Urology/gynaecological pathology

Question 1

23559 – Clinical manifestations of renal adenocarcinoma may include evidence of
1: amyloidosis
2: polycythaemia
3: hypercalcaemia
4: fever and cachexia

Answer 1

TTTT
Robbins 5th ed. Chapter: 20 Pages: 987
Renal adenocarcinoma is a rich source of ‘paraneoplastic’ syndromes and of syndromes relating more directly to some of the legitimate endocrine functions of the kidney. Polycythaemia is a classical association with renal carcinoma (5-10% incidence) and this neoplasm is one of the group which produces hypercalcaemia (even in the absence of bone metastases at times, but particularly in association with tumour osteolysis). It is one of the classical causes of ‘pyrexia of uncertain cause’ and is the major cancer apart from myeloma which causes amyloidosis (but of the AA type, not AL).

Question 2

24029 – A young man with osteosarcoma is given cyclical chemotherapy including high dose intravenous methotrexate. Following the third cycle, there is a marked deterioration in renal function. Possible causes and contributing factors include
1: acute renal tubular necrosis
2: crystalluria
3: tumour lysis syndrome
4: concurrent use of indomethacin

Answer 2

FTTF
ACP 1996

Question 3

17778 – Clinical manifestations/ complications of renal adenocarcinoma may include
1: amyloidosis
2: polycythaemia
3: fever and cachexia
4: hypercalcaemia

Answer 3

TTTT
Renal adenocarcinoma is a rich source of ‘paraneoplastic’ syndromes and of syndromes relating more directly to some of the legitimate endocrine functions of the kidney. Polycythaemia is a classical association with renal carcinoma (5-10% incidence) and this neoplasm is one of the group which produces hypercalcaemia (even in the absence of bone metastases at times, but particularly in association with tumour osteolysis). It is one of the classical causes of ‘pyrexia of uncertain cause’ and is the major cancer apart from myeloma which causes amyloidosis (but of the AA type, not AL).

Question 4

13095 – Conditions contributing to renal failure which complicates multiple myeloma include
1: amyloidosis
2: protein deposition
3: pyelonephritis
4: hypercalcaemia

Answer 4

TTTT
The hypercalcaemia accompanying the skeletal demineralisation of multiple myeloma characteristically leads to renal failure (D true). Renal tubules may be blocked by Bence Jones protein (B true). Amyloidosis often complicates multiple myeloma and causes renal damage (A true). Patients with multiple myeloma show increased susceptibility to infection by pyogenic organisms, and thus to pyelonephritis (C true).

Question 5

13115 – A two-week-old renal infarct has
1: granulation tissue at the periphery of the lesion
2: a whitish-yellow colour macroscopically
3: macrophages containing haemosiderin at its periphery
4: an easily identifiable outline of the original renal architecture on microscopic examination, although devoid of nuclei

Answer 5

TTTT
By the time a renal infarct is two weeks old it will show clear morphological evidence of tissue death. The affected tissue is whitish yellow in the gross specimen (B true). The dead tissue excites an inflammatory reaction, which includes macrophages. These ingest haemosiderin which is a breakdown product of haemoglobin from the red cells that have seeped into the area (C true). By two weeks healing will have started at the periphery of the lesion, and granulation tissue is discernible (A true). A ghostly outline of the original architecture is perceptible in many infarcts (D true).

Question 6

14721 – Alkaline urine predisposes to
1: oxalate stones
2: phosphate stones
3: uric acid stones
4: cystine stones

Answer 6

FTFF
Refer to Robbins, 6th Ed, Ch 21, page 989-990

Question 7

23324 – In cases of prostatic carcinoma
1: haematogenous spread occurs chiefly to bone
2: plasma prostate-specific antigen (PSA) levels correlate well with total tumour volume
3: raised plasma prostate-specific antigen (PSA) level is a reliable marker for the disease in asymptomatic men
4: most patients, at presentation with symptomatic disease, have carcinoma which is localised within the gland

Answer 7

TTFF
Robbins 5th ed. Chapter: 22 Pages: 1028-1031
PSA is of value in diagnosis and management of prostatic cancer. PSA levels correlate well with total tumour volume. However, PSA levels are also raised in prostatic hyperplasia and, because of overlap between levels found in hyperplasia and in early and localised cancer, PSA alone cannot be used for the reliable detection of early cancer. More than 75% of patients have advanced prostatic cancer when diagnosed. When haematogenous spread occurs, it is chiefly to the axial skeleton and produces predominantly osteoblastic metastases.

