EMRCS PATHOLOGY 2 Flashcards
A 23 year old woman has undergone a pan proctocolectomy and ileoanal pouch because she suffers from familial adenomatous polyposis coli. What is the commonest extra colonic lesion in this disorder?
Gastric fundal polyps Trichilemmomas Duodenal polyps Fibrocystic disease of the breast Skull osteomas
Duodenal polyps are the commonest extra colonic lesion in FAP. Gastric fundal polyps are seen in 50% of patients. Skull osteomas are seen in Gardeners syndrome which is a variant of FAP.
A 2 year old boy is brought to the clinic by his mother who has noticed that he has developed a small mass. On examination; a small smooth cyst is identified which is located above the hyoid bone. On ultrasound the lesion appears to be a heterogenous and multiloculated mass. What is the most likely diagnosis?
Cystic hygroma Thyroglossal cyst Dermoid Branchial cyst Rhabdomyosarcoma
Dermoid cysts are usually multiloculated and heterogeneous. Most are located above the hyoid, and their appearances on imaging differentiate them from thyroglossal cysts.
A 35 year old male presents with haematuria. He is found to have bilateral masses in the flanks. He has a history of epilepsy and learning disability. Which of the lesions below is most likely?
Angiomyolipoma Renal cortical cysts Transitional cell cancer Nephroblastomas Staghorn calculi
This patient has tuberous sclerosis. This is associated with angiomyolipoma, which is present in 60-80% patients. It is a benign lesion.
A pathologist is examining a histological section and identifies Hassall’s corpuscles. With what are they most commonly associated?
Follicular carcinoma of the thyroid Medulla of the thymus Medulla of the spleen Medulla of the kidney Fundus of the stomach
Hassall’s corpuscles are the concentric ring of epithelial cells seen in the medulla of the thymus
A 64 year old man presents to the clinic with right upper quadrant discomfort. He has never attended the hospital previously and is usually well. He has just retired from full time employment as a machinist in a PVC factory. CT scanning shows a large irregular tumour in the right lobe of his liver. Which of the following lesions is the most likely?
Liposarcoma Angiosarcoma Hamartoma Hyatid liver disease Benign angioma
Angiosarcoma of the liver is a rare tumour. However, it is linked to working with vinyl chloride, as in this case. Although modern factories minimise the exposure to this agent, this has not always been the case.
A 32 year old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two weeks post incident he develops oedema of both lower legs. The most likely cause of this is:
Iliofemoral deep vein thrombosis Venous obstruction due to scarring Hypoalbuminaemia Excessive administration of intravenous fluids None of the above
Loss of plasma proteins is the most common cause of oedema developing in this time frame.
A 38 year old sheep farmer presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On examination, he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases, his full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and demonstrates a calcified lesion in the right upper quadrant of the abdomen. What is the most probably underlying diagnosis?
Mesenchymal hamartoma Clonorchiasis Fasciolopsiasis Liver cell adenoma Hydatid cyst
Hydatid disease is more common in those who work with sheep or dogs. Liver function tests may be abnormal and an eosinophilia is often present. Plain radiographs may reveal a calcified cyst wall. Fasciolopsiasis infection is confined to intestinal wall in most cases.
A 43 year old female presents with recurrent urinary tract infections. She describes blood and frothy urine. She is 6 weeks post operative for a left hemicolectomy for crohn’s disease. What is the most likely reason for this presentation?
Colovesical fistula Enterovesical fistula Entero-entero fistula Entero-colic fistula Vesico-cutaneous fistula
The commonest event here is an anastomotic leak. It is possible that the patient (who has Crohns) originally had a colovesical fistula that was then addressed with a resection. In the event that these leak, the fistula reforms.
A 32 year old man presents to the vascular clinic with symptoms of foot pain during exertion. He is a heavy smoker and has recently tried to stop smoking. On examination, he has normal pulses to the level of the popliteal. However, foot pulses are absent. A diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew shaped collateral vessels distally. What is the most likely diagnosis?
Buergers disease Wegeners granulomatosis Giant cell arteritis Takayasu's arteritis Polyarteritis nodosa
Buergers disease is most common in young male smokers. This demographic is changing in those areas where young female smokers are more common. In the acute lesion the internal elastic lamina of the vessels is usually intact. As the disease progresses the changes progress to hypercellular occlusive thrombus. Tortuous corkscrew collaterals may reconstitute patent segments of the distal tibial or pedal vessels.
