Path - Histopathology

Question 1

Which of the following is true of bullous pemphigoid?

A. It is indicated by the presence of Wickham’s striae in the buccal cavity
B. Bullae can be found on the extensor serfaces
C. It is an auto-inflammatory condition present in older patients
D. Tense bullae are produced
E. It is a Type III hypersensitivity reaction

Answer 1

D. Tense bullae are produced

Bullous pemphigoid is an autoimmune condition present in elderly patients characterised by the formation of tense bullae formed on the flexural surfaces. It is characterised as a type II hypersensitivity reaction as it is mediated by IgG against desmosomes (as are all pemphigus types). Wickham’s striae are a sign of lichen planus.

there is stereotypically no mucosal involvement (i.e. the mouth is spared)- classic differentiator between pemphigoid and pemphigus

Question 2

Which of the following conditions would cause mitotically active melanocytes to be seen on histopathology?

A. Squamous cell carcinoma
B. Pregnancy
C. Basal cell carcinoma
D. Psoriasis
E. This is a normal finding

Answer 2

B. Pregnancy

Mitotically-active melanocytes are usually a sign of melanoma. A notable exception is when this appearance is noted in a pregnant patient, as this is normal.

In melanoma, upwards migration of melanocytes towards the epidermis will be seen, and melanocytes will fail to decrease in size as they migrate.

Question 3

Where does damage occur in pemphigus vulgaris?

A. Between the basement membrane and the bottom of the epidermis
B. Between keratinocytes in the epidermis
C. The surface of the epidermis
D. Between the dermis and epidermis
E. Subcorneal layer of epidermis

Answer 3

B. Between keratinocytes in the epidermis

Pemphigus is caused by antibodies against desmosomes. The type of desmosomes targeted determines which type of pemphigus will arise.

‘A’ describes the site of damage and separation in bullous pemphigoid, and’E’ refers to pemphigus foliaceous.

remember pemphigus is more superficial so flaccid blisters that burst easily. Opposite for BP as deeper (sub-epidermal) so tense blisters (+ red, itchy, hives)

Question 4

Match the appearances on immunofluorescence with the disease they are each most associated with

A. Homogenous
B. Speckled
C. Centromere pattern
D. Nucleolar pattern

1. Diffuse cutaneous systemic sclerosis
2. Limited cutaneous systemic sclerosis
3. Mixed connective tissue disease
4. SLE

Answer 4

A. Homogenous - 4. SLE
B. Speckled - 3. Mixed connective tissue disease (mixed and speckled are sort of synonyms)
C. Centromere pattern - 2. Limited cutaneous systemic sclerosis (CREST)-remember Centromere and Crest (C and C)
D. Nucleolar pattern - 1. Diffuse cutaneous systemic sclerosis

NB: None of these patterns are 100% specific e.g. SLE can give almost any of these appearances on immunofluorescence.

Homogenous pattern indicates Anti-dsDNA
Speckled pattern indicates Anti-Ro, La, and Sm
Nucleolar pattern indicates ANti-SCL70 (anti-topoisomerase)

pic shows main anti-nuclear (ANA) patterns on immunofluorescence

Mixed connective tissue disease, commonly abbreviated as MCTD, is an autoimmune disease characterized by the presence of elevated blood levels of a specific autoantibody, now called anti-U1 ribonucleoprotein (RNP) together with a mix of symptoms of systemic lupus erythematosus (SLE), scleroderma, and polymyositis.[2] The idea behind the “mixed” disease is that this specific autoantibody is also present in other autoimmune diseases such as systemic lupus erythematosus, polymyositis, scleroderma, etc.

scleroderma split into- systemic scelrosis (diffuse type- usually ant-Scl-70) and CREST (limited cutaneous)

Question 5

A kidney biopsy shows thickened glomerular capillary loops (a wire loop appearance)

Which disease is this suggestive of?

A. SLE
B. Scleroderma
C. Sarcoidosis
D. Goodpasture's disease
E. GPA

Answer 5

A. SLE

The wire loop appearance is the classic appearance of lupus nephritis, and is caused by immune complex deposition in the glomerular capillary loops causing thickening.

Question 6

Which vessels are most often affected by polyarteritis nodosa?

A. Coronary arteries
B. Temporal and retinal arteries
C. The aorta and its branches
D. Renal and mesenteric arteries
E. Vessels in the kidneys, lungs, and upper respiratory tract

Answer 6

D. Renal and mesenteric arteries

Polyarteritis nodosa is a necrotising arteritis affecting medium vessels. It most often affects the renal and mesenteric arteries, and causes a series of aneurysms in close proximity, creating the ‘rosary beads’ appearance on angiography. It is classically associated with hepatitis B infection.

Polyarteritis nodosa (PAN) is a systemic necrotizing inflammation of blood vessels (vasculitis) affecting medium-sized muscular arteries, typically involving the arteries of the kidneys and other internal organs but generally sparing the lungs’ circulation

rosary baeds appearance is key

Question 7

What is the most common form of thyroid cancer?

Answer 7

Papillary

Though thyroid carcinomas are rare, within that group papillary thyroid cancer is the most common. They are especially associated with radiation exposure.

Question 8

What form of thyroid cancer arises from parafollicular ‘C cells’?

Answer 8

Medullary

Medullary carcinoma makes up 5% of thyroid carcinomas. 80% are spontaneous, but 20% are associated with a MEN syndrome.

Question 9

What is the most common type of pituitary adenoma?

A, Gonadotrophin-secreting
B. ACTH-secreting
C. Non-functioning
D. Prolactinoma
E. TSH-secreting

Answer 9

D. Prolactinoma

Prolactinomas make up 20-30% of pituitary adenomas, with the next most common adenoma being a non-functioning one.

Question 10

Muscle weakness, hypertension, and congestive cardiac failure are all possible complications of adenomas secreting which hormone?

A. Somatotrophin
B. Prolactin
C. Somatostatin
D. Gonadotrophin
E. TSH

Answer 10

A. Somatotrophin

Muscle weakness, hypertension, T2DM, and congestive cardiac failure are all potential complications of acromegaly which is caused by excess somatotrophin (a.k.a. growth hormone).

Question 11

What is the most common cause of goitre worldwide?

A. Iodine deficiency
B. Hashimoto's thyroiditis
C. Toxic multinodular goitre
D. Graves' disease
E. Papillary thyroid cancer

Answer 11

A. Iodine deficiency

Although very rare in the west because of iodine-fortified food, iodine deficiency is very common in parts of the developing world and so is still the commonest cause of goitre.

Question 12

Which of the following statements about thyroid nodules is FALSE?

