Histopathology

Question 1

Which of these options is a type of fracture?

(a) Extended
(b) Contracted
(c) Communal
(d) Confounding
(e) Comminuted

Answer 1

The correct answer is (e), comminuted.

A comminuted fracture is where there is splintered bone with intact soft tissue.

Question 2

In children with osteomyelitis, what is the most common affected site?

(a) Vertebrae
(b) Long Bones
(c) Jaw
(d) Toe
(e) Pelvis

Answer 2

The correct answer is (b), long bones.

The most common site in children for osteomyelitis is the long bones, usually the metaphysis of that bone. Vertebrae, jaw (secondary to dental abscess) and toe (secondary to diabetic ulcer) are the common sites in adults.

Question 3

What causative organism of osteomyelitis is associated with sickle cell disease?

(a) Klebsiella
(b) E. Coli
(c) Salmonella
(d) Staph. Aureus
(e) Pseudomonas

Answer 3

The correct answer is (c), salmonella.

Osteomyelitis caused by salmonella is associated with sickle cell disease. Of the others, pseudomonas is associated with IV drug users.

Question 4

There are four stages in fracture repair. They are as follows:

1. Organisation of haematoma at the fracture site (pro-callus).
2. Formation of fibrocartilaginous callus
4. Remodelling of bone along weight-bearing lines.

What is the third stage of fracture repair?

Answer 4

The third stage of fracture repair is mineralisation of the fibrcartilaginous callus.

Question 5

Pott’s Disease is a skeletal deformity associated with osteomyelitis of the spine due to infection with what organism?

(a) Pseudomonas
(b) Mycobacterium Tuberculosis
(c) Klebsiella
(d) Staph. Aureus
(e) E. Coli

Answer 5

The correct answer is (b) Mycobacterium Tuberculosis.

Question 6

Which of the following is NOT a feature of osteoarthritis?

(a) Fibrin deposition
(b) Cartilage degeneration
(c) Fissuring
(d) Abnormal matrix calcification
(e) Osteophytes

Answer 6

The correct answer is (a), fibrin deposition. This is a clinical feature of rheumatoid arthritis.

Question 7

Rheumatoid factor forms immunocomplexes with which of the following?

(a) IgG
(b) IgM
(c) IgE
(d) C3
(e) C4

Answer 7

The correct answer is (a) IgG.

Rheumatoid factor mostly interacts with IgM but it forms immunocomplexes with IgG which may cause the extra-articular disease associated with rheumatoid arthritis.

Question 8

In rheumatoid arthritis, on histology, you would see thinning of the synovial membrane. True or false?

Answer 8

False. Rheumatoid arthritis causes a proliferative synovitis which leads to thickening of the synovial membrane.

Question 9

In gout, what percentage of the cases are primary?

a. 10%
b. 30 %
c. 50%
d. 70%
e. 90%

Answer 9

The correct answer is (e) 90% of gout cases are primary.

Question 10

What is the name of the pathognomonic lesion found in Gout?

Answer 10

Tophus is the name of the pathognomonic lesion found in Gout.

Question 11

Pseudogout of the knee is characterised by formation of what main type of crystal in the joint?

Answer 11

Calcium pyrophosphate crystals.

Calcium pyrophosphate crystals are what’s formed in pseudogout in the joints, particularly the knee. Calcium phosphate (hydroxyapatite) crystals can form in the knees and shoulders but the main pathological driving force in pseudogout of the knee is Calcium pyrophosphate crystal build up.

Question 12

A 60 year old patient comes in complaining of “horrid skin lesions”. Bloods show an IgG antibody is to blame, and the histology on skin biopsy shows subdermal bulla with eosinophils. There is a linear deposition of IgG along the basement membrane.

What condition is this patient suffering from?

(a) Dermatitis herpetiformis
(b) Pemphigoid
(c) Pemphigus vulgaris
(d) Pemphigus foliaceus
(e) Discoid eczema

Answer 12

The correct answer is (b) Pemphigoid.

In Pemphigoid IgG antibodies bind to hemidesmosomes of basement membrane causing subepidermal bulla. Clinical features are large tense bullae on erythematous base, often in forearms, grown and axillae of the elderly. Bullae do not rupture as easily as pemphigus.

In Pemphigus vulgaris (c) the IgG antibodies bind to desmosomal proteins causing intraepidermal bulla. These bulla are easily ruptured and are found on skin and mucosal membranes. Under histology there are intrapeidermal bulla with a netlike pattern of intercellular IgG deposits.

