Download AJCP Journal CME/SAM

AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
Montgomery (page 305)
1. An excisional lymph node biopsy shows effacement of the normal node
architecture by a population of intermediate-to-large cells with vesicular
chromatin that are intermixed with scattered tingible-body macrophages. By
flow cytometry, the neoplastic cells are k-restricted B cells that are positive for
CD10 and negative for CD5. Immunohistochemistry shows strong BCL2 staining
in the neoplastic cells, approximately 80% of which are also stained with a Ki-67
antibody. TdT and cyclin D1 immunohistochemical (IHC) testing are negative.
Routine karyotype and fluorescence in situ hybridization (FISH) testing are
positive for t(8;14)/MYC-IGH but negative for BCL2 or BCL6 translocations. What
is the most appropriate diagnosis?
A. Burkitt lymphoma (BL)
B. B-lymphoblastic lymphoma
C. Diffuse large B-cell lymphoma (DLBCL)
D.B-cell lymphoma, unclassifiable, with features intermediate between diffuse large
B-cell lymphoma and BL (BCL-U)
2. An oophorectomy is performed for a right-sided adnexal mass. Microscopic
evaluation demonstrates a population of neoplastic B cells diffusely infiltrating
the ovarian stroma. The specimen had been placed in formalin at the time of
triage, and neither flow cytometry nor routine cytogenetic studies are available.
IHC stains show that the neoplastic cells are positive for CD10, CD19, and
TdT. They also appear to be weakly CD20 positive, with much stronger CD20
expression observed in background nonneoplastic small lymphocytes. The
neoplastic cells do not express CD5 or cyclin D1 by IHC. MYC, BCL2, and BCL6
FISH are all negative. What is the most appropriate diagnosis?
A. Burkitt BL
B. B-lymphoblastic lymphoma
C.DLBCL
D.BCL-U
3. A core needle biopsy of an enlarged lymph node shows diffuse growth of
intermediate-sized lymphoid cells with scant cytoplasm and high nuclear/
cytoplasmic ratios. Scattered tingible body macrophages are present in the
background, imparting a “starry-sky” appearance. By immunohistochemistry
and flow cytometry, the neoplastic cells are l-restricted B cells that express
CD10, CD19, and CD20. They also exhibit strong and diffuse BCL2 staining. Ki-67
stains approximately 70% to 80% of the neoplastic cells. CD5 and cyclin D1 are
negative. FISH testing reveals a chromosomal rearrangement involving MYC.
FISH testing for BCL2 and BCL6 abnormalities are negative. Which is the most
appropriate diagnosis?
A.DLBCL
B.BL
C. Burkitt-like lymphoma
D.BCL-U
4. An excisional lymph node specimen shows diffuse growth of intermediateto-large lymphoid cells with smooth, blast-like chromatin. By flow cytometry
and IHC, the neoplastic cells are positive for CD5, CD20, and cyclin D1. They
are negative for CD10, CD23, and TdT. Ki-67 stains approximately 70% of the
neoplastic cells. There is a complex karyotype, which includes t(11;14). MYC
FISH testing is negative. What is the most appropriate diagnosis?
A. Blastoid variant of mantle cell lymphoma
B. B-lymphoblastic lymphoma
C.DLBCL
D.BL
5. What is the prognostic significance of “double-hit” cytogenetics in BCL-U?
A. Indolent clinical behavior
B. Survival comparable to DLBCL without a MYC translocation
C. Survival intermediate between DLBCL and BL
D. Survival worse than either DLBCL or BL
Spicer (page 318)
1. Case-based curricula have become popular because trainees
A. are interested in getting to know each patient.
B. do not need to prepare in advance.
C. show more enthusiasm for learning.
D. like coursework that is concise.
B. The chances of creating high-impact research are increased.
C. It wastes time, since it is not difficult for clinicians to provide care without
multidisciplinary help.
D. It promotes relationships and communication between the members of the laboratory
and practitioners in different disciplines.