A. Solitary nodules are more often neoplastic than multiple nodules
B. Solid nodules are more likely to be neoplastic than cystic nodules
C. Nodules in younger patients are more likely to be neoplastic than those in older patients
D. Nodules in females are more likely to be neoplastic than those in males
E. Nodules that don’t take up radio-labelled iodine (cold) are more commonly neoplastic than hot nodules

Answer 12

D. Nodules in females are more likely to be neoplastic than those in males

Medullary part of MEN-2 commonly.
Anaplastic v poor prognosis.

this is false. The key is the rest are true!

Question 13

What findings on microscopy would suggest a papillary thyroid carcinoma?

Answer 13

Optically clear nuclei, intranuclear inclusions, and psamomma bodies

Diagnosis of papillary carcinoma does not necessarily focus on the overall architecture, as the classic papillary shape may not be present. Instead the cell morphology is analysed.

The nuclei in papillary thyroid carcinomas are visibly empty, hence ‘optically clear nuclei’ is a sign.

Psamomma bodies are round foci of calcification that appear in many cancers, but the only thyroid cancer they appear in is papillary.

Papillary thyroid cancer gets its name from the papillae among its cells, visible on microscopy.

Question 14

Which of the following is not a complication or sign of primary hyperparathyroidism?

A. Depression
B. Pancreatitis
C. Osteitis fibrosa cystica
D. Paraesthesia
E. Tetany

Answer 14

E. Tetany

All the other options are complications of hypercalcaemia, whereas tetany results from hypocalcaemia. Hyperparathyroidism causes hypercalcaemia as the excess PTH increases serum calcium beyond normal limits.In 80-90% of cases, primary hyperparathyroidism is caused by an adenoma, with 10-20% of cases being due to generalised parathyroid hyperplasia (which can be part of a MEN syndrome). Parathyroid carcinoma accounts for <1% of hyperparathyroidism cases.

Hyperparathyroidism may also be secondary, in which case chronic kidney disease is the most common cause, leading to insufficient 25-hydroxycholecalciferol hydroxylation (low active vitamin D).

Osteitis fibrosa cystica is a skeletal disorder resulting in a loss of bone mass, a weakening of the bones as their calcified supporting structures are replaced with fibrous tissue (peritrabecular fibrosis), and the formation of cyst-like brown tumors in and around the bone. It is caused by hyperPTism (due to osteoclast overactivity)

Question 15

Which pathogens are particularly associated with pelvic inflammatory disease after a woman has undergone a TOP?

A. Stapylococci
B. Salmonella
C. Gonococci
D. Shigella
E. Chlamydia

Answer 15

A. Staphylococci

Gram positive cocci (Staphylococci, Streptococci), coliform bacteria (E. coli, Klebsiella, Enterobacter etc.), and C. perfringens are particularly important causes of PID after a TOP.

Question 16

Which of the following HPV types is most associated with cervical cancer?

A. 6
B. 9
C. 11
D. 18
E. 33

Answer 16

D. 18

16 and 18 are the most common cancer-causing sub-types. They have a strong association with cervical cancer, but may also cause vulval, vaginal, penile, and anal cancer.

6 and 11 are the most common low-risk, wart-causing HPV sub-types.

Question 17

Describe the Cervical Screening Program for the following age brackets:

25-49
50-64
65+

Answer 17

25-49: 3 yearly
50-64: 5 yearly
65+: only if not screened since age 50 or recent abnormal tests

Question 18

A woman undergoes surgery for resection of an endometrial carcinoma. During surgery the para-aortic lymph nodes are found to be involved, though not the pelvic. The primary tumour has spread into the fallopian tubes.

What is the correct FIGO staging of this cancer?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. Stage 5

Answer 18

C. Stage 3

Stage 1 – confined to uterus
Stage 2 – spread to cervix
Stage 3 – spread to adnexae (fallopian tubes, ovaries, potentially nearby ligaments), vagina, local lymph nodes (pelvic or para-aortic)
Stage 4 – other pelvic organs distant spread inc any other distant lymph node groups

NB: there is no stage 5

Question 19

Which of the following is false?

A. Endometriosis may be associated with a variety of ovarian tumours especially clear cell carcinoma
B. Epithelial serous ovarian tumours are the most common type and are bilateral in 30-50% of cases
C. Endometriosis may lead to scarring and infertility
D. Most cases of ovarian cancer have a genetic component
E. Some germ cell tumours can grow teeth and hair

Answer 19

D. Most cases of ovarian cancer have a genetic component

Question 20

A woman attends her GP for a cervical smear, having not been vaccinated against HPV and having not engaged with smear services before. The doctor notices a visible abnormality of the cervix, which is swabbed, and later biopsied. The biopsy shows a neoplasia of the cervical epithelial squamous cells which occupies 3/4 of the thickness of the cervix but has not breached the basement membrane.

Which of the following options best describes the biopsied lesion?

A. Cervical intra-epithelial neoplasia 1
B. Cervical intra-epithelial neoplasia 2
C. Cervical intra-epithelial neoplasia 3
D. Carcinoma
E. Metastasis

Answer 20

C. Cervical intra-epithelial neoplasia 3

The staging system for a cervical intra-epithelial neoplasia is as follows:

CIN 1 - neoplasia occupies <1/3 of the thickness of the epithelium
CIN 2 - neoplasia occupies 1/3 - 2/3 of the thickness of the epithelium
CIN 3 - neoplasia occupies >2/3 of the thickness of the epithelium
Carcinoma - neoplasia has invaded the basement membrane

This is clearly not a metastasis as the biopsy shows the cells are from the cervical epithelium

Question 21

Which of the following statements concerning HPV and cervical cancer is false?

A. 90% of HPV infections are cleared within 2 years
B. Most women over 65 are not invited to cervical screening
C. The HPV virus can inactivate both the p53 and Retinoblastoma tumour suppressor genes
D. Adenocarcinomas occur 4 times less often than squamous cell carcinomas
E. Non-productive infection of cells cannot be identified due to the lack of infective virions

Answer 21

E. Non-productive infection of cells cannot be identified due to the lack of infective virions

It’s true that non-productive infection does not produce infectious virions, and that infected cells do not display the cytological and histological changes associated with HPV infection. However non-productive infection can still be identified using molecular tests (e.g. PCR) as the HPV DNA still resides in the cells and is replicated along with the host cell.

Some of the early genes expressed by HPV, such as E6 and E7, act as oncogenes that promote tumor growth and malignant transformation- E6 protein inactivates p53 (TSG) and E7 inactivates Rb (TSG)

Question 22

Which of the following is true

A. Mucinous and secretory endometrial carcinomas have better prognoses than serous and clear cell types
B. Leiomyomas (fibroids) affect ~40% of women <35
C. Diabetes, obesity, and multiparity are risk factors for endometrial carcinoma
D. Leiomyosarcomas may result from fibroids, and have a positive prognosis
E. Endometrial cancers are rare among cancers in the developed world

Answer 22

A. Mucinous and secretory endometrial carcinomas have better prognoses than serous and clear cell types

Endometrial cancer can be divided into two types:
Type I - 80-85% of cases, presents younger, oestrogen dependent, low grade, less invasive, usually mucinous or low grade endometrioid/ serous
Type II - 10-15% of cases, presents older, less oestrogen dependent, high grade, more deeply invasive, feature worse mutations e.g. in p53 (serous carcinoma), usually high grade serous

A Leiomyoma is a benign smooth muscle tumour colloquially known as a fibroid. They occur in 20% of women <35, are the commonest type of uterine tumour, and usually occur in multiples.

