Written Questions Flashcards by Sarah Ip

2022
Question 1 (Start Q1 answer booklet)

A 55-year-old female presents with a right retroperitoneal mass in the vicinity of the right kidney. A guided core biopsy is performed on the lesion.

A) The biopsy reveals an oncocytic lesion in the right kidney. What is your differential diagnosis? How would you proceed in diagnosing and reporting this biopsy for 3 common oncocytic entities?

B) The biopsy reveals an adrenocortical carcinoma. The right adrenal gland is subsequently resected. How should the specimen be reported?

(Reference to health and safety issues is not required in your response)

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2022
Question 2 (Start Q2 answer booklet)

A 45-year-old woman has a left breast mass detected on palpation. A left mastec- tomy and axillary dissection are performed.

A) How do you macroscopically assess the mastectomy and axillary dissection spec- imens? Include details of your block selection.

B) Discuss the technical aspects, and the reporting requirements, of the prognosti- cally important ancillary investigations used in the assessment of breast carcinoma.

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2022
Question 3 (Start Q3 answer booklet) Answer the following questions:

A) In the assessment of solid pancreatic lesions, what are the advantages and disadvantages of endoscopic ultrasound guided core biopsy versus fine needle aspiration biopsy?

B) What are the characteristics of pancreatic neuroendocrine neoplasms (tumours and carcinomas) by fine needle aspiration cytology?

C) Describe the impact of human papilloma virus (HPV) detection on cervical screening and its role in cervical cytopathology.

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Question 4 (Start Q4 answer booklet) Answer the following questions:

A) Discuss the pre-analytical and analytical issues in the use of formalin fixed paraffin embedded tissue for molecular testing, in the prediction of response to targeted therapy in lung adenocarcinoma (excluding immunotherapy).

B) How is formalin fixed paraffin embedded tissue from malignant tumours used to predict response to immunotherapy?

C) Describe the principles underlying the assessment of HER-2 in oesophageal carcinoma.

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Question 5 (Start Q5 answer booklet) Answer the following questions:

A) In the management of a patient with cancer, what are the roles and responsibilities of the anatomical pathologist in the multidisciplinary team?

B) While reviewing a colorectal resection specimen, reported by a colleague, for a multidisciplinary meeting, you notice that some of the lymph nodes show features that you suspect might be small lymphocytic lymphoma/chronic lymphocytic leukaemia. How do you proceed with handling this problem in the department, and at the subsequent meeting?

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Made up questions
What are the important biomarkers relevant to treatment of ovarian tumours?

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Made up questions
What are the important biomarkers relevant to diagnosis and prognostication of endometrioid endometrial carcinoma?

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Made up questions
What are the important ancillary tests for diagnosis, prognostication and treatment of NSCLC?

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What are the salivary gland tumours with good prognosis and their morphologic and molecular features?

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Made up questions
What are the differential diagnosis for tumours in the retromolar trigone area? What are their morphologic features? How can they be differentiated using ancillary tests?

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Made up questions
How are meningiomas graded? Give morphologic and molecular features of two subtypes in each grade.

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Made up questions
Writes notes on Lynch syndrome.

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2021
Question 1 (Start Q1 answer booklet)

A 45-year-old woman has a right ovarian mass identified on CT scan. She under- goes surgery, and the right ovary is sent to your laboratory as a fresh specimen.

A) How do you assess an ovarian mass specimen macroscopically?
.
B) A frozen section reveals signet ring tumour cells and mucin. What additional clini- cal information do you require from the surgeon, and what is your differential diagno- sis?

C) Discuss the ancillary techniques you would use in assessing this tumour, both for diagnosis and prognosis.

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2021
Question 2 (Start Q2 answer booklet)

A 55-year-old male presents with a 44mm diameter ulcerative lesion in the lower oesophagus.

A) What are the pathological diagnostic possibilities for such a lesion?

B) If a diagnosis of cancer is reported, and oesophagectomy is performed after neoadjuvant therapy, how should the specimen be handled and reported? (Reference to health and safety issues is not required in your response)

C) How do you classify and report epithelial dysplasias in the oesophagus?

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Question 3 (Start Q3 answer booklet) Answer the following questions:

A) Discuss the principal staining techniques used in Aspiration Cytopathology.

B) Give an account of the cytological features of thyroiditis.

C) Describe the Bethesda/Australasian system for reporting thyroid cytopathology.

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Question 4 (Start Q4 answer booklet) Answer the following questions:

A) Discuss the approach to the diagnosis of giant cell (cranial) arteritis, and briefly list its complications.

B) Describe the use of FISH in the diagnosis and prognosis of Non-Hodgkin lymphoma.

C) Describe the diagnostic clinicopathological features of malignant adipocytic tumours.

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Question 5 (Start Q5 answer booklet) Answer the following questions:

A) Describe the microscopic morphology of three germ cell tumours of the testis.

B) List five (5) hazards which may be encountered in the Anatomical Pathology Laboratory.

C) What features do you include in the report of an orientated excision specimen of squamous cell carcinoma of skin?

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Question 1 (Start Q1 answer booklet)

You have been asked to attend a Multidisciplinary (MDT) meeting with your consultant in which two cases of colorectal carcinoma that you have reported are to be discussed. One patient is a 48-year-old woman who has a biopsy confirmed rectal carcinoma. The carcinoma appears to be extensive and not operable by clinical examination. The other patient is a 32-year-old man who has had a right hemi-colectomy for adenocarcinoma of the ascending colon.

A) Provide a definition of the MDT meeting, and describe its functions. Describe the roles of a pathologist in this multidisciplinary meeting.

B) How does the MDT meeting function as a quality measure in pathology? Give examples.

C) Apart from the MDT meeting, describe in detail any three quality processes in which your department participates.

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Question 2 (Start Q2 answer booklet)

Page 1 of 2

A cystic mass is noted in the head of pancreas of a 46-year-old woman on endoscopic ultrasound examination.

A) What are the differential diagnoses?

B) What are the pathological diagnostic modalities for such a lesion?

C) If a Whipple operation was performed with a pre-operative diagnosis of an adenocarcinoma, how is the specimen cut up and reported in your laboratory? (Reference to health and safety issues is not required in your response)

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Question 3 (Start Q3 answer booklet) Answer the following questions:

A) Describe the use of molecular markers in the work-up of non-small cell lung carcinoma.

B) Explain the classification of Hodgkin Lymphoma.

C) What are the features which distinguish cellular dermatofibroma from dermatofibrosarcoma protruberans (DFSP)?

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Question 4 (Start Q4 answer booklet) Answer the following questions:

A) A fine needle aspiration of the thyroid gland yields oncocytic cells. Explain their significance.

B) Describe the subtypes of oropharyngeal squamous cell carcinoma.

C) Describe the diagnostic and clinical features of eosinophilic oesophagitis.

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Question 5 (Start Q5 answer booklet) Answer the following questions:

A) Explain the relationship between endometrial hyperplasia and carcinoma.

B) Explain the classification of urothelial neoplasia.

C) Describe the histological features of subtypes of breast carcinoma having an excellent or good prognosis.

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Question 1 (Start Q1 answer booklet)

A lytic lesion was detected radiologically in the right ethmoid sinus of a 23-year-old male. The biopsy revealed infiltrative clusters of tumour cells with hyperchromatic nuclei, high nuclear to cytoplasmic ratios, prominent nuclear pleomorphism and conspicuous mitotic figures.

A. What is your differential diagnosis in this patient?

B. What are the morphological hallmarks of each differential diagnosis and what ancillary tests would you do to resolve the diagnosis?

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Question 2 (Start Q2 answer booklet)

A 48-year-old woman presented with rectal bleeding and a polypoid mass in the lower rectum. Biopsy confirmed the tumour to be an adenocarcinoma. The patient received pre-operative chemoradiation and you subsequently received the resected specimen.

A. At the time of macroscopic examination, no tumour was identified in the rectum. Discuss how you would process and report this specimen including the selection of blocks.

B. What are the histological features that you may encounter in the tumour bed following neoadjuvant therapy?

C. Please comment on how neoadjuvant therapy impacts the assessment of lymph node status for this patient.

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Question 3 (Start Q3 answer booklet) A 58-year-old man presented with 6 weeks of confusion and a space-occupying lesion in the right temporal lobe, which is radio enhancing. An intraoperative sample is sent to your laboratory. Smear cytology demonstrates a diffuse population of large malignant cells. A. What is your differential diagnosis? When you phone your provisional diagnosis, the surgeon tells you that the patient is HIV positive and is sending more fresh tissue from the tumour. B. Does this additional information change your differential diagnosis? C. How you would handle and triage the additional specimen to reach a diagnosis?

Question 4 (Start Q4 answer booklet) Write short notes on: A. The classification of cystic lesions of the pancreas. B. The routine assessment of a twin placenta. C. The morphological features of Lentigo maligna/Hutchinson’s Melanotic Freckle.

Question 5 (Start Q5 answer booklet) Write short notes on: A. The classification of benign renal tumours, describing the features of one of them. B. The significance of HER-2 assessment in lower oesophageal and gastric adenocarcinoma. C. The current morphological and molecular classification of liposarcoma.

made up question Write notes on the current and morphological and molecular classification of thyroid tumours.

made up questions What are the lung tumours with good prognosis? What are their morphologic features and relevant ancillaries tests to distinguish them.

Question 1 (Start Q1 answer booklet) A 60-year-old man has a space-occupying lesion in the upper lobe of the right lung. A biopsy is obtained by bronchoscopy. A. Briefly describe how you would triage the biopsy material. Discuss the differential diagnoses and ancillary studies you may want to undertake to arrive at a diagnosis. B. Discuss the current WHO classification of malignant glandular neoplasms of the lung (excluding salivary gland type tumours). C. The biopsy shows adenocarcinoma. The patient subsequently has a right upper lobectomy. What features would you include in your structured (synoptic) cancer report (including any additional ancillary tests that are commonly required for pulmonary adenocarcinoma)?

Question 2 (Start Q2 answer booklet) A-35-year-old woman, on steroid treatment for systemic lupus erythematosus (SLE), develops high fever and flu symptoms after a trip to China. She collapses at a shopping centre and is admitted to the Emergency Department. A chest X-ray reveals bilateral haziness in the chest Page 1 of 2 and ascites in the abdomen. She dies shortly after admission. A limited autopsy is performed on her chest and abdomen (with retroperitoneum). A. With this history, what safety precautions would you take when performing the autopsy? B. What are the likely findings at the limited autopsy and what ancillary investigations would you like to perform?

Question 3 (Start Q3 answer booklet) A 63-year-old man has a bladder biopsy for investigation of haematuria. At low power examination you see clusters and nests of urothelial cells under the surface raising your suspicion of invasive malignancy A. Discuss how you would distinguish those benign lesions that may mimic invasive malignancy by histology and other appropriate means. B. Discuss subtypes of urothelial carcinoma that may be mistaken as benign proliferations and their key histological features. Briefly indicate the biological behaviour of these tumours. (Pleases note that you may combine your answers to A. and B). C. The biopsy shows a high-grade urothelial carcinoma. A cystoprostatectomy is performed. Discuss how you would dissect the specimen and which macroscopic characteristics you would be particularly interested in and would take sections from?

Question 4 (Start Q4 answer booklet) You attend an ultrasound guided fine needle aspiration of a submandibular mass in a 69-year- old woman A. Outline how the specimen could be triaged in the ultrasound suite in order to obtain maximal diagnostic material B. Discuss the main differential diagnoses and the key cytological features of each.

Question 5 (Start Q5 answer booklet) Write brief notes on ALL of the following: A. Clinical implications and principles of testing PD-1 or PD-L1 by pathologists B. The use of FISH and immunohistochemistry in the diagnosis of common gliomas.

Question 1 (Start Q1 answer booklet) A 60-year-old man has a follow-up oesophageal biopsy for his long standing Barrett’s oesophagus. A. What are the clinical and histological criteria for making the diagnosis of Barrett oesophagus? B. Describe the histological features of high grade dysplasia and its mimics. C. What is your approach for reporting endoscopic mucosal resection (EMR) of oesophagus?

Question 2 (Start Q2 answer booklet) A 35-year-old man presents to a hospital Emergency Department with shortness of breath and palpitations. He has physical signs of heart failure and dies soon after admission. Autopsy was limited to the chest. A. What are the possible causes of sudden cardiac death in this patient? B. What specific macroscopic features would you look for in your examination of the heart?

Question 3 (Start Q3 answer booklet) A 35-year-old woman has a left complex cystic ovarian mass, 10cm in diameter, detected on pelvic ultrasound. Histology shows serous carcinoma. A. What is the accepted classification of serous carcinoma of the ovary? Outline the clinical, pathological features and ancillary tests (including molecular tests) that are relevant to the diagnosis and management of a patient with serous carcinoma. B. What are the morphological and molecular features of ovarian tumours found in hereditary breast and ovarian cancer syndrome and Lynch syndrome?

Question 4 (Start Q4 answer booklet) You are asked to attend an ultra-sound guided fine needle aspiration of a solitary solid lesion in the right lobe of thyroid of a 42-year-old woman. A. Describe how an adequate sample can be obtained at the time of aspiration and what the cytological features of an adequate thyroid aspirate specimen are. B. Name and discuss one standardised classification system for reporting fine needle aspirations of thyroid. C. What ancillary tests are helpful in the diagnosis of thyroid tumours?

Question 5 (Start Q5 answer booklet) Write brief notes on ALL of the following: A. An oncologist requests EGFR testing on a lung biopsy showing carcinoma. How do you assess the suitability of the biopsy prior to molecular testing? B. Describe, with examples, the application and importance of fluorescence in situ hybridization (FISH) in 3 different types of tumour. C. Histological features of sessile serrated polyps of colon.