Conversely, dermatitis herpetiformis (a) occurs when IgA antibodies bind to basement membrane, creating subepidermal bulla. This causes a clinical picture of itchy vesicles on extensor surfaces of elbows, buttocks. The histology is miceoabscesses which coalesce to form subepidermal bulla. there are neutrophil and IgA deposits at tips of dermal papillae.

Question 13

Which of the following is not a cause of crescentic glomerulonephritis?

(a) Amyloidosis
(b) Immune complex deposition
(c) Anti-GBM disease
(d) Pauci-immune - associated with anti-neutrophil cytoplasm antibodies.
(e) All of the above

Answer 13

The correct answer is (a) Amyloidosis.

Question 14

Which of the following is not a feature of Hirschsprung’s disease?

(a) Absence of ganglion cells in myenteric plexus
(b) 50:50 split in gender
(c) Symptoms are constipation, abdominal distension, vomiting and ‘overflow’ diarrhoea.
(d) Associated with Down’s syndrome (2%)
(e) Genetic abnormality associated is RET proto-oncogene Cr10 + others.

Answer 14

The correct answer is (b) 50:50 split in gender.

Instead, 80% of Hirschsprung’s disease occurs in male patients.

Question 15

Which of the follow is not an extraintestinal manifestation of Ulcerative colitis?

(a) Arthritis
(b) Myositis
(c) Uveitis
(d) Pyoderma gangrenosum
(e) Primary biliary cirrhosis

Answer 15

The correct answer is (e) Primary biliary cirrhosis.

Ulcerative colitis instead causes primary sclerosing cholangitis.

Question 16

A 60 year old man undergoes an endoscopy wherein the surgeon notices a growth in his colon. The surgeon biopsies it and the histological results show a dark hyperchromatic, disorganised,pseudostratified epithelium with evidence of increased mitotic activity and disordered proliferation with no invasion through the basement membrane.

What is this growth likely to be?

(a) Hyperplastic polyp
(b) Peutz Jeghers polyp
(c) Tubular adenoma
(d) Adenocarcinoma
(e) Carcinoid tumour

Answer 16

The correct answer is (c) Tubular adenoma.

This tumour has all the excess epithelial proliferation and dysplastic signs of a tubular adenoma. It is not cancerous as it has not invaded through the basement membrane. It is a pre-cancerous state, that might progress to cancer later on.

20-30 percent of <40 year olds will have an adenoma, increasing to 40-50% prevalence after age 60.

Question 17

Which of the following statements is true about the risk of a polyp becoming cancerous?

(a) Size of polyp is related to cancer risk, if a polyp is more than 2cm it has a 50% chance of becoming malignant.
(b) If the polyp is hamartomatous then it’s neoplastic, meaning it has the potential at a later stage to progress to cancer.
(c) If an adenoma has a high proportion of villous component it increases the risk of it becoming cancerous.
(d) Low degree of dysplastic change within polyp increases the risk of developing into cancer.
(e) Inflammatory “pseudo-polyps” are different to hyperplastic polyps in that hyperplastic polyps are neoplastic and can progress to cancer at a later stage.

Answer 17

The correct answer is (c) If an adenoma has a high proportion of villous component it increases the risk of it becoming cancerous.

The size of a polyp is a risk factor, however, if a polyp is >4cm approximately 45% have invasive malignancy so the numbers in (a) are incorrect.

Hamartomatous polyps (b) are non-neoplastic polyps that do not progress to cancer. Peutz Jeghers are a type of hamartomatous polyp, which are associated with an increased risk of bowel cancer, but it’s not due to the polyps themselves but the genetic syndrome that causes the polyps.

If there is a high degree of dysplastic change within a polyp it increases the risk of developing into cancer, not low like (d).

Both inflammatory pseudo-polyps and hyperplastic polyps are non-neoplastic so neither can progress to cancer, meaning (e) is also wrong.

Question 18

Familial adenomatous polyposis is caused by a deletion of which of the following?

(a) 9:22
(b) 22q11
(c) 5q21
(d) 14q16
(e) 13:21

Answer 18

The correct answer is (c) 5q21. This is the APC tumour suppressor gene.

APC is an autosomal dominant condition where the average onset is 25 years old. The condition causes adenomatous polyps to form mostly colorectally. There’s a minimum of 100 polyps, average around 1000 polyps. Virtually 100% of these patients will develop cancer within 10-15 years.

Question 19

55 year old alcoholic with a 40 pack year history has a biopsy taken from his pancreas after presenting with painless jaundice. Macroscopically the tissue is gritty and grey, and shows signs of invading adjacent structures. Microscopically it is made up of mucin secreting glands set in desmoplastic stroma.