Leiomyosarcomas are rare malignant smooth muscle tumours, but do not evolve from benign leiomyomas. They occur usually in post-menopausal women, and have a 5 year survival rate of 20-30%.

Endometrial carcinoma is the most common gynaecological malignancy in the developed world. Diabetes and obesity are indeed risk factors, but nulliparity, not multiparity, also increases the risk.

remember obesity is major RF for endometrial ca (also breast) as increases oestrogen exposure (as high aromatase in adipose tissue)

Question 23

Describe the pathogenesis of atherosclerosis

Answer 23

LDLs are deposited in the subintimal space of arteries and become oxidised by free radicals in the endothelium
Macrophages are recruited to the site of inflammation, take up the LDLs and become foam cells
Foam cells (along with platelets that adhere to the damaged endothelium) release factors that recruit vascular smooth muscle cells and stimulate them to lay down extracellular matrix within the plaque
Smooth muscle cells also form the fibrous cap over the top of the plaque in response to endothelial damage
Macrophages/ foam cells also release proteinases(metalloproteinases) which eventually degrade the fibrous cap of the plaque, and tissue factor which makes the plaque contents thrombogenic
Eventually the foam cells die and contribute to the lipid rich plaque core

Question 24

Which of the following is the most significant independent risk factor for cardiovascular disease?

A. Hypertension
B. Gender
C. Age
D. Family history
E. Smoking

Answer 24

D. Family history

Question 25

Why are the majority of myocardial infarctions not preceded by symptoms?

Answer 25

Because symptoms of arterial stenosis only occur at around 70% stenosis Atheromatous plaques may rupture well before this stage, exposing their thrombogenic contents to the bloodstream and causing a coronary artery thrombosis ## Footnote go from 0-100 really quick (ie not all the way up to 70 first ie when sxs show)

Question 26

Why is ischaemia less well tolerated by the myocardium than pure hypoxia?

Answer 26

Because of the failure to remove toxic waste products from the myocardium in ischaemia

