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Flashcards in Pathology II Deck (31):
1

A 64-year-old woman is commenced on 5-fluorouracil following resection of a Dukes' C1 adenocarcinoma of the rectum.
What is the mechanism of action of this agent?
(Please select 1 option)
Alkylating agent
DNA polymerase inhibition
Oestrogen receptor antagonism
Thymidylate synthetase inhibition
Topoisomerase II inhibition

Thymidylate synthetase inhibition

The active metabolites of 5-FU inhibit thymidylate synthetase through covalently binding to it. The drug is commonly used in the treatment of colorectal cancer usually with folinic acid. It is now often combined with oxaliplatin or irinotecan in advanced disease.

Methotrexate is a dihydrofolate reductase (DHFR) inhibitor.

Cytarabine used in acute myelogenous leukaemia (AML), is a DNA polymerase inhibitor.

Tamoxifen is an oestrogen receptor antagonist and irinotecan is an example of a topoisomerase II inhibitor.

2

A 74-year old male attends the emergency department complaining of back pain and an x ray suggests the presence of multiple metastases.
Which of the following is the most likely site for the primary tumour?
(Please select 1 option)
Bladder
Colorectal
Lung
Lymph glands
Thyroid

Lung

There are five common primary sites that result in bone metastases. These are

Lung
Breast
Prostate
Kidney
Thyroid.
Lung cancer is more common than thyroid cancer, so represents the most likely primary site in this case.

3

A 52-year-old lady presents to breast clinic with a 3 cm mass in her left breast. There are no skin changes and no evidence of fixation.
Imaging and pathology confirms that she has breast carcinoma.
According to the TNM staging system the tumour would be classified as which of the following?
(Please select 1 option)
T0
T1
T2
T3
T4

T12

The TNM classification of breast cancer is:

Tis - Ductal carcinoma in situ, Paget's disease of the breast.

T1 Tumour diameter 2cm
T3 Tumour diameter >5cm
T4 Any size tumour with skin changes Fixation

4

A patient with AIDS is being counselled with regard to the risks of developing malignancies associated with retroviral infection.
Which of the following malignancies characteristically occurs in patients with AIDS?
(Please select 1 option)
Anaplastic carcinoma of the thyroid
Basal cell carcinoma of the skin
B cell non-Hodgkin’s lymphoma
Oesophageal squamous cell carcinoma
Pancreatic adenocarcinoma

B cell non-Hodgkin’s lymphoma

Lymphoma (commonly a B cell non-Hodgkin's lymphoma but also a T cell non-Hodgkin's lymphoma)
Kaposi's sarcoma
Squamous cell carcinoma of the skin and
Squamous cell carcinoma of the cervix and larynx
characteristically occur in patients with AIDS.

5

A 68-year-old male has recently undergone surgery for a tumour in his sigmoid colon.
Pre-operative investigations did not reveal any distant metastases. The pathology results confirm positive regional lymph nodes with tumour in the apical node.
What stage cancer does the patient have according to Dukes' staging system?
(Please select 1 option)
A
B
C1
C2
D

C2

Dukes A involves lesions confined to the bowel wall, Dukes B reach the serosa. Dukes grade C1 has local nodes involved but apical nodes are spared. Dukes C2 involve the apical nodes and Dukes D with the worst prognosis have distant metastases.

6

Which of the following is an example of a tumour suppressor gene?
(Please select 1 option)
Int-2
Myc
Ras
Retinoblastoma gene (Rb)
Sis

Retinoblastoma gene (Rb)

Retinoblastoma gene is the only tumour suppressor gene or growth inhibiting anti-oncogene.

The others are all growth promoting proto-oncogenes.

7

A 20-year-old male has been diagnosed with a testicular teratoma.
Which tumour marker is most likely to be elevated?
(Please select 1 option)
Alpha-fetoprotein
CA15-3
Calcitonin
Placental alkaline phosphatase
Prostate-specific antigen (PSA)

AFP

A tumour marker is a substance that is reliably found in the circulation of a patient with a neoplasm. It is directly related to the presence of the neoplasm.

Alpha-fetoprotein, ß-human chorionic gonadotrophin (ß-hCG) and carcinoembryonic antigen (CEA) are tumour markers associated with testicular teratomas.

