Path 2020 Flashcards
Hepatic adenoma with malignant transformation. Most likely subtype:
a. Inflammatory
b. Beta catenin
c. HNF1-alpha
d. Nodular
e. Atypical FNH
b. Beta catenin
Hepatic adenoma with malignant transformation. Most likely subtype:
a. Inflammatory - F, intermediate risk
b. Beta catenin - T, very high risk
c. HNF1-alpha - F, virtually no risk
d. Nodular - F, distractor
Nodular regenerative hyperplasia denotes a liver entirely transformed into nodules—grossly similar to micronodular cirrhosis—but without fibrosis. Nodular regenerative hyperplasia can lead to the development of portal hypertension and occurs in association with conditions affecting intrahepatic blood flow, including solid-organ (particularly renal) transplantation, hematopoetic stem cell transplantation, and vasculitis. It also occurs in HIV-infected persons and in association with rheumatologic diseases such as SLE. Most such patients are asymptomatic and the condition is found at autopsy.
e. Atypical FNH - F, distractor
spontaneous mass lesion in an otherwise normal liver, most frequently in young to middle-aged adults.
Hepatic masses include nodular hyperplasias (FNH and nodular regenerative hyperplasia) and true neoplasms (benign and malignant). Benign = cavernous haemangiomas (most common) and hepatocellular adenomas.
Hepatocellular adenomas are benign tumors of neoplastic hepatocytes. Most can be subclassified on the basis of molecular changes:
■ HNF1-α inactivated adenomas, with virtually no risk of malignant transformation, often associated with oral contraceptive pill use or in individuals with MODY-3
■ β-Catenin activated adenoma, with mutations in the β-catenin gene leading to marked atypia and associated with a very high risk for malignant transformation
■ Inflammatory adenomas, the hallmark of which is up-regulation of C-reactive protein and serum amyloid A (often derived from gp130 mutations); 10% of these have concomitant β-catenin activating mutations. Risk for malignant transformation is intermediate.
Most likely feature of FNH
a. Significantly associated with OCP use
b. Stellate central fibrous lesion
c. Dark on opposing phase
d. Often complicated by haemorrhage
e. Associated with malignant degeneration in beta catenin type
b. Stellate central fibrous lesion
Most likely feature of FNH
a. Significantly associated with OCP use - F
Both oral contraceptives and anabolic steroids are associated with the development of adenomas.
Oral contraceptives do not cause FNH but have trophic effect on growth
b. Stellate central fibrous lesion - T
Typically, there is a central gray-white, depressed stellate scar from which fibrous septa radiate to the periphery.
c. Dark on opposing phase - F
Hepatic adenoma HNF1a subtype - signal dropout on opposed-phase GRE T1WI
d. Often complicated by haemorrhage -F
adenoma haemorrhage: Intrahepatic or intraperitoneal (40%)
e. Associated with malignant degeneration in beta catenin type - F, beta catenin adenoma
What is not associated with EBV
a. Nasopharyngeal carcinoma
b. Hodgkins lymphoma
c. Burketts
b. Hodgkins lymphoma (may be associated, but definitely the best of the 3 options)
What is not associated with EBV
a. Nasopharyngeal carcinoma
Nasopharyngeal carcinoma is characterized by a distinctive geographic distribution, a close anatomic relationship to lymphoid tissue, and an association with EBV infection.
b. Hodgkins lymphoma
Little is known about the basis for the morphology of Reed-Sternberg cells and variants, but it is intriguing that EBV-infected B cells resembling Reed-Sternberg cells are found in the lymph nodes of individuals with infectious mononucleosis, strongly suggesting that EBV-encoded proteins play a part in the remarkable metamorphosis of B cells into Reed-Sternberg cells.
c. Burketts
Essentially all endemic Burkitt lymphomas are latently infected with EBV, which is also present in about 25% of HIV-associated tumors and 15% to 20% of sporadic cases.