Question 8

17788 – In cases of prostatic carcinoma
1: raised plasma prostate-specific antigen (PSA) level is a reliable marker for disease in asymptomatic men
2: plasma prostate-specific antigen (PSA) levels correlate well with total tumour volume
3: most patients, at presentation with symptomatic disease, have carcinoma which is localised within the gland
4: haematogenous spread occurs chiefly to bone

Answer 8

FTFT
PSA is of value in diagnosis and management of prostatic cancer. PSA levels correlate well with total tumour volume. However, PSA levels are also raised in prostatic hyperplasia and, because of overlap between levels found in hyperplasia and in early and localised cancer, PSA alone cannot be used for the reliable detection of early cancer. More than 75% of patients have advanced prostatic cancer when diagnosed. When haematogenous spread occurs, it is chiefly to the axial skeleton and produces predominantly osteoblastic metastases.

Question 9

27627 – Prostate cancer is best diagnosed by
A. digital rectal examination
B. prostate specific antigen (PSA) serum levels
C. transrectal ultrasound of the prostate and biopsy
D. a combination of the above three responses
E. cystoscopy and endoscopic biopsy of the prostate

Answer 9

D
When patients are first seen in the consulting rooms wishing a prostate check up, a digital rectal examination and PSA are often done to work-up symptoms or possibly as a routine prostate check. The definitive form of diagnosis, however, is with a transrectal ultrasound of the prostate with several biopsies. Diagnosis is best made by a combination of the three previous responses A, B & C (D is correct). Biopsies are taken from the base, mid, and apex of each lobe of the prostate gland and submitted for histopathologic review. Many prostate cancers are isoechoic and hence are unable to be clearly identified on ultrasound, but some are associated with a hypoechoic nodule and hence can be targeted specifically if identified on ultrasound. There is very little, if any place, for a cystoscopy and endoscopic biopsy in the diagnosis of the vast majority of prostate cancers. As mentioned earlier, most cancers begin in the peripheral zone rather than in the periurethral zone and hence are unlikely to be sampled endoscopically (E False).

Question 10

25989 – Carcinoma of the prostate is frequently associated with
1: raised serum acid phosphatase
2: androgen dependency
3: osteoblastic (osteosclerotic) bony metastases
4: raised serum calcium

Answer 10

TTTF
Robbins 5th ed. Chapter:22 PAGE:1029-1031

Question 11

27682 – Common occurrences in advanced prostate cancer include
1: spinal cord compression
2: haematuria
3: jaundice from hepatic metastase
4: renal failure from bilateral ureteric obstruction
5: respiratory distress and pneumonia secondary to lung metastases

Answer 11

TTFTF
The most common are problems in advanced hormone-refractory prostate cancer and are associated with ongoing progression of bony metastatic disease as well as morbidity related to local spread. Hence ongoing bone pain is an issue and if affecting the thoracic/lumbar cord may lead to cord compression and to a rapid onset of paraparesis and paraplegia in affected individuals (1 True). This needs prompt treatment with urgent radiotherapy, or if unsuccessful urgent decompression laminectomy. Other strategies to assist in the management of bone pain include local radiotherapy, chemotherapy using mitozantrone and steroids, administration of radioactive strontium or palladium, referral to palliative care team and administration of analgesia (for example, MS Contin). The other problems relate to local growth of tumour, which include ongoing lower urinary tract symptoms, such as hesitancy, diminishing urinary stream, frequency, and nocturia (which may require palliative TURP) as well as haematuria due to the fragility of the neoplastic blood vessels (which may require cystoscopy and diathermy) (2 True). As the tumour infiltrates the base of the bladder, bilateral ureteric obstruction is a common accompaniment of the disease requiring endoscopic manipulation in the form of nephrostomies and ureteric stents (4 True). Hepatic and lung metastases are uncommon in advanced prostate cancer, although they may occur; but require palliation far less frequently than the previously mentioned problems (3 & 5 False).