In contrast, testicular seminomas are associated with placental alkaline phosphatase and sometimes ß-hCG.

8

You are in the weekly breast clinic and an anxious young lady whose mother is currently being treated for breast cancer in your unit asks you about the risk factors for developing breast cancer.
Which of the following has been linked with a significantly increased risk of breast cancer?
(Please select 1 option)
Breast feeding
Late menarche
Late menopause
Multiparity
Oophorectomy

Late menopause

Risk factors linked to breast cancer include

Genetic factors (BRCA1/2, ataxia-telangiectasia, Li-Fraumeni)
Family history - x2 for 1 first degree and x5 for 2 first degree relatives
Proliferative benign breast disease with or without atypia
Early menarche
Late menopause
Nulliparity or late pregnancy
Chest radiation
Prolonged use of hormone replacement therapy.

9

You are carrying out an abdominal examination on a 30-year-old female.
The patient appears to have massive splenomegaly.
Which of the following is the most likely cause?
(Please select 1 option)
Amyloidosis
Autoimmune haemolytic anaemia
Infectious mononucleosis
Malaria
Rheumatoid arthritis

Malaria

The definition of 'massive' splenomegally is variable.

It can be a spleen

With any dimension greater than 20 cm
That weighs more than 1,500 gm or
Which reaches the iliac crest.
Except in infants, a spleen needs to be about twice normal size to be palpable.

The following conditions are associated with massive splenomegaly:

Malaria
Chronic myeloid leukaemia
Myelofibrosis
Kala-azar, and
Gaucher's disease.
The other conditions listed may be associated with mild to moderate splenomegaly. There are, of course, exceptions to all rules.

10

A 35-year-old female presents to head and neck clinic with a small lump in the anterior triangle of her neck.
Which of the following is true?
(Please select 1 option)
Colloid fine needle aspirate is suspicious of malignancy
FNA can diagnose papillary carcinoma
FNA excludes malignancy
FNA revealing follicular cells indicates malignancy
The diagnosis of follicular carcinoma can be made with FNA

FNA can diagnose papillary carcinoma

FNA (fine needle aspiration biopsy) is a useful investigation for patients presenting with a solitary thyroid nodule. However, diagnosis depends on the material aspirated and there is a false negative rate of between 1 and 6%.

FNA is extremely accurate at diagnosing papillary carcinoma.

Follicular cells can be found with follicular adenoma and carcinoma. Therefore, the diagnosis of follicular carcinoma cannot be made with FNA.

Colloid and macrophages in the aspirate strongly suggest benign disease.



11

Your consultant suspects a patient on the ward might have amyloidosis.
Which of the following tests would diagnose this disease?
(Please select 1 option)
Abdominal ultrasound
ECG
Echocardiogram
Tissue or organ biopsy
Urinalysis

Tissue or organ biopsy

Diagnosis of amyloidosis is based on finding amyloid deposits in organs or other body tissues.

Biopsies are typically taken from the rectum, abdominal fat or bone marrow under local anaesthesia.

Only bone marrow tests or biopsies of tissue can positively establish the diagnosis of amyloidosis and classify the type.

However, there may be abnormalities in the other tests listed above depending on the organs affected.

12

There has recently been a great deal of controversy relating to the use of Herceptin in breast cancer but how common is Her-2 over-expression?
(Please select 1 option)
0-5%
5-10%
15-25%
40-50%
75-85%

Her-2 over-expression has a prevalence of between 15-25% in breast cancer.

13

A 62-year-old surgical patient has undergone anterior resection for a rectal mass.
The histology report describes a moderately differentiated adenocarcinoma which invades into the muscle, but not through the wall. One out of 13 lymph nodes is involved by metastatic tumour, but the high tie node is tumour free.
A liver biopsy from a suspicious lesion in the liver shows 'no evidence of malignancy'.
What stage is this patient's cancer?
(Please select 1 option)
Dukes' A
Dukes' B
Modified Dukes' C1
Modified Dukes' C2
Modified Dukes' D

Modified Dukes' C1

This patient has Dukes' grade C1 carcinoma of the colon as local nodes are involved but apical nodes are spared.

Dukes' A involve lesions confined to the bowel wall
Dukes' B reach the serosa
Dukes' C2 involve the apical nodes
Dukes' D with the worst prognosis have distant metastases.

