Cervical & Vaginal Cytology

Question 1

Which of the following guidelines should be followed in order to obtain an ideal Pap smear specimen?
A. A lubricated speculum is favored over a non-lubricated speculum
B. The sample should be obtained after the application of acetic acid
C. Excess mucus or other discharge should be retained for examination
D. An optimal specimen includes cells exclusively from the ectocervix
E. Two weeks after the LMP is the preferred examination time

Answer 1

E. Two weeks after the LMP is the preferred examination time

Question 2

According to the specimen adequacy criteria in the 2014 Bethesda System, which of the following Pap smear specimens is considered unsatisfactory for evaluation?
A. TP smear containing approx 6000 squamous cells
B. Conventional smear containing approx 6000 squamous cells
C. Smear without endocervical cells
D. Smear with 50% of epithelial cells obscured by inflammation
E. Smear with 50% of epithelial cells obscured by drying artifact

Answer 2

B. Conventional smear containing approx 6000 squamous cells

Question 3

How many well-visualized squames must be present on a liquid-based Pap slide from a healthy woman so that the specimen would be considered to be satisfactory for evaluation? 
A. 1000
B. 2500
C. 5000
D. 8000
E. 10000

Answer 3

C. 5000

Question 4

Pap smear specimens with less than 5000 squamous cells may still be considered adequate in which of the following conditions?
A. Women younger than 21 years
B. Women aged 21-29 years
C. Women who are pregnant
D. Women who received radiation therapy for cervical cancer
E. Women who are on oral contraceptives

Answer 4

D. Women who received radiation therapy for cervical cancer

Question 5

The Pap smear from a 38yo female woman showed cohesive flat sheets of cells with large nuclei, pale chromatin, abundant cytoplasm, and prominent nucleoli. Occasional mitoses were seen. These features are characteristics of which of the following?
A. Atrophy
B. Repair
C. Atypical endocervical cells, not otherwise specified
D. Endocervical adenocarcinoma
E. Squamous cell carcinoma

Answer 5

B. Repair

Question 6

When estimating cellularity on Pap smear slide, what type of cells should be included in the evaluation?
A. Metaplastic squamous cells
B. Squamous cells obscured by neutrophils
C. Endocervical cells
D. Endometrial cells
E. Histiocytes

Answer 6

A. Metaplastic squamous cells

Question 7

Which of the following cytologic features is characteristic of radiation changes seen in a Pap smear?
A. High N/C ratio
B. Abundant isolated cells
C. Cytoplasmic vacuolization and polychromasia
D. Frequent mitoses
E. Coarsely granular and hyperchromatic chromatin

Answer 7

C. Cytoplasmic vacuolization and polychromasia

Question 8

Women born to mothers who took diethylstilbestrol (DES) during pregnancy would most likely show what type of changes in their vaginal smear specimens?
A. A shift in vaginal flora
B. LSIL
C. HSIL
D. Atrophic vaginitis 
E. Presence of glandular cells

Answer 8

E. Presence of glandular cells

Question 9

HPV infection is established in which layer of the squamous epithelium?
A. Anucleated surface keratin layer
B. Parakeratotic surface squamous cells
C. Superficial squamous cells
D. Intermediate squamous cells
E. Basal squamous cells

Answer 9

E. Basal squamous cells

Question 10

Which of the following statements is TRUE regarding cervical oncogenesis and the genome of HPV?
A. The E1 and E2 are most responsible for the cervical oncogenesis
B. The E3 and E4 are the principal components of the HPV vaccines
C. L1 binds to the retinoblastoma tumor suppresion protein pRB and abolishes cell-cycle arrest
D. E6 binds to p53 and results in blocking of apoptosis
E. E7 binds to p16 and results in proliferation of cells

Answer 10

D. E6 binds to p53 and results in blocking of apoptosis

Question 11

Which of the following statements is TRUE regarding HPV?
A. HPV is a small RNA virus
B. HPV 6, 11 is the most common subtypes detected in cervical cancer
C. Only a minority of HPV infections persist and lead to cancer
D. Koilocytes are an artifact if fixation and not related to HPV
E. Serology is an accurate way to detect HPV infection

Answer 11

C. Only a minority of HPV infections persist and lead to cancer

Question 12

Which of the following is the MOST important cytomorphologic feature for HSIL?
A. Prominent nucleoli
B. Syncytial growth 
C. Prominent cytoplasmic vacuoles
D. Large cell size
E. High nuclear-to-cytoplasm ratio