Question 12

27645 – Concerning prostate specific antigen (PSA)
1: PSA is a glycoprotein secreted by prostate cells into the ejaculate
2: PSA serum levels are almost always raised in prostate cancer
3: PSA serum levels are unaffected by age of the patient
4: PSA serum levels may be elevated in benign prostatic hyperplasia, prostatitis or prostatic infarct
5: PSA is universally endorsed and recommended as a screening test for prostate cancer

Answer 12

TFFTF
Prostate specific antigen is a glycoprotein secreted by the prostate cells into the ejaculate (1 True), whose functions is to assist in the breaking down of gel proteins within the ejaculate - leading to liquefaction. Small quantities of prostate specific antigen leak into the peripheral circulation and hence can be detected on serum studies. Prostate specific antigen is not always elevated in the presence of prostate cancer (2 False) and up to 20% of cancers may be missed if relying on prostate specific antigen levels alone. Digital rectal examination must, therefore, be done in all patients who wish a check up of their prostate. Prostate specific antigen levels can be elevated with benign prostatic hyperplasia, prostatitis and prostatic infarct and hence 70-80% of men with mildly elevated levels will, in fact, have one of these conditions rather than prostate cancer (4 True). As one would expect, the degree of benign prostatic hyperplasia tends to increase with age - one would also expect prostatic specific antigen levels to similarly increase with age, and age specific levels have been designed by many laboratories to take this factor into account (3 False). The use of prostate specific antigen as a formal screening test for prostate cancer is controversial. It is endorsed by the American Urologic Association as well as the American Cancer Society, but it is not endorsed in many other countries including Australia and New Zealand (5 False). This uncertainty regarding its efficacy for screening is based on the lack of results of randomised controlled trials identifying a mortality benefit. Nonetheless, PSA detected cancers are significant cancers based on volume of tumor and histological grade and are more likely to be confined within the prostate and hence amenable to cure. A reduction in mortality has been seen in the 1990’s throughout the world including Australia, which may possibly be due to PSA based screening. Obviously definitive results of the
randomised controlled trials will provide an answer, which will settle this controversy, but unfortunately these answers may only be available in five to ten years time. Until then the uncertainties of the benefits of screening must be discussed with the patient and informed consent obtained.

Question 13

27657 – What factors may influence choice of initial treatment for prostate cancer?
1: age of patient
2: co-morbid illnesses
3: patient preference
4: doctor preference
5: grade of the cancer

Answer 13

TTTFT
Various factors influence the choice of therapy for localised prostate cancer. An older man, in particular, over 70 years of age, especially within the presence of co-morbid illnesses is more likely to die of those co-morbid illnesses rather than from the prostate cancer. Therefore, the expected ten-year life expectancy of the patient must be taken into account if active therapy is being considered. Grade of the tumor plays a major role, as a well-differentiated cancer has excellent 10-15 year cause-specific survival regardless of therapy (1, 2 & 5 True). Moderate and poorly differentiated tumors do show a survival advantage of treatment over no treatment and hence it is imperative that one identifies a patient with these grades of tumors before contemplating active therapy. Patient preference also plays a major role in the choice of therapy for localised prostate cancer (3 True). The treatment of prostate cancer is commonly associated with impotence, in the case of surgery a low but definite risk of incontinence, and in the case of radiotherapy a low but definite risk of rectal irritation, diarrhea and rectal bleeding. No early treatment, as a preferred first option, clearly preserves rectal function, continence and erectile ability and hence many patients may choose no initial therapy to avoid the side effects of treatment even if it may ultimately compromise long-term survival. Doctors’ preference should play a relatively minor role in the choice of therapy for the patient in these circumstances (4 False).