14

A 84-year-old man is admitted on the surgical intake complaining of jaundice, weight loss, dark urine and urticaria. He drinks 30 units of alcohol per week.
On examination he is found to have a palpable gallbladder. Admission bloods include the following LFTs:
Bilirubin 156 µmol/L (1-22)
ALT 68 U/L (5-35)
Alkaline phosphotase 1896 U/L (45-105)
What is the most likely diagnosis from the list below?
(Please select 1 option)
Cholangiocarcinoma
Cholecystitis
Cholelithiasis
Liver cirrhosis
Pancreatic carcinoma

Pancreatic carcinoma This is the correct answerThis is the correct answer
This gentleman's history suggests that he has obstructive rather than hepatocellular jaundice.

The liver function profile also has an obstructive pattern.

Courvoisier's law states that, in the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; rather carcinoma of the pancreas or lower biliary tree is more likely.

Pancreatic cancer is far more common than cholangiocarcinoma.

15

Concerning hamartomas, which of the following statements is correct?
(Please select 1 option)
Adenoma sebaceum seen in tuberous sclerosis is a type of hamartoma
Contains cells from all three germ layers
Contains metaplastic cell types
Does not predispose to malignancy
Usually develop in adolescents

Adenoma sebaceum seen in tuberous sclerosis is a type of hamartoma

The term hamartoma refers to an abnormal growth that consists of the same tissue from which it is derived. There may be variations in cellular numbers and cellular structure may be disorganised. Studies seem to indicate that a hamartoma occurs when the tissue in the growth did not develop completely.

They are usually present at birth.

Hamartomas may occur throughout the body, but are often found in the head and neck, particularly around the ears.

If hamartomas occur in multiple sites throughout the body, their presence is called Cowden disease.

By definition there is no metaplasia in hamartomata. There is evidence that polyps in Peutz-Jeghers, which are hamartomas, may progress to adenocarcinomas of the stomach, duodenum or colon and bronchial hamartomas may transform into carcinoma.

16

Which of the following is true of amyloidosis?
(Please select 1 option)
Can cause hepatosplenomegaly
Is only found in chronic inflammatory states
Methylene blue staining of the affected tissue is usually diagnostic
Results from primarily intracellular accumulation of amyloid deposits
Surgical excision of all affected tissue is usually curative

Can cause hepatosplenomegaly

Amyloid is a large family of insoluble fibrillar glycoproteins, chemically distinct but with identical physical properties.

Amyloidosis is a disorder characterised by extracellular deposits of the degradation resistant protein. They are usually divided into

Primary amyloidosis (where no cause in found) and
Secondary amyloidosis (due to chronic states such as tuberculosis, bronchiectasis, rheumatoid arthritis, osteomyelitis and neoplasia).
Amyloid accumulates to cause a simple bulk effect or could accumulate around the vessels to cause vascular occlusion. It can also affect the kidneys, liver and spleen presenting as nephrotic syndrome or hepatosplenomegaly.

Rectum is the favoured site for biopsy and the diagnosis of amyloidosis is made after Congo red staining of the affected tissue. Surgery rarely helps.

Secondary amyloidosis may improve if the primary disease is treated.

Immunosuppression may cause deposits to regress.

17

Dupuytren's contracture is associated with which of the following?
(Please select 1 option)
Chronic pancreatitis
Oral contraceptive pill
Peyronie's disease
Rheumatoid arthritis
Systemic lupus erythematosus

Peyronie's disease

Dupuytren's contracture remains an ill understood condition.

It is more common in Caucasians, the tendency to contracture in probably inherited, with the majority of the patients having a positive family history. Associations with epilepsy (or anti-convulsant therapy) seem certain.

Fibromatosis of the plantar fascia and Peyronie's disease are, on occasion, seen in those with a strong diathesis. Such patients are likely to develop the condition in their 30s and 40s with relentless progression and recurrence after surgery.

It is also associated with alcoholic liver disease, but not chronic pancreatitis.

