Pathology Test Part 1
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A 69 year old lady has a stroke on the ward 4 days after hysterectomy. What type of necrosis typically occurs in cerebral infarction?
Explanation: The brain undergoes liquefactive (AKA colliquative necrosis). In this situation digestion of dead cells form a viscous liquid mass
2) A patient asks you in clinic when she can start trying to conceive again. She has just completed chemotherapy for gestational trophoblastic disease (GTD)?
Explanation: RCOG Greentop guideline 38 states: 'Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment'
3) Paraneoplastic Cushing's syndrome is most commonly associated with which of the following malignancies?
Explanation: Paraneoplastic Cushing's syndrome is caused by tumours secreting ACTH and is most commonly seen in small cell lung cancer
4) Endometriosis is an example of which of the following?
Explanation: Endometriosis is an example of pathological hyperplasia
5) A patient attends the maternity unit as her waters have broken but she hasn't had contractions. She is 39+6 weeks gestation. Speculum examination confirms prelabour rupture of membranes (PROM). What is the risk of serious neonatal infection with PROM?
Explanation: The risk is 1 in 100 (or 1%). The risk is double that of a patient with intact membranes (1% vs 0.5%)
You are reviewing a patient with a scan suggestive of partial molar pregnancy. What is the typical genotype of a partial molar pregnancy?
Explanation: The partial mole is produced when an egg is fertilized by two sperm producing genotype 69 XXY (triploid). It can also occur when one sperm reduplicates itself yielding the genotypes 92 XXXY (tetraploid) though this is less common The genotype of a complete mole is typically 46 XX (diploid) but can also be 46 XY (diploid)
7) During pre‐op assessment for hysterectomy and oophorectomy a patients chest XRAY shows a Ghon focus suggestive of past tuberculosis infection. What kind of necrosis is seen in tuberculosis infection?
Explanation: TB causes granuloma formation and granulomatous (or caseous) necrosis
8) Closure of a patent ductus arteriosus in a term infant should be via?
Explanation: Its important to read the question here and also be familiar with the different strategies for PDA closure in term and preterm infants. In preterm infants closure can be achieved by NSAIDs typically indomethacin but ibuprofen could be used. In term infants surgical closure is indicated. Prostaglandin infusion may be used in this situation but this is to keep the DA patent until surgery.
9) Hepatocellular carcinoma
Explanation: AFP is associated with non‐seminomatous germ cell tumours and hepatocellular carcinoma
10) Ovarian cancer is associated with which type of metastasis?
Explanation: Metastasis Metastasis is the spread of disease from one organ to another site in the body. It is a property of most cancers (Very rare in BCC and glioma). They are a number of routes of spread and some cancers spread preferentially via certain routes: Lymphatic Carcinoma Haematogenous Sarcoma Renal cell carcinoma Choriocarcinoma Transcoelomic Ovarian Implantation/transplantation Movement of malignant cells during biopsy/surgery/procedure Exam Tip In the exam it is most likely you will asked about malignancies that spread via non‐lymphatic routes i.e. transcoelomic spread in ovarian cancer or haematogenous spread of choriocarcinoma. Renal cell carcinoma is unusual for carcinoma in that it spreads via the bloodstream rather than lymphatics so again may be something examiners pick to test you.
11) A 77 year old woman undergoes staging investigations for endometrial carcinoma. This shows invasion of the inguinal lymph nodes. What is this patients 5‐year survival?
Explanation: Inguinal lymph node involvement is stage 4 (4B) and carries the worst prognosis
12) The increase in size of endometrial cells during pregnancy is an example of
Explanation: The increase in cell size is hypertrophy An increase in cell number is hyperplasia
13) You review a patients blood results and find the following:
Na+ 123 mmol/l K+ 5.0 mmol/l Urea 2.5 mmol/l Creatinine 70 µmol/l You diagnose SIADH. Which malignancy is most commonly associated with SIADH?
Explanation: SIADH is classically associated with small cell lung cancer
14) What percentage of cervical cancers are HPV related?
Explanation: HPV subtypes 16 and 18 are responsible for 70% of cervical cancers All HPV types account for 99.7% of cervical cancers
15) A 29 year old is diagnosed with stage 1A2 cervical cancer. Which of the following is the most appropriate treatment option?
Explanation: For stage 1A cervical cancers treatment options are hysterectomy, LLETZ or trachelectomy. Radiotherapy and chemotherapy are indicated for stage 2 and beyond
16) The UK childhood vaccination schedule includes vaccination against HPV for girls aged 12 to 13. What HPV subtypes are vaccinated against with the vaccine Gardasil®?