Question 14

27675 – Hormone manipulation for prostate cancer can be optimally administered by
1: orchidectomy
2: LHRH agonist
3: antiandrogen therapy
4: orchidectomy plus antiandrogen therapy
5: LHRH plus antiandrogen therapy

Answer 14

TTFFF
Prostate cancer is a known hormonally sensitive cancer in 80% of cases and will respond to testosterone deprivation therapy. The bulk of the male androgens come from the testes and hence either a surgical castration in the form of a bilateral orchidectomy or a medical castration in the form of an LHRH agonist, for example, Zoladex (10.8mg subcutaneously three-monthly) or Lucrin depot (22.5mg IM three-monthly) are acceptable alternatives (1 & 2 True). There is no need to add an LHRH to an orchidectomy, as they serve the same function, and side-effects are identical (namely, hot flushes, impotence, weight gain, gynaecomastia and mood disturbances).

Oral anti-androgen therapy alone has generally not been recognised as adequate treatment (3 False) although the steroidal anti-androgen Cyproterone Acetate (100mg three times a day) may be used as monotherapy in selective cases. The non-steroidal anti-androgens, namely, Flutamide (250mg orally TDS), Nilutamide (150-300mg daily), and Bicalutamide (50mg a day) are not as effective as monotherapy in current dosage schedules. The anti-androgens have the theoretic advantage that they may eradicate the additional 5-10% of male androgens that are derived from the adrenal gland rather than from the testes. Hence there has been considerable debate, as to whether combined androgen blockade, in the form of an orchidectomy, or LHRH agonist in conjunction with an antiandrogen may provide superior results to an orchidectomy or LHRH agonist alone. Although some randomised controlled trials do show a slight survival advantage in the combined androgen blockade group, this data overall has not been conclusive with many conflicting reports showing no benefit (4 & 5 False). Figure 9 shows the hormonal influences affecting the prostate cell and the site of action of some drugs used in treatment of prostate cancer.

LHRH analogues inhibit pituitary secretion and diminish testosterone secretion, as does orchidectomy. Anti-androgens act peripherally to block testosterone action on androgen receptors. Agents such as ketoconazole and aminoglutethamide inhibit circulating androgens.

Question 15

27651 – Once diagnosed, appropriate choices of therapy for prostatic cancer may include
1: no initial treatment
2: external beam radiotherapy alone
3: brachytherapy alone
4: external beam radiotherapy plus brachytherapy
5: surgery (radical prostatectomy)

Answer 15

TTTTT
There is no doubt that all of the options ranging from no immediate treatment (viz. ‘watchful-waiting’ with the institution of delayed hormonal therapy) may be useful treatment options; together with all the radiotherapeutic options and surgery in the form of radical prostatectomy.

Question 16

27669 – After definitive treatment for localised prostate cancer, follow-up is optimally done by
1: bone scan
2: CT scan of abdomen and pelvis
3: PSA
4: a digital rectal examination
5: transrectal biopsies of the vesico-urethral anastomosis (after surgery) or prostate (after radiotherapy)

Answer 16

FFTTF
After definitive treatment for localised prostate cancer follow-up is usually done by prostate specific antigen (PSA) assay and digital rectal examination (3 & 4 True). In the case of surgery PSA should fall to undetectable levels (less than 0.3 nanogram per ml) and following radiotherapy one would want to see a level below 1 nanogram per ml and preferably below 0.5 nanogram per ml. Rectal examination is also performed to exclude a palpable local recurrence. In the absence of an elevated PSA, a bone scan and CT scan are usually unnecessary, as are biopsies of the vesico-urethral anastomosis or the prostate (1, 2 & 5 False). Clearly, if there is evidence of PSA failure following surgery or radiotherapy then a biopsy of these regions may become necessary as may a bone scan or CT scan

