right buttock. Her parents state that the lesion has been present since birth and has not changed in appearance. The figure shows the representative microscopic appearance of the lesion. What is the most likely diagnosis of this lesion?
A 44-year-old woman has developed skin lesions over her elbows and knees during the past year. The lesions start as 4 mm pustules with surrounding erythema but then evolve into 1 to 5 cm plaques that are covered with a silvery-white scale. The lesions appear first in areas of local trauma, but exposure to sunlight causes the lesions to regress. A biopsy of one lesion shows thinning of stratum granulosum with marked overlying parakeratotic scale containing microabscesses. Which of the following risk factors is most likely to be associated with her skin disease?
Germline HLA-C allele
A 70-year-old man has a lesion on the right side of his face that has enlarged slowly over the past 5 years. On examination the 3 cm lesion has irregular borders and irregular brown to black pigmentation and a 2 mm raised blue-black nodule. The lesion is resected and microscopically shows radial growth of large round malignant cells singly and in nests in the epidermis and superficial papillary dermis. The cells have prominent red nucleoli and dust-like cytoplasmic pigment. Which of the following mutated genes is most likely to be present in the skin lesion of this man?
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