EMRCS PATHO 1 Flashcards
A 40 year old women presented with a mass on her forehead. On examination, she had a fluctuant pulsatile mass on her head. Examination of her neck revealed a mass inferior to the hyoid with a positive Berry’s sign. What is the most likely underlying diagnosis?
Follicular thyroid cancer Medullary thyroid cancer Papillary thyroid cancer Anaplastic thyroid cancer Parathyroid gland cancer
Papillary thyroid cancers will tend to spread via lymphatics and present with disease that is nearly always confined to the neck. Follicular carcinomas may metastasise haematogenously and the skull may be the presenting site of disease in between 2 and 8% of patients.
What is the most common cause of mesenteric infarction?
Mesenteric vein thrombosis Acute embolism affecting the superior mesenteric artery Acute on chronic thrombus of the superior mesenteric artery Sub intimal dissection of the superior mesenteric artery Proximal migration of abdominal aortic aneurysm
Acute embolic events account for up to 50% of cases of mesenteric infarcts. These may occur as a result of long standing atrial fibrillation, ventricular anuerysms and post myocardial infarction
A term neonate is undergoing an open inguinal herniotomy. During the operation, the operating surgeon identifies a small round yellow nodule within the inguinal canal. What is this most likely to represent?
Ectopic lymphatic tissue Adrenal rest Encysted hydrocele of the cord Yolk sac tumour Hamartoma
Adrenal rests are a very common finding in term neonates (50%) and most regress so that by adulthood the population incidence is 1%. The adrenal glands and gonads both develop from the urogenital ridge. In early embryogenesis, the adrenal cortical tissue can migrate with the descending gonads.
In which of the following conditions is a Ghon complex most likely to be found?
Actinomycosis Infection with mycobacterium tuberculosis Mycosis fungoides Lewy body dementia Chronic lymphocytic leukaemia
Infection with mycobacterium tuberculosis
Ghon focus is primary infection
Ghon complex is primary infection and regional nodal involvement
A 26 year old man who smokes heavily develops aching, crampy pains in his legs. On examination, distal limb pulses are diminished. What is the most likely cause?
Vasculitis Steal syndrome Clot embolus Vasospasm Arterial injury
Vasculitis
This is likely to represent Buergers disease. It is commonest in young males who smoke heavily.
A 22 year old female undergoes a thyroidectomy. The resected specimen shows a non encapsulated tumour with papillary projections and pale empty nuclei. What is the underlying diagnosis?
Papillary carcinoma Follicular carcinoma Medullary carcinoma Anaplastic carcinoma B Cell lymphoma
The presence of papillary structures together with the cytoplasmic features described is strongly suggestive of papillary carcinoma. They are seldom encapsulated.
A 78 year old lady presents 6 years following a successfully treated squamous cell carcinoma of the oesophagus. She has a long history of dysphagia but it is not progressive. What is the most likely diagnosis?
Recurrent malignancy Oesophageal candidiasis Radiation stricture Globus Pharyngeal pouch
Radiation stricture
SCC of the oesophagus is commonly treated with chemoradiotherapy. Fibrosis and dysphagia may occur in survivors. At 6 years post treatment, recurrence would be most unusual.
A 4 year old boy presents with haematuria and on examination is found to have a right sided renal mass. What is the most likely cause?
Wilms tumour Glomerulonephritis Horseshoe kidney Renal adenocarcinoma Ureteric transitional cell carcinoma
Wilms tumours (nephroblastoma) usually present in the first 4 years of life and may cause lung metastases.
A 74 year old woman presents with an erythematous rash originating in the nipple. It is spreading to the surrounding areolar area and the associated normal tissue. What is the most likely cause?
Nipple eczema Pagets disease of the nipple Fibroadenosis Invasive lobular carcinoma Radial scar
Paget’s is associated with DCIS or invasive carcinoma. Unlike eczema of the nipple which predominantly affects the areolar region, Pagets will usually affect the nipple first and then spread to the areolar area. Diagnosis is made by punch biopsy.
A 60 year old man presents with recurrent renal stones. He is found to have a calcium of 2.72 (elevated) and a PTH of 12 (elevated). What is the most appropriate long term management plan?
Neck exploration and parathyroidectomy CT scanning of the neck MRI scanning of the neck Medical treatment alone External beam radiotherapy to the neck
This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication for parathyroidectomy.
Pagets disease of the nipple is most likely to be associated with which of the lesions listed below?
Invasive lobular carcinoma Ductal carcinoma in situ Invasive ductal carcinoma Lobular carcinoma in situ Inflammatory breast cancer
Most cases of Pagets disease of the nipple are associated with invasive ductal carcinoma.
A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and serum alpha feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the right lobe of the liver which has a mixed echoity and heterogeneous texture. What is the underlying lesion most likely to be?
Liver cell adenoma Hydatid cyst Hepatocellular carcinoma Cystadenoma Mesenchymal hamartoma
Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function tests are often normal. The lesions will typically have a mixed echoity and heterogeneous texture.
Which of the following events is most classically seen in the arterioles of patients with malignant hypertension?
Caseous necrosis Coagulative necrosis Fibrinoid necrosis Apoptosis Colliquative necrosis
Fibrinoid necrosis is seen in the arterioles of patients with malignant hypertension.
A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results are obtained:
Corrected Calcium 3.84 mmol/l
PTH 88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis?
