Path August 2018 Flashcards

Question

Regarding pulmonary hypertension: Defined as over 40mmHg Sleep apnoea is a possible aetiology

Answer 1

Sleep apnoea is a possible aetiology MAP > 25mmHg at rest

Answer 2

COP - not fibrotic, no interstitial fibrosis

Answer 3

Silicosis fibrosis is primarily in lower zones.

Answer 4

Which is false regarding aspergillosis: -Target sign in invasive from gelatinous exudates - ?false. Target lesions (seen as CT halo sign) - the halo is haemorrhage. Maybe referring to cryptococcus in CNS, causes gelatinous pseudocysts in BG -Can have haemoptyis from chronic non invasive aspergillis - true. Wall of aspergilloma is lined by vascular granulation tissue, can cause haemoptysis Aspergilloma (“fungus ball”) formation occurs by fungal colonization of preexisting pulmonary cavities (e.g., dilated bronchi or lung cysts, posttuberculosis cavitary lesions). These masses may act as ball valves to occlude the cavity, thereby predisposing the patient to infection and hemoptysis. - ABPA is from colonization of mucosa and treatment includes asthma control - true, superficial colonisation of bronchial mucosa causing hypersensitivity reaction. - Invasive aspergillis can look like mucormycosis in the immunocompromised. - True. Rhinocerebral aspergillus infection in immunocompromised resembles disease caused by mucormycosis (Robbins)

Answer 5

Tyrosine kinase can treat adeno lung

Answer 6

Most abscesses contain oral commensal anaerobes - true, oral cavity anaerobes are the only isolated microorganism in 60%. e..g. Bacteroides, Fusobacterium, Peptococcus (Robbins p 708) Regarding lung infections: - Staph is the most common CAP - strep pneumoniae - Viral have higher CRP than bacterial - false, there are some studies showing higher in bacterial (google) - Most URTIs are bacterial - viral - Mycoplasma common in elderly - children/young adults.

Answer 7

Panacinar emphysema is worse in bases

Answer 8

H pylori is associated with MALToma - true Intestinal type is associated with linitis plastica - false. Intestinal type causes exophytic mass or ulcerated tumour/ulcer. Diffuse type (less common **previously) - infiltrative growth pattern with desmoplastic reaction and linitis plastica **In the United States, gastric cancer rates dropped by more than 85% during the twentieth century. Adenocarcinoma of the stomach was the most common cause of cancer death in the United States in 1930 and remains a leading cause of cancer death worldwide, but now accounts for fewer than 2.5% of cancer deaths in the United States. The cause of the overall reduction in gastric cancer is most closely linked to decreases in H. pylori prevalence. Notably, the remarkable decrease in gastric cancer incidence applies only to the intestinal type, which is most closely associated with atrophic gastritis and intestinal metaplasia. As a result, the incidence of diffuse type gastric cancer, which was previously low, is now similar to intestinal type gastric cancer.

Answer 9

BRCA Peutz-Jeghers highest risk 130 x incr risk Others: BRCA, (4-10 x incr), HNPCC, hereditary pancreatitis, familial melanoma syndrome, strong family hx with unknown genes. Robbins p 894. TP53 does increase risk, but not one of the core cancers ass/w Li Fraumeni (breast, sarcoma, brain tumours, adrenocortical carincoma, leukaemia)

Answer 10

Pancreas divisum

Answer 11

-10% is caused by alcohol and biliary tract pathology Biliary tract disease and alcoholism account for approximately 80% of cases of acute pancreatitis in Western countries Although most pancreatic enzymes are secreted as inactive zymogens, lipase is produced in an active form and has the potential to cause local fat necrosis. Hypocalcemia may result from precipitation of calcium soaps in necrotic fat.

Answer 12

C) Often has hepatic fatty infiltration Wilson disease is an autosomal recessive disorder caused by mutation of the ATP7B gene, which results in impaired copper excretion into bile and a failure to incorporate copper into ceruloplasmin The liver often bears the brunt of injury. The hepatic changes are variable, ranging from relatively minor to massive and mimic many other disease processes. There may be mild to moderate fatty change (steatosis) associated with focal hepatocyte necrosis. Acute, fulminant hepatitis can mimic acute viral hepatitis. Chronic hepatitis in Wilson disease exhibits moderate to severe inflammation and hepatocyte necrosis, areas of fatty change, and features of steatohepatitis (hepatocyte ballooning with prominent Mallory-Denk bodies). In advanced cases, cirrhosis may be seen. Toxic injury to the brain primarily affects the basal ganglia. Nearly all patients with neurologic involvement develop eye lesions called Kayser-Fleischer rings, green to brown deposits of copper in Desçemet membrane in the limbus of the cornea.