1. Discuss 5 quality measurements that are used in your anatomical pathology laboratory and outline how these contribute to risk management

3. A 45-year-old woman had bilateral adrenal masses noted on CT scan. A. Discuss the differential diagnoses of the adrenal tumours in this patient. B. Outline the morphological features and ancillary tests (including molecular tests) that are relevant to the diagnosis and management of this patient.

4. A 42-year-old man presented with abdominal pain and a CT scan reveals a mass involving the pancreas. You are asked to attend the diagnostic FNA procedure for the patient. A. Describe the different techniques for obtaining cytological samples of the pancreas and the surrounding structures. B. A lesion in the head of pancreas is identified. What is your differential diagnosis? C. Discuss the cytological features you would see in pancreatic ductal adenocarcinoma. D. Discuss the cytological differential diagnoses of well-differentiated pancreatic ductal adenocarcinoma. E. Discuss how endoscopic fine needle aspiration of the pancreas can be used for staging of pancreatic adenocarcinoma.

5. Write brief notes on BOTH of the following: A. The role of HPV in head & neck cancer and of its significance for the anatomical pathologist. B. The immunohistochemical assessment of mismatch repair protein expression in colorectal carcinoma including a discussion of the various expression profiles that you may encounter and its impact on patient management.

1. A 56-year-old man has transrectal ultrasound guided needle biopsies (TRUS) of his prostate for suspected prostatic adenocarcinoma.

3. A 45-year-old woman had a tumour in the lower portion of the oesophagus. She underwent oesophagogastrectomy after neo-adjuvant chemotherapy and radiation. A. Discuss the different histological types of tumours that can occur in the oesophagus of this patient and how you arrive at the diagnosis at the time of endoscopic biopsy B. At the time of macroscopic examination, no tumour is identified in the oesophagus. Discuss how you would process and report this oesophagogastrectomy specimen including the selection of blocks.

4. A 60-year-old woman presented with ascites. Cell block and smears reveal atypical cells in the ascitic fluid. Describe your differential diagnoses. How would you distinguish reactive mesothelial cells from malignant cells in ascetic fluid? Include any ancillary tests that help in the making the diagnosis

5. Write brief notes on ALL of the following: A. Her-2 in human cancers B. Prognostic markers in gliomas. C. Significance of Ki-67 in breast and gastrointestinal tumours.

1. You have received a laparoscopic biopsy from a 50-year-old woman with a retroperitoneal mass detected by CT. The biopsy shows a small round cell tumour. Discuss your differential diagnoses and how you will apply clinicopathological features, immunohistochemistry and other ancillary tests which may provide diagnostic and prognostic information.

3. A 50-year-old woman has a squamous cell carcinoma of the right side of tongue. The specimen received include a partial glossectomy and right selective neck dissection. Discuss the following areas: A. Management/handling of the glossectomy and neck dissection from the time of receipt. B. Discuss the features you would include in your structured/synoptic report and give the reasons of incorporating the features C. Discuss the relevance of assessing the positivity of p16 immunohistochemistry in this patient.

4. You receive a cervical punch biopsy on a 30 year old woman which shows no evidence of dysplasia or invasive malignancy. You note that the patient had a cervical smear reported as a high grade squamous intraepithelial lesion (HSIL) in your laboratory 3 months ago. Discuss possible causes for this lack of correlation between the cervical smear and punch biopsy results and your process for determining the most likely explanation.

5. Write brief notes on ALL of the following: A. Significance of Braf mutation in human malignancies B. Grading of Astrocytoma C. Use of immunofluorescence in diagnosing bullous skin lesions

1. You have received a transbronchial biopsy from a 40-year-old woman (non-smoker) with a mass in the right upper lung. The biopsy shows a large cell malignancy. Discuss your differential diagnoses and how you will apply immunohistochemistry and other ancillary tests which may provide diagnostic, therapeutic and prognostic information.

2. A 19-year-old woman, who had been well until the previous evening, went to bed after a night out with friends. She was found dead the next morning. What are three likely causes of death and what specific findings (based on morphological features and ancillary investigations) would you expect at autopsy in each of these?

3. A 35-year-old woman has a right mastectomy for ductal carcinoma of the breast. The specimen also includes a sentinel lymph node. Discuss the following areas: A. Management/handling of the mastectomy specimen from the time of receipt. B. Outline the options for examination of the sentinel lymph node. C. Discuss the features you would include in your structured/synoptic report.

4. You are asked to supervise a first year registrar on their first day of cut up. The trainee is required to process 20 - 30 gastrointestinal mucosal biopsies from a variety of patients. Outline your instructions to the registrar with particular reference to occupational health requirements, possible sources of errors and how to safeguard against them.