The other pre-disposing factors/associations of Dupuytren's contracture include

Smoking
Trauma
Heavy manual labour
AIDS

18

Which of the following is not a characteristic feature of malignancy?
(Please select 1 option)
Abnormal mitoses
Abnormalities of the cytostructure
Anaplasia
Invasiveness
Reactive hyperplasia in regional lymph nodes

Reactive hyperplasia in regional lymph nodes This is the correct answerThis is the correct answer
Features of malignancy include

Invasiveness
Anaplasia (different appearance from parent tissue)
Numerous and abnormal mitoses
Invasiveness and abnormalities of the cytostructure.
Fibrous stroma would not be characteristic and reaction of lymph nodes suggests infection.

19

The following tumours belong to the amine precursor uptake and decarboxylation (APUD) group:
(Please select 1 option)
Adenoid cystic carcinoma
Bronchial carcinoma
Mucoepidermoid carcinoma
Phaeochromocytoma
Prostate carcinoma

Phaeochromocytoma

Apudomas are neoplasms known to produce many biologically active amines. Carcinoid tumours (Neuroendocrine tumours), Oat cell cancer of lung, Paragangliomas, Phaeochromocytoma and Medullary Thyroid carcinoma are classified as APUDomas.

20

Which of the following tissues is incapable of cellular regeneration?
(Please select 1 option)
Bone marrow
Connective tissue
Epidermis
Liver
Spinal cord

Spinal cord This is the correct answerThis is the correct answer
Skin and bone marrow are particularly active in cellular turnover and capable of regeneration.

The liver is also capable of regeneration as is often seen in cirrhosis with regenerating nodules amongst the cirrhotic tissue.

Myocardium and spinal cord do not regenerate.

21

Which of the following is correct concerning diabetic foot disease?
(Please select 1 option)
Doppler is a very useful investigation to accurately assess the foot pulses
Gangrene of the toes is usually preceded by loss of peripheral pulses
Is seen in less than 5% of patients with diabetes
More than 80% of amputations in diabetic patients are preceded by a foot ulcer
There is a 80% mortality after one year of a major limb amputation in diabetic patients

More than 80% of amputations in diabetic patients are preceded by a foot ulcer

Up to 15% of diabetic patients will develop a foot ulcer.

It has been estimated that 40-60% of all non-traumatic amputations are for patients with diabetes and nearly 85% of these amputations are preceded by a foot ulcer. Within five years, up to 45% of patients undergo amputation of the contralateral limb.There is 50% mortality three years after a major limb amputation in diabetic patients.

In diabetes, a presence of foot pulse could be misleading or erroneous since there might be no macrovascular involvement even in the presence of microvascular disease. In addition, there might be intimal hyperplasia and medial sclerosis leading to thickening of the vessel wall.

Therefore, gangrene of the toes or even the foot (due to microvascular damage) can occur in the presence of peripheral pulses and a normal Doppler.

22

Regarding management of chronic wounds, which of the following is correct?
(Please select 1 option)
Alginate dressings should be used for dry and granulating wounds
Hydrogel dressings provide autolytic debridement
Iodine based dressings are effective in the management of heavily exuding wounds
Occlusive dressings are useful in infected wounds

Hydrogel dressings provide autolytic debridement

Hydrogels (for example, GranuGel, Intrasite Gel, Intrasite Conformable, Iodoflex, Iodosorb) retain moisture or provide dehydration and are thus useful in dry, necrotic wounds. They facilitate autolytic debridement of necrotic tissues.

Alginate dressings such as Kaltostat, Sorbsan, and Urgosorb are highly absorbent, have haemostatic properties and are useful in packing cavities. Since they absorb moisture they are not useful in dry or granulating wounds.

Occlusive dressings should be avoided in infected wounds as they can worsen the infection by retaining the exudate and causing maceration of the surrounding skin.

Iodine based dressings are not effective in the management of exuding wounds although they are useful in infected ulcers, particularly diabetic foot ulcers.

Sharp debridement, either with a curette or a scalpel, is useful in stimulating healing of inert and static ulcers. Sharp debridement removes excess exudate, necrotic material, bacterial colonies and other foreign bodies which are detrimental to healing, besides stimulating an acute wound healing response.

23

Which of the following is correct regarding wound healing?
(Please select 1 option)
Delayed primary healing is characterised by a scar with reduced tensile strength
Healing by secondary intention occurs by both wound contraction and epithelialisation
Myofibroblasts play no role in secondary healing
Secondary closure is recommended for clean, surgical wounds
Split-thickness skin graft sites heal by first intention

Healing by secondary intention occurs by both wound contraction and epithelialisation

Primary healing (healing by first intention) occurs when a wound is closed within hours of its creation as in clean surgical wounds.