A tall 32 year old lady presents with a diffuse neck swelling, a carcinoma of the thyroid medullary type is diagnosed. What is the underlying problem?
MEN I MEN II Von Recklinghausen's disease Kartagener's syndrome Neurofibromatosis
This is a case MEN type IIb. It is associated with phaeochromocytomas and is transmitted in an autosomal dominant pattern if inherited. All MEN II tend to have medullary carcinoma of the thyroid as a presenting feature.
A 42 year old man from Southern India presents with chronic swelling of both lower legs, they are brawny and indurated with marked skin trophic changes. Which of the following organisms is the most likely origin of this disease process?
Loa loa Wuchereria bancrofti Trypanosoma cruzi Trypanosoma gambiense None of the above
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction. Infection with Loa loa typically occurs in the African sub continent and usually results in generalised sub cutaneous infections without lymphatic obstruction. Trypanosomal infections would not produce this clinical picture.
A 22 year old woman presents with macroscopic haematuria. She is sexually active. She is known to have renal calculi and had a berry aneurysm clipped. What is the most likely cause?
Interstitial nephritis Membranous glomerulonephritis Renal vein thrombosis Endometriosis Adult polycystic kidney disease
APKD is associated with liver cysts (70%), berry aneurysms (25%) and pancreatic cysts (10%). Patients may have a renal mass, hypertension, renal calculi and macroscopic haematuria.
A 45 year old lady has recently undergone a thyroidectomy for treatment of medullary thyroid cancer. Which of the following tumour markers is used clinically to screen for recurrence?
Free T3 Thyroglobulin Calcitonin Free T4 Thyroid stimulating hormone
Calcitonin is clinically utilised to screen for medullary thyroid cancer recurrence. Thyroid function testing does not form part of either diagnosis or follow up from a malignancy perspective. However, routine assessment of TSH may be needed in patients on thyroxine.
A 22 year old man is kicked in the head during a rugby match. He is temporarily concussed, but then regains consciousness. Half an hour later he develops slurred speech, ataxia and loses consciousnesses. On arrival in hospital he is intubated and ventilated. A CT Scan is performed which shows an extradural haematoma. What is the most likely cause?
Basilar artery laceration Middle meningeal artery laceration Laceration of the sigmoid sinus Laceration of the anterior cerebral artery Laceration of the middle cerebral artery
The most likely vessel from those in the list to cause an acute extra dural haemorrhage is the middle meningeal artery. The anterior and middle cerebral arteries may cause acute sub dural haemorrhage. Acute sub dural haemorrhages usually take slightly longer to evolve than acute extra dural haemorrhages.
Which of the following is not characteristic of a granuloma?
Altered macrophages Fused macrophages Epithelioid cells Mixture of chronic inflammatory cells Polymorphnuclear leucocytes, cellular debris and fibrin
These are typical components of an abscess cavity. Polymorphonuclear leucocytes may be found in a granuloma if there is a focus of suppuration.
A 42 year old man presents with a painless lump in the left testicle that he noticed on self examination. Clinically there is a firm nodule in the left testicle, ultrasound appearances show an irregular mass lesion. His serum AFP and HCG levels are both within normal limits. What is the most likely diagnosis?
Yolk sack tumour Seminoma Testicular teratoma Epididymo-orchitis Adenomatoid tumour
Seminomas typically have normal AFP and HCG. These are usually raised in teratomas and yolk sac tumours
This man’s age, presenting symptoms and normal tumour markers make a seminoma the most likely diagnosis. Epididymo-orchitis does not produce irregular mass lesions which are painless.
A 60 year old man is found to have a 2 cm diameter mass in the upper lobe of his left lung.The lesion is excised and it is found that the lesion includes connective tissue, mature cartilage and ciliated epithelium. What is the most likely diagnosis?
Sarcoma Adenocarcinoma Squamous cell carcinoma Hamartoma Chondroma
Only a hamartoma will have all these tissue elements, chondroma will not contain ciliated epithelium.
A 62 year old man is admitted with dull lower back pain and abdominal discomfort. On examination, he is hypertensive and a lower abdominal fullness is elicited on examination. An abdominal ultrasound demonstrates hydronephrosis and intravenous urography demonstrated medially displaced ureters. A CT scan shows a periaortic mass. What is the most likely cause?