Question 27

Give 5 complications of an MI

Answer 27

``` Arrhythmia Cardiac rupture Cardiogenic shock/ chronic heart failure Dressler syndrome Mural thrombi (e.g. causing bowel infarction) ```

Question 28

What would a 'nutmeg' appearance of the liver indicate?

Answer 28

Venous congestion of the liver from right/ congestive heart failure

Question 29

How does a complete hydatidiform mole form?

Answer 29

Either: One sperm fertilises an empty egg and its DNA replicates to make a 46XX diploid cell OR Two sperm fertilise an empty egg to make either a 46XY or 46XX diploid cell ## Footnote remember complete mole forms as no maternal genetic material present A molar pregnancy, also known as a hydatidiform mole, is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus. It falls under the category of gestational trophoblastic diseases.[1] During a molar pregnancy, the uterus contains a growing mass characterized by swollen chorionic villi, resembling clusters of grapes.[2] The occurrence of a molar pregnancy can be attributed to the fertilized egg lacking an original maternal nucleus. As a result, the products of conception may or may not contain fetal tissue. A complete mole is caused by either a single sperm (90% of the time) or two sperm (10% of the time) combining with an egg that has lost its DNA. In the former case, the sperm reduplicates, leading to the formation of a "complete" 46-chromosome set.[3] Typically, the genotype is 46,XX (diploid) due to subsequent mitosis of the fertilizing sperm, but it can also be 46,XY (diploid).[3] However, 46,YY (diploid) is not observed. On the other hand, a partial mole occurs when a normal egg is fertilized by one or two sperm, which then reduplicates itself, resulting in genotypes of 69,XXY (triploid) or 92,XXXY (tetraploid).

Question 30

How does a partial hydatidiform mole form?

Answer 30

Either: A normal egg is fertilised by 2 sperm to form a 69XXY, XXX, or XYY cell OR A normal egg is fertilised by a 46XY sperm resulting in a 69XXY cell Remember: 69 isn't full sex (complete means normal chromosome number), it's partial NB: partial moles don't become malignant (don't become choriocarcinoma/invasive mole) ## Footnote while both choriocarcinoma and invasive mole arise from abnormal placental tissue (both trophoblastic origin), choriocarcinoma is more aggressive, has a higher potential for metastasis, and can occur after various types of pregnancies, whereas invasive mole is typically associated with molar pregnancies and has a lower metastatic potential. a partial mole occurs when a normal egg is fertilized by one or two sperm, which then reduplicates itself, resulting in genotypes of 69,XXY (triploid) or 92,XXXY (tetraploid).[3]

Question 31

The findings of an OGD + biopsy are: a lesion in the mid-oesophagus, which on histopathology is seen to feature intercellular bridges. Which of the following would you most expect to find in this patient's history? ``` A. Previous episodes of gastritis B. Epigastric or chest pain worse on lying down C. A family history of malignancy D. High alcohol intake and smoking E. Dysphagia to liquids ```

Answer 31

D. High alcohol intake and smoking This history suggests squamous cell carcinoma of the oesophagus, which is the commonest oesophageal cancer worldwide and is particularly linked to high alcohol intake (linked to acetaldehyde pathway) and smoking. The most common cause of oesophageal cancer in the UK is adenocarcinoma, which is linked to GORD and progresses from Barrett's. NB: High keratin content and intercellular bridges are features of squamous cell carcinoma

Question 32

Match each histological description to the appropriate disease: ``` A. PSC B. PBC C. Alcoholic hepatitis D. Acute hepatitis E. Cirrhosis F. Steatosis G. Chronic hepatitis ``` 1. Intrahepatic bile duct granulomatous inflammation, damage, and loss associated with anti-mitochondrial antibodies 2. Interface hepatitis 3. Ballooning of hepatocytes and Mallory-Denk bodies 4. Bile duct scarring and concentric fibrosis within the liver 5. Fatty pockets within the liver linked to acute alcohol intake or dietary factors 6. Nodules of regeneration causing disruption of vascular architecture 7. Spotty necrosis

Answer 32

A. PSC - 3. Bile duct scarring and concentric fibrosis ('onion skinning') within the liver B. PBC - 1. Intrahepatic bile duct granulomatous inflammation, damage, and loss associated with anti-mitochondrial antibodies C. Alcoholic hepatitis - 2. Ballooning of hepatocytes and Mallory-Denk bodies D. Acute hepatitis - 7. Spotty necrosis (eg viral, AI and drug induced- as all acute) E. Cirrhosis - 5. Nodules of regeneration cause disruption of vascular architecture F. Steatosis - 5. Fatty pockets within the liver linked to acute alcohol intake or dietary factors G. Chronic hepatitis - 2. Interface hepatitis (eg chronic hep B) ## Footnote Primary biliary cholangitis - the M rule- IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females Piecemeal necrosis (more currently called “interface hepatitis” [IH]) is a relatively common type of necrosis seen in hepatitis. It is characterized by inflammation extending from the portal tract (PT) into the periportal zone, with necrosis of periportal hepatocytes and disruption of the limiting plate.Basically necrosis at the lobular-portal interface.

Question 33

Which of the following statements is false? A. Acute pancreatitis may cause the formation of pseudocysts lined with necrotic and granulated tissue but not epithelium B. Gallstones are the most common cause of pancreatitis and are usually made of radiolucent cholesterol C. Cholecystitis is usually associated with gallstones D. Pancreatic cancer rarely produces secretions E. The most common form of pancreatic cancer is ductal adenocarcinoma

Answer 33

D. Pancreatic cancer rarely produces secretions Ductal adenocarcinomas are the most common type of pancreatic cancer (85%), and secrete mucin.

Question 34

Match each histological finding to the appropriate disease: 1. A multinodular mass of expanded intralobular stroma and compressed, slit-like ducts 2. A rapid-growing tumour with overlapping cells that have a leaf-like architecture 3. Inflamed and dilated ducts filled with secretions 4. Cysts and mild epithelial and stromal proliferation 5. Polypoid mass with epithelial outside lining and fibrovascular core 6. Sclerosing lesion with scarred centre surrounded by proliferating glandular tissue ``` A. Fibroadenoma B. Duct ectasia C. Phyllodes tumour D. Intraductal papilloma E. Radial scar F. Fibrocystic changes ```

Answer 34

A. Fibroadenoma - 1. A multinodular mass of expanded intralobular stroma and compressed, slit-like ducts B. Duct ectasia - 3. Inflamed and dilated ducts filled with secretions (**proteinaceous secretions!**) C. Phyllodes tumour - 2. A rapid-growing tumour with overlapping cells that have a leaf-like architecture D. Intraductal papilloma - 5. Polypoid mass with epithelial outside lining and fibrovascular core E. Radial scar - 6. Sclerosing lesion with scarred centre surrounded by proliferating glandular tissue F. Fibrocystic changes - 4. Cysts and mild epithelial and stromal proliferation

Question 35

Match each histological finding to the appropriate disease: 1. Large pleomorphic cells that move from the ducts to the stroma 2. Sheets of markedly atypical cells with prominent lymphocytic infiltrate 3. Lots of seemingly empty spaces that are actually filled with secretions 4. Ducts filled with atypical epithelial cells, but with a regular lumen 5. Cells are monomorphic and organised in a linear fashion ``` A. DCIS B. Basal-like carcinoma C. Invasive ductal carcinoma D. Invasive lobular carcinoma E. Invasive mucinous carcinoma ```

Answer 35

A. DCIS - 4. Ducts filled with atypical epithelial cells, but with a regular lumen B. Basal-like carcinoma - 2. Sheets of markedly atypical cells with prominent lymphocytic infiltrate C. Invasive ductal carcinoma - 1. Large pleomorphic cells that move from the ducts to the stroma D. Invasive lobular carcinoma - 5. Cells are monomorphic and organised in a linear fashion E. Invasive mucinous carcinoma - 3. Lots of seemingly empty spaces that are actually filled with secretions ## Footnote Basal-like tumors have cells that look similar to the epithelial cells of the outermost, basal layer of the breast's milk ducts. Basal-like breast cancer is a term often used interchangeably with triple negative breast cancer.- filled w. lymphocytes Mucinous breast cancer is a rare type of breast cancer. It gets its name because the cancer cells are surrounded by a substance called mucin.