In delayed primary healing, as seen in a contaminated or poorly delineated wound (for example, bites, trauma), the skin and subcutaneous tissues are left unapposed and closure is performed after a few days. Collagen metabolism is usually undisturbed and hence the wound retains its tensile strength as if closure had been immediate.

Grossly contaminated wounds are left to heal by secondary healing (healing by second intention) when the wound closes by both wound contraction and epithelialisation.Myofibroblasts are thought to play a key role in this type of healing. They appear in the wound approximately three days after wounding and increase in number to a maximal level between the 10th and 21st day.

Healing of superficial (or partial-thickness) wounds, as in split-thickness donor graft sites, occurs by epithelialisation.

24

Which of the following skin conditions is pre-malignant?
(Please select 1 option)
Dermatitis herpetiformis
Keratoacanthoma
Molluscum contagiosum
Pyogenic Granuloma
Solar keratosis (actinic keratosis)

Solar keratosis (actinic keratosis) This is the correct answerThis is the correct answer
Keratoacanthoma is not a premalignant lesion but often mimics SCC. Although the lesion might involve and disappear without specific therapy (hence the name 'self-limiting' SCC), early conservative excision of sufficient depth to eliminate the entire lesion is recommended.

Pyogenic granulomas are fruit-like cutaneous vascular lesions which occur either spontaneously or secondary to some form of trauma. They grow rapidly, erupting through the skin and forming a stalk or pedicle. They may regresses spontaneously but sometimes require cauterisation and/or surgical excision.

Solar keratosis is the most common premalignant lesion usually seen in older light complexioned individuals. The progression from actinic ketratosis to invasive malignancy occurs by several routes and the resulting cancer is a SCC in almost all cases.

Dermatitis herpetiformis is seen in patients with coeliac disease. They are extremely itchy, burning blisters over the elbows, scalp, shoulders and ankles. They are not premalignant.

Molluscum contagiosum has wart like lesions commonly found on the hands of children or adolescents. They are caused by a virus and are not premalignant.

25

Which of the following is true of papillary carcinoma of the thyroid gland?
(Please select 1 option)
Has a good response to chemotherapy
Has a worse prognosis than follicular carcinoma
Is associated with hypocalcaemia in 20% of cases
Is the third most common cause of thyroid malignancy
Thyroglobulin is a sensitive marker for recurrence

Thyroglobulin is a sensitive marker for recurrence This is the correct answerThis is the correct answer
Thyroglobulin is a very sensitive marker for recurrence. After total thyroidectomy and radioiodine ablation, serum thyroglobulin levels should be

26

Papillary:

80% of cases
Average age 40
10 year survival 80%.
Histology: complex branching fronds of cells,
Slow lymphatic spread
Treated with surgery/131I.

27

Follicular:

15% of cases
Average age 50
Ten year survival 60%
Histology: well differentiated. like normal thyroid. Cannot be diagnosed on FNA.
Blood spread to lung and bones
Treated with radical surgery/131I.

28

Anaplastic:

29

Medullary:

5% of cases
Average age 50
Ten year survival 50%,
Histology: well differentiated. parafollicular cells (MEA 2).

30

Lymphoma:

1% of cases
Average age 60
Ten year survival 10%.
Treatment with DXT.

31

Which of the following is a radiological feature of avascular necrosis?
(Please select 1 option)
Intra-articular calcification
Juxta-articular osteoporosis
Osteochondral fragments
Osteoporosis
Widening of joint surface

Osteochondral fragments

Avascular necrosis can occur after fractures or as a result of caisson or sickle cell disease.

Sites that have a poor blood supply, such as the femoral head, the scaphoid and the lunate bones, appear to be particularly susceptible. The arterial supply or venous drainage may be cut off or the capillaries may become occluded. The bone dies and then repairs if the blood supply is restored.

The condition causes pain and loss of movement.

The radiographic features include

Sclerotic or porotic bone due to infarction
Joint surface collapse and
Osteochondral fragments.
Juxta-articular osteoporosis is a feature of rheumatoid arthritis.

Intra-articular calcification and peri-articular calcification, classically in the menisci and the intervertebral discs, is a feature of pseudogout.