Bacteroides lung infection. Most likely:
a. Gastric contents aspiration
b. Oral contents aspiration
c. Inhaled contents from immunosuppressed person coughing.
b. Oral contents aspiration
Bacteroides is an anaerobe
Pulmonary abscess aetiology -
Aspiration: Mixed aerobic & anaerobic polymicrobial bacterial infection originating in gingiva
Which has the highest risk of prostate cancer?
a. Microsatellite instability
b. BRCA2
c. VHL
d. NF1
b. BRCA2
Men with germline mutations of the tumor suppressor BRCA2 have a 20-fold increased risk of prostate cancer
Which tumour secretes AFP
a. Choriocarcinoma
b. Dysgerminoma
c. Yolk sac tumour
d. Teratoma
c. Yolk sac tumour
Elevated AFP is most often seen with yolk sac tumor and less often embryonal tumors
Regarding Langerhans cell histiocytosis, which is most correct?
a. Letterer-Siwe has a peak age of onset of 15-20yr
b. Pulmonary type is mostly associated with smoking
b. Pulmonary type is mostly associated with smoking
Regarding Langerhans cell histiocytosis, which is most correct?
a. Letterer-Siwe has a peak age of onset of 15-20yr - F
Multifocal multisystem Langerhans cell histiocytosis (Letterer-Siwe disease) occurs most frequently before 2 years of age but occasionally affects adults. The course of untreated disease is rapidly fatal. With intensive chemotherapy, 50% of patients survive 5 years.
b. Pulmonary type is mostly associated with smoking - T
More than 95% of affected patients are relatively young adult smokers who get better after smoking cessation, suggesting that in some cases the lesions are a reactive inflammatory process.
Which is the correct association?
a. Islet cell tumour and gastric ulcer
a. Islet cell tumour and gastric ulcer
- gastrinoma with Zollinger-Ellison syndrome
In the Zollinger-Ellison syndrome, hypergastrinemia gives rise to extreme gastric acid secretion, which in turn causes peptic ulceration (Chapter 17). The duodenal and gastric ulcers are often multiple; although they are identical to those found in the general population, they are often unresponsive to therapy. In addition, ulcers may occur in unusual locations such as the jejunum; when intractable jejunal ulcers are found.
Regarding TNM staging, what is the correct stage for an anal cancer which has invaded through the muscularis propria and 1mm into the mesorectal fat?
a. T1
b. T2
c. T3
d. T4
e. T0
c. T3
The question is asking about staging of rectal cancer, not anal cancer, which is T-staged based on size.
T3: tumour invades through the muscularis propria into the subserosa or into non-peritonealised perirectal tissues without reaching the mesorectal fascia or adjacent organs
Global ischaemic encephalopathy, which is least affected with acute/necrotic change.
a. Surface cortical grey matter
b. Basal ganglia
c. Corpus callosum
d. Watershed areas
e. Deep white matter
c. Corpus callosum - T? by process of elimination
Global ischaemic encephalopathy, which is least affected with acute/necrotic change.
a. Surface cortical grey matter - F, affected in severe
b. Basal ganglia - F, affected in severe
c. Corpus callosum - T? by process of elimination
d. Watershed areas - F, affected in mild-to-moderate
e. Deep white matter - F? involved in watershed zone.
Preterm neonates more likely to have associated white matter injury & hemorrhage
__________
Injury patterns highly variable depending on brain maturity, severity and length of insult
Mild to moderate: Watershed zone infarcts
Severe: Gray matter structures (basal ganglia, thalami, cortex, cerebellum, hippocampi)
*IVM If referring to HIE children and adults (vs neonatal), primarily effects grey matter structures.
What has the highest correlation
a. Lynch syndrome and endometrial carcinoma
The most common extracolonic tumor in Lynch syndrome is endometrial cancer.
SCS edit
Lynch Syndrome AKA HNPCC
- DNA mismatch repair gene, most frequently resulting in CRC
-Extra colonic malignancies:
GU- Endometrial (most often endometroid type)>Ovarian>Prostate>TCC
SB adeno (duo> jejunum>ileum), Gastroc Ca., HPB malignancies.