Question 17

17783 – With adenocarcinoma of the prostate
1: there is good correlation between tumour differentiation and prognosis
2: early haematogenous visceral metastatic dissemination is common
3: lymph node metastases are unusual
4: local extension commonly involves seminal vesicles

Answer 17

TFFT
The Gleason staging system is best known; in prostatic carcinoma there is generally fairly good correlation between prognosis and degree of differentiation; grading is therefore considered to be of considerable importance. Local extension to involve seminal vesicles and base of bladder is common.

Lymph node metastases are common and often this mode of dissemination precedes spread to the bones. When haematogenous spread occurs, it is very commonly confined at first to the axial skeleton. Massive visceral dissemination is unusual.

Question 18

27639 – What statements are true regarding prostate cancer?
1: the incidence of the disease increases with increasing age
2: younger patients have a more virulent form of prostate cancer than older patients
3: it is the most prevalent male cancer in men over 45 years of age
4: most men die with the disease rather than of the disease
5: typically begins in the transition or periurethral zones of the prostate

Answer 18

TFTTF
There is no doubt that the incidence of prostate cancer increases with increasing age, with the vast majority of cancers being detected in men over 70 years of age (1 True). It is the most prevalent male cancer in men over 45 years of age (3 True). There is no evidence to suggest that younger patients have a more vigorous course than older patients (2 False), but, rather, as prostate cancer is a relatively slow growing disease and younger patients have less co-morbid illnesses, younger patients are, therefore, more likely to die of their prostate cancer than older patients. Overall most men die with prostate cancer rather than of prostate cancer (4 True). However, this has been shown repeatedly in studies not to be true in younger men (50-60 years) diagnosed with the disease. Prostate cancer claims approximately 2,500 Australian lives per year and, hence, demonstrates a similar incidence and mortality to breast cancer in women. Prostate cancer typically begins in the peripheral zone of the prostate in 70% of cases, which is the zone immediately adjacent to the anterior surface of the rectum. It only uncommonly involves the transitional/periurethral zones of the prostate (5 False), which explains why prostate cancer typically presents with symptoms late in the cause of the disease rather than early.

Question 19

27717 – The following statements concern haematuria
1: microscopic haematuria is defined as >10
^4 RBC/ml urine
2: dysmorphic RBC may be present in stale urine samples and in patients with renal cell tumour
3: asymptomatic microscopic haematuria in the absence of protein casts is rarely associated with pathology in people aged less than 50 years
4: painless macroscopic haematuria always requires further investigation
5: the most common cause of abdominal pain associated with haematuria is renal cell carcinoma

Answer 19

TFTTF
1. Microscopic haematuria is defined by the individual laboratory giving a normal range (usually less than 10^4 RBC/ml urine, or less than ten blood cells per high power field). Urine is also examined for casts, protein, bacteria and crystals. The aetiology of microscopic haematuria includes glomerulonephritis, renal cell tumour, inflammation, stones, urothelial bladder or renal tumour (transitional cell carcinoma), prostatic causes (benign and malignant enlargement) and urinary tract infection (1 True).
2. Dysmorphic cells are always present in stale urine but if in fresh urine this may indicate a source of bleeding from glomerulonephritis. Renal cell tumours typically demonstrate non-glomerulated red
cells (2 False).
3. Haematuria in the younger age group (less than 50 years) and in the absence of protein casts or infection is rarely associated with pathology (3 True). Causes include: stone, tumour, obstruction, inflammation.
4. Painless macroscopic haematuria is a critical symptom always requiring further investigation - no exceptions (4 True).
5. Microscopic haematuria is always looked for in a patient with severe abdominal pain. Renal calculi are the most common cause of abdominal pain and haematuria. The classic triad of presentation of renal cell carcinoma is abdominal pain, macroscopic haematuria and a palpable mass - but the incidence of haematuria with stone disease is significantly higher (5 False). If abdominal pain is present with haematuria the cause is usually renal pathology. In the absence of haematuria we look for other causes of severe pain, including pancreatitis, perforated ulcer and ruptured aortic aneurysm.
* Haematuria present – renal colic 95% or other renal pathology
* Haematuria absent – pancreatitis, perforated ulcer, ruptured AAA