Abdominal liposarcoma Metastatic pancreatic cancer Abdominal aortic aneurysm Retroperitoneal fibrosis Colonic cancer
Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass
A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries. The most likely underlying diagnosis is:
Choanal atresia Oesophageal reflux Tetralogy of Fallot Oesophageal atresia Congenital diaphragmatic hernia
In Choanal atresia the episodes of cyanosis are usually worst during feeding. Improvement may be seen when the baby cries as the oropharyngeal airway is used.
A 28 year old lady presents with a pigmented lesion on her calf. Excisional biopsy confirms a diagnosis of melanoma measuring 1cm in diameter with a Breslow thickness of 0.1mm. The lesion is less than 1 mm at all resection margins. Which of the following surgical resection margins is acceptable for this lesion?
5 cm 1 cm 0.5 cm 2 cm 3 cm
Margins of excision-Related to Breslow thickness
Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
A 20 year old man is involved in a road traffic accident. Following the incident he is unable to extend his wrist. However, this improves over the following weeks. Which type of injury is he most likely to have sustained?
Radial nerve neurotmesis Radial nerve neuropraxia Axillary nerve axonotmesis Ulnar nerve neuropraxia Ulnar nerve axonotmesis
Transient loss of function makes neuropraxia the most likely injury. The wrist extensors are innervated by the radial nerve making this the most likely site of injury.
A 53 year old lady has undergone a bilateral breast augmentation procedure many years previously. The implants are tense and uncomfortable and are removed. During their removal the surgeon encounters a dense membrane surrounding the implants, it has a coarse granular appearance. The tissue is sent for histology and it demonstrates fibrosis with the presence of calcification. The underlying process responsible for these changes is:
Hyperplasia Dysplasia Metastatic calcification Dystrophic calcification Necrosis
Breast implants often become surrounded by a pseudocapsule and this may secondarily then be subjected to a process of dystrophic calcification.
A 4 year old girl presents with symptoms of right sided loin pain, lethargy and haematuria. On examination she is pyrexial and has a large mass in the right upper quadrant. The most likely underlying diagnosis is:
Perinephric abscess Nephroblastoma Renal cortical adenoma Grawitz tumour Squamous cell carcinoma of the kidney
In a child of this age, with the symptoms described a nephroblastoma is the most likely diagnosis. A perinephric abscess is most unlikely. If an abscess were to occur it would be confined to Gerotas fascia in the first instance, and hence anterior extension would be unlikely.
The cell of origin in virtually all pancreatic carcinomas is which of the following?
The acinar cells The islet beta cells The islet alpha cells The interstitial fibroblasts The ductular epithelium
Over 90% of pancreatic carcinomas are adenocarcinomas and are thus of ductular epithelial origin.
From which of the following cell types do giant cells most commonly originate?
Neutrophils Myofibroblasts Fibroblasts Macrophages Goblet cells
Although many cell types may give rise to giant cells, macrophages remain the most common
A 22 year old man presents with dyspnoea. He is previously well and apart from an orchidopexy 17 years previously has no medical history. A chest x-ray demonstrates some opacities affecting both lung fields. What is the most likely underlying diagnosis?
Renal cell carcinoma Testicular seminoma Testicular teratoma Sarcoidosis Rhadomyosarcoma
Testicular tumours are one of the commonest solid tumours to affect young males and there is a peak in incidence of teratoma in this age group. The need for orchidopexy is associated with an increased risk in developing testicular cancer.
A 43 year old lady with hypertension is suspected of having a phaeochromocytoma. Which of the following investigations is most likely to be beneficial in this situation?
Dexamethasone suppression test Urinary 5-Hydroxyindoleacetic Acid (5-HIAA) Histamine provocation test Tyramine provocation test Urinary vanillylmandelic acid measurements
Urinary VMA measurements are not completely specific but constitute first line assessment. Stimulation tests of any sort are not justified in first line assessments.
A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
Colonic adenocarcinoma Pancreatic adenocarcinoma Tropical sprue Glucagonoma Insulinoma
Glucagonoma is strongly associated with necrolytic migratory erythema.
Which of the following features are not typically seen in a venous stasis ulcer?
Located above the medial malleolus Haemosiderin deposits Variable scarring Exophytic granulation tissue Varicose veins
Whilst the base of the ulcer may be lined by granulation tissue, this is seldom exophytic. One of the concerns would be that this represents a malignant transformation.
A 56 year old man presents with symptoms of neuropathic facial pain and some weakness of the muscles of facial expression on the right side. On examination he has a hard mass approximately 6cm anterior to the right external auditory meatus. What is the most likely diagnosis?