What is this pathology and presentation indicative of?

(a) Ductal carcinoma
(b) Acinar carcinoma
(c) Serous cystadenocarcinoma
(d) Mucinous cystic neoplasm
(e) Islet cell tumour

Answer 19

The correct answer is (a) Ductal carcinoma.

This is the classic presentation, with two of the main risk factors of smoking and chronic pancreatitis observed, alongside painless jaundice which indicates a tumour of the head of the pancreas.

Both the macroscopic and microscopic findings are indicative of a ductal carcinoma. Desmoplastic is just a fancy word for fibrotic, which again indicates that this tumour arose against a background of chronic pancreatitis. 60% of duct carcinomas are found at the head of the pancreas.

An important complication of ductal carcinomas is venous thrombosis. This is due to the mucin production by the tumour subsequently entering the blood stream to cause thrombosis elsewhere.

Question 20

What is the most common neuroendocrine tumour of the pancreas?

Answer 20

The correct answer is insulinomas. These tumours are derived from beta cells and they are the commonest type of secretory tumour. They usually arise from the tail of the pancreas.

Question 21

What are Rokitansky-Aschoff sinuses?

Answer 21

Rokitansky-Aschoff sinuses are diverticula of the bile duct. They may act in a similar way to diverticula of the bowel, and they can cause chronic cholecystitis, and often contain gallstones.

Question 22

All of the following are causes of chronic pancreatitis except:

(a) Alcohol
(b) Gall stones
(c) Cystic fibrosis
(d) Drugs

Answer 22

The correct answer is (d) Drugs. Drugs can cause acute pancreatitis but apart from some very rare exceptions they do not cause chronic pancreatitis.

Question 23

Which of the following is a sign or symptom only associated with subtentorial tumours?

(a) Long tract signs
(b) Focal neurological deficit
(c) Seizures
(d) Headache
(e) Change in mental status

Answer 23

The correct answer is (a) Long tract signs.

The other options reflect signs and symptoms you’d expect to see in supratentorial tumours.

Some are a little non-specific and might be seen in both.

Subtentorial tumours are also associated with cerebellar ataxia and cranial nerve palsy.

Question 24

A 9 year old boy presents to his GP with pain in his hands. His mother says he’s a very fussy eater. On examination the child has tender regions in his hands but no inflammation or signs of infection. Further examination of the child reveal pigeon chest and frontal bossing. X-ray of the hands show Looser’s zones.

What biochemical picture would you expect to see in this child?

(a) Normal or decreased calcium, low phosphate, raised alkaline phosphatase and a low vitamin D.
(b) Normal calcium, phosphate and alkaline phosphatase but a low vitamin D.
(c) High calcium, low or normal phosphate with raised or normal alkaline phosphate, with raised parathyroid hormone.
(d) Low calcium, high phosphate, raised parathyroid hormone and a metabolic acidosis.
(e) Normal calcium, normal phosphate and extremely high alkaline phosphatase.

Answer 24

The correct answer is (a) Normal or decreased calcium, low phosphate, raised alkaline phosphatase and a low vitamin D.

This child is presenting with Rickets, due to reduced dietary vitamin D. This can present in children with bone pain, bowing tibia, rachitic rosary, frontal bossing, pigeon chest and delayed walking. On x-ray you can see Looser’s zones, also known as pseudo fractures. You can also see splaying of metaphysis.

Option (c) describes the biochemical results you’d expect to see primary hyperparathyroidism. Signs and symptoms you’d see in this condition would be hypercalcaemic signs such as depression/confusion, bone pain and constipation as well as polyuria and polydipsia. X-ray findings can show brown’s tumours, salt and pepper skull and subperiosteal bone resorption in phalanges.

Option (d) describes the biochemical results you’d expect to see in renal osteodystrophy.

Option (e) describes the biochemical results you’d expect to see in Paget’s disease of the bone. The signs and symptoms you’d expect to see in this patient would be bone pain, microfractures, nerve compression, skull changes (increase in head size), deafness and high output cardiac failure. X-ray changes are mixed lytic and sclerotic. In the skull you can get osteoporosis circumscripta, or a cotton wool appearance. In the vertebra you get picture frame and ivory vertebra changes and in the pelvis you get sclerosis and lucency.

Question 25

A 19 year old male has a biopsy taken from a lesion on his femur. The histology shows sheets of small round cells and on x-ray onion skinning of the periosteum is seen. Genetic analysis shows a T 11:22 translocation.

What type of neoplastic bone disease is this presentation indicative of?