Explanation: HPV Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18 HPV types16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV. As well as cervical cancer they are associated with cancers of the oropharynx and anogenital region. There are over 100 genotypes of HPV including several other high risk HPV types. HPV is thought to induce cancer via onco‐proteins. The primary once‐proteins are E6 and E7 which inactivate two tumor suppressor proteins, p53 (inactivated by E6) and pRb (inactivated by E7) HPV genotypes 6 and 11 are low risk and cause anogenital warts.
17) A 74 year old patient undergoes biopsy of an ulcerated vulval lesion. What is the most likely cancer type?
Explanation: Organ Most Common Cancer Type Vagina Squamous cell (90%) Vulva Squamous cell (85%) Ovary Epithelial (85%) Serous 75% of these Endometrium Endometrioid carcinoma (80%) Cervix Squamous Cell (80%)
18) Choriocarcinoma is associated with which type of metastasis?
Explanation: Metastasis Metastasis is the spread of disease from one organ to another site in the body. It is a property of most cancers (Very rare in BCC and glioma). They are a number of routes of spread and some cancers spread preferentially via certain routes: Lymphatic Carcinoma Haematogenous Sarcoma Renal cell carcinoma Choriocarcinoma Transcoelomic Ovarian Implantation/transplantation Movement of malignant cells during biopsy/surgery/procedure
Exam Tip In the exam it is most likely you will asked about malignancies that spread via non-lymphatic routes i.e. transcoelomic spread in ovarian cancer or haematogenous spread of choriocarcinoma. Renal cell carcinoma is unusual for carcinoma in that it spreads via the bloodstream rather than lymphatics so again may be something examiners pick to test you.
19) A 55 year old presents to clinic due to vulval itch and discolouration. examination reveals pale white discoloured areas to the vulva. A biopsy conforms Lichen Sclerosus (LS). What is the risk of developing squamous cell carcinoma compared to patients with normal vulval biopsy?
Explanation: Patients with LS are at slightly increased risk of developing SCC. <5% according to the 2014 BASHH guidelines. Management is typically with a 3 month course of ultra‐potent topical steroids though there is no evidence as to the optimal regime
20) A 42 year old smoker attends clinic due to vulval soreness and shows you a number of vulval lumps. Biopsy is taken and reported as showing epithelial nuclear atypia, loss of surface differentiation and increased mitosis. What is the diagnosis?
Explanation: This is VIN. Smoking is a risk factor. It is also more common in immunocompromised patients.
The change of cervical simple columnar epithelium with stratified squamous epithelium is an example of
Explanation: This is telling you one cell type has been replaced by another differentiated cell type i.e. metaplasia.
You are assessing a patient with an ovarian mass and are using the Risk of Malignancy Index 1 (RMI) score. Which of the following is used to calculate the RMI?
Explanation: The answer is Ca125. There are a number of RMI scores (RMI 1 and RMI 2 being the most common). Both use an ultrasound score, menopause score and Ca125 level but award different values to the individual scores (see table). The RCOG advises RMI 1 should be used
23) A 69 year old patient undergoes staging investigations for endometrial carcinoma. This shows invasion of the vaginal wall but no nodal involvement or distant metastasis. What FIGO stage is this?
Explanation: The RCOG syllabus states candidates should be familiar with classification of gynaecological cancers.
24) A patients MSU comes back showing heavy growth of E.Coli that is resistant to trimethoprim, amoxicillin and nitrofurantoin. You decide to prescribe a course of Cefalexin. What is the mechanism of action of Cefalexin?
Explanation: Cephalosporins, like penicillins, are active via Beta‐Lactams which inhibit peptidoglycan cross‐links in bacterial cell walls. Note Beta Lactamase enzymes are produced by bacteria resistant to Beta‐Lactam antibiotics.
25) Regarding the diagnosis of Gestational Diabetes which of the following tests is recommended by the WHO for diagnosis?
Explanation: WHO advise the 75g OGTT for diagnosis. Although the interpretation is not as straight forward as would be expected as there are WHO and modified WHO values for diagnosis
26) You see a patient with the rash below:
Which of the following cancer types is this most strongly associated with?
Explanation: This is Acanthosis Nigricans (AN). It typically effects the neck and axilla. There are several non‐malignant causes of AN such as familial, medication and endocrine causes. If AN is caused by malignanny then GI cancers, most commonly stomach cancer, account for around 90% of malignant cases. It should be noted a number of commonly used revision resources for the MRCOG state AN is associated with various other cancers such as uterine, breast and lung cancers. AN may occasionally be caused by these types of cancer and others such as lymphoma but GI cancer is by far the most commonly associated cancer
A couple come to see you in clinic. The male partner reveals he has cystic fibrosis and wants to know what his likelihood of being infertile is. What is the male infertility rate in CF patients?
Explanation: In males with CF 98% are infertile. This is typically due to failure of the vas deferens to develop properly
28) Regarding Venous Thomboembolism (VTE) in pregnancy which of the following statements are TRUE?
Explanation:Regarding VTE in pregnancy 10‐20% of VTEs are PE's. The majority are DVT Inherited Thrombophilia is present in approximately 40% of women with pregnancy associated VTE Obesity (BMI >30) increases DVT risk by 4 to 5 times
29) What is the incidence of hyperthyroidism in complete molar pregnancy?
Explanation: 3% of molar pregnancies are effected by hyperthyroidism. The cause is excessive HCG
You are asked to review a 32 year old patient who is 34 weeks pregnant on the early pregnancy unit who has attended due to severe abdominal pain. After sending bloods you are phoned by the lab as the serum amylase has come back raised at 450 U/L. You diagnose acute pancreatitis. What kind of necrosis is seen in this situation?
Explanation: Fat necrosis is seen in the pancreas as activated lipases are released and breakdown the fatty tissues
31) What percentage of patients with breast cancer have hypercalcaemia
Explanation: Hypercalcaemia effects 10‐30% of cancer patients. The main mechanism is trough osteoclastic bone resorption which can occur with or without bony mets.
It is usually associated with disseminated disease and has a poor prognosis. 80% of patients with malignancy associated hypercalcaemia will die within 1 year.
A 28 year old primigravida carrying a twin pregnancy presents at 32 weeks gestation. She is lethargic, clinically jaundiced and complains of abdominal pain with frequent vomiting. Her bloods are as follows: Bilirubin 62 µmol/l ALP 640 u/l ALT 196 u/l γGT 185 u/l Albumin 24 g/l INR 3.2 What is the likely diagnosis?
Explanation: This patients bloods and symptoms suggest she has hepatic impairment. Acute fatty liver of pregnancy typically presents after the 30th week and she has risk factors for acute fatty liver of pregnancy: Multiple pregnancy Primigravida
A 35 year old woman has a pelvic ultrasound scan showing multiple fibroids. What is the most common form of fibroid degeneration?
Explanation: Hyaline degeneration is the most common form of fibroid degeneration except during pregnancy when red (carneous) degeneration is more common. Hyaline degeneration accounts for 60% of cases
34) Renal cell carcinoma is associated with which type of metastasis
Explanation: Most carcinomas spread primarily via lymphatic invasion. Renal cell is the exception spreading via the bloodstream
35) Regarding the rash below which of the following statements is true?
Explanation: This rash is Polymorphic eruption of pregnancy (PEP or PUPPP). It is a benign and typically self limiting condition so treatment is aimed at symptom relief. This can usually be achieved with emollients +/‐ topical steroids/antihistamines. In severe cases oral steroids can be considered. It is not directly associated with birth complications and generally has an excellent prognosis. It is most common in women during their first pregnancy with recurrence rates in subsequent pregnancies around 7%. Associations include: Multiple gestation pregnancies Excessive maternal weight Rh‐positive blood type
A patient has returned to your clinic. She presented with painful periods 18 months earlier and laparoscopy confirmed endometriosis. She now gets pain on opening her bowels as well as low back pain. What structure is likely to be involved?
Explanation: Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!
A 25 year old primigravida carrying a twin male pregnancy presents at 31 weeks gestation. She is lethargic, clinically jaundiced and complains of abdominal pain with frequent vomiting. You suspect acute fatty liver of pregnancy (AFLP). What is the the primary cause of AFLP?
Explanation: Fetal deficiency of long‐chain 3‐hydroxyl‐CoA dehydrogenase leads to the accumulation of toxic products of impaired fatty acid metabolism which then accumulate in the maternal circulation
38) Which age group has the highest rates of chlamydia infection?
Explanation: In the UK in 2013, the most commonly diagnosed STI was chlamydia with 208,755 new cases representing 47% of STI diagnoses in GUM clinics. The under 25 age group has the highest rates with the 20‐24 age subgroup the highest among them. Prevalence of chlamydia of those screened in the under 25's in the UK is 5‐10%
39) A 30 year old women who is 24 weeks pregnant attends EPU due to suprapubic pain. Ultrasound shows a viable foetus and also a fibroid with a cystic fluid filled centre. What is the likely diagnosis?
Explanation: Red degeneration of fibroids is one of 5 methods of fibroid degeneration. Although uncommon outside pregnancy it is thought to be the most common form of fibroid degeneration during pregnancy and typically occurs in the 2nd trimester. It is thought to arise from the fibroid outgrowing its blood supply and haemorrhagic infarction occurs. Ultrasound will typically show a localised fluid collection (blood) within the fibroid.
40) You are asked to review a patient. They have attended for a scan at 13 weeks following a positive pregnancy test. The patient has had 2 previous pregnancies for which she opted for termination on both occasions. The scan shows a large irregular haemorrhagic mass that appears to be invading into the myometrium. What is the likely diagnosis?
Explanation: These are the typical features of choriocarcinoma. 20% occur after TOP.
41) Regarding Gestational Diabetes which of the following statements is TRUE?
Explanation: Epidemiology of gestational diabetes is part of MRCOGs Module 9 syllabus. It effects 2‐5% of pregnancies
A 35 year old women attends clinic following laparotomy and unilateral oophorectomy. The histology shows Psammoma bodies. What type of tumour would this be consistent with?
Explanation: There are general histopathological features of ovarian tumours that are suspicious of malignancy such as irregular cell surface, irregular cystic regions, necrosis and haemorrhage. There are also 2 histological features specific to Serous and Mucinous tumour types that lend themselves well to exam questions (see below)! Serous tumours = Psammoma bodies Mucinous tumours = Mucin vacuoles
43) A couple have been referred to the infertility clinic. The male partner Is 25 and has CF, his semen analysis shows azoospermia. What is the likely underlying cause?
Explanation: In CF the thickened intraluminal secretions lead to progressive obstruction and destruction of the vas deferens in utero leading to congenital absence of the vas deferens in most cases. In treating such patients for infertility sperm can be retrieved from the epididymis.
44) Endometrial tissue found within the myometrium is classed as
Explanation: Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma's) sometimes called myoma's
45) You are asked to review a patient. They have attended for a scan at 13 weeks following a positive pregnancy test. The patient has had 2 previous pregnancies for which she opted for termination on both occasions. The scan shows no identifiable fetal tissue or gestational sac and you note the radiologist has reported a 'bunch of grapes sign'. What is the likely diagnosis?
Explanation: These are the features of a complete molar pregnancy (see below) Ultrasound features of complete hydatidiform mole Solid collection of echoes with numerous small anechoic spaces (snowstorm or granular appearance). Bunch of grapes sign which represents swelling of trophoblastic villi. Normal interface between abnormal trophoblastic tissue and myometrium. No identifiable fetal tissue or gestational sac. Ultrasound Features of Partial Hydatidform mole Enlarged placenta with multiple diffuse anechoic lesions Fetus with severe structural abnormalities or growth restriction Oligohydramnios or deformed gestational sac
46) The increase in number of endometrial cells during pregnancy is an example of
47) A 38 year old women attends clinic follow up. You note pelvic ultrasound shows a 60mm simple cyst. What is the most appropriate course of action regarding this cyst according to the RCOG green top guidelines?
Explanation: Ovarian Cyst RCOG Greentop Guidline Number 62 states the following "Women with simple ovarian cysts of 50‐70 mm in diameter should have yearly ultrasound follow‐up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention" "A serum CA‐125 assay does not need to be undertaken in all premenopausal women when an ultrasonographic diagnosis of a simple ovarian cyst has been made"
48) A 30 year old patient has a cervical smear. The report shows anisocytosis, poikilocytosis and hyperchromatism. What are these features suggestive of?
Explanation: Dysplasia has 4 microscopic characteristics: Anisocytosis (unequal cell size) Poikilocytosis (abnormal cell shape) Hyperchromatism (pigmentation) Mitotic figures (increased cells currently dividing)
49) A 77 year old woman undergoes investigation for postmenopausal bleeding. A lesion is biopsied from t he cervix that is histologically confirmed as endometrial carcinoma. Further staging investigations shows no spread to the serosa or adnexa, no spread to the para‐aortic, pelvic or inguinal lymph nodes and no evidence of distant metastasis. What FIGO stage is this?
Explanation: This is stage 2 disease
50) A 24 year old who is 32 weeks pregnant presents with a rash to the abdomen. Looking at the picture below what is the diagnosis?
Explanation: This is Polymorphic Eruption of Pregnancy (PEP) also known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP). Palpules and plaques form on the abdomen (commonly within striae). It is most common in women during their first pregnancy and typically occurs in the 3rd trimester.
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