2. Microbiology vignettes were used as an educational tool to
A. introduce trainees to methods used in the microbiology laboratory.
B. train patients to understand their infectious complications.
C. improve communication between administrators and the laboratory.
D. describe training opportunities in infectious disease pathology.
4. Discussion of the questions in the case-based vignettes
A. is well-scripted and always the same.
B. expands, depending on the expertise of the attendees.
C. is usually confined to core faculty members.
D. exclusively highlights microbiology methods.
3. Which of the following statements best describes the major impact of having
a multidisciplinary group participate in case-based presentations as part of
microbiology rounds?
A. Learners can rely on the expertise of others.
5. The use of case-based vignettes in microbiology rounds
A. takes away time from patient care–related issues.
B. allows instruction regarding unusual pathogens.
C. decreases the number of patients that can be presented at rounds.
D. makes topics that are presented more repetitive from week to week.
Ware (page 334)
1. A 55-year-old man presented with a deep thigh mass. Histologic examination
showed a well-differentiated lipomatous neoplasm with scattered, questionable
atypical stromal cells. Fluorescence in situ hybridization (FISH) revealed an
average probe number per cell of 5 for MDM2 and 3 for CEP12. What can be
concluded from the results?
A.The MDM2 gene is amplified, helping to confirm the diagnosis of well-differentiated
liposarcoma (WDL).
B.The MDM2 gene is not amplified, helping to confirm the diagnosis of lipoma.
C.The MDM2 gene is not amplified, helping to confirm the diagnosis of WDL.
D.The MDM2 gene is amplified, helping to confirm the diagnosis of lipoma.
2. The lowest levels of MDM2 amplification by FISH can be found in which neoplasm?
A. Dedifferentiated liposarcoma (DDL), low grade
B. DDL, high grade
C.WDL
D. “Borderline” areas within liposarcoma
© American Society for Clinical Pathology
3. Amplification of the MDM2 gene promotes oncogenesis by what means?
A. Causing mutations in the p53 gene
B. Inactivation of the retinoblastoma gene
C. Increasing the degradation and subsequent inactivation of the p53 gene
D. Upregulation of the tyrosine kinase pathway
4.Currently, MDM2 amplification for lipomatous neoplasms is used in the
clinical setting to do what?
A. Determine treatment algorithms for liposarcomas
B. Diagnose all subtypes of liposarcomas
C. Predict morbidity and mortality characteristics
D. Distinguish benign lipomatous neoplasms from WDLs
5. What is the definition of “borderline” areas in liposarcoma?
A. Areas composed predominantly of mature adipocytes with no significant atypia
B. Areas with spindle cell morphology and no adipocytic differentiation
C. Areas with a mixture of lipoblast and mature adipocytes
D. Areas with increased atypia and cellularity, but with preserved lipomatous differentiation
Am J Clin Pathol 2014;141:443-446
443
443
443
AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
Schumacher (page 348)
1. Why is the TCRG gene the target for most clinical T-cell clonality assays?
A.The TCRG gene rearranges early in T-cell development.
B. TCRG is expressed in the context of the T-cell receptor and is functional in most T-cell
neoplasms.
C. TCRG has the most sequence complexity of the T-cell receptor genes.
D. TRCG is rearranged in only gd T-cells.
2. Which of the following accurately describes the appearance of a case that is
positive for clonality by capillary electrophoresis (CE)–based methods?
A. A clonal case appears as three or more peaks of differing lengths.
B. A clonal case appears as one or two dominant peaks.
C. A clonal case appears as a series of peaks with a Gaussian distribution of fragment
lengths.
D. A clonal case will demonstrate no peaks, because it will not yield amplicons in the
preceding polymerase chain reaction (PCR).