Answer 13

B) Serum copper is an important marker for diagnosis Serum copper levels also are of no diagnostic value, as they may be low, normal, or elevated, depending on the stage of the liver disease.

Answer 14

50% get CRC by 50 100% get CRC, often by 30 yr

Answer 15

Rare after colectomy

Answer 16

Fibrosis and stricture Robbins: “Recurrent diverticulitis can cause segmental colitis, fibrotic thickening in and around the colonic wall, or stricture formation.

Answer 17

Sometimes present with hypertension and hypokalaemia (implies secretion of aldosterone - adrenal cortical hormone. Phaeo is adrenal medullary - neuroendocrine origin) The dominant clinical manifestation of pheochromocytoma is hypertension, observed in 90% of patients. Of these, approximately two thirds have “paroxysmal” episodes associated with sudden rise in blood pressure and palpitations, which can, on occasion, be fatal. Ten percent of adrenal pheochromocytomas are biologically malignant, defined by the presence of metastatic disease. Malignancy is more common (20% to 40%) in extra-adrenal paragangliomas, and in tumors arising in the setting of certain germline mutations...Like other inherited cancer disorders (Chapter 7), endocrine tumors arising in the context of MEN syndromes have certain distinct features that contrast with their sporadic counterparts...These tumors are usually more aggressive and recur in a higher proportion of cases than do similar sporadic endocrine tumors.

Answer 18

* LW: - -> rarely idiopathic which is incorrect, hence correct answer. Bilateral idiopathic hyperaldosteronism (IHA), characterized by bilateral nodular hyperplasia of the adrenal glands, is the most common underlying cause of primary hyperaldosteronism, accounting for about 60% of cases. Individuals with idiopathic hyperaldosteronism tend to be older and to have less severe hypertension than those presenting with adrenal neoplasms. Second most common cause is adrenocortical neoplasm, either an aldosterone-producing adenoma (the most common cause) or, rarely, an adrenocortical carcinoma. In approximately 35% of cases, primary hyperaldosteronism is caused by a solitary aldosterone-secreting adenoma, a condition referred to as Conn syndrome. This syndrome occurs most frequently in adult middle life and is more common in women than in men (2 : 1). < 2cm in size. thus this option true. Children cause is usually adrenalcortical (broad term), is is usally due to primary idiopathic hyperplasia. ...alternatively: Adrenocortical carcinomas are rare neoplasms that can occur at any age, including childhood. They are more likely to be functional than adenomas and are often associated with virilism or other clinical manifestations of hyperadrenalism. Previous answer ?Adrenocortical a cause in children

Answer 19

*LW: Interstitial cystitis - FALSE; chronic inflammation not associated with bladder cancer, although clinically mimics CIN. Interstitial cystitis ?least true Chronic cystitis of uncertain aetiology, controversial dx. Transmural fibrosis late in disease mimics CIS clinically (needs bx to ddx) Which is not associated with bladder cancer: Radiation cystitis - true Shistosoma - true Urachal remnant with cystitis glandularis - true, metaplastic glandular epithelium ass/w adenocarcinoma Other option seemed correct

Answer 20

Papillary RCC hypervascular

Answer 21

?Poor recall Nephropthisis - nephronopthisis. Part of medullary cystic disease complex, most forms AR inheritance Cystic dysplasia - ?? vague term, could mean lots of things. If they mean MCDK - is sporadic, so this would be the answer Adult medullary cystic disease - also part of medullary cystic disease complex 20% of medullary cystic disease complex overall is sporadic non-familial ... Robbins: - As a group, the nephronophthisis complex is now the most common genetic cause of end-stage renal disease in children and young adults. - Adult-onset medullary cystic disease has an autosomal dominant pattern of transmission.