5. Write brief notes on ALL of the following: A. Cytological presentation of urothelial carcinoma in urine. B. Discuss benign mimics of high grade squamous intraepithelial lesions in Pap smear. C. Preparation and use of cell blocks in diagnostic cytology.

1. You are asked to attend an ultra-sound guided fine needle aspiration of an enlarged cervical lymph node of a 55-year-old female. The patient was referred from the surgeon with an enlarged right cervical lymph node which had been present for 3 months. A. Discuss the role and limitations of fine needle aspiration in the diagnostic work-up of this lesion, include reference to any clinical information you may consider helpful. B. At the time of aspiration, smears reveal a population of large atypical epithelioid cells with a high nuclear to cytoplasmic ratio. What cytological features would you use to establish your differential diagnosis and direct further ancillary testing?

2. A 40 year old woman has a right hemi-thyroidectomy performed for follicular neoplasm as reported on fine needle aspiration. Discuss the following areas: A. The role of frozen section. B. Management/handling of the specimen from the time of receipt in the laboratory C. Discuss the histological features you would use to reach a diagnosis D. If a primary thyroid cancer is detected in the specimen, list the features you would include in your structured/synoptic report.

3. A 60-year-old woman was admitted to hospital with fever and shortness of breath. She had a history of kidney transplant for IgA glomerulonephritis 5 years ago. Despite intensive treatment, she died 2 days post-admission. Permission was granted for a full hospital autopsy. Discuss the possible findings and their significance including any relevant ancillary investigations.

4. You have received endoscopic biopsies from the lower gastrointestinal tract of a 45-year-old man with symptoms of altered bowel habit. Histology reveals active inflammation. Discuss your differential diagnosis with reference to the microscopic features, clinical information and ancillary tests.

5. Write brief notes on ALL of the following: A. Management of a large formalin spill in an Anatomical Pathology laboratory B. Outline the steps to optimise Kohler illumination on your light microscope C. Selection of control tissue for immunohistochemical testing D. Precautions required in the sampling of tissue for molecular testing such as PCR

1. A 50 year old man was admitted to hospital with fever and shortness of breath. He gave a history of being diagnosed with “interstitial lung disease” 2 years ago in the United States of America. Supportive treatment including oxygen and intravenous antibiotics was given. He died 3 days after admission. Permission was granted for a full hospital autopsy. Discuss the possible findings and their significance including any relevant ancillary investigations.

2. A 45 year old female presents with asymmetrical enlargement of the thyroid for two (2) months. The surgeon requests an ultrasound-guided fine needle aspiration of the thyroid. A. Discuss the role and limitations of fine needle aspiration in the diagnostic work-up of this patient, including reference to any clinical information you may consider helpful. B. Your fine needle aspirate reveals a cellular sample with microfollicles. Discuss the likely differential diagnoses with reference to the currently recommended reporting categories and their cytological features

3. A colonic resection from a 65 year old male with biopsy-proven rectal adenocarcinoma is received in your laboratory. Discuss the following areas: A. Handling of the specimen from the time of receipt in the laboratory. B. Features that you would include in your structured report and comment on their relevance.

4. Write brief notes on three of the following: A. The spectrum of Human Herpes Virus- 8 (HHV-8) related disease B. Cardiomyopathy C. “Triple negative” breast carcinoma D. Clinical relevance of EGFR mutations in lung carcinoma E. Tissue microarrays

5. Identify five (5) occupational health and safety risks in an anatomical pathology laboratory and discuss how these risks can be managed.

1. You receive a radical prostatectomy specimen with biopsy-proven adenocarcinoma. Discuss the following areas: A. Management/handling of the specimen from the time of receipt in the laboratory B. Features you would include in your synoptic report and comment on their relevance C. Why there may be discordance between the biopsy Gleason score and the final Gleason score in the radical prostatectomy

2. Discuss the following; A. The role of immunoperoxidase stains in the diagnosis of breast lesions; B. The use of immunoperoxidase stains and other ancillary tests in breast lesions to determine prognosis and treatment options.

4. Write brief notes on three of the following: A. The spectrum of IgG4 related disease B. Application of In-situ hybridization techniques C. p16 in histological practice D. Clinical relevance of BRAF and KRAS in colorectal carcinoma E. Diagnostic and therapeutic significance of E tyrosine kinases

5. A 35-year-old male presents with a right submandibular mass which had been present for 2 months. A. Discuss the role and limitations of fine needle aspiration in the diagnostic work-up of this lesion, include reference to any ancillary procedures you may consider undertaking. B. Your fine needle aspirate reveals a conspicuous background component of extracellular mucoid material. Discuss the likely differential diagnoses and their cytologic features.

