Pathology Flashcards
Vasculitis involving renal arteries
PAN
PAN spares:
The pulmonary circulation
Which vasculitis affects the aorta and kidneys in a 30 year old?
Takayatsu
Giant cell arteritis
Polyarteritis nodosa
Wegener granulomatosis
Respiratory
Takayatsu
Was this the one with absent pulses?
Polyarteritis nodosa
Behcets – cerebral vasculitis and genito-oral ulcars
Takaysu
Takaysu
Which of the following is most correct regarding giant cell arteritis?
A negative temporal artery biopsy excludes giant cell arteritis
Occurs in <30y/o
Neither
a) false, skip lesions
b) false, typically >50 and peak 70-80
20 year old female with headache and hypertension and narrowing at ostia of renal artery on angiogram
NF1
FMD
SLE
Polyarteritis nodosa
Giant cell arteritis
NF1 – Can get Moya Moya
FMD – whole artery
SLE – small vessel
Polyarteritis nodosa – usually men, older
Giant cell arteritis – older women
In contrast to the atherosclerotic renal artery stenosis, FMD rarely affects the proximal or ostial section of renal artery.
What is false regarding granulomatosis with polyangiitis (Wegeners)?
Renal artery vasculitis
Upper respiratory tract necrotizing granulomas
Lower respiratory tract necrotizing granulomas
Pulmonary artery vasculitis
Glomerulonephritis
Renal artery vasculitis
Upper respiratory tract necrotizing granulomas - True
Lower respiratory tract necrotizing granulomas - True
Pulmonary artery vasculitis - More in TA
Glomerulonephritis - Necrotising glomerulonephritis in ~60%
pANCA is most associated with:
Churg-Strauss (Eosinophilic granulomatosis with polyangiitis) -~75%
May correlate with disease activity of polyarteritis nodosa
Least likely to affect the lungs and kidneys: (March 2015)
Anticardiolipin - Antiphospholipid syndrome
Anti-neutrophil cytoplasmic antibody
PAN
SLE
Alpha-1 antitrypsin
PAN - spares the lungs
Anticardiolipin - Antiphospholipid syndrome
Anti-neutrophil cytoplasmic antibody - ANCA, all have renal involve
SLE -
Alpha-1 antitrypsin
Regarding varicose veins :
Varicose venous thrombosis is a clinically significant risk factor for pulmonary embolism
Thickened vein walls
Veins are dilated
Something about valves
Veins are dilated
Which is most correct regarding Marfan’s syndrome?
Associated with cystic degeneration of the media
Commonly associated with mitral valve prolapse, without life threatening
Regurgitation
Arachnidactyly is associated with pathological fractures
Aortic rupture is most common in 50-75 year olds
Associated with cystic degeneration of the media - A hallmark histologic change associated with dissection in those with Marfan syndrome
Which is not a feature of malignant hypertension? (March 2017)
Diastolic pressure above 110mmHg
Fibrinoid necrosis
Can occur in previously normotensive people
Can complicate 1-5% of patients with essential hypertension
Diastolic pressure above 110mmHg - Characterized by severe hypertension: systolic >200, diastolic >120
Fibrinoid necrosis - is a feature
- Present in malignant hypertensions
- A pattern of irreversible cell death that occurs when antigen-antibody complexes are deposited in the walls of blood vessels along with fibrin. Common in the immune-mediated vasculities, a result of type III hypersensitivity
Can occur in previously normotensive people - True, though normally superimposed on pre-existing ‘benign’ hypertension
Can complicate 1-5% of patients with essential hypertension - True, a small number, up to 5%
Fibrinoid necrosis is seen in which of the following? (March 2014)
a. Myocardial infarction
b. Vasculitis
c. TB 0 gaseous or caseous
d. Trauma
b. Vasculitis
A pattern of irreversible cell death that occurs when antigen-antibody complexes are deposited in the walls of blood vessels along with fibrin. Common in the immune-mediated vasculitis, a result of type III hypersensitivity
Regarding aortic dissection, which is true? (March 2016, August 2016, March 2017)
a 5-10% have no intimal tear - visible
b 70-80% involve the aortic arch and the proximal descending thoracic aorta
c Cystic medial necrosis is not commonly found in patients without a dissection
d None of the above
None are true
5-10% have no intimal tear - visible
- False, this is the pathogenesis.
- In rare cases, interruption of the vasa vasum
70-80% involve the aortic arch and the proximal descending thoracic aorta
- Approximately 60% involve the ascending aorta: Radiopaedia
- 40% are Type B - beyond the brachiocephalic vessels: Radiopaedia
Cystic medial necrosis is not commonly found in patients without a dissection
- False, the most frequent preexisting histologically detectable lesion is cystic medial degeneration: Robbins 504
A n elderly patient has a saccular aortic aneurysm with raised inflammatory markers. What is the most likely diagnosis? (March 2014)
a. Inflammatory aortic aneurysm
b. Mycotic saccular aneurysm
True: Mycotic saccular aneurysm : Mycottic aneurysms are saccular, and in patients with risk factors e.g. IVDU etc.
Mycotic AAA - lesions infected by circulating microorgansims
Inflammatory aortic aneurysm : Aneurysmal dilation of the aorta, not saccular. A younger cohort
Inflammatory AAA - 5-10% of all AAA, typically in younger patients, who present with back pain and elevated inflammatory markers.
A subset may be vascular manifestations of a recently recognised entity - IgG4 related disease
What is not a cause of aortic dilation? (March 2015)
Loeys-Dietz
Kawasaki
Takayasu
Syphilis
Ehlers-Danlos
Kawasaki
What is not a cause of renal microaneurysms? (August 2016)
Diabetic nephropathy
Neurofibromatosis
Hypertension
Diabetic nephropathy - Results in atherosclerosis and arteriosclerosis
Neurofibromatosis - Associated with renal artery aneurysm
Hypertension - 75% associated with renal artery aneurysms
Patient with back and chest pain. There is contrast in the media of the aorta. What is the most likely diagnosis? (September 2013)
Dissection
Rupture
Penetrating atherosclerotic ulcer
Aneurysm
Dissection - Occurs when blood enters the medial layer of the aortic wall
Rupture
Not contained in the layers
Penetrating atherosclerotic ulcer
Involves the intima and tracks along the media
Aneurysm
Involves all three layers of the vessel
Aortic aneurysm with an endoluminal stent inserted. Contrast is seen outside of the stent and the proximal end of the stent is not opposed to the aneurysmal wall. What is MOST likely?
Type 1 leak
Type 2 leak
Type 3 leak
Dissection
Type 1 leak
Acute aortic syndrome associated with a penetrating atherosclerotic ulcer. Which of the following is FALSE?
The ulcer needs to penetrate to at least the media (macroscopic ulceration)
Can be caused by a penetrating ulcer in the abdominal aorta
Can be caused by aortic dissection secondary to a penetrating ulcer
Can be caused by a ruptured aortic aneurysm
Can be caused by a mural haematoma secondary to a penetrating ulcer
Can be caused by a mural haematoma secondary to a penetrating ulcer
False - intramural haematoma
What is a true association? (March 2015)
a. Cerebral thrombosis from prothrombin G20210A mutation
b. Migratory superficial thrombophlebitis is from metastatic microthrombi
c. Spontaneous DVT in patients older than 60 suggests Factor V Leiden
Answer: a. Cerebral thrombosis from prothrombin G20210A mutation
Associated with venous thrombotic events in unusual places including cerebral venous sinus
b. Migratory superficial thrombophlebitis is from metastatic microthrombi
Trousseau syndrome: an association between migratory thrombophlebitis and malignancy
c. Spontaneous DVT in patients older than 60 suggests Factor V Leiden
False. Factor V leiden is a single point mutation in F5 gene, on chromosome 1. Usually presents earlier.
What is the least likely cause of extensive small bowel ischaemia? (September 2013)
a. Atrial fibrillation
b. PAN
c. Behcet disease
d. Aortic dissection
Answer C: Behcets
Multi-systemic and chronic inflammatory vasculitis of unknown aetiology
6-60% GIT involvement
Atrial fibrillation
PAN Systemic inflammatory necrotising vasculitis that involves small to medium-sized arteries.
GIT involvement 50-70%
Aortic dissection
SMA origin narrowing 2/3 of cases from occlusion
What is the least constituent of an atherosclerotic plaque? (August 2016, March 2017)
Platelets
Stroma
Smooth muscle
Inflammatory cells
Fat
Platelets - don’t form part of the plaque
Q1. Which is more commonly associated with PSC compared to PBC.
A. Sjogrens
B. Crohns
C. Uveitis
D. Coeliac disease
B. Crohn’s disease
(UC would be a better answer if this was an option)
Immune mediated disease causing progressive multifocal stricturing
and fibrosis of intra and extrahepatic ducts.
Young males in Europe & Nth America
ANA, ANCA, ASMA
⅔ have coexisting inflammatory bowel disease (UC > Crohn’s)
What is the most common cause of hypopituitarism and diabetes
insipidus in the post-partum period.
A. Sheehan syndrome.
B. Lymphocytic hypophysitis
C. Adenoma
D. Sarcoid
E. Tuberculosis
B - Lymphocytic hypophysitis
Post-partum pituitary disease:
1. Lymphocytic hypophysitis
- most common form of hypophysitis
- post-partum women, do NOT need hypotension
- headaches disproportionate to mass
- anterior and posterior pituitary dysfunction
- Sheehan Syndrome
- post-partum pituitary infarction due to haemorrhagic shock (usually
needs blood transfusion)
- panhypopituitarism (esp. anterior hormones)
- diabetes insipidus is rare (posterior pituitary)
Other causes of hypophysitis
- Drug-induced E.g. CTLA4 (ipilimumab)
- Granulomatous E.g. LCH/TB/sarcoid/Wegener’s
Which is most likely to cause hypopituitary and diabetes insipidus in
30yo female?
A. Macroadenoma
B. Lymphocytic hypophysitis
C. Craniopharyngioma
D. Rathke’s cleft cyst
E. Empty sella syndrome
B > C - Lymphocytic hypophysitis more common in females
A. False - DI rare
B. Lymphocytic hypophysitis - F > M (rare → 1-2% of sella lesions)
C. Craniopharyngioma - M = F; bimodal (5-15, >65)
D. Rathke’s - rarely symptomatic
E. Empty sella syndrome
UpToDate:
“Unlike diseases that involve the pituitary directly, any of these
conditions can also diminish the secretion of vasopressin, resulting in
diabetes insipidus. Pituitary lesions alone do not cause diabetes
insipidus, since some vasopressin-producing neurons terminate in the
median eminencE.”
Most correct in regards to DCIS
A. Linear branching 1mm smooth calcifications
B. Coarse branching calcification
C. Clinically palpable mass
D. Mass-like enhancement on MRI
E. Micropapillary DCIS can extend beyond the macroscopic extent
Answer: E (depending on phrasing)
A - False. Fine linear branching, or pleomorphic
B - False. Fine linear branching, or pleomorphic
C - False. No mass
D - False. MRI shows non-mass enhancement
E - True
BPH what is most correct
A. Usually arises/most severe in peripheral zone
B. Is a precursor for prostatic adenocarcinoma
C. Does not cause significant increase in PSA
D. Is composed mostly of nodules of fibrostromal tissue
E. Early complications can include hydronephrosis and hydroureter
A - False. Arises from transitional zonE.
B - False.
C - False. PSA is elevateD.
D - True.
E - False. Late complication.
Regarding BPH: T/F
A. PSA not specific for prostate cancer
B. Prostate cancer most common in transition zone
C. Usually arises in the peripheral zone
D. PSA can reflect prostate hypertrophy or prostate carcinoma
A - True. PSA nonspecific
B - False. Prostate cancer is more common in PZ
C - True. Typically peripheral/posterior
D - True. PSA nonspecific
Circumvallate placenta least associated with
A. Placenta accreta
B. Abnormal fetal cardiotocography (CTG)
C. Premature delivery
D. Fetal morbidity
E. Oligohydramnios
A - circumvallate placenta not associated with accreta
Circumvallate placenta = small chorionic plate + overhanging
extrachoroidal placental tissuE. Associated with premature
separation, haemorrhage, IUGR/oligo, abruption.
PML is associated with
A. JC virus
B. HIV
C. HSV
A
StatDx:
Progressive multifocal leukoencephalopathy (PML)
- Subacute opportunistic infection caused by DNA virus JC
polyomavirus (JCV)
- JCV infects oligodendrocytes, causes demyelination in
immunocompromised patients
- Associated with immunosuppression, often AIDS
- Multifocal subcortical WM lesions without mass effect or
enhancement in AIDS patients
Robbins:
- Primary infection is asymptomatic
- Reactivation causes PML
Least likely cause of dilated cardiomyopathy?
A. Alcohol
B. Haemochromatosis
C. Sarcoid
D. Radiation
E. Myocardial ischaemia
Answer: Radiation causes restrictive not dilated CM
RCM - amyloidosis, radiation, idiopathic
DCM - idiopathic, peripartum, alcohol, genetic, myocarditis,
haemochromatosis, doxorubicin and sarcoidosis
Which is NOT a cause of dilated cardiomyopathy?
A. Sarcoid
B. Haemochromatosis
C. Wilson
D. Chemotherapy
E. Alcohol
Answer: Wilson’s disease does not cause CM
RCM - amyloidosis, radiation, idiopathic
DCM - idiopathic, peripartum, alcohol, genetic, myocarditis,
haemochromatosis, doxorubicin and sarcoidosis
24 year olD. woman returns from Andes with progressive headaches.
Well-defined thin-walled ring-enhancing low density lesion with small
eccentric nodule in the parietal lobE. What is most likely?
A. Cryptococcus
B. Sarcoid
C. Cysticercosis
D. TB
E. Hydatid
Answer: (neuro)cysticercosis
Stages:
1. early vesicular - viable parasite with intact membrane
2. colloidal vesicular - dead parasite, turbid fluid, oedema ++
3. granular nodular - reduced size, reduced oedema
4. calcified nodular - calcified granuloma
CNS parasitic infection caused by pork tapeworm, Taenia solium
Spinal extraparenchymal form uncommon (5% of cases)
Patient is having a right lobe biopsy, and when you retract the stylus
the patient has a seizurE. What is most likely?
A. Air embolism
B. Pneumothorax
C. Haemothorax
D. Drug reaction
A
StatDx - treatment:
100% inspired oxygen
To trap air in right heart and prevent embolization to lungs
Left lateral decubitus position
Trendelenburg (head down) position
Regarding aspergillus infection: (rephrased stem)
A. The halo sign is caused by an expanding ring of gelatinous exudate
B. In diabetic patients aspergillus can mimic mucormycosis.
A - False. Haemorrhagic infarct due to vessel invasion.
B - True. Invasive fungal sinusitis is due to both Aspergillus (80%
neutropaenic) and Rhizopus/Mucor (80% diabetes).
Angioinvasive Aspergillosis: Characteristic CT findings consist of
nodules surrounded by a halo of ground-glass attenuation (“halo
sign”) or pleura-based, wedge-shaped areas of consolidation. These
findings correspond to hemorrhagic infarcts. In severely neutropenic
patients, the halo sign is highly suggestive of angioinvasive
aspergillosis.
Fetus has ascites and a high PSV of the MCA. Mother is rhesus
positive and (uterine/umbilical) Doppler is normal. What is most likely?
A. CDH
B. Rhesus incompatibility
C. Parvovirus B19
D. Urinary tract obstruction
E. MCDK
C
A - False. Not associated with high MCA PSV. Oligo.
B - False. Mother Rh positive - can’t be Rh incompatibility.
C - True. Most common infective cause of fetal anaemiA.
D - False. Not associated with high MCA PSV. Oligo.
E - False. Oligo.
Hydrops DDx
1. Immune
- Rh incompatibility (-ve mother +ve fetus)
- lesser antibodies
2. Non-immune
- infection
- anaemia
- aneuploidy
- mass
- arrhythmia
Regarding colitis which is true:
A. Most forms of acute colitis are associated with toxic megacolon
B. Pseudopolyps are associated with Crohn’s
C. Pseudomembranous colitis is associated with superficial mucosal
erosion and fissures
D. Ischaemic colitis is most associated with the rectosigmoid junction
E. Ulcerative colitis causes diffuse involvement of distal small bowel
Answer: B.
A - False. UC, C. difficile, Crohn’s, ischaemia, ileus
B - True. Seen in IBD, UC > Crohn’s
C - False. Elevated yellow-white plaques that coalesce to form
pseudomembranes on the mucosA. Fissures not described in
Robbins.
D - False. Splenic flexure and descending > sigmoiD.
E - False. Backwash ileitis - terminal ileum only.
Regarding PAP, which is least likely
A. Acquired PAP is the most common type
B. Secondary PAP is associated with haematopoetic syndromes
C. Congenital PAP may resolve at 6 months
D. Congenital PAP presents with symptoms from birth
E. Acquired can be considered an autoimmune disorder
Answer: C.
A. True. “Autoimmune (formerly called acquired)” is the most common
cause (90%).
B. True. Secondary PAP is associated with haematopoietic disorder,
malignancy, immunodeficiency, silicosis etC.
C. False. Congenital has variable but poor prognosis. Spontaneous
remission described in autoimmune typE.
D. True. “Most cases present during neonatal period or early infancy”
- UpToDate
E. True. “Autoimmune (formerly called acquired).”
StatDx / Robbins:
Pulmonary alveolar proteinosis (PAP): Syndrome characterized by
accumulation of surfactant in alveoli and terminal bronchioles
- Autoimmune (90%) [formerly called acquired]
- Secondary
- Hereditary and congenital
UpToDate:
Congenital PAP = disorder of surfactant production/metabolism
Primary PAP = disruption of GM-CSF (autoimmune, hereditary)
Secondary PAP = underlying condition affects alveolar macrophages
(haematologic malignancy, MDS, infection, silicosis)
Which is LEAST correct regarding PAP?
A. Acquired is usually autoimmune
B. Secondary is seen in immunodeficiency
C. Rapidly progressive in a child
Answer (of these options): C.
A - True. “Autoimmune (formerly called acquired)” (Robbins)
B - True.
C - Depends. UpToDate: Congenital PAP usually fatal. Can be slowly
progressive/stable for many years or severe and progressivE.
Regarding primary biliary cirrhosis. Which is least likely associated?
A. Inflammatory bowel disease
B. Rheumatoid
C. Sjogrens
A is false.
A - IBD not associated (PSC not PBC)
B - True.
C - True.
“I am a 70yo woman with Sjogren’s, autoimmune thyroiditis, PBC and
an intense rash. AMA.”
Robbins:
“The cardinal feature of PBC is a nonsuppurative destruction of small
and medium-sized intrahepatic bile ducts.
PBC is primarily a disease of middle-aged women (40-50yo).
Associated extrahepatic conditions include the Sjögren syndrome of
dry eyes and dry mouth, scleroderma, thyroiditis, rheumatoid arthritis,
Raynaud phenomenon, and celiac diseasE.”
Which of the following is least likely to cause generalised cirrhosis?
A. Haemochromatosis
B. Wilson disease
C. Hepatitis C
D. Budd-Chiari syndrome
E. Alcohol
F. Alpha-1 antitrypsin
g. Schistosomiasis
Answer: BCS (StatDx)
BCS - centrilobular fibrosis
Schisto - pipestem (periportal) fibrosis
A. HCT - → fibrosis → cirrhosis
B. Wilson’s - fatty → hepatitis → cirrhosis (Robbin’s)
C. Hep C → 20% have cirrhosis (Robbins)
D. BCS - centrilobular congestion, necrosis then fibrosis (not
cirrhosis) - Robbins
E. Alcohol → leading cause of cirrhosis
F. A1AT - childhood OR adult cirrhosis
G. Schistosomiasis: ”cut surfaces reveal granulomas and widespread
fibrosis and portal enlargement without intervening regenerative
nodules… fibrous triads = “pipestem fibrosis” - Robbins.
“Hepatic schistosomiasis may cause or simulate cirrhosis from other
causes” - StatDx
Least likely to be associated with generalised liver fibrosis
A. Budd-Chiari
B. Wilson’s
C. Haemochromatosis
D. Alpha-1 antitrypsin
E. Hepatitis C
Probably Budd-Chiari
A. BCS - centrilobular congestion, necrosis then fibrosis (not
cirrhosis) - Robbins
B. Wilson’s - fatty → hepatitis → cirrhosis (Robbin’s)
C. HCT → fibrosis → cirrhosis
D. A1AT - childhood OR adult cirrhosis
E. Hep C → 20% have cirrhosis (Robbins)
Which is recognised as a precursor for malignant melanoma:
A. Congenital Nevus
B. Blue nevus
C. Spindle cell nevus
D. Dysplastic nevus
E. Halo nevus
D
“Dysplastic nevi are important because they may be direct precursors
of melanoma” - (Robbins)
What is the most common pure germ cell tumour is seen in 60 year old
men?
A. Spermatocytic seminoma
B. Lymphoma
C. Embryonal (yolk sac) tumour
D. Choriocarcinoma
E. Teratoma
A
Most common PRIMARY testicular tumours as per age groups:
o 1st decade – yolk sac tumour and testicular teratoma
o 2nd decade – choriocarcinoma
o 3rd decade – embryonal cell carcinoma
o 4th decade – seminoma
o 7th decade and above – lymphoma and spermatocytic seminoma
Which testicular tumour is most likely in a 60 yo man
A. Spermatocytic seminoma
B. Seminoma
C. Mature teratoma
D. Leydig cell tumour
E. Lymphoma
E
“Aggressive non–Hodgkin lymphomas account for 5% of testicular
neoplasms, and are the most common form of testicular neoplasms in
men older than age 60 years.” - Robbins
Most common PRIMARY testicular tumours as per age groups:
o 1st decade – yolk sac tumour and testicular teratoma
o 2nd decade – choriocarcinoma
o 3rd decade – embryonal cell carcinoma
o 4th decade – seminoma
o 7th decade and above – lymphoma and spermatocytic seminoma
Which is LEAST true in regards to solid pseudopapillary tumour of the
pancreas:
A. Tends to be well circumscribed
B. Usually partially cystic
C. Most common in late middle aged women
D. Good prognosis with surgical resection
E. Associated with VHL
C is definitely false.
E is probably false.
A. True. “Large, well-circumscribed” - Robbins
B. True. “Solid and cystic components filled with haemorrhagic
debris” - Robbin’s
C. False. “Mainly in young women” - Robbins
D. True. “Most patients are cured following surgical resection of the
neoplasm” - Robbins
E. False. “Pancreatic manifestations of VHL include simple pancreatic
cysts, serous cystadenomas, and neuroendocrine tumors (PNETs).” -
RCNA VHL review article
Regarding pleomorphic xanthoastrocytoma: T/F
A. If in adults, usually found in the frontal lobe
B. If in child, usually found in the brainstem or cerebellum
C. Peak age 30-40
D. Common in 50 years
E. Usually high grade (WHO III and IV)
F. Usually involves grey matter and adjacent meninges
G. Superficial with leptomeningeal involvement
H. Irregular margin
I. Temporal lobe
A. False. Temporal lobe most common (approx 50%)
B. False. 98% supratentorial.
C. False. Peak age 10-30 yo (Radiopaedia)
D. False. Usually found children or young adults
E. False. Low grade (WHO II), can be anaplastic (WHO III)
F. True. Cortical baseD. Can have dural tail.
G. True. Cortical baseD. Can have dural tail.
H. False. Well-circumscribed macroscopically.
I. True. Temporal lobe most common (approx 50%)
Robbins: Pleomorphic Xanthoastrocytoma
“This tumor occurs most often in the temporal lobe in children and
young adults, usually with a history of seizures. The tumor consists of
neoplastic, occasionally bizarre, astrocytes, which are sometimes
filled with lipids; these cells can express neuronal and glial markers.
The degree of nuclear atypia can be extreme and may suggest a
highgrade astrocytoma, but the presence of abundant reticulin deposits, relative circumscription, and chronic inflammatory cell
infiltrates, along with the absence of necrosis and mitotic activity,
distinguish this tumor from more malignant types. The pleomorphic
xanthoastrocytoma is usually a low-grade tumor (WHO grade II/III
2016) with a 5-year survival rate estimated at 80%. Necrosis and
mitotic activity are indicative of higher grade tumors and predict a
more aggressive coursE.”
Regarding pleural effusion which is LEAST true:
A. Obstruction of thoracic duct by malignancy is a common cause of
chylothorax
B. Direct spread of intraparenchymal infection is a common cause of
empyema
C. Renal failure is a common cause of haemorrhagic effusion
D. Blunt trauma is a common cause of haemothorax
E. Hypoalbuminemia is a common cause of hydrothorax
C is false.
A. True - transudative
B. True - exudative
C. False - transudative
D. True - haemothorax
E. True - transudative
Which of the following is MOST correct regarding pleural effusions?
A. Chylothorax is caused by extra-thoracic neoplasm.
B. Haemorrhagic pleural effusion can be caused by neoplasm.
C. Exudative effusion caused by liver pathology.
B is true.
A. False - needs to be intrathoracic (unless mets) “Usually such
cancers arise within the thoracic cavity” - Robbins
B. True - haemorrhagic serositis can be due to pleural neoplasm
C. False - transudative
MRI safety question. Which is most true?
A. Patient with ferromagnetic body piercing not able to be removed is
disqualified from entering a 1.5T magnet
B. A patient with a copper ICD is disqualified from entering a 1.5T
magnet
C. External insulin pump which is connected to the patient can get into
a 1.5T magnet
D. A patient cochlear implant is not disqualified from getting into 1.5T
magnet
E. Person with metallic shrapnel foreign bodies from combat is not
disqualified from getting into 1.5T magnet if they are far from vital
organs
A. False. Probably conditional.
B. False. Copper and silver IUD ok for 1.5T (conditional at 3T)
C. False. Insulin pump = absolute contraindication
D. False. Cochlear implants conditional at 1.5T
E. True. Certain shrapnel ok if away from vital organs
“Because pellets, bullets, and shrapnel are frequently contaminated
with ferromagnetic materials, the risk versus benefit of performing an
MR procedure should be carefully considereD. Additional
consideration must be given to whether the metallic object is located
near or in a vital anatomic structure, with the assumption that the
object is likely to be ferromagnetic and can potentially movE.”
Source: mrisafety.com
Liver biopsy patient goes bradycardic, and hypotensivE. What is best management?
A. Atropine 0.6mg IV
B. Atropine 0.6 mg IM
C. Adrenaline 1mg IV
D. Adrenaline 1mg IM
E. Lignocaine
RANZCR 2016:
Vasovagal reaction (hypotension and bradycardia)
- keep supine, elevate legs
- oxygen by mask (6-10L/min)
- atropine
> adults: 0.6-1.0mg IV q3-5min to max 3mg
> paediatric: 0.02mg/kg IV to max 2mg total
- IV fluids (N/S or Hartmann’s 20mL/kg
There is a level 5 node, what neck region does this correspond to?
A. Submental
B. Posterior triangle
C. Hyoid
D. Supraclavicular fossae
E. Mediastinum
5 = Posterior triangle
1A = submental
1B = submandibular
2 = jugular above hyoid
3 = between hyoid and cricoid
4 = below cricoid
5 = posterior triangle
6 = pre/paratracheal (Delphian)
Cervical lymph node above hyoid, anterior to submandibular gland
A. 1
B. 2
C. 3
D. 4
E. 5
A. Level 1A or 1B (posterior border SMG divides 1 from 2)
1A = submental
1B = submandibular
2 = jugular above hyoid (2A is anterior to IJV, 2B is posterior)
3 = between hyoid and cricoid
4 = below cricoid
5 = posterior triangle
6 = pre/paratracheal (Delphian)
Wilms least associated with
A. Denys-Drash
B. WAGR
C. Hutchinsons
D. Perlman syndrome
E. Beckwith-Weidemann
ANSWER: Hutchinson syndrome is not associated with Wilms
tumour.
(Hutchinson syndrome defined as limping and irritability from skeletal
metastases of neuroblastoma - Radiopaedia)
Overgrowth syndromes (WT2 gene)
- Beckwith-Wiedemann (omphalocele, macroglossia, hemihypertrophy, cardiac, hepatosplenomegaly)
- Sotos (cerebral gigantism)
- Perlman syndrome
Non-overgrowth syndromes (WT1 gene)
- WAGR syndrome (Wilms, aniridia, genital anomalies, retardation)
- Denys-Drash (Wilm, male pseudohermaphroditism, proressive
glomerulonephritis)
Isolated abnormalities
- Cryptorchidism
- Hemihypertrophy
- Hypospadias
- Cryptorchidism
Patient has Lynch syndrome (hereditary non-polyposis colorectal
cancer). Which is not typical?
A. Colorectal cancer under 50 years
B. Colorectal cancer in two first degree relatives
C. Metachronous colorectal cancer and endometrial cancer
D. Metachronous colorectal cancer and urothelial cancer
E. Small bowel adenocarcinoma
B
A. T - included in Amsterdam; mean age 45y
B. F - Amsterdam criteria requires 3+ relatives
C. T - COUGR
D. T - COUGR
E. T - COUGR
Most common CRC syndrome (3%)
Autosomal dominant
Microsatellite instability (mismatch repair) - MSH2/MLH1
COUGR - colorectal, ovarian, uterine, gastrointestinal & renal tract
Amsterdam Criteria: (3/2/1 rule)
- 3+ relatives with Lynch-associated cancer
- 2+ generations of Lynch-associated cancer
- 1+ cancer diagnosed before age 50
Lynch syndrome which is least correct
A. More common on the right
B. 50% get cancer by 50
C. Metachronous endometrial cance
B
A. T - 60-80% are right sided (UpToDate)
B. F - can’t find a stat supporting this (U2D / Robbins / StatDx)
C. T - COUGR
Most common CRC syndrome (3%)
Autosomal dominant
Microsatellite instability (mismatch repair) - MSH2/MLH1
COUGR - colorectal, ovarian, uterine, gastrointestinal & renal tract
Amsterdam Criteria: (3/2/1 rule)
- 3+ relatives with Lynch-associated cancer
- 2+ generations of Lynch-associated cancer
- 1+ cancer diagnosed before age 50
With regards to Wilms tumour, which is LEAST correct?
A. Peak age 2-5 years
B. Nearly all bilateral tumours are presumed to have a germ line
mutation
C. Nearly 100% with bilateral tumours have nephrogenic rests
D. Approximately 50% of unilateral tumours have a germ line mutation
E. 10% of patients have lung metastases at primary diagnosis
D is false
A. T - Peak age 2-5; 95% <10y (Robbins)
B. T - “these patients are presumed to harbor a germline mutation”
(Robbins)
C. T - “frequency nearly 100% in bilateral Wilms” (Robbins)
D. F - Syndromic Wilms only 10% (Robbins)
E. T - “Lung metastases in 10-20% at diagnosis” (StatDx)
Peak age 3-4 yo (80% of cases below 5yo)
10-20% have 11p13 (WT1) deletion
10-20% have lung mets at diagnosis
Overgrowth syndromes (WT2 gene, 15p15):
· Beckwith-Wiedemann
· Perlman syndrome
· Simpson-Golabi-Behmel syndrome
· Sotos syndrome
Non-overgrowth syndromes (WT1 gene, 11p13):
· WAGR syndrome
· Denys-Drash syndrome
Isolated abnormalities:
· Cryptorchidism
· Hemihypertrophy
· Hypospadias
· Sporadic aniridia
· Renal fusion
Regarding hydroxyapatite deposition disease: T/F
A. Occurs at the tendon insertions in psoriatic arthritis
B. Occurs in the fingers in scleroderma
C. Is in the calcification in dermatomyositis
D. Has a characteristic appearance in the supraspinatus and the biceps
tendons
E. Can occur at the gluteal muscle insertion in a patient presenting with
hip pain
A. F - psoriasis has enthesitis + periostitis
B. T - secondary HADD
C. T - secondary HADD
D. T - Calcific tendinitis, classic primary HADD
E. T - Calcific tendinitis, classic primary HADD
StatDx:
Broad spectrum of musculoskeletal pathology due to hydroxyapatite
crystal deposition
1. Primary HADD
- calcific tendonitis and bursitis
2. Secondary hydroxyapatite related to underlying disease
- End-stage renal disease
- Collagen vascular disease
- Vitamin D intoxication
- Tumoral calcinosis
Of bone forming tumours, which is most likely to present as a painless
mass?
A. Telangiectatic osteosarcoma
B. Small cell osteosarcoma
C. High grade surface osteosarcoma
D. Parosteal osteosarcoma
E. Periosteal osteosarcoma
Answer: Parosteal osteosarcoma
lowest grade = least aggressive = least painful
Parosteal: low-grade, 20-40F, metaphysis, posterior distal femoral
metaphysis, cauliflower-like with string sign and marrow extension
Periosteal: intermediate, 15-25M, medial distal femoral diaphysis,
densely ossified with no marrow extension
Telangiectatic: containing or largely consisting of large blood-filled spaces, 2nd decade, intramedullary, rare
Carcinoid tumour:
Most aggressive location?
Most common location?
A. Stomach
B. Duodenum.
C. Ileum
D. Appendix
E. Rectum
Answer: C. Ileum is most common AND most aggressive
A. Stomach <10%
B. Duodenum <10%
C. Ileum (jejunum + ileum) >40%
D. Appendix <25%
E. Rectum <25%
Well-differentiated neuroendocrine tumor originating in the digestive
tract (or less commonly, lung or genitourinary tract)
Hirschsprung disease. Which is FALSE?