Answer 22

Small cell carcinoma - not mentioned in big Rob, google says its rare, so this would be the least common of the 3 answers. Papillary adenoma - common Collecting duct carcinoma - rare (1% or less of renal epithelial neoplasms) Small, discrete adenomas arising from the renal tubular epithelium are found commonly (7% to 22%) at autopsy. They are most frequently papillary and are therefore called papillary adenomas. Collecting duct (Bellini duct) carcinoma represents approximately 1% or less of renal epithelial neoplasms. They arise from collecting duct cells in the medulla. Several chromosomal losses and deletions have been described, but a distinct pattern has not been identified. Histologically these tumors are characterized by malignant cells forming glands enmeshed within a prominent fibrotic stroma, typically in a medullary location. Medullary carcinoma is a morphologically similar neoplasm that is seen in patients with sickle cell trait.

Answer 23

B) Uric acid Uric acid stones are common in individuals with hyperuricemia, such as patients with gout, and diseases involving rapid cell turnover, such as the leukemias.

Answer 24

C) Oncocytoma In gross appearance, the tumors are tan or mahogany brown, relatively homogeneous, and usually well encapsulated with a central scar in one-third of cases. However, they may achieve a large size (up to 12 cm in diameter). There are some familial cases in which these tumors are multicentric rather than solitary.

Answer 25

Choriocarcinoma The rare pure choriocarcinoma is the most aggressive NSGCT. It may not cause any testicular enlargement but instead spreads predominantly and rapidly by the bloodstream. Therefore, lungs and liver are involved early in virtually every case.

Answer 26

*AJL - I favour seminoma. Robbins says "Seminomas are most common, accounting for about 50% of testicular germ cell neoplasms. It also says that testicular neoplasms peak in the 15-34yr age group. AND in post pubertal males 95% of testicular neoplasms are germ cells (and malignant). Therefore seminomas are most common testicular neoplasm. **LJS - Embryonal - 20-30 yr peak Seminoma - 40-50yr, most common testicular malignancy but 20yr would be young for this. * LW: robbins states peaks in 30s. * ESG: Robbins: "The peak incidence is the third decade" = in 20s, correct answer Lymphoma - older men 60+ Endodermal sinus tumour - young kids, peak 3 yr Teratoma - any age Choriocarcinoma is also peak age 20-30 yr, but rare

Answer 27

ipsilateral retroperitoneal Testicular tumors have a characteristic mode of spread. Lymphatic spread is common to all forms of testicular tumors. In general, retroperitoneal para-aortic nodes are the first to be involved. Subsequent spread may occur to mediastinal and supraclavicular nodes. Hematogenous spread is primarily to the lungs, but liver, brain, and bones may also be involved.

Answer 28

Endodermal sinus tumour = yolk sac tumour Marked elevation of serum AFP or HCG levels are produced by yolk sac tumor and choriocarcinoma elements, respectively. Both of these markers are elevated in more than 80% of individuals with NSGCT at the time of diagnosis.

Answer 29

Type 1 usually arise in the context of endometrial atrophy Type 1 (80%) arises from endometrial hyperplasia in perimenopausal women (55-65y), risk factors unopposed oestrogen, obesity, HTN, diabetes. Relatively indolent, spreads via lymphatics. Type 2 (15%) is sporadic, arising from atrophic endometrium in older women (65-75y) with thin physique. Aggressive, spreads via intraperitoneal (trans-tubal) and lymphatics, more likely to be advanced stage at diagnosis with poor prognosis.

Answer 30

?Can have malignant foci Nodular serosal surface - adenomyoma could cause Can have symptoms like endometriosis - true Can have malignant foci ??? don't think so. No mention of this in Robbins. Ill defined junctional zone - true Thickening of myometrium - true *ESG: Adenocarcinoma can arise from adenomyosis just like it can from endometriosis, but very rare. I think nodular serosal surface implies subserosal fibroids and not adenomyoma (radiopaedia adenomyoma: "in general the degree to which the contour of the uterus is distorted is less marked")

Answer 31

C) SCC of the cervix has a better prognosis than neuroendocrine carcinoma Stage III—Carcinoma has extended to the pelvic wall. On rectal examination there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the LOWER third of the vagina ``` Natural history over 2 years: LSIL: - 60% regress - 30% persist - 10% progress to HSIL HSIL: - 30% regress - 60% persist - 10% progress to carcinoma (within 2-10 years) ``` The progression time from in situ to invasive adenosquamous and neuroendocrine carcinomas is shorter than in squamous cell carcinoma, and patients with these tumors often present with advanced disease and have a less favorable prognosis. The prognosis and survival for invasive carcinomas depend on the stage of the cancer at diagnosis and to some degree on histologic subtype, with small-cell neuroendocrine tumors having a very poor prognosis.