Question 36

For the purposes of the Path exam: What diagnosis would you suspect if histology showed caseating granulomas?

Answer 36

Tuberculosis In reality diagnosis is not this simple, but in your Path exam they are

Question 37

For the purposes of the Path exam: What diagnosis would you suspect if histology showed non-caseating granulomas?

Answer 37

Sarcoidosis In reality diagnosis is not this simple, but in your Path exam they are

Question 38

Name a disease associated with each type of amyloid deposition: AA (serum amyloid) AL (light chain amyloid)

Answer 38

AA - Rheumatoid arthritis, Crohn's disease (any chronic inflammatory disease really) AL - Multiple myeloma, B-cell lymphoma (anything producing large amounts of abnormal proteins)

Question 39

Which of the following stains is used in the detection of amyloid proteins, and appears apple green under polarised light? ``` A. Rhodanine stain B. Perl's stain C. Sudan Black D. Congo Red E. Auramine stain ```

Answer 39

D. Congo Red ## Footnote apple green birefringence in polarised light

Question 40

Which of the following statements about pancreatic ductal adenocarcinoma is false? A. Ductal adenocarcinomas are the most common pancreatic cancer and most often develop in the head of the pancreas B. They can be seen on histology using a stain for chromografin C. Ductal adenocarcinomas can cause migratory thrombophlebitis by releasing mucin into the bloodstream D. Macroscopically, they appear gritty and grey, and often invade local structures E. Ductal adenocarcinomas are almost always associated with K-ras mutations, and arise from dysplastic precursors

Answer 40

B. They can be seen on histology using a stain for chromografin Chromografin stains neuroendocrine tumours

Question 41

What does a 'nutmeg' appearance of the liver suggest?

Answer 41

Right-sided heart failure causing venous congestion of the liver

Question 42

Which of the following is not a feature of acute pancreatitis? A. It's most often caused by gallstones B. Hypocalcaemia C. Elevated faecal elastase D. White and yellow appearance to the pancreas E. Development of a non-epithelial lined sac filled with enzymes and necrotic material afterwards

Answer 42

C. Elevated faecal elastase A - Half of all cases of acute pancreatitis is caused by gallstones, with 33% being caused by alcohol intake. B - One of the enzymes released from damaged pancreatic acinii is lipase. Lipase breaks down triglycerides in the abdomen into free fatty acids. These fatty acids then forma complex with calcium which precipitates, and cause the yellow/white flecked appearance typical of pancreatitis (D). This also lowers the serum calcium. 'C' is a finding in chronic pancreatitis, the most common cause (by far) of which is alcohol-decreased faecal elastase (as panc insufficiency- stool sample). E - This describes a pseudosac/cyst which is a possible complication of acute pancreatitis and can be a serious issue if it becomes infected or perforates

Question 43

A 20-year-old male dies during a motor vehicle accident. His body is taken to the coroner's office for autopsy. He has no significant past medical history, and toxicology testing of his blood reveals no ethanol or drugs. He is a member of his college's track and field team. Examination of the skeletal muscle fibers in his thigh would reveal which of the following? A. Pathologic hyperplasia B. Pathologic hypertrophy C. Physiologic hyperplasia D. Physiologic hypertrophy

Answer 43

D. Physiologic hypertrophy NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 44

During a self-exam, a 44-year-old female detects a mass in her left breast. A biopsy subsequently confirms an invasive ductal carcinoma. A CT scan performed for the purpose of staging identifies a mass in her left ovary, which is subsequently removed, and a diagnosis of a granulosa cell tumour is made. Blood drawn prior to the removal of the tumour confirms an elevated level of oestrogen in the blood, which drops back to normal following the oophorectomy. If an endometrial biopsy had been performed at the time of the oophorectomy, of the following, which was most likely to be identified? A. Pathologic endometrial hyperplasia B. Pathologic endometrial hypertrophy C. Physiologic endometrial hyperplasia D. Physiologic endometrial hypertrophy

Answer 44

A. Pathologic endometrial hyperplasia This is a slightly confusing question because you could validly argue that the endometrium itself is not pathological - it is responding very normally to elevated oestrogen. However physiological endometrial hyperplasia is that which takes place in a regulated fashion in line with the menstrual cycle: this case clearly falls outside that definition and so it is pathological because of its cause. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 45

A 53-year-old male leaves a bar after work intoxicated and while driving home over-corrects on the road, flips his vehicle, and is ejected from the car, striking his head on the ground. He is found dead by first responders. His past medical history includes hypertension, which he has had for 15 years. He is not a chronic alcoholic. Which of the following is the most likely finding at autopsy? A. Cardiac hyperplasia B. Cardiac hypertrophy C. Pulmonary hyperplasia D. Pulmonary hypertrophy

Answer 45

B. Cardiac hypertrophy The increased afterload caused by hypertension over a long period of time will stimulate a physiological response within the cardiac muscle. This response is for the myocytes to get bigger and stronger - hypertrophy. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 46

A 51-year-old male presents to the emergency room with his wife with complaints of chest pain that has been occurring for the past 4 hours. He describes the chest pain as being behind his sternum and feeling as though someone is compressing his chest. The pain does not vary with inspiration or expiration. Laboratory testing reveals an elevated troponin I, indicating damage to cardiac myocytes. A cardiac catheterization procedure is performed, revealing an obstruction of the proximal distribution of the left anterior descending coronary artery. Which of the following mechanisms best describes how the injury to the myocytes occurred? ``` A. Hypoxia B. Immunologic C. Infectious D. Ischemia E. Trauma ```

Answer 46

D. Ischaemia Ischaemia, not hypoxia, is the mechanism of injury in MI. This is because it results from an interruption in blood supply which doesn't just cause hypoxia. The distinction between ischaemia and hypoxia is important because ischaemia it causes deficiency of cell nutrients e.g. glucose, and it causes toxic waste products to build up. This is more damaging to cardiac muscle than pure hypoxia. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 47

A 71-year-old male has slowly developed over 10 years a significant degree of stenosis in his left femoral artery, which impairs blood flow to his left lower extremity. Of the following, which change would be expected in the skeletal musculature? ``` A. Atrophy B. Coagulative necrosis C. Hyperplasia D. Hypertrophy B E. Metaplasia ```

Answer 47

A. Atrophy NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 48

An 8-year-old boy is brought to the pediatrician's office for evaluation of a red, swollen, painful lump on his arm. A diagnosis is made of bacterial abscess. The abscess is drained, and the boy is sent home with antibiotics. The associated morphologic pattern of tissue necrosis associated with this child's bacterial infection was the likely result of hydrolytic enzymes released from what cell type? ``` A. Eosinophils B. Fibroblasts C. Lymphocytes D. Macrophages E. Neutrophils ```

Answer 48

E. Neutrophils NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 49

A haematologist is conducting an observational study on the principles of laminar flow as it relates to the transport of red and white blood cells. She has noted that she can induce a peripheral redistribution of leukocytes towards a vessel's wall by slowing the flow of blood. This physiologic response is termed: ``` A. Adhesion B. Chemotaxis C. Diapedesis D. Margination E. Transmigration ```

Answer 49

D. Margination NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 ## Footnote Proper functioning of white blood cells is not possible without their ability to adhere to vascular endothelium, which may occur only if they are close enough to vessel walls. To facilitate the adhesion, white blood cells migrate toward the vessel walls in blood flow through a process called margination. TEM, or diapedesis, is the process whereby the leukocyte squeezes in ameboid fashion across the endothelial cells.