(a) Osteosarcoma
(b) Chondrosarcoma
(c) Ewing’s sarcoma
(d) Giant cell
(e) Osteochondroma

Answer 25

The correct answer is (c) Ewing’s sarcoma.

Osteosarcoma (a) presents in adolescence so that part fits, but it predominantly affects the knee (60%). Histology would show malignant mesenchymal cells, alkaline phosphatase positive. X-ray of the lesion would show elevated periosteum (codman’s triangle) and a classical “sunburst” appearance.

Chondrosarcoma (b) occurs in those >40. It typically affects the axial skeleton, femur/tibia/pelvis. Histology is of malignant chondrocytes. X-ray appearance is classically a lytic lesion with “fluffy” calcification.

Giant cell (d) is a borderline malignancy condition which occurs generally between 20 and 40 years in females more than males. It affects the knee epiphysis and the histology shows osteoclast-type multinucleate giant cells on background of spindle/ovoid cells. X-ray appearance is a lytic/lucent lesion right up to articular surface.

Osteochondroma (e) is a benign bone tumour (all the other options are malignant) which typically affects adolescents. It characteristically occurs in the long bones and the special features are cartilage capped bony outgrowth and you get multiple exostoses, short stature and bone deformities. Histology is of cartilage capped bony outgrowth and the x-ray appearance is well defined bony protuberance from bone.

Question 26

Match the following skin pathology terms (letters to numbers) to their description.

(a) Hyperkeratosis
(b) Parakeratosis
(c) Acanthosis
(d) Acantholysis
(e) Spongiosis

(1) Increase in stratum spinosum
(2) Presence of nuclei in stratum corneum
(3) Decreased cohesions between keratinocytes
(4) Increase in stratum corneum/ increased keratin
(5) Intercellular oedema.

Answer 26

(a) Hyperkeratosis is an increase in stratum corneum/ increased keratin(4).
(b) Parakeratosis is the presence of nuclei in the stratum corneum(2).
(c) Acanthosis is an increase in stratum spinosum(1) .
(d) Acantholysis is decreased cohesions between keratinocytes(3).
(e) Spongiosis is intercellular oedema(5).

Question 27

Acutely, the histology shows spongiosis, inflammatory infiltrate in the dermis and dilated dermal capillaries. In addition, chronically this condition causes the histology to show acanthosis and crusting or scaling.

What condition does this skin histology describe?

(a) Atopic dermatitis
(b) Contact dermatitis
(c) Seborrhoeic dermatitis
(d) All of the above
(e) None of the above.

Answer 27

The correct answer is (c) All of the above.

Dermatitis is a term used to describe a group of disorders with the same histology and presenting with inflamed, dry, itchy rashes.

Atopic dermatitis affects infants on the face and scalp. Older children and adults it affects the flexural areas. If chronic it can cause lichenification. More likely to persist into adulthood in those with a family history of atopy.

Contact dermatitis is a type IV hypersensitivity reaction, usually to substances like nickel or rubber. It’s features are erythema, swelling and pruritis. Commonly affects ear lobes and neck (from jewellery), wrist (watch and jewellery), feet (shoes and abdomen (belt).

Sebeorrhoeic dermatitis is an inflammatory reaction to a yeast - Malassezia. In infants this presents as cradle cap (large yellow scales on scalp). In young adults you have mild erythema, fine scaling, mildly pruritic, affects face, eyebrow, eyelid, anterior chest and external ear.

Question 28

A patient is in dermatology clinic for diagnosis of their skin condition. They describe Koebner’s phenomenon. On examination the doctor elicits Auspitz’s sign. A skin biopsy shows histology of parakeratosis, with a loss of granular layer, and clubbing of rete ridges that look like “test tubes in a rack”. Munro’s microabcesses are also present.

What is this skin condition?

(a) Urticaria
(b) Lichen Planus
(c) Psoriasis
(d) Discoid Lupus
(e) Erythema multiforme.

Answer 28

The correct answer is (c) Psoriasis.

Commonest form is chronic plaque psoriasis with salmon pink plaques with silver scale affecting extensor aspects of knee, elbows and scalp.

Auspitz sign is if when you rub the plaques it causes pin-point bleeding.

Koebner phenomenon is where lesions form at sites of trauma.

Associated with arthritis (5-10%) and nail changes which can be remembered by the acronym POSH.
Pitting
Onycholysis
Subungual Hyperkeratosis.

Question 29

You’re in a dull dermatology clinic when a reg calls you in to see a classic pre-malignant skin lesion. The lesion belongs to a cheery 76 year old man who lets you examine it on his head. It is a rough, sandpaper like scaly lesion.