Answer 32

Partial mole has 2% chance of chorio *AJL - Partial mole has no risk of choriocarcinoma. It has a reduced risk (c.f complete mole) of invasive mole. Continuous elevation of HCG may be indicative of persistent or invasive mole, which develops in up to 15% of molar pregnancies and is seen more frequently with complete moles. In addition, 2.5% of complete moles give rise to gestational choriocarcinoma.

Answer 33

Twins Ectopic pregnancies account for 2% of confirmed pregnancies. The most important predisposing condition, present in 35% to 50% of patients, is prior pelvic inflammatory disease resulting in intralumenal fallopian tube scarring (chronic salpingitis). The risk of ectopic pregnancy is also increased with peritubal scarring and adhesions, which may be caused by appendicitis, endometriosis, and previous surgery. In some cases, however, the fallopian tubes are apparently normal. Use of an intrauterine contraceptive device is associated with twofold increase of ectopic pregnancy.

Answer 34

Monochorionic monoamniotic has to be monozygotic

Answer 35

SCC of the cervix has a better prognosis than neuroendocrine carcinoma (and adenosquamous carcinoma)

Answer 36

Endocervical polyp - can be large and polypoid and extend through cervical os

Answer 37

*LW: ``` Endometroid carcinoma (40% are bilateral). Although only make up 10-15% of all ovarian cancers. ``` ``` Overall spectrum (based on Robbins numbers) *Serous carcinomas are bilateral 66%, 20% in benign serous cystadenoma, 30% serous borderline. Most common malignant ovarian neoplasm (40% of over all tumours), with 70% reflecting benign or borderline based on frequency, 30% malignant frequency. ``` Thus as an overall total frequency; Serous cystadenocarcimoma most frequently bilateral at 8%, serous benign & borderline at 7%, and endometriod 6%, mucinous 1%. (this doesn't change the above answer out of options listed tho) Mucinous, although make up 20-25% of all ovarian neoplasms, only 5% primary mucinous cystadenoma and carcinoma are bilateral.

Answer 38

>10cm high likelihood of malignancy Leiomyomas are sharply circumscribed, discrete, round, firm, gray-white tumors varying in size from small, barely visible nodules to massive tumors that fill the pelvis. An extremely rare variant, benign metastasizing leiomyoma, is a uterine leiomyoma that extends into vessels and spreads hematogenously to other sites, most commonly the lung. Another variant, disseminated peritoneal leiomyomatosis, presents as multiple small peritoneal nodules. Both are considered benign despite their unusual behavior.

Answer 39

**LJS Radial scar is proliferative without atypia (1.5-2x incr risk) Proliferative breast disease with atypia is x5 incr risk Non-proliferative breast changes have no increased risk

Answer 40

Calc on biopsy of LCIS is incidental *AJL LCIS is usually an incidental finding on biopsy of calc. Some LCIS (pleomorphic type (RP)) is associated with calc. Robbins: LCIS is always an incidental biopsy finding, since it is not associated with calcifications or stromal reactions that produce mammographic densities.

Answer 41

PASH - rounded mass

Answer 42

Diagnosis needs further work up

Answer 43

Get in BRCA1 Among cancers arising in BRCA1 carriers, 13% are of medullary type, and up to 60% have a subset of medullary features. The basis for the relatively good prognosis of this subtype compared to other poorly differentiated carcinomas is not known, but it has been noted that the presence of lymphocytic infiltrates within the tumors is associated with higher survival rates and a greater response to chemotherapy, suggesting that improved outcomes may be related to a host immune response to tumor antigens.

Answer 44

Nuclear grade most important for prognosis. Low grade - noncomedo High grade - necrosis, poorer prognosis .... DCIS can be divided into two major architectural subtypes, comedo and noncomedo. Some cases of DCIS have a single growth pattern, but most are comprised of a mixture of patterns. Nuclear grade and necrosis are better predictors of local recurrence and progression to invasion than architectural type. If untreated, women with small, low-grade DCIS develop invasive cancer at a rate of about 1% per year. The majority of these invasive cancers occurs in the same quadrant and have a similar grade and expression pattern of ER and HER2 as the associated DCIS. Tumors with high-grade or extensive DCIS are believed to have a higher risk for progression to invasive carcinoma.