Pleomorphic adenoma Adenocarcinoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Lymphoma
The patient is most likely to have a malignant lesion within the parotid. Of the malignancies listed; adenoid cystic carcinoma has the greatest tendency to perineural invasion.
A 10 year old boy who has learning difficulties, is reported as having a difference in size between his two legs. What is the underlying disorder?
Neurofibromatosis Type I Neurofibromatosis Type II Kartagener's syndrome Multiple endocrine neoplasia type II Multiple endocrine neoplasia type I
Neurofibromatosis type I. A hallmark finding is a plexiform neurofibroma, which is a sheet of neurofibromatosis tissue which encases major nerves. In children this attracts extra blood circulation, which can accelerate growth of the affected limb.
Other features include:
Schwannoma, > 6
Cafe au lait spots, axillary freckling, Lisch nodules, Optic glioma. Meningiomas, Glioma, or Schwannoma.
A 20 year old African lady undergoes an open appendicectomy. She is reviewed for an unrelated problem 8 months later. On abdominal inspection the wound site is covered by shiny dark protuberant scar tissue that projects beyond the limits of the skin incision. Which of the following is the most likely underlying process?
Hypertrophic scar Keloid scar Marjolins ulcer Repeated episodes of wound sepsis Mycosis fungoides
Keloid scars extend beyond the limits of the incision. Mycosis fungoides is a cutaneous T cell lymphoma.
A 28 year old man has a long history of recurrent chest infections. On examination, he is noted to have no palpable vas deferens. However, both testes are located within the scrotum. What is the most likely underlying disease association?
Kleinfelters syndrome Kallmann syndrome Cystic fibrosis Coeliac disease Gardners syndrome
99% of males with cystic fibrosis will have absent vas
The pathogenicity of the tubercle bacillus is due to which of the following?
Necrosis caused by expanding granulomas Ability to multiply within fibroblasts Delayed hypersensitivity reaction against bacteria Effect of antibody response Direct toxic effect on host cells
Mycobacteria stimulate a specific T cell response of cell mediated immunity. This is effective in reducing the infection, the delayed hypersensitivity also damages tissues. Necrosis occurs in TB but is usually within the granuloma.
What is the commonest malignant tumour of the anal canal?
Lymphoma Melanoma Squamous cell carcinoma Adenocarcinoma Sarcoma
Anal cancers are usually squamous cell carcinomas
A 45 year old women with a thyroid carcinoma undergoes a total thyroidectomy. The post operative histology report shows a final diagnosis of medullary type thyroid cancer. Which of the tests below is most likely to be of clinical use in screening for disease recurrence?
Serum CA 19-9 Levels Serum thyroglobulin levels Serum PTH levels Serum calcitonin levels Serum TSH levels
Medullary thyroid cancers often secrete calcitonin and monitoring the serum levels of this hormone is useful in detecting sub clinical recurrence.
A 15 year old boy undergoes an emergency splenectomy for trauma. He makes a full recovery and is discharged home. Eight weeks post operatively the general practitioner performs a full blood count with a blood film. Which of the following is most likely to be present?
Myofibroblasts Howell-Jolly bodies Multinucleate giant cells Reed Sternberg Cells None of the above
Post splenectomy blood film features: Howell- Jolly bodies Pappenheimer bodies Target cells Irregular contracted erythrocytes
A 43 year old woman is identified as being a carrier of a BRCA 1 mutation. Apart from breast cancer, which of the following malignancies is she at greatest risk of developing?
Colonic cancer Ovarian cancer Follicular carcinoma of the thyroid Pituitary adenoma Phaeochromocytoma
BRCA 1 mutation patients are 55% more likely to get ovarian cancer. Those with BRCA 2 are 25% more likely. The risk of developing other malignancies is slightly increased but not to the same extent, and not enough to justify screening.
A 53 year old man is due to undergo a splenectomy as a treatment for refractory haemolytic anaemia. The underlying pathological basis for haemolytic anaemia is thought to be a Type 2 hypersensitivity response. Which of the following mechanisms best describes this process
Deposition of immune complexes Cell mediated immune response IgE mediated response Formation of autoantibodies against cell surface antigens None of the above
Type 2 hypersensitivity reactions (which includes haemolytic anaemia) are associated with formation of antibody against cell surface antigens
Which of the tumour markers listed below is most likely to be elevated in a patient with colorectal cancer?
CEA CA19-9 IgG 4 AFP PSA
Tumour marker Association
Prostate specific antigen (PSA) Prostatic carcinoma
Alpha-feto protein (AFP) Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA) Colorectal cancer
Which of the following is not an oncogene?
ras myc sis Ki 67 erb-B
Ki 67 is a nuclear proliferation marker (used in immunohistochemistry). Although, Ki67 positivity is a marker of malignancy, it is not itself, an oncogene.
A 25 year old man is injured in a road traffic accident. His right tibia is fractured and is managed by fasciotomies and application of an external fixator. Over the next 48 hours his serum creatinine rises and urine is sent for microscopy, muddy brown casts are identified. What is the most likely underlying diagnosis?
Acute interstitial nephritis Acute tubular necrosis Glomerulonephritis IgA Nephropathy Thin basement membrane disease
This patient is likely to have had compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis. Acute interstitial nephritis usually arises from drug toxicity and does not usually produce urinary muddy brown casts. Thin basement membrane disease is an autosomal dominant condition that causes persistent microscopic haematuria, but not worsening renal function.
A 24 year old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur. What is the most likely diagnosis?
Subclavian steal syndrome Aortic coarctation Patent ductus arteriosus Aortic dissection Takayasu's arteritis
Takayasu’s arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding. The CNS symptoms may be variable.
A 56 year old man has undergone a radical nephrectomy. The pathologist bisects the kidney and identifies a pink fleshy tumour in the renal pelvis. What is the most likely disease?
Renal cell carcinoma Transitional cell carcinoma Angiomyolipoma Phaeochromocytoma Renal adenoma
Most renal tumours are yellow or brown in colour. TCC’s are one of the few tumours to appear pink.
A 65 year old lady presents with a lesion affecting her right breast. On examination she has a weeping, crusting lesion overlying the right nipple, the areolar region is not involved. There is no palpable mass lesion in the breast, there is a palpable axillary lymph node. The patient’s general practitioner has tried treating the lesion with 1% hydrocortisone cream, with no success. What is the most likely diagnosis?
Infection with Staphylococcus aureus Pagets disease of the nipple Phylloides tumour Nipple eczema Basal cell carcinoma
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy).
An obese 40 year old male presents with episodes of anxiety, confusion and one convulsive episode. CT brain is normal. An abdominal CT scan shows a small 1.5cm lesion in the head of the pancreas. What is the most likely diagnosis?
Glucagonoma Insulinoma Somatostatinoma Adenocarcinoma Squamous cell carcinoma
These episodes are due to hypoglycaemia. Insulinomas are normally solitary tumours and may not be seen by radiological imaging. Resection is the treatment of choice.
A 17-year-old girl presents with a swelling over her right knee. Movements of her knee are restricted. A plain x-ray of the affected site shows multiple lytic and lucent lesions with clearly defined borders. What is the most likely diagnosis?
Osteoclastoma Osteoblastoma Osteosarcoma Ewings sarcoma Osteoid osteoma
Osteoclastoma has a characteristic appearance on x-ray with multiple lytic and lucent areas (Soap bubble) appearances. Pathological fractures may occur. The disease is usually indolent.
A 73 year old man presents with haemoptysis and is suspected of suffering from lung cancer. On examination he has an enlarged supraclavicular lymph node. Which of the following features is most likely to be present on histological examination?
Increased mitoses Apoptosis Barr Bodies Multinucleate giant cells Granuloma
Increased mitoses are commonly seen in association with malignant transformation of cells. Apoptosis is not a common feature of metastatic cancer. Barr Bodies are formed during X chromosome inactivation in female somatic cells.
Which of the following pathological explanations best describes the initial pathological processes occurring in an abdominal aortic aneurysm in an otherwise well 65 year old, hypertensive male?
Loss of elastic fibres from the adventitia Loss of collagen from the adventitia Loss of collagen from the media Loss of elastic fibres from the media Decreased matrix metalloproteinases in the adventitia
Loss of elastic fibres from the media
In established aneurysmal disease there is dilation of all layers of the arterial wall and loss of both elastin and collagen. The primary event is loss of elastic fibres with subsequent degradation of collagen fibres.
A 28 year old lady has a malignant melanoma removed from her calf. Which of the following pathological criteria carries the greatest prognostic weighting?
Vascular invasion Abnormal mitoses Breslow thickness Perineural invasion Lymphocytic infiltrates
The Breslow thickness has considerable prognostic importance. Lymphocytic infiltrates may be associated with an improved prognosis, but do not carry nearly the same weight as increased thickness