Which of the following would you not expect to see on histology of a skin biopsy of this lesion?

(a) Solar elastosis
(b) Parakeratosis
(c) Dysplasia
(d) Full thickness atypia
(e) Inflammation

Answer 29

The correct answer is (d) Full thickness atypia.

The lesion in question is an Actinic keratosis, sometimes referred to as solar or senile keratosis. The signs on histology can be helpfully remembered with the acronym SPAIN.

Solar elastosis
Parakeratosis
Atypia/dysplasia
Inflammation
Not full thickness

From this we can see that while there is atypia, it is not full thickness.

If there were to be full thickness dysplasia/atypia we’d be looking at Bowen’s disease which is intra-epidermal squamous cell carcinoma in situ. A patient with this would have flat, red, scaly patches on sun exposed areas. The basement would still be intact, which is what differentiates it with squamous cell carcinoma, when the basement membrane is invaded. There is also nuclear crowding in SCC.

Question 30

Which of the following statements about pathology of the CNS is false?

(a) Marinesco bodies are small spherical nuclear inclusions seen in pigmented nerve cells of the substantia nigra, often seen in patients with Parkinson’s disease.
(b) Primary demyelination depends on genetic defects of myelin whereas secondary demyelination is caused by any inflammatory, toxic, metabolic cause that leads to breakdown of myelin sheaths.
(c) Neurofibrillary tangles are predominantly observed in ageing, Alzheimer’s disease, progressive supranuclear palsy.
(d) Neuritic plaques consist of clusters of radially orientated abnormal axons and dendrites and often contain a core of amyloid (dystrophic neurites).
(e) Degeneration of distal axons when severed, called Wallerian degeneration starts within days after damage with breakdown of myelin followed by phagocytosis of myelin and axonal debris by macrophages.

Answer 30

The correct answer is (a) Marinesco bodies are small spherical nuclear inclusions seen in pigmented nerve cells of the substantia nigra, often seen in patients with Parkinson’s disease.

Marinesco bodies are indeed small spherical nuclear inclusions seen in pigmented nerve cells of the substantia nigra, but they are often seen in patients with liver insufficiency, not Parkinson’s disease.

Parkinson’s disease has a different type of neuronal inclusion, Lewy bodies, also seen in Lewy body dementia.

Question 31

Which of the following statements about proteins causing degeneration of affected neurons is correct?

(a) Mutations in Tau protein are reported in the chromosome 17-linked dementia.
(b) Amyloid accumulation results from excessive cleavage of amyloid precursor protein.
(c) Alpha-synuclein is a small conserved intracellular protein which binds other proteins targeting for degradation.
(d) Ubiquitin is a small protein of 18 kDa, which is known to be associated to plasma membranes (synapses) due to its ability for binding lipids.
(e) Prion protein is an intracellular glycoprotein whose function in neurons and astrocytes is still unknown.

Answer 31

The correct answer is (a) Mutations in Tau protein are reported in the chromosome 17-linked dementia.

Amyloid accumulation (b) results from defective, not excessive, cleavage of amyloid precursor proteins. This causes fragments to build up, such as fragment 39-43 which accumulates in Alzheimer’s disease.

Statement (c) actually describes Ubiquitin, and statement (d) describes Alpha-synuclein, in a straight swap.

(e) Prion protein is not an intracellular glycoprotein, it is a membrane associated glycoprotein.

Question 32

Which of the following diseases causing dementia does not have Tau as a pathologic protein in the disease process?

(a) Alzheimer’s disease
(b) Lewy body dementia
(c) Corticobasal degeneration
(d) Frontotemporal dementia linked to Chromosome 17
(e) Pick’s disease

Answer 32

The correct answer is (b) Lewy body dementia, where the pathological protein is alpha-synuclein.

All the other options are caused by Tau protein pathology. Beta-amyloid is also indicated as a pathological protein in Alzheimer’s disease.

Question 33

Which of the following statements about pathological findings in Alzheimer’s disease is incorrect?

(a) Severe brain atrophy particularly prominent in hippocampus.
(b) Loss of neurons – reactive astrocytosis
(c) Presence of senile plaques
(d) Neurofibrillary tangles - amyloid angiopathy
(e) There is always deposition of amyloid in the leptomeningeal and cortical arteries.

Answer 33

The correct answer is (e) There is always deposition of amyloid in the leptomeningeal and cortical arteries.

In Alzheimer’s disease all of the other options describe the pathological findings, but less commonly (not always as said in (e)) there is deposition of amyloid in the leptomeningeal and cortical arteries.

Question 34

Which of the following is not a clinico-pathological feature of Parkinson’s disease?

(a) Clinical presentation classically of resting tremor, rigidity, bradykinesia.
(b) Unresponsive to L-DOPA
(c) Psychiatric features such as hallucinations, anxiety and dementia generally occur much later in disease progression.
(d) Substantial cell death in the substantia nigra, resulting in depigmentation and depigmentation of the Locus coeruleus.
(e) Necessary to lose 80-85% of dopaminergic neurones and deplete dopamine levels by 70% before clinical symptoms of Parkinson’s disease appear.

Answer 34

The correct answer is (b) unresponsive to L-DOPA.

L-DOPA is a precursor to dopamine so one of the main features of Parkinson’s disease is that it is responsive to dopamine.

All the other options are correct.

Question 35

Which of the following is not a clinical feature of classical Polyarteritis Nodosa?

(a) Pyrexia of unknown origin
(b) Weight loss
(c) Liver failure
(d) Hypertension
(e) Malaena

Answer 35

The correct answer is (c) liver failure.

Instead you might see renal failure in polyarteritis nodosa.

Other features not listed here are: muscle aches, neuropathy, haematuria and abdominal pain.

Question 36

Which of the following statements about immune abnormalities in sarcoidosis is correct?

(a) Raised CD8>CD4 cells in the lung
(b) Raised CD4>CD8 in the blood
(c) Lymphopenia
(d) Alveolar macrophages are activated causing hypocalcaemia
(e) Alveolar macrophages are activated causing a low serum angiotensin converting enzyme.

Answer 36

The correct answer is (c) Lymphopenia.

In terms of (a) and (b), there is raised CD4>CD8 cells in the lung due to activation of T-helper cells. The opposite is true for the blood.

In terms of (d) and (e) alveolar macrophages are indeed activated but this causes hypercalcaemia and increased serum ACE.

Question 37

Which of the following is not seen classically in the pathology of sarcoidosis?

(a) Langhan’s giant cells
(b) Schaumann bodies
(c) Asteroid bodies
(d) Epithelioid cells
(e) Necrosis

Answer 37

The correct answer is (e) necrosis.

Necrosis is not usually seen in sarcoidosis.

Additional pathology of sarcoidosis is the classical non-caseating granulomas, and typically a thin rim of lymphocytes which later progresses to fibrosis.

Question 38

Curschmann’s spiral and Charcot Leyden crystals might be both present on the histology of a lung biopsy in what condition?

(a) Tuberculosis
(b) COPD
(c) Asthma
(d) Pulmonary Fibrosis
(e) Cystic Fibrosis.

Answer 38

The correct answer is (c) asthma.

Both of these findings are indicative of a disease involving eosinophilic inflammation or proliferation, such as is found in allergic reactions and parasitic infections.
Curschmann’s spirals refers to a finding in the sputum of spiral shaped mucus plugs.
Charcot-Leyden crystals are microscopic crystals found in people who have allergic diseases.The Charcot-Leyden crystal protein interacts with eosinophil lysophospholipases and is often seen pathologically in patients with bronchial asthma.

Question 39

Cadmium exposure is a rare cause of what lung pathology?

(a) Pulmonary Fibrosis
(b) Mesothelioma
(c) Bronchial carcinoma
(d) Emphysema
(e) Chronic bronchitis

Answer 39

The correct answer is (d) Emphysema.

The classic cause of emphysema is cigarette smoke which causes emphysema through two routes. Firstly it activates neutrophils and macrophages in the lung which increase the activity of proteases such as elastase in the lung. Secondly it reduces activity of alpha 1 antitrypsin and other antiproteases which all have an inhibitory effect on proteases in the lung. Both of these mechanisms increase/stimulate proteases in the lung causing tissue damage.

Another cause, as you can guess from the above explanation, is alpha 1 antitrypsin deficiency, which causes emphysema in a similar pattern but earlier and without the factor of smoking cigarettes.

Other rarer causes of emphysema are causes that directly cause tissue damage such as cadmium exposure, IV drug abuse and connective tissue disorders such as Marfan’s syndrome.

Question 40

Which of the following is not a complication of Bronchiectasis?

(a) Amyloidosis
(b) Sarcoidosis
(c) Pulmonary hyptertension
(d) Recurrent infections
(e) Haemoptysis

Answer 40

The correct answer is (b) Sarcoidosis.

All the others are complications of bronchiectasis.

Question 41

56 year old retired farmer visits his GP due to shortness of breath. He says he used to suffer with it before when he was working the farm, but it got a lot better after he retired. Over the past three months he’s been helping run a petting zoo, and he’s found the shortness of breath coming back during the week, but it is a lot better across the weekend.