4. How are traditional CE-based T-cell clonality assays typically interpreted?
A. By a comparison of a patient sample to a control sample
B. By a comparison of a patient sample to a T-cell line
C.By a comparison of peak heights of potentially clonal rearrangement to the flow
cytometry results
D. By a comparison of peak heights of a potentially clonal rearrangement to that of the
polyclonal sample background
5. Some cases that meet criteria for clonality by CE do not meet criteria by NGS.
What is an explanation for these discrepant cases?
A. CE is more sensitive than NGS.
B. NGS generates false polyclonal results
C. A presumed clonal peak by CE may actually be composed of multiple unique rearrangements that are the same length.
D. NGS analysis does not properly account for sequencing errors.
3. What is the primary advantage of next-generation sequencing (NGS)
compared to CE-based methods for assessing T-cell clonality?
A. Overall work flow is much faster.
B. Overall costs are much lower.
C. NGS is better suited to detecting low-level residual disease in posttreatment samples.
D. Unlike CE-based methods, NGS does not require PCR or other amplification steps.
Patel (page 360)
1. Which of the following arteries does not provide blood supply to the testicle?
A. Deferential artery
B. Testicular artery
C. Pudendal artery
D. Cremasteric artery
2. Which of the following is the rarest complication of vasectomy?
A.Hematoma
B. Sperm granuloma
C.Infection
D. Testicular necrosis
3. Which of the following can the surgeon rely on to advise the patient
that vasectomy has been successful and that other birth control can be
discontinued?
A. Successful visual identification and transection of vas deferens during the vasectomy
procedure
B. Confirmation of transection of two vasa deferentia on histologic analysis
C. Failure to see sperm on postvasectomy semen analysis
D. Confirmation of transection of two vasa deferentia on histologic analysis and after 20
postvasectomy ejaculation semen analyses
4. What percentage of patients comply with providing a postvasectomy semen
analysis?
A.5-20
B.15-30
C.55-70
D.75-90
5. You are performing histologic analysis of a vasectomy specimen and notice
that there is a 3.0 mm artery. You do not see a cut cross-section of vas deferens.
Which of the following is not a potential implication of this finding?
A. Future injuries to the collateral blood supply to the testis may lead to compromised
testicular blood flow.
B. Postvasectomy semen analysis will likely show presence of sperm.
C. This is a critical result that should be communicated to the surgeon as soon as possible.
D. The case can be signed out as usual.
Klein (page 381)
1. For patients with advanced classical Hodgkin lymphoma (CHL), what is the
rate of relapse or death after standard therapy?
A.1%-3%
B.5%-10%
C.20%-30%
D.40%-50%
2. Risk stratification of CHL patients with the international prognostic score
includes which of the following?
A. Age greater or less than 25 years
B. Albumin greater or less than 4 g/dL
C. Hemoglobin greater or less than 8 g/dL
D. WBC count greater or less than 10,000/µL
3. In CHL, which of the following is associated with the tumor microenvironment
recently shown to be correlated with treatment outcome?
A. Expression of FOXP3 on B lymphocytes
B. Epstein-Barr virus–encoded small RNAs expressed on Reed-Sternberg cells
C. CD68 expressed on B lymphocytes
D. CD20 expressed on T lymphocytes
444
444
Am J Clin Pathol 2014;141:443-446
4. What was overall survival in CHL found to be?
A. Significantly higher in patients with >5% of macrophages staining for CD163 than in
patients with <5%
B. Significantly lower in patients with <5% of macrophages staining for CD163 than in
patients with >5%
C. Significantly higher in patients with mean CD163 macrophage staining of >25%
D. Significantly higher in patients with mean CD163 macrophage staining of <25%
5. Variability in reported results for correlation of macrophage expression in CD68 with survival in CHL may be due to what?