CNS - GBM
Ewings sarcoma
a. Typical age 15-20
b. Differential is chondrosarcoma
c. Presents similar to osteomyelitis
d. Most commonly occurs in metaphysis of long bones
c. Presents similar to osteomyelitis
Ewings sarcoma
a. Typical age 15-20, F (-ish, a bit too old)
StatDx: 5-30 years (median: 13 years), 80-90% < 20 years
Radiopaedia: children and adolescents between 10 and 20 years of age (95% between 4 and 25 years of age)
b. Differential is chondrosarcoma, F (osteosarcoma)
c. Presents similar to osteomyelitis - T (-ish, a classic mimic)
Most common signs/symptoms:
Painful (82-88%) mass (60%)
Fever (20-49%), anemia, leukocytosis, ↑ ESR (43%), mimicking infection
d. Most commonly occurs in metaphysis of long bones - F, Diaphysis or metadiaphysis of long bones (70%)
What is least likely hereditary?
a. ADPKD
b. ARPKD
c. Medullary sponge kidney
d. Juvenile nephronopthisis
e. Adult onset medullary cystic kidney disease
c. Medullary sponge kidney
What is least likely hereditary?
a. ADPKD - autosomal dominant
b. ARPKD - autosomal recessive
c. Medullary sponge kidney - not inherited. pathogenesis unknown
d. Juvenile nephronopthisis - autosomal recessive
e. Adult onset medullary cystic kidney disease - autosomal dominant
Cholangiocarcinoma, associated with:
a. Stained green
b. Most are intrahepatic
c. Associated with IBD
Unsure
*WJI: I’d run c as this is definitely true. PSC is strongly associated with UC. PSC is commonest cause Cholangiocarcinoma (Recurrent pyogenic cholangitis in Asia)
*SD: I’d favor associated with IBD.
CCF: I back the lads^ -C. Lads lads lads
*ESG: Depends on whether the wording is talking about the tumour or the liver being bile-stained. If liver, I’d go with a) as c) is an indirect association. from StatDx: Drawing of an axial section through the liver shows a Klatskin tumor , a small mass at the confluence of the main right and left bile ducts invading the adjacent liver and the hepatic vein. The intrahepatic ducts are dilated, and the liver is bile stained.
Cholangiocarcinoma, associated with:
a. Stained green - T?
Bile-stained liver occurs in biliary cirrhosis - results from uncorrected biliary obstruction.
RY - Tumor is pale, not green (Robbins). Note: Different recall questions (see hepatobiliary section) have focused on HCC occasionally being green (i.e. bile stained). Adenomas are also bile stained.
b. Most are intrahepatic - F
The extrahepatic forms include perihilar tumors known as Klatskin tumors, which are located at the junction of the right and left hepatic ducts. Fifty percent to 60% of all cholangiocarcinomas are perihilar (Klatskin) tumors, 20% to 30% are distal tumors, arising in the common bile duct where it lies posterior to the duodenum. The remaining 10% are intrahepatic.
c. Associated with IBD - T?
Associated with PSC, which is associated with UC
Ovarian tumour associated with elevated increased beta HCG
a. Yolk sac tumour
B. Choriocarcinoma
choriocarcinoma - beta-HCG (*SD also dysgerminomas and embryonal carcinomas)
yolk sac tumour - aFP
Associations of Wilson disease, least correct:
A. Nutmeg liver
B. Chronic hepatitis
C. Acute hepatitis
D. Fatty liver
E. Cirrhosis
A. Nutmeg liver
Associations of Wilson disease, least correct:
A. Nutmeg liver - F, due to a perfusion abnormality of the liver usually as result of hepatic venous congestion
B. Chronic hepatitis - T
C. Acute hepatitis - T
D. Fatty liver - T
E. Cirrhosis - T
Branchial cleft cyst 2, least likely
a. Commonly occurs intra parotid
b. Can present with otorrhoea
c. Posterior to mandible
d. Something about supraclavicular location
Two answers
_______
Branchial cleft cyst 2, least likely
a. Commonly occurs intra parotid - F
1st BCC location
b. Can present with otorrhoea -F
1st BCC common presentation. Cystic mass near pinna & EAC or extending from EAC to angle of mandible
c. Posterior to mandible - T,
2nd BCC posterolateral to submandibular gland. Most are at or immediately caudal to angle of mandible
d. Something about supraclavicular location - T?
2nd BCC with fistula: If tract courses inferiorly, it passes along anterior carotid space, reaching supraclavicular skin
Fibroadenoma in a 40yo
a. Usually solitary
b. Dense calcifications are common
c. No enhancement on MRI
d. Posterior shadowing on USS
e. Most common cancer occurring within fibroadenoma is invasive ductal
Possibly b) “most” correct?