A. Female more than male
B. Commonly associated with fluid and electrolyte abnormality
C. Typically presents failure to pass meconium
D. Can get megacolon and perforation
E. Can effectively entire colon
Answer: A is false
A. F - 4:1 M>F
B. T
C. T - most classic presentation
D. T - classic presentation
E. T - rare, long-segment Hirschsprung
Congenital anomaly of enteric nervous system
- Absence of ganglion cells in myenteric & submucosal plexus of
intestine
- Lack of peristalsis → functional bowel obstruction
- Aganglionic segment extends retrograde from anus for variable
length with gradual transition to innervated colon
You are about to do a biopsy of a pancreatic head mass. Which are the
most suitable laboratory values?
A. INR 1.2, platelet 30,000, Hb 14. EGFR 85
B. INR 1.3, platelet 90,000, Hb 8.5, EGFR 45
C. INR 1.6. Platelet 40,000. Hb 9.0. EGFR 60
D. INR 1.7. Platelet 90,000. Hb 10
Answer: B
Plts >50
INR < 1.5
eGFR >30 (if IV contrast)
A left SVC most commonly drains into?
A. Right atrium
B. Inferior vena cava
C. Coronary sinus
D. Left atrium
E. Left pulmonary vein
Answer: C. Coronary sinus
RA is defined by the IVC
RV is defined by the moderator band
Most likely lung cancer in non smoking women?
A. Carcinoid
B. Small cell lung cancer
C. Large cell lung cancer
D. Adenocarcinoma
E. Squamous cell carcinoma
“In women and nonsmokers, adenocarcinomas are the most
common” (Robbins)
A. False - 1-5%, M=F, smokers <40.
B. False - 14%, smoking associated
C. False - 3%
D. True - 38%, most common
E. False - 20%, smoking-associated
“The incidence of adenocarcinoma has increased significantly
in the last 2 decades. Adenocarcinoma is now the most common form
of lung cancer in women and, in many studies, men as well.”
(Robbins)
“Cancers in nonsmokers are more likely to have EGFR mutations,
and almost never have KRAS mutations”
Which is most true in osteogenesis imperfecta?
A. All types are associated with “dentinogenesis imperfecta”
B. Type I related with kyphoscoliosis
C. Type II is associated with survival
D. Type III is associated with hearing difficulties
E. Type IV with blue sclera
Answer: D is true
A. False - dentinogenesis not seen in type II
B. False - kyphoscoliosis in type III
C. False - type II is fatal
D. True - type I & III have hearing impairment
E. False - blue at birth → becomes white
Type 1, AD, survives, blue sclera, joint laxity
Type 2, AR, dies, blue sclera
Type 3, AD, progressive deformity, hearing impairment
Type 4, AD, survives, normal sclera
dentinogenesis imperfecta in non-lethal forms
Regarding fibrous dysplasia, what is most correct?
A. Changes in McCune Albright variant are commonly unilateral
B. Calcification and matrix cannot be differentiated from
osteochondroma
C. Leontiasis ossea usually has extracranial involvement
D. Mono-ostotic usually presents earlier than polyostotic
E. Spinal involvement in 10%
Answer: A and C both truE
A. True - McCune-Albright = precocious puberty, polyostotic FD &
Coast of Maine spots (usually unilateral)
B. False - typically ground-glass matrix vs. stippled rings & arcs
C. True - facial involvement in leontiasis ossea
D. False - polyostotic syndromic presents earlier
E. False - spine is rare (<2.5%)
45yo man confused with basal ganglia hemorrhage. The MRI
characteristics are: Iso on T1, Hyperintense on T2. When was the
bleed?
A. < 3 hours.
B. 3 - 72 hours.
C. 3 days to 7 days
D. 7 days to 14 days
E. > 14 day
Answer: A. <3h (hyperacute)
A. True - oxyHb (T1 iso, T2 bright - Prometheus)
B. False - deoxyHb (T1 iso, T2 dark)
C. False - intracellular metHb (T1 bright, T2 dark)
D. False - extracellular metHb (T1 bright, T2 bright)
E. False - extracellular metHb (T1 bright, T2 bright)
>28 days
Juvenile papillomatosis of the breast. T/F?
A. Presents as a palpable mass
B. Nipple discharge is a common finding
C. Occurs in pre-pubertal
D. Appears well defined on mammogram
E. Presents with nipple discharge
F. Occurs in 30-40yo
g. Appears as a mass on ultrasound
A. True - firm mobile mass
B. False - usually no nipple discharge
C. False - young women (mean 19-23)
D. False - occult on mammogram
E. False - usually no nipple discharge
F. False - young women (mean 19-23)
G. True - “Swiss Cheese” disease hypoechoic multicystic mass
Benign localised proliferative breast lesion in young women <30
- presents as a firm mass (no nipple discharge)
- inhomogenous hypoechoic with multiple internal cysts (Swisscheese )
- occult on mammogram (or amorphous calcs)
- MRI multiple T2 bright cysts, benign kinetics
Regarding medullary breast carcinoma. Which is most correct?
A. Poor prognosis
B. Associated with BRCA1
C. ER+, PR+, HER2/neu +
D. Presents as a firm palpable mass with indistinct spiculated margins
E. Special type of invasive lobular carcinoma
B is true.
A. False - “relatively good prognosis compared to other poorly
differentiated carcinomas” (Robbins)
B. True - BRCA1 associated carcinoma
C. False - triple negative “Basal-like cancer, ER/PR/HER2(-)
CK5/6(+)” (StatDx)
D. False - circumscribed mass
E. False - special type of IDC (ductal not lobular)
Medullary breast cancer. Most likely?
A. Spiculated mass on MMG
B. Well circumscribed mass on MMG
C. Cystic component on US
D. Mass like enhancement on MR
E. Hyperechoic on US
B is true.
A. False - circumscribed mass.
B. True - circumscribed mass
C. False - pseudocystic appearance (hypoechoic, posterior
enhancement)
D. False - rim enhancement (StatDx)
E. False - hypoechoic, posterior enhancement
Medullary breast cancer: T/F
A. dense calcifications
B. round
C. usually more benign than other cancers
D. NOS is usually triple negative
A. False - calcifications uncommon
B. True - circumscribed with partially indistinct margins
C. Depends - better prognosis than other poorly differentiated
cancers
D. False - NST “does not meet criteria for special types” (75%)
whereas triple negative = basal-like i.E. a special type (10%)
IDC: E-cadherin retained
ILC: E-cadherin lost in >90%; mostly ER+ve (StatDx)
Luminal A (40-50% as per Flinders 2015): ER+ PR+ HER2 -
Luminal B (15-20%): ER+ PR+ HER2+
HER2 enriched (10%): ER- PR- HER2+
Basal-like (10-20%): ER- PR- HER2- (triple negative)
Least likely complication of acute myocardial infarct MI
A. Acute aortic regurgitation
B. Acute mitral regurgitation
C. Pericardial tamponade
D. Fibrinous pericarditis
E. Left ventricular thrombus
F. Left ventricular aneurysm
G. Left ventricular pseudoaneurysm
A. False - not associated
B. True - papillary muscle rupture
C. True - free wall rupture (ventricular most common) →
haemopericardium → tamponade
D. True - Dressler syndrome (fibrinous or fibrinohaemorrhagic)
E. True - hypokinesis (causing stasis) + endocardial damage
(thrombogenic surface) fosters mural thrombosis
F. True - anterolateral wall, mouth > body
G. True - posterolateral wall, mouth < body; high rupture risk
Contractile dysfunction (LV failure → cardiogenic shock)
Arrhythmias
Myocardial rupture (free wall, septum, papillary muscle)
Ventricular aneurysm
Fibrinous pericarditis (Dressler)
Mural thrombus
Papillary muscle dysfunction
Progressive heart failure
Regarding the oesophagus, which is most correct?
A. Achalasia predisposes to GORD
B. Barrett’s mucosa is characterised by intestinal columnar metaplasia
C. Zenker’s is a traction diverticulum
D. Scleroderma affects the upper ⅓ of the oesophagus
E. Oesophageal serosa acts as a barrier to spread of oesophageal
carcinoma
Answer: B is true
A. False. Failure of LES relaxation; myotomy may cause reflux.
B. True. “Intestinal-type metaplasia… a replacement of the squamous
esophageal epithelium with goblet cells” (Robbins).
C. False. Zenker is pulsion diverticulum above cricopharyngeus.
D. False. Aperistaltic lower ⅔ of oesophagus. (StatDx)
E. False. Rapid local spread “because the oesophagus lacks a
serosa” (Radiographics)
Regarding the oesophagus, which is most correct?
A. H. pylori is associated with oesophageal cancer
B. Zenker diverticulum occurs in the posterior aspect of the upper third
of the thoracic oesophagus
C. Oesophageal adenocarcinoma most commonly occurs secondary to
Barretts
D. Sliding hiatus hernia is the most common cause of reflux
Answer:
A. False. “Some serotypes of H. pylori… decrease risk of esophageal
adenocarcinoma, because they cause gastric atrophy” (Robbins)
B. False. Pharyngeal pulsion diverticulum above cricopharyngeus
C. True. “Most esophageal adenocarcinomas arise from Barrett
esophagus” (Robbins)
D. False. “The most common cause of GE reflux is transient lower
esophageal sphincter relaxation” (Robbins)
Most common cause of jaundice in pregnancy?
A. Acute fatty liver of pregnancy
B. HELLP
C. Viral hepatitis
D. Pre-eclampsia
E. Intrahepatic cholestasis of pregnancy
Answer: C. “Viral hepatitis is the most common cause of jaundice in
pregnancy” (Robbins)
In a very small subgroup of pregnant women (0.1%), hepatic
complications develop that are directly attributable to pregnancy.
These disorders include preeclampsia and eclampsia, acute fatty liver
of pregnancy, and intrahepatic cholestasis of pregnancy. In extreme cases, eclampsia and acute fatty liver of pregnancy may be fatal.
By Trimester:
1st: hyperemesis gravidarum
2nd/3rd: intrahepatic cholestasis > pre-eclampsia > HELLP > AFLDP
(microvesicular steatosis)
Recommendations:
1/ cholelithiasis - common, leave alone unless symptomatic
2/ cholecystitis - lap cholecystectomy
3/ liver mass - monitor adenomas (resect if >5cm)
Which is least correct regarding pituitary adenomas?
A. Macroadenoma commonly invades the cavernous sinus
B. Macroadenomas are commonly nonfunctional
C. Most common secreting hormone is prolactin
D. Associated with MEN2
E. Up to 25% present at autopsy
A. True. Commonly invades cavernous sinus.
B. True. “Nonfunctional adenomas are likely to come to clinical
attention at a later stage… more likely to be macroadenomas”
(Robbins)
C. True. PRL-secreting adenomas “are most frequent… 30%”
(Robbins)
D. False. Associated with MEN1
MEN1 = pituitary, pancreas NET, parathyroid
MEN2A = MTC + phaeo + parathyroid
MEN2b = MTC + phaeo + mucosal neuromas/marfanoid
E. True. 20-25% incidental (StatDx) but about 14% (Robbins)
Which is in the diagnostic criteria for SLE?
A. Erosions
B. Pericarditis
C. Peripheral neuropathy
D. Pulmonary hypertension
Answer: B is true.
A. False - erosions not typical of SLE arthritis
B. True - serositis is major criterion
C. False - not typical of SLE
D. False - common (SLE ILD or CTEPH) but not specific
Dx Criteria for SLE: SOAP BRAIN MD
- serositis
- oral ulcers
- arthritis
- photosensitivity
- bloods (pancytopaenia)
- renal (nephritic, nephrotic)
- ANA
- immunological (dsDNA, Smith, histone)
- neurological (seizures, psychiatric)
- malar rash
- discoid rash
What is least likely in regards to tubular carcinoma?
A. Prognosis is 50% in 5 years
B. Commonly her2/neu negative
C. Spiculated lesion
D. Commonly picked up on mammo
E. Most common age is 50 years old
Answer: A is false.
A. False. Excellent prognosis - 97% at 10 years.
B. True. Usually ER+ PR+ Her2- (StatDx)
C. True. Small spiculated mass.
D. True. Small spiculated mass.
E. True. Mean age 50 (StatDx)
Tubular breast cancer (StatDx)
- uncommon subtype of IDC
- mean age 50
- small spiculated mass (<1cm)
- slow growth, well-differentiated, rare metastasis
- excellent prognosis (97% at 10 years)
- multifocal/multicentric in 10-20%
- typically ER+ PR + HER2-
Least likely to be a spiculated mass?
A. Medullary
B. Tubular
C. Fat necrosis
D. Sclerosing adenosis
E. DCIS
Answer: A - Medullary
A. Medullary - usually well defined breast mass
B. Tubular - spiculated mass
C. Fat necrosis - chronic (>1.5yrs) can be a shadowing spiculated
mass
D. Sclerosing adenosis - usually microcalc +/- distortion (StatDx)
E. DCIS - microcalc +/- mass/distortion (StatDx)
Least likely to be spiculated lesion?
A. PASH
B. Sclerosing adenosis
C. Surgical scar
D. IDC – tubular type
E. ILC
Answer: A - PASH
A. PASH - large circumscribed mass in woman of reproductive age
(StatDx)
B. Sclerosing adenosis - usually microcalc +/- distortion (StatDx)
C. Surgical scar - architectural distortion +/- oil cysts
D. Tubular - spiculated mass
E. ILC - spiculated, distortion, shrinking breast (StatDx)
Which is the most likely composition of renal stones in a patient with
leukaemia
A. Struvite
B. Uric acid
C. Calcium oxalate
D. Cysteine
E. Calcium phosphate
Answer: B. Uric acid
A. False. Struvite - magnesium ammonium phosphate - staghorn
calculi, infections with urea-splitting bacteria (Proteus, staph)
(Robbins).
B. True. Urate - gout, leukaemias. More than half of patients with
urate calculi do not have hyperuricaemia or increased urinary
excretion of uric acid (Robbins)
C. False. Oxalate - hypercalcaemia, & hypercalciuria (hyperPTH,
bone diseases, sarcoid, Crohn’s) (Robbins)
D. False. Due to genetic defects in absorption of amino acids, leading
to cystinuria. Also forms at low urinary pH
AlkalOS - oxalate, struvite
AcidUC - urate, cysteine
Lady with no symptoms has bilateral triangular regions of sclerosis on
iliac sides of sacroiliac joints. What is most likely?
A. Psoriasis
B. Ankylosing spondylitis
C. Osteitis condensans ilii
D. Osteopoikilosis
E. Insufficiency fracture
Answer: Osteitis condensans ilii.
A. False. Painful asymmetric sacro-iliitis
B. False. Painful symmetric sacro-iliitis
C. True.
D. False. Multiple, focal, subarticular & metaphyseal.
E. False. Vertical lucencies lateral to sacral foraminA. Normal stress,
osteoporotic bonE.
Osteitis condensans ilii: response to mechanical stress (StatDx)
- Bilateral, symmetric sclerosis of ilium along sacroiliac joint
- No changes along sacral articular surface
- Absence of other findings
Sacro-iliitis is symptomatic, involves both sides of the joint, with
erosions and joint space narrowing +/- subchondral cysts
Which ovarian lesion is MOST commonly bilateral?
A. Mucinous adenocarcinoma
B. EndometrioidC. Teratoma
D. Brenner
E. Thecoma
F. Clear cell
Answer: B. Endometrioid
Bilateral: Serous (high > low), endometrioid, clear cell and metastases
A. Mucinous cystadenoca: <5% bilateral (Robbins)
B. Endometrioid: 40% bilateral (Robbins)
C. Teratoma: “rare” bilateral (Robbins)
D. Brenner: 10% bilateral (Robbins)
E. Thecoma: 10% of fibroma/fibrothecoma are bilateral (Robbins)
Which ovarian tumour is LEAST likely to be bilateral?
A. Mucinous cystadenocarcinoma
B. Clear cell carcinoma
C. Serous cystadenocarcinoma
D. Metastasis
Answer: A.
Bilateral: serous (high > low), endometrioid, clear cell and metastases
A. Mucinous cystadeno: <5% bilateral (Robbins)
B. Clear cell: 40% bilateral (Robbins)
C. Serous cystadenoca: 65% bilateral (Robbins)
D. Metastasis: >50% bilateral (Robbins)
What is true regarding pseudomembranous colitis.
A. Complicates all acute colitis
B. Involves sloughing of membranes and pseudopolyps
C. Can be a cause of toxic megacolon
Answer: C.
A. False.
B. False. Pseudopolyps in UC > Crohn’s, not C. diff. (Robbins)
C. True. 3% progress to toxic megacolon (StatDx) but UC is the most
common cause (Radiopaedia).
“Fully developed C. difficile–associated colitis is accompanied by
formation of pseudomembranes, made up of an adherent layer of
inflammatory cells and debris at sites of colonic mucosal injury. While
pseudomembranes are not specific and may occur with ischemia or
necrotizing infections, the histopathology of C. difficile-associated
colitis is pathognomonic. The surface epithelium is denuded, and the
superficial lamina propria contains a dense infiltrate of neutrophils
and occasional fibrin thrombi within capillaries. Superficially damaged
crypts are distended by a mucopurulent exudate that forms an
eruption reminiscent of a volcano (Fig. 17-29C). These exudates
coalesce to form pseudomembranes.”
Which chondroid tumour will most likely cross an open growth plate?
A. Enchondroma
B. Osteochondroma
C. Chondroblastoma
D. Chondromyxoid fibroma
E. Periosteal chondroma
Answer: C more likely than D.
A. False. Geographic chondroid lesion centrally in metaphysis.
B. False. Cartilage-covered, arises from cortical surface, continuous
with normal cortex and marrow.
C. True. Eccentric lucent epiphyseal lesion with sclerotic margin that
often crosses physis into metaphysis as it enlarges (25-50%; StatDx).
Prox humerus > prox tibia.
D. True. Geographic metaphyseal (53%) or diaphyseal (43%) lesion;
metaphyseal ones can cross physis into epiphysis. Typical location
proximal tibia; very rare lesion.
E. False. Arises from cortical surface; does not have continuous
cortex and marrow with underlying bone.
What is most likely to appear as a stellate lesion?
A. DCIS
B. LCIS
C. Radial scar
D. Duct ectasia
E. Involuting fibroadenoma
Answer: C. Radial scar
A. False. Fine linear branching pleomorphic calcs.
B. False. Mammographically occult
C. True. “dark star”
D. False. Dilated ducts (MG: linear branching lucencies)
E. False. Popcorn calcifications.
Regarding osteomyelitis: True/False
A. Staph. aureus is an uncommon organism
B. Organisms are located in the epiphysis in adolescence
C. Infection is mostly from direct spread
D. Brodie’s abscess involves the cortex
E. E. coli most common organism
F. Sclerosing osteomyelitis of Garre effects clavicles
G. Sequestrum is infected bone that has become necrotic
A. False. Staph. aureus is 80-90% of pyogenic osteomyelitis
(Robbins).
B. Probably False. “In children, localisation of microorganisms in the
metaphysis is typical. After growth plate closure, the metaphyseal
vessels reunite with their epiphyseal counterparts and provide a route
for the bacteria to seed the epiphyses and subchondral regions,
which are common sites of infection in the adult.” (Robbins)
C. Depends. Children usually haematogenous, adults usually direct
spread.
D. True. “Brodie abscess is a small intraosseous abscess that
frequently involves the cortex and is walled off by reactive bone.”
(Robbins)
E. False. Staph aureus 80-90% (Robbins)
F. False. Sclerosing osteomyelitis of Garre involves mandible -
odontogenic infection, onion skin laminar periosteal reaction.
G. True. “Dead bone is known as a sequestrum” (Robbins).
StatDx:
Neonates = Staph, GBS, E coli
Normal child = Staph
SCD = Staph + Salmonella
Normal adult = Staph, enterics
IVDU = gram neg like Pseudo and Klebsiella
Involucrum is subperiosteal new bone.
Cloaca is the draining sinus.
Garré sclerosing osteomyelitis (Statdx)
- Lytic bone destruction with exuberant periosteal reaction
- Periosteal reaction is typically laminar (“onion skin’)
- Arises from odontogenic (common) or hematologic (uncommon)
origin: Look for involved teeth or follicles
What favors Hodgkin’s over Non Hodgkin’s
A. Localised to a lymph node group
B. Bone marrow involvement
C. Extranodal site involvement
D. Spinal cord involvement
E. Small bowel mesentery involvement
Answer: A is true.
A. True. Hodgkin arises in a single node or chain of nodes and then
spreads to contiguous nodes.
B. False. Bone marrow is extranodal.
C. False. Hodgkin’s rarely extranodal.
D. False. Spinal cord is extranodal.
E. False. “Mesenteric nodes and Waldeyer ring rarely involved”
Hodgkin’s (Robbins):
- More often localised to single axial group of nodes (cervical,
mediastinal, para-aortic)
- Orderly spread by contiguity
- Mesenteric nodes and Waldeyer’s ring rarely involved
- Extranodal presentation rare
An enlarged lymph node with contiguous spread is most likely?
A. Non-Hodgkin’s lymphoma
B. Hodgkin’s lymphoma
Answer: Hodgkin’s lymphoma
Regarding meningioma, which is true?
A. Multiple suggests NF2 mutation
B. Extends into the spinal canal
C. Can invade spinal cord and cause neurology
D. Most common in lumbosacral region
Answer: A is true
A. True. NF2, Familial clear cell meningioma syndrome, multiple
meningiomatosis
B. ?False. “Expands centripetally within dural sac”
C. False. “Slow growing, compresses but does not invade adjacent
structures” (StatDx)
D. False. Thoracic (80%) > cervical (16%) > lumbar (4%)
StatDx Pearls:
1. Tumor dorsal to cord likely meningioma, not schwannoma (nerve
roots are anterolaterally located)
2. Thoracic tumor in female patient is more likely meningioma
3. MR features favouring schwannoma over meningioma: Foraminal
enlargement, located within lumbar spine, fluid signal on T2WI, rim
enhancement.
Which is MOST correct regarding cervical carcinoma?
A. Invasion of the upper third of the vagina confers a worse prognosis
B. High grade cervical intra-epithelial neoplasms have a 50% of
progression to malignant lesions within 5 years
C. LSIL has 50% chance of carcinoma transformation over 5 yrs
D. Neuroendocrine tumours have a worse prognosis than SCC
E. Decreased invasive cervical carcinoma incidence has decreased
since HSV2 vaccination
Answer: D
A. False - Upper vaginal involvement does not have a poor prognosis
– there is 29% mortality at 5 years (stage IIA disease)
B. False - HSIL progression to carcinoma is 10% within 2-10 years
(Robbins)
C. False - LSIL 10% progress to HSIL at 2 years (Robbins)
D. True - Small cell neuroendocrine tumours have a very poor
prognosis (Robbins)
E. False - HPV vaccination.
Cervical cancer - true
A. adenocarcinoma most common
B. most commonly due to HPV 6 and 11
C. extension into upper vagina confers poor prognosis
D. death is usually due to local pelvic complications
E. metastatic to liver and lung
Answer: D > E.
A. False - SCC is most common subtype of invasive cervical
carcinoma (accounts for 80%; second is adenoca 15%) Robbins
B. False - High-risk types are 16 & 18 = SCC of cervix, anogenital,
oropharynx. Low-risk types are 6 & 11 are genital warts.
C. False - Upper vaginal involvement does not have a poor prognosis
– there is 29% mortality at 5 years (stage IIA disease)
D. True - Death is due to local complications such as ureteric
obstruction, pyelonephritis, uraemia. (Robbins)
E. True - Metastasis to the lung, liver, bone marrow. (Robbins)
Cervical cancer most correct
A. Stage II involves pelvic sidewall
B. SCC worse than neuroendocrine
C. Neuroendocrine worse than SCC
D. Local invasion and risk of death
Answer: D
A. False - Pelvic side wall involvement (or lower ⅓ vagina) is stage III
(Robbins)
B. False - “Small cell neuroendocrine tumours have a very poor
prognosis” (Robbins)
C. False (as above).
D. True - Death is due to local complications such as ureteric
obstruction, pyelonephritis, uraemia.
Leiomyosarcoma which statement is MOST correct?
A. Cords of smooth muscle cells involving the veins around the uterus
is a reliable sign of malignancy
B. Intra-uterine bleeding is a reliable sign of malignancy
C. Majority of leiomyosarcomas arise de novo and rarely arise from
leiomyomas
D. Peritoneal lesions are a reliable sign of malignancy
E. Metastasise early to the lungs via haematogenous spread
Answer: C
A. False - “the distinction from leiomyoma is based on nuclear atypia,
mitotic index, and zonal necrosis… presence of 10 or more mitoses
per HPF” (Robbins). “Benign metastasising leiomyoma… extends into
vessels” (Robbins)
B. False. “abnormal bleeding” seen in leiomyomas too (Robbins). No
way this can be specific.
C. True. Leiomyosarcomas “usually arise de novo” (Robbins). Re:
leiomyoma “malignant transformation to leiomyosarcoma, if it occurs
at all, is extremely rare” (Robbins).
D. False. This can be seen with disseminated peritoneal
leiomyomatosis, considered benign (Robbins).
E. Likely False. “more than half eventually metastasise to lungs,
bone, brain” (Robbins)
Regarding DCIS which is most correct?
A. Prognosis associated with nuclear grade
B. Prognosis associated with histological architecture
C. Prognosis not associated with cellular necrosis
D. Recurrence is most common with wide resection margins
E. Prognosis not associated with extent of disease
Answer: A is true. DCIS grading based on nuclear atypia, intraluminal
necrosis and mitotic activity
“nuclear grade and necrosis are better predictors of local recurrence
and progression to invasion than architectural type”
DCIS grading: (little nim)
Low, intermediate or high grade based on
> nuclear atypia
> intraluminal necrosis
> mitotic activity
Invasive grading: (big tnm)
Nottingham criteria
Grade 1 (well Dx) to 3 (poorly Dx) based on
> tubule formation
> nuclear pleomorphism
> mitotic count
Re: DCIS (which is most true?)
A. comedo type calcification is due to tumour cell producing calcium
rich (?secretions)
B. extent of tumour is related to the degree of necrosis of tumour
C. likelihood of recurrence is due to whether there is wide margin of
excision
Probably C.
A. False. Comedo DCIS defined by “high-grade nuclei and areas of
central necrosis” - comedo is a specific form of necrosis (Flinders
Path). Robbins also mentions”calcifications may also be seen in
noncomedo forms of DCIS in association with focal necrosis or
intraluminal secretions”
B. Probably false. “Nuclear grade and necrosis are better predictors
of local recurrence and progression to invasion than architectural
type” (Robbins)
C. Probably true. “The major risk factors for recurrence are (1) high
nuclear grade and necrosis, (2) extent of disease and (3) positive
surgical margins” (Robbins)
Q. Which is least likely secondary to diabetic microangiopathy?
A. Papillary necrosis
B. Glomerulosclerosis
C. Autonomic neuropathy
D. Sensorimotor neuropathy
E. Macular oedema
Answer: D is least clearly linked to microvascular disease
The microangiopathy underlies the development of diabetic
nephropathy, retinopathy, and some forms of neuropathy.
A - True. DM is a classic cause of “necrotising papillitis”.
B - True. Kimmelstiel-Wilson lesion (nodular glomerulosclerosis) is
the hallmark of diabetic nephropathy.
C - True. Autonomic neuropathy is asymmetric due to microvascular
disease.
D - False. Inflammation & cellular dysfunction +/- vascular insult.
E - True. Due to capillary permeability.
Coal workers pneumoconiosis which is LEAST associated with?
A. 1-2mm coal laden macules
B. Coal nodules
C. Honeycombing
D. PMF
E. Centrilobular emphysema
Answer: C is least associated with CWP.
A. False. “Simple coal worker’s pneumoconiosis is characterised by
coal macules (1 to 2mm) and somewhat larger coal nodules”
(Robbins).
B. False. As above.
C. True. Honeycombing is not typical of CWP
D. False. PMF = complicated CWP (Robbins)
E. False. “Coal macules…are scattered throughout the lung (upper
lobes and upper zones of lower lobes more heavily involved), located
primarily adjacent to resp bronchioles. In due course, dilation of adj
alveoli occurs, sometimes giving rise to centrilobular emphysema.”
(Robbins)
Polyarteritis nodosa (PAN) typically spares:
A. GIT
B. Heart
C. Lung
D. Kidney
E. Temporal arteries
Answer: C. PAN spares the lungs
PAN:
Medium vessel vasculitis
“Segmental transmural necrotising inflammation of small to medium
sized arteries”
Hep B positive (30%) young adult
Kidneys > heart > liver > GIT. Spares the lungs.
Acute - eccentric transmural inflammation, fibrinoid necrosis
Chronic - fibrosis
Untreated PAN is typically fatal; 90% remission if treated.
Polyarteritis nodosa MOST likely affects
A. Renal arteries
B. Pulmonary arteries
C. Carotid arteries
Answer: A. PAN is a cause of renal microaneurysms
PAN:
Medium vessel vasculitis
“Segmental transmural necrotising inflammation of small to medium
sized arteries”
Hep B positive (30%) young adult
Kidneys > heart > liver > GIT. Spares the lungs
Acute - eccentric transmural inflammation, fibrinoid necrosis
Chronic - fibrosis
Untreated PAN is typically fatal; 90% remission if treated.
Carcinoid related heart disease, most commonly involves?
A. Tricuspid and pulmonary
B. Aortic and mitral
C. Aortic and pulmonary
D. Mitral and tricuspid
E. Tricuspid and aortic
A - tricuspid and pulmonary valves (right sided).
Carcinoid is a well differentiated neuroendocrine tumour which
secretes serotonin (5-HT).
MAO (lungs, liver) breaks down serotonin.
- Carcinoid valvular disease is typically right sided
- Left sided disease only in 7% of pts with bronchial carcinoid or R to
L shunts
Carcinoid syndrome is due to systemic serotonin.
Neonate has an abnormal brain. Which is least likely?
A. Ulegyria
B. Bleeding into dentate
C. Periventricular cysts
D. Periventricular leukomalacia
E. Intraventricular hemorrhage isolated to the region of the thalamus
Answer: B
A. True - Ulegyria in TERM neonate - shrunken, flattened cortex due
to global hypoxic injury (deepest part of the gyrus is most susceptible
to ischaemic damage)
B. False - seen in adult hypertensive haemorrhage
C. True - periventricular cystic leukomalacia in neonates
D. True - periventricular leukomalacia is seen in neonates
E. True - intraventricular haemorrhage in caudothalamic groove
Periventricular leukomalacia:
Grade 1. increased periventricular echogenicity for >7 days
Grade 2. small periventricular cysts
Grade 3. extensive occipital and frontoparietal cysts
Grade 4. extensive subcortical cysts
Germinal matrix haemorrhage:
Grade I - limited to caudothalamic groove (good prognosis)
Grade II - into ventricles, no hydrocephalus (good prognosis)
Grade III - into ventricles, with hydrocephalus (20% mortality)
Grade IV - intraparenchymal (90% mortality)
Which renal stone is least likely?
A. Uric acid stone in alkaline.
B. Struvite stone in infection.
Answer: A is false.
A. False - AcidUC = urate + cysteine. AlkalOS = oxalate + struvite.
B. True - Struvite (Mg ammonium phosphate) with urea-splitting
bacteria such as Proteus in alkaline urine.
Regarding renal calculi, T/F:
A. Struvite calculus and proteus
B. People with hypercalcaemia develop stone
C. Calcium oxalate and staghorn calculus
D. Calcium oxalate stones account for about 30% of all stones
E. Cystine stones occur in acidic urine
F. Uric acid calculus always occur in patient with hyperuricemia
A. True - Struvite (Mg ammonium phosphate) with urea-splitting
bacteria such as Proteus in alkaline urine. (Robbins)
B. True - Calcium stones (70%) associated with hypercalcaemia and
hypercalciuria (⅔) (Robbins).
C. False - Staghorn calculi from struvite calculi (Robbins).
D. False - 70% of stones are calcium oxalate.
E. True - AcidUC = urate + cysteine. AlkalOS = oxalate + struvite.
F. False - “More than half of patients with uric acid calculi have
neither hyperuricaemia nor increased urinary excretion of uric acid”
(Robbins).
What is least likely cause of papillary necrosis.
A. Phenacetin associated analgesics
B. Sickle cell
C. NSAIDS
D. Diabetes
E. Infection
Answer: All of these are causes
“Papillary necrosis is not specific for analgesic nephropathy, and is
also seen in diabetes mellitus, as well as in urinary tract obstruction,
sickle cell disease or trait (described later), and focally in renal
tuberculosis.” (Robbins)
A. True
B. True
C. True
D. True
E. True
Most likely bilateral renal tumour?
A. Clear cell RCC
B. Papillary RCC
C. Chromophobe RCC
D. Collecting duct RCC
Answer: B. Papillary RCC is most likely bilateral.
A. False - “Usually solitary unilateral” (Robbins)
B. True - “Can be multifocal and bilateral” especially hereditary
papillary RCC syndrome (Robbins)
C. False - In Robbins, bilaterality is only specifically mentioned for
papillary RCC (and syndromes - hereditary papillary RCC, VHL etc).
D. False - See above.
What is best prognosis renal cell cancer?
A. Clear cell RCC
B. Papillary RCC
C. Chromophobe RCC
D. Collecting duct RCC
Answer: C. Chromophobe RCC have the best prognosis.
Chromophobe RCC “have an excellent prognosis compared with that
of clear cell and papillary cancers” (Robbins)
Regarding thyroid disease, which is least true?