What condition is this man likely suffering from?

(a) COPD
(b) Pulmonary Fibrosis
(c) Mesothelioma
(d) Extrinsic allergic alveolitis
(e) Pneumoconiosis

Answer 41

The correct answer is (d) Extrinsic allergic alveolitis.

Question 42

Which of the following is not a carcinogen contained in cigarette smoke?

(a) Polycyclic aromatic hydrocarbons
(b) Phenols
(c) Beryllium
(d) Arsenic
(e) Nickel

Answer 42

The correct answer is (c) Beryllium. Beryllium is a carcinogen found in rocket fuel.

All the other options are carcinogens present in cigarette smoke.

Question 43

The progression of this disease begins with atypical cell hyperplasia before proliferation of these cells lining the alveolar walls. The focus is an acinar pattern with destruction of underlying elastin and desmoplasia with angular glands and single cell infiltration.

These histological findings describe what type of lung pathology?

(a) Small cell lung cancer
(b) Non-small cell lung cancer
(c) Adenocarcinoma
(d) Squamous cell carcinoma
(e) Mesothelioma

Answer 43

The correct answer is (c) Adenocarcinoma.

Histology of an adenocarcinoma shows evidence of glandular differentiation.

The progression the disease begins with atypical adenomatous hyperplasia, but I thought that’d give the game away.

Question 44

Which of the following questions about liver pathology is correct?

(a) Genetic haemochromatosis is genetically determined increased gut iron absorption, it’s autosomal recessive and coded for by a gene on chromosome 13.
(b) Wilson’s disease is a a genetic condition characterised by failure of copper excretion by hepatocytes, it’s autosomal recessive and coded for by genes on chromosome 6.
(c) Kayser-Fleischer rings, seen in Wilson’s disease are identified as the golden-brown pigment deposits in Descemet`s membrane in the periphery of the iris.
(d) A Rhodanine stain of a liver biopsy is used in diagnosis of alpha-one antitrypsin deficiency.
(e) An unusual opthalmologic manifestation of cholangiocarcinoma is “sunflower cataracts”.

Answer 44

The correct answer is (c) Kayser-Fleischer rings, seen in Wilson’s disease are identified as the golden-brown pigment deposits in Descemet`s membrane in the periphery of the iris.

While the statements (a) and (b) are mostly correct, the chromosomes have been switched. Genetic haemochromatosis is associated with chromosome 6 and Wilson’s disease with chromosome 13.

A Rhodanine stain (d) is useful in diagnosis of Wilson’s disease.

Sunflower cataracts (e) are an unusual feature of Wilson’s disease.

Question 45

Which of the following statements about ovarian epithelial tumours is correct?

(a) Clear cell carcinomas have abundant clear cytoplasm due to intracellular glycogen and a strong association with endometriosis as well as being related to endometrioid carcinoma.
(b) Mucinous tumours are the most common ovarian tumour and are divided into benign, borderline and malignant tumours.
(c) Serous tumours account for 10-20% of ovarian tumours and are usually endocervical in type.
(d) Endometrioid tumours account for 10-24% of ovarian tumours, 10-20% of them are associated with endometriosis and they have a much worse prognosis than serous and mucinous carcinomas as most endometrioid tumours are poorly differentiated.
(e) Leiomyosarcomas are the malignant counterpart of leiomyomas and account for 5% of ovarian tumours.

Answer 45

The correct answer is (a) Clear cell carcinomas have abundant clear cytoplasm due to intracellular glycogen and a strong association with endometriosis as well as being related to endometrioid carcinoma.

(b) describes serous tumours and (c) describes mucinous tumours.
(d) Endometrioid tumours do account for 10-24% of ovarian tumours, 10-20% of them are associated with endometriosis but they have a much better prognosis than serous and mucinous carcinomas as most endometrioid tumours are well-differentiated.
(e) Leiomyosarcomas are the malignant counterpart of leiomyomas which is the posh word for fibroid, which should tell you that they occur in the uterus and therefore do not account for 5% of ovarian tumours.

Question 46

Which of the following statements about neoplastic bone disease is false?