*SD: disagree, 40y is premenopausal, calcifications tend to occur as they involute postmenopausally. I’d favor a) usually solitary.
**SCS: Robbins 9th Ed. Pg 1069. Probably best answer; but note “most occur in their 20s and 30s and they are frequently multiple and bilateral”
Fibroadenoma in a 40yo
a. Usually solitary - T
15% of adult-type FA are multiple; juvenile type usually solitary
b. Dense calcifications are common - T
Mammogram: Circumscribed mass ± coarse popcorn Ca⁺⁺; coarse heterogeneous Ca⁺⁺ with no visible mass
c. No enhancement on MRI - F?
Variable enhancement
- Usually homogeneous with medium initial rise, persistent delayed phase
- Uncommon: Rapid enhancement with washout
- Weak to no enhancement if densely hyalinized
d. Posterior shadowing on USS - T?
Posterior enhancement variable. Posterior shadowing if hyalinized or large Ca⁺⁺
e. Most common cancer occurring within fibroadenoma is invasive ductal - F (=LCIS)
Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) can occur in FA. Rarely, foci of DCIS or invasive ductal or lobular carcinoma develop within or involve FA
Breast:
a. Medullary breast cancer occurs in young person
b. Medullary carcinoma poor prognosis, 70% 5YS
c. Lucent centered calcifications
Breast:
a. Medullary breast cancer occurs in young person - T
Rare: 1-2% of breast cancers
10% of breast cancers in patients < age 35
Age range: 30-86 years (mean: 54)
b. Medullary carcinoma poor prognosis, 70% 5YS - F
Survival better than IDC NST
5-year survival: 89-95%
c. Lucent centered calcifications
? describing dermal calcifications or oil cysts
Paget disease of the breast:
a. eczematous reaction
b. Occult IDC 50%.
a. eczematous reaction
Paget disease of the breast:
a. eczematous reaction -T
Clinical: Erythema, flaking and ulceration of skin of nipple
b. Occult IDC 50%. - F, if occult means not seen on imaging.
Underlying associated malignancy found in 86%
- 96% high nuclear grade DCIS
- 50% have palpable mass; 90-94% of those have IDC, usually grade 3
US: Underlying DCIS often occult; invasive cancer well seen
Paget disease can be undetectable on mammography in ~50% of cases
SCS:
pagets is rare- 1-4% of cases.
DCIS extends into nipple skin without crossing basement membrane via the lactiferous system
Most assoiated with breast high grade IDC:
a. Well defined mass
Mammography - mass:
Spiculated margins: More common in low grade (41% grade 1 vs. 26% grade 3)
Circumscribed margins: More common in high grade (18% grade 1 vs. 36% grade 3)
Benign proliferative breast lesions without atypia:
a. Most biopsies contain ADH (wording not quite correct)
b. Difference between LCIS and atypical lobular hyperplasia is e-cadherin
No correct answer
Benign proliferative breast lesions without atypia:
a. Most biopsies contain ADH (wording not quite correct) - F
ADH present in 5% to 17% of specimens from biopsies performed for calcifications.
ALH is an incidental finding and is found in fewer than 5% of biopsies.
b. Difference between LCIS and atypical lobular hyperplasia is e-cadherin - F
Atypical lobular hyperplasia consists of cells identical to those of lobular carcinoma in situ, but the cells do not fill or distend more than 50% of the acini within a lobule. Atypical lobular hyperplasia shows loss of E-cadherin expression, a feature it shares with lobular carcinoma in situ.