Question 20

21753 – Human bladder cancer is a recognised complication of exposure to
1: cigarette smoke
2: asbestos
3: 2-naphthylamine
4: lead

Answer 20

TFTF
Robbins 5th ed. CHAPTER: 7; 21 PAGE: 282; 1001

Question 21

17743 – Testicular seminoma
1: when dissemination occurs, is usually first manifest by blood stream spread
2: is highly radiosensitive
3: when associated with raised plasma human chorionic gonadotrophin (HCG), shows no different clinical behaviour
4: is the least aggressive of the testicular germ cell neoplasms

Answer 21

FTTF
Seminoma and ‘non-seminomatous germ cell tumours’ (NSGCT) are the clinically important testicular tumours. Seminomas remain confined to the testis longer and typically metastasise to lymph nodes, with blood spread occurring (when it does) as a later phenomenon. NSGCT metastasise earlier and more frequently by blood stream. Seminomas are extremely radiosensitive whereas NSGCT are radio-resistant. Significance of a positive HCG in some seminoma patients is unknown; it does not alter the generally good prognosis for seminoma.

Question 22

27695 – The following statements are correct regarding treatment of testicular tumours
1: seminoma is highly radiosensitive
2: most centres adopt a management policy of intense surveillance without additional therapy after orchidectomy for organ-confined seminoma
3: most centres adopt a management policy of intense surveillance without additional therapy after orchidectomy for organ-confined non-seminomatous germ cell tumour
4: residual masses in the chest and retroperitoneum after chemotherapy for non-seminoma are best managed by surgical resection
5: a solid mass arising within the testis has a 50% risk of being malignant

Answer 22

TFTTF
Seminoma is exquisitely radiosensitive (1 True) and for stage I and early stage II tumors 95% of patients are cured with retroperitoneal low dose radiotherapy. (Delivery of 25-30 Gray to the retroperitoneal and ipsilateral pelvic lymph nodes). Response 2 is false. Seminomas of high stage and with bulky retroperitoneal nodes or distant metastatic disease are treated with systemic chemotherapy using a regime of Bleomycin, Etoposide and Cis-platinum. Four cycles of treatment, three weeks apart, are associated with cure rates of >90% in this group of patients. The treatment of node negative disease is more controversial.
‘Watchful-waiting’ in this group has several disadvantages: Natural History: 25% of patients can be expected to relapse, usually with retroperitoneal nodal disease - in seminoma relapse occurs up to 5 years after orchidectomy. Ease of surveillance: Tumour markers are generally not elevated so surveillance is with CT imaging alone - this is quite a lot of radiation with regular CT for 5 years. Patient compliance also becomes a
factor. Low dose radiotherapy to the retroperitoneum is well tolerated and minimises the risk of recurrence to <5%.
Conclusion - Radiotherapy to the retroperitoneal lymph nodes for stage I disease is the preferred treatment in the vast majority of centres. Stage 1 non-seminomatous germ cell tumour is treated with surveillance after orchidectomy (3 True). Seventy-five per cent of patients with stage 1 NSGCT are cured with inguinal orchidectomy alone. Twenty-five per cent of patients relapse, usually in the retroperitoneal lymph nodes within two years. For this reason close follow-up with chest x-rays, CT, and tumour markers on clinical examination are appropriate. Tumour markers are checked six-weekly on clinical examination and chest x-rays and CT scans are checked three-monthly in the first year; with gradually diminishing intensity of follow-up over the subsequent two to three years. The majority of relapses occur within the first year and many cases of residual disease are detected by failure of tumor markers to normalise following inguinal orchidectomy.
Overall in this group 25% of patients will develop recurrent disease. This risk increases to 45-50% in patients with embryonal cancer, with vascular invasion present in the inguinal orchidectomy specimen, or with a higher T stage. In patients who develop recurrent disease the appropriate treatment in the first instance is chemotherapy, again, initially with four cycles of BEP. Greater than 90% of patients can expect to be cured. (Response 4 is true) High stage NSGST is treated initially following orchidectomy with chemotherapy. If residual retroperitoneal mass exists despite chemotherapy and tumour marker normalisation, retroperitoneal lymph nodes dissection is required. Twenty per cent of these masses contain residual tumour, 40% mature teratoma, and 40% fibrosis. (Mature teratoma is generally benign but may cause local compression to neighbouring structures and can rarely undergo malignant degeneration.) Overall, 70% of patients with high volume disease are cured with chemotherapy +/- retroperitoneal lymph node dissection. Residual chest masses similarly are best excised. The risk of malignancy is very high in patients with a solid testicular mass (5 False). Such patients have a testicular malignancy until proven otherwise.