Question 50

A pathologist is examining a lung biopsy in a patient suspected of having tuberculosis. Numerous granulomas are identified throughout the biopsy. An acid-fast stain reveals occasional acid-fast bacilli, consistent with tuberculosis. Of the following, what did every granuloma have? ``` A. A fibrous rim B. A rim of lymphocytes C. Central necrosis D. Epithelioid macrophages E. Giant cells B ```

Answer 50

D. Epithelioid macrophages The defining feature of a granuloma is the macrophages that comprise it. These macrophages are referred to as epithelioid because of the appearance they take on when they grow larger (intracellular organelle growth) in order to attack the focus of the granuloma. Whilst in Path, caseating/ necrotic granulomas are very much associated with TB, not every granuloma will be caseating. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 51

A 22-year-old male slides into the plate during a league softball game and scrapes his left knee. Penetration through which of the following layers indicates that he is most likely to develop a scar? ``` A. Basement membrane B. Stratum basale C. Stratum corneum D. Stratum granulosum E. Stratum spinosum ```

Answer 51

A. Basement membrane NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 Think deeper wound- more likely to scar

Question 52

A 13-year-old girl has been having a cough and fever for the last four days, and over the last day developed some difficulty breathing. Her parents did not take her to the emergency room, because they knew a cold was going around. In the morning, they found her unresponsive in her bed. An ambulance was called, but she was pronounced dead. An autopsy was performed, and in the left pleural cavity was a thick white-yellow cloudy fluid substance. Microscopic examination of the lungs confirmed a lobar pneumonia. Of the following, which term best describes the substance in the left pleural cavity? ``` A. A fibrinous transudate B. A purulent exudate C. A purulent transudate D. A serous exudate E. A serous transudate ```

Answer 52

B. A purulent exudate NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 Transudate squeezed through - hence ‘trans’

Question 53

A pathologist is examining a section of gallbladder that was resected from a patient having abdominal pain. Of the following, which would indicate the patient had chronic cholecystitis instead of acute cholecystitis? A. Dilated blood vessels B. Neutrophilic infiltrate C. New blood vessel formation D. Oedema of the wall of the gallbladder

Answer 53

C. New blood vessel formation NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 54

A vascular surgeon has been researching the physiologic mechanisms of normal haemostasis. He has observed that after induction of vascular injury, arterioles undergo an immediate but short-lived vasoconstrictive response that is augmented by the release of a potent endogenous vasoconstrictive mediator. From which of the following does this vasoconstrictive mediator most likely originate? ``` A. Endothelial cells B. Macrophages C. Neutrophils D. Platelets E. Red blood cells ```

Answer 54

A. Endothelial cells Endothelial cells line blood vessels, and are a very active and important organ. Among other things, they control the tone of contractile vessels by releasing vasodilators and vasoconstrictors which act on smooth muscle cells. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 55

A 42-year-old female is presenting to her general surgeon for a visit after having undergone a partial mastectomy and lymph node dissection of the right breast for the treatment of invasive ductal carcinoma. The surgeon notes during physical examination swelling of the patient's right arm and forearm. Of the following, which is the most likely mechanism responsible for this physical examination finding? ``` A. Decreased hydrostatic pressure B. Decreased plasma osmotic pressure C. Increased hydrostatic pressure D. Increased plasma osmotic pressure E. Lymphatic obstruction ```

Answer 55

E. Lymphatic obstruction NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 56

A 64-year-old male with congestive heart failure due to end-stage systemic hypertension presents to his primary care physician. Physical examination reveals rales and pitting oedema of the lower extremities. Of the following, which mechanism was most responsible for his physical findings? A. Decreased hydrostatic pressure B. Decreased plasma osmotic pressure C. Increased hydrostatic pressure D. Increased plasma osmotic pressure

Answer 56

C. Increased hydrostatic pressure NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 57

A 69-year-old man with progressive cough and shortness of breath presents to clinic for evaluation. After multiple laboratory tests, radiographs, and eventual renal biopsy, a diagnosis is made of AA amyloidosis. Which of the following would be a likely contributory medical condition for this patient? ``` A. Alzheimer disease B. Crohn's disease C. Medullary thyroid carcinoma D. Multiple myeloma E. Splenectomy ```

Answer 57

B. Crohn's disease NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 In amyloidosis kidneys and heart most commonly affected

Question 58

A 43-year-old man spends a Saturday morning mowing his yard, after which he complains to his wife of sinus pressure, runny nose, watery eyes, and relentless sneezing. The man's symptoms are most likely the result of which type of hypersensitivity reaction? A. Type I hypersensitivity B. Type II hypersensitivity C. Type III hypersensitivity D. Type IV hypersensitivity

Answer 58

A. Type I hypersensitivity NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 59

A 61-year-old woman with recent diagnosis of autoimmune haemolytic anaemia presents to her physician's office for discussion of treatment options. In addition to medications, including immune-suppressing drugs, the physician presents her with a surgical option. For certain diseases resulting from type II hypersensitivity reactions (such as autoimmune haemolytic anaemia), surgical removal of which organ/ tissue may be of clinical benefit? ``` A. Gallbladder B. Mediastinal lymph nodes C. Retroperitoneal lymph nodes D. Spleen E. Thymus ```

Answer 59

D. Spleen Some diseases involving type II autoimmune reactions against RBCs cause intravascular haemolysis, and some involve a degree of extravascular, which is carried out in the spleen. Removing the spleen removes the location of haemolysis in these conditions. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 60

A pathologist is reviewing old autopsy slides from the file of the hospital at which he works. One of the slides includes a section of liver and gallbladder from a person who was exposed to carbon tetrachloride at the dry-cleaning store he worked at. At which of the following locations will the pathologist identify the greatest amount of cellular injury? ``` A. Centrilobular hepatocytes B. Mucosa of the gallbladder C. Muscularis of the gallbladder D. Periportal hepatocytes E. Portal arteries ```

Answer 60

A. Centrilobular hepatocytes This is not as niche a questions as it seems, the majority of liver toxins are metabolites: the chemical that enters the liver is not toxic, but is metabolised to a hepatotoxic compound. The most metabolically active area of the liver is the perilobular hepatocytes, hence these toxic metabolites are most concentrated there and they are the most affected. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 The regions surrounding the hepatic arteries and portal veins are known as periportal (zone 1), while those adjacent to the central vein are called the pericentral areas of the lobule (zone 3), with the cells in between these regions, referred to as mid-lobular hepatocytes (zone 2). This specialization is reflected histologically; the detoxifying zone III cells have the highest concentration of CYP2E1 and thus are most sensitive to NAPQI production in acetaminophen toxicity.[12] Other zonal injury patterns include zone I deposition of hemosiderin in hemochromatosis and zone II necrosis in yellow fever

Question 61

A 23-year-old male develops abdominal pain. A CT scan reveals a mass in the liver. A surgical resection is performed. Microscopic examination of the mass by the pathologist reveals a diagnosis of metastatic osteosarcoma. Subsequently, radiologic examination of the right knee reveals a mass. Of the following, which route most likely allowed the neoplasm to spread from the knee to the liver? A. Spread of tumour cells along the surface of nerves B. Spread of tumour cells through the blood C. Spread of tumour cells through the lymphatics D. Spread of tumour though the tissue