A. Patients with Hashimoto have an increased risk of Hodgkins
lymphoma
B. There can be decreased uptake in De Quervain’s thyroiditis
C. (Something about Grave’s)
D. Hashimoto’s thyroiditis is associated with Sjogren’s and other
autoimmune
Answer: A is false.
A. False - Hashimoto’s patients “at increased risk for the development
of extranodal marginal B-cell lymphomas” (Robbins)
B. True - On Tc-99m pertechnetate scan, acute/subacute de
Quervain can have a focal defect or large area of decreased/absent
uptake due to failure of iodine trapping. During recovery phase,
increased uptake before returning to normal (StatDx).
C. No comment.
D. True - Hashimoto’s patients “at increased risk for developing other
autoimmune diseases, both endocrine (T1DM, autoimmune
adrenalitis) and nonendocrine (SLE, myasthenia gravis, Sjogren’s)”
(Robbins).
Cavernoma least likely
A. There is internal normal brain tissue within lesions
B. Presents with epilepsy
C. Recurrent small hemorrhages results in a hemosiderin rim
D. They are occasional associated with a small developmental venous
anomaly
E. They are associated with a large draining vein
Answer: A - No normal intervening brain tissue
A. False. No normal intervening brain (capillary telangiectasias have
relatively normal intervening brain) (Robbins)
B. True. Most common symptom is seizure 50% (Statdx)
C. True.
D. True. 15-20% of DVAs associated with cavernoma (StatDx)
E. True. Are associated with DVAs which can have a large collector
vein
Cavernoma T/F:
A. Macrophages stained with haemosiderin are rare
B. Intervening normal brain
C. Arterial and venous shunting is rarely seen
D. Adjacent brain shows ischaemic change/gliosis (steal phenomenon)
E. Chronic small vessel ischaemic change is common next to it
A. False. Pseudocapsule of gliotic, hemosiderin-stained brain
(Statdx).
B. False. No normal intervening brain (Robbins)
C. True.Comprise low flow channels that do not participate in AV
shunting (Robbins)
D. False. Steal phenomenon occurs with AVM & Sturge-Weber
E. True. “Foci of old haemorrhage, infarction and calcification frequently surrounding the abnormal vessels.” (Robbins)
Gestational trophoblastic disease what is T/F
A. Gestational trophoblastic disease that arises 2 years from last
pregnancy has a better prognosis that occurs 15 years after pregnancy
B. Invasive mets are responsive to chemotherapy
C. Occurs in premenopausal women
Answer: All true.
A. True. Gestational choriocarcinoma has better prognosis than nongestational (note: ovary can be either gestation or non-gestational).
B. True. “The results of chemotherapy are spectacular and result in
nearly 100% remission and high rates of cure” (Robbins).
C. True. Can happen after molar pregnancy (usually complete mole),
ectopic or normal pregnancy. Can happen months after (Robbins)
GTD which is true?
A. All triploid
B. Partial mole is diploid
C. Placental trophoblastic site tumour can occur 2 year after pregnancy
and often more aggressive
Answer: C
A. False. Complete is diploid. Partial is triploid.
B. False. Complete is diploid. Partial is triploid.
C. False. “May manifest many years after a term pregnancy”
(Radiographics). Seems less aggressive than chorio based on limited
sources. “Localised disease have excellent prognosis - 10-15% die of
disseminated disease” (Robbins)
Regarding GTN what is T/F
A. Partial mole is triploid
B. Partial mole can have fetal parts
C. 10% progress to invasive
D. 2-3% complete progress to choriocarcinoma
E. 2-3% partial progress to choriocarcinoma
F. Bimodal with young and older mothers
G. Hydropic villi
A. True. Complete is diploid. Partial is triploid.
B. True. Partial can have fetal parts (complete does not).
C. Trueish - 15% of molar pregnancies progress to persistent/invasive
(Robbins)
D. True - 2.5% of complete moles progress to choriocarcinoma
(Robbins)
E. False - Partial “not associated with choriocarcinoma” (Robbins)
F. True. “Molar pregnancy can develop at any age, but the risk is
higher at the two ends of reproductive life, in teenagers and
between the ages of 40 and 50 years” (Robbins)
G. True. Hydropic villi more seen in complete > partial.
GTN – 4 types
Invasive mole
Choriocarcinoma
PSTT placental site trophoblastic tumour
Epithelioid trophoblastic tumour
Complete
15-20% develop invasive mole
1-2% develop choriocarcinoma
Partial mole
1-4% develop invasive mole
Choriocarcinoma is very rare (almost never)
Regarding retinoblastoma: T/F
A. Bilateral retinoblastoma suggests germline mutation
B. Trilateral Rb means associated intracranial germinoma
C. Retinoblastoma is usually bilateral
D. Retinoblastoma is always associated with a germline mutation
E. Retinoblastoma is autosomal recessive
Answer: A
A. True
B. False. Trilateral = 2 x RB + “pineoblastoma” (Robbins).
“Trilatera l RB: Bilateral ocular tumors + midline intracranial
neuroblastic tumor, typically pineal” (StatDx). Not a germ cell tumour.
Quadrilateral adds a suprasellar tumour.
C. False. 40% bilateral (StatDx)
D. False. 40% inherited (Robbins)
E. False - Autosomal dominant.
Q. Infective endocarditis. T/F:
A. Infection of the aortic valve may spread through the aortic valve ring
to the pericardium
B. Infection of the aortic valve may cause aortic incompetence
C. Patients with IVDU is most associated with right sided valves.
D. fungal endocarditis is a rare cause
A. False. “vegetations… can erode into the underlying myocardium
and produce an abscess (ring abscess)” (Robbins)
B. True. New valvular regurgitation is a major Duke criterion.
C. True. “valves of the right heart may also be involved, particularly in
IVUD” (Robbins)
D. True. Mostly bacterial, but occasionally fungal. “Candida
endocarditis is the most common fungal endocarditis, usually in the
setting of prosthetic heart valves or IV drug abusers” (Robbins)
Which favours acute infective over subacute endocarditis
A. vegetation >1cm in size
B. affect previously abnormal valve
A. Probably true. “The vegetations of subacute endocarditis are
associated with less valvular destruction than those of acute…
although the distinction can be subtle” (Robbins)
B. False. Subacute is characterised by lower virulence (eg. viridans
streptococci), affecting deformed valves, with less destruction
(Robbins)
Q. Regarding acute and subacute bacterial endocarditis.
A. There is a ?size difference between marantic and acute endocarditis
B. No perforation of leaflets
C. Systemic emboli
A. True. Marantic is 1-5 mm and is associated with cancer (esp
mucinous adenoca) and sepsis (Robbins). Infective endocarditis
vegetations range from few mm to > 1cm (Statdx).
B. Acute = destruction of valve leaflets. Subacute = less destruction(Robbins).
C. Both acute and subacute can embolise
Which is not associated:
A. Renal nephrosclerosis and hypertension
B. Ureteric fibroepitheal polyps and desmoids
C. Schistosomasis and SCC
D. RCC and smoking
E. Diffuse cortical necrosis and abruptio placenta
ANSWER: B is not associated.
A. True - Hypertensive nephropathy characterised by hyaline
glomerulosclerosis
B. False - Ureteric polyps associated with Peutz-Jegher syndrome
(also nasal, bronchial, gallbladder, colonic hamartomatous polyps).
Desmoids are associated with APC mutation (FAP) and adenomatous
colonic polyps.
C. True - Chronic schistosomiasis causes squamous metaplasia and
predisposes to SCC.
D. True - Smoking is a major risk factor for RCC and TCC.
E. True - “Diffuse cortical necrosis - uncommon condition occurs most
frequently after an obstetric emergency, such as abruptio placentae
(premature separation of the placenta), septic shock, or extensive
surgery. The cortical destruction has the features of
ischemic necrosis.”
What is associated with anti-basement membrane antibody?
A. Goodpasture’s disease
What is the inheritance pattern of Haemophilia?
What are the associated factor deficiencies?
A. X-linked recessive
X linked recessive, A is commonest (80%)
Haemophilia A: VIII deficiency
Haemophilia B (Christmas disease): IX deficiency
Haemophilia C: XI deficiency
Extremely rare in females because X linked recessive
What is true regarding osteogenesis imperfecta?
A. Type I is AD mutation in type I collagen synthesis
B. Type II compatible with life
C. Type IV has blue sclera
A. True - Type I decreased synthesis of pro-alpha 1 chain.
B. False - Type II dies “perinatal lethal” (Robbins)
C. False - type IV has “normal sclerae” (Robbins)
Type 1, AD, survives, normal stature, blue sclera, joint laxity
Type 2, AR, fatal, blue sclera
Type 3, AD, progressive deformity, hearing impairment
Type 4, AD, survives, normal sclera
FMD – least likely associated with:
A. TIA
B. Pulsatile tinnitus
C. Angina
D. Abdominal pain
E. Claudication
C is true.
A - True - (extracranial ICA)
B - True - (extracranial ICA)
C - False
D - True - (splanchnic)
E - True - (common iliac arteries)
FMD affects extracranial ICA, renal arteries and common iliac
arteries. Intimal, intimomedial or medial fibroplasia
Globular uterus
A. Adenomyosis
B. Leiomyoma
Answer: A.
A. True - “Enlarged globular uterus without well-defined mass or
external contour abnormality - asymmetric uterine wall thickening
posterior > anterior” (StatDx)
B. False - “Homogenous, round, well-defined myometrial mass”
(StatDx)
Which is true/false regarding mucinous cancer of the ovary?
A. Is commonly unilateral
B. Is multicystic with external papillary projections
C. Unilateral multicystic smooth walled ovarian lesion.
A. True. Only 5% of primary mucinous cystadenomas and mucinous
carcinomas are bilat (Robbins)
B. False - “Serous tumours are multicystic OR mass projecting from
the ovarian surface” (Robbins). Multiloculated tumour is true, however
(internal) papillary projections are a feature of serous tumours.
(Robbins)
C. True - “Only 5% of primary mucinous cystadenomas and mucinous
carcinomas are bilateral… They are multiloculated tumors filled with
sticky, gelatinous fluid rich in glycoproteins” (Robbins)
Mucinous - surface rarely involved, only 5% bilateral (Robbins)
Serous - multicystic lesion in which papillary epithelium is within
fibrous cysts (intracystic) or as a mass projecting from the ovarian
surface (Robbins)
AFP elevated in which testicular tumour
A. Seminoma
B. Teratoma
C. Embryonal
D. Endodermal sinus tumour (yolk sac)
E. Choriocarcinoma
ANSWER: Yolk sac. “Presence of AFP is highly characteristic of yolk
sac tumours” (Robbins)
Simplified (Robbins p.979)
AFP = yolk sac
bhCG = choriocarcinoma (or seminoma in 15%, but lower values than
chorio)
LDH = nonspecific related to tumour burden
Wilson’s T/F
A. Commonly presents with corona radiata abnormalities early in the
course
B. Wilsons presents after 6th decade
C. Depositing in lentiform nucleus causing movement disorder
D. Elevated serum ceruloplasmin
E. No increase risk of cancer
F. Wilsons not associated with HCC
A. False. Corona radiata abnormalities not specifically mentioned.
StatDx mentions frontal lobe WM abnormalities.
B. False. Presents between 6 and 40 years age (Robbins p.850).
C. True - Putamen > caudate > thalami > GP - therefore involves the
lentiform (StatDx). Mimics Parkinsonism (Robbins).
D. False - Biochemical Dx “based on decrease in serum
ceruloplasmin, increase in hepatic copper content, and increased
urinary excretion of copper” (Robbins p.850).
E and F. False but controversial. New studies showing some
increased risk of HCC in the setting of earlier onset cirrhosis
Wilson’s True/False:
A. Autosomal recessive
B. Serum copper is an important marker for diagnosis
C. Deposition in the pancreas causes diabetes mellitus
D. Deposition in the basal ganglia causes destruction
E. Deposition in the liver causes chronic hepatitis and cirrhosis
A. True. Autosomal recessive, ATP7B gene.
B. False. “Serum copper levels are of no diagnostic value in Wilson’s”
(Robbins). Biochem Dx requires “decreased serum ceruloplasmin,
increased hepatic iron content and increased urinary excretion of
copper” (Robbins).
C. False. Haemochromatosis deposits in pancreas causing DM.
D. True. “Toxic injury to the brain primarily affects the basal ganglia,
particularly the putamen” (Robbins)
E. True.
Wilson’s True/False:
A. Can show steatosis early
B. Mild signal intensity change within the supratentorial white matter is
the earliest change
C. Presents in neonatal or early childhood period
D. Patchy involvement of corona radiata
A. True. Steatosis progresses to fibrosis then cirrhosis.
B. False.
C. False. 6-40 yo. False. Presents between 6 and 40 years age
(Robbins p.850)
D. False. Involvement is basal ganglia and cerebellum.
Tongue SCC. LEAST likely cause?
A. Alcohol
B. Cocaine
C. HPV
D. Marijuana
E. Syphilis
Answer: B
A. True - strong risk factor
B. False - no references support this (Robbins, StatDx etc.)
C. True - oncogenic HPV strains.
D. Probably True - Articles in literature which both support and dont
support association between marijuana and SCC. Usually used with
tobacco.
E. True. Multiple articles supportive of link between syphilis and
tongue SCC.
Risk factors: alcohol, tobacco, betel/paan, sunlight
Achalasia, which is false?
A. Associated with Chagas disease
B. Associated with SCC
C. Aperistalsis
D. Partial relaxation of lower oesophageal sphincter
E. Decreased resting tone of lower oesophageal sphincter
Answer: E is false.
A. True - Secondary (pseudo)achalasia
B. True - Associated with SCC
C. True - Aperistalsis
D. True - “incomplete LES relaxation, increased LES tone and
aperistalsis”
E. False - Increased tone
Achalasia triad is
1. incomplete LES relaxation
2. increased LES tone
3. aperistalsis
Thyroid malignancy T/F
A. Follicular and regions with low iodine levels
B. Papillary and previous XRT
Answer:
A. True - “Follicular = more frequent in areas with dietary iodine
deficiency” (Robbins)
B. True - Papillary “account for the majority of thyroid carcinomas
associated with previous exposure to ionizing radiation” (Robbins)
True/False:
Which of the following is associated with cholangiocarcinoma: T/F
a) Crohns
b) PBC
c) Cholecystitis
d) Gardner syndrome
e) Cholelithiasis
f) Lynch syndrome
g) Choledochal cyst
h) Hashimotos
Answer:
A - True (IBD -> PSC -> CCA. Also UpToDate)
B - False
C - True
D - False (UTD: Lynch syndrome, BRCA-1, CF, biliary papillomatosis)
E - True
F - True (UTD: Lynch syndrome, BRCA-1, CF, biliary papillomatosis)
G - True
H - False
Risk factors (StatDx):
- PSC
- Fibropolycystic liver disease (choledochal cysts)
- Biliary papillomatosis
- Parasites (Clonorchis & Opisthorchis), recurrent pyogenic
cholangitis
- Cholelithiasis & hepatolithiasis
- Lynch syndrome
- Thorotrast exposure
- Chronic liver disease
What is a false statement
A. ADEM is associated with post bacterial infection
B. In relapsing-remitting multiple sclerosis (MS) the axons are
preserved in the plaques.
C. Central pontine myelinolysis occurs in liver transplants.
A. False. - “follows either a viral infection or, rarely, a viral
immunisation” (Robbins)
B. True - “Within a plaque there is relative preservation of axons”
(Robbins)
C. True - can be a rare complication of liver transplants
Endometrial cancer, least likely risk factor?
A. Diabetes
B. Hypertension
C. Atrophy
D. OCP
Answer: D is false.
A. True - type 1 (endometrioid ca)
B. True - type 1
C. True - type 2
D. False - OCP “have a protective effect” against endometrial and
ovarian ca. (Robbins p. 421)
Type 1 = unopposed estrogen
Risk factors: anovulation, PCOS, diabetes, hypertension, obesity,
tamoxifen, estrogen producing tumours
Type 2 = atrophy
Risk factors: endometrial atrophy, thin physique
Regarding endometrial cancer, true/false:
A. Type 1 usually arise in the context of endometrial atrophy
B. Type 2 is young
C. Type 1 is due to estrogen excess
D. Type 2 has a poor prognosis
A. False (type 2 = atrophy)
B. False (type 1 is 55-65yr, type 2 is 65-75 yr) (Robbins)
C. True
D. True (type 1 is indolent, type 2 is aggressive) (Robbins)
Post menopausal bleeding causes. T/F
A. atrophy
B. polyp
Both true. FIGO: PALM-COEN
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial (hyperplasia, polyp, atrophy)
Iatrogenic
Not classified
Least likely to have polypoid or sessile lesion in the upper vagina
A. endometrial polyp
B. cervix cancer
C. rhabdomyosarcoma
D. endocervical polyp
Answer: E (all true)
A. True - can protrude into upper vagina
B. True - sessile lesion in upper vagina
C. True - (also called sarcoma botryoides “grapelike”)
D. True - can protrude into upper vagina
Associated with von Hippel Lindau T/F:
A. Multiple hepatic cysts
B. Pancreatic adenocarcinoma
C. Clear cell RCC
D. Spinal haemangioblastoma
E. Carcinoma of ampulla of Vater
F. Phaeochromocytoma
G. Pancreatic cysts
A. True
B. False more than true
C. True
D. True
E. False more than true
F. True
G. True (usually serous)
CNS:
- Haemangioblastoma (cerebellar, retinal, cord)
- Endolymphatic sac tumour
Pancreas:
- Pancreatic cysts (serous)
- Neuroendocrine tumours
- Adenocarcinoma (rare)
Renal:
- RCC (clear cell)
- Renal cysts
Liver:
- Hepatic cysts
Genitals:
- Epididymal cysts
- Phaeochromocytoma/extra-adrenal
Cutaneous (less than 5%):
- Capillary malformations
COPD: Most correct:
A. Panacinar in the lower lobe
B. Centriacinar with alpha 1 antitrypsin
C. Cor pulmonale
Answer: A and C both true.
A. True - A1AT and IV methylphenidate.
B. False - A1AT is panacinar (panlobular) not centrilobular
C. True - Right heart failure secondary to respiratory disorder
Pulmonary hypertension, which is correct
A. Cor pulmonale occurs 15-20yrs after pulmonary hypertension
B. Pulmonary hypertension is defined as mean pulmonary arterial
pressure of >100mmHg
C. Interstitial lung disease increases blood flow and leads to pulmonary
hypertension
D. OSA is associated with pulmonary hypertension
ANSWER: D
A. False - death from decompensated cor pulmonale within 2-5 years
in 80% of patients (Robbins p.700)
B. False - mean pulmonary arterial pressure >25mmHg (Robbins p.
700)
C. False - obliterate alveolar capillaries increasing resistance and
increasing pressure (Robbins p.700)
D. True - OSA is group 3 cause of pulmonary HTN
CLASSIFICATION (NICE 2013)
1 (Primary) Pulmonary arterial hypertension
2 Left heart disease
3 Lung disease/hypoxia
4 CTEPH
5 Multifactorial
Which is LEAST associated with UIP
A. Idiopathic pulmonary fibrosis
B. Chronic hypersensitivity pneumonitis
C. Chronic organising pneumonia
D. Rheumatoid arthritis
E. Asbestosis
ANSWER: C. COP is least associated
A. False - typically UIP
B. False - can be UIP pattern (Cluster 2)
C. True - not UIP
D. False - typically UIP
E. False - typically UIP
Typically UIP: IPF, RA, Asbestosis
Sometimes UIP: chronic HP
Not UIP: COP
In RA, UIP > NSIP
Which is MOST likely to develop UIP pattern fibrosis
A. Chronic HP
B. COP
C. RA
D. Asbestosis
E. Silicosis
Answer: D. Asbestosis is most associated
C could also be true depending on wording
A. False - sometimes UIP (Cluster 2)
B. False - not UIP
C. False - UIP > NSIP
D. True - only UIP
E. False - not UIP (upper lobe)
Brain demyelinating disorders T/F:
A. Pontine demyelinosis is most commonly from rapid correction of
hypernatremia
B. Acute hemorrhagic encephalomyelitis is more common in children
C. ADEM follows bacterial infection
D. Multiple sclerosis early is characterized by multiple lesions
destroying axons
A - False. Hyponatraemia.
B - False. AHEM/AHLE (Weston-Hurst) seen in young adults,
contrary to ADEM in children.
C - False. ADEM follows viral infection.
D - False. Demyelination “characterised by preferential damage to
myelin with relative preservation of axons” (Robbins p. 1283)
Demyelination. What is INCORRECT?
A. Relapsing remitting MS usually preserves the axons
B. PML has a predilection for frontal lobes
C. Devic disease usually has bilateral optic neuritis
D. ADEM caused by bacterial infection
E. Central pontine myelinolysis associated with liver transplantation
Answer: D is false. ADEM is post-viral
A. True. Demyelination“characterised by preferential damage to
myelin with relative preservation of axons” (Robbins p. 1283)
B. True-ish. StatDx: “propensity for frontal and parietooccipital region,
thalamus.”
C. True. NMO: “More posterior involvement of optic nerve including
chiasm and simultaneous bilateral disease” (StatDx). “NMO is a
syndrome with synchronous (or near synchronous) bilateral optic
neuritis and spinal cord demyelination (Robbins)
D. False. Viral only. ADEM: “Acute disseminated encephalomyelitis is
a diffuse, monophasic demyelinating disease that follows either a viral
infection or, rarely, a viral immunization.”
E. True. Classically described following rapid correction of
hyponatraemia in alcoholics and liver transplant setting (Radiopaedia)
Which testicular tumour has the WORST prognosis:
A. Seminoma
b . Yolk sac (endodermal sinus) tumour
C. Teratoma
D. Sertoli-Leydig cell
E. Choriocarcinoma
E. True. “The rare pure choriocarcinoma is the most aggressive
NSGCT” (Robbins p.979)
Other trivia:
“Seminomas tend to remain localised to the testis for a long time”
(Robbins p.979)
“In the child, differentiated mature teratomas usually follow a benign
course. In the postpubertal male all teratomas are regarded as
malignant” (Robbins p.979)
Testis: choriocarcinoma is worst
Ovary: non-gestational choriocarcinoma is worst
Most correct:
A. Adenocarcinoma can be treated with tyrosine kinase receptors
B. Small cell lung cancer is not sensitive to chemotherapy
C. Over 70% of bronchial carcinoid will produce carcinoid syndrome
Answer: A is true
A. True - “Targeted treatment of patients with adenocarcinoma and
activating mutations of EGFR… prolongs survival” (Robbins p.718)
B. False - “Small cell lung carcinomas are best treated by
chemotherapy” (Robbins p.719)
C. False - “Approximately 10% of bronchial carcinoids give rise to
[carcinoid] syndrome” (Robbins p.720)
Aspergillus questions least correct:
A. ABPA is caused by a superficial colonisation of bronchial mucosa
B. Ground glass change around invasive aspergillus due to gelatinous
exudate
C. Invasive aspergillus extra-lung in brain and kidney
D. Invasive aspergillus can look like mucormycosis in the
immunocompromised
E. Gelatinous production gives rise to the “halo” sign
Answer: B and E both false
A. True. “This disease is characterised by a hypersensitivity reaction
to Aspergillus that colonises the airways” (Webb p.197)
B. False. StatDx: “CT halo sign pathologically represents
haemorrhage around foci of invasive aspergillosis.”
C. True. “The primary lesions are usually in the lung, widespread
haematogenous dissemination with involvement of heart valves and
brain is common.”” (Robbins 388). Case reports in kidney.
D. True. “Rhinocerebral Aspergillus infection in immunosuppressed
individuals resembles that caused by Mucormycoses” (Robbins p.
389)
E. False. StatDx: “CT halo sign pathologically represents
haemorrhage around foci of invasive aspergillosis.”
Pulmonary aspergillosis can be subdivided into five categories:
1/ saprophytic aspergillosis (aspergilloma)
2/ hypersensitivity reaction (ABPA)
3/ semi-invasive (chronic necrotizing) aspergillosis
4/ airway-invasive aspergillosis (acute tracheobronchitis,
bronchiolitis, bronchopneumonia, obstructing bronchopulmonary
aspergillosis)
5/ angioinvasive aspergillosis
Which is false?
A. Haemoptysis is seen in non-invasive aspergillosis
B. Lucency on CXR around lesion due to gelatinous exudate
C. Most commonly involves the lungs
D. Can also involve CNS
Answer: B
A. True. “the most common clinical manifestation of saprophytic
aspergillosis (aspergilloma; non-invasive) is hemoptysis”
(Radiographics)
B. False. StatDx: Lucency is air-crescent sign due to infarction
leading to progrssive cavitation.
C. True. “The primary lesions are usually in the lung, widespread
haematogenous dissemination with involvement of heart valves and
brain is common.”” (Robbins 388).
D. True. As above.
Pulmonary aspergillosis can be subdivided into five categories:
1/ saprophytic aspergillosis (aspergilloma)
2/ hypersensitivity reaction (ABPA)
3/ semi-invasive (chronic necrotizing) aspergillosis
4/ airway-invasive aspergillosis (acute tracheobronchitis,
bronchiolitis, bronchopneumonia, obstructing bronchopulmonary
aspergillosis)
5/ angioinvasive aspergillosis.
Which of the following is most associated with pancreatic ductal
adenocarcinoma?
A. BRCA 2
B. Li Fraumeni syndrome
C. vHL
D. MEN 1
E. FAP
Answer: A.
A - True. BRCA1/BRCA2 associated with pancreatic adenocarcinoma
B - False. Li Fraumeni = GBM, breast ca, sarcomas, leukaemia
C - False. VHL more associated with pancreatic cysts and
neuroendocrine tumours. Rarely result in adenocarcinoma
(Radiopaedia)
D - False. MEN1 = PPP (organs) = parathyroid, pancreas (islet cell
tumours) & pituitary
MEN2A = MTC & phaeo + parathyroid hyperplasia
MEN2B = MTC & phaeo + marfans/mucosal neuromas
E - False. FAP = 5, colon cancer
+ epidermoid/desmoid/thyroid = Gardner
+ medulloblastoma = Turcot
HPNCC - 8-10x increased risk of pancreatic adenoca.
True/False:
A. Buerger’s causes radial and tibial occlusion in nonsmokers
ANSWER: False. Smoking-related disease.
Thromboangiitis obliterans
Seen in young male smokers with a lower limb predominance
Non-atheromatous vasculitic process
Medium/small vessels - typically radial and tibial arteries
Improves after cessation of smoking
Male smokers <35yo with digital infarcts / autoamputation (think
scleroderma in nonsmoking women)
Least likely regarding renal cell carcinoma:
A. Clear cell hypervascular
B. Papillary carcinoma is hypervascular
C. Papillary carcinoma is rarely bilateral
D. Metachronous tumours
ANSWER: B is false. C is probably false.
A. True. Clear cell = T2 bright, hypervascular
B. False. Papillary = T2 dark, hypovascular (but it will still enhance) -
often bilateral
C. Probably False. “Papillary carcinomas are frequently multifocal in
origin.” (Robbins p.954)
D. True. Requisites: 10% of RCC are multifocal in the same kidney at
diagnosis.
Chromophobe = T2 iso-bright, hypovascular
VHL (chromosome 3) associated with VEGF pathway
Least common renal tumour
A. Papillary adenoma
B. Papillary carcinoma
C. Collecting duct carcinoma
D. Small cell carcinoma
Answer: D is even rarer than C
Collecting duct (Bellini duct) carcinoma represents approximately 1%
or less of renal epithelial neoplasms.
Small cell neuroendocrine carcinoma - 60 cases in literature.
Thyroid papillary cancer least correct:
A. Calcifications within the lesion
B. Lymph nodes have calcifications
C. Lymph nodes cystic
D. Hypovascular
E. Papillary adenoma has ill defined borders
ANSWER: D or E
A - True. Microcalcifications are specific for papillary thyroid ca.
(Psammoma bodies)
B - True. LN calcifications are strongly associated with papillary
thyroid ca.
C - True. Cystic metastases may be seen in children with papillary
thyroid ca.
D - False. StatDx describes “chaotic doppler vascularity” which looks
very vascular on the images.
E - False. Adenoma is usually follicular. Adenoma has well defined
margins (StatDx)
What is MOST correct regarding thyroid lesions
A. Papillary thyroid carcinoma often presents with haematogenous
metastases
B. Anaplastic thyroid carcinoma often causes death via direct invasion
C. Follicular thyroid carcinoma presents with lymph node metastases
D. Papillary thyroid cancer with neck lymph nodes has poor prognosis
Answer = B.
A. False. Papillary “often metastasise by way of lymphatics, but the
prognosis is excellent” (Robbins)
B. True. “most cases death occurs in <1yr due to aggressive growth
and compromise of vital structures in the neck” - Robbins
C. False. Follicular “little propensity for invading lymphatics, regional
lymph nodes rarely involved… vascular (haematogenous)
dissemination common” (Robbins)
D. False. Papillary “often metastasise by way of lymphatics, but the
prognosis is excellent” (Robbins)
Radial scar question T/F
A. Aetiology is not related to ischaemia
B. The central fat is often replaced by soft tissue
C. Radial scar has short spicules
D. Requires further management.
E. Should be re-biopsied
F. Palpable as a clinical mass.
G. No follow up required
H. Is centrally opaque on mammography
A. True. “The term radial scar is a misnomer, as these lesions
are not associated with prior trauma or surgery” (Robbins)
B. False. “A central nidus of entrapped glands in a hyalinized
stroma is surrounded by long radiating projections into
stroma” (Robbins)
C. False. Long spicules.
D. True. High risk lesion. Wide local excision.
E. False. Wide local excision.
F. False. “Rarely palpable, no skin thickening or retraction” (Robbins)
G. False. Wide local excision.
H. False. Lucent centre. Black star
Regarding sclerosing adenosis T/F
A. Sclerosing adenosis is non-proliferative
B. Hyperplasia causes 5% increase risk in malignancy
C. Non-proliferative increases risk of malignancy
D. Radial scar is non-proliferative
E. Proliferative without atypia increases risk 5x
Answer: All false.
A. False. Sclerosing adenosis is proliferative without atypia.
B. False. Moderate-florid is proliferative without atypia; RR = 1.5-2,(lifetime is 5-7%).
C. False. Nonproliferative lesions do not increase risk of malignancy
D. False. Proliferative disease without atypia (complex sclerosing
lesion)
E. False. Proliferative disease without atypia increase RR 1.5-2
(lifetime risk 5-7%)
True/False?
A. Deep abdominal desmoid commonly metastases
ANSWER: A is false.
Desmoid tumour = deep fibromatosis
- large infiltrative occasionally painful mass that frequently recur but
do not metastasise
- teens to 30s; F>M
- abdo fibromatosis favours anterior abdo wall
- majority are sporadic (APC or beta-catenin gene); association is
FAP (Gardner - APC gene)
- histo resembles scar
- Mx = COX2 inhibitor; tyrosine kinase inhibitor, tamoxifen
Which is more likely to cause hyperaldosteronism
A. Adrenal carcinoma in children
B. Adrenal adenoma in adults
C. Secondary hyperaldosteronism with activation of the RAAS
D. Pregnancy
A. This is extremely uncommon.
B. Aldosterone secreting adenoma causes primary
hyperaldosteronism (Conns)
C. Secondary hyperaldosteronism is renovascular disease.
D. Pregnancy is a cause of secondary hyperaldosteronism (Robbins)
Which is more likely to cause hyperparathyroidism:
A. Parathyroid adenoma
B. MEN1
C. Chronic renal failure
D. Parathyroid hyperplasia
E. Small cell lung cancer
ANSWER: 2* hyperPTH more common than 1* and is most
commonly due to chronic renal failure (Radiographics)
A. False. 1* hyperPTH: Adenoma (80%) > MEN1
B. False. 1* hyperPTH: Adenoma (80%) > MEN1
C. True. 2* hyperPTH: CKD > low Ca intake > Vit D deficiency
D. False. 1* hyperPTH: Adenoma (80%); hyperplasia 10-20%
E. False. Paraneoplastic PTHrP is not true PTH.
https://pubs.rsna.org/doi/full/10.1148/rg.2016160004
Phaeochromocytoma is associated with (T/F)
A. NF2
B. Sturge-Weber
C. MEN 1
D. TS
E. VHL
F. NF1
A. False. NF1 not NF2 (Robbins)
B. True. Sturge-Weber is an association (StatDx)
C. False. MEN2A/MEN2B not MEN1 (Robbins)
D. True. TS is associated (StatDx)
E. True. vHL is associated (StatDx)
F. True. NF1 is associated (Robbins)
Phaeochromocytoma hereditary syndromes:
MEN2A, 2B (not MEN1)
vHL
NF1 (not NF2)
SDH
Sturge-Weber
Carney triad
Adenomyosis: T/F
A. monoclonal cells
B. relatively symmetric enlargement of uterus
C. rarely can have venous invasion
D. early loss of responsiveness to cyclic hormones
E. 1% of women have it on autopsy
D is true, others false.
A. F - Non-neoplastic condition (ectopic tissue).
B. F - Asymmetric thickening of posterior myometrium.
C. F - Pathogenesis is likely endometrial invagination or endometrial
rests in myometrium
D. T - “Because adenomyotic endometrium looks like the basalis
endometrium, which seldom responds to hormonal stimuli, cyclic
changes including degeneration, bleeding, and regeneration are less
common in adenomyosis than in endometriosis”
E. F - 20% of uteri (Robbins)
Endometrial layers:
Functionalis: compactum + spongiosum
Basalis
Regarding oesophageal carcinoma:
A. Adenocarcinoma has a better prognosis than SCC
B. Barrett’s is associated with SCC
C. Tracheo-oesphageal fistula increases risk of SCC
D. Scleroderma affects proximal ⅓
E. H.pylori is a risk factor for oesophageal carcinoma
F. SCC has no gender predilection
G. Zenkers affects the upper thoracic oesophagus
A. False. Can’t find anything in Robbins, StatDx or UpToDate to
support this. KM curve similar. Prognosis mainly based on staging.
B. False. Barrett’s associated with adenocarcinoma.
C. True. Risk of oesophageal cancer is increased 50x (UpToDate).
D. False. Scleroderma causes atony/aperistalsis of the distal 2/3 of
the oesophagus.
E. False. “Some serotypes of H. pylori are associated with decreasedrisk of esophageal adenocarcinoma because they cause gastric
atrophy” (Robbins p758).
F. False. Oesophageal SCC “occurs in adults older than age 45 and
affects males four times more frequently than females.” (Robbins p.
759).
G. False. Zenkers is pharyngoesophageal “through Killian triangle, an
area of muscular weakness between transverse fibers of
cricopharyngeus and oblique fibers of lower inferior constrictor”
(StatDx)
Lobular carcinoma most correct:
A. Limited by basal membrane
B. LCIS arises from ducts and tubules
Answer: B
A. False. This describes LCIS
B. True. LCIS arises from the TDLU
Most correct:
A. Ductal ectasia can clinically mimic cancer
True. Duct ectasia may present with noncyclical pain, nipple
discharge, retraction, inversion orpalpable abnormality.
True/False regarding polyposis syndromes
A. Turcot has increased risk of developing medulloblastoma
B. Gardner’s has increased risk of medullary thyroid cancer
C. FAP has increased risk of right sided colon cancer
D. FAP 50% get CRC by 50
E. FAP gets ampullary tumour
F. Lynch have right sided masses
G. Gardner have desmoids
A. True. Turcots = GI and CNS neoplasm. Type 1 is HNPCC +
glioma; Type 2 is FAP + medulloblastoma (StatDx)
B. ?False. Gardners has thyroid carcinomas but not specifically MTC.
C. False. FAP polyps happen everywhere.
D. False. 100% of FAP patients get CRC by age 50.
E. True. FAP get adenomas “particularly adjacent to the ampulla of
Vater and in the stomach” (Robbins p.809)
F. True. HNPCC “tend to occur at younger ages… and are often
located in the right colon” (Robbins p.810).
G. True. Gardners get “osteomas, thyroid and desmoid tumours, skin
cysts” (Robbins p. 806)
What is least likely regarding cholangiocarcinoma?
A. Cholangiocarcinoma causes bile production
B. PSC is a risk factor
C. Cholangitis is a risk factor
ANSWER: A is false.
A. False. Hepatocytes secrete bile
B. True. Definitely a risk factor
C. True. Definitely a risk factor (PSC, RPC)
Risk factors (Radiographics): All due to chronic biliary inflammation
Liver fluke
Recurrent pyogenic cholangitis
PSC
Viral - HIV, HepB, HepC, EBV
Anomaly/malformation (Todani)
Environmental - thorotrast + PVC
Biliary-enteric drainage
Heavy alcohol consumption
Which of the following is (true/false) regarding Ewing sarcoma and
primitive neuroectodermal tumour (PNET) of the bone?
A. Most commonly 15-20 year olds
B. Neuroblastoma is in the differential
C. Occurs in metaphysis of long bones
D. Aggressive chondroblastoma is in the differential
E. Commonly occurs in the extremities
Answer:
A. False. Age 5-25; most common 10-15yrs.
B. True. Metastatic neuroblastoma is a differential; both SRBCs.
C. False. Small bone lesion, large soft tissue mass in diaphysis of a
long bone.
D. False. Chondroblastoma is epiphyseal extends into metaphysis.
E. True. Ewings occurs in long bone diaphyses, “especially the femur
and flat bones of the pelvis”
Which of the following is (true/false) regarding Ewing sarcoma and
primitive neuroectodermal tumour (PNET) of the bone?
A. Has a known propensity to metastasise to liver even at presentation
B. Osteomyelitis is a clinical differential
C. Malignant teratoma is a differential diagnosis
D. Has a bimodal age distribution
E. Aggressive chondrosarcoma is in the differential
Answer:
A. False. Metastasises to lung and bone marrow over liver.
B. True. Both OM and Ewings present with fever and raised
inflammatory markers.
C. False. Teratomas favour midline soft tissue locations.
D. False. Age 5-25y (most common 10-15y).
E. False. Chondrosarcomas usually metaphyseal and have a
chondroid matrix.
Most correct regarding skin lesions:
A. Melanomas with a familial association account for 1% of melanoma’s
B. Immunocompromised patients have predilection for BCC
C. Melanoma’s are most common on areas of skin that don’t receive
sunlight
D. SCC is related to number of blistering UV sunburns below 20yrs
E SCC is more common than BCC
ANSWER: B is true.
A. F - 10-15% inherited in AD trait (Robbins)
B. T - BCC and SCC associated with immunosuppression
C. F - most commonly arise on sun-exposed surfaces (Robbins)
D. F - this is related to melanoma
E. F - BCC > SCC >all other cancers
Regarding bladder/urothelial cancer (T/F):
A. Serous type most common in renal pelvis
B. Papillary type most common in ureter
C. Non-papillary most common in the bladder
D. Renal pelvis most likely papillary
E. Renal pelvis most likely sessile
F. Ureter more likely papillary
G. Ureter more likely sessile
H. Bladder most likely papillary
I. Bladder more likely sessile
Basically summarised in these Robbins quotes:
- “There are two distinct precursor lesions to invasive urothelial carcinoma: noninvasive papillary tumors and flat noninvasive urothelial carcinoma. The most common precursor lesions are the noninvasive papillary tumors, which originate from papillary urothelial hyperplasia.”
- “Pelvic/ureteric “are the exact counterpart of those found in the urinary bladder”
Overall most common in bladder (posterolateral) and renal pelvis.
Within the ureter, distal (¾) > mid (¼) > proximal (3%). Think about urine stasis.
Regarding prognosis of bladder/urothelial cancer (T/F)
A. Lesions at renal pelvis tend to be large at presentation
B. Lesion morphology determines aggressiveness
C. Papillary is usually aggressive
D. Papillary confers worse survival
E. Polypoid lesions worse than flat lesions
A. False. “Renal pelvic tumours… are almost invariably small when
discovered” due to haematuria, hydronephrosis, pain (Robbins p.956)
B. True. Ta = exophytic papillary lesions “relatively benign and do not
invade”. Tis = carcinoma in situ or flat tumours. (UpToDate).
Also papillary ”[may be low or high grade] and flat urothelial
carcinoma in situ (uniformly high grade)”. (Robbins p.968).
C. False. “Overall the vast majority of papillary tumours are low
grade” (Robbins p. 965)
D. False. Major determinant of survival is detrusor involvement.
E. False. Flat lesions are “uniformly high grade” (Robbins p.968).
Regarding risk factors for bladder cancer (T/F)
A. Exstrophy with cystitis glandularis
B. Interstitial cystitis
C. Analgesia
D. Smoking
E. Schistosoma haematobium
F. Radiation cystitis
G. Urachal remnant with cystitis glandularis
H. Chronic infection
I. Bladder calculi
J. Bladder diverticulum
A. True. “The exposed bladder mucosa may undergo colonic
glandular metaplasia [cystitis glandularis]… have an increased risk of
adenocarcinoma arising in the bladder remnant” (Robbins p.962)
B. False. Interstitial cystitis may clinically mimic carcinoma in-situ
(Robbins p. 963) but doesn’t increase risk of cancer.
C. True. Chronic analgesics → TCC (Robbins p.965)
D. True. Smoking “is clearly the most important influence, increasing
the risk threefold to sevenfold” for TCC (Robbins p.965)
E. True. Ova deposits in bladder wall → squamous metaplasia →
SCC; 70% SCC and remainder TCC or adenoca. (Robbins p.965)
F. True. “bladder cancer occurs many years after the irradiation”
(Robbins p.956)
G. True. Cystitis glandularis = colonic metaplasia. Urachal remnant
“account for 20-40% of all bladder adenocarcinomas” (Robbins p.962)
H. True. “Pure squamous cell carcinomas are nearly always
associated with chronic bladder irritation and infection” (Robbins
p.967)
I. True. Squamous cell carcinomas associated with calculi
(UpToDate).
J. False. Nothing about this in Robbins or UpToDate.
Urothelial Cancer Epidemiology:
M>F (3:1), Age 50-80y, Not familial (rare exceptions)
Smoking (3-7x risk)
Exposures: aryl amine, radiation
Medication: analgesics, cyclophosphamide
Infection: Schistosoma haematobium
Regarding risk factors for bladder adenocarcinoma (T/F)?
A. Urachal remnant
B. Bladder exstrophy
C. Schistosomiasis
D. Chronic infection
E. Bladder calculi
A. True. Urachal remnant “account for 20-40% of all bladder
adenocarcinomas” (Robbins p.962)
B. True. “The exposed bladder mucosa may undergo colonic
glandular metaplasia [cystitis glandularis]… have an increased risk of
adenocarcinoma arising in the bladder remnant” (Robbins p.962)
C. True. Ova deposits in bladder wall → squamous metaplasia →
SCC; 70% SCC and remainder TCC or adenoca. (Robbins p.965)
D. False. “Pure squamous cell carcinomas are nearly always
associated with chronic bladder irritation and infection” (Robbins
p.967)
E. False. Squamous cell carcinomas associated with calculi
(UpToDate).
Regarding bladder/urothelial cancer (T/F):
A. 50% of ureteric TCC will have bladder TCC
B. Usually diagnosed at a low stage
C. Lymph node invasion is what results in greatest reduction in 5 year survival
D. Pre-cancerous/high risk lesions treated with BCG
A. True. “50% of renal pelvis tumours have pre-existing or
concomitant bladder urothelial tumour” (Robbins p. 956)
B. False. “A significant issue is that 50% of invasive bladder cancers
present with muscle-invasive disease and have a relatively poor prognosis despite therapy.” (Robbins p. 968).
C. False. “the major decrease in survival is associated with invasion
of the muscularis propria (detrusor muscle). Once [this] occurs there
is a 30% 5 year mortality rate.” (Robbins p. 964).
D. True. “Patients at high risk of recurrence and/or progression…
receive intravesical [BCG vaccine]” (Robbins p.968).
K gated encephalitis occurs within?
Hippocampus.
60% of patients have circulating serum autoantibodies:
- Anti-Hu (lung cancer): Limbic encephalitis
- Anti-Ta (testicular germ cell tumors): Limbic encephalitis, brainstem
encephalitis
Cell surface antigens:
- Voltage-gated potassium channels (VGKC)
- N-methyl-D-aspartate receptor (NMDAR)
Regarding rheumatoid arthritis, which is correct?
A. Radiology is completely useless
B. Antibodies are T-cell mediated
C. RA is a cause for Baker’s cyst
D. Ankylosis of the joint is not a late presentation
E. Systemic amyloidosis in 50% of cases
ANSWER: C is true.
A. False. Radiology for active disease
B. False. Antibodies create by B cells; immune response T-cell
mediated.
C. True. Baker’s cyst can be due to any cause of synovitis.
D. False. Ankylosis is a late feature of RA.
E. False. Systemic amyloidosis (SAA) in 5-10% (Robbins)
Which cystic renal disease is hereditary?
A. Multicystic renal dysplasia
B. Adult-onset medullary cystic renal disease
C. Juvenile nephronopthisis
D. Acquired renal cystic disease.
E. Medullary sponge kidney.
Answer: B and C.
A. False. Sporadic. Irregular kidneys with cysts of variable size.
B. True. Dominant. Corticomedullary cystd, shrunken kidneys.
C. True. Recessive. Corticomedullary cysts, shrunken kidneys.
D. False. Sporadic. Cystic degeneration in end-stage kidneys.
E. False. Sporadic. Medullary cysts on excretory urography
Mode of spread for testicular cancer
A. ipsilateral inguinal nodes
B. ipsilateral pelvic nodes
C. ipsilateral retroperitoneal nodes
D. lung
E. bone
ANSWER: C Retroperitoneal nodes.
Robbins:
Lymphatic spread is common to all forms of testicular cancer;
generally retroperitoneal para-aortic nodes are first to be involved.
Haematogenous spread is primarily to the lungs.
Seminomas remain confined to the testis for a long time and spread
mainly to paraaortic nodes – distant spread is rare. Non-seminomas
tend to spread earlier and involve haematogenous route more
frequently
Regarding lung infections
A. Staph aureus is the most common cause of community acquired
pneumonia
B. Viral have higher CRP than bacterial infections
C. Most URTIs are bacterial
D. Most abscesses contain oral commensal anaerobes
E. Mycoplasma common in elderly
Answer: D is true. Others all false.
A. False. “S. pneumoniae (the pneumococcus) is the most common
cause of community-acquired acute pneumonia; the distribution of
inflammation is usually lobar.” (Robbins p.707)
B. False. “C-reactive protein and procalcitonin, both acute-phase
reactants produced primarily in the liver, are significantly elevated in
bacterial more than in viral infections.” (Robbins p.702)
C. False. “The vast majority are upper respiratory tract infections
caused by viruses (common cold, pharyngitis)…” (Robbins p.702)
D. True. “Lung abscess is often caused by anaerobic organisms or by
mixed infections and frequently occur in debilitated individuals
following aspiration of oral flora” (Robbins p. 708).
E. False. “Mycoplasma infections are particularly common among
children and young adults. They occur sporadically or as local
epidemics in closed communities (schools, military camps, and
prisons).” (Robbins p.704)
LRTI - most correct
A. Klebsiella presents with haemoptysis
B. Pseudomonas is seen in chronic alcoholics
C. Strep. pneumoniae usually bronchopneumonia
D. Staph A. is the most common organism in COPD
Answer: A is true.
A. True. “Thick, mucoid, (often blood-tinged) sputum is characteristic,
because the organism produces an abundant viscid capsular
polysaccharide, which the patient may have difficulty expectorating.”
(Robbins p.703)
B. False. P. aeruginosa is “seen in persons with cystic fibrosis, in
burn victims, and in patients with neutropenia” (Robbins p. 708). K.
pneumoniae is seen in chronic alcoholics.
C. False. Strep. pneumoniae is “the most common cause of
community-acquired acute pneumonia; the distribution of
inflammation is usually lobar.”
D. False. “common causes of acute pneumonias in the community
include H. influenzae and M. catarrhalis (both associated with acute exacerbations of COPD)” (Robbins p.708). Staph aureus is described
as “usually secondary to viral infections”.
Which is least likely to cause lung consolidation?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Klebsiella
D. Legionella
Answer: All of these cause lung consolidation. Mycoplasma, PJP and
viral pneumonia are reasonable alternatives.
A. False. “Consolidation usually limited to 1 lobe, almost always abuts
visceral pleural surface; air bronchograms present; lacks
extrapulmonary features” (StatDx)
B. False. Staph aureus preferentially causes bronchopneumonia.
“patient with fever, cough, & multifocal consolidation” (StatDx)
C. False. Klebsiella typically causes “lobar pneumonia with bulging
fissures” and cavitates in 30-50% (StatDx).
D. False. Legionella causes “rapidly progressive, asymmetric lung
consolidation” (StatDx)
Spondylitis T/F
A. TB spondylitis is more aggressive than Staph aureus spondylitis
True. “Mycobacterial osteomyelitis tends to be more destructive and
resistant to control than pyogenic osteomyelitis.” (Robbins p. 1196).
Regarding thyroglossal duct T/F?
A. Carcinoma in the duct arise in elderly patient
B. Thyroglossal duct cyst is usually <1cm in size
C. Increased risk of SCC
D. SCC rarely metastasizes
E. UV importan
A. True. “Malignant transformation within the lining epithelium has
been reported but is rare” (Robbins p. 741).
B. False. “1 to 4 cm in diameter” (Robbins p. 741).
C. True. “Malignant transformation within the lining epithelium has
been reported but is rare” (Robbins p. 741).
D. True - probably. See above. Not specified in Robbins.
E. False. No mention of UV in Robbins
Regarding hyperaldosteronism, which is incorrect?
A. Adrenocortical carcinoma is more common in children
B. Adrenocortical adenoma is more common in adult
C. Primary hyperaldosterone is rarely idiopathic
Answer: C is most false.
A. True. “Adenomas and carcinomas are about equally common in
adults; in children, carcinomas predominate.” (Robbins p. 1132).
B. True. Adenoma prefers adults. “Adenomas and carcinomas are
about equally common in adults; in children, carcinomas
predominate.” (Robbins p. 1132).
C. False. “Bilateral idiopathic hyperaldosteronism (IHA)… is the most
common underlying cause of primary hyperaldosteronism, accounting
for about 60% of cases.” (35% is Conn’s adenoma).
Regarding phaeochromocytoma, which is false:
A. Elevated urine VMA
B. It is typical but not common to present with hypertension and
hypokalaemia
C. Commonly presents with intermittent hypertension
D. Rare, but recognised location is organ of Zuckerkandl
E. Extra-adrenal is more likely malignant than adrenal
F. MEN 2 is more associated with malignant phaeochromocytoma
Answer: B is false.
A. True. “The laboratory diagnosis of pheochromocytoma is based onthe demonstration of increased urinary excretion of free
catecholamines and their metabolites, such as vanillylmandelic acid
and metanephrines.” (Robbins p.1137)
B. False. This is typical of Conn’s syndrome due to an aldosteronesecreting adrenal adenoma.
C. True. “Approximately two thirds of patients with hypertension
demonstrate paroxysmal episodes” (Robbins p. 1136)
D. True. “Ten percent of pheochromocytomas are extra-adrenal,
occurring in sites such as the organs of Zuckerkandl and the
carotid body.” (Robbins p. 1136)
E. True. “Malignancy is more common (20% to 40%) in extraadrenal
paragangliomas, and in tumors arising in the setting of certain
germline mutations.”
F. True - Probably. “Malignancy is more common (20% to 40%) in
extraadrenal paragangliomas, and in tumors arising in the setting of
certain germline mutations.”
Eosinophilic pneumonia, which is incorrect?
A. Loeffler has reticulonodular opacity and is self-limiting
B. Chronic eosnophic pneumonia is airspace opacity and not
responding to steroids
C. Acute eosinophilic pneumonia is diffuse opacity and responds well to
steroids
D. Tropical eosinophilic pneumonia responds well to anti-filarial
medication
Answer: B is more incorrect than A.
A. True. Drug-induced is “migratory mid and upper lung zone
peripheral ground-glass opacities &/or consolidations ± centrilobular
nodules” but the tropical/parasitic version has “fine, diffuse
reticulonodular opacities in lower lung zones” (StatDx)
B. False. “These patients have cough, fever, night sweats, dyspnea,
and weight loss, all of which respond to corticosteroid therapy.”
(Robbins p. 695).
C. True. “The chest radiograph shows diffuse infiltrates, and
bronchoalveolar lavage fluid contains more than 25% eosinophils.
Histology shows diffuse alveolar damage and many eosinophils.
There is a prompt response to corticosteroids.” (Robbins p.695)
D. True. “Tropical pulmonary eosinophilia = fine, diffuse
reticulonodular opacities in lower lung zones; caused by filarial worms
Wuchereria bancrofti and Brugia malayi” (StatDx)
Which is most correct regarding intracranial haemorrhage?
A. Amyloid bleed is more peripherally distributed
B. Hypertensive bleed is centered on centrum ovale
C. Herpes haemorrhagic encephalitis is in occipital lobe
Answer: A is true.
A. True. Cortical/subcortical microhaemorrhage. “Lobar > > basal
ganglionic hemorrhage.” (StatDx).
B. False. “Deep structures (basal ganglia, thalami, cerebellum) >
cortex, subcortical WM” (StatDx)
C. False. “Medial temporal and inferior frontal cortex… involvement of
cingulate gyrus and contralateral temporal lobe highly suggestive”
(StatDx).
Which is most correct regarding endometrial carcinoma
A. Patients with endometrial carcinoma commonly develop breast
cancer
B. Can spread to the serosa
C. Indolent in elderly women
Answer: B.
A. False. Depends on wording - tamoxifen (breast cancer Rx) causes
endometrial hyperplasia and increases ca. risk.
B. True. Serosal involvement is stage IIIA.
C. False. Type 2 endometrial cancer is worse than type 1.
What is the MOST likely palpable testicular tumour in a 20yo male?
A. Seminoma
B. Endodermal sinus tumour
C. Teratoma
D. Embryonal carcinoma
E. Lymphoma
ANSWER:
Not clear. Likely seminoma > embryonal carcinoma.
Robbins:
“In the 15- to 34-year age group, testicular germ cell tumors constitute
the most common tumor of men and cause approximately 10% of all
cancer deaths.”
“Seminomas are the most common type of germ cell tumor, making
up about 50% of these tumors. The peak incidence is the third
decade and they almost never occur in infants.”
“Embryonal carcinomas occur mostly in the 20- to 30-year age group.
These tumors are more aggressive than seminomas.”
Which is more likely to suggest UC?
A. Fistula and sinuses are common
B. Transmural inflammation
C. Thick fibrosed bowel wall
D. Granulomas present in 1/3 of cases
E. Rare recurrence after colectomy
Answer: E.
A. False. Penetrating disease is a feature of Crohn’s.
B. False. Transmural inflammation is a feature of Crohn’s. UC
inflammation is mucosal and submucosal.
C. False. Fibrostenosing disease is due to transmural inflammation,
seen in Crohn’s.
D. False. Non-caseating granulomas are a hallmark of Crohn’s
disease, seen in 35%. Not present in UC.
E. True. “Colectomy effectively cures intestinal disease in ulcerative
colitis, but extraintestinal manifestations may persist” (Robbins p.
800).
Acute pancreatitis which is false?
A. 10% is caused by alcohol and biliary tract pathology
B. Get foci of fat necrosis
C. Hypocalcaemia is a common biochemical finding
A. False - “Gallstones are present in 35-60% of cases… The proportion of cases of acute pancreatitis caused by excessive alcohol
intake varies from 65% in the United States to…5% or less in
[France/UK]” (Robbins p.884)
B. True. “Macroscopically, the pancreatic substance is red-black from
hemorrhage and contains interspersed foci of yellow-white, chalky fat
necrosis” (Robbins p. 887). This is the archetype of fat necrosis.
C. True. “Hypocalcemia may result from precipitation of calcium
soaps in necrotic fat.” (Robbins p.887) Part of Ranson’s criteria
Regarding GIST (T/F)
A. Usually treated with tyrosine kinase inhibitors
B. GISTs <5cm are unlikely to metastasize
C. Stomach GISTs are more aggressive than small bowel GIST
D. Carney triad is defined as GIST tumour, phaeochromocytoma and
skin nodules
E. Presents as an exophytic mucosal lesion
F. The term GIST encompasses mesenchymal tumors leiomyosarcoma
and leiomyoma
G. If greater than 3cm indicates poor prognosis
H. Most common in the small bowel and colon
I. Associated with NF1
J. Metastasize early
K. Size determines grade
A. True. “95% of GISTs express growth factor receptor with tyrosine
kinase activity (c-KIT [CD117])” (StatDx). This is the basis of imatinib
(TK inhibitor) treatment.
BTrue. “Recurrence or metastasis is rare for
gastric GISTs smaller than 5 cm but common for mitotically active
tumors larger than 10 cm.” (Robbins p.776).
C. False. “The prognosis correlates with tumor size, mitotic index, and
location, with gastric GISTs being less aggressive than those
arising in the small intestine.” (Robbins p.776)
D. False. Carney triad = Malignant epithelial gastric GIST, pulmonary
chondroma and extraadrenal paraganglioma (StatDx)
E. False. Exophytic “submucosal tumor of (GI) tract derived from
interstitial cells of Cajal” (StatDx).
F. False. “Distinct, not synonymous with leiomyoma/sarcoma”
(StatDx)
G. False. “Prognosis often depends on tumor size - Poor if > 5 cm”
(StatDx); as above, less likely to metastasize if <5cm.
H. False. “Stomach is most common site (2/3 of cases); small bowel
(especially duodenum) is 2nd most common site” (StatDx)
I. True. Associated with NF1, Carney triad, and SDH mutations
(Carney-Stratakis syndrome: GIST + paraganglioma) (Robbins).
J. False. “Recurrence or metastasis is rare for gastric GISTs smaller
than 5 cm but common for mitotically active tumors larger than 10 cm.”
K. True. “The prognosis correlates with tumor size, mitotic index, and
location” (Robbins p. 776)
Which is most correct regarding Marfan’s syndrome?
A. Associated with cystic degeneration of the medial
B. Commonly associated with mitral valve prolapse, without life
threatening regurgitation
C. Arachnodactyly is associated with pathological fractures
D. Aortic rupture is most common in 50-75 year olds
A. True. “Histologically the changes in the media are virtually identical
to those found in cystic medionecrosis not related to Marfan
syndrome” (Robbins p.145).
B. True. “The two most common lesions are mitral
valve prolapse [and aortic aneurysm]… Although mitral valve lesions
are more frequent, they are clinically less important than aortic
lesions” (Robbins p.145). MVP develops complications in 3% of
cases (Robbins p. 556).
C. False. “Typically the patient is unusually tall with exceptionally long
extremities and long, tapering fingers and toes. The joint ligaments in
the hands and feet are lax, suggesting that the patient is doublejointed; typically the thumb can be hyperextended back to the wrist.”
but no mention of pathologic fractures (Robbins p. 145).
D. False. Younger. “Aortic dissection occurs principally in two groups
of patients: (1) men aged 40 to 60 years with antecedent
hypertension (more than 90% of cases) and (2) younger adults with
systemic or localized abnormalities of connective tissue affecting the
aorta (e.g., Marfan syndrome).” (Robbins p. 504).
Marfan’s Syndrome:
autosomal dominant CTD due to fibrillin 1 mutation → fragmentation
of elastic lamellae → cystic medial degneration
Which is least likely regarding Hirschsprung disease?
A. Loss of the Auerbach plexus
B. Loss of the Myenteric plexus
C. Commonly spares the rectum
D. Associated with Trisomy 21
E. A cause of megacolon
Answer: C is false.
A. True. Aganglionic “distal intestinal segment that lacks both the
Meissner submucosal and the Auerbach myenteric plexus” (Robbins
p.751)
B. True. Aganglionic “distal intestinal segment that lacks both the
Meissner submucosal and the Auerbach myenteric plexus” (Robbins
p.751)
C. False. “The rectum is always affected, but the length of the
additional involved segments varies widely” (Robbins p.752).
D. True. “10% of all cases occur in children with Down syndrome”
(Robbins p. 751)
E. True. Electrolyte imbalance, megacolon, perforation, sepsis.
What is (true/false) regarding aortic dissection?
A. Hypertension least likely in younger adults
B. Hypertension is an important antecedent in young patients
C. 5-10% don’t have an obvious intimal tear.
D. If an intimal tear is seen, it is most likely in aortic arch or proximal
descending aorta in 70-80% of cases
E. Blood dissects into the inner media
F. Type B dissection can involve the left common carotid causing
strokes
G. Cystic medial necrosis is found in <5% of autopsies
A. True. “two groups (1) men aged 40 to 60 years with antecedent
hypertension (more than 90% of cases) and (2) younger adults with
systemic or localized abnormalities of connective tissue affecting the
aorta (e.g., Marfan syndrome)” (Robbins p. 504)
B. False. See above.
C. True. “5-10% are without intimal tear; dissection is attributed to
rupture of aortic vasa vasorum” (StatDx).
D. False. “Type A (60%): Involves ascending aorta, ± descending
aorta [90% within 10 cm of aortic valve]. Type B (40%): Excludes
ascending aorta; involves descending aorta &/or aortic arch.” (StatDx)
E. True. “Once a tear has occurred, blood flow under systemic
pressure dissects through the media, leading to progression of the hematoma.” (Robbins p. 504).
F. False. Type B is distal to subclavian origin, does not involve the great vessels.
G. False. “The most frequent preexisting histologically detectable
lesion is cystic medial degeneration” (Robbins p.504)
An emanciated alcoholic patient has a lung abscess with Bacteroides on culture. What is the most likely causative mechanism?
A. Chronic aspiration with infection from a mouth commensal
B. Chronic aspiration with infection from a GIT commensal
C. Complicated infection from diverticulosis
Answer: A
A. True. Aspiration typically due to oral anaerobes including
Bacteroides spp.
B. False. GI commensals commonly seen with bowel obstruction.
C. False. This requires septic embolism
aspiration Bacteroides spp., mixed anaerobes (most common)
septic emboli Staph aureus
bacteraemia E. coli, Staph aureus
colorectal ca. Strep. bovis (typically causes endocarditis)
What is the most common orbital tumour of childhood?
A. Haemangioblastoma
B. Lymphoma
C. Retinoblastoma
D. Optic sheath meningioma
Answer: C
Retinoblastoma is 10 x more common than rhabdomyosarcoma
Rhabdomyosarcoma is the most common mesenchymal tumour of
childhood
Infantile hemangioma is the most common tumour of infancy
*if infantile hemangioma is offered choose this
A post-partum woman has swelling in the basal ganglia and thalami.
Which is most likely thrombosed?
A. SSS
B. ISS
C. Internal cerebral vein
D. Cavernous sinus
E. Vein of Labbe
C
Cavernous sinus thrombosis
- distended superior opthalmic vein + proptosis
- typically a complication of orbital/periorbital cellulitis
Dural venous sinus & cortical vein thrombosis
- empty delta sign
- typically a complication of hypercoagulable state
Venous infarcts show:
- oedema - expansion, loss of GWMI, T1 low T2/FLAIR high signal
- may not restrict diffusion
- non-enhancing oedematous brain
Which of the following is not associated with Lyme disease?
A. Locomotor ataxia
B. Cranial nerve VII palsy
C. Radiculoneuritis
D. Aseptic meningitis
E. Encephalomyelitis
Answer: A.
A. True. Locomotor ataxia is not typical of Lyme disease.
B,C,D,E. False. “Involvement of the nervous system is referred to as
neuroborreliosis. Neurologic symptoms are highly variable and
include aseptic meningitis, facial nerve palsies and other
polyneuropathies, as well as encephalopathy.” (Robbins p. 1275).
Lyme disease is essentially confined to northeastern USA (New York,
DC, Massachusetts).
Def Lyme neuroborreliosis
Epi most common vector-borne illness in USA
Aet Borrelia burgdorferi - from Ixodes tickbite
Path Meningo-polyneuritis, radiculitis
Rad enhancing cranial nerves, cauda equina
rarely, meningo-encephalitis
Rx doxycycline
Which of the following is not associated with a prion?
A. Subacute sclerosing panencephalitis
B. Cruetzfeldt-Jakob Disease
C. Kuru
D. Familial Fatal Insomnia
E. Gerstmann-Sträussler-Scheinker syndrome
Answer: A.
A. SSPE is due to measles (behavioural changes, diffuse white
matter disease, ant → post)
B,C,D,E. All prion diseases.
Which of the following is not a spongiform disease?
A. Cruetzfeldt-Jakob Disease
B. Bovine spongiform encephalopathy
C. Kuru
D. Familial Fatal Insomnia
E. Gerstmann-Sträussler-Scheinker syndrome
Answer: D. “Unlike other prion diseases, FFI does not show
spongiform pathology. Instead, the most striking alteration is neuronal
loss and reactive gliosis in the anterior ventral and dorsomedial nuclei
of the thalamus; neuronal loss is also prominent in the inferior olivary
nuclei.” (Robbins p. 1283).
n.b. BSE is in cows; humans get variant CJD from the same agent.
Which demonstrates X-linked recessive inheritance?
A. Adrenoleukodystrophy
B. Metachromatic leukodystrophy
C. Alexander disease
D. Canavan disease
E. Krabbe
Answer: A
A. True. X-linked adrenoleukodystrophy.
B. False. Metachromatic leukodystrophy is autosomal recessive.
C. False. Alexander is autosomal dominant.
D. False. Canavan is autosomal dominant.
E. False. Krabbe is autosomal recessive.
Which of the following cancer is unlikely to involve brain
A. Lung
B. RCC
C. Breast
D. Prostate
E. Melanoma
Answer: D. Prostate metastases are usually dural.
“Lung, breast, melanoma most common primary malignancies”
(StatDx)
RCC is a classic haemorrhagic metastasis (MRCTBB).
Which is not a feature of NF2?
A. Ependymoma
B. Meningioma
C. Schwannoma
D. Optic nerve glioma
E. Lens calcification
Answer: D. Optic nerve sheath tumours seen in NF1, not NF2.
A. True.
B. True.
C. True.
D. False. Optic nerve sheath gliomas are characteristic of NF1.
E. True. Juvenile posterior subcapsular cataracts (Chap & Nak).
Autosomal dominant disorder, NF2 gene chromosome 22 producing
merlin.
50% result from new dominant gene mutation.Neurofibromatosis type 2 (NF2) = inherited syndrome with multiple
schwannomas, meningiomas, & ependymomas
Which pancreatic neoplasm has the least malignant potential?
A. Insulinoma
B. Islet cell tumour
C. IPMN
D. Solid pseudopapillary neoplasm
E. Pancreatic intraepithelial neoplasm
A or C (if side-branch is specified)
A. Insulinoma: 10% malignant
B. Islet cell - nonfunctioning typically large, solid, malignant
C. IPMN - 8% overall; 5% side-branch, 60% main duct
D. SPEN - low-grade malignancy (WHO)
E. PIN - precursor lesion to pancreatic cancer
WHO Classification of pancreatic neoplasms
Epithelial Tumours:
Benign Serous cystadenoma, Acinar cell carcinoma
Premalignant Pancreatic intra-epithelial neoplasia
IPMN
MCN
Malignant All other exocrine pancreatic neoplasms
Which is true regarding the management of Paget disease of the
breast?
A. Referral to a breast surgeon
B. Referral to a dermatologist for management of the eczema
Answer: A
1-3% of female breast cancers
Diagnosis by wedge biopsy (NOT a punch biopsy)
Single file adenocarcinoma cells
Can mimic melanoma if containing melanin
A man has a solid, vascular epididymal lesion/mass. What is the most
likely diagnosis?
A. Adenomatoid tumour
B. Angiosarcoma
C. Leiomyosarcoma
D. Kaposi sarcoma
E. Fibrosarcoma
Answer: A. Adenomatoid tumour. (The only consistent answer)
Most common (30%) extratesticular neoplasm. Well-defined, solid,
hypoechoic mass with peripheral vascularity on color Doppler
(StatDx)
“Less common diagnoses” on StatDx:
1. Lipoma most common benign neoplasm - often hypoechoic
2. Most common malignant tumors include rhabdomyosarcoma and
liposarcoma - large, irregular, heterogeneous masses
3. Papillary cystadenoma of epididymis - seen in 65% of patients with
VHL. Often bilateral, young adults. Ill-defined solid-cystic mass with scattered cysts.
Most likely vascular epididymal mass in a young person
A. Adenomatoid tumour
B. Lymphoma
C. Thrombosed varix
D. Torted appendix of Morgagni
Answer: A. Adenomatoid tumour. (The only consistent answer)
Most common (30%) extratesticular neoplasm. Well-defined, solid,
hypoechoic mass with peripheral vascularity on color Doppler
(StatDx)
B. Lymphoma in testis. Solitary, multifocal or diffusely infiltrating.
Hypoechoic and vascular. May be bilateral. Older (>50).
C. Varicocele. Dilated veins of pampiniform plexus > 2-3 mm,
increasing with Valsalva. Usually isolated to spermatic cord. (StatDx).
D. Torted appendage. Small avascular mass adjacent to testis or
between testis & epididymis; variable echogenicity, depending on
duration of symptoms; typically hypoechoic acutely. Surrounding
hyperemia. (StatDx).
What does analgesic nephropathy cause?
A. Renal papillary necrosis
Caused by direct toxicity and ischaemia
Paracetamol → glutathione depletion + oxidative metabolites
NSAIDs → less vasodilator prostaglandins + IgE hypersensitivity
Causes of papillary necrosis include:
drugs (NSAIDs)
sickle cell disease
diabetes mellitus
obstruction
infection (TB)
renal vein thrombosis
Which is the most common presentation of angiomyolipoma?
A. Haematuria
B. Retroperitoneal haemorrhage
C. Obstruction
Answer: A. Haematuria
UpToDate:
Most patients asymptomatic with normal renal function
If symptomatic, flank pain > haematuria > retroperitoneal
haemorrhage
Robbins:
The clinical importance of angiomyolipoma is due largely to their
susceptibility to spontaneous hemorrhage.
What is not a maternal risk factor for pre-eclampsia?
A. Anti-phospholipid syndrome
B. Hypertension
C. Glomerulonephritis
D. Liver problems
E. Diabetes mellitus
Answer: D. Pre-existing maternal liver disease not a risk factor.
Known risk factors for pre-eclampsia:
General (age >35, previous Hx, family Hx)
Vascular (pre-existing DM, HTN, obese BMI >25, CKD)
Specific first pregnancy, SLE, anti-phospholipid syndrome
Paradoxical decreased risk in smokers
Regarding interstitial lung disease, which is false?
A. RB-ILD is associated with smoking
B. Idiopathic UIP has a better prognosis than NSIP
C. Idiopathic UIP has a worse prognosis than NSIP
D. DIP has a better prognosis than UIP
Answer: B is false.
A. True. RB-ILD is symptomatic upper lobe centrilobular GGO
associated with smoking.
B. False. Idiopathic UIP (IPF) has a worse prognosis than NSIP.
C. True. Idiopathic UIP (IPF) has a worse prognosis than NSIP.
D. True. DIP is basal peripheral GGO in smokers, thin-walled cysts. It
has a good prognosis if smoking ceased.
Which is a cause of platelet dysfunction?
A. Splenomegaly
B. Uraemia
A. False. Splenomegaly is nonspecific.
B. True. “Uremia (renal failure)… alters platelet function through
uncertain mechanisms” (Robbins p. 121)
Regarding solitary fibrous tumour of pleura, which is the most common presentation?
A. Haemorrhage into bronchial tree
B. Pleural effusion
C. Incidental finding on imaging
Answer: C - most commonly asymptomatic incidental finding.
StatDx:
Up to 50% of patients asymptomatic small LFTP
Large LFTP typically symptomatic
- cough, dyspnea, chest pain/discomfort
- paraneoplastic syndrome
> hypoglycaemia (Doege-Potter syndrome) ?due to IGF-2
> HPOA (Pierre Marie-Bamberger syndrome) ?due to GH
> clubbing
SFTs and cranial hemangiopericytomas are in the same group.
Hemangiopericytomas have more aggressive behaviour
Usually asymptomatic or nonspecific pulmonary symptoms
Changes shape and location on different CXRs
Well defined homogenous mass with low T1 and low T2
Which is least correct regarding cervical cancer?
A. Involves para-aortic nodes first
B. Haematogenous spread to lung and liver
Answer: B is false.
A. True. Pelvic sidewall (usually) or para-aortic (uncommon)
B. False. Haematogenous spread is rare, lungs > liver > bone
Histology is SCC (⅔) or adeno (¼), rarely other
Which uterine tumour responds well to estrogen therapy? (i.e. cured by
oestrogen)
A. Leiomyosarcoma
B. Adenofibroma
C. Adenosarcoma
D. Stromal tumour
E. Carcinosarcoma
Answer: C. Adenosarcoma is oestrogen-sensitive.
A. False. “Leiomyosarcomas (malignant smooth muscle tumors) are
uncommon, highly malignant myometrial tumors that usually arise de
novo” (Robbins p.1021). No relation to hormones.
B. False. “Benign endometrioid tumors, called endometrioid
adenofibromas… are uncommon” (Robbins p. 1027). No relation to
hormones.
C. True. “The principal diagnostic dilemma is distinguishing these
tumors from large benign polyps. The distinction is important,
because adenosarcoma is estrogen-sensitive and responds to
oophorectomy.” (Robbins p. 1019).
D. False. Low- and high-grade variants. (Robbins p. 1021). No
relation to hormones.
E. False. MMMTs/carcinosarcomas “the vast majority of these tumors are carcinomas with sarcomatous differentiation”. (Robbins p.1018).
No relation to hormones.
Berry aneurysm - least correct
A. 2% found post mortem
B. 25 % infarct due to vascular spasm 24 after bleed
C. Presents with severe headache and meningism
D. Rate of growth 0.7% per year
Answer: B and D are both false.
A. True. “Saccular aneurysms are found in about 2% of the
population according to recent data from community-based radiologic
studies.” (Robbins p.1270)
B. False. “Starts ~ day 3-4 post SAH; peaks ~ 7-9 days, lasts ~ 12-16
days” (StatDx). “In the first few days after the hemorrhage” (Robbins).
C. True. Classic presentation.
D. False. Growth rate = 3.9% per year (StatDx).
Rupture risk for saccular aneurysm
Size: Low risk of SA rupture if < 7 mm
Growth rate = 3.9% per year
1.8% per year rupture risk
~ 20% of ruptured unsecured SA rebleed in 2/52, 50% in 6 months
Shape: Daughter lobe likely ↑ risk of future SAH; Murphy teat = site of
recent rupture and possible rebleed if untreated
↑ in females with history of HTN, smoking
Which is most correct regarding oesophageal carcinoma?
A. Spread to mediastinal structures is early as there is no serosal
covering
B. Perineural invasion
Answer: A.
A. True. “Absence of esophageal wall serosa → malignancy easily
spreads to adjacent structures (trachea, thyroid, aorta)” (StatDx).
B. False. Modes of spread are direct invasion, lymphatic spread,
haematogenous metastasis. Perineural not mentioned in Robbins or
StatDx.
Regarding multiple myeloma what is true/false:
A. Light chain proteinuria contributes to renal failure
B. Patients are susceptible to viral illnesses
C. Polyclonal gammopathy
D. Expansile lesions most commonly in the appendicular skeleton
A. True. The single most important factor seems to be Bence-Jones
proteinuria, as the excreted light chains are toxic to renal tubular
epithelial cells.” (Robbins p.600).
B. False. “Decreased production of normal Igs sets the stage for
recurrent bacterial infections. Cellular immunity is relatively
unaffected.” (Robbins p. 600).
C. False. Monoclonal Ig production - the “monoclonal Ig identified in
the blood is referred to as an M component, in reference to myeloma”
(Robbins p. 600).
D. False. “Multiple myeloma usually presents as destructive plasma
cell tumors (plasmacytomas) involving the axial skeleton.” (Robbins
p.599)
What features favours UC over Crohn’s disease?
A. Fissure
B. Fistula
C. Pseudopolyp
D. Fat creeping
E. Sacroiliitis
F. Uveitis
Answer: C is true.
A. False. Crohn’s mucosal ulcers with longitudinal fissures, these
develop into fistulae.
B. False. Fistula = Crohn’s
C. True. In UC, isolated islands of regenerative mucosa bulge into the
lumen to create pseudopolyps
D. False. Creeping fat - mesenteric fat extending around serosal
surface in Crohn’s.
E. False. IBD-associated arthropathy seen in both UC & Crohn.
F. False. Uveitis seen in both UC & Crohn.
Which is most correct regarding autoimmune pancreatitis?
A. Extensive calcification
B. Diffuse enlargement
C. Narrowing of the common bile duct
D. Irregular dilatation of the pancreatic duct
E. Gland enlargement similar to chronic pancreatitis
Answer: B is true.
A. False. Calcification is seen with chronic / recurrent pancreatitis
B. True. Classic feature
C. False. Narrowing of pancreatic duct
D. False. Narrowing of pancreatic duct
E. False. Chronic pancreatitis has atrophy and calcifications.
Autoimmune pancreatitis (IgG4)
Diffuse form:
- Sausage like enlargement of the pancreas (smooth contour) with
low density halo
- Delayed enhancement
- Diffuse/segmental narrowing of pancreatic duct
- No inflammatory change/pseduocysts
Focal form:
- Focal mass/enlargement with delayed enhancement
Which of the following is unlikely to involve basal ganglia?
A. Hypertensive haemorrhage
B. Amyloid angiopathy
Answer: B. Amyloid angiopathy least likely to involve basal ganglia.
A. False. Hypertensive headache favours “deep structures (basal
ganglia, thalami, cerebellum) > cortex, subcortical WM” (StatDx)
B. True. Cortical/subcortical microhaemorrhage. “Lobar > > basal
ganglionic hemorrhage.” (StatDx).
Regarding choriocarcinoma and gestational trophoblastic disease,
true/false:
A. Can happen after months of pregnancy
B. Ovarian choriocarcioma has better prognosis than placental type
C. Invasive mole metastasises
D. Complete mole have foetal part
E. In teenagers, it is associated with choledochocoele
F. can be due to ectopic pregnancy
G. More common in women of reproductive age than postmenopause
A. True. “may appear in the course of an apparently normal
pregnancy, after a miscarriage, or after curettage. Sometimes the
tumor does not appear until months after these events”(Robbins
p.1041).
B. False. “In contrast to choriocarcinomas arising in placental tissue,
those arising in the ovary are generally unresponsive to
chemotherapy and are often fatal.” (Robbins p. 1031).
C. False. “Hydropic villi may embolize to distant sites, such as lungs
and brain, but do not grow in these organs as true metastases, and
even without chemotherapy they eventually regress.” (Robbins
p.1041).
D. False. “In complete moles the embryo dies very early in
development and therefore is usually not identified” (Robbins p.
1040).
E. False. Cholangiocarcinoma is the distractor.
F. True. “50% arise in complete hydatidiform moles, 25% in previous
abortions, approximately 22% follow normal pregnancies, with the
remainder occurring in ectopic pregnancies” (Robbins p.1041).
G. False. Depends on question wording though “Nongestational type
occurs in prepubertal girls and postmenopausal women. Gestational
type occurs during reproductive years. “ (StatDx).
Which of the following is not associated with oesophageal varices?
A. Hepatitis A
B. Cystic fibrosis
C. Wilsons disease
Answer: A. Hepatitis A does not cause cirrhosis nor portal
hypertension.
Which is the most likely association?
A. Gonorrhoea with pyelonephritis
B. HPV with urethritis
C. Chlamydia with prostatitis
D. Treponema with epididymitis
Answer: D > C although counterintuitive
A. False. “Extension of infection from the posterior urethra to the
prostate, seminal vesicles, and then to the epididymis is the usual
course of a neglected gonococcal infection.” (Robbins p. 974)
B. False. “Urethritis is classically divided into gonococcal and
nongonococcal causes.” (Robbins p. 970). HPV not listed.
C. False. “E.coli and other gram negative rods” (Robbins) also similar
in StatDx. Chlamydia not listed.
D. True. “The testis and epididymis may be affected in both acquired and congenital syphilis, but almost invariably the testis is involved
first, and in many cases the epididymis is spared
altogether.” (Robbins p. 974)
Which is most correct?
A. Non-Hodgkin lymphoma is associated with Reed Sternberg cells
B. Hodgkin involves Waldeyer’s ring
C. Non-Hodgkin lymphoma has non-contiguous spread
Answer: C is true.
A. False. The Reed-Sternberg cells define Hodgkin disease
B. False. Waldeyer’s ring is organised MALT tissue and therefore
extranodal (can’t be Hodgkin)
C. True. NHL can do whatever it wants.
Contiguous extension is a feature of Hodgkin lymphoma (spread from
one lymph node to the next)
Non-contiguous extension is a feature of Non-Hodgkin lymphoma
Waldeyer’s ring is a special kind of mucosal-associated lymphoid
tissue (MALT) and therefore is not a site of Hodgkin disease
Which association is correct?
A. IVC syndrome with HCC
B. SVC syndrome with thymoma
C. Burkitt’s lymphoma and lymphedema
D. Non- Hodgkin lymphoma and chylous ascites
Answer: A is directly referenced in Robbins
A. True. “The inferior vena cava syndrome can be caused by
neoplasms that compress or invade the inferior vena cava (IVC) or by
thrombosis of the hepatic, renal, or lower extremity veins that
propagates cephalad. Certain neoplasms—particularly hepatocellular
carcinoma and renal cell carcinoma—show a striking tendency to
grow within veins, and these can ultimately occlude the IVC.”
(Robbins p.515)
B. True - but less true than A. “The superior vena cava syndrome is
usually caused by neoplasms that compress or invade the superior
vena cava, such as bronchogenic carcinoma or mediastinal
lymphoma.” (Robbins p. 515)
C. False. Burkitts is often extranodal and favours mandible and
ileocaecal region. (Robbins p. 597)
D. False. Ascites not mentioned in lymphoma chapter. “Rupture of
dilated lymphatics (e.g., secondary to obstruction from a tumor) leads
to milky accumulations of lymph designated as chylous ascites
(abdomen), chylothorax, and chylopericardium.” (Robbins p. 515)
Burkitt’s lymphoma True/False:
A. Rapid growth is hallmark of Burkitt lymphoma
B. B cell lymphoma more common than Burkitts in transplant
C. Herpes zoster is associated with Burkitts lymphoma
D. Sporadic Burkitt lymphoma presents with mass in the abdomen
E. Endemic Burkitt lymphoma presents with mass in the mandible
F. Patients with HIV tend to get other B-cell lymphomas
A. True. “Burkitt lymphoma is believed to be the fastest growing human tumor” (Robbins p. 597)
B. True. “Some persons with AIDS or who receive
immunosuppressive therapy for preventing allograft rejection develop
EBV positive B-cell tumors, often at multiple sites and within
extranodal tissues such as the gut or the central nervous
system.” (Robbins p. 328)
“In allogeneic hematopoietic stem cell and organ transplant
recipients, the bowel is also the most frequent site for Epstein-Barr
virus-positive B-cell lymphoproliferations.”
C. False. “Tumor cells often are latently infected by EBV.”
D. True. “Sporadic Burkitt lymphoma most often appears as a mass
involving the ileocecum and peritoneum.” (Robbins p.597)
E. True. “Endemic Burkitt lymphoma often presents as a mass
involving the mandible and shows an unusual predilection for
involvement of abdominal viscera, particularly the kidneys, ovaries,
and adrenal glands.”(Robbins p.597)
F. True. See B.
Bolded in Robbins: “In the case of Burkitt lymphoma, it seems that
EBV is not directly oncogenic, but by acting as a polyclonal B-cell
mitogen, it sets the stage for the acquisition of the (8;14) translocation
and other mutations that ultimately produce a full-blown cancer… The
role played by EBV is more direct in EBV-positive B-cell lymphomas
in immunosuppressed patients.”
Regarding pericardial effusions (True/False)?
A. SLE causes constrictive pericarditis
B. TB causes haemorrhagic pericarditis
C. Autoimmune pericarditis post acute MI (Dressler syndrome)
D. Radiation causes pericarditis
E. Hypothyroidism causes pericarditis
A. False. Characteristically serous. “Serous pericarditis is
characteristically produced by noninfectious inflammatory diseases,
including rheumatic fever, SLE, and scleroderma, as well as tumors
and uremia.” (Robbins p.573)
B. True. “Hemorrhagic pericarditis can also be found in bacterial
infections, in persons with an underlying bleeding diathesis, and in
tuberculosis.” (Robbins p.574).
C. True. “Fibrinous and serofibrinous pericarditis are the most
frequent types of pericarditis… Common causes include acute MI,
postinfarction (Dressler) syndrome (an autoimmune response
appearing days-weeks after an MI), uremia, chest radiation, rheumatic fever, SLE, and trauma.”
D. True. Fibrinous/serofibrinous (see C).
E. False. Pericardial effusion but not pericarditis. Not in Robbins
table.
Which is true/false regarding leiomyosarcoma?
A. Leiomyoma rarely undergo malignant transformation
B. Leiomyosarcoma has a high recurrence rate post surgery
C. Uncommon in postmenopausal women
D. Leiomyoma is a precursor
A. True. Leiomyosarcomas “thought to arise from the myometrium or
endometrial stromal precursor cells, rather than leiomyomas.”
(Robbins p. 1020).
B. True. “These tumors often recur following surgery, and more than
half eventually metastasize hematogenously to distant organs, such
as lungs, bone, and brain.” (Robbins p. 1021).
C. False. “Leiomyosarcomas occur both before and after menopause,
with a peak incidence at 40 to 60 years of age.” (Robbins p. 1020).
D. False. See A
Which of the following is/is not a cause of systemic hypertension?
A. Conn’s syndrome
B. Coarctation of aorta
C. Renal artery stenosis
D. Abdominal aortic aneurysm
E. Adrenal insufficiency
F. Chronic pulmonary emboli
G. Diabetes
H. OCP
A. True. Hyperaldosteronism - hypertension, hypokalaemia.
B. True.
C. True.
D. False. A complication, not cause.
E. False. Adrenocortical hyperfunction, not insufficiency.
F. False. Causes pulmonary hypertension.
G. Maybe, via chronic renal failure - but not on the Robbins list.
H. True. Exogenous oestrogens
Which of the following is/is not a cause of colonic pneumatosis?
A. Ischaemia
B. Shigella
C. Pseudomembranous colitis
D. Cystic fibrosis
E. Asthma
F. Connective tissue disorder
A. True. “Small bowel (SB) ischemia is usually due to occlusion of
SMA or SMV. Colonic ischemia more often due to hypoperfusion; not
thrombotic.” (StatDx).
B. False. Causes haemorrhagic colitis, Reiter’s syndrome and
haemolytic uraemic syndrome, but rarely toxic megacolon or
obstruction. (Robbins p.788)
C. True. C. diff causes toxic megacolon. “Acute transmural fulminant
colitis with neuromuscular degeneration and colonic dilation” (StatDx).
D. True. Barotrauma. “Gas dissects down mediastinum, into
retroperitoneum, out mesentery, into bowel wall” (StatDx)
E. True. Barotrauma. “Gas dissects down mediastinum, into
retroperitoneum, out mesentery, into bowel wall”
F. True. “Scleroderma and other forms of mixed connective tissue
disease. Intramural gas may result from bowel disease itself,
associated medications (e.g., corticosteroids), or ischemia” (StatDx).
DDx for intestinal pneumatosis?
DDx for intestinal pneumatosis:
1. ischaemia
2. medications (steroids, -mabs)
3. post-procedure (anastomosis, endoscopy via mucosal tear)
4. barotrauma (asthma, COPD, CF, ventilator)
5. scleroderma & mixed connective dissue disease
6. pneumatosis cystoides intestinalis
Also pseudo-pneumatosis (faeces)
Regarding prostate cancer, which is true?
A. Affects anterior more than the rest
B. There is early involvement of the urethra
C. Spreads preferentially to liver over lung
D. Rarely involves the rectum due to the Denonvillier fascia
A. False. 70% “in the peripheral zone of the gland, classically in a
posterior location” (Robbins p.985)
B. False. “Local extension most commonly involves periprostatic
tissue, seminal vesicles, and the base of the urinary bladder.”
(Robbins p.985)
C. False. “Hematogenous spread occurs chiefly to the bones,
particularly the axial skeleton, but some lesions spread widely to
viscera.” (Robbins p.986)
D. Probably true. “Local extension most commonly involves
periprostatic tissue, seminal vesicles, and the base of the urinary
bladder.”
What is false regarding mesothelioma?
A. Malignant mesothelioma difficult to differentiate histologically and
macroscopically from adenocarcinoma metastasis
B. Primary peritoneal mesothelioma disease is rare
C. Primary presents with pleural effusion
D. Commonly associated with asbestosis
E. Parietal and visceral pleura involved
Answer: D is false.
A. True. “epithelioid type [resembles] adenocarcinoma.
Immunohistochemical stains are very helpful in differentiating it from
pulmonary adenocarcinoma.” (Robbins p. 724)
B. True. All mesothelioma is rare. “Peritoneal mesotheliomas are
related to heavy asbestos exposure in 60% of males” (Robbins
p.724).
C. True. “The presenting complaints are chest pain, dyspnea…
recurrent pleural effusions.” (Robbins p.724).
D. False. “Concurrent pulmonary asbestosis (fibrosis) is present in
only 20% of individuals with pleural mesothelioma.” (Robbins p.724).
E. True. “thoracic mesothelioma arises from either the visceral or the
parietal pleura” (Robbins p.723)
Mesothelioma subtypes:
epithelioid → resemble adenocarcinoma on microscopy
sarcomatoid
biphasic (mixed)
Which of the following regarding asbestos related lung disease is
true/false?
A. Pleural plaques involve both parietal and visceral pleura.
B. Calcified pleural plaque has no zonal predominance.
C. Early lung changes has lower zone predominance
D. Pleural plaques contain asbestos fibres.
E. Associated with lung adenocarcinoma and SCC
A. False. “They develop most frequently on the anterior and
posterolateral aspects of the parietal pleura and over the domes of
the diaphragm.”
B. False. “Most common along diaphragmatic & posterolateral pleura,
typically spare apical, costophrenic & mediastinal pleura” (StatDx).
C. True. UIP pattern. “Consider asbestosis in patients with basilar
interstitial lung disease and pleural plaques” (StatDx).
D. False. “They do not contain asbestos bodies; however, only rarely
do they occur in individuals who have no history or evidence of
asbestos exposure.” (Robbins p. 692).
E. True. “The latent period before the development of lung cancer is
10 to 30 years. Lung cancer is the most frequent malignancy in
individuals exposed to asbestos, particularly when coupled with
smoking.” (Robbins p.713). Listed under adenoca in StatDx.
Brown pigment biliary stones
A. TPN
B. Chronic hemolysis
C. Hypertriglyceridemia
D. Cystic duct with obstruction and gallbladder mucocele
E. Infection
Answer: E. “In general, black pigment stones are found in sterile
gallbladder bile and brown stones are found in infected large bile
ducts.”
A. False. Black pigment stones.
B. False. Black pigment stones.
C. False. Cholesterol stones.
D. False. Gallbladder hydrops. “Distended gallbladder secondary to
chronic obstruction filled with watery mucoid material” Due to chronic
obstruction, can massively distend. RUQ pain. Kawasaki’s in kids.
Stone, tumour, extrinsic or parasite in adults. (StatDx)
E. True. “In general, black pigment stones are found in sterile
gallbladder bile and brown stones are found in infected large bile ducts.” (Robbins p. 877).
Cholesterol stones cause by ^ cholesterol secretion
- fat, female, forty, fertile
Pigment stones caused by ^ unconjugated bili
- inadequate conjugation
> chronic haemolysis (Hb-opathies)
> chronic liver disease
- deconjugation
> biliary parasites
- enterohepatic recirculation of unconjugated bilirubin
> terminal ileal disease, resection or bypass
Which doesn’t cause Meig’s syndrome
A. Dysgerminoma
B. Granulosa cell
C. Brenner
D. Fibroma
E. Thecoma
Answer: A. Dysgerminoma is least associated.
A. False… but still a case report reference in StatDx.
B. True. “Some cases demonstrate pseudo-Meigs syndrome with
pleural effusion and ascites” (StatDx)
C. True. Can present with “ascites or Meigs syndrome” (StatDx)
D. True. “1% associated with Meigs syndrome” (StatDx)
E. True. “1% associated with Meigs syndrome” (StatDx)
Associated with tuberous sclerosis (TS) - true/false
A. Skin angiofibroma
B. Leptomeningeal angiomatosis
C. LAM
D. AML
E. Hepatic cysts
F. SEGA
G. Hamartomas
H. Cardiac rhabdomyomas
I. Subependymoma
A. True. Facial angiofibromas = major criterion.
B. False. Leptomeningeal angiomatosis = Sturge-Weber syndrome
C. True. LAM = major criterion.
D. True. Renal angiomyolipomas = major criteria.
E. True. Hepatic cyst associated with TS (STatDx) but not a
diagnostic criterion.
F. True. Subependymal giant cell tumour = major criterion.
G. True. Retinal hamartomas (& cortical tubers) = major criterion.
H. True. Cardiac rhabdomyoma = major criterion.
I. False. Mostly sporadic. Distractor for SEGA.
Which is most correct regarding orbital tumours?
A. Retinoblastoma is usually bilateral
B. Capillary haemangioma of orbits can occur in adults
C. Uveal melanoma preferentially spreads to the liver
Answer: C is true.
A. False. “Unilateral in 60%, bilateral in 40%” (StatDx).
B. False. Orbital cavernous venous malformation (“hemangioma”) is
the most common ault orbital mass lesion; but “distinct lesion from infantile (“capillary”) hemangioma, neoplastic tumor of infancy”
(StatDx) using latest ISSVA classification.
C. True. “Uveal melanoma disseminates hematogenously and the
first evidence of metastasis is typically detected in the liver.” (Robbins
p. 1332).
Which does NOT cause splenomegaly
A. Amyloid
B. Sarcoid
C. Thrombocytopaenia
D. Heart failure
Answer: C. Thrombocytopaenia is a consequence not a cause.
A. True. “Amyloidosis of the spleen may be inapparent grossly or may
cause moderate to marked splenomegaly (up to 800 g).” Patterns
described as “sago spleen” and “lardaceous spleen”. (Robbins p.
261).
B. True. “The spleen is affected in about three fourths of cases, but it
is enlarged in only one fifth.” (Robbins p. 694).
C. False. “With splenomegaly up to 80% to 90% of the total platelet
mass can be sequestered in the interstices of the red pulp, producing
thrombocytopenia.” (Robbins p. 623). Conversely in ITP “the spleen is
normal in size”.
D. True. Cardiac cirrhosis induces congestive splenomegaly (Robbins
p. 530).
Rheumatoid arthritis most likely
A. Can have pulmonary nodules at presentation
B. Small joints of the hand and feet are spared
C. Common (or early) presentation with honeycombing
D. Renal failure is most commonly caused by rheumatoid vasculitis
Answer: A is true. Pulmonary nodules can precede MSK findings of RA in Caplan syndrome.
A. True. In Caplan syndrome (RA + pneumoconiosis - typically CWP
+ PMF) - “lung abnormalities may precede bone disease” (StatDx).
The original description included patients who developed RA 5-10
years after lung disease.
B. False. “RA typically manifests as a symmetric arthritis principally
affecting the small joints of the hand and feet.” (Robbins p. 1211)
C. False. Even though UIP/NSIP/OP are all seen, honeycombing is
an end-stage feature of lung fibrosis.
D. False. “Rheumatoid vasculitis occurs predominantly in the setting
of long-standing, severe rheumatoid arthritis and usually affects
small- and medium-sized arteries, leading to visceral infarction; it may
also cause a clinically significant aortitis.” (Robbins p.512).
Conversely “1% to 7% of patients with rheumatoid arthritis treated
with penicillamine or gold (drugs now used infrequently for thispurpose) develop membranous nephropathy.” (Robbins p. 915).
Polycythemia vera (true/false):
A. Gallstones due to hyperbilirubinemia
B. Uric acid stones due to hyperuricemia
C. Thromboembolic disease due to platelet dysfunction
D. Transformation to AML
E. Venous occlusion
F. Cyanotic disease due to vascular stagnation
A. False. Not described in Robbins or UpToDate
B. True. Increased cell breakdown → hyperuricaemia → gout
C. True. Thrombocytosis with abnormal platelets → prothrombotic
and procoagulant (excess vWF binding)
D. True. “Transformation to AML, with its typical features, occurs in
about 1% of patients.” (Robbins p.619).
E. True. “About 25% of patients first come to attention due to deep
venous thrombosis, myocardial infarction, or stroke. Thromboses
sometimes also occur in the hepatic veins (producing Budd-Chiari
syndrome) and the portal and mesenteric veins (leading to bowel
infarction).” (Robbins p.619).
F. True. “Patients are plethoric and cyanotic due to stagnation and
deoxygenation of blood in peripheral vessels.” (Robbins p. 619).
UpToDate:
Polycythemia vera (PV) is a chronic myeloproliferative neoplasm
characterized by clonal proliferation of myeloid cells and an elevated
red blood cell mass. Between 95-100% of patients have JAK2 kinase
mutation involving exon 14 or 12.
PV should be suspected in any patient with an increased red blood
cell mass or increased hemoglobin/hematocrit and an arterial oxygen
saturation >92 percent. PV should also be suspected in patients with
the Budd-Chiari syndrome and portal, splenic, or mesenteric vein
thrombosis, particularly women under the age of 45.
*Splenomegaly
*Thrombocytosis and/or leukocytosis
*Thrombotic complications
*Erythromelalgia or pruritus
Which is correct regarding cerebrovascular disease?
A. Lacunar infarcts are secondary to microemboli
B. Bone marrow embolisation causes multiple white matter changes
C. Cerebral amyloid commonly causes catastrophic bleed
A. False. Due to arteriolosclerosis.
B. True. “Widespread hemorrhagic lesions involving the white matter
are characteristic of embolization of bone marrow after trauma”
(Robbins p.1265)
C. False. Robbins describes “evidence of numerous small
hemorrhages within the brain (“microbleeds”)” so this is probably not
the answer. However “acute hematomas are large, often irregular,
with dependent blood sedimentation” (StatDx)
Myasthenia Gravis most correct
A. Thymoma in 10%
B. Occurs in the elderly mostly
C. Fatal in 50%
D. Antibodies block the release of acetylcholine
E. Does not involve the extraocular muscles
Answer: A is true.
A. True. “Approximately 10% of patients [with MG] have a thymoma…
30% of patients (and particularly those who are young) [have] thymic
hyperplasia.” (Robbins p.1236)
B. False. “shows a bimodal age distribution” (Robbins p.1235)
C. False. “Overall mortality has dropped from over 30% in the 1950s
to less than 5% with current therapies.” (Robbins p.1236).
D. False. “About 85% of patients have autoantibodies against
postsynaptic acetylcholine receptors” (Robbins p.1236)
E. False. “Diplopia and ptosis due to involvement of extraocular
muscles are common and distinguish myasthenia gravis from
myopathies, in which involvement of extraocular muscles is unusual”
(Robbins p. 1236)
Regarding herpesviruses:
A. HSV is seen in the motor neurons of the spinal cord
B. VZV is seen in the motor neurons of the spinal cord
Both false.
A. “Latent VZV infection is seen in neurons and/or satellite cells
around neurons in the dorsal root ganglia.” (Robbins p.358)
B. “[HSV1 & 2] spread to sensory neurons that innervate primary sites
of replication… Viral nucleocapsids are transported along axons to the
neuronal cell bodies, where the viruses establish latent infection.”
(Robbins p. 357)
Which of the following is most correct regarding achondroplasia?
A. Instability of atlantoaxial joint
B. General have shorter life span
A. False. But more true than B. “C1-C2 instability rare”
B. False. “The skeletal abnormalities are usually not associated with
changes in longevity, intelligence, or reproductive status.” (Robbins
p.1184).
StatDx: Best diagnostic clue:
- Flattened vertebral bodies with short pedicles
- Interpediculate distance of lumbar spine decreases in caudal direction (reversal of normal relationship)
- Severe dwarfism involves trunk and extremities - more obvious in
proximal limbs (rhizomelic dwarfism)’
Robbins:
Achondroplasia is the most common skeletal dysplasia and a major
cause of dwarfism. It is an autosomal dominant disorder resulting in
retarded cartilage growth. Affected individuals have shortened
proximal extremities, a trunk of relatively normal length, and an
enlarged head with bulging forehead and conspicuous depression of
the root of the nose. It is caused by gain-of-function mutations in the
FGF receptor 3 (FGFR3). Approximately 90% of cases stem from
new mutations.
Which of the following is true/false in Down syndrome?
A. Moderate risk of Alzheimers
B. Moderate risk of acute leukemia
C. Moderate risk of biliary stasis
D. Moderate risk of duodenal atresia
E. Moderate risk of secondary biliary cirrhosis
F. Moderate risk of ASD
G. Moderate risk of atlantoaxial subluxation
A. True. “Virtually all [Down] patients… older than age 40 develop
neuropathologic changes characteristic of Alzheimer disease”
(Robbins p.163). Due to extra chromosome 21 - APP.
B. True. “10-fold to 20-fold increased risk of developing acute
leukemia. Both acute lymphoblastic leukemias and acute myeloid
leukemias occur. The latter, most commonly, is acute
megakaryoblastic leukemia.” (Robbins p.163)
C. False. Not described in Robbins or UTD. Annular pancreas is the
main hepatobiliary anomaly.
D. True. Duodenal atresia occurs in 2.5% off DS (UTD)
E. False. Not described in Robbins or UTD. Annular pancreas is the
main hepatobiliary anomaly.
F. True. “CAVSD 37%, VSD 31%, ASD 15%, PAVSD 6%, Tetralofy of
Fallot 5%” (UTD). 40% of DS have congenital cardiac disease
(Robbins).
G. True. “Approximately 13 percent of individuals with DS have
asymptomatic AAI, while spinal cord compression due to the disorder
affects approximately 2 percent” (UTD).
~40% have congenital heart disease
GIT: duodenal atresia (2.5%) > imperforate anus > esophageal
atresia +/- tracheo-esophageal fistula > Hirschsprung disease (1%)
Pancreatitis (T/F)
A. Lipase is elevated within 24 hours of acute pancreatitis onset
B. Alcohol is more commonly associated with acute rather than chronic
pancreatitis
C. Pseudocyst is a necrotic collection
D. Pseudoaneurysms is a common complication
E. Pseudocysts have an epithelial lining
F. Necrotic pancreatic collections are less likely to get infected within
the first week
A. True. “Laboratory findings include marked elevation of serum
amylase levels during the first 24 hours, followed by a rising serum
lipase level by 72 to 96 hours after the beginning of the attack.”
(Robbins p.887)
B. False. Alcohol is the most common cause of chronic pancreatitis,
and a common cause of acute pancreatitis. (Robbins)
C. True. “Pseudocysts are localized collections of necrotic and
hemorrhagic material that are rich in pancreatic enzymes and lack an
epithelial lining.” (Robbins p.889).
D. True. Pseudoaneurysm in 10% of severe pancreatitis (StatDx).
E. False. “Pseudocysts are localized collections of necrotic and
hemorrhagic material that are rich in pancreatic enzymes and lack an
epithelial lining.” (Robbins p.889)
F. True. Infection more common after 10 days (Atlanta / StatDx); 75%
gut-derived/enteric flora
In primary (hereditary) haemachromatosis which is not involved:
A. Spleen
B. Pancreas
C. Liver
D. Cardiac
E. Joints
Answer: A. Spleen is not involved in primary haemochromatosis.
A. False. Spleen not involved in primary haemochromatosis.
B. True. Pancreas involved in primary haemochromatosis.
C. True. Liver involved in primary haemochromatosis.
D. True. Heart involved in primary haemochromatosis.
E. True. Joints involved in both primary and secondary
haemochromatosis. “Radiographic signs of hemochromatosis
arthropathy may occur prior to other signs of primary
hemochromatosis” (StatDx).
StatDx:
Primary (hereditary) hemochromatosis affects parenchymal cells of
liver, pancreas, and heart.
Secondary (acquired due to transfusions, Fe intake etc.)
hemochromatosis affects RES: Liver, spleen, nodes. However it
eventually deposits everywhere including the pancreas, heart,
kidneys etc.
Both affect joints and skin later
Causes of small renal artery aneurysms (True/False)
A. Diabetes
B. Fibromuscular dysplasia
C. Renal cell carcinoma
D. Classical polyarteritis nodosa
E. Behcet’s disease
F. Tuberous sclerosis
G. Marfan’s disease
Answer: Taken from Radiopaedia list
A. False.
B. True. FMD is classic, listed in Robbins.
C. False.
D. True. PAN is classic. Listed in Robbins.
E. True. Behcet’s is a variable vessel vasculitis. Radiopaedia.
F. True. Phakomatoses including NF and TS. Radiopaedia.
G. True. Connective tissue disorders including Marfan and EhlersDanlos.
Radiographics: FMD, atheroma, vasculitis and trauma.
Clinical Imaging: FMD, atheroma, phakomatoses, connective tissue
disorders, vasculitis and trauma.
Which of the following is the most common cause of splenic infarction?
A. Sickle cell disease
B. Alpha thalassemia
C. Spherocytosis
D. Beta thalassaemia
E. Hypersplenism
F. Gaucher disease
Answer: A. Sickle cell disease
A. True. “In childhood, the spleen is enlarged… by red pulp
congestion… caused by the trapping of sickled red cells in the cords
and sinuses. With time, the chronic erythrostasis leads to splenic
infarction, fibrosis and progressive shrinkage (autosplenectomy)”
(Robbins p. 636).
B. False. “Both phagocyte hyperplasia and extramedullary
hematopoiesis contribute to enlargement of the spleen, which can
weigh as much as 1500 gm.” (Robbins p. 640).
C. False. “Moderate splenomegaly is characteristic; in few other
hemolytic anemias is the spleen enlarged as much or as consistently.
Splenomegaly results from congestion of the cords of Billroth and
increased numbers of phagocytes.” (Robbins p. 633).
D. False. See B.
E. False. “enlargement can cause a syndrome known as
hypersplenism, which is characterized by anemia, leukopenia,
thrombocytopenia, alone or in combination.” (Robbins p.624).
F. False. “Glucocerebrosides accumulate in massive amounts within
phagocytic cells throughout the body in all forms of Gaucher disease.
The distended phagocytic cells, known as Gaucher cells, are found in
the spleen, liver, bone marrow, lymph nodes, tonsils, thymus, and
Peyer patches… In type I disease, the spleen is enlarged, sometimes up to 10 kg.” (Robbins p. 153).
Summary: B - F cause splenomegaly, which predisposes to infarct
but sickle cell causes autosplenectomy due to chronic stasis and
recurrent infarcts.
Cardiac myxoma, what is not seen or associated:
A. Valvular dysfunction
B. Pulmonary emboli
C. Systemic emboli
D. Fever
E. Pituitary adenoma
Answer: B is less true than C. E is rare but a classic association.
A. True. “Sometimes mobile tumors exert a “wrecking-ball” effect,
causing damage to the valve leaflets.” (Robbins p.576).
B. Less true than C. “About 90% of myxomas arise in the atria, with a
left-to-right ratio of approximately 4:1”. (Robbins p.575).
C. True. “Sometimes fragmentation and systemic embolization calls
attention to these lesions.” (Robbins p. 576).
D. True. “Constitutional symptoms are probably due to the elaboration
by some myxomas of the cytokine interleukin-6, a major mediator of
the acute-phase response.” (Robbins p.576).
E. True. Carney complex.
“The major clinical manifestations are due to valvular “ball-valve”
obstruction, embolization, or a syndrome of constitutional symptoms,
such as fever and malaise. Sometimes fragmentation and systemic
embolization calls attention to these lesions.” (Robbins p.576)
Cardiac tumour least likely complication
A. Pericardial effusion
B. Arrhythmia/conduction defects
C. Tumour embolism/thrombosis
D. Valve damage
E. Outflow obstruction
Answer: Pericardial effusion is not described in Robbins for a primary
cardiac tumour.
A. Most false. Direct invasion causes pericardial effusion (UTD) but
this is not described in Robbins.
B. True. Direct invasion causes arrhythmias (UTD). “[Lipomas] may
be asymptomatic, or produce ball-valve obstructions or arrhythmias”
(Robbins p. 576).
C. True. Systemic and pulmonary embolism (UTD). Described in
myxomas (Robbins p. 576).
D. True. “wrecking ball” effect (Robbins, UTD). Described in
myxomas (Robbins p. 576).
E. True. “ball-valve” obstruction (Robbins). Described in myxomas
(Robbins p. 576)
Mechanisms of symptom production of cardiac tumours (UTD)
1. Direct invasion of myocardium can cause LV dysfunction,
arrhythmias, heart block, pericardial effusion.
2. Embolisation. Systemic and pulmonic emboli.
3. Valve damage. Mobile tumours can exert “wrecking ball effect”.
4. Obstruction. Ball valve obstruction
5. Invasion into lungs.
Which of the following is least likely regarding fat embolism?
A. Emboli are composed of adipose tissue
B. Presents clinically 1-3 days post injury
C. Can have lung haemorrhage and inflammation
D. Can have skin petechiae
E. Can be due to long bone fracture
F. Grey matter haemorrhage
Answer: C and F both false.
A. True. “Presumably these injuries rupture vascular sinusoids in the
marrow or small venules, allowing marrow or adipose tissue to
herniate into the vascular space and travel to the lung.” (Robbins p.
128).
B. True. “Typically, 1 to 3 days after injury there is a sudden
onset of tachypnea, dyspnea, and tachycardia; irritability
and restlessness can progress to delirium or coma.” (Robbins p. 128).
C. False. Does cause inflammation (ARDS) but not haemorrhage.
“Embolic obstruction of medium-sized arteries with subsequent
vascular rupture can result in pulmonary hemorrhage” (Robbins p.
127).
D. True. “A diffuse petechial rash (seen in 20% to 50% of cases) is
related to rapid onset of thrombocytopenia and can be a useful
diagnostic feature.” (Robbins p. 128).
E. True. “Microscopic fat globules—sometimes with associated
hematopoietic bone marrow—can be found in the pulmonary
vasculature after fractures of long bones or, rarely, in the setting of
soft tissue trauma and burns.” (Robbins p.128).
F. False. “Widespread hemorrhagic lesions involving the white matter
are characteristic of embolization of bone marrow after
trauma” (Robbins p. 1265).
Regarding endocarditis, which is true?
A. In regards to prosthetic valve vegetations are seen along the margin
of the sewing ring
B. Staph aureus is the most common bug in subacute
C. Strep viridians is the most common bug for acute
D. Acute affects an abnormal valve
ANSWER: A is true,
A True. “The vegetations of prosthetic valve endocarditis are usually
located at the prosthesis-tissue interface, and often cause the
formation of a ring abscess, which can eventually lead to a paravalvular regurgitant blood leak.” (Robbins p. 563)
B False. “Subacute IE is characterized by organisms with lower
virulence (e.g., viridans streptococci) that cause insidious infections of
deformed valves with overall less destruction.” (Robbins p.559).
C False. “Acute infective endocarditis is typically caused by infection
of a previously normal heart valve by a highly virulent organism (e.g.,
Staphylococcus aureus) that rapidly produces necrotizing and
destructive lesions.” (Robbins p.559)
D False. Acute affects a previously normal valve. See B & C.
Endocarditis least likely
A. 10% have positive BCs
B. Abscess in sewing ring
C. Subacute in a damaged valve
D. Staph in elderly
E. Right sided valves >50% in IVDU
ANSWER: A is definitely false. D may be false.
A. False. “In about 10% of all cases of endocarditis, no organism can
be isolated from the blood (“culture negative”endocarditis)” (Robbins
p.560) so 90% are culture positive.
B. True. Ring (annular) abscess is frequent in mechanical valve
endocarditis. “The vegetations of prosthetic valve endocarditis are
usually located at the prosthesis-tissue interface, and often cause the
formation of a ring abscess, which can eventually lead to a
paravalvular regurgitant blood leak.” (Robbins p. 563)
C. True.“Subacute IE is characterized by organisms with lower
virulence (e.g., viridans streptococci) that cause insidious infections of
deformed valves with overall less destruction.” (Robbins p.559).
D. ?False. “Endocarditis of native but previously damaged or
otherwise abnormal valves is caused most commonly (50% to 60% of
cases) by Streptococcus viridans, a normal component of the oral
cavity flora.” (Robbins p. 559).
E. True (probably). “In a series of addicted patients admitted to the
hospital, more than 10% had endocarditis, which often takes a
distinctive form involving right-sided heart valves, particularly the
tricuspid.” (Robbins p.424)
Subacute thyroiditis (De Quervain)
A. Gland grossly enlarged
B. Gland small and shrunk
C. Normal size
D. Slight enlargement
E. Gland nodular and enlarged
ANSWER: UNCLEAR. C?
Robbins pg 1088: “The gland may be unilaterally or bilaterally
enlarged and firm” and “There is variable enlargement of the thyroid”.
Radiopaedia: “Thyroid gland size mostly normal but can occasionally
be enlarged or smaller in size”.
Which paraneoplastic syndrome is not associated with SCLC?
A. Lambert-Eaton
B. Cushing’s
C. Limbic encephalitis
D. Dilated cardiomyopathy
E. SIADH
ANSWER: D
From Robbins (mostly):
A. Lambert Eaton = lung, thymic
B. Cushings = SCLC, pancreas, neural
C. Limbic encephalitis = SCLC, testicular cancer, ovarian teratomas
(Radiopaedia)
D. Dilated cardiomyopathy = no mention in Robbins (Google says
cardiomyopathy can rarely occur in RCC, breast)
E. SIADH = SCLC, intracranial neoplasms
Which of the following is not a manifestation of paraneoplastic
syndrome in bronchogenic tumour?
A. SIADH
B. Lambert-Eaton myasthenia gravis
C. Limbic encephalitis
D. Cushing syndrome
E. Hypocalcemia
ANSWER: E
From Robbins (mostly)
A. SIADH = SCLC, intracranial neoplasms
B. Lambert Eaton = lung, thymic
C. Limbic encephalitis = SCLC, testicular cancer, ovarian teratomas
(Radiopaedia)
D. Cushings = SCLC, pancreas, neural
E. Hypocalcaemia is not a paraneoplastic syndrome. Hypercalcaemia
= Squamous cell lung cancer, breast, RCC, leukaemia/lymphoma
Most common atresia of the GIT
A. Anal atresia
B. Duodenal atresia
C. Jejunal atresia
Answer: A.
Choose oesophageal > imperforate anus > duodenal.
“Atresia occurs most commonly at or near the tracheal bifurcation and
is usually associated with a fistula connecting the upper or lower
esophageal pouches to a bronchus or the trachea… Intestinal atresia
is less common than esophageal atresia but frequently involves the
duodenum. Imperforate anus, the most common form of congenital
intestinal atresia, is due to a failure of the cloacal diaphragm to
involute.” (Robbins p.750).
Which of the following is LEAST correct regarding appendicitis?
A. Commonly has an overt obstruction
B. Due to impaired arterial blood supply
C. Most common in kids and young adults
D. Portal vein thrombosis is a known complication
E. Bacterial overgrowth and ischaemia
B
A. True. “50-80% of cases is associated with overt luminal
obstruction” (Robbins)
B. False. “Initiated by progressive increases in intraluminal pressure
that compromise venous outflow” (Robbins)
C. True. “most common in adolescents and young adults” (Robbins)
D. True. “complications of appendicitis include pyelophlebitis, PV
thrombosis, liver abscess and bacteraemia” (Robbins)
E. True. “stasis of luminal contents, which favours bacterial
proliferation, triggers ischaemia and inflammatory responses”
(Robbins)
Which is true
A. Mitral stenosis is essentially only seen in rheumatic heart disease
B. Marantic vegetations are associated with SLE
C. Acute endocarditis affects abnormal valves
D. Subacute endocarditis destroys the valves slowly but causes big
vegetations
ANSWER: A is most true. D is also true but depends on phrasing.
A. True. “RHD is virtually the only cause of mitral stenosis” (Robbins
p.557)
B. False. Marantic = non-bacterial thrombotic endocarditis;
associated with mucinous adenocarcinomas and sepsis. LibmanSacks Disease = SLE (Robbins p. 561)
C. False. “Acute infective endocarditis is typically caused by infection
of a previously normal heart valve by a highly virulent organism (e.g.,
Staphylococcus aureus) that rapidly produces necrotizing and
destructive lesions.” (Robbins p.559)
D. True. “Infective endocarditis (IE) is characterized by large, irregular
masses on the valve cusps that can extend onto the chordae”
(Robbins p. 560). “The vegetations of subacute endocarditis are
associated with less valvular destruction than those of acute
endocarditis,although the distinction can be subtle.” (Robbins p.560).
Which of the following is most correct regarding valvular disease?
A. Non-bacterial thrombotic endocarditis is associated with SLE
B. Rheumatic heart disease is caused by gram -ve bacteria.
C. Subacute infective endocarditis involves severe destruction of the
valve.
D. Fungal infection is common.
ANSWER: D (of these options, but check wording on the day)
A. False. NBTE = Marantic. Libman-Sacks Disease = SLE
B. False. RHD = Gram positive (Group A streptococci)
C. False. Subacute vegetations cause less valvular destruction than
acute (Robbins)
D. Robbins pg 559: “Although fungi and other classes of
microorganisms can be responsible, most infections are bacterial” Candida is most common fungus
Regarding acute vs subacute endocarditis
A. 1cm vegetations
B. Slow progression
C. Absence of disseminated sepsis
D. Previous valve damage
ANSWER: All false.
A. False. “HACEK group (Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, Kingella) may cause large vegetations >
1 cm” (StatDx)
B. False. “Acute infective endocarditis is typically caused by infection
of a previously normal heart valve by a highly virulent organism (e.g.,
Staphylococcus aureus) that rapidly produces necrotizing and
destructive lesions.” (Robbins p.560)
C. False. Disseminated lesions (e.g. Osler’s nodes, vascular lesions
etc.) are part of the Minor Duke’s criteria.
D. False. See B.
Gynaecomastia
A. Rare under 40yo
B. Symmetric in 60%
C. Progresses to cancer in 5%
D. Associated with lung, pituitary and adrenal tumours
E. Same rate of cancer as females
Answer: D is true.
A. False. Gynaecomastia is common in infancy, puberty and middle
to older men (UpToDate).
B. False. “When bilateral, could be asymmetric in 67%” (StatDx).
C. False. “Not causally related to male breast cancer” (StatDx).
D. True. Hormone-producing tumours (Testicular tumors: Germ cell,
Leydig, Sertoli; Non-testicular tumours: Pituitary, adrenal, liver, lung,
renal”
E. False. “Not causally related to male breast cancer” (StatDx)
n.b. Robbins says “Similar to proliferative disease in women,
gynecomastia may be associated with a small increased risk of
breast cancer.”
DDx: systemic disease (liver, renal failure or ^ thyroid), hormoneproducing tumour, hyperestrogenic (obese ^thyroid), gonadal failure.
Paragangliomas, LEAST LIKELY.
A. NF2
B. Carney syndrome
C. Charcot marie tooth type II
ANSWER: A (but check wording, depends if Carney complex,
Carney-Stratakis syndrome, or Carney triad)
A. False. NF1 not NF2.
B. Carney triad or Carney-Stratakis Syndrome, NOT Carney complex.
C. True. KIF1Bbeta mutation associated with CMTD and
paragangliomas.
https://doi.org/10.1530/ERC-11-0170
Paragangliomas and syndromes:
- MEN2A, MEN2B
- NF1
- VHL
- Carney triad (paraganglioma + GIST + pulmonary chondroma)
Carney Complex = cardiac myxoma + blue naevi + other features
(extracardiac myxomas, pituitary adenoma, testicular tumours,
schwannoma) (rare MEN syndrome)
Carney-Stratakis Syndrome = paraganglioma + gastric stromal
sarcoma
T/F: Paraganglioma more likely to be malignant in extra-adrenal sites
True.
From UTD:
- 10% of pheos are malignant (Rule of 10s).
- 20-25% of extra-adrenal paragangliomas in the
abdomen/pelvis/mediastinum are malignant
- In the neck, vagale most likely malignant
Which of the following is most correct regarding colorectal cancer?
A. 70% of patients with familial adenomatous polyposis develop colon
cancer
B. Most commonly occur in the right sided colon.
C. Most commonly occur in the left sided colon.
D. Morphology of the colorectal polyp is an important factor in
determining its risk of malignancy.
ANSWER: All false.
A. False. “Colorectal adenocarcinoma develops in 100% of untreated
FAP patients, often before age 30 and nearly always by age 50.”
(Robbins p. 809).
B. False. Colonic adenocarcinomas equally distributed over entire
length of colon (Robbins)
C. False. Colonic adenocarcinomas equally distributed over entire
length of colon (Robbins)
D. False. Size is more important than architecture (tubular,
tubulovillous, villous) (Robbins pg 808)
What causes hypercalcaemia?
A. chronic dialysis
B. hypophosphatemia
C. chronic diarrhoea
D. primary osteoporosis
E. post menopausal osteoporosis
F. duodenal ulcer
A. True, ish. “Patients with secondary hyperparathyroidism
associated with severe chronic kidney disease usually have
parathyroid hyperplasia and frankly low or low-normal serum calcium concentrations. However, with prolonged disease, some patients may
develop hypercalcemia.” (UpToDate)
B. False. “Prolonged hypophosphatemia produces a number of
effects on both the kidney and bone. Distal tubular reabsorption of
calcium and magnesium are inhibited, and striking hypercalciuria
ensues” (UpToDate)
C. False. “Patients with malabsorption or short-bowel syndrome may
have higher than normal calcium and vitamin D requirements due to
diminished calcium absorption” (UpToDate)
D. False. Normocalcaemic.
E. False. Normocalcaemic.
F. False. Probably referring to milk-alkali syndrome “the triad of
hypercalcemia, metabolic alkalosis, and acute kidney injury
associated with the ingestion of large amounts of calcium and
absorbable alkali… originally described use of milk and sodium
bicarbonate for the treatment of peptic ulcer disease” (UpToDate).
“Among all causes of hypercalcemia, primary hyperparathyroidism
and malignancy are the most common, accounting for greater than 90
percent of cases” (UpToDate)
Robbins (Table 24-5):
Raised [PTH]:
Hyperparathyroidism (Primary (adenoma > hyperplasia), Secondary,
Tertiary)
Decreased [PTH]
Hypercalcemia of malignancy, Vitamin D toxicity, Immobilization,
Thiazide diuretics, Familial hypocalciuric hypercalcemia,
Granulomatous disease (sarcoidosis)
Gallbladder cancer (true/false)
A. Infiltrating pattern is more common than exophytic
B. More common in men than women
C. Usually not associated with stones
D. Usually found at an early stage with good prognosis
ANSWER:
A. True. “The infiltrating pattern is more common and usually appears
as a poorly defined area of diffuse mural thickening and induration.”
(Robbins p. 880)
B. False. “Gallbladder cancer is at least twice as common in women than in men” (Robbins p. 879).
C. False. “The most important risk factor for gallbladder cancer
(besides gender and ethnicity) is gallstones which are present in 95%
of cases.” (Robbins p. 879).
D. False. “Typically they are detected late because of non specific
symptoms and hence carry a poor prognosis.” (Robbins p.880).
Regarding gout, T/F
A. can have gout without hyperuricaemia
B. most common with increased turnover
C. 20% die of renal failure
A. False. Robbins pg 1215 “Hyperuricaemia is necessary but not
sufficient for the development of gout”
B. False. Robbins pg 1214: Primary form of gout (90% of cases) is
where cause is unknown (compared to secondary where high uric
acid is due to known underlying disease). Then Robbins pg 1215:
“Vast majority of primary gout is caused by increased uric acid
biosynthesis for unknown reasons”
C. True. “About 20% of those with chronic gout die of renal failure.”
(Robbins pg 1216)
Peripheral nerve sheath tumours - most correct
A. Malignant peripheral nerve sheath tumours are almost exclusive to
NF1
B. neurofibromas involve optic nerve in NF1
C. Schwannomas involve acoustic part of CNVIII in NF2
D. Schwann cells are the neoplastic cells involved in neurofibromas
Answer = D.
A. False. “About half arise in NF1 patients and are assumed to result
from malignant transformation of a plexiform neurofibroma. Sporadic
cases may arise de novo.” (Robbins p.1249)
B. False. Typically optic nerve gliomas; alternatively optic nerve
sheath meningiomas
C. False. 95% of schwannomas arise from vestibular nerve; bilateral
in NF2
D. True. Schwann cells are the neoplastic component of the
neurofibroma. “Only the Schwann cells in neurofibromas show
complete loss of neurofibromin (a tumour suppressor), indicating they
are the neoplastic cells” (Robbins)
Which of the following is most correct regarding schwannoma of the cranial nerves?
A. Schwannoma of the glossopharyngeal nerve is located at the level of
hyoid.
B. Schwannoma has high T2 signal due to cell packing
C. Vestibular schwannoma most commonly arises from the acoustic
portion of the CN8
Answer = most correct is prob B.
A. False. CN9 schwannoma usually at inferior CP angle or jugular
foramen
B. False. High T2 from Antoni B cells which are loosely packed and
prone to cystic degeneration. (Antoni A are densely packed, arranged
in fascicles; low T2).
C. False. Usually vestibular component of CN8
Jugular foramen anatomy
Pars nervosa (anteromedial) - CN9
Pars vascularis (posterolateral) - IJV, CN10, CN11
Regarding RCC (true/false):
A. Cystic RCC is most likely papillary
B. Difficult to differentiate between clear cell RCC and oncocytoma
C. Renal vein invasion of RCC has a 5 year survival of 15%
D. VHL associated with multiple chromophobe
ANSWER: All false.
A. False. “Papillary carcinomas… are typically hemorrhagic and
cystic, especially when large.” (Robbins p. 955)
B. False. Not for clear cell. “Chromophobe carcinoma… histologic
from oncocytoma can be difficult.” (Robbins p. 954).
C. False. “With renal vein invasion or extension into the perinephric
fat, the [5YS] figure is reduced to approximately 60%” (Robbins p.
955)
D. False. vHL associated with clear cell RCC, BHD associated with
chromophobe RCC
Second most common site of hydatid (after liver)
A. Spleen
B. Lung
C. Retroperitoneum
D. Kidney
ANSWER: B
UTD: The liver is affected in approximately two-thirds of patients, the
lungs in approximately 25 percent, and other organs including the
brain, muscle, kidneys, bone, heart, and pancreas in a small
proportion of patients.
Chronic lymphadenitis most correct
A. Severe infection
B. Most likely in the inguinal region
C. Complicated by fistula
D. Painful masses
E. Can be generalised in systemic viral infection
Answer = B.
A. False. Severe infection favours the picture of severe pyogenic
infection causing acute suppurative lymphadenitis
B. True. “Chronic lymphadenitis is particularly common in inguinal
and axillary nodes, which drain relatively large areas of the body and
are frequently stimulated by immune reactions to trivial injuries and
infections of the extremities” (Robbins)
C. False. Fistula/draining sinus to skin is a complication of severe
acute lymphadenitis → Under acute nonspecific lymphadenitis:
“suppurative infections penetrate through the capsule of the node and
track to the skin to produce draining sinuses” (Robbins)
D. False.”characteristically lymph nodes in chronic reactions are
nontender” (Robbins)
E. False. “Systemic viral infections and bacteraemia often produce
acute generalised lymphadenopathy” (Robbins)
Testicular tumour associated with gynaecomastia (T/F)
A. Leydig
B. Sertoli
C. Seminoma
Leydig, Sertoli (Robbins), germ cell (StatDx)
A. True.
B. True.
C. False
Neonatal hepatitis associated with
alpha-1 antitrypsin disease
one of many causes (Robbins p.857)
Regarding diabetes - True/False:
A. Type 2 has higher incidence of renal failure than Type 1
B. Associated with mononeuropathy
C. Leading cause of death is by infection
D. Macrovascular complications don’t include coronary artery disease
E. Diabetic retinopathy is almost always seen in chronic diabetes
A. False. “A considerably smaller fraction of patients with type 2
diabetes progress to end-stage renal disease”; “the progression from
overt nephropathy to ESRD is highly variable but by 20 yrs, more
than 75% of T1DM and approximately 20% of T2DM with overt
nephropathy will develop ESRD” (Robbins)
B. True. “Diabetic mononeuropathy which may manifest as sudden
footdrop, wristdrop or isolated cranial nerve palsies” (Robbins 1120)
C. False. “Myocardial infarction caused by atherosclerosis of the
coronary arteries is the most common cause of death in diabetics
(Robbins)
D. False. Hallmark of macrovascular disease is accelerated
atherosclerosis involving the aorta and large and medium sized
vessels (coronary arteries are medium sized vessels). Macrovascular
complications include MI, which is caused by atherosclerosis of the
coronary arteries (Robbins)
E. True. “approx 60-80% of pts develop some form of diabetic
retinopathy by 15-20yrs post diagnosis” (Robbins)
Choroid plexus papillomas (T/F)
A. Associated with calcification
B. Age less than 2
C. Trigone lateral ventricle
D. Malignant transformation rare
Answer: All true.
A. True. “Ca++ in 25%”
B. True. “Most common brain tumor in children < 1 year old…
Consider CPP if intraventricular mass in child < 2 years old” (StatDx)
C. True. “50% in lateral ventricle (usually atrium)” (StatDx)
D. True. “Benign, slowly growing - Malignant progression rare”
(StatDx).
Extralobar sequestration (T/F)
A. Presents <1yr age
B. Drains into pulmonary veins
C. Males more than females
D. No systemic arterial supplY
A. True. “Neonates, infants; M:F = 4:1” (StatDx)
B. False. “Characteristic systemic blood supply & systemic venous
drainage” (StatDx)
C. True. “Neonates, infants; M:F = 4:1” (StatDx)
D. False. Characteristic systemic blood supply & systemic venous
drainage” (StatDx)
Neonate with respiratory distress, CXR initially shows opacity in the L
upper zone, next CXR shows a subtle lucency in the left upper zone.
A. CPAM
B. Sequestration
C. Congenital lobar emphysema
Answer: C. Congenital lobar overinflation.
A. False. “Abnormal mass of pulmonary tissue with varying degrees
of cystic change. Communicates with tracheobronchial tree; normal
blood supply & venous drainage” (StatDx).
B. False. “Sequestered lung. No normal communication to
tracheobronchial tree, systemic blood supply” (StatDx).
C. True, “Progressive overdistention of a pulmonary lobe due to 1-
way valve airway obstruction. Best diagnostic clue = Progressively
hyperlucent & hyperexpanded lobe. Initially opaque due to retained
fetal lung fluid.” (StatDx).
Portal hypertension does not cause
A. Splenomegaly
B. Ascites
C. Ischaemic hepatitis
D. Thrombocytopenia
E. Portal varices
Answer: C.
A. True. Congestive splenomegaly.
B. True. Transudative ascites.
C. False. Portal biliopathy but not ischaemic hepatitis.
D. True. Hypersplenism causes thrombocytopaenia.
E. True. Portosystemic shunting.
Pituitary (T/F)
A. ACTH secreting tumour is usually a microadenoma
A. True. “Corticotroph adenomas are usually microadenomas at the
time of diagnosis.” (Robbins p.1079
Regarding endocrine disorders:
A. Distinguish Cushings disease vs Cushing syndrome?
B. Endogenous is most common cause of Cushings (T/F)?
C. Cushing’s is more likely in micro or macroadenomas?
D. What is Nelson syndrome?
ANSWER:
A. Cushing syndrome = hypercortisolism of any cause. Cushing
disease = “hypercortisolism due to excessive production of ACTH by
the pituitary” (Robbins p. 1079).
B. False. “The vast majority of cases of Cushing syndrome are the
result of the administration of exogenous glucocorticoids” (Robbins p.
1123).
C. “Large destructive pituitary adenomas [develop] after surgical
removal of the adrenal glands for treatment of Cushing syndrome…
most often because of a loss of the inhibitory effect of adrenal corticosteroids on a preexisting corticotroph microadenoma.”
(Robbins p. 1080).
Regarding chondroid tumours - True/False:
A. Chondrosarcoma and enchondroma can be impossible to distinguish
on imaging and path
B. Maffucci increased risk of sarcomatous change
C. Olliers is multiple osteochondromas
D. Chondrosarcoma degeneration in an osteochondroma occurs in the
bony stalk
E. Chondrosarcoma mostly epiphyses
F. Enchondromas are epiphyseal
G. In a child a new chondroid lesion with soft tissue mass is suggestive
of chondrosarcoma
H. New lucent lesion in phalanx in child with chondroid matrix is most
likely chondrosarcoma
I. New lucent lesion in pelvis in adult with chondroid matrix most likely
enchondroma
J. Diaphyseal aclasis is multiple appendicular enchondromas
A. True. Enchondroma and low grade chondrosarcoma difficult to
differentiate (StatDx)
B. True. In Maffucci: 25% risk of enchondromas undergoing
malignant transformation into chondrosarcoma by 40yo (rarely can
transform into fibrosarcoma) (StatDx)
C. False. Olliers = multiple enchondromas
D. False. Osteochondroma degeneration occurs in cartilage cap
E. False. Chondrosarcoma is mainly metaphyseal or metadiaphyseal.
Epiphyseal is uncommon; however an epiphyseal chondroid lesion
which is not a chondroblastoma should raise concern for
chondrosarcoma as enchondromas do not occur in epiphyses
(StatDx)
F. False. Enchondromas are metaphyseal/metadiaphyseal and
intramedullary. Epiphyseal location is so rare that you should
consider chondrosarcoma first (StatDx)
G. False. First consider osteochondroma
H. False. Enchondroma.
I. False. Chondrosarcoma
J. False. Multiple osteochondromas (HME).
Which is not associated with chondrocalcinosis
A. Haemochromatosis
B. Wilsons
C. Diabetes
Answer:
A. True.
B. False.
C. True.
Arthritis in B&W:
- idiopathic CPPD
- haemochromatosis
- hyperparathyroidism
Robbins adds the following:
- OA (“previous joint damage”)
- ochronosis
- diabetes
- hypoMg
- hypothyroid
“The secondary form is associated with various disorders, including
previous joint damage, hyperparathyroidism, hemochromatosis,
hypomagnesemia, hypothyroidism, ochronosis, and diabetes”
(Robbins p.1217).
Pulmonary Alveolar Proteinosis (true/false):
A. Congenital is rapidly fatal
B. Acquired is due to overproduction of protein rich surfactant
C. Acquired is like an autoimmune disease
D. Secondary can be seen in immunocompromised
E. Superimposed infection common problem
ANSWER: B false.
A. True. Congenital has variable but poor prognosis. Spontaneous
remission described in autoimmune type. (UpToDate).
B. False. “Autoimmune (formerly called acquired) PAP is caused by
circulating neutralizing antibodies specific for GM-CSF… [this impairs
alveolar macrophages] ability to catabolize surfactant” (Robbins
p.696).
C. True. See B.
D. True. “Secondary PAP is uncommon and is associated with
diverse diseases, including hematopoietic disorders, malignancies,
immunodeficiency disorders… these diseases somehow impair
macrophage maturation or function, again leading to inadequate
clearance of surfactant from alveolar spaces.” (Robbins p.697)
E. True. “These patients are at risk for developing secondary
infections with a variety of organisms.” (Robbins p.697)
Lung cancer (true/false)
A. in never smokers tends to have EGFR mutation
B. heavy asbestos exposure increases lifetime risk of mesothelioma
C. passive smokers have 5x increased risk of lung cancer
D. mesothelioma tends have 5 year latent period
A. True. Usually adenocarcinomas. “Cancers in nonsmokers are
more likely to have EGFR mutations, and almost never have KRAS
mutations” (Robbins p.714)
B. True. “Malignant mesotheliomas, although rare, have assumed
great importance in the past few decades because of their increased
incidence among people with heavy exposure to asbestos” (Robbins
p.723)
C. False. “Passive smoking (proximity to cigarette smokers) increases
the risk for lung cancer development to approximately twice that of
nonsmokers.” (Robbins p. 713).
D. False. “There is a long latent period of 25 to 45 years for the development of asbestos-related mesothelioma” (Robbins p. 723)
Regarding PE - most correct?
A. Occlusion of medium size vessel can cause haemorrhage without an
infarct
B. 60% are associated with infarct
C. Multiple large emboli cause cor pulmonale
D. Approximately half arise secondary to splanchnic venous
thromboses
Answer = A is most correct.
A. True. “smaller emboli travel out inot more peripheral vessels,
where they may cause haemorrhage or infarction” (Robbins)
B. False. “About 10% of emboli cause infarction” (Robbins)
C. False. “Over the course of time multiple small emboli may lead to
pulmonary HTN and chronic cor pulmonale” (Robbins)
D. False. >95% originate from thrombi in the deep veins of the leg
(Robbins)
Regarding Charcot spine - least correct
A. Neurosyphilis most common cause
B. Differential diagnosis includes osteomyelitis and adjacent segment
degeneration
C. Involves the whole joint at the one level (i.e. disk and facets)
Answer: A is false.
A. False. “Most common cause: Neuropathy due to diabetes mellitus.
Neurosyphilis is cause originally described by Charcot - more
commonly involves hips, knees than spine” (StatDx)
B. True. StatDx lists pyogenic infection, atypical infection,
degenerative disc disease with instability as differentials. Adjacent
segment disease is due to abnormal biomechanical stress following
spinal surgery.
C. True. “Best Diagnostic Clue: Florid destruction of discs and facet
joints with preserved bone density, involving 1-2 spinal levels”
(StatDx).
StatDx Summary:
Almost always in lumbar spine
Vertebral endplate destruction + facet joint destructive arthropathy
Preserved bone density
Nonunited fractures
Vertebral subluxations
Bony debris around vertebrae +/- soft tissue mass
Heterogeneous enhancement of vertebrae and soft tissue mass
Which of the following is a cause of cor pulmonale?
A. Chronic recurrent pulmonary embolism
A is true.
Which of the following is a cyanotic congenital heart disease?
A. ASD
B. VSD
C. PDA
D. Tetralogy of fallot
E. Coarctation of aorta
Answer: D. Fallot’s tetralogy is cyanotic.
Others are left to right shunts (or not shunts)
1 - Truncus arteriosis
2 - Transposition of the great arteries
3 - Tricuspid atresia/Ebstein’s
4 - Tetralogy of fallot
5 - TAPVR
Which of the following is a feature of HELLP syndrome?
A. Thrombocytopenia
Haemolysis, Elevated LFTs, Low Platelets
3rd trimester, associated with pre-eclampsia
20 week anatomy scan, abdominal wall mass, cord inserting at apex
A. omphalocele
B. gastroschisis
C. physiologic herniation
Answer: A. Omphalocele.
A. True. “Membrane-covered midline abdominal wall defect with
herniation of abdominal contents into base of cord” (StatDx)
B. False. “Bowel herniation through right paramedian abdominal wall
defect” (StatDx)
C. False. “Bowel returns to abdomen by 11-12 weeks” (StatDx)
Echogenic bowel (true/false)
A. associated with trisomy 18
B. associated with trisomy 21
C. associated with cystic fibrosis
D. not associated with infection
E. associated with fetal growth restriction
F. associated with perigestational haemorrhage
Answer:
A. False. Not listed in StatDx.
B. True. “6.7x ↑ maternal a priori risk when isolated” (StatDx)
C. True. “4-5% cases of EB with cystic fibrosis” (StatDx)
D. False. “4-6% cases of EB from infection” (StatDx)
E. True. “10% of 2nd-trimester fetuses with EB develop FGR. EB
probably from hypoperfusion to bowel.” (StatDx)
F. True. Associated with ingested blood. “Dependent layering in
stomach is clue - Look for evidence of prior perigestational
hemorrhage as source for blood” (StatDx)
StatDx Common: Idiopathic, T21, infection (parvovirus, CMV), CF,
ingested blood. Bowel ischaemia rare but important.
What renal lesion is most likely to be 10cm in size, brown with central
scarring?
A. Papillary carcinoma
B. Clear cell RCC
C. Oncocytoma
D. Chromophobe RCC
E. AML
ANSWER: C
Robbins pg 953: Oncocytomas = tan or mahogany brown, relatively
homogeneous, usually well encapsulated, with a central scar in ⅓ of
cases, and may achieve a large size (up to 12 cm in diameter)
Which is true regarding meningitis:
A. Fungal meningitis less likely to spread into brain by direct extension
than bacterial
B. Hydrocephalus caused by too much CSF production by a choroid
plexitis.
C. E coli most common pathogen for meningitis
D. Haemorrhagic infarct is caused by thromphlebitis
A. False. “The brain is usually involved following widespread
hematogenous dissemination of fungi” (Robbins p.1279).
B. False. Extraventricular obstructive hydrocephalus.
“Leptomeningeal fibrosis may follow pyogenic meningitis and cause
hydrocephalus.” (Robbins p.1273).
C. False. Depends on wording: “E. coli and the group B streptococci
in neonates; at the other extreme of life, Strep. pneumoniae and
Listeria monocytogenes are most common; and Neisseria
meningitidis in adolescents and in young adults” (Robbins p. 1272).
D. True. “Phlebitis may lead to venous thrombosis and hemorrhagic
infarction of the underlying brain.” (Robbins p. 1273)
Regarding the larynx:
A. Hyperplasia increases risk of cancer by 10%
B. Epithelial changes induced by smoking can reverse after cessation
C. Most cancers are adenocarcinomas
D. Cancers rarely involve the vocal cords
Answer: B is true.
A. False. “Orderly hyperplasias have almost no potential for malignant
transformation, but the risk rises to 1% to 2% during the span of 5 to
10 years with mild dysplasia and 5% to 10% with severe dysplasia.”
(Robbins p.739)
B. True. “The epithelial alterations described above are most often
related to tobacco smoke, the risk being proportional to the level of
exposure. Indeed, up to the point of cancer, the changes often
regress after cessation of smoking.” (Robbins p.739).
C. False. “Carcinoma of the larynx is typically a squamous cell
carcinoma seen in male chronic smokers.” (Robbins p. 739).
D. False. “The tumor usually develops on the vocal cords, but it may
also arise above or below the cords, on the epiglottis or aryepiglottic
folds, or in the pyriform sinuses.” (Robbins p.740).
What is the commonest pancreatic congenital abnormality
A. Pancreas divisum
B. Annular pancreas
C. Dorsal agenesis
ANSWER: A
UTD: Pancreas divisum is the most common congenital pancreatic
anomaly (10% of individuals)
Which kidney disease is not inherited:
A. Nephropthisis
B. Cystic dysplasia
C. Adult onset medullary cystic disease
D. Childhood polycystic kidney disease
Answer: B is not inherited.
A. True. Autosomal recessive.
B. False.
C. True. Autosomal dominant.
D. True. ARPCKD
Polycythemia Rubra vera - most common complication
Transformation to AML
Transformation to CML
Others
Transformation to AML - One study shows that anywhere from 2% to 14% of the time, polycythemia vera changes into AML within 10 years.
What is not associated with polycythaemia rubra vera? (March 2014)
Cyanosis
Thrombocytosis
Gout
Budd-Chiari syndrome
AML
High serum EPO
Cyanosis - Usually plethoric
Which of the following is the least likely association? (March 2014)
Autoimmune haemolytic anaemia is associated with thrombotic thrombocytopaenic purpura
HUS can occur in pregnancy
Gallstones are associated with polycythaemia ver
Gallstones are associated with polycythaemia vera - rare
Hyperuricaemia from increased cell turnover > gout
Factors promoting thrombosis include any of the following, except:
Inflammation of the blood vessels
Impedance of blood flow
Thrombocytosis
Polycythaemia
Thrombocytopenia
Thrombocytopenia
Which is false regarding multiple myeloma? (March 2017)
Predisposes to viral infections
Osteoporosis can occur in the absence of lytic lesions
Blood has high viscosity
Renal failure is a complication
Answer: Predisposes to viral infections - Significantly increased risk of bacterial infection
Osteoporosis can occur in the absence of lytic lesions - Osteolysis induced by cancer -
Less common, as per Robbins
Blood has high viscosity
- hyperviscosity results from increased circulating serum immunoglobulins and can be seen in multiple myeloma
Renal failure is a complication
t/f cmv implicated in pathogenesis of plasmocytoma
Not implicated
Which is NOT associated with EBV?
Burkitts lymphoma
NK/T cell lymphoma
Hodgkin lymphoma
Plasmacytoma of the head and neck
Nasopharyngeal cancer
Plasmacytoma of the head and neck
Regarding renal involvement in multiple myeloma, which one of the following statements is false?
The most common cause of renal failure is amyloidosis
Hypercalcaemia is frequently present
Light-chain deposition disease is well recognised
The most common cause of renal failure is related to Bence Jones proteinuria
Hyperuricaemia is often present
Answer: The most common cause of renal failure is amyloidosis - Bence Jones proteinuria is most common
What is not associated with multiple myeloma?
Anaemia
Lymphocytosis
Hypercalcaemia
Renal failure
Lymphocytosis
Which is true?
Proteus is associated with the formation of struvite stones
Multiple myeloma is associated with recurrent pyelonephritis
Proteus is associated with the formation of struvite stones
Which is most correct?
Non-Hodgkin lymphoma is associated with Reed Sternberg cells
Hodgkin involves Waldeyer’s ring
Non-Hodgkin lymphoma has non-contiguous spread
Answer: Non-Hodgkin lymphoma has non-contiguous spread
Non-Hodgkin lymphoma is associated with Reed Sternberg cells - Hodgkin
Hodgkin involves Waldeyer’s ring - false, spares waldeyers and mesentery
What favours Hodgkin’s over Non Hodgkins
Localised to a lymph node group.
Bone marrow involvement.
Extranodal site involvement.
Spinal cord involvement.
Small bowel mesentery involvement
Localised to a lymph node group.
Which of the following is not a type of Hodgkin’s lymphoma? (September 2013)
Anaplastic
Nodular sclerosing
Mixed cellularity
Lymphocyte rich
Lymphocyte depleted
Anaplastic (NHL)
Which is true regarding Hodgkin’s lymphoma? (September 2013)
The Reed Sternberg cell is an abnormal B cell
Lymphocyte depleted is the most common subtype
Cannot be diagnosed by FNA
The Reed Sternberg cell is an abnormal B cell - Derived from the germinal centre or postgerminal centre B cells
Which lymphoma is least likely to be treated with curative intent? (March 2015)
Nodular sclerosing Hodgkin’s disease
Diffuse large B cell lymphoma
Mycosis fungoides
Follicular lymphoma
ALL
Mycosis fungoides - Treatment goals are palliative
EBV is least associated with which of the following?
Mycosis fungoides
Burkitts lympoma
Post transplant B cell lymphoma
Hodgkins lymphoma
Nasopharyngeal carcinoma
Mycosis fungoides
Regarding follicular subtype of NHL, which is FALSE?
Most common age 30-40 - usually age 65
Indolent course but poor response to chemo
Can transform higher grade lymphoma
Can coexist with other types of lymphoma
Most common age 30-40 - usually age 65
What is the most likely lesion to be negative on PET? (March 2014)
Nodular sclerosing Hodgkin disease
T cell lymphoma
Lymphocyte depleted lymphoma
Follicular B cell lymphoma
Follicular B cell lymphoma - low avidity
Which of the following is NOT a round blue cell tumour?
Lymphoma
Rhabdomyosarcoma
Medulloblastoma
Desmoplastic fibroma
Desmoplastic fibroma
What is the currently used system for lymphoma classification?
REAL
Working
WHO
WHO
The least common parotid tumour is?
Metastases
Lymphoma
Warthins
Pleomorphic adenoma
Lymphoma
Which is false regarding Hodgkins lymphoma?
The Reed Sternberg cell is an abnormal B cell
Lymphocyte depletion is the most common subtype
Cannot be diagnosed by FNA
Hodgkins can co-exist with NHL
Lymphocyte depletion is the most common subtype - nodular sclerosing is most common
Which of the following is most likely regarding testicular tumour?
Embryonal carcinoma is low grade
Seminoma has elevated AFP
Lymphoma in a patient >60yo
Yolk sac tumour occurs in the 4th-5th decade
Lymphoma in a patient >60yo
Burkitt lymphoma, which is correct?
Sporadic BL presents with mass in the abdomen
Endemic BL presents with mass in the mandible
Rapid progression is ?hallmark of BL
Rapid progression is ?hallmark of BL
Regarding Burkitts lymphoma, which of the following is least correct?
Disease is largely of children and young adults
EBV is seen in almost all cases of Burkitt’s lymphoma
Bone marrow and peripheral bone involvement is uncommon
Tumours are usually extra-nodal
It has an aggressive course but a good response to treatment
EBV is seen in almost all cases of Burkitt’s lymphoma
Regarding marginal zone lymphoma, which is not associated?
Helicobacter Pylori
Sjogren’s syndrome
Hashimoto thyroiditis
Gluten sensitivity
Zollinger-Ellison syndrome
Gluten sensitivity - Enteropathic T cell lymphoma
Which is not a common complication of H-pylori
MALT
Erosive gastritis
DU
GU
MALT - 1%
What is the most common long term CNS consequence of HIV/AIDS?
Primary CNS lymphoma
Meningovasculitis
Primary CNS lymphoma
Which is TRUE regarding amyloid?
B2 causes cardiomyopathy
AA is seen in medullary thyroid
AL is associated with chronic lymphoid leukaemia
AA is associated with bronchiectasis
TTR associated with haemolysis
AA is associated with bronchiectasis - also lymphoma
Diffuse thickening of the stomach rugae with preservation of the architecture?
MALT
Diffuse type adenocarcinoma- linitis plastica
Intestinal type adenocarcinoma
GIST
Carcinoid
MALT
Which lymphoma cell type has an identical appearance to CML?
Lymphoblastic
Small non-cleaved
Large cell
Follicular cleaved
Lymphoblasts
Lymphoblasts - similar to myeloblasts
Which lymphoma is most curable?
ALL
Small lymphocytic lymphoma
Mantle cell
Nodular sclerosing
Marginal zone
Nodular sclerosing
Which is not a cause of pneumatosis intestinalis?
Cystic fibrosis
Asthma
Connective tissue disease
Necrotising enterocolitis
Lymphoma
Lymphoma
Which is least correct regarding Waldenstrom macroglobulinaemia? (March 2014)
Bone lesions can be painful
Cold agglutinins are positive
Coombes test are positive
Answer: Bone lesions can be painful - Not typically painful
Cold agglutinins are positive - 5% had positive cold aglucinins
Coombes test are positive - Positive in about 10%
Which of the following is the most common cause of splenic infarction?
Sickle cell disease
Alpha thalassemia
Spherocytosis
Beta thalassaemia
Sickle cell disease
Which is the least likely to cause moderate - severe splenomegaly?
Schistosoma mansoni
Burkitt lymphoma
Polycythaemia vera
Myelofibrosis
Sickle cell anaemia
Sickle cell anaemia
Renal medullary cystic cancer is a disease of childhood. Most likely?
Sickle cell disease
Thalassaemia major
Sickle cell trait
Thalassaemia minor
Leukaemia
Sickle cell trait
Which of the following commonly causes cholesterol gallstones?
Ileal bypass
Sickle cell anaemia
TPN
Ascariasis
TPN
Which is not associated with osteonecrosis?
Cirrhosis
Chronic pancreatitis
Gaucher’s disease
Connective tissue disease
Sickle cell disease
Cirrhosis
Which is least associated with Sickle cell disease? (March 2014)
Acute chest pain
Shock with splenic sequestration
Aplastic crisis
Staph aureus with autosplenectomy
Staph aureus with autosplenectomy
Sickle cell - a common hereditary haemoglobinopathy, a mutation in the B-globin promotes the polymerization of deoxygenated haemoglobin leading to red cell distortion etc.
Staph aureus isn’t associated with autosplenectomy
Which is not a cause of moderate to massive splenomegaly?
Schistosoma
Sickle cell anaemia
Thalassemia major
Myelodysplasia
Burkitts lymphoma endemic and non-endemic
Sickle cell anaemia
Which is least likely to result in splenomegaly? (March 2017)
a. Hepatitis B
b. Budd Chiari
Budd Chiari
Hepatic venous outflow obstruction, partial or complete obstruction of the hepatic veins.
Which is least likely to cause generalised cirrhosis?
Hepatitis
Budd-chiari syndrome
Schistosomiasis
Budd-chiari syndrome
Which is a cause of platelet dysfunction? (August 2014)
Splenomegaly
Uraemia
Answer: Uraemia
Due to chronic kidney disease
The second condition exemplifying an acquired defect in platelet function. The pathogenesis of platelet dysfunction in uraemia is complex and involves defects in adhesion, granule secretion and aggregation.
Splenomegaly :
Thrombocytopenia of hypersplenism is caused primarily by increased splenic platelet pooling.
Which is not a feature of sarcoidosis?
Hepatosplenomegaly
Mculikz syndrome
Both are
Which does not cause splenomegaly?
Biliary ascariasis
Schistosomiasis
Malaria
Answer: Biliary ascariasis
Schistosomiasis
Yes, secondary to portal hypertension
Malaria
Congestive splenomegaly `
Man with HIV presenting with multiple small lesions in the liver and spleen. Most likely?
Candida
Lymphoma metastases
Candida
Hepatosplenic candidiasis - multiple microabscesses scattered through the liver and splenic parenchyma
Splenectomy increases susceptibility to which bacteria? (August 2014)
H. influenzae
Tuberculosis
Mycosis fungoides
H. influenzae
Increased susceptibility to sepsis caused by encapsulated bacteria.
The decrease in phagocytic capacity and antibody production that result from asplenia both contribute to the increased risk of sepsis
Regarding splenomegaly - most correct
Right heart failure causes massive splenomegaly -
Myelofibrosis is the most common cause of splenomegaly in Australia
Chronic splenic enlargement predisposes to spontaneous rupture
Congestive splenomegaly is the most common cause of hypersplenism
Enlarged spleen rarely infarcts
Congestive splenomegaly is the most common cause of hypersplenism
Regarding hereditary spherocytosis, which is FALSE?
During an aplastic crisis reticulocytes leave the peripheral blood
Autosomal dominant
Jaundice is a feature
Splenomegaly is a feature
The red cells are more deformed than usual
The red cells are more deformed than usual
Leukaemia, which renal stones associated
Urate stones
Multiple other stone materials
Urate stones
Epstein Barr Virus most associated with
Natural killer NK/T cell leukaemia/lymphoma
Pure red cell aplasia
Hypergammaglobulinemia
Natural killer NK/T cell leukaemia/lymphoma
Which is false of CML? (March 2015)
Philadelphia chromosome
Transforms to AML
Bone marrow fibrosis
Thrombocytosis
ANSWER: Bone marrow fibrosis . Relates to polycythaemia vera and essential thrombocytopaenia
Transforms to AML :In blast crisis about 2/3 of cases CML transforms into a disease resembling AML. The remainder transform into disease resembling ALL - CML leukaemia foundation
Thrombocytosis : Can be present in CML
Which is associated with the Philadelphia chromosome t(9;22)?
ALL
CLL
A: ALL
Pick CML if its an option
Characteristic of CML and a subset of B-cell acute lymphoblastic leukaemias, can be seen in ALL
Regarding CML, which of the following is not associated?
Philadelphia chromosome – 9 and 22
Transforms into AML
Bone marrow fibrosis - 30-40% of patients before treatment
Splenomegaly
Erythrocytosis
Erythrocytosis
What situation is most important to do a core biopsy?
Lymph node with possible lymphoma
Lung carcinoma
Thyroid lesion.
Lymph node with suspected secondary cancer when primary cancer is known.
Prob this: Lymph node with possible lymphoma - need to assess architecture
Lung carcinoma - huge immuno work-up needed for neoadjuvant therapy
Flow cytometry is most useful for which lesion:
Chloroma
Pancreatic adenocarcinoma.
Thymic carcinoma
NET
Chloroma - Granulocytic sarcoma. Neoplasm of myeloid precursor cells.
Need to determine the clonality of cells
Flow cytometry is used for: (September 2013)
Determining the clonality of lymphomas
Detecting microsatellite instability in colon cancer
Determining HER-2 status in breast cancer
Determining the clonality of lymphomas
Can rapidly and quantitatively measure several individual cell characteristics, but mainly for identifying cellular antigens expressed by ‘liquid’ tumours, those that arise from blood-forming tissues.
Multiple antigens can be assessed simultaneously on individual cells using combinations of specific antibodies linked to different fluorescent dyes.
Recommended for classification and staging of lymphomas.
Which is the most likely to present as petechial mucosal haemorrhages? (March 2015)
a. Christmas disease (Haemophilia B)
b. Lupus anticoagulant
c. Vitamin K deficiency
Answer: c. Vitamin K deficiency
A clotting dyscrasia, vital as a cofactor for the enzymatic activation of several key components of the clotting pathway
Might be myelofibrosis/myelodysplasia
Christmas disease (Haemophilia B)
X linked recessive, exclusively in males. Usually presents with clinically significant bleeding or haemarthrosis
Lupus anticoagulant
A prothrombotic with greater propensity for thrombosis
Which is not associated with EBV? (March 2015)
Burkitt’s Lymphoma
NK/T cell lymphoma
Hodgkin Lymphoma
Plasmacytoma of the head and neck
Nasopharyngeal cancer
Plasmacytoma of the head and neck
What is the most common risk factor for thymoma? (August 2016)
EBV
Radiation for Hodgkin’s lymphoma
Chemotherapy
EBV
EBV is most associated with?
Natural killer NK/T cell leukaemia/ lymphoma
Recent bone marrow transplant, RIF pain, palpable mass (rdr q-BS)
Typhlitis
Pseudomembranous
Crohns
Carcinoma
Typhlitis
Least likely to lead to thrombosis
Turbulent flow
Leukocytosis
Heparin induced thrombocytopenia
Widespread malignancy
Leukocytosis
Which is a typical receptor profile combination for invasive lobular carcinoma? (may not be correct answer sets)
ER+, PR+, HER2+
ER-, PR-, HER2-
ER+, PR+, HER2-
ER-, PR+, HER2-
ER-, PR-, HER2+
ER+, PR+, HER2- - Tumours are generally of a good prognostic phenotype, being low histological grade and low mitotic index, hormone receptor positive and HER2 -ve.
Regarding high risk breast lesions:
ADH is found in 70% of biopsy
Breast cysts are proliferative disease without atypia
Sclerosing adenosis (radial scar) is not associated with cancer
Calcification in comedocarcinoma is due to calcium-rich secretions from viable cancer cells
Loss of E cadherin differentiates LCIS from atypical lobular hyperplasia
Loss of E cadherin differentiates LCIS from atypical lobular hyperplasia
Breast carcinoma:
- Atypical lobular hyperplasia and LCIS. Difference between them is presence of E-cadherin.
- Ductal hyperplasia without atypia not associated with increased malignancy.
Lobular carcinoma – PATH (possibly mixed up with a similar question as well about DCIS?)
Likely bilateral in .. ?%
Contralateral breast cancer risk is 30-40%
?LCIS is 20-40% bilateral
DCIS is 20-40% bilateral
Something about lifetime risk for breast ca
Comedonecrosis is low grade
?LCIS is 20-40% bilateral (true as per statdx)
DCIS is 20-40% bilateral (not true) – 10%
Which of the following is least likely to present as a well-circumscribed mass?
Invasive ductal carcinoma
Invasive lobular carcinoma
Medullary
Papilloma
Mucinous
Invasive lobular carcinoma
Breast calcifications are biopsied. The pathology report describes LCIS. What is the most likely explanation?
Calcification due to necrotic cells in the duct lumen
Sclerosis/fibrosis/inflammation around the duct
Calcification is an incidental finding in LCIS
Calcification implies invasion of the stroma
Calcification is an incidental finding in LCIS
Which is least correct regarding invasive lobular carcinoma?
Metastasises to the lung
Metastasises to the brain
Metastasises to the peritoneum
Metastasises to the brain - favours leptomeninges rather than brain parenchyma
Which does not present with microcalcifications?
Invasive lobular carcinoma
Papilloma
Sclerosing adenosis
Invasive lobular carcinoma
Which lesion is most likely B2 (benign) lesion?
Atypical lobular hyperplasia.
Atypical ductal hyperplasia.
Both are borderline lesions
BIRAD 2
Calcified fibroadenoma
Multiple secretory calcification
Fat-containing lesions e.g. oil cyst, breast lipoma, hamartoma
Cutaneous neruofibroma
Intramammary lymph nodes
Sebaceous cyst
Simple breast cyst
Regarding LCIS, which is true?
Diagnosis is as significant as a diagnosis of DCIS
Risk of invasive carcinoma is similar in both breasts
Invasive carcinoma develops within 5yrs
Risk of invasive carcinoma is similar in both breasts
Regarding LCIS, which is false?
Often bilateral
Increased incidence of invasive carcinoma over decades
Eventually almost everyone will go on to develop invasive carcinoma
Often occurs in younger women (40-50yo)
Eventually almost everyone will go on to develop invasive carcinoma FALSE
Least likely to be a spiculated mass.
Medullary
Tubular
Fat necrosis
Sclerosing adenosis
DCIS
Medullary
Which is correct regarding features of medullary carcinoma?
Well circumscribed
Associated with BRCA1
Associated with BRCA1 - In familial form of breast cancer with BRCA1 gene mutation medullary and mucinous cancers are more common.
Which of the following is associated with medullary breast carcinoma
BRCA 1
BRCA 2
PTEN
TP53
ATM
BRCA 1
A breast lesion is triple negative. What is the most likely lesion?
Invasive tubular
Lobular invasive
Mucinous
Medullary
Apocrine
Medullary
Regarding medullary breast carcinoma. Which is most correct?
Poor prognosis.
Associated with BRCA 1
ER+, PR+, HER2/neu +
Presents as a firm palpable mass with indistinct spiculated margins.
Special type of Invasive lobular carcinoma.
Associated with BRCA 1
Which is true regarding the management of Paget disease of the breast?
Referral to a breast surgeon
Referral to a dermatologist for management of the eczema
Referral to a breast surgeon
Paget’s disease of the nipple. Which is correct?
More than 50% associated with DCIS.
More than 50% associated with invasive ductal carcinoma.
More than 50% the nipple looks macroscopically normal.
More than 50% associated with calcification in the lactiferous ducts adjacent to the nipple.
More than 50% associated with DCIS. (95%+ DCIS)
Paget disease of the nipple often has a normal mammogram. Why?
It is confined to the nipple
There is an intact basement membrane
DCIS infiltrates the areolar and rarely extends to the lactiferous sinuses
Pagets is subareolar and DCIS is often occult
It is an eczematoid reaction
Pagets is subareolar and DCIS is often occult
Why is pagets occult?
It is an eczematoid reaction and may be associated with other conditions
DCIS infiltrates the areola and may be mammographically occult
DCIS infiltrates the areola and rarely extends beyond the lactiferous sinuses
A paraneoplastic reaction
DCIS infiltrates the areola and may be mammographically occult
Which of the following is TRUE regarding Paget disease of the nipple?
Associated with LCIS
Not associated with underlying invasive carcinoma
Palpable mass is present in 10%
Malignant cells invade through the basement membrane
Prognosis is not affected by the presence of DCIS involving the skin
Prognosis is not affected by the presence of DCIS involving the skin
Gynaecomastia not associated with
Klinefelters
Hypothyroidism
Cirrhosis
Dialysis
Lung cancer
Hypothyroidism – happens in hyper
Gynaecomastia (true)
60% bilateral/symmetrical
Same rate of cancer as females
Rare under 40yrs old
Can be due to lung, liver or pituitary problems
ANSWER Can be due to lung, liver or pituitary problems
Gynecomastia typically presents as two-sided or “bilateral” growth, but in small percentage of men (less than 5-10%), it can present as single-sided “unilateral”.
Breast Cancer - most correct. (these may be from different questions)
Medullary is a neuroendocrine - this was from a thyroid stem
Hurthle cells differentiate follicular adenoma from carcinoma
Lymphocytic mastopathy is related to T2DM
The absence of E-cadeherin differentiates ALH from LCIS
Lymphocytic mastopathy is related to T2DM
The absence of E-cadeherin differentiates ALH from LCIS
Most commonly associated with T2DM?
Fibroadenoma
Fibroadenolipoma
Lymphocytic mastitis
Lymphocytic mastitis
Lymphocytic mastitis which false?
SOFT
Can look like cancer
Bilateral
Can be determined clinically
SOFT
Which of the following regarding breast pathology is most correct?
Lymphocytic mastopathy occurs in diabetic
Fat necrosis can have calcification
ANSWER: Fat necrosis can have calcification
Lymphocytic mastopathy occurs in diabetic (no, SLE, Sjogrens and hashimotos)
Which of the following can be diagnosed on FNA?
PASH
LCIS
Diabetic mastopathy
Radial scar
Fat necrosis
Fat necrosis
Regarding breast pathology, which of the following has the highest risk of malignancy?
Sclerosing adenosis –
Duct ectasia
Apocrine metaplasia
Radial scar
PASH - Pseudoangiomatous stromal hyperplasia
ANSWER Radial scar
Sclerosing adenosis – does increase but not highest
PASH - Pseudoangiomatous stromal hyperplasia - benign
Radial scar question (repeat)
Aetiology is not related to ischaemia
There is complete replacement of fat
Radial scar has short spicules
If Bx shows radial scar, it needs further management
If Bx shows radial scar, it needs further management
Radial scar, which has an identical imaging appearance?
Tubular carcinoma
Mucinous carcinoma
Intraductal papillary tumour
Tubular carcinoma
What is most likely to appear as a stellate lesion?
DCIS.
LCIS
Radial scar
Duct ectasia.
Involuting fibroadenoma.
Radial scar
DDx stellate lesion. Which cancer?
Medullary
Tubular
Papillary
Tubular
Most likely to appear as a spiculated mass (possibly repeated in pathology and RDx)
Fibroadenoma
Papillary neoplasm
Mucinous carcinoma
Medullary carcinoma
Tubular carcinoma
Tubular carcinoma
STARFACE
Summation shadow
Tumour I.e. invasive breast cancer
Abscess
Radial scar
Fibroadenoma/fat necrosis
Adenosis (sclerosing)
CE: Other causes, haematoma e.g. post-operative/post-biopsy
Most correct in regards to DCIS
Linear branching 1mm smooth calcifications
Coarse branching calcification
Palpable mass
Mass like enhancement on MRI
Linear branching 1mm smooth calcifications
Regarding DCIS which is most correct?
Prognosis associated with nuclear grade.
Prognosis associated with histological architecture.
Prognosis not associated with cellular necrosis.
Recurrence is most common with wide resection margins.
Prognosis not associated with extent of disease.
Prognosis associated with nuclear grade.
Re:DCIS
Comedo type calcifiation is due to tumour cell producing calcium rich something
Extent of tumour is related to the degree of necrosis of tumour
Likelihood of recurrence is due to whether there is wide margin of excision
Likelihood of recurrence is due to whether there is wide margin of excision
Juvenile papillomatosis of the breast. What is most likely?
Presents as a palpable mass.
Nipple discharge is a common finding.
Occurs in pre-pubertal.
Appears well defined on mammogram.
Nipple discharge presentation.
Presents as a palpable mass.
What is least likely in regards to tubular carcinoma?
Prognosis is 50% in 5 years.
Commonly her2/neu negative.
Spiculated lesion.
Commonly picked up on mammo.
Most common age is 50 years old.
Prognosis is 50% in 5 years.
Which has the highest rate of developing malignancy?
Sclerosing adenosis
Ductal ectasia
Sclerosing adenosis - 2 x higher
Least likely to be spiculated lesion?
PASH
Fat necrosis
Surgical scar
IDC – tubular type
ILC
PASH – benign and circumscribed
Regarding PASH, which is correct?
It is an incidental finding, no further treatment required
50% will be associated with ?(some kind of malignancy) on open surgical biopsy
It is an incidental finding, no further treatment required
Which is correct in regards to Mucinous breast carcinoma
Most prevalent in less than 50 years
Well defined on Mammo
Well defined on Mammo
Male breast cancer which is correct
Most are IDC
Have a poor prognosis in comparison to female of same age
Can’t remember other options
Most are IDC
Male breast cancer, which is ((true/false?))
Lobular is more common in men compared to women
Histologically, the vast majority are invasive ductal carcinoma (85-90%) or ductal carcinoma in situ.
T/F Angiosarcoma is caused by chemotherapy
False; Angiosarcs of the breast are related to RTX
Breast lymphoma, most likely appearance
Mass with axillary nodes
this presentation occurs in 30-50% breast lymphoma, R breast involved more than left (60% to 40% respectively) main pathology is DLBCL.
False?
Papillary carcinoma presents as nipple discharge 25% of the time.
Papillary carcinoma appears as a stellate mass
On cut section, papillary carcinoma appears as a cystic mass?
FALSE Papillary carcinoma appears as a stellate mass - The most common mammographic pattern of invasive papillary carcinoma is a round, oval or lobulated mass.
Nipple discharge with haemorrhage. Most common cause?
Papilloma
Pagets disease of breast.
Something about DCIS
Papilloma
Regarding bloody nipple discharge:
Duct ectasia presents with bloody nipple discharge
Bloody nipple discharge almost always malignant
Almost always a papilloma
Almost always a papilloma
BRCA 1. Not associated with increased risk of?
Male breast cancer
Cholangiocarcinoma
Pancreatic cancers
Prostate cancer
Cholangiocarcinoma
Least associated with Phylloides tumour
Circumscribed but not encapsulated
Mastectomy and lymph node excision
Mastectomy and lymph node excision
Least likely feature of a Phylloides tumour:
Contains cystic spaces -
Large rapidly enlarging lesions
Contains foci of chondroid, osteoid and lipoid (?) metaplasia
Contains foci of chondroid, osteoid and lipoid (?) metaplasia (can be, but rare)
Other two are common
Which is LEAST LIKELY to present as a speculated breast lesion
Invasive medullary
Invasive papillary
Invasive mucinous
Phylloides
(Tubular was not an option)
Phylloides
Least likely breast tumour to arise in stroma
Lipoma
Myofibroblastoma
Phyllodes
Collagenous spherosis
Angiosarcoma
Fibrolipoma
Collagenous spherosis - Myoepithelial proliferative breast disease
Myofibroblastoma (looked this up, it does arise in stroma, so it is incorrect).
Which of the following is the most ideal way to diagnose inflammatory breast cancer?
Stereotactic core Bx
Hook wire open Bx
Vacuum assisted Bx
FNA
Skin punch Bx
Skin punch Bx
Regarding risk factors for breast cancer, which is the least likely association?
Von Hippel Lindau
Cowden sydnrome
Li Fraumeni
Ataxia telangectasia
BRCA 2
Von Hippel Lindau
T/F : Hypertension not assoc with addisons
true
Adrenal insufficiency
Addison’s disease:
acute stage: the patient presents with fever, back pain, hypotension, weakness
chronic stage: progressive lethargy, weakness, cutaneous pigmentation, weight loss
Hyperaldosterone, which is incorrect?
Adrenocortical carcinoma is more common in children
Adrenocortical adenoma is more common in adult
Primary hyperaldosterone is rarely idiopathic
Primary hyperaldosterone is rarely idiopathic
Regarding phaeo, which is incorrect?
Has elevated VMA - in the urine
A typical or recognized location is in the organ of Zukerkandl
neither
What is false regarding phaechromocytomas
a) elevated urine VMA
b) can rarely present with hypertension and hypokalemia
c) typically present with intermittent hypertension
d) rare, but known location is organ of Zuckerkandl
e) adrenal is more likely malignant cf. extra-adrenal
FALSE b) can rarely present with hypertension and hypokalemia - hyperaldosterosis, Conn syndrome. 10% are not associated with hypertension
With regards to the adrenal gland, which is correct?
Cushing disease is caused by an ACTH secreting adrenal adenoma
Neuroblastoma arises from the adrenal cortex
Bilateral metastasis is the most common cause of Addison’s disease
Conn’s syndrome is due to bilateral adrenal hyperplasia
all false
Cushing disease is caused by an ACTH secreting adrenal adenoma - False
Disease is caused by a pituitary adenoma. Syndrome is caused by others
Neuroblastoma arises from the adrenal cortex
False, arise from adrenal medulla precursors
Bilateral metastasis is the most common cause of Addison’s disease - idiopathic autoimmune disorders are the most common cause in developed countries (80% of cases)
Conn’s syndrome is due to bilateral adrenal hyperplasia
False - Conn syndrome: when primary hyperaldosteronism is due to an aldosterone-producing adenoma
Which associations are true?
Renal nephrosclerosis and hypertension
Diffuse cortical necrosis with placenta abruptio
Was there something about nephrolithiasis???
Renal nephrosclerosis and hypertension
What does analgesic nephropathy cause? (August 2014)
Renal papillary necrosis
Glomeruli are involved
Interstitial non-necrotising granulomas
Renal cell carcinoma
Nephrotic syndrome
Renal papillary necrosis - but not specific for analgesic nephropathy.
Necrosis and sloughing of papillary tissue, can result in substantial loss of renal function
Analgesics are LEAST LIKELY to cause:
TCC
Papillary necrosis
Renal stones
Renal artery stenosis
Acute cortical necrosis
Renal artery stenosis
Which of the following associations is false?
A. Hyperparathyroidism and renal calculi
B. Analgesics and papillary necrosis
C. NSAIDS and diffuse cortical necrosis
D. Sickle Cell and acute tubular necrosis
E. Chemotherapy and nephrocalcinosis (or cortical necrosis)
C. NSAIDS and diffuse cortical necrosis - Renal cortical necrosis (RCN) is characterized by patchy or diffuse ischemic destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury.
Which causes papillary necrosis? (March 2017)
a. NSAIDs
b. Steroids
c. Warfarin
d. Streptokinase
a. NSAIDs
Mneumonic NSAID: NSAIDS, sickle cell disease, paracetamol, infection (pyelonephritis, TB), DM or diabetes
Which is least likely secondary to diabetic microangiopathy?
a. Papillary necrosis
b. Glomerulosclerosis
c. Autonomic neuropathy
d. Sensory motor neuropathy
e. Macular oedema.
a. Papillary necrosis
What is least likely cause of papillary necrosis.
a. Phenacetin associated analgesics
b. Sickle cell
c. NSAIDS
d. Diabetes
e. Infection (?)
d. Diabetes
What is the MOST LIKELY association?
NSAID and diffuse renal cortical necrosis
Multiple myeloma and recurrent pyelonephritis
Multiple myeloma and recurrent pyelonephritis
Which condition does sarcoid not cause? (March 2016)
a. Chronic glomerulonephritis -
b. Choroid retinitis -
c. Splenomegaly
d. Non-caseating granulomas in the lungs
a. Chronic glomerulonephritis - rare
Which is false regarding xanthogranulomatous pyelonephritis? (April 2013)
a. Rarely bilateral
b. Less than 10% are associated with obstruction
c. Associated with gram negative infection
d. Can mimic a renal cell cancer on imaging
b. Less than 10% are associated with obstruction – false, almost all associated with obstruction
Which is MOST LIKELY association?
Gonorrhoea with pyelonephritis
HPV with urethritis
Chlamydia with prostatitis
Treponema with epididymitis
Chlamydia with prostatitis
Which two conditions are not associated? (March 2016)
a. Xanthogranulomatous pyelonephritis and pelvicalyceal obstruction
b. Ureteric lesion and fibromatosis
b. Ureteric lesion and fibromatosis
HIV patient has renal ultrasound demonstrates echogenic foci within the cortex of the kidney with some shadowing. What is most likely?
a. HIV nephropathy.
b. CMV nephropathy.
c. HAART nephropathy.
d. TB nephropathy.
e. AIDS nephropathy.
f. Normal vascular structures
b. CMV nephropathy.
HIV patient with bilateral echogenic kidneys. What is most likely?
a. HIV nephropathy.
b. CMV nephropathy
c. HAART nephropathy.
d. TB nephropathy.
e. AIDS nephropathy.
a. HIV nephropathy.
What is the most likely cause of diffuse/nodular parathyroid hyperplasia?
a) Vitamin D deficiency
b) Renal failure
c) Hypophosphataemia
b) Renal failure
Primary parathyroid hyperplasia
Sporadic (80%): associated with exposure to radiation and lithium
Familial (20%): associated with MEN 1 and MEN 2a
Secondary parathyroid hyperplasia
Renal failure
What is NOT a cause of renal microaneurysms
Diabetic nephropathy
Neurofibromatosis
Hypertension
Fibromuscular dysplasia
NF1
Diabetic nephropathy
Multiple intracranial aneurysms, areas of stenosis involving ICA and renal disease, which is MOST LIKELY?
FMD
PAN
SLE
Behcet
GCA
FMD
Wegener’s is least likely to have
a. Non-caseating pulmonary granulomas
b. Non-caseating sinus granulomas
c. Glomerulonephritis
d. Renal artery vasculitis
e. Pulmonary artery vasculitis
d. Renal artery vasculitis
Most likely bladder injury following blunt trauma? (RPT)
Intraperitoneal
Extraperitoneal -
Combined intra & extra
Bladder laceration
Extraperitoneal - (60%)
Which is false of polycystic kidney disease? (March 2015)
a. Fibrosis of the liver
b. Liver cysts
c. Caroli disease
d. Alagille syndrome
. Alagille syndrome - variable renal involvement, including cystic kidney disease
Polycystic kidney disease has NO ASSOCIATION with:
Liver fibrosis \
Von Meyenberg complexes
Liver fibrosis - ARPKD
Von Meyenberg complexes - ADPKD
Depends on the type of PKD
Which of the following is MOST CORRECT regarding renal cystic disease?
Cysts of dialysis behave like normal cysts
ADPKD has an increased risk of RCC
Juvenile ARPKD needs renal transplant
MCDK associated with downstream/lower urinary tract abnormality
Medullary sponge kidney is a pediatric condition
MCDK associated with downstream/lower urinary tract abnormality
which cystic renal disease is not hereditary??
Multicystic renal dysplasia
Acquired/or ?adult medullary cystic renal disease
Juvenile ?? cystic renal disease
Multicystic renal dysplasia
Least likely inheritable renal cystic disease:
Childhood nephronophthisis
Childhood polycystic kidney
Medullary sponge kidney
Adult-onset medullary cystic kidney
Adult polycystic kidney
Medullary sponge kidney
Which is true? (March 2015)
a. Proteus is associated with the formation of struvite stones
b. Multiple myeloma is associated with recurrent pyelonephritis
BOTH
a. Proteus is associated with the formation of struvite stones
Alkalinizes the urine by hydrolyzing urea to ammonia. This leads to precipitation of organic and inorganic compounds which lead to struvite stone formation.
b. Multiple myeloma is associated with recurrent pyelonephritis
associated with anaemia, renal failure, proteinuria, hypercalcaemia, pathological fractures, amyloidosis, recurrent infections, plasmacytomas, polyneuropathy
Which is the most likely composition of renal stones in a patient with leukaemia? (March 2017)
Uric acid
Magnesium ammonium phosphate
Calcium oxalate
Cystine
Mixed calcium oxalate and calcium phosphate
Uric acid - Robbins 952, due to high cell turnover
Which is true regarding pelviureteric junction obstruction? (March 2015)
a. Associated with contralateral renal agenesis
b. Associated with vesico-ureteric reflux
c. Associated with lower moiety
d. More common on the right
e. More common in girls
b. Associated with vesico-ureteric reflux
Ureteropelvic junction obstruction (UPJO) and vesicoureteric reflux (VUR) are the most common pathological conditions in pediatric urology, with 9%–14% of patients with UPJO likely to have concomitant VUR.
Which of the following is most correct regarding urolithiasis? there were two stones questions getting mixed up so might be two correct answers listed.
a)
b) Calcium oxalate stones account for about 30% of all stones
c) Cystine stones occur in acidic urine
d) Struvite calculus occurs in the setting of infection
e) Uric acid calculus always occur in patient with hyperuricemia
d) Struvite calculus occurs in the setting of infection – Specific infection
Regarding PUJ obstruction, which is LEAST COMMON?
Occurs more commonly in the inferior moeity in duplex kidneys as opposed to the upper moeity -
Occurs more commonly in males than females
Occurs more commonly on the right than the left -
Associated with contralateral renal agenesis
Bilateral in 10-30% of congenital PUJ
Occurs more commonly on the right than the left - FALSE
Which is MOST LINKED to tuberous sclerosis?
AML
Clear cell carcinoma
AML
What is associated with rhabdomyomas?
Angiomyolipomas
Rhabdomyosarcoma
Angiomyolipomas CAYUSE OS TS
Which is most likely to affect the lungs and the kidneys?
TS
PAN
Diabetes
TS
Regarding VHL, which is the LEAST COMMON feature?
Pancreatic adenocarcinoma
Multiple liver cysts
RCC - usually the clear cell type
Pancreatic adenocarcinoma
Bilateral pheo DIAGNOSIS
VHL
MEN 1
NF2
TS
VHL
Which is FALSE regarding VHL?
Associated with papillary RCC
Associated with clear cell RCC
Associated with renal haemangioblastoma
Assocaiated with cerebellar haemangioblastoma
Pheochromocytoma
Associated with papillary RCC
(Associated with renal haemangioblastoma ALSO NOT TRUE)
Association with multiple AMLs
LAM
TS associated LAM
Sporadic LAM
TS associated LAM
Which is the most common presentation of angiomyolipoma? (March 2016)
a. Haematuria
b. Retroperitoneal haemorrhage
c. Obstruction
Haematuria
Kid in an accident. Lesion consistent with angiomyopipoma. Clinically stable. Next best step?
MRI
DSA
Family history
Renal scintigraphy
Renal surgery
Family history
Which renal tumour is closely associated with cardiac tumour
AML
RCC
AML
Regarding the affects of RCC (March 2015)
a. Hypertension
b. Feminisation
c. Limbic encephalitis
a. Hypertension
Causes all (paraneoplastic syndromes), but hypertension is most common
What is the MOST CORRECT association?
Juvenile ARPCKD and transplant
ADPCKD and RCC
Juvenile ARPCKD and transplant - worse liver than kidneys
Which is associated with the highest risk for RCC? (March 2016)
a. Nephronopthisis
b. Medullary cystic disease
c. Acquired renal cystic disease?
d. ARPKD
e. ADPKD
c. Acquired renal cystic disease?
Most associated with renal cell ca
a) Dialysis associated dysplasia
Which paraneoplastic syndrome is not associated with RCC?
A. Hypertension
B. Feminisation
C. Limbic encephalitis
D. Neutrophilia
E. Polycythaemia
Neutrophilia
Which is not associated? (April 2013)
a. Pyelocalyceal obstruction and xanthogranulomatous pyelonephritis
b. Horseshoe kidney and renal calculi
c. ARPKD with congenital hepatic fibrosis
d. Renal cell carcinoma and analgesic abuse
e. Schistosomiasis and bladder wall calcification
d. Renal cell carcinoma and analgesic abuse
Analgesics are associated with UCC, not RCC
Urothelial cell risk factors:
Smoking
Aryl amines
Schistosomiasis
Long term use of analgesics
Heavy long term exposure to cyclophosphamide
Irradiation
Which of the following associations is FALSE?
Lead and sarcoma
Mercury and RCC
Smoking and oropharyngeal cancer
Asbestos and lung cancer
Asbestos and mesothelioma
Lead and sarcoma
Which is LEAST LIKELY regarding the affects of RCC?
Hypertension
Feminisation
Limbic encephalitis
Cushing syndrome
Eosinophilia
Limbic encephalitis
With regards to RCC, which is correct?
Oncocytoma can be confused with clear cell carcinoma
Papillary RCCs are cystic
Invasion of the renal vein confers a 15% 5 year survival rate
Papillary RCCs are cystic – They can be when large
Which is LEAST associated with RCC?
TS
VHL
NF1
Smoking
Dialysis, renal cysts
NF1
Most likely bilateral renal tumour?
a. Clear cell RCC
b. Papillary RCC
c. Chromophobe RCC
d. Collecting duct RCC.
b. Papillary RCC
What is best prognosis renal cell cancer?
a. Clear cell RCC
b. Papillary RCC
c. Chromophobe RCC
d. Collecting duct RCC.
c. Chromophobe RCC
Regarding renal oncocytomas, which is MOST TRUE
Oncocytoma can pathologically look similar to RCC
Central scar in 75%
10% TS has AML
Oncocytoma can pathologically look similar to RCC
Histologic description of a tumour, eosinophilic cellular material, central scar
Oncocytoma
All EXCEPT which of the following commonly occur in children under 5yrs of age?
Clear cell carcinoma
Clear cell sarcoma
Rhabdoid tumour
Nephroblastoma
Nephroma
Clear cell carcinoma
Average age of onset for sporadic ccRCC is 61yo.
VHL RCC is 36yo
Regarding renal tumours, which is MOST CORRECT?
Renal vein invasion of RCC has a 5yr survival of 15%- false, 60%
VHL associated with multiple chromophobe RCCs
Clear cell and oncocytoma can be difficult to differentiate
Hereditary leiomyomatosis is associated with clear cell RCCs
Subpleural cysts and fibrofolliculomas are associated with chromophobe RCCs
Clear cell and oncocytoma can be difficult to differentiate
Regarding Wilms tumour, which is true? (September 2013)
a. Usually diagnosed before age 2
b. WAGR – the ‘a’ represents adrenal tumours
c. Carries a poor prognosis
d. If bilateral, is associated with nephrogenic rests -
e. Is associated with a syndrome of deletion of the 11p chromosome
e. Is associated with a syndrome of deletion of the 11p chromosome
With regard to Wilms tumour, which is LEAST correct?
Peak age of 2-5yo
Near all bilateral tumours are presumed to have a germ line mutation
Near 100% with bilateral tumours have nephrogenic rests
Approximately 50% of unilateral tumours have a germ line mutation
10% of patients have lung mets at primary diagnosis
Approximately 50% of unilateral tumours have a germ line mutation
False, 10%
Which is Wilms tumour not associated with? (August 2014)
a. Denys-Drash
b. WAGR
c. Perlman
d. Hutchison
e. Beckwith-Wiedeman
d. Hutchison - Radiopaedia, skeletal mets from neuroblastoma
3yo child has a large solid mass with a small amount of central cystic change arising from the kidney. Biopsy shows epithelial, stromal and blastemal elements. What is the MOST LIKELY diagnosis?
Wilms
Mesoblastic nephroma
Clear cell sarcoma
Rhabdoid
Multilocular cystic nephroma
Wilms
What is not a risk factor for adenocarcinoma of the bladder? (March 2015)
a. Urachal remnant
b. Bladder exstrophy - associated
c. Schistosomiasis
d. Chronic infection
e. Bladder calculi
f. Diverticuli
g. Aniline dye
g. Aniline dye - increased risk of bladder cancer (TCC)
A woman has umbilical discharge and a carcinoma of the dome of the bladder. What is the most likely diagnosis? (March 2016)
a. Adenocarcinoma
b. TCC
c. SCC
d. Metastases
a. Adenocarcinoma
Which of the following is a risk factor for adenocarcinoma of the bladder?
A. Urachal remnant
B. Bladder exstrophy
C. Schistosomiasis
D. Chronic infection
E. Bladder calculi
F. Bladder diverticulum
A. Urachal remnant
Regarding bladder tumours, which is TRUE?
High risk of non-muscle invasive disease is treated with BCG
Lesions at the renal pelvis tend to be large at presentation
Lymph node invasion is what results in greatest reduction in 5yr survival
Lesion morphology determines aggressiveness
Polypoid lesions are worse than flat lesions
High risk of non-muscle invasive disease is treated with BCG
Calcified bladder in a Nigerian patient. Most likely malignancy? (March 2015)
a. SCC
b. Adenocarcinoma
a. SCC - schistosomiasis predisposes an individual to SCC
Bladder calcification: Schistosomiasis, cytotoxic, radiation, interstitial cystitis, TB, TCC
An African man with known schistosomiasis is admitted with a polypoid bladder mass. It is most likely
A. Adenocarcinoma
B. Squamous cell carcinoma
C. Transitional cell carcinoma
D. Rhabdomyosarcoma
E. ?
B. Squamous cell carcinoma
T/F Schistosomiasis assoc with portal hypertension
TRUE The classic form of presinusoidal portal hypertension is caused by the deposition of Schistosoma oocytes in presinusoidal portal venules, with the subsequent development of granulomata and portal fibrosis.
Regarding the aetiology of bladder tumours, which is false? (September 2013)
a. Urachus and adenocarcinoma
b. Strongoloides and transmittal (?transitional)
c. Schistosomiasis and SCC
d. Calculi and SCC
e. Anyline dyes and TCC
b. Strongoloides and transmittal (?transitional)
Which of the following is NOT a risk factor for adenocarcinoma of the bladder?
- Urachal remnant
- Bladder exstrophy
- Schistosomiasis
- Chronic infection
- Bladder calculi
- Bladder diverticulum
- Bladder calculi
All of the following metastasise to the brain except?
Lung
RCC
Breast
Prostate
Melanoma
Prostate - mets to dura via vertebral plexus seeding
Regarding prostate cancer, which statement is true?
A. Affects anterior gland more than rest
B. Early involvement of urethra
C. Spreads preferentially to liver over lung
D. Rarely invades rectum due to Denonvillier fascia
E. Early spread to para-aortic lymph nodes
D. Rarely invades rectum due to Denonvillier fascia
Which vitamin is associated with prostate cancer?
a. A
b. B
c. C
d. D
e. E
f. K
d. D
Regarding malignant para-testicular tumours, which is most common?
A. Angiosarcoma
B. Leiomyosarcoma
C. Kaposi sarcoma
D. Fibrosarcoma
E. Liposarcoma
E. Liposarcoma (46%)
A barium swallow shows a lesion in the upper oesophagus. What is the most likely cause? (August 2014)
a. Schatzki ‘A’ ring
b. Vertical shelf - oesophageal web
c. Adenocarcinoma
d. Barret oesophagus
ANSWER: Vertical shelf - oesophageal web
Most likely
Schatzki ‘A’ ring
- Occurs in the distal 1/3, above the gastro-oesophageal junction - Robbins 753
- A few cm proximal to the B ring (located at the GOJ, seen in the setting of hiatus hernia)
- B ring - represents the junction of the squamous and columnar epithelium (Z-line), usually 1-3mm in length. May obstruct and doesn’t change during the examination
Adenocarcinoma
- Usually occur in the distal 1/3 of the oesophagus - Robbins 758
- SCC is in the middle 1/3 of the oesophagus
- Stricture with an irregular (ulcerated) surface.
- Arises from Barrets oesophagus, so usually the lower oesophagus
d. Barret oesophagus
- No, distal 1/3 of the oesophagus - same distribution as adenocarcinoma, of which it’s a precursor. Presents as a high stricture and hiatus hernia.
- Long segment stricture in the mid-lower oesophagus. Reticular mucosal pattern with thickened folds.
- Associated with reflux
Oesophageal varices, which is least correct?
a. Linear filling defects parallel to the long axis of the oesophagus
b. Round sessile filling defect in the oesophagus
c. Can be caused by SVC obstruction
d. Can be caused by cirrhosis
b. Round sessile filling defect in the oesophagus
Which is not associated with oesophageal varices?
a. Hepatitis A
b. Cystic fibrosis
c. Wilsons disease
a. Hepatitis A
Which is an association? (March 2015)
a. Oesophageal web with graft vs host disease
b. Oesophageal ring with peripheral neuropathy
c. Corkscrew oesophagus with obesity
a. Oesophageal web with graft vs host disease
Also GORD, radiation and Plummer-Vinson syndrome
Which is the least likely association?
A. Oesophageal web with graft versus host disease
B. Oesophageal ring with autonomic neuropathy
C. Tyrypanosoma cruzi and secondary achalasia
D. Nutcracker oesophagus and obesity
E. Oseophageal spasm and oesophageal diverticula
B. Oesophageal ring with autonomic neuropathy
Which is true regarding the oesophagus? (March 2016)
a. Traction diverticuli affect the mid-oesophagus
b. Schatzki rings affect the mid-oesophagus
a. Traction diverticuli affect the mid-oesophagus
Which is correct regarding Barret oesophagus? (March 2014
Predisposes to adenocarcinoma
What is true of Barrett oesophagitis? (August 2016)
Metaplastic columnar epithelium
Diagnosis requires detection of metaplastic columnar mucosa above the GOJ
A binge drinker experiences pain on swallowing. A barium study shows a nodular distal oesophagus. (March 2015)
a. Reflux
b. Carcinoma
c. Varices
d. Caustic injury
Reflux
Which is not considered a risk factor for oesophageal adenocarcinoma and squamous cell carcinoma?
(March 2016)
a. Smoking
b. Alcohol
c. Obesity
d. H pylori
e. Hot beverages
d. H pylori - radiopaedia
Considered protective
Which is correct regarding oesophageal cancer?
a. Serosa as limiting surface
b. Perineural invasion
b. Perineural invasion – Happens and has very poor prognosis
Re oesophageal carcinoma
H.pylori is a risk factor of oesophageal carcinoma
Scc no gender predilection
Adeno better prognosis than SCC
TOF predispose to SCC
Adeno better prognosis than SCC
Risk factors for SCC and adenocarcinoma, which one do they have in common?
a. Tobacco
b. Alcohol
c. Hot drinks
d. ?H. Pylori
Tobacco
Oesophageal - most correct
a) oesophageal adenocarcinoma most commonly occurs secondary to Barretts
b) sliding hiatus hernia is the most common cause of reflux
a) oesophageal adenocarcinoma most commonly occurs secondary to Barretts (90-100%)
Diffuse thickening of the stomach rugae with preservation of the architecture. (August 2016, September 2013)
a. MALT lymphoma
b. Diffuse type adenocarcinoma (Linitis plastica)
c. Intestinal type adenocarcinoma
d. GIST
e. Carcinoid
ANSWER. MALT lymphoma - Thickening of the stomach wall with large lateral extension of the tumour
b. Diffuse type adenocarcinoma (Linitis plastica) - thickened with small lumen
c. Intestinal type adenocarcinoma - tend to be bulky and grow along broad cohesive fronts to form an exophytic mass or an ulcerated tumour
d. GIST - usually forms a solitary, well-circumscribed, fleshy, submucosal mass
e. Carcinoid - intramural or submucosal masses that create small polypoid lesions. They are yellow or tan in appearance
Gastric cancer is most associated with: (August 2016)
a. Bilroth I
b. Bilroth II
c. Roux en y
b. Bilroth II
Increased risk of gastric adenocarcinoma post op - Radiopaedia
Resection of distal stomach/partial gastrectomy
Not associated with increased risk of gastric cancer
a. Atrophic gastritis
b. Hyperplastic polyp
c. Adenomatous polyp
d. Gastric fundal polyp
b. Hyperplastic polyp
Which of the following is most correct regarding gastric cancer?
a) Gastric cancer with local nodes has a 5 year survival of 20%
b) Gastric cancer is often symptomatic and presents early
c) H. pylori is associated with gastric adenocarcinoma
c) H. pylori is associated with gastric adenocarcinoma
Regarding GIST, which is true? (March 2014)
a. Stomach GIST are the most malignant
b. Leiomyomas are associated with MEN syndrome
c. Recurrence of GIST is related to the initial size
d. Oesophageal GIST - rare, <1%
c. Recurrence of GIST is related to the initial size
Recurrence or metastases is rare for gastric GISTs smaller than 5cm, common if >10cm
What is the most likely? (March 2015)
a. Leiomyoma in the duodenum
b. GIST in the rectum
c. Carcinoid in the oesophagus
a. Leiomyoma in the duodenum: 10-20%
What is the most common location for small bowel adenocarcinoma? (March 2017)
a. Duodenum
b. Proximal jejunum
c. Distal jejunum
d. Proximal ileum
e. Distal ileum
Duodenum
What is the most likely cause of pseudomyxoma peritonei? (August 2015)
a. Low grade appendiceal tumour
b. Ovarian cystadenoma
c. Ovarian cystadenocarcinoma
a. Low grade appendiceal tumour
Mucinous appendiceal tumour is the most common cause
What is the most benign carcinoid? (March 2015)
a. Appendix
b. Stomach
c. Oesophagus
d. Jejunum
e. Rectum
a. Appendix <5% have mets at diagnosis
Foregut - rarely metastasize, generally cured by resection
Midgut - tend to be aggressive - jejunum and ileum
Hindgut - appendix and colorectum, incidentally. Appendix are nearly benign
Where is the most aggressive carcinoid? (August 2014)
a. Oesophagus
b. Appendix
c. Stomach
d. Colon
e. Terminal ileum
e. Terminal ileum
What is the most common location for small bowel carcinoid? (March 2016, August 2016)
a. Distal ileum
b. Proximal ileum
c. Jejunum
d. Duodenum
a. Distal ileum 40% small intestine, most frequently the terminal ileum - Radiopaedia
Colorectal cancer most correct
a) caecal cancer presents with fatigue and weakness
b) adenoma architecture has greatest impact on risk of malignancy
c) left-sided cancer way more common than right-sided
d) anal carcinoma tend to metastasise to liver
a) caecal cancer presents with fatigue and weakness - right-sided cancers present with
generalised fatigue and lethargy (or something similarly vague) rather than occult bleeding
Rectal circumferential mass. No pelvic lymph nodes or metastases. Likely: (rdr)
a) Stage I
b) Stage II
c) Stage IIIa
d) Stage IIIb
e) Stage IV
b) Stage II
Rectal carcinoma involving the muscularis propria with 1mm mesorectal fat involvement
T1
T2
T3
T4
T3
Which of these is true? (March 2015)
a. Vulval carcinoma predisposes to/has an association with anal cancer
b. Anal melanoma is inherited
a. Vulval carcinoma predisposes to/has an association with anal cancer
Radiopaedia - previous in situ or invasive cervical, vulva or vaginal cancer
How would anal cancer be staged if there was involvement of ipsilateral iliac or inguinal lymph nodes?
(August 2014)
a. I
b. II
c. IIIA
d. IIIB
d. IIIB
Which of the following is least associated with GI cancer? (September 2013)
a. Cronkhite-Canada
b. Celiac disease
c. Ulcerative colitis
d. Pernicious anaemia
e. Previous gastrectomy
a. Cronkhite-Canada
Which is least likely to cause cancer of the stomach? (March 2017)
a. Cronkhite-Canada
b. Peutz-Jegher
c. Hyperplastic polyps
d. Sporadic/fundal gland polyp.
e. Atrophic gastritis
a. Cronkhite-Canada
Not associated with malignancy
Which is most associated with colorectal cancer? (March 2017)
a. Crohns disease
b. Ulcerative colitis
c. Coeliac disease
d. Peutz-Jegher
Peutz-Jegher
Which does not cause pneumatosis intestinalis?
Asthma
SMA atherosclerosis
Cystic fibrosis
Peutz Jehgers
Myocardial infarction
Peutz Jehgers
Which syndrome commonly causes caecal/ascending colon carcinoma?
Gardners syndrome
Cowdens syndrome
Lynch syndrome
Peutz-Jeghers
Lynch syndrome - More frequently right sided (70% proximal to the splenic flexure).
Regarding HNPCC, which is least likely? (March 2014)
a. HNPCC is associated with endometrial cancer
b. HNPCC is associated with small bowel adenocarcinoma
c. HNPCC is associated with urothelial cancer
c. HNPCC is associated with urothelial cancer
1 - 7%
Hereditary non-polyposis colorectal cancer. Which is not typical?
a. Colorectal cancer under 50 years
b. Colorectal cancer in two first degree relatives
c. Metachronous colorectal cancer and endometrial cancer
d. Metachronous colorectal cancer and urothelial cancer
e. Small bowel adenocarcinoma
b. Colorectal cancer in two first degree relatives - autosomal dominant
Which of these is not associated
Turcot syndrome and meningioma
Lynch syndrome and endometrial carcinoma
Peutz Jegher syndrome and colorectal carcinoma
Gardner syndrome and desmoid
Turcot syndrome and meningioma UM ACTUALLY ITS Glioblastoma and medulloblastoma
Stomach and small bowel adenomas are associated with what?
Peutz-Jeghers
Familial adenomatous polyposis
Familial adenomatous polyposis