Answer 45

B) This is an incidental finding on biopsy LCIS is always an incidental biopsy finding, since it is not associated with calcifications or stromal reactions that produce mammographic densities. Approximately 20% (range 18-25%) of cases diagnosed with LCIS at core needle biopsy were upgraded to more invasive cancer pathologies at surgical excision. Therefore when LCIS is discovered on a needle biopsy specimen, an excisional biopsy should be performed.

Answer 46

All of cribriform, papillary and micropapillary are non-comedo Cribriform can have rounded cookie cutter like spaces within ducts. Can also be solid Micropapillary - can extend beyond MG abn *AJL - Comedo is defined by; pleomorphic high grade nuclei, and necrosis.

Answer 47

Sarcomatous changes has increased risk in Maffucis *AJL added all the other options to make this a question rather than a statement.

Answer 48

-Bakers cyst - common in RA * *LJS - 3% RA pt get secondary amyloid (AA type). RA is most common cause of secondary reactive amyloidosis - Bakers cyst common in RA - Get ankylosis late in RA - pannus bridges bone and causes fibrous ankylosis. Can progress to bony ankylosis ... In time, after the cartilage has been destroyed, the pannus bridges the apposing bones to form a fibrous ankylosis, which eventually ossifies and results in fusion of the bones, called bony ankylosis Amyloidosis is reported to occur in approximately 3% of patients with rheumatoid arthritis and is clinically significant in one half of those affected. Large synovial cysts, like the Baker cyst in the posterior knee, may develop as the increased intra-articular pressure causes herniation of the synovium.

Answer 49

Clear cell chondrosarcoma The clear cell variant is unique in that it originates in the epiphyses of long tubular bones. Distinguishing between a chondroblastoma and an epiphyseal clear cell chondrosarcoma can be difficult.

Answer 50

Mycobacterial osteomyelitis tends to be more destructive and resistant to control than pyogenic osteomyelitis In infants, but uncommonly in adults, epiphyseal infection spreads through the articular surface or along capsular and tendoligamentous insertions into a joint, producing septic or suppurative arthritis, which can cause destruction of the articular cartilage and permanent disability.

Answer 51

Parosteal - low grade tumour, may present as painless mass

Answer 52

Senile osteoporosis no gender predilicion

Answer 53

No ankylosis in OA | Heberdens nodes more common in women

Answer 54

* *LJS ?none are correct * AJL - agree none are correct Chondrosarc mostly epiphyses - only clear cell subtype In exostoses malignancy starts in the bony stalk - cartilage cap Enchondromas are epiphyseal - medulla of metaphyses/diaphyses Olliers is defined as multiple osteochondroma - multiple enchondroma

Answer 55

B) Immunocompromised patients have predilection for BCC Incidence of BCC incr in immunosuppression (as with SCC)

Answer 56

Haemorrhage

Answer 57

left lower lobe

Answer 58

B) Bilateral suggests a germline mutation

Answer 59

Peak 15-20

Answer 60

Leptomeningeal angioma

Answer 61

Pancreatic adenocarcinoma cancer

Answer 62

??Fibroepithelial ureteric polyp and desmoids ``` Renal cortical (or maybe papillary) necrosis and abruptio placenta - yes. Obstetric catastrophies such as abruption ass/w diffuse renal cortical necrosis - Robbins Smoking and RCC - yes ```

Answer 63

Parathyroid adenoma is most common cause of primary HPT CRF is most common cause of secondary HPT Robbins says primary HPT is the most common cause of hypercalcaemia overall.

Answer 64

Lymphocytic hypophysitis Hypopituitarism accompanied by evidence of posterior pituitary dysfunction in the form of diabetes insipidus is almost always of hypothalamic origin.... Hypothalamic lesions that cause hypopituitarism include tumors, which may be benign (e.g., craniopharyngioma) or malignant; most of the latter are metastases from tumors such as breast and lung carcinoma. Hypothalamic insufficiency can also appear following irradiation of brain or nasopharyngeal tumors.