Question 1 A 22 year old male presents complaining of shortness of breath and a chest radiograph shows a large mediastinal mass. The clinician is going to biopsy the mass and contacts you to discuss the most appropriate method of biopsy and handling of the specimen. (a) Discuss the most likely diagnoses and how they would be differentiated by histology and cytology. (b) What would you advise the clinician, including possible ancillary tests, and why?

Question 3 Discuss the concept of “microsatellite instability”, including pathological manifestations and implications for future clinical management. Include in your discussion one tumour of your choice as an illustration.

Question 4 A 35-year-old woman presented with advanced carcinoma of cervix and a history of a previous negative smear. Discuss why the screening procedure may have failed in this patient?

Question 5 Write short notes on THREE of the following: a) Langerhans cell histiocytosis b) HER-2/neu (c-erbB2) assessment c) Papillary lesions of the bladder d) Ig A nephropathy e) Apicocystic disease of lung

1. You are contacted by the clinician at you local breast who says that your report on a patient’s recent breast core biopsies is no consistent with the clinical findings. The clinician is concerned that the biopsies may have may have been mixed up with another patient in the laboratory. a) How would you investigate the claim? If the complaint is correct: b) What procedures would you put in place to ensure it does not happen again? c) What would you do/and or recommend to protect the patient and ensure that the correct patient is assigned to the correct patient?

2. 56 year old man has a pigmented lesion on the left arm biopsied. Initial examination of the incisional biopsy shows a melanocytic lesion. Discuss you possible differential diagnoses and how you would report the incisional biopsy. If the incision shows a melanoma, what would you include in your report?

3. A 26 year old man has an incidental CT finding of a right adrenal mass. a) What are your ddx? What clinical investigations may be performed? Describe the possible macroscopic and microscopic features and ancillary tests which may be used to distinguish between these diagnoses. b) It the left adrenal gland also shows a lesion, how may this change you ddx and possible patient management?

Question 5. Write short notes on three of the following: a) The clinicopathological features and differential diagnoses of eosinophilic esophagitis. b) Diagnosis and implications of lichen planus in the oral mucosa. c) Immunohistochemistry in the management of colorectal tumours. d) Nature, clinical features and diagnosis of cerebral amyloid angiopathy. e) Different subtypes of liposarcoma and their clinical & diagnostic features.

2006 Question 1 A 74-year-old male with severe chronic obstructive airways disease presents with abdominal discomfort and is found on imaging to have a thickening in his terminal ileum and retroperitoneal lymphadenopathy. After assessment he is found to be a poor risk for general anaesthetic and open biopsy. The radiologists have been asked to obtain material from his peritoneal lymph nodes under imaging guidance. You are called by the radiologist on duty and asked for advice as to the specimens you would prefer to maximise the chance of reaching a definitive diagnosis. State what advice you would give, considering the possible differential diagnoses, including the reasons for each type of specimen you would require. How would you handle and distribute each of the specimens once they are collected?

Question 2 Write short notes on three of the following: a) The use of micro-arrays in defining tumour differentiation b) Implications of a diagnosis of serrated adenoma c) Flow cytometry and gene re-arrangement studies in the diagnosis of cutaneous lymphomas d) Micro-satellite instability in large bowel adenocarcinomas e) Electron microscopy in the diagnosis of soft tissue tumours

Question 3 You are directed by the Coroner to perform an autopsy on the body of a 38-year-old male who has died following perforation of the oesophagus, followed by suppurative mediastinitis and septicaemia. Endoscopy four days prior to death showed an oesophageal ulcer and biopsy revealed herpes virus inclusions in the squamous epithelium adjacent to the ulcer and fungal elements, presumed to be Candida sp., in the ulcer slough. Describe your approach to the autopsy under the following headings: - Possible differential diagnoses as to any underlying disease process you might expect to encounter; Occupational health and safety issues; Macroscopic examination; Specimen collection and examination: Potential microscopic findings in examination of lymph nodes.

Question 4 A 34-year-old female with an abnormal cervical cytology result has a colposcopic- guided cervical biopsy, which you are asked to examine. Describe the protocol you would use for the processing and examination of the biopsy material. On microscopic examination, you find extremely inflamed cervical tissue with marked changes in the squamous epithelial cells. Discuss approaches to differentiate between a significant dysplasia and marked reactive/reparative change. In this tissue the basement membrane appears deficient in one area – if you determine that the epithelium is dysplastic, how would you assess the sections for possible micro-invasive carcinoma in this region and what is the significance of this finding?

Question 5 Discuss your approach to and the techniques you would use in differentiating between the possible differential diagnoses in: a) A biopsy showing a "small blue round cell tumour" in a child; b) A renal biopsy from a patient presenting with acute renal failure.

1. Give an account of the cardiac and neurological causes of sudden unexpected natural death in a thirty-year old male making particular reference to the autopsy investigation in such a case.

2. Write short notes on the following: 2.1 The use of synoptic reporting and minimum data sets in routine anatomical pathology 2.2 The role of genomic and expression microarray technology in surgical pathology 2.3 Special staining techniques for the identification of viral inclusions in routine histological sections 2.4 Quality assurance and quality control in anatomical pathology

3. You receive fresh within the laboratory breast tissue from a mammographically detected area of microcalcification. Discuss: 3.1 How you would deal with the specimen in the cut-up area 3.2 What features you would include in your histological reporting of the specimen 3.3 What special stains you might consider in assisting you with the diagnosis, prognosis and clinical therapeutic regimes 3.4 The reproducibility of histological prognostic indicators

4. Give brief accounts of the diagnostic features and the diagnostic pitfalls: 4.1 In the fine needle aspiration cytology of a thirty four year old female with a clinically apparent solitary thyroid nodule 4.2 In the pleural aspiration cytology from a fifty five year old male shipyard worker 4.3 In a cervical smear from a postmenopausal female with postmenopausal bleeding

5. You receive slides with sections of endoscopic gastric biopsies from a 36-year old male with acute myeloblastic leukaemia. There are three fragments of mildly chronically inflamed gastric mucosa with no Helicobacter species and no intestinal metaplasia or dysplasia in the sections. The fourth biopsy fragment in your sections contains severely dysplastic glands with one area that may be intramucosal adenocarcinoma; this fragment appears out of place in the biopsy series and you consider whether or not this may be a contaminating fragment of tissue from another case. 5.1 Describe in detail how you would investigate this occurrence and establish the origin of this tissue. 5.2 Give an outline of artefacts that might lead to a false-positive diagnosis of malignancy and that may be encountered in small biopsy specimens.

1. A newly qualified intern telephones the Histopathology Department asking for advice regarding the taking and submission of a skin biopsy from a 65-year-old female with a history of coeliac disease presenting with a bullous skin disorder. Being responsible for the surgical cut-up for that day, you are asked to deal with the request. 1.1. What advice would you offer the intern with respect to the site of biopsy and the nature of specimen(s) that should be submitted? 1.2. What clinical information would you request? 1.3. Give an account of the histological appearances of the possible differential diagnoses. 1.4. What ancillary tests or investigations might aid you in making a definitive diagnosis?

2. A right hemicolectomy specimen from a 44-year-old female resected for a biopsy proven mucinous carcinoma of the ascending colon is received fresh in the Department. 2.1. From the time of reception in the Department, describe how you would handle the specimen. 2.2. What information would you include in your macroscopic report? 2.3. What information would you include in your histology report? 2.4. What ancillary tests or investigations would you request and what ethical considerations might you consider in making these requests?

4. A 52-year-old male with a 5cm linear scar on the left leg now presents with an enlarged lymph node in the left groin. You are asked to attend a fine needle aspiration biopsy performed by the treating clinician, with regard to providing advice on the nature of the specimens required for diagnosis and preparation of these specimens. 4.1. Give a brief account of the nature of the specimens you require, your reasons for so advising the clinician and the preparation of these specimens. 4.2. Give an account of the cytological appearances of the possible differential diagnoses. 4.3. On the material provided, what ancillary tests or investigations would you consider in helping you to arrive at a definitive diagnosis?

5. Write short notes on: 5.1. The advantages/disadvantages of employing a non-medically qualified “Pathologist Assistant” or “Technical/Scientific Officer” to perform the surgical cut-up. 5.2. Quality Assurance programs in Anatomical Pathology. 5.3. Audit procedures in diagnostic surgical pathology. 5.4. The investigation of “carry-over” and “floaters” on a histological slide. 5.5. The use of tissue/DNA microarrays in diagnostic surgical pathology.

2. Your cytology department is asked to attend an image-guided fine needle aspiration procedure in the radiology department for a 3cm mass in the posterior segment of the right upper lobe of the lung of a 57-year old female. Discuss: 2.1 The advantages and disadvantages of attendance by a pathologist versus a qualified cytology screener 2.2 How you would allocate portions of the specimen for different investigative procedures 2.3 The possible cytological findings 2.4 The possible complications of the procedure

3. A hemithyroidectomy specimen arrives from theatre with a request for frozen section examination and a statement on the request form “solitary nodule in left lobe of thyroid - ? cancer”. Discuss: 3.1 From the time of reception in the laboratory, how you would handle the specimen 3.2 The possible findings and the information you can give to the surgeon at the time of frozen section examination 3.3 The limitations of the frozen section procedure 3.4 Any additional information and its implications you may obtain from subsequent paraffin sections

4 Discuss: 4.1 The diagnosis of columnar-lined (Barrett’s) oesophagus in biopsy specimens 4.2 The grading and criteria you use when assessing dysplasia in Barrett’s oesophagus 4.3 The advantages/disadvantages of a two-tier versus a three-tier system for grading dysplasia in this context 4.4 How you would test the reproducibility of the grading system you use.

5 Discuss the use of immunohistochemical, cytogenetic and molecular pathology techniques as diagnostic adjuncts in the assessment of “small round cell” tumours.

1. Discuss the possible origins and significance of, the finding of glandular cells in a cervical smear preparation.

3. Write short notes on the following: 3.1. The approach to the examination of the placental mass from a twin pregnancy 3.2. The histopathological features and their prognostic significance in the various types of meningioma 3.3. The histopathological changes that might be encountered in a colonic biopsy from a case of “microscopic colitis”

4. You receive fresh in the laboratory two liver biopsy cores from a 45 year old male with known Hepatitis B infection and suspected haemochromatosis. From the time of arrival in the laboratory, discuss: 4.1. How you would handle the specimens 4.2. What special stains and ancillary investigations you would request 4.3. The assessment of iron overload in such specimens 4.4. The possible histopathological features that might be encountered

5. Discuss quantitation procedures and their reproducibility in routine surgical pathology practice, illustrating your answer with reference to: 5.1. The staging of endometrial adenocarcinoma in a hysterectomy specimen 5.2. Oestrogen and progesterone receptor expression in breast carcinoma Proliferative markers in smooth muscle tumours.

1. You receive in the laboratory fresh renal tissue from a male aged 37 undergoing renal biopsy for the investigation of microscopic haematuria. Describe how you would handle the specimen, and discuss the possible pathological features that might be encountered.

2. A 60 year old male with acquired immune deficiency syndrome (AIDS) undergoes ileocaecal resection for acute intussusception. You receive the operative specimen fresh in a sealed appropriately labelled container. Discuss: a. How you would handle the specimen. b. The selection of blocks for histological examination. c. The possible pathological findings.

3. Discuss briefly: a. The autopsy investigation and findings in a case of drowning b. The possible intracranial findings at autopsy in a patient dying with raised intracranial pressure.

4. Discuss the following: 4.2 The possible advantages of fluid based cytology samples for cervical screening. 4.2 The difficulties in interpretation of aspirates from a solitary cold nodule in the thyroid gland. NB Part 1 is worth one third and part 2 two thirds of the marks.

5. You are asked by the radiologist what specimens you would ideally require from a 68 year old man undergoing image guided biopsy for a pleural based mass. 1.1. Discuss 1.2. Initial histology reveals a spindle cell lesion. List the differential diagnoses and discuss the possible immunoperoxidase reactions which may help in the definitive diagnosis.

1. Discuss the following: 1.3. How you would handle a fresh lymph node biopsy taken for the investigation of cervical lymphadenopathy, outlining any ancillary procedures you would undertake. 1.4. How you would handle an upper lobectomy lung specimen from a 60 year old male with a cavitating lesion received fresh and with a request for frozen section and the stated clinical history of “? infective, ? neoplastic”.

2. Describe the possible extrahepatic findings at autopsy in a 65 year old male who has died as a result of chronic alcoholic liver disease.

3. Contrast the various types of parenchymal tumours of the kidney in adults and discuss the relationship between tumour genotype and phenotype.

4. Give accounts of the following: 4.1 Artefacts that may lead to difficulties in the diagnosis of breast lesions using fine needle aspiration (FNA) biopsy. 4.2 Fine needle aspiration (FNA) biopsy criteria for the diagnosis of a 20 mm nodule in the liver.

Give an account of the light microscopic features seen, and ancillary techniques used, in the diagnosis of viral disease in human tissue.

1. Discuss the principles and applications of the following stains in diagnostic tissue pathology: 1.1 The Perls’ Prussian blue stain. 1.2 Silver stains (impregnations).

2. A radical prostatectomy specimen is received fresh in your laboratory, as treatment for prostate carcinoma. Discuss in detail how you would handle and cut up the specimen. What pathological findings should be highlighted in your report as indicators of prognosis?

3. Give a critical discussion of the uses and limitations of mitosis counting for the assessment of malignancy in various tumours; illustrate your account by specific reference to mitosis counting in smooth muscle tumours and neuroendocrine neoplasms, among others.

4. Write notes on the following: 4.1 Pseudomyxoma peritonei. 4.2 Desmoplastic mesothelioma. 4.3 The liver biopsy diagnosis — and histological grading and staging — of chronic hepatitis C infection.

5. Write notes on: 5.1 Possible autopsy findings in a case of infective endocarditis. 5.2 The pathology of Henoch-Schönlein purpura.

Bilateral adrenalectomy is performed, how would you cut up and report the specimen?