Difference between LCIS and DCIS is e-cadherin (DCIS does not have loss of e-cadherin)
Hyperphosphataemia most likely caused by:
a. Primary hyperparathyroidism
b. Secondary hyperparathyroidism
c. Tertiary hyperparathyroidism
d. Vitamind D deficiency
e. Calcium deficiency
Hyperphosphataemia most likely caused by:
None of the options. Generally caused by:
●Acute phosphate load (i.e. tumour lysis)
●Acute extracellular shift of phosphate (Lactic or ketoacidosis)
●Acute or chronic kidney disease
●A primary increase in tubular phosphate reabsorption (Hypoparathyroidism, vitamin D toxicity)
*note, as renal failure is a common cause of both hyperphosphataemia and secondary hyperparathyroidism, then secondary hyperparathyroidism this would be a correct answer if the question was worded along the lines of “hyperphosphateamia most likely seen in…”
/rant
a. Primary hyperparathyroidism - F
Any cause of hypersecretion of PTH can lead to hypophosphatemia. This occurs in primary hyperparathyroidism (in which hypercalcemia is usually the most prominent abnormality) and in secondary hyperparathyroidism induced by any of the causes of vitamin D deficiency. Most patients with primary hyperparathyroidism have mild hypophosphatemia. It may be more severe in those with vitamin D deficiency and secondary hyperparathyroidism because they have not only increased urinary phosphate excretion, but also decreased gastrointestinal phosphate absorption.
b. Secondary hyperparathyroidism - F (caused by hyperphosphataemia)
Phosphate retention thought to play a central role in the development of secondary hyperparathyroidism.
see above
c. Tertiary hyperparathyroidism - F (caused by hyperphosphataemia)
The state of prolonged stimulation of parathyroid cell growth in CKD patients due to high phosphate, low calcitriol, and hypocalcemia results in nodular hyperplasia
d. Vitamind D deficiency - F
Vitamin D deficiency can cause hypophosphatemia both by decreasing gastrointestinal phosphate absorption and by causing hypocalcemia and secondary hyperparathyroidism, resulting in increased urinary phosphate excretion.
e. Calcium deficiency - F
causes secondary hyperparathyroidism
Bilateral enlarged ovaries, most likely
a. Serous tumour
b. Mucinous tumour
c. Dermoid
d. Brenner
a. Serous tumour
has been asked on multiple previous questions
Which is most associated with associated with knee OA?
a. CPPD
b. Hydroxyapatite disease
c. Ochronosis
d. Gout
a. CPPD
CPPD crystal deposition can be associated with osteoarthritis (OA)
May be synchronous and unrelated to OA, or may be due to repetitive microtrauma
Regarding colon cancer what is most correct
a. Nodule architecture is the most important factor in assessing risk
b. Caecal cancer typically presents with fatigue and weakness not occult rectal bleeding.
c. (the possible other correct answer)
b. Caecal cancer typically presents with fatigue and weakness not occult rectal bleeding.
Regarding colon cancer what is most correct
a. Nodule architecture is the most important factor in assessing risk - F (assuming this is regarding colorectal adenomas)
Adenomas can be classified as tubular, tubulovillous, or villous based on their architecture. These categories, however, have little clinical significance in isolation.
b. Caecal cancer typically presents with fatigue and weakness not occult rectal bleeding. - T
Cecal and other right-sided colon cancers are most often called to clinical attention by the appearance of fatigue and weakness due to iron deficiency anemia.
Left-sided colorectal adenocarcinomas may produce occult bleeding, changes in bowel habits, or cramping and left lower quadrant discomfort.
c. (the possible other correct answer)
Regarding bowel ischaemia
a. Venous ischaemia has a gradual transition
b. Watershed area is at the hepatic flexure
a. Venous ischaemia has a gradual transition
Regarding bowel ischaemia
a. Venous ischaemia has a gradual transition - T
b. Watershed area is at the hepatic flexure - F
splenic flexure and descending colon > sigmoid
Small bowel ischaemic, least likely:
a. SMA thrombus
b. IMA occlusion
c. Aneurysm
d. Acute MI
b. IMA occlusion (causes ischaemic colitis)
_______
Ischaemic enteritis causes:
Vascular occlusion: Embolic events (atrial fibrillation, endocarditis), thrombotic events (atherosclerosis), mechanical obstruction (strangulation, tumor). Closed-loop obstruction especially dangerous
Hypercoagulable states: Oral contraceptives, protein C deficiency, factor V Leiden deficiency
Inflammatory: Pancreatitis, peritonitis, vasculitis (Angiography may show microaneurysms and occluded vessels)
Iatrogenic : Radiation and chemotherapy, therapeutic drugs (digitalis, dopamine, vasopressin), illicit drugs (heroin, cocaine, amphetamines)
Hypoperfusion (more common in ischemic colitis): Low-flow states, hypotension, sepsis, heart failure
Several questions about pneumatosis causes
- Essentially caused by ischaemia and respiratory causes.
Intraluminal GI gas: Intramural pressure or mucosal injury → gas enters wall
Bacterial gas production: Bacterial invasion → high tension → gas diffusion
Regarding gout
a. Primary gout is 30% associated with…..
b. Not associated with hyperuricaemia
c. 20% of chronic gout die from renal failure
d. Most people only have one episode
c. 20% of chronic gout die from renal failure
Regarding gout
a. Primary gout is 30% associated with….. ?
Gout can be divided into primary and secondary forms, both sharing the common feature of hyperuricemia. In the primary form (90% of cases), gout is the major manifestation of the disease and the cause is usually unknown. In secondary gout (10% of cases), uric acid is increased because of a known underlying disease that usually dominates the clinical picture.
b. Not associated with hyperuricaemia - F
see above
c. 20% of chronic gout die from renal failure - T
Renal manifestations sometimes appear in the form of renal colic associated with the passage of gravel and stones and may proceed to chronic gouty nephropathy. About 20% of those with chronic gout die of renal failure.
Gouty nephropathy refers to the renal complications caused by MSU crystals or tophi in the renal medullary interstitium or tubules. Complications include uric acid nephrolithiasis and pyelonephritis, particularly when the urates induce urinary obstruction.
d. Most people only have one episode - F
Although some patients never have another attack, most experience a second acute episode within months to a few years. In the absence of appropriate therapy, the attacks recur at shorter intervals and frequently become polyarticular.
ABC most likely
a. Most commonly associated with another tumour
b. Usually vertebral bodies
c. Arises from the metaphysis in the long bone
d. More than 50% recurrence following curettage
c. Arises from the metaphysis in the long bone
ABC most likely
a. Most commonly associated with another tumour - F
70% of aneurysmal bone cysts (ABCs) are primary
b. Usually vertebral bodies - F (15%)
c. Arises from the metaphysis in the long bone- T
It most frequently develops in the metaphysis of long bones (70-90%) and the posterior elements of vertebral bodies (15%)
d. More than 50% recurrence following curettage - F
The treatment of aneurysmal bone cyst is surgical, usually curettage or, in certain situations, en bloc resection. The recurrence rate is low, and spontaneous regression may occur following incomplete removal.
StatDx: Recurrence rate following curettage is variable in different series (20-50%)
Infective endocarditis, which is false?
a. Strep pneumonia is most common cause of acute
b. Prosthetic vale sewing ring
c. isolated organism in up to 60%
d. IVDU involves right valves.
a. Strep pneumonia is most common cause of acute
Infective endocarditis, which is false?
a. Strep pneumonia is most common cause of acute - F, Staph aureus
b. Prosthetic vale sewing ring - T?
Endocarditis of mechanical valves; often starts at sewing cuff or from thrombi near sewing ring; leads to paravalvular leak, ring abscess, extension of infection into adjacent tissue
c. isolated organism in up to 60% - T?
In about 10% of all cases of endocarditis, no organism can be isolated from the blood (“culture- negative” endocarditis); reasons include prior antibiotic therapy, difficulties in isolating the offending agent, or because deeply embedded organisms within the enlarging vegetation are not released into the blood.
d. IVDU involves right valves. - T
Approximately 90 percent of patients with right-sided IE are people who inject drugs (PWID); in contrast, PWID comprise approximately 20 percent of cases of left-sided IE
Pancreatic ductal adenocarcinoma most likely:
- Li Fraumeni
- BRCA2
- MEN1
- VHL
- FAP
- BRCA2
Pancreatic ductal adenocarcinoma most likely:
- Li Fraumeni - F - Not associated
- BRCA2 -T - Increased, 5- 10% lifetime risk
- MEN1 - F (pancreatic NETs)
- VHL - F (serous cystadenomas and NETs)
- FAP - F - Increased, unknown lifetime risk
____
Heritable syndromes associated with ↑ risk include
Hereditary pancreatitis, hereditary breast and ovarian cancer syndrome, Peutz-Jeghers, ataxia telangiectasia, familial colon cancer, Gardner syndrome, and familial aggregation of pancreatic cancer