Carcinoma of the bronchus Secondary hyperparathyroidism Primary hyperparathyroidism Tertiary hyperparathyroidism Carcinoma of the breast
In this situation the most likely diagnosis is primary hyperparathyroidism. The question mentions that serum urea and electrolytes are normal, which makes tertiary hyperparathyroidism unlikely.
A 24 year old man is diagnosed as having Hodgkins lymphoma. Which subtype is associated with the most favorable prognosis?
Nodular sclerosing Lymphocyte depleted Nodular lymphocyte predominant Classical lymphocyte predominant Mixed cellularity
The classical lymphocyte predominant variant has the most favorable prognosis. Nodular lymphocyte predominant disease is a very different disease entity and does not have the same favorable prognosis
A 32 year old man who has suffered from Crohns disease for many years presents with intermittent jaundice. When it occurs, it is obstructive in nature. It then usually resolves spontaneously. What is the most likely cause?
Crigler Najjar syndrome Parasitic infection of the liver Bile duct stones Gilberts syndrome Multi cystic liver disease
Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.
Which of the tumour markers listed below is most likely to be elevated in a patient with ovarian cancer?
IgG 4 CEA CA125 CA19-9 AFP
CA125
CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CA 15-3 Breast cancer
A 23 year old lady presents with a nodule in the right lobe of the thyroid. Examination of the neck is otherwise unremarkable and clinically she is euthyroid. Imaging shows a solid nodule at the site. What is the correct course of action?
Image guided core biopsy Image guided fine needle aspiration for cytology Arrange a hemithyroidectomy Perform an incision biopsy Perform an excision biopsy
FNAC is the first line investigation in this setting. Whereas FNAC has declined in popularity recently (in breast investigation), it remain a very popular option in the investigation of thyroid masses. It cannot reliably diagnose a follicular tumour.
A 73 year old lady is admitted with small bowel obstruction and following surgery is diagnosed as having diaphragm disease. Which of the agents listed below is the most likely precipitant?
Alcohol abuse Oral non steroidal anti inflammatory drugs Abdominal radiotherapy Oral steroids Chronic laxative misuse
Diaphragm disease of the small intestine is caused by NSAIDS in most cases and treated by surgical resection
A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?
Infectious hepatitis Acute cholecystitis Cholangitis Hereditary spherocytosis Gilberts syndrome
The child is most likely to have hereditary spherocytosis. In these individuals there may be disease flares precipitated by acute illness. They form small pigment stones. These may cause biliary colic and some may require cholecystectomy.
Gilbert’s syndrome is an inherited condition causing unconjugated hyperbilirubinaemia. Patients may have jaundice or be asymptomatic. The other LFTs are normal and Gilbert’s may be confirmed with a fasting test or Nicotinic acid test. There is no need for treatment as it is a benign condition.
A 78 year old lady presents to the surgical clinic with symptoms of both dysphagia and dyspnoea. On examination, there is a large mass in the neck that moves on swallowing. CT scanning of the neck shows a locally infiltrative lesion arising from the thyroid and invading the strap muscles. What is the most likely diagnosis?
Lymphoma Follicular carcinoma Multinodular goitre Anaplastic carcinoma Papillary carcinoma
Marked local invasion is a feature of anaplastic carcinoma. These tumours are more common in elderly females.
A 28 year old man has a carcinoid tumour identified in his appendix. Blood testing for which of the substances listed below is likely to be helpful during follow up?
CA19-9 Alkaline phosphatase AFP CEA Chromogranin A
It is important to distinguish between blood and urine tests for carcinoid syndrome. Blood tests usually measure chromogranin A,neuron-specific enolase (NSE), substance P, and gastrin. Urine tests usually measure 5 HIAA, which is a metabolite of serotonin. Sometimes blood tests for 5 hydroxytryptamine (serotonin) are also performed.
A 28 year old female attends the gynaecology unit for a D+C following an incomplete miscarriage. She has previously had recurrent pulmonary embolic events. After the procedure she is persistently bleeding. Her APTT is 52 (increased). What is the most likely cause?
Antiphospholipid syndrome DIC Haemophilia B von Willebrand disease Factor V Leiden deficiency
A combination of thromboembolism and bleeding in a young woman should raise the possibility of antiphospholipid syndrome. Other features may include foetal loss, venous and arterial thrombosis and thrombocytopenia. A Lupus anticoagulant may be present and the APTT is prolonged.
A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was normal. What is the most likely cause of his jaundice?
Hepatocellular carcinoma Liver metastasis from colonic cancer Pancreatic carcinoma Duodenal carcinoma Metastatic gastric carcinoma
Metastatic gastric carcinoma
Lynch syndrome usually results in colonic cancer which is right sided and mucinous. The next most common site to be affected is the uterus. The stomach is at particular risk and this risk is up to 10 times greater in HNPCC (Lynch) patients than the general population. Duodenal adenomas (and rarely carcinoma) are usually seen in association with FAP. Whilst pancreatic carcinoma is associated with HNPCC it is far less likely to occur than gastric cancer.
We are often asked how these patients become jaundiced, this occurs as a result of nodal spread along the hepatoduodenal ligament nodes to occlude the porta hepatis resulting in jaundice
A 65 year old man presents with a history of progressive dysphagia over the past 4 weeks. For the preceding 5 years he had regularly attended his general practitioner with symptoms of dyspepsia and reflux. What is the most likely cause?
Leiomyoma of the oesophagus Plummer Vinson syndrome Squamous cell carcinoma of the oesophagus Adenocarcinoma of the oesophagus Achalasia
Adenocarcinoma of the oesophagus
A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic. In such cases, the tumours are adenocarcinoma.