Answer 12

E. High nuclear-to-cytoplasm ratio

Question 13

Which of the following statements is TRUE about the follow-up management after a Pap smear interpretation of LSIL?
A. Adolescents with LSIL are managed less aggressively
B. Postmenopausal women with LSIL are managed more aggressively
C. Pregnant women with LSIL are managed more aggressively
D. HPV testing is recommended for premenopausal women with LSIL
E. Diagnostic excisional procedures are routinely used in women with LSIL

Answer 13

A. Adolescents with LSIL are managed less aggressively

Question 14

A 30yo woman had a routine Pap smear. The smear showecells of squamous metaplasia with some degree of nuclear atypia, concerning but definitive for the diagnosis of high-grade dysplasia. How these cells are best classified?
A. ASCUS
B. ASCH
C. LSIL
D. HSIL
E. SCC

Answer 14

B. ASCH

Question 15

A 25yo pregnant woman had a Pap smear which was interpreted as HSIL. Which of the following is CORRECT for pregnant women with HSIL?
A. Colposcopy during pregnancy is not recommended
B. The diagnostic excisional procedure should only be performed immediately postpartum
C. Colposcopy and repeat Pap testing should be performed immediately postpartum
D. Biopsy of lesions suspicious for CIN 2 or CIN3, if feasible
E. Endocervical curettage (ECC) should be always performed

Answer 15

C. Colposcopy and repeat Pap testing should be performed immediately postpartum

Question 16

Which of the following is a specific cytomorphologic feature of squamous intraepithelial lesion?
A. Prominent halos
B. Nuclear enlargement
C. Prominent nucleoli
D. Hyperchromasia and irregular nuclear membrane
E. Finely granular chromatin

Answer 16

D. Hyperchromasia and irregular nuclear membrane

Question 17

Which HPV subtype accounts for the majority of cervical squamous cell carcinoma worldwide?
A. HPV 6
B. HPV 11
C. HPV 16
D. HPV 18
E. HPV 31

Answer 17

C. HPV 16

Question 18

Which of the following cytologic features may help distinguish SCC from HSIL?
A. Tumor diathesis
B. High N/C ratio
C. Abundant keratinizing cytoplasm
D. Hyperchromasia
E. Irregular cell shapes

Answer 18

A. Tumor diathesis

Question 19

Prominent macronucleoli are cytologic features of cells classified under which one of the following diagnoses? 
A. LSIL cells
B. HSIL cells
C. Squamous cells in atypical repair
D. Parabasal squamous cells in atrophy
E. Benign endometrial cells

Answer 19

C. Squamous cells in atypical repair

Question 20

“Feathering” is a term used to describe Pap smear findings in which of the following entities?
A. Tubal metaplasia
B. Endocervical adenocarcinoma in-situ (AIS)
C. Exfoliated endometrial cells
D. HSIL
E. Invasive adenocarcinoma

Answer 20

B. Endocervical adenocarcinoma in-situ (AIS)

Question 21

Which of the following features is more typical of neoplastic endocervical cells (AGUS or AIS) than reactive/ reparative endocervical cells?
A. Flat sheet arrangement
B. Prominent nucleoli
C. Marked variation in nuclear size
D. Elongated and hyperchromatic nuclei
E. Presence of mitosis

Answer 21

D. Elongated and hyperchromatic nuclei

Question 22

When differentiating endocervical adeno from endometrial adeno, which of the following features favor endometrial rather than endocervical adeno?
A. Prominent nucleoli
B. Mitoses
C. Tumor diathesis
D. Intracytoplasmic neutrophils
E. Abundant cytoplasm

Answer 22

D. Intracytoplasmic neutrophils

Question 23

Which of the following represents the MOST common metastatic tumor to the cervix?
A. MET breast ca
B. MET melanoma
C. MET rectal ca
D. MET ovarian ca
E. MET urothelial ca

Answer 23

D. MET ovarian ca

Question 24

A 30yo woman had a Pap test showing HSIL at the time of her annual gyn exam. She underwent a colposcopic examination. A biopsy of the cervix showed moderate squamous dysplasia (CIN 2). What is the MOST appropriate management recommendation for this woman?
A. Repeat the Pap test in 6 months
B. Perform the loop electrosurgical excision procedure (LEEP)
C. High-risk HPV test
D. Hysterectomy
E. Endocervical curretage