(a) Enchondromas are tumours composed of cartilage arising in the medulla of the bone. Multiple enchondromata is Ollier’s syndrome and multiple enchondromata with multiple haemangiomas is referred to as Maffucci’s syndrome.
(b) An osteoid osteoma is a small, benign, bone-forming lesion which is very painful. It usually occurs in the diaphyseal cortex of a lower limb. Histology shows an active, well-defined, woven bone-forming lesion.
(c) Giant cell tumour usually occurs on an epiphysis which metaphyseal extension. On histology there are osteoclasts on a background of spindle/ovoid cells. They are locally aggressive but do not metastasise.
(d) Fibrous dysplasia mainly affects long bones, ribs and skull and has x-ray findings of “soap bubble” osteolysis and characteristic ground glass appearance. Histologically characterised by irregular trabeculae of woven bone in a bland spindle cell stroma.
(e) An osteochondroma is a cartilage capped bony protruberance of the metaphysis of diaphysis which grows by virtue of enchondral ossification of the cartilage cap. Occurs in the young, 50% are between 10-20 and the ratio of M:F is 2:1.

Answer 46

The correct answer is (c) Giant cell tumour usually occurs on an epiphysis which metaphyseal extension. On histology there are osteoclasts on a background of spindle/ovoid cells. They are locally aggressive but do not metastasise.

All of this statement is correct apart from the last sentence. Giant cell tumours are locally aggressive, may recur and can metastasise.

Question 47

Which of the following statements about breast pathology is false?

(a) Duct ectasia is inflammation and dilation of large breast ducts. Cytology of smears shows macrophages and proteinaceous material and histology shows dilated ducts with periductal inflammation and filled with secretions.
(b) Acute mastitis is acute inflammation of the breast. Staphylococci is the most common causative organism. FNA cytology shows abundant neutrophils and histology shows acute inflammation +/- abscess formation.
(c) Fat necrosis is an inflammatory reaction to damaged adipose tissue in the breast. Associated with trauma, surgery and radiotherapy. FNA cytology shows degenerate fat, foamy macrophages and giant cells. Histology shows degenerate adipocytes surrounded by foamy macrophages, giant cells, lymphocytes and plasma cells. Later changes include fibrosis and calcification.
(d) Fibrocystic change is a spectrum of changes which reflect abnormal, pathological, hormonal responses. It’s reasonably rare with only 5% of women ever suffering from it. Histological changes include cysts, apocrine metaplasia, adenosis, mild usual epithelial hyperplasia and stromal hyperplasia. There is a slight increased risk of malignancy.
(e) Fibroadenoma is a benign fibroepithelial tumour of the breast. It’s common, and FNA cytology shows branching sheets of epithelium, bare bipolar nuclei and stroma. Histology shows a multinodular mass composed of expanded intralobular stroma and compressed slit-like ducts.

Answer 47

The correct answer is (d) Fibrocystic change is a spectrum of changes which reflect abnormal, pathological, hormonal responses. It’s reasonably rare with only 5% of women ever suffering from it. Histological changes include cysts, apocrine metaplasia, adenosis, mild usual epithelial hyperplasia and stromal hyperplasia. There is a slight increased risk of malignancy.

Instead, fibrocystic change is a spectrum of changes which reflect normal, albeit exaggerated, hormonal responses. It’s very common, found in over one third of premenopausal women. Presents with breast lumpiness and nodularity which may be cyclical. Histology is as described above, but there is no increased risk of malignancy.

Question 48

Which of the following is a cause of nephrotic syndrome?

(a) SLE
(b) Sarcoidosis
(c) Wegener’s granulomatosis
(d) Thrombotic microangiopathy
(e) IgA nephropathy

Answer 48

The correct answer is (a) SLE

Question 49

Which of the following statements about pathology of brain tumours is correct?

(a) Well-differentiated astrocytomas are well-defined, non-infiltrative and benign.
(b) Pilocytic astrocytomas are mostly malignant tumours that are more common in children but may occur at any age.
(c) Oligodendrogliomas are most common in adulthood, they often are well-differentiated without cytogenic abnormalities and are better demarcated than infilatrating astrocytomas.
(d) Metastatic neoplasms are usually poorly demarcated and infiltrative and occur most commonly in the elderly.
(e) Ependymomas occur at any age, intracranial lesions are most common in the first two decades of life, and cord lesions are more common in adults. They are usually well demarcated.

Answer 49

The correct answer is (e) Ependymomas occur at any age, intracranial lesions are most common in the first two decades of life, and cord lesions are more common in adults. They are usually well demarcated.

Well-differentiated astrocytomas (a), despite the name, are poorly defined, infiltrative and expand the parenchyma obliterating the grey-white interface.

Pilocytic astrocytomas (b) are rarely malignant.

Oligodendrogliomas (c) often have cytogenic abnormalities, but they are better demarcated than infiltrating astrocytomas.

Metastatic neoplasms (d) are usually well demarcated, with a sharp interface existing between the metastasis and the surrounding parenchyma.