A. High background staining with the KP-1 antibody due to nonspecific binding to
T lymphocytes and myeloid elements
B. High background staining with the KP-1 antibody due to nonspecific binding to
macrophages and monocytes
C. Frequent expression of CD68 by Reed-Sternberg cells, confounding quantitation
and interpretation
D. Frequent expression of CD68 by background plasma cells
© American Society for Clinical Pathology
AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
Fromm (page 388)
1. Immunophenotyping of a left cervical lymph node results in the following light
scatter properties and immunophenotype: large cell size (increased forward and
side light scatter), expression of moderate apparent CD3, intermediate CD30,
bright expression of CD40 (higher than the level of the small reactive B cells),
and bright CD95, without CD20 or CD64. Which of the following is true?
A.The lack of expression of CD20 on this population is an uncommon flow cytometric
finding in classical Hodgkin lymphoma (CHL).
B. Intermediate CD30 on this population by flow cytometry is not a feature of CHL.
C. The lack of expression of CD64 on this population excludes a diagnosis CHL.
D. The apparent expression of CD3 on this population is consistent with a diagnosis
of CHL.
2. While nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) cannot
be consistently immunophenotyped with this assay, which of the following
immunophenotypic findings could help distinguish a lymphocyte-predominant
cell population of NLPHL from an Hodgkin and Reed Sternberg (HRS) cell
population of CHL by flow cytometry?
A. Expression of CD64 would be more typical of CHL.
B. The lack of expression of CD20 would be more typical of CHL.
C. The lack of expression of CD40 would be more typical of CHL.
D. The lack of expression of CD95 would be more typical of CHL.
3. Which of the following is not required for a population to be considered a
HRS cell population from CHL?
A. The cells must have increased side scatter (compared to the small lymphocytes).
B. The cells must express CD40 at an intensity less than the reactive B cells.
C. The cells must express CD30.
D. The cells must express no or low-level CD20.
4. A worker notes the presence of an abnormal T-cell population (on routine
immunophenotyping of the T cells) and a separate CD30+ population composed
of cells with large size (increased forward and side light scatter) and bright
CD40 and CD95 expression without CD3 or CD20 expression in an axillary lymph
node from a 63 year-old woman. Which of the following would be a reasonable
diagnostic conclusion, given this data?
A.The presence of both populations could represent a T-cell lymphoma with Hodgkin
cells.
B. The presence of both populations is not possible and thus implies that a technical
artifact in the Hodgkin tube is being interpreted as a real population.
C. The cells with CD30 and CD40 expression can be safely ignored, as such a population
cannot be identified in the presence of an abnormal T-cell population.
D. The abnormal T-cell population can be ignored, as such a population cannot be identified in the presence of a CD30- and CD40-positive population.
5. You study an inguinal lymph node from a 33-year-old man and identify the
following immunophenotype and light scatter properties on a distinct population:
expression of intermediate to bright CD20, weak CD30, bright CD40 (at a level
slightly higher than the normal B cells), and low CD95, without CD3 or CD64.
The cells also have increased forward and side light scatter. What is the best
diagnostic conclusion?
A.CHL
B. Anaplastic large cell lymphoma
C. Angioimmunoblastic T-cell lymphoma
D. Diffuse large B-cell lymphoma
Londero (page 404)
1. How do poly adenosine diphosphate ribose polymerase inhibitors work for
the treatment of ovarian cancer?
A. They promote the ability of cells to repair single strand DNA breaks, leading to cell death.
B. They promote the production of free radicals capable of to damage DNA, leading to
cell death.
C. They promote the senescence pathway of the cell, leading to cell growth arrest.
D. They suppress the ability of cells to repair single-strand DNA breaks, leading to cell death.
2. What is nucleophosmin 1 (NPM1)?
A. A protein that resides specifically within the nucleus
B. A protein that resides specifically within the granular region of the nucleolus
C. The main apurinic/apyrimidinic endonuclease in mammalian cells
D. The key enzyme responsible for the incision of the AP sites and the generation of a
3’-OH, which represents a primer for Pol-β.
3. What is the molecular interaction between NPM1 and apurinic endonuclease
1 (APE1)?
A. It modulates a new function of APE1 in mRNA metabolism.
B. It involves Lys27/31/32/35 residues of NPM1 and the oligomerization domain of APE1.
C. It is characterized by a significant stimulatory effect by NPM1 on APE1 DNA-repair
activity in base excision repair (BER), and the loss of this interaction impacts on proliferation of tumor cells.
D. NPM1–/– cells have impaired BER, which results in less sensitivity to alkylating agents.
© American Society for Clinical Pathology
4. What is the overall survival of serous ovarian carcinoma patients?
A. Decreased in the group of women expressing NPM1 at levels higher than the median
value of the distribution
B. Increased in the group of women with a nuclear expression of APE1 higher than the
median value of the distribution
C. Increased in the group of women expressing NPM1 at levels higher than the median
value of the distribution
D. Decreased in the group of women with a nuclear expression of APE1 lower than the
median value of the distribution
5. Nuclear H-score value of NPM1 impacted survival in high-grade ovarian
serous cancers in what way?
A. Women with high-grade cancer expressing high nuclear NPM1had a significant longer
overall survival than the subgroup with low expression of this protein.
B.Women with high-grade cancers expressing low nuclear NPM1 had a significant
longer overall survival than the subgroup with high expression of this protein.
C. H-score values of NPM1 show statistically significant differences between women
with International Federation of Gynecology and Obstetrics (FIGO) stages I-II and those
with stages III-IV.
D. The overall survival in the FIGO I-II stages was statistically significantly longer with
low NPM1 nuclear expression than in the subgroup with high NPM1 expression.
Am J Clin Pathol 2014;141:443-446
445
445
445
AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
Li (page 420)
1. Which of the following genes is not routinely tested for in cytology specimens
of lung adenocarcinomas?
A. EGFR
B. KRAS
C. ALK1
D. PTEN
2. Which of the following gene mutations is least often detected in lung
adenocarcinoma?
A. EML4-ALK1 deletion or inversion
B.EGFR point mutation
C. EGFR deletion
D. KRAS mutation
3. A non–small cell lung carcinoma with cytologic features of acinar
differentiation with less pleomorphism and an absence of necrosis is more
likely to have which of the following mutations?
A. EGFR
B. KRAS
C. ALK1
D. BRAF
4. A non–small cell lung cancer with cytologic features of a poorly
differentiated adenocarcinoma with more pleomorphism and necrosis is more
likely to have which of the following genetic mutations?
A. EGFR point mutation
B. KRAS mutation
C. EGFR deletion
D. BRAF mutation
5. Lung carcinomas that test positive for EGFR, KRAS, or ALK genetic mutations
are typically in which of the following subtypes of lung cancer?
A. Squamous cell carcinoma
B. Large cell neuroendocrine carcinoma
C. Carcinoid tumors
D.Adenocarcinoma
Zhu (page 429)
1. What is the incidence of primary lung adenocarcinoma in patients with a
history of previous extrapulmonary malignancy (EPM) who present with new
lung nodules?
A.7%
B.27%
C.47%
D.67%
2. Which is the most specific immunohistochemical approach to confirm a
diagnosis of primary lung adenocarcinoma?
A. Thyroid transcription factor 1 (TTF-1) only
B. Napsin A only
C. Combination of TTF-1 and napsin A
D. Combination of TTF-1 and CK7
4. Which organ is the most common primary site of origin for a malignancy that
metastasizes to lung?
A.Breast
B.Colon
C.Kidney
D.Pancreas
5. Which group of patients with a diagnosis of primary lung adenocarcinoma
has the highest rate of smoking history?
A. Primary lung adenocarcinoma patients with a history of EPM
B. Primary lung adenocarcinoma patients without a history of EPM
C. Patients with metastatic malignancy to lung
D. Patients without history of malignancy
3. Which organ is the most common site of EPM malignancy in patients who
also have a diagnosis of primary lung adenocarcinoma?
A.Breast
B.Colon
C.Kidney
D.Pancreas
446
446
Am J Clin Pathol 2014;141:443-446
© American Society for Clinical Pathology