Question 23

27622 – Concerning invasive cancer of the cervix
1: screening programmes have significantly reduced the death rate from this condition
2: specific human papilloma virus (HPV) types are associated with cervical cancer and not condylomata
3: peak incidence is in post-menopausal women
4: the cancer is usually an adenocarcinoma

Answer 23

TTFF
Screening programmes, using the Papanicolaou smear, have reduced the US death rate from cancer of the cervix by two-thirds (1 True). Fifty years ago cancer of the cervix was the leading cause of cancer death in women, it has now been reduced to eighth. The human papilloma virus is currently considered an important factor in cervical oncogenesis (2 True). This sexually transmitted virus is found in 85% of cervical cancers and interestingly certain sub-types of HPV are specifically associated with these cancers; and a separate group is associated with condylomata. (This association between HPV and the cervix is well treated in Cotran, Kumar, Collins, Robbins Pathologic Basis of Disease, Saunders, 6th Edition, 1999; Chapter 24.
The peak incidence of cervical cancer is 40-45 years (3 False) but can occur from the second decade to old age. The very great percentage of cervical cancers are of squamous type (4 False) owing to the epithelial surface of the cervix. However the endocervix contains a glandular epithelium which may develop an adenocarcinoma in 10% of cases.

Question 24

16870 – Choriocarcinoma of gestational origin
1: can be monitored clinically by plasma gonadotrophin (HCG) levels
2: metastases early and widely
3: has a generally good prognosis with chemotherapy
4: can be monitored clinically by plasma gonadotrophin (HCG) levels

Answer 24

TTTT
This cancer is one of the success stories of modern systemic chemotherapy. It contrasts markedly with the still formidable mortality of non-gestational choriocarcinoma, despite the fact that both neoplasms share the same morphology, cell markers, HCG elaboration etc.

Question 25

20295 – S. There is a positive association between granulosa cell tumour of the ovary and endometrial carcinoma BECAUSE R. granulosa cell tumour produces large amounts of oestrogen

Answer 25

S is true, R is true and a valid explanation of S
Robbins 5th ed. CHAPTER: 23 PAGE: 1074-1075

Question 26

21438 – With respect to lactation in women
1: milk secretion is stimulated by oxytocin
2: suckling stimulates the release of antidiuretic hormone (ADH)
3: milk ejection is stimulated by prolactin (PRL)
4: suckling stimulates the release of prolactin (PRL)and oxytocin

Answer 26

FTFT
Ganong 13th Ed. CHAPTER: 23/14 PAGE: 378-379/197-201

Question 27

23789 – Use of oral contraceptive agents is associated with an increased
incidence of the following neoplasms
1: ovarian carcinoma
2: hepatic adenoma
3: cervical carcinoma
4: endometrial carcinoma