Answer 61

B. Spread of tumour cells through the blood NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 62

A pathologist is examining a tumour removed from the left testis of a young boy. Within the tumour, she identifies squamous epithelium overlying sebaceous glands, hyaline cartilage, neural tissue, and hepatocytes. ``` Of the following, what is the correct name for this tumour? A. Carcinoma B. Ectopic tissue C. Hamartoma D. Sarcoma E. Teratoma ```

Answer 62

E. Teratoma NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 63

A medical student is on a 4th year pathology elective and is sitting at the microscope with a pat physiologist looking at a biopsy of a cervix. The pathologist points out areas of dysplasia to the medical student. The finding of which of the following features would indicate carcinoma was present within the areas of dysplasia? A. Dysplastic cells extending from the basement membrane to the apical surface B. Increase in nuclear: cytoplasm ratio C. Markedly increased number of mitotic figures D. Prominent new blood vessel formation E. Separate nests of dysplastic squamous cells, but in the dermis

Answer 63

E. Separate nests of dysplastic squamous cells, but in the dermis NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 Topologically, the apical surface of the epithelial cells generally faces the outside compartment of the organism, and the basal and lateral (basal-lateral) surfaces, which are attached to the substratum and the neighboring cells, respectively, face the serosa and inside compartment of the organism.

Question 64

A pathologist is examining a prostate biopsy. Focally, within the biopsy is a small cluster of tissue characterized as small glands that are back-to-back, as opposed to the normal prostatic glandular tissue that is characterized by large glands with intervening space. The pathologist determines that the focus of cells is neoplastic. Of the following, what would be the best name for this focus of neoplastic cells? ``` A. Adenocarcinoma B. Leiomyosarcoma C. Lymphoma D. Squamous cell carcinoma E. Teratoma ```

Answer 64

A. Adenocarcinoma NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 65

A 19-year-old male dies due to sepsis secondary to a pulmonary bacterial infection. At autopsy, sectioning of the lungs reveals plugging of the airways, dilation of airways, and an enlarged right ventricle with a thickened wall. Cultures of the lung grow Pseudomonas aeruginosa. Of the following, which is autopsy examination also likely to reveal? ``` A. Dilation of aortic root B. Multiple liver haemangiomas C. Pancreatic acinar atrophy D. Pancreatic islet metaplasia E. Patent ductus arteriosus ```

Answer 65

C. Pancreatic acinar atrophy NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 Right ventricle hypertrophy and dilatation are classic autopsy findings in cystic fibrosis. LV dysfunction is rare.

Question 66

A 56-year-old male with alcoholic cirrhosis develops a liver tumour. This is most likely to be which type of tumour? ``` A. Haemangioma B. Hepatic adenoma C. Hepatoblastoma D. Hepatocellular carcinoma E. Leiomyoma ```

Answer 66

D. Hepatocellular carcinoma NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 67

A clinician is reviewing the pathology report of a patient with adenocarcinoma of the colon. Of the following, which helps determine the grade of the tumour? ``` A. Depth of invasion of wall of colon B. Metastatic spread to another organ C. Number of mitotic figures per high-power field D. Number of positive lymph nodes E. Size of the tumour ```

Answer 67

C. Number of mitotic figures per high-power field NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 68

A 4-year-old boy is evaluated by his paediatrician for 1 week of intermittent haematuria. On examination he appears well developed and well nourished, except a right flank mass is palpable. A biopsy of the mass is performed, which reveals primitive looking small blue cells. What is the diagnosis? ``` A. Medulloblastoma B. Neuroblastoma C. Polycystic kidney disease D. Rhabdoid tumour E. Wilm's tumour ```

Answer 68

E. Wilm's tumour NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 small-round-blue-cell tumor (SRBCT) or a small-round-cell tumour (SRCT), is any one of a group of malignant neoplasms that have a characteristic appearance under the microscope, i.e. consisting of small round cells that stain blue on routine H&E stained sections.

Question 69

A 56-year-old male is diagnosed with pancreatic adenocarcinoma. He undergoes a Whipple procedure and has a 20-year postoperative survival, with no recurrence of the tumour. Of the following, what was the most likely site of the tumour? ``` A. Distal body of the pancreas B. Ectopic pancreatic tissue in the spleen C. Head of the pancreas D. Proximal body of the pancreas E. Tail of the pancreas ```

Answer 69

C. Head of the pancreas NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 70

A 32-year-old female has a brown macule on her left forearm that she asks her dermatologist to remove. The skin lesion is examined by a pathologist who identifies proliferations of bland nevus cells in the dermis. No mitotic figures are identified. Of the following, what is the diagnosis? ``` A. Compound nevus B. Dysplastic nevus C. Intradermal nevus D. Junctional nevus E. Malignant melanoma ```

Answer 70

C. Intradermal nevus NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 intradermal nevus (also called an intradermal melanocytic nevus) is simply a classic mole or birthmark

Question 71

A 37-year-old female presents to her gynaecologist. Over the past 6 months, she has had occasionally non-milky discharge from her left nipple; however, two days ago, she had bloody discharge. She has no history of breast cancer in her family but is still concerned by the symptoms. Physical examination reveals no masses in the left or right breast; however, compression of the left areola does express a small amount of slightly blood-tinged fluid, and a small nodule is palpable in the areola. The overlying skin has no changes. Of the following, what is the most likely diagnosis? ``` A. Intraductal papilloma B. Invasive ductal carcinoma C. Leiomyoma of the nipple D. Paget's disease of the nipple E. Phylloides tumour ```

Answer 71

A. Intraductal papilloma NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 72

A 71-year-old male who has emphysema and a 60-pack-per-year smoking history presents to his GP complaining of weakness in his thighs and arms. A CT scan of his chest and abdomen reveal a 3.5 cm left hilar mass and several up to 2.0-cm masses in the liver. If the CT scan findings and presenting complaint are related, what is the most likely diagnosis of the lung mass? ``` A. Adenocarcinoma B. Large-cell carcinoma C. Pulmonary hamartoma D. Small-cell carcinoma E. Squamous cell carcinoma ```

Answer 72

D. Small-cell carcinoma This is a history of small-cell lung carcinoma causing a paraneoplastic syndrome, specifically Lambert-Eaton myasthenic syndrome (LEMS). This is similar to myasthenia gravis, but causes weakness that improves as the muscles are used. The weakness in LEMS is typically in the proximal sections of the limbs, and does not affect the face and eyes as often as myasthenia gravis does. LEMS is usually associated with small-cell lung carcinoma, and ~2% of patients with this cancer will develop LEMS. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 LEMS pathology is anti- VGCa2+ channels In LEMS, antibodies against VGCC, particularly the P/Q-type VGCC, decrease the amount of calcium that can enter the nerve ending, hence less acetylcholine can be released from the neuromuscular junction. Apart from skeletal muscle, the autonomic nervous system also requires acetylcholine neurotransmission; this explains the occurrence of autonomic symptoms in LEMS Repeated stimuli over a period of about 10 seconds eventually lead to sufficient delivery of calcium, and an increase in muscle contraction to normal levels

Question 73

A 37-year-old male presents to an acute care clinic. Over the past year, he has developed hearing problems and quite frequently has problems with his balance. The symptoms have progressed to the point that he cannot handle them anymore. Physical examination reveals decreased hearing in his left ear, and balance problems, being unable to stand on one leg unaided. A CT scan of the head reveals a mass. Of the following, what is the most likely diagnosis? ``` A. Craniopharyngioma B. Ependymoma C. Glioblastoma multiforme D. Meningioma E. Schwannoma ```