Answer 24

B. Perform the loop electrosurgical excision procedure (LEEP)

Question 25

``` What is the MOST common anatomic location of cervical squamous intraepithelial neoplastic (CIN) lesions? A. Lateral side of ectocervix B. The T-zone/squamocolumnar junction C. Lower end of the endocervical canal D. Upper end of the endocervical canal E. Vaginal fornix ```

Answer 25

B. The T-zone/squamocolumnar junction

Question 26

Which of the following statements is TRUE about the currently used HPV vaccine Gardasil? A. The vaccine covers all high-risk HPV subtypes B. Women are no protected if they have been infected by the same HPV types prior to vaccination C. The vaccine is approved for use in sexually active women of all ages D. The vaccine contains inactivated live viruses subtypes 16 and 18 E. The vaccine is given orally in 3 doses over a 6-month period

Answer 26

A. The vaccine covers all high-risk HPV subtypes

Question 27

Dark blue or purple calcific spheres with concentric laminations are rarely encountered in Pap smears. What is the clinical significance of the finding? A. It represents a rare contaminant of no clinical significance B. It represents a rare microorganism C. It may be associated with endometriosis D. It may be associated with an endocrine disorder E. It may be associated with an ovarian neoplasm

Answer 27

E. It may be associated with an ovarian neoplasm

Question 28

``` What is the recommended initial workup for women with a Pap smear diagnosis of atypical endometrial cells? A. Reflex high-risk HPV testing B. Immediate repeat Pap smear C. Colposcopic examination D. Endometrial and endocervical sampling E. Simple hysterectomy ```

Answer 28

D. Endometrial and endocervical sampling

Question 29

``` Hyperchromatic crowded groups (HCGs) seen in a Pap smear under low power are helpful diagnostic features for which of the following conditions or diseases? A. ASCUS B. LSIL C. HSIL D. Repair E. Radiation changes ```

Answer 29

C. HSIL

Question 30

``` When differentiating endocervical adeno from endometrial adeno, which positive IHC stain favors the diagnosis of endocervical adeno? A. ER B. Vimentin C. p16 D. Pancytokeratin E. Beta-catenin ```

Answer 30

E. Beta-catenin

Question 31

``` According to the current (pub in 2012) joint recommendations of the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, cervical cancer screening for women in the general population should begin at what age? A. The age of sexual initiation B. The age of 1st pregnancy C. Age 21 D. Age 30 E. Age 35 ```

Answer 31

C. Age 21

Question 32

A 35yo woman presents for her well woman exam. Which of the following statements is TRUE regarding her cervical cancer screening according to the current ASCCP screening guideline? A. She can be screened every year with Pap smear alone B. She can be screened every year with an HPV test alone C. She can be screened every year with Pap smear and HPV co-testing D. She can be screened every three years with Pap smear and HPV co-testing E. She can be screened every five years with Pap smear and HPV co-testing

Answer 32

E. She can be screened every five years with Pap smear and HPV co-testing

Question 33

``` Which of the following is an acceptable management choice for women > age 30, who are cytology negative but HPV positive? A. Repeat cytology in 6 months B. Repeat cytology in 12 months C. Repeat co-testing in 6 months D. Repeat co-testing in 12 months E. Refer for immediate colposcopy ```

Answer 33

B. Repeat cytology in 12 months

Question 34

A Pap smear was performed on a 42yo woman and reported atypical endocervical cells NOS. What is the appropriate management for her? A. Reflex HPV testing B. Repeat cytology in 12 months C. Endocervical sampling D. Colposcopy E. Colposcopy with endocervical sampling and endometrial sampling

Answer 34

C. Endocervical sampling

Question 35

In which of the following populations that cervical cancer screening is not necessary? A. Women who are vaccinated against HPV B. Women who are postmenopausal C. Women who are younger than 21 years D. Women who underwent total hysterectomy five years ago and had CIN II E. Women older than 65 years with a history of CINN III 10 years ago

Answer 35

C. Women who are younger than 21 years

Question 36

A 68yo women had a recent Pap smear reported as ASCUS and the reflex HPV test is negative. Her two previous Pap smears were negative. Which of the following statements is CORRECT regarding her management? A. She is allowed to exit from screening because she is over 65 years B. She should be referred to colposcopy C. She should be further tested for HPV 16 and HPV 18 D. She should repeat screening in 3 years E. She should repeat screening in 1 year

Answer 36

E. She should repeat screening in 1 year