Answer 27

FTTF
Robbins 6th ed. Page: 414

Question 28

23774 – Which of the following is/are recognised as contributing to the renal failure which complicates multiple myeloma
1: amyloidosis
2: renal tubular protein casts
3: pyelonephritis
4: hypercalcaemia

Answer 28

TTTT
Robbins 5th ed. CHAPTER: 20 PAGE: 975

Question 29

27602 – Concerning vaginal bleeding
1: menorrhagia is a feature in 50% of women with von Willebrand’s disease
2: vaginal bleeding is almost never confused with rectal bleeding
3: vaginal bleeding is seen in 70% of ruptured ectopic pregnancies
4: vaginal bleeding is excessive in Graves’ disease

Answer 29

TFTF
Surgeons need to remember that clotting abnormalities do occur and that such a disorder may manifest itself as abnormal menstrual loss - 50% of those with von Willebrand’s disease (1 True) and 50% with idiopathic thrombocytopenic purpura - so don’t just ask about abnormal bleeding or bruising. Elderly women, in particular, can easily confuse vaginal bleeding for a rectal source (2 False) as they do not believe a vaginal loss is possible once menstruation has ceased. Placement of a tampon can be an easy way to resolve the problem if a thorough clinical examination does not demonstrate the source. Yes, it is reported that some 70% of ruptured ectopics will have some vaginal loss at the time of presentation (3 True). This can be misleading as it can be interpreted as the late arrival of the previously missed period. Remember this fact. Excessive menstrual loss is a feature of hypothyroidism (myxoedema). Menstrual loss can become scanty or absent in Graves’ disease (hyperthyroidism); and oligomenorrhoea may be a presenting symptom (4 False).

Question 30

27607 – When differentiating between a ruptured ectopic pregnancy and a threatened abortion
1: pain is not a feature of a threatened abortion
2: ultrasound is very helpful
3: amenorrhoea is consistent with both diagnoses
4: the two can be differentiated from each other by a serum β-hCG

Answer 30

FTTF
Pain can certainly be a feature of both a threatened abortion as well as a ruptured ectopic pregnancy (1 False). The pain of a threatened abortion is often described as colicky and tends to be sited centrally at the pelvic brim. A ruptured ectopic may be localised to the relevant iliac fossa and may be associated with hypotension and shoulder tip pain. Pain is usually more constant and severe. Amenorrhoea, obviously, will be present in both conditions as conception has taken place (3 True). For this same reason a serum/urinary β-hCG will be positive, at the time of presentation, in both instances (4 False). Ultrasound of the uterus is the most useful defining investigation (2 True), as presence of products of conception within the uterine cavity would indicate a threatened abortion. In the case of a ruptured ectopic one would expect the uterine cavity to be empty. The ectopic itself may be visualized in a Fallopian tube and fluid (blood) is likely to be seen in the pelvis.

Question 31

27689 – The following statements refer to tumour markers commonly used for testicular cancer
1: cAMP and P57 are the most useful markers in testicular tumour
2: tumour markers are optimally first measured within 48 hours after orchidectomy for testicular cancer
3: tumour markers have a role for all the following - histological diagnosis, prognosis, response to treatment, long term follow up
4: seminoma is never associated with elevation of tumour markers
5: all patients with non-seminoma have elevated tumour markers

Answer 31

FFTFF
Beta-HCG and alpha Feto-protein are the most useful tumour markers (1 False). LDH is a non specific marker commonly elevated with significant metastatic disease. In cases of suspected testis tumor, tumor markers should be checked prior to inguinal orchidectomy to assess the baseline level
with the primary tumour in situ (2 False, 3 True). Five to ten per cent of seminomas have elevated Beta HCG (Syncitio-trophoblastic component) (4 False). Alpha feto-protein is elevated in 35-70% of patients with nonseminomatous germ-cell tumors (and never in pure seminoma). Beta HCG is
elevated in 30-60% of patients with nonseminomatous germ-cell tumour, including virtually 100% of patients with choriocarcinoma (5 False).