Answer 73

E. Schwannoma NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020 The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves: cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus cranial nerve V: absent corneal reflex cranial nerve VII: facial palsy Bilateral vestibular schwannomas are seen in neurofibromatosis type 2.

Question 74

A 67 year old man has long standing infection with Helicobacter pylori. Which of these gastric tumours is associated with Helicobacter infection? ``` A. Adenoma B. Gastro-intestinal stromal tumour C. Leiomyoma D. Lymphoma E. Squamous cell carcinoma ```

Answer 74

D. Lymphoma H. pylori infection is associated with gastric MALT lymphoma, which can often be treated by simply treating the H. pylori infection. NB: This question is replicated from Prof. Rob Goldin's Path Mock 2020

Question 75

Which of the following compositions of renal calculus is most associated with Proteus species UTI? ``` A. Cystine B. Calcium oxalate C. Uric acid D. Magnesium ammonium phosphate E. Calcium chloride ```

Answer 75

D. Magnesium ammonium phosphate (aka triple stones) Also known as Struvite or Staghorn- staghorn calculus

Question 76

Match each of the descriptions to the appropriate upper GI lesion: A. Barrett's oesophagus may lead to this cancer B. Coeliac disease increases the risk of this cancer C. A poorly differentiated cancer with signet ring cells D. Features high keratin content and intercellular bridges 1. Diffuse gastric adenocarcinoma 2. Oesophageal squamous cell carcinoma 3. Enteropathy-associated T-cell lymphoma 4. Oesophageal adenocarcinoma

Answer 76

1. Diffuse gastric adenocarcinoma - C. A poorly differentiated cancer with signet ring cells 2. Oesophageal squamous cell carcinoma - D. Features high keratin content and intercellular bridges 3. Enteropathy-associated T-cell lymphoma - B. Coeliac disease increases the risk of this cancer 4. Oesophageal adenocarcinoma - A. Barrett's oesophagus may lead to this cancer

Question 77

Why is ischaemic disease of the liver relatively uncommon?

Answer 77

Because the liver has a dual blood supply: from the haptic artery and the portal vein, hence it is less likely then other organs to be damaged by ischaemia

Question 78

Which zone of hepatocytes is most vulnerable to toxic damage?

Answer 78

Zone 3 - the peri-central hepatocytes (near the central vein) This is for two main reasons: 1. These hepatocytes are the most metabolically active, and many toxins that damage the liver are actually generated by the liver e.g. alcohol is not hepatotoxic but acetaldehyde is. Alcohol is converted to acetaldehyde mostly in zone 3 (peri-central) so that zone will be most affected by the toxin. Eg most P450 in zone 3 so most NAPQI generated here from paracetamol OD so most damage. 2. Blood passes through zones 1 and 2 before reaching 3. In cases where there is a toxic insult to the liver, metabolism of the toxin in zones 1 and 2 will deplete the blood of oxygen. By the time the blood reaches zone 3, significant oxygen has been removed which makes zone 3 hepatocytes hypoxic.

Question 79

What stage of liver fibrosis is classified as cirrhosis?

Answer 79

F4 Metavir score Bridging fibrosis – an advanced stage of liver fibrosis, seen in the progressive form of chronic liver diseases. The term bridging refers to the formation of a "bridge" by a band of mature and thick fibrous tissue from the portal area to the central vein. This form of fibrosis leads to the formation of pseudolobules

Question 80

How does cirrhosis impair liver function?

Answer 80

It causes loss of functional tissue, but also both intra and extra hepatic shunting of blood: Blood is shunted into other veins to bypass the liver (e.g. paraumbilical - caput Medusa, oesophageal - varices)- as pressure of hepatic vessels is high as fibrosis surrounding them- blood takes oath of last resistance Blood is also shunted along scar tissue within the liver in a way that bypasses hepatocytes so they do not metabolise products in the blood

Question 81

Match each description to the appropriate liver pathology: A. Associated with primary sclerosing cholangitis B. Associated with cirrhosis C. The most common benign tumour found in the liver D. The most common malignant tumour found in the liver 1. Hemangioma 2. Cholagiocarcinoma 3. Metastases 4. Hepatocellular carcinoma

Answer 81

1. Hemangioma - C. The most common benign tumour found in the liver 2. Cholagiocarcinoma - A. Associated with primary sclerosing cholangitis 3. Metastases - D. The most common malignant tumour found in the liver 4. Hepatocellular carcinoma - B. Associated with cirrhosis

Question 82

Which of the following histological appearances is consistent with Hirschprung's disease? A. Atresia of bowel segments B. An absence of ganglia in the myenteric plexus C. Diverticulae in the rectum D. An absence of nerve fibres in the rectum E. Vascular malformation in the bowel wall

Answer 82

B. An absence of ganglia in the myenteric plexus Hirschprung's disease affects 1 in 5000 live births, and 80% of affected people are male. It is caused by a failure of parasympathetic nerve migration, leading to an absence of ganglia within the myenteric plexus. This results in a section of colon with only sympathetic input - it is permanently constricted and cannot relax to allows stool to pass effectively. Treatment is with resection of the affected segment (pull-through). NB: Though there is this absence of ganglia, the **nerve fibres in the rectum hypertrophy**

Question 83

Which of the following findings is not associated with Crohn's disease? A. Primary sclerosing cholangitis B. Cobblestone mucosal appearance on endoscopy C. Rose thorn ulcers seen on a barium follow-through D. Transmural inflammation with non-caseating granulomas E. Uveitis and arthritis

Answer 83

A. Primary sclerosing cholangitis PSC is associated with ulcerative colitis (UC), but not Crohn's. Crohn's is an autoinflammatory condition which causes skip lesions (non-continuous) of transmural inflammation. These lesions may appear anywhere in the GI tract but classically spare the rectum. Both Crohn's and UC may cause multiple extra-GI symptoms e.g. arthritis, uveitis, erythema nodosum, pyoderma gangrenosum.

Question 84

Which of the following characteristics of a colon adenoma increases the risk of cancer? ``` A. A size of 2cm B. A lone polyp C. A low degree of dysplasia D. A high proportion of villous content E. Age under 40 ```

Answer 84

D. A high proportion of villous content 98% of colon carcinomas develop from adenomatous polyps. Multiple polyps, size >4cm, villous type polyp, high degree of dysplasia, and advanced age are all risk factors for developing cancer. Hereditary syndromes can increase the risk of colon cancer, e.g. Familial Adenomatous Polyposis which is an autosomal dominant condition causing hundreds - thousands of polyps tog row in the colon. Almost 100% of people with this condition will develop cancer by the age of 25 if unmanaged.

Question 85

Which is the most common type of renal cell carcinoma? ``` A. Clear cell B. Papillary C. Chromophobe D. Oncocytoma E. Adenoma ```

Answer 85

A. Clear cell Clear cell renal carcinomas make up around 70% of renal cell carcinomas. Clear cell carcinomas appear on histology as nests of clear cells set within a capillary network. They appear grossly as a golden/ yellow tumour with haemorrhagic areas.

Question 86

Which cancer is also referred to as 'transitional cell carcinoma'? ``` A. Urothelial carcinoma B. Clear cell carcinoma C. Papillary carcinoma D. Prostate adenocarcinoma E. Chromophobe cell carcinoma ```

Answer 86

A. Urothelial carcinoma Urothelial carcinoma is the most common type of bladder cancer, and is sometimes known as a 'transitional cell carcinoma'. Transitional cells specific to bladder (and few other tissues) as stretches (transitions)

Question 87

Match each of the tumours to the corresponding description: A. Germ cell tumours B. Leydig cell tumour C. Prostate adenocarcinoma 1. The most common malignancy in men 2. May cause precocious puberty in pre-pubertal boys 3. Accounts for 90% testicular tumours, highly sensitive to platinum-based chemotherapy, excellent prognosis

Answer 87

1. The most common malignancy in men - C. Prostate adenocarcinoma 2. May cause precocious puberty in pre-pubertal boys - B. Leydig cell tumour 3. Accounts for 90% testicular tumours, highly sensitive to platinum-based chemotherapy, excellent prognosis - A. Germ cell tumours