FRCPath Part 1

FRCPath Part One Revision

Below are the topics that have come up in the Royal College MCQ/EMQ part one exam. The
topics are in reverse date order. For the years preceding the exam I took (Spring 08), I have
made brief notes on each of the topics which I have typed out below. If a question came up
more than once I have only made notes on it once. For some questions I have not written
notes for one reason or another, and some notes are a bit brief.

Please feel free to make notes on the post-Spring 08 exam questions that have not come up
before and also expand and correct any of the other notes.

The exam consists of a number of MCQ questions – pick the best option from a list and EMQ
questions where you have 5 scenarios on a theme and you match each scenario to one of a
huge list of options.

Advice for revision

Please all add to this...

I still think a good knowledge of the systems chapters in Robbins is a good place to start. It is
worth a brief read through of the first 10 chapters, but only paeds, microbiology and
genetics has come up.

There are usually a few TNM questions, so far breast, renal, lung (I wouldn't read the more
obscure tumour types) and a question on the nomenclature - itc, y, T0. The minimum
datasets are also important to learn

The Robbins, Sternberg and Pathology question books are ok, but I haven't found one which
is exactly the same as the part one, but they get you into the question answering frame of
mind.

Lymphomas tend to come up although we only had one or two obscure references to this
dark art in Spring 08.

Cytology comes up which is really difficult as there are no pictures, just rubbish descriptions.

Go through the past question topics as you can see below - these are starting to come up
again and again.

Spring 2010
MCQs

1. Metastatic lobular breast cancer to ovary

2. Burkitt’s lymphoma
3. Mechanism of death with excess alcohol
4. Stain for Cryptococcus
5. Breast cytology
6. Stain for neurofilbrillary tangles
7. Immuno for pemphigoid
8. LCH
9. Cytology of endocervical neoplasia
10. Lung cancer immuno – renal metastasis
11. Lung TNM
12. Bowel TNM
13. Genetics of hydatidiform moles
14. Malakoplakia
15. Arias stella reaction
16. Histology of trigone
17. Cytology of neck lump
18. What blocks not to be taken in a sarcoma (a Px has a large retroperitoneal
sarcoma. You consultant tells you that you have taken too many blocks. Which
one is unnecessary?)
19. Immuno for thyroid tumours
20. Medicolegal PM – Can the family be told the result by the pathologist?
21. Genes of HOCM
22. Body in fire – what features are seen antermortem?
23. Whipple’s disease
24. Breast hamartomas
25. Cow milk allergy
26. CF
27. Spindled tumour in abdominal wall post pregnancy
28. A1 antitrypsin deficiency
29. Infectivity of Hazard group 3 pathogens
30. Dysplastic naevus
31. Basal cell markers breast
32. Mucoepidermoid in child
33. FNA of Warthin’s
34. Features of a malignant parathyroid lesion
35. Features of a malignant adrenal lesion
36. Genes in phaeochromocytomas
37. Immuno of follicular hyperplasia vs follicular lymphoma
38. LN in cat scratch disease – which pathogen?
39. Chemosensitive features in oligodendroglioma
40. Cause of death in a patient with a fractured NOF, PE, dementia
41. Flow cytometry
42. Child with biliary atresia – features on liver biopsy
43. Cause of nephrotic syndrome
 44. Xanthogranulomatous lesion in a child
45. Cause of PE in a patient with myeloma
46. Cause of death in a young man with Marfan’s
47. Prognostic feature in lobular breast cancer
48. Which immuno is a waste of money
49. What do you need to do to a microscope to see amyloid
50. Where do you inject the dye to do a sentinel node biopsy?

EMQs

1. Glomerulonephritis/renal biopsy
2. Bullous skin lesions – pemphigus, pemphigoid, polymorphous light eruption, HSP
3. Lymphomas - immuno and cytogenetics
4. Dental cysts/tumours
5. Brain infections
6. Brain tumours
7. Head and neck tumours/masses
8. Bowel biopsies – normal, Crohn’s, infective, ischaemic
9. Cytology of bronchiolar lavage – asthma, lipoproteinosis
10. Bladder biopsies
11. Immuno for ovarian tumours
12. PM infectious causes of death – meningitis, viral pericarditis, TB
13. Liver biopsies
14. Thyroid gland histology
15. Endocrine tumours and underlying diseases

Spring 2009

Spring 2008

MCQs
Pagets of the nipple immuno - Options were c-erb2, S-100

Clinical description and FNA findings of a breast lump - I think this was a fibroadenoma

Lesion of the breast following trauma - ?fat necrosis

Blood over surface of brain in a young adult, ?source - options were aneurysm, hypertensive
bleed

Miscarriage in someone with a fever, fetal meningitis/pneumonia ?source - ascending,

haematogenous

Description of an oligodendroglioma what is the most important prognostic factor? vascular

prolif, capillary network, necrosis, things like that

Prognostic factors in a kidney tumour - size, site, renal vein invasion, which is most
important

Multiple problems in someone with a lung tumour, which is paraneoplastic? options were
low calcium, high sodium, Horners

What is the likely diagnosis in a child with a parotid tumour? options included Warthins,
pleomorphic adenoma, acinic, mucoepidermoid

Who do you need to contact for ethical approval? Ethics committee, local health authority

Which of the following break Caldicott guidelines? We think it is faxing to a reception area

Which station lymph node is involved in a neck tumour with a positive node behind the
SCM? Options I-V

Storage diseases - Someone with a cherry red spot on the macula ?Tay Sachs

How do you record individual tumour cell positivity in the TNM 6?

Poorly differentiated skin tumour which immuno will show you it is a squamous tumour?

Which clinical features are most important in a melanoma? site, shape, colour etc

Elderly woman dies a few days post op, following fracture repair to the NOF what is the
likely cause? PE, pneumonia, fat embolus

Macroscopic description of a joint disease which is most likely? OA/RA/tumour/met

(sounded like OA)

Description of a prostate tumour which is the correct Gleason grade? Options were 3+3, 3+4
etc

What is the likely cause of abnormal cells in the urine of someone treated with
Cyclophosphamide? Tumour, the drugs

What is the immuno profile of Langhans cells in the skin and endocrine cells in the bowel?
Dead body in a pool of blood, knife under him, disturbed furniture in kitchen. Knife wounds
in chest and arm, no cuts in t-shirt. ?suicide, ?accident, ?one or two assailants

Dead following a motorcycle accident, brief trip to ITU ?likely cause - paradoxical emboli,
DAI

Microscopic description of a skin lesion - I think this was a seb k (they called it a basal cell
papilloma)

EMQs

Thyroid lesions FNA'd - options were papillary tumour, mets from the lung, prostate, small
cell lung, T- cell lymphoma

Cervical biopsy and smear descriptions what is the dx? options - HPV, CIN, immature
metaplasia, CGIN

Post-mortems - Drug deaths (alcohol, cocaine, volatiles, steroids)

Neuro infections - herpes, JC, TB

Neuro injuries - (macro findings) DAI, fat emboli

Glomerulonephritis - Description of the micro appearance to fit with the diagnosis;

membranous, diabetes, light chain, amyloid

BAL specimens - description of the smears, some with differential white cell counts;
pneumonia, DIP, eosinophilic bronchitis, asthma, lipoproteinosis

Bowel macro - Crohns, UC, angiodysplasia, perforation in caecum in an

immunocompromised young patient (?CMV)

Bone lesions - x-ray and clinical - things like - bone cysts, osteosarcoma in someone with
Pagets, post-trauma in a child, and in someone with renal failure

Cardiomyopathy - HCM, granulomas (?sarcoid), waxy (?amyloid), right ventricular dysplasia

Ovarian tumour macroscopic appearances - mucinous, serous, teratoma, Meigs syndrome

Embolic phenomenon - fat, paradoxical, tumour, bone marrow

Autumn 2007

EMQs

Thyroid Tumours

Follicular – Adenoma - Hurthle cell change/Clear cell/Signet ring – endocrine atypia

-Encapsulated, bulging tumour, uniform follicles, bland, non-

mitotic

-Unilat, painless mass, cold on scan

-Carcinoma -10-20% of cases, female, ½ have RAS mut, infiltration of

capsule or vascular invasion. Light tan with focal haemorrhage.
Papillary – 75-85%, RET mutation (TK) or BRAF/RAS. Can be encapsulated, fibrotic and
calcified, usually papillary with characteristic nuclei and psammoma bodies. Follicular
variant.

Medullary – C-cells, unencapsulated, RET mutation, firm tumour, pale grey/tan, infiltrative.
Amyloid. Familial cases have c-cell hyperplasia.

Anaplastic – Undiff, high mortality

Insular – poorly diff variant

BAL Specimens

Inflammatory Bowel Disease

Vade mecum p144

Paediatric Lung

Pulmonary agenesis – rare, incompatible with life, unless unilateral – long term survival

Sequestrations – extralobar mass of pulmonary tissue, outside pleura

Hypoplasia – reduction in size of lung due to reduction in number of acini

Congenital cystic adenomatoid malformation/Congenital pulmonary airway malformation –

hamartomatous lesions of lung (1/5000 births), 5 major types, some cystic, some
adenomatoid.

Hyaline membrane disease – firm atelectatic lungs (looks like liver), haemorrhage and
oedema, with hyaline membranes. Occurs in prematurity with reduced surfactant.

Ovarian Tumour Immuno

Endom ov – CK7+ CK20-ve ER mod CEA mod

Clear cell ov – CK7+ve CK20-ve ER mod

Mucinous ov – CK7+ve CK20+ve ER low

Brenner – CEA/EMA/19.9 (like TCC)

Granulosa – vimentin/SMA/CD99/PR+ve/ER-ve

Sertoli – inhibin +ve (Call-Exner bodies)

Lymphoma

See end

Skin Blistering Disorders

Pemphigus – autoimmune against intercellular attachments men=women 4-6th decades. IgG

to cement substance – net like immunofluorescence

-vulgaris = 80% - mucosa/skin (scalp, face, axillae, groin), acantholysis immediately

above basal layer, cells become rounded with a tombstone appearance.

- vegetans = rare, warty plaques studded with pustules, overlying hyperplasia, same
split as vulgaris

-foliaceous = S.American, epidemic, superficial bullae, subcorneal split

-erythematous = locaslised, less severe form of foliaceous

Bullous pemphigoid – elderly – tense bullae, heal without scars. Subepidermoid, non-
acantholytic blisters. Perivascular lymphocytes, superficial oedema. Ab to hemidesmosomes
– IgG linear

Dermatitis herpetiformis – papules/vesicles/bullae, males, assoc with celiac. Bilat.

Symmetrical distribution, pruritic. Fibrin and neutrophils at tips of papillae, overlying
vacuolisation leading to dermal-epidermal separation and coalescence leading to blisters.
Granular IgA deposit at papillae tips. Ab present against gliadin

Epidermolysis bullosa – blisters at pressure points due to mutation in keratin genes, simplex,
junctional and dystrophic types.

Porphyria – Inborn error of porphyrin metabolism (pigment in Hb), 5 types. Subepidermal

vesicle with thickened superficial dermal vessels.

CNS Infections

Meningitis – Bacterial – Neonates – E.Coli/GrpB Strep/H.Inf/S.pneumoniae (infants)

Adults – N.meningitidis

Elderly – S.pneumoniae/Listeria

Immunocompromised – Klebsiella/anaerobes

CSF – increased neutrophils, increased protein, reduced glucose

-Viral – mod increased lymphocytes, mod protein, normal glucose,

enteroviruses, echo, coxsackie, polio. Mild brain swelling
 Abscess – locations can be brain, subdural, extradural

Meningoencephalitis

–chronic TB, mononuclear cells, some neutrophils, protein increases,

glucose reduced, gelatinous/fibrinous exudates

-syphilis, obliterative endarteritis, paretic neurosyphilis is invasion by

Treponema pallidum, Tabes dorsalis, Charcot joints (loss of sensation)

-viral, perivascular and parenchymal mononuclear infiltrate, HSV –

temporal lobes, Polio – perivascular cuffs, ant horn cells, HIV – itis,
dementia (ADC), clear meninges, ventricular dilatation, microglial
nodules

-Fungal – candida, mucor, aspergillous, cryptococcus – meningitis,

vasculitis, parenchymal invasion

Glomerulonephritides

Paraneoplastic Syndromes

Cushings – small cell / pancreatic – ACTH

SiADH – small cell / intracranial tumour – ADH/ANP
Hypercalcaemia – SCC lung / Breast / RCC – PTH
Carcinoid – bronchial adenoma / pancreatic / gastric – serotonin / bradykinin
Polycythaemia – RCC / hepatocellular – EPO
Myaesthenia – bronchogenic – immunologic
Acanthosis nigricans – gastric / lung / uterine – immunologic
Dermatomyositis – bronchogenic / breast – immunologic
HOA/Clubbing – bronchogenic
Venous thrombosis / Trousseau – pancreas / bronchial – mucins activating clotting
Nephrotic – various – Ag/Immune complex

Head and Neck Tumours

Mouth = SCC ?bkd of leukoplakia

Nasopharyngeal carcinoma – lymphoid associated

1 – Keratinising SCC

2 – Non-keratinising SCC

3 – Undifferentiated with non-neoplastic lymphoid infiltrate

Carotid body tumour – paraganglioma

Salivary Glands

- Pleomorphic adenoma (mixed tumour), 60% of parotid tumours, derived from

ductal and myoepthelial cells. Epithelial element dispersed in a myxoid,
chondroid or osseous background. Rounded well circumscribed masss, grey-
white cut surface. Painless and slow growing

- Warthins, parotid tumour, 8x increased risk is a smoker. Round and

encapsulated, pale grey, cysts/clefts. Double layered cyst wall (oncocytic cells) in
a dense lymphoid stroma.

- Mucoepidermoid, 15% of tumous, squamous/mucus cells 60-70% in the parotid,

some in minor glands. Commonest malignant tumour. Lacks capsule, pale grey
surface – cords, sheets, cysts. Low/mod/high grade.

- Adenoid cystic, 50% in minor glands, small encapsulated, small dark cells, scant
cyt – tubular, solid, cribriform patterns. Perineural invasion common.

- Acinic cell, serous acinar cells, uncommon, parotid, cleared cytoplasm – sheets
and multicystic.

Vasculitides

Giant cell – commonest vasculitis in adults, acute or chronic, granulomatous of arteries

small to large. Nodular thickenings, segmental – thrombosed lumens. Granulomatous
inflammation of inner ½ media, and internal elastic lamina, with giant cells. Steroid
responsive, usually over 50s.

Takayasu – granulomatous, med/large arteries – ocular disturbance and weak pulse –

fibrous thickening of the aorta. Females less than 40, aortic arch, intimal, adventitial
mononuclear infiltrate with perivascular cuffing of v. vasorum, may look identical to giant
cell.

Polyarteritis noodosa (PAN) – small/medium muscular arteries causing ischaemic infarcts.

Segmental transmural nectrotising inflammation of artery. Frequently K/GI/Liver/heart, esp
at branch points causing aneurismal dilatation. Young adults, remitting disease, varied
sites/signs. 30% hep Bag +ve, ANCA –ve.

Kawasaki – Children, coronary a. assoc with mucocutaneous lymph node syndrome. Aspirin
sensitive. PAN-l;ike necrosis – transmural.

Microscopic polyangitis – arterioles/cap/venules – palpable purpura of skin/GI/K/M,

immune reaction to penicillin/step, 70% pANCA +ve (also +ve in Churg-Strauss –
eosinophilic). Segmental fibrinoid necrosis of media, leukocytoclastic.

Wegners – acute necrotising granulomas URT/LRT with granulomatous vasculitis of

small/med cap/vein/art esp in lungs, focally in kidneys. cANCA 95%. 40yr.
Thromboangiitis obliterans/Buergers – segmental thrombosing acute and chronic
inflammation of med-small art. Smokers. Upper/lower extremities. Microabscess in
thrombus.

Bone Tumours

Benign Gynae Lesions

Bartholin cyst – vulval lesion, transitional epithelial lining or squamous, painful if infected
Lichen sclerosus – BXO
Lichen simplex chronicus – itchy, thickening with inflammation
Papillary hidradenoma – ectopic breast – hidradenoma or Paget’s
Condyloma/verrucca – koilocytic lesion
Endocervical polyp – (2-5% women) – spotting, mucoid lesionwith dilated glands,
inflammation on squamous metaplasia with a dense fibrous stroma.
DUB – Prepuberty/precocious – hypothyroid/pit/ov
Adolescence ; anovulatory cycle – prolonged oestropgen no progesterone, or coag
disorder. Reproductive – pregnancy, leiomyoma, adenomyosis, anovulation,
inadequate luteal (reduced corpus luteum, endometrium date lags behind).
Endometritis – PID, postpartum, abortion, IUCD, tb (military) – plasma cells!
Endometriosis – ovary, ligaments, pouch of Douglas, scars. +/- adenomyosis (2-3mm deep) –
colicky dysmenorrhoea. Occurs in 10% of women due to retrograde spread, metaplasia or
lymphatic spread.
Endometrial polyp – Functional endometrium/hyperplastic (cystic) – adeno ca
Leiomyoma – commonest human tumour
Ov cysts – graafian follicle, corpus luteal, polycystic ov

Opportunistic Infections

Ab deficiency (agammaglobulinaemia) – bac inf, S Pneumoniae/H inf/S Aureus, viral

(rota/entero)

Complement deficiency – bac – S Pneumoniae/H Inf / N Meningitidis

Neutrophil dysfunction – S Aureus/ g –ve

CF – Pseudomonas / S Aureus / Burkholderia cepacia

Sickle Cell – S Pneumonia

Leukaemia – opportunistic

Burns – Pseudomonas
AIDS - pneumonia (P Jirovecii), Candida, CMV, mycobacterial (m avum/ m tb), cryptococcus,
toxo, HSV, HPV, histoplasma, HHV8

MCQs

XXY Ovarian Lesions

Massons Fontana

Melanin, argentaffin, chromaffin, lipofuscin – black, nuclei red

Health and Safety (TB)

Aerosol/percutaneous spread. Respiratory protection ideal, formalin fix for 48hrs in

suspected cases.

Medullary ca Thyroid prognostic factors

Better prognosis if amyloid is present, small size, fewer nodes/mets. C-cell hyperplasia
implies a familial cause

Breast TNM

SNOMED

Systematised Nomenclature of Medicine (CT – clinical terms)

Traumatic Head Injury

Skull # - diastatic - crosses suture, displaced – displacement greater than skull thickness

Concussion – altered consciousness secondary to injury, LOC/transient neurological

dysfunction/loss of reflexes/amnesia

Contusion – bruising

Laceration – tearing

Parenchymal injury – gyral crests of frontal/temporal lobes

Coup/Contrecoup – wedge-shaped area of injury – oedema and haemorrhage, 24hours –

neuronal injury – eosinophilic nuclei, pyknosis, cell disintegration, neut/macr – eventually a
yellow/brown plaque

DAI – centroaxial white matter esp c-c, paraventricular, hippo, cerebral peduncles –
damaged axon at node of Ranvier causing altered cytoplasmic flow, axonal swelling, Aβ
protein +ve

Epidural haemorrhage – ruptured m.m.a.

α1-AT Deficiency

Autosomal recessive, reduction in protease inhibitor which normally dampens the effects of
elastase, cathepsin, proteinase activity (released from neutrophils at sites of inflammation).
Causing destruction of pulmonary tissue resulting in panacinar emphysema. 75 α1 gene
forms PiMM = 90% of individual genotypes. PiZZ homo have 10% normal levels due to
defective transport from ER –golgi. 10% of Pizz have liver disease due to accumulated α1 in
cells – round inclusions in cytoplasm, acidophilic D-PAS +ve – hepatitis and cirrhosis often in
childhood.

Muscular Dystrophy

X-linked – Duchene – sever e, 1/3500, manifests at 5yrs, wheelchair by 10-12 yrs, death
early 20’s

Beckers – less common, less severe

Both Xp21 – Dystrophin gene, usually deletion, 2/3rds familial, increased serum CK in female
carriers

Protein is in the sarcolemmal membrane at the Z-bands, binds acting, absence leads to
myocyte degeneration. Variation in fibre diameter, causing splitting, internalised nuclei,
necrosis, and fatty replacement which leads to calf pseudohypertrophy
Sarcoid

Systemic non-caseating granulomatous disease. Bilat hilar lymphadenopathy (90%), eye

then skin involvement. > in females > in blacks. ?CD4 T-cell driven, increased Th1 CK.
Familial racial clustering, HLA class I, granulomas + laminated concretions of ca –
Schaumann bodies, stellate inclusion – giant cell/ Asteroid body.

Pleural Effusion

Increased fluid – increased pressure (CHF); increased permeability (pneumonia), reduced

osmotic pressure (nephritic syndrome), reduced lymphatic drainage (mediastrinal ca)

Transudates - <30g/l protein >30g/l - exudate

Sudden Death and Drugs

Glomerulonephritides

Vasculitis

Melanoma Macro

Confidentiality

Audit

Molluscum

Self-limiting, viral, poxvirus – brick shaped, dumbbell DNA core. Direct contact spread.
Multiple skin lesions, trunk and anogenital, firm pruritic skin coloured papules. Cuplike
verrucous hyperplasia with molluscum bodies, homogenous cyt. Inclusion in stratum
granulosum/corneum, eosinophillic bodies contain virions.
Neck Anatomy

I – Under the mandible

II,III,IV – Along the SCM from top to bottom in thirds

V – Behind the SCM

VI – In front of the SCM

VII – Behind the sternum

Urinary Calculi

5-10% of the pop, 4 types;

70% calcium oxalate – hypercalcaemia/hypercalciuria (PtH)

15% triple (magnesium/ammonium phosphate) – proteus infection – stag horn

5-10% uric acid – gout, radiolucent

1-4% cystine – defective reabsorption of amino acids

80% unilateral

Lymophoma (Mantle)
Spring 2007

Amyloid

AL – Amyloid light chain - myeloma/myelodysplasia

AA – Amyloid associated – reactive, systemic, and FMF

Aβ – Alzheimers

Aβ2M – Haemodialysis associated (β2 microglobulin) CRF

ACal – calcitonin – medullary thyroid

PrP – Prion

Congenital Anomalies and associated chromosomal/genetic abnormalities

In reducing frequency;

Trisomy 21 – Downs

Klinefelters XXY

Turner XO

Trisomy 13 - Patau

Hereditary cancer syndromes

Beckwith-Wiedemann – Wilms, neuroblastoma, hepatoblastoma, rhabdo

BRCA 1/2 – Breast and ovary

Carney complex – myxoma, sertoli cell tumour, thyroid, pit adenoma

Carney triad – GIST/ pulmonary chondroma / paraganglioma

FAP – Colorectal ca, upper GI, desmoid, osteoma, thyroid, brain

Familial medullary thyroid – RET mutation

HNPCC – mismatch repair – colon, endom, stomach, liver

LiFraumeni – p53 – sarcoma, breast, leukaemia, osteo

MEN I – pit/panc/parathyroid (MEN gene)

MEN 2a – parathyroid/med thyroid/phaeo (RET mut)

MEN 2b – med thyroid/phaeo + marfanoid (RET mut)

Gorlin – BCC/odonotgenic keratocysts

NF 1 – neurofibroma/leukaemia, Café spots, lisch nodules, ax freckles

NF 2 – bilat vest schwannoma

PJ – STK11, colon, breast, stomach, perioral pigment, hamartomatous polyps

VHL – Haemangioblastoma/RCC

Bone tumours and X-ray appearances

Bone Forming –

Osteoma – benign project from subperiosteal/endosteal surface. Skull/facial bones.

Middle aged. Gardner = multiple. Woven/lamellar bone +/- marrow

Osteoid osteoma / Osteoblastoma – Benign

Osteoma - <2cm, teens, appendicular skeleton, within medullary cavity, pain

ful, reduced with aspirin

Osteoblastoma – spinal, dull pain

Both haemorrhagic gritty tissue, well circ. Mass of trabeculae, rimmed by osteoblasts, loose
ct and blood vessels, with reactive surrounding bone

Osteosarcoma – malignant tumour producing bone matrix, 20% of bone tumours. Young
unless assoc with Pagets/irradiation. Metaphysis of long bones. Rb gene mut. Invades soft
tissue, lytic areas, lifts periosteum – Codmans triangle.

Cartilage forming –

Osteochondroma – exostosis, cart capped outgrowth, young male, arise from metaphyseal
region of long bone, capped with hyaline cart. Medullary cavity in continuity.

Chondroma – benign tumour of hyaline cartilage – medullary cavity = enchondroma,

grey/blue nodular tumour. Surface = subperiosteal/juxtacortical chondroma. Neoplastic
chondrocytes reside in lacunae appear bland. Well circ lucency with O ring of radiodense
bone.
Chondroblastoma – rare/benign <1% - sheets of compact polyhedral chondroblasts –
chicken wire, epiphysis

Chondrosarcoma – neoplastic cart, usually >40. Central skeleton, rarely distal. Painful mass.
Endosteal scalloping, soft tissue mass, well circ.

Chronic SDH in elderly

Chronic – dating,

0-3 Acute – clotted – fibrin on arachnoid side, intact RBC

3-20 Subacute – clot and fluid +/- membrane – rbc degeneration, Perls+ve 5-10/7,
fibroblasts from dura, capillaries

>20 – Chronic – fluid + membrane – cap/mature ct. Membrane at 4 weeks

Diatoms

Fresh vs sea water (different populations) >10 000 types. If alive when entering water
diatoms enter circulation and reach organs. They can be identified following digestion of the
organ. If dead on entering the water diatoms are found in the lungs alone. This probably
does not work due to diffusion of diatoms pm.

T0 in TNM

T0 = no evidence of primary tumour

y – post multimondal treatment

c – clinical C – certainty factor (re evidence)

r – recurrent tumour

G – histopath grade

a – autopsy

L – lymphatic invasion

p – pathological

V – venous invasion

m – multiple tumours

R – resection
Who writes the TNM

Internation union against cancer (UICC)

Consent

Fixative for testicular biopsy

Bouins – better cytology for sperm identification

Fixative for EM

Gluteraldehyde

Skin lesions and clinical appearances

Naevus – small/flat/symmetric/uniform pigmentation

Dysplastic naevus – asymmetric, pale shoulder around a naevus

Melanoma – enlarging, itchy, painful, new occurance, irregular border with variegated
colour

Seb K – well circ, coin-like, pigmented with a stuck on appearance, pore-like ostia

Fibroepithelial polyp – stalk, bag-like tag

Epithelial cyst – domed +/- pain, well circ, movable

Keratoacanthoma – mimics SCC, often heals spontaneously in sun exposed males, white
>50, fleshy dome, keratin plug.

AK – chronic sun exposed site, tan lesion, sandpaper consistency +/- horn

SCC – males>females, sunlight exposed areas, ulcer, osteomyelitis, scar, arsenic, radiation,
XP, nodular ulcerated lesion

BCC – chronic sun exposed site, pearly papule, dilated vessels, +/- melanin

Breast lesions clinical/gross appearances

Periductal mastitis – painful subareolar mass (90% smokers), deep keratinisation of ducts

Mammary duct ectasia – poorly defined subareolar mass, skin retraction, thick white
secretion, dilated ducts, inspissated secretion, interstitial chronic inflammation.
Fat necrosis – painless palpable mass, thick retracted skin – prior trauma. Grossly
haemorrhagic with fat necrosis +/- areas of calc, giant cells, haemosiderin

Fibrocystic change – palpable lump, density, calc, discharge – cyst, fibrosis, adenosis

Proliferative breast disease – rarely forms masses, usually density. Epi hyperplasia (2 cell
layers), sclerosing adenosis (increased lobules/fibrosis), complex sclerosing lesion (radial
scar), papilloma, FA

ADH/ALH – Found in calc, biopsies, less often in lumps/mass

DCIS – Often founf incidentally/vague nodularity

Carcinoma – Firm hard irregular lesion, foci of calc

Medullary – soft, fleshy, well circ

Mucinous – v.soft, pale, grey-blue “gelatinous”

FA – Sharp circ, mobile, rubbery surface, bulge with slit-like gaps

POMPE’s

Glycogen storage disease type II – myocardial fibres full of glycogen – cardiomegaly. Defect
in synthesis & catabolism of glycogen, enzyme deficiency means glycogen is stored in few or
many sites. Glycogen is the storage of glucose. 3 types of GSD, hepatic forms – storage in
liver and reduced blood glucose (G6PD – von Gierke) type I. Myopathic forms – glycogen
stored in muscle – weakness, reduced muscle phosphorylase – McArdle, type V, muscle
cramps. Neither form – multi-organ, early death, type II- Pompes.

Other Storage Diseases;

Glucocerebrosidase – Gauchers

G-6-P – von Gierke

Hexosaminidase A – Tay Sachs (red spot retina)

Homogentisic – Alkaptonuria

Myophosphorylase – McArdles

Sphingomyelin – Niemann Pick

Erythema nodosum/panniculitis

Panniculitis –inflammation of subcut fat/ct

EN – commonest panniculitis, acute presentation often assoc with infection (βhaem
strep/tb/drug/sarcoid). Widened ct septa (oedema/fibrin/neut) – lymphocytes,
macrophages, giant cells, eosinophils forming tender plaques.

Lichen planus/simplex

Planus – pruritic purple polygonal papules. Self limited (over 1-2 yrs), oral may persist. Flat
topped + Wickham striae. Dense continuous band of lymphocytes and dermoepidermal
junction – degeneration of basal keratinocytes – destruction of contour/zigzag. Anucleate
necrotic cells in dermis – Civatte bodies.

Simplex – rubbing/scratching esp vulval – acanthotic, hyperkeratotic with lymph infiltrate,

not premalignant.

Post infectious GN

Post infectious/Acute proliferative – 1-4/52 post strep skin/pharynx. Child 6-10yrs. Granular
immune depostis in gloms, enlarged and hypercellular (lymp/neut) prolif of endo and
mesangial cells – cresents if severe. EM – amorphous depostis on epi side (humps).

Rapidly progressive (Cresentic) –

Type I – Idiopathic/Goodpastures – anti GBM – liner IgG

Type II – Idiopathic/postinfectious/SLE/HSP – immune complex – granular deposit

Type III – ANCE/Wegner/mPAN – pauci immune, systemic vasculitis

50% idiopathic. Enlarge K, pale, pets on cortical surface. Focal necrotic gloms with cresents.

Membranous – commonets nephrotic syndrome in adults, diffuse thickening of the GBM,

depostis on subepi side.

-Drugs (gold/NSAIDS)

-Malignancy

-SLE

-Infection (Hep B/C/syphilis)

85% idiopathic. Spikes on silver – granular !gG/C3

Minimal Change – Nephrotic syndrome in children, effaced foot processes on EM, but
normal by LM. Responds to steroids ? previous infection/immunisation.

FSGS – Nephrotic, assoc with HIV, heroin, obesity, post IgA, idiopathic. Poor response to
steroids. Lipid droplets, foamy macrophages often present.

Membranoproliferative –

Type I – Subendothelial depostis, gloms hypercellular, mesangial proliferation,

lobular gloms, double wall, C3 granular. May have cresents.

Type II – Dense deposit disease – lamina densa – ribbon, C3 in mesangium

?alternative complement. Secondary to SLE, hep B, HIV, α1AT, malignancy

IgA – Bergers, IgA deposits in mesangium – haematuria (recurrent), systemic = HSP. Variable
LM appearance, cresents/proliferative.

PM #NOF and pneumonia

ARVD

R sided failure, rhythm disturbance, tachy

Sudden death

Severely thinned r.vent – myocyte loss, fatty infiltrate, fibrosis, chrom 14 gene defect

Autumn 2006

EMQs

5 lists of ICC – various tumours, lung/pleura

Lung Adeno SCC Small Cell Meso

CEA 34βE12 CD56 Calret

TTF-1 CK5/6 Chromogranin WT1

LeuM1 EMA CK5/6

CK7 CK 7 -ve p16 Mesothelin

TTF-1 –ve

Cx Smear descriptions to fit diagnoses

Cx Biopsy descriptions to fit diagnoses

Congenital heart disease

1% live births,

Left to Right shunt (The D’s), increased pulmonary flow, causes r vent hypertrophy, medial
hypertrophy, shunt reverses, causing late cyanosis (Eisenmengers)

ASD – not the same as a patent foramen ovale (1/3rd of people), secundum 90% - deficient
oval fossa, primum 5% - adjacent to AV leaflets, sinus venosus 5% near SVC, +/- anomalous
connection of r pulmonary v

VSD – most common anomaly, 30% isolated. 90% in membranous septum, remainder below
pulmonary valve or in muscular septum – Swiss cheese

PDA – 90% isolated, harsh murmur

AVSD – incomplete closure of endocardial cushion – lack of AV septum, inadequate tricuspid

and mitral valves

Right to Left shunt (The T’s), cyanotic, commonest is TOF

Tetralogy of Fallot – VSD, subpulmonary stenosis, overriding aorta, right ventricular

hypertrophy. Boot shaped, if stenosis mild maybe a L-R shunt – no cyanosis. As resistance
increases shunt R-L, and therefore cyanosis.

Transposition of Great Arteries – requires shunt for survival – VSD=stable, PDA will close

Truncus Arteriosus – persistent truncus, non-separated aorta/pulmonary a – single large a.

with underlying VSD

Tricuspid Atresia – occluded valve, with hypoplastic r vent

Total anomalous pulmonary venous connection – no pulmonary veins draining into the l
atrium, drains into coronary sinus, PFO/ASD always present.
Obstructive Congenital Anomalies,

Coarctation of the aorta – males more than females unless Turners, with PDA is worse, early
presentation

Pulmonary stenosis & atresia – pulmonary valve stenosis – rv hypertrophy

Aortic stenosis % atreasia – aortic stenosis – hyperplastic/dysplastic/reduced no of cusps,

hyoplpastic l heart with endocardial fibroelastosis

Bacteriology

Neuroanatomy – fit symptoms to location

Metastases – sites

Breast – axilla, lung, liver, bone, brain

Colorectal – liver, lung, peritoneum

Lung – liver, brain, bone

Ovary – Peritoneum, diaphragm, liver, lung

Prostate – bone

Testicle – lungs, liver

Lymphoma

Gastric biopsy

Parietal cells – pink, acid secreting

Chief – blue, pepsinogen

Endocrine – triangular

Cardia – mucus cells only

Fundus – Parietal and chief

Body – Parietal, chief and endocrine, short, straight foveolae

Antrum – mucus, G-cells, branched, longer foveolae

Gastritis – acute (NSAID/alcohol/smoking/chemo/stress) – oedema, congestion, neutrophils

= active, erosions

- chronic (H.pylori/autoimmune( against parietal cells in body)/toxic) – leads to

cancer/MALT – lymphocytic with plasma cells in lp, neutrophils indicate active chronic –
metaplasia/atrophy/dysplasia

Cardiac causes of death

Bone Tumours

Endocrine – hormone markers

Ca125 – ovarian

Ca153 – breast, endom

AFP – liver, yolk sac, testicular

Ca19.9 – pancreas, colorectal

βHCG – testicular

VMA – phaeo

Prolactin – pituitary

PSA – Prostate

ACTH – pituitary, lung

LDH – test, liver

Neck swellings

Skin blistering diseases

Urology

MCQs

Female with PMP – ovarian masses, what is the origin

Mucocele – appendix dilated by mucin, obstructed causing an increase in mucin

Mucinous adenocarcinoma – invades the wall

Mucinous cystadenocarcinoma of ovary may disseminate and the peritoneal implants may
fill the abdo with mucin - pseudomyxoma

Why should you do CPD

Who should you inform if confidentiality is breached

Breast TNM

Lung TNM

Size, pleural onvolvment, chest wall, distance from hilus, atelectasis, obstructive
pneumonia, effusion. Nodes – ipsi, hilar, contralat, deposit in diff lobe

Subtypes of lung ca

ICC for a thyroid tumour

Spindle/polygonal cells on FNA suggest a medullary tumour, this would be positive with
calcitonin, chromogranin, CEA, CK7, CK19 with S100 in sustentacular cells

Male with a parietal tumour, VIn palsy – what is the cause

Long intracranial course, compression can be from brainstem glioma, increased cranial
pressure compressing it against the petrous bone, or a nasopharyngeal tumour
Old lady with #NOF, increased calcium – what is the cause

Alcoholic with ascites – fluid contains berry clusters and inflammatory cells, what is the
cause

Female could have breast cancer or adeno carcinoma, it could be mesothelial, or bacterial
peritonitis

Renal biopsy for EM, what fixative should you use

Gluteraldehyde

PM Fire Death Injuries

Injuries that can occur PM during a fire include – skin splitting, contractures of muscle,
subdural haemorrhage, soot in the mouth. Carbon monoxide level causing death is
approximately 40%

Granulosa cell tumour – what stain should you use

Unilateral, solid or cystic, yellow – cuboidal – polygonal cells in cords or sheets with gland-
like structures with acidophilic material “follicles” – Call Exner bodies = granulosa
component – inhibin +ve. Thecoma component – clusters/sheets of cuboidal cells.
Luteinised are plumper

Prognostic factors in breast cancer, which is most important

How would you take blocks from an EOS with a pigmented lesion

Invasive disease vs DCIS

Distant mets – cure unlikely, if absent axillary node status is the most important prognostic
factor. Tumour size second most then local invasion, and inflammatory cancer.

Minor – subtype, grade, hormone status, LV invasion

Swollen FT in pt with low BP, shoulder tip pain – what is it

Ectopic

Giant cell arteritis

Nodular thickenings – reduced lumen with thrombosis. Commonly granulomatous, inner ½

media centered in IEL, lymphocytes and giant cells

Lymphocyte rich HD

Types of necrosis

Coagulative – preservation of cell outline, firm texture (proteolysis blocked) i.e. MI –

anucleate cells

Liquefactive – fungal/bacterial – inflammation – digestion of cells – liquefied viscous mass &

in the CNS

Gangrene – limb – coagulative if infected, becomes liquefactive “wet” gangrene

Fat necrosis – activated lipases esp from pancreas, combines with calcium – chalky
saponification

Cx smear – which infection

An MLA in lab says relative has colectomy and wants result – what can you do

Elderly female, dead with pale area in heart – what is it

IVDU PM how do you clean instruments

?autoclave

MRSA PM what precautions to take

Standard

Frozen section – which infection is contraindicated

?CJD

How do you polarise

Analyser and polariser

Burkitts

Nsaopharyngeal ca – what is the infectious cause

Association with EBV in the undifferentiated and non-keratinising types

Child with nephrotic syndrome – what is the diagnosis

Female with painful breast lesion following RTA

Stain for Lewy bodies

α-synuclein
Spring 2006

EMQs

Cervical lesions

Cervicitis – menarche; increased glycogen, increased infection risk – strep/e.coli/staph, if

follicular GC Chlamydia is likely.

Nabothian cysts – entrapped glandular epithelium during metaplasia

Endocervical polyps – 2-5%, spotting, soft/mucoid

CIN

Invasive malignancy

Ectropion

Patterns of Injury

Prostate Reports

Gleason grade 1-5 well-poorly differentiated

1 – uniform glands, round, packed into nodules

5 – no glandular differentiation, tumour – stroma in cords/sheets/nests.

Dominant grade + secondary grades

Grades 2+4 = small transitional zone cancers, only seen on TURP. Needle cores grades 5-7
(8&10 – uncurable)
GI Polyps

Non-neoplastic – hyperplastic - <5mm, nipple like, smooth, moist protrusion on top of fold,
usually rectosigmoid. Well-formed glands/crypts, infolding – serrated appearance

Juvenile/Hamartomatous - <5yrs (adult = retention polyp), 80% rectal, 1-3cm,

rounded/lobulated +/- stalk, mostly l.p. enclosing cystic glands often inflamed. Juvenile
polyposis syndrome - >50 polyps

Peutz-Jeghers – also hamartomatous, involve l.p and m.m, rare AD condition – multiple
polyps and skin pigmentation, firm lobulated polyp – arborising connective tissue with
smooth muscle surrounding abundant glands. Increased risk of pancreatic, breast, lung,
ovarian, uterine cancers. STK11 mutation

Cowden – AD, multiple hamartomas of all 3 germ cell layers – intestinal polyp,
trichelemmoma, oral papilloma, with thyroid and breast can. PTEN mut.

Cronkhite-Canada – GI hamartomas & ectodermal – nail atrophy/skin

pigmentation/alopecia.

Adenomas – tubular or villous 50% pt over 60yrs.

Tubular = >75% tubular, pedunculated, small – rarely malignant

Villous = >50% villous, large sessile – cancer risk esp if >4cm with severe dysplasia

Tubulovillous = 25-50% villous

Familial polyposis – FAP; mutation of APC gene, classic have 500-2500 +/- stomach/s.int
100% cancer risk. Attenuated – 30 polyps – proximal colon 50% cancer risk

Gardner – polyps + multiple osteomas, epidural cysts, fibromatosis

Turcot – polyps + CNS tumours (medulloblastomas)

HNPCC – (Lynch), AD, increased cancer risk bowel/endom, microsatellite instability

Thyroid FNA’s

H&N Anatomy

TNM
Lung Anatomy

Trachea- L&R main bronchi into hila of lung – lobar bronchi – segmental bronchi – bronchi
branch – terminal bronchioles – respiratory bronchioles – alveolar ducts – sacs. Bronchioles
lack cartilage.

Bone Tumours

Brain macros (Dementia)

AD – cortical atrophy – widened sulci especially frontal/temporal and parietal, with

ventricular enlargement (hydrocephalus ex vacuo). Microscopically – neuritic plaques,
tangles and amyloid angiopathy. Ageing changes accelerated. Plaques – silver staining
collection of neuritis, central amyloid (Aβ from APP) core in the hippocampus, amygdala and
neocortex. Tangles – filaments in cytoplasm – flame shaped, silver and tau positive. Amyloid
in vessel walls.

Frontotemporal Dementia – FT & Parkinsonism – tau gene mutation, atrophy of frontal and
temporal lobes.

Pick – rare, early onset, frontal and temporal (language) signs. Pronounced asymmetrical
frontal/temporal atrophy – knife edge +/- caudate/putamen. Neuronal loss in outer 1/3rd of
cortical layers, swollen cells may contain Pick bodies – round filamentous, basophilic
inclusions, silver positive.

Parkinsons – Pallor of substantia nigra and locus ceruleus. Reduced pigment in

catecholaminergic neurons + Lewy bodies (alpha-synuclein) – eosinophillic cytoplasmic
inclusion, dense core with halo. Dementia occurs in 10-15%.

Huntingdons – AD, atrophy of caudate +/- putamen, with dilated lateral and 3rd ventricle
with frontal atrophy. Loss of striatel neurons progressing from medial to lateral.

Arteritides

PM Findings – Cause of Death

Skin IMF

Lymphoma immuno

MCQs

HNPCC

Alcoholic with ascites/effusion

>500ml becomes detectable, generally serous (<3gm/dl protein) scanty mesothelial cells
and lymphocytes. Neutrophils would suggest infection, rbc in malignancy. Spontaneous
bacterial peritonitis can occur.

Ascites collect due to

• Sinusoidal hypertension – fluid accumulates in the space of Disse which is then

removed by lymphatics, increased if albumin reduced

• Hepatic lymph will collect in the peritoneal cavity if flow is greater than the capacity
of the thoracic duct

• Intestinal fluid can leak if there is portal hypertension due to increased perfusion
pressure in the intestinal capillaries

• Secondary hyperaldosteronsim will cause sodium and water retention

CKs (basal)

Basal cell markers – p63, SMA, CD10, Calponin – myoepithelial cells in breast

HMWCK/34βE12 – prostate & p63

PCTs
Clinical Governance

Allergic polyps

Recurrent rhinitis – mucosal protrusions – polyps 3-4cm long, oedematous mucosa with a
loose stroma, cystic glands, inflammatory cells (n/e/p/l clusters). May ulcerate/infect.

Hirschsprungs

Aganglionosis of portion of GI tract. Arrest of neural crest cells before reaching anus.
Segment lacking Meisners and Auerbachs myenteric plexus. Intestinal dilatation proximal to
segment. ? RET gene mutation – 50% familial, 15% sporadic. Absence of ganglion cells and
ganglia in m wall and submucosa, always involves rectum upto the entire colon. Thickened
n. fibres are preganglionic fibres. 1/5000 births 4male:1female. 10% in Downs pt. Failure to
pass meconium. Acquired megacolon = Chagas, Trypanosomas invade & destroy the plexus.
Toxic megacolon - UC

Artefactual staining of RBCs

H&N dataset

Paraneoplastic syndromes

TB Cerebral

Headache, malaise, confusion. Moderate CSF pleocytosis, lymphocytes, neutrophils, protein

increased, but reduced glucose with a gelatinous, fibrinous exudates in subarachnoid space,
+/- white nodules with a usual meningoencephalitis. Microscopy may show well formed
granulomas, with mixed inflammation. Obliterative endarteritis with intimal thickening, AFB
on ZN stain. Can cause a tuberculoma, well circumscribed lesions with central caseation.
Arachnoid fibrosis can lead to hydropcephalus, endarteritis will lead to infarction.

LCH

Dendritic or macrophage proliferation. Tumour cells S-100 positive, and CD1a positive.
Abundant vacuolated cytoplasm, grooved/folded nuclei with surrounding eosinophils.
Birbeck granules on EM, 3 entities;
 • Multifocal multisystem LCH (Letterer-Siwe), <2yrs, often cutaneous lesions, front,
back scalp. Hepatosplenomegaly, lymphadenopathy, destructive osteolytic bone
lesions – anaemia, reduced platelets and infections.

• Unifocal/multifocal unisystem LCH (eosinophilic granuloma), expanding erosive

lesion usually in medullary cavity

• Unifocal unisystem LCH – young children, bony mass, Hand-Schuller-Christian

Adult smokers can get pulmonary LCH

Myeloma (renal)

Plasma cell neoplasm – skeletal involvement @ multiple sites with positive lymph nodes. IL-
6 is needed for plasma cell survival (increased serum level). Produce factors for bone
destruction (MIP1a, NF-kb – osteoclastic). Multiple plasmacytomas occur in the axial
skeleton (vert 66%, ribs 44%) – punched out defect on x-ray, containing gelatinous, soft, red
tumour mass. BM >30% cells plasma cells – normal plasmablasts, or bizarre multinucleated
cells, Mott/flame cells, Russell bodies, Dutcher bodies. Age is 50-60yrs with increased
calcium (confusion, weakness, lethargy) with increased infections, B-J proteinuria, light
chain Ig in blood.

Myeloma K – BJ proteinuria and cast nephropathy. Light chains are toxic to podocytes and
casts form (pink/blue tubular casts with giant cells and inflammation). Amyloid formation
occurs in the gloms. Light chains can also cause a glomerulonephropathy.

Urine Specimens

WPW

Sudden death

Kawasakis

Chorioamnionitis

Infection of fetal membranes, ascending (PROM) or haematogenous (transplacental),

usually bacterial
TORCH – toxo/syphilis/rubella/CMV/herpes, tb, listeria, grp B strep if acute

AFE

Paracetamol OD (liver)

Zone 3 necrosis

Molluscum

Erythema Nodosum

Ovarian tumour immuno

Pap / cervical smear

Myeloma

Query re result

Hep B renal disease

Membranoproliferative type I

Membranous

Post infectious glomerulonephritis

Rapidly progressive cresentic GN

Thiamine deficiency

Thiamine regulates synthesis of ATP and maintains neural membranes. Rice diets may lack
thiamine, and 1/4th of alcoholics admitted to hospital. 3 syndromes;
 • Dry beriberi – polyneuropathy, myelin degeneration – legs then arms sensory then
motor

• Wet beriberi – CVS, peripheral v/d, av shunting, flabby myocardium – thrombi

• Wernicke-Korsakoff –

• Wernicke – nystagmus, ataxia, confusion

• Korsakoff – amnesia, confabulation

• Both can have mamillary body haemorrhage

Actinomycoses (Grocott/Control)

Gram positive bacteria, granulomatous infection in human, ZN positive, and Grocott positive

Muscle biopsy

Pagets – bone, what Ix need doing

Collage of matrix madness – osteoclastic bone resorption (lytic stage) followed by a mixed
stage, then a burnt out osteoclerotic stage with an increasing bone mass. ?paramyxoviral
aetiology. Mosaic pattern of bone, prominent cement lines, pain due to micro fractures and
bone overgrowth. Serum alk phos increase with urinary hydroxyproline. Osteosarcoma is a
risk.

Nipple discharge

Pleomorphic Adenoma

60% of parotid tumours, mixed ductal/epithelial cells. Radiation increase the risk of
development. Usually rounded, well circumscribed, <6cm. Histologically heterogeneous,
with ductal cells, myoepithelial cells forming ducts/acini in a mesenchymal background with
chondroid or bone formation. Painless and slow groaing, malignant change can occur (CEPA)

Lymphoma

Cystic fibrosis
1/3200 AR, chloride channel on the plasma membrane encoded by CFTR gene. Multiple
genetic abnormalities, commonest is ∆F508 (3 base deletion). Sweat has an increased Na
while mucus has less Na, therefore less water and is thicker. Pancreatic involvement occurs
in 85-90%, with mucus plugs and gland fibrosis. Liver can have plugged bile canaliculi
causing steatosis and biliary cirrhosis. The lungs develop distended bronchioles with
infection and abscess formation (infection from s.aureus, H.inf, P.aeuriginosa)

Sampling of thyroid tumours

Cold leg

Hyperparathyroidism

Thyroid

Hypothyroidism –

Primary – developmental/surgical/iodine deficiency/lithium/ & autoimmune – Hashimoto –

chronic lymphocytic inflammation with diffuse enlargement, germinal centres, Hurthle cell
lining of atrophic glands (FNA – Hurthle and lymphocytes = Hashi)

Secondary – Pituitary failure

Tertiary – Hypothalamic failure

Subacute granulomatous / De Quervains – post viral causing autoimmune destruction, firm

enlarged gland with disrupted follicles +/- neutrophils, there are lymphocytes, macrophages
and plasma cells around follicles with giant cells. Patient usually hyper, then hypo then
euthyroid.

Graves – Hyperthyroid, also autoimmune, due to ab against TSH receptor. Symmetric

enlargement, smooth. Too many cells, tall, crowded follicular cells, papillae lack cores with
pale scalloped colloid.

Carcinoid

Indolent tumour from resident endocrine cells, GI/lung predominantly 6th decade. Well diff
neuroendocrine tumour, a small cell tumour is a poorly diff ne tumour. Appendix most
common site (-s.int, rectum, stomach, colon). Solid, yellow-tan tumour. Islands of cells –
trabeculae, monotonous cells, scant cyt, round-oval nuclei. Can produce hormones (gastrin
– ZE). 1% (20% with mets) – carcinoid syndrome, serotonin release.

Mesothelioma cytology

Grading breast ca

Pagets disease – nipple

AE1/AE3 Cam5.2 EMA S100/HMB45 Her2

Pagets + + + - +

SCC + - + - -

Melanoma - - - + -

Toker cells Her2 -

Synovial sarcoma

10% of soft tissue tumours, 20-40yr old, deep soft tissue, lower extremities. Biphasic,
epithelial cells (cuboidal – columnar), cords/aggregates. Spindle cellular fascicles, calcific
concretions. T(x:18) – syt – ssx1/2 fusion.

Prostate mets

Osteoblastic, sclerotic bone mets

NEC
Autumn 2005

EMQs

Head Injuries

Bronchial Washings

Cystic Kidneys in the Fetus

Cystic renal dysplasia – persistence of cart/mesenchymal/abnormal lobar organisation.

Enlarged, irregular, cystic kidneys

Childhood polycystic kidneys – AR, perinatal, neonatal and juvenile types. Fibrocystin gene
PKHD 1. Large smooth kidneys with small cortical, medullary cysts (sponge-like). Saccular
dilatation of collecting tubules. Hepatic fibrosis can also occur.

Definition of Clinical Governance, Audit

Viruses – clinical scenarios (inc tropical)

Measles – single stranded RNA, red-brown rash – face/trunk due to dilated vessels,
ulcerated mucosal lesions. Follicular hyperplasia + Warthin-Finkeldy cells.

Mumps – URT entry to LN causing salivary gland desquamation/inflammation with asceptic

meningitis. Parotitis is doughy, orchitis may cause sterility

Polio – Faeco-oral transmission, 1/100 – CNS invasion

West Nile – Arthropod transmission (mosquito – bird – mammal). 20% mild febrile illness.
10% mortality – meningoencephalitis, esp in immunosupressed

Viral haemorrhagic fever – systemic, animal/insect vector. Infectious dose low. Causes
haemodynamic deterioration & shock ? by endothelial infection causing DIC

Herpes – chronic, latent infections

• HSV 1/2 – skin/mucus membranes, all HSV – pink, purple inclusions (Cowdry type A).
causing cold sores, genital, corneal keratotis, encephalitis

• HHV8/KSHV – Kaposi sarcoma

• CMV – also a herpes virus, congenital common, school children. Distinct nuclear
inclusions in an enlarged cell. Congenital – mental retardation, hearing loss,
pneumonitis. Perinatal infection can cause failure to thrive. Mononucleosis – fever,
lymphocytosis +/- mild hepatitis

• Varicella – chickenpox/shingles. 2/52 post resp infection – macule – vesicles, rupture

and crust

Bone Tumours

Bladder Biopsies

Cystitis – E.Coli, Proteus, Klebsiella (-pyelonephritis)). TB usually descends from K.

Haemorrhagic cystitis can occur following BCG or radiotherapy.

Chronic cystitis – heaping of epithelium, red/friable/granular/ulcerated surface

Interstitial cystitis – Hunner ulcer, persistent painful involvement of all the wall layers with
granulation tissue formation, prominent mast cells

Malacoplakia – vesical inflammation, yellow mucosal plaques. Foamy macrophages, giant

cells, lymphocytes. Foam cells contain PAS+ cellular/bacterial debris. Laminated concretions
– Michaelis-guttmann bodies
Cystitis Glandularis – Brunns nests transformed to a cuboidal epithelium

Cystitis cystica – Brunns nests transformed to urothelium

Neoplasia - Papilloma – rare, benign papilloma, young pt, normal urothelium

PUNLMP- thicker urothelium, mild atypia

Carcinoma, graded 1-3, higher grade more likely to invade

CIS – flat urothelium containing malignant cells, lacks cohesiveness

SCC – can occur rarely

Colorectal anatomy

Endocrine abnormalities

Head and Neck Tumours

Dementia – clinical scenarios

Lymph nodes with immuno panels

FNA Cytology + additional stains

Dermatology – clinical skin appearances

Ovarian tumours

MCQs
CF – mucin characteristics

Acid = AB +ve

Birefringent material

-ve = monosodium glutamate (Gout)

+ve = calcium pyrophosphate (Pseudogout)

PM cases – drugs, drowning, old lady with hip #

Bone mineralisation

Autopsy safety – CJD

Infection of lab staff by specimens

Bladder tumour TNM

Colorectal cancer TNM

TNM p prefix

GIST immuno

CD117(KIT) +ve, CD34 +ve, vimentin +ve, S100 focal, Desmin –ve, AE1AE3 -ve

Lung cancer immuno

Retroperitoneal tumours – cut up

Soft tissue tumours – margins if macro <2cm (ink), sample macroscopically different areas.
Submit non-necrotic areas for EM. % necrosis can be important
Papillary thyroid tumour – cut up

Whole tumour <2cm, larger – tumour edge, margin with normal thyroid, background from
normal x2 for each lobe.

Melanoma – prognostic factor

Breslow – most important prognostically;

<1mm – T1

1mm-2mm – T2

2mm-4mm – T3

>4mm – T4

Ulceration is the second most important factor

Clark level;

I – Intraepidermal

II – Within papillary dermis

III – Expands papillary dermis (superficial vascular plexus)

IV – Within reticular dermis

V - Fat

Neurotropic/desmoplastic have a better prognosis

Regression has a worse prognosis

Vascular invasion has a poor prognosis

Breast palpation – what could the mass be

Radial scar

Breast cut-up – what tumour is it from macro description

Multiple myeloma
Cervical dysplasia + HPV

Lung cancer and Cushings

Bladder biopsy and histological appearances

Parathyroid gland frozen section

Usually 4, can be anywhere in pharyngeal pouch development. Predominantly Chief cells,

light-dark pink, polygonal, secretory granules contain PTH. Oxyphil, larger, bluer cells in
clusters, packed with mitochondria. Water clear cells contain glycogen lakes.

Prioritising cases

Use of Hydrogen peroxide in immuno

Blocks endogenous peroxidase activity

Gene testing in breast cancer – Her-2

Bodies in the bladder – Michaelis-Guttman, Psammoma, Corpora amylacea

Michaelis-Guttman – malacoplakia, laminated concretions containing calcium in lysosomes

Psammoma – TCC

Corpora amylacea – normal prostate

Burkitt in child

PM heart microscopy

Parathyroid gland anatomy

Normal skin melanocyte histology

LCH

Lung cancer prognostic factors

Size, NSC vs SC, invasion, LN, complete excision

Spring 2005
EMQs

Macroscopic brain appearances

Paediatrric microbiology

Transcervical – chorioamnionitis, HSV

Transplacental – haematogenous spread; parvovirus B19 (intranuclear inclusions in RBC

precursors), can cause spontaneous abortion, still borth, hydrops. TORCH

Early onset sepsis = Group B strep - meningitis

Listeria/Candida – latent period

Pharynx/larynx anatomy

Pharynx connects nasal/oral cavities to oesophagus

Nasopharynx – sphenoid to soft palate (post nasal space)

Oropharynx – epiglottis and posterior 1/3rd tongue

Larnygopharynx – to lower cricoid

Larynx regions – supraglottic (epiglottis/arytenoids)

- glottic (true cords and both commisures)

- subglottic (1cm below true cords)

Tongue = genioglossus

PM Scenarios – ancillary tests

Blood – biochem and toxicology

Urine – morphine and alcohol

Hair – cocaine and cannabis

Bile – morphine accumulates in bile (broken down from heroin) other tox

Vitreous – biochem, potassium, U+E more stable, alcoholic ketoacidosis, glycaemia

Stomach contents – drugs, alcohol

Dental – identification, along with fingerprints, tattoos, clothes, jewellery

Imaging – CT/MRI. MRI is poor at cardiac anomalies, IHD, CAA, thrombus vs clot

Inflammatory/Bullous skin disorders

Bone pathology

Lymphoma immuno panels

Sudden cardiac death

CAA, myocardial bridging (85% finding, probably incidental, 10mm long, >3mm deep), LVH –
idiopathic (no disarray), myocarditis, long QT (genetic – deafness, mental retardation)
1/5000 carriers, 10% mortality, Brugarda (AD, males, death in sleep at 20-30 yrs), short QT

Cardiomyopathy;

HOCM - >10% fibre disarry, fibrosis, thick septum

LV non-compaction – abnormal trabeculation (fetal persistence)

Arrhythmogenic – RV abnormal shape, adipose, fibrosis

Dilated – common clinical entity, 30% familial, alcoholics, non-specific histology

Restrictive – reduced compliance; amyloid, radiation fibrosis, sarcoid, tumour – heart

normal appearance. Atria can be dilated, patchy fibrosis.

Pathogens and pathology (Whipples, HPV, Herpes zoster)

Cervical cytology

Identify the gene concerned (Burkitt, HNPCC)

Burkitt t(8:14) MYC fusion

Colon HNPCC – MLH1/MSH2 95% of HNPCC is sporadic

FAP – APC gene mutation (80% sporadic)

 LKB1/STK11 – PJ

Ewings/PNET – t(11:22) EWS-FLI1 fusion (80%)

GIST – KIT mutation/PDGFRA mutation >90%

Phaeochromocytoma – sporadic >90% losses on 1p

-familial >90% MEN2A/MEN2B

RCC, clear cell – deletion of 3p

Rb – 13q14 deletion (Rb1)

Synovial sarcoma – t(x:18) syt-SSX fusion >90%

Thyroid, medullary – RET activating mutations >90%

Wilms, WT1 inactivation (11p13 del, trisomy 12), WT2 – Beckwith-Weidman

CML – t(9:22), BCR-ABL fusion – Philadelphia

Mantle – t(11:14) CCND1-IgH fusion – cyclin D1 increase

Follicular – t(14:18) IgH-BCL2

Paediatrics (Wilms, rhabdo, hirschprungs)

Wilms – commonest renal tumour of childhood, 10% bilat. 3 syndromes;

- WAGR – aniridia, genital anomalies, retardation, 33% - Wilms, del 11p13 (WT1)

- Denys-Drash 90% have a Wilms

- Beckwith-Wiedemann – WT2

Large solitary mass, soft, homogenous, occ cysts and necrosis. Triphasic – blastemal (small
blue cells), stroma (fibrotic/myxoid), epithelium (tubules/glom). Good prognosis

Rhabdomyosarcoma – commonest soft tissue tumour of child and adolescence <20yr olds.
Head and neck and genitourinary. Often t(1:13) Pax3:FKHR fusion. All contain
rhabdomyoblasts, are myoD1 and myogenin +ve. 3 types;

- Embryonal – commenest, includes sarcoma botryoides. Soft grey mass, spindle

cells, myxoid stroma, cambium layer.

- Alveolar – Deep muscle, extremities, at least one alveolus.

- Pleomorphic
Hirschprungs – Congenital megacolon, arrest of neural crest cells, aganglionic segment +
hypertrophic nerve bundles.

Predisposition to adult tumours (coeliac – Tcell lymphoma, SCC, gastrinomas)

Angiomyolipoma of kidney in Tuberous sclerosis, also rhabdomyomas

BCC in nevoid BCC syndrome and medulloblastomas

Breast cancer with BRCA1/2 mutations (2 in males)

GI neuroendocrine tumours in MEN1

Juvenile polyps in JPS

Medullary thyroid in MEN2a/b

T cell lymphoma in celiac disease

Gastric maltoma in H pylori

Cervical in HPV infection

KS in HHV8 infection

Thyroid nodules

Lung pathology (asthma, sarcoid, COAD, PCP)

MCQs

MI micro

0 - 30 mins, mitochondrial swelling

30mins – 4 hours, waviness of fibres

4 – 12 hours, mottled, coagulative necrosis, oedema, haemorrhage

12 – 24 hours, pyknosis of nuclei, hypereosinophilia, contraction band necrosis, neutrophil

infiltrate

1 – 3 days, loss of nuclei, increased neutrophils

3 – 7 days, hyperaemic border, disintegration of dead cells, macrophages at border

7 – 10 days, fibrovascular granulation

CSF Cells

Normal Viral Pyogenic TB

Appearance Clear Clear/turbid Turbid/purulent Turbid/viscous

Lymphocytes <5mm3 10-100 mm3 <50 mm3 100-300 mm3

Neutrophils 0 0 200-300 mm3 0-200 mm3

Protein 0.2-0.8g/l 0.4-0.8 g/l 0.5-2 g/l 0.5-3 g/l

Glucose 2/3-1/2 >1/2 <1/2 <1/3

(cf blood)

Renal TNM

SNOMED coding

CPD registration

Clinical Governance

Consent and Coroners PM

Language and consent

Glomus tumour

Perivascular glomus body, blue-red nodule. Capillary sized venules surrounded by glomus
cells, can appear oncocytic. Painful – av shunt. SMA, Collagen IV, vimentin +ve, differential
with a Merkel cell – which would be CK20+ve.

Alcohol and aspiration pneumonia

Anaerobic flora; bacteroides, fusobacterium, strep pneumoniae, staph aureus, h. inf, p.
aeuriginosa

IVDU and alcoholic liver disease

IVDU and HepC cirrhosis

Her2/cerb2

HNPCC discordant genes

Liver pathology

Chronic hepatitis-

- HBV – ground glass (orcein +ve)

- HCV – lymphoid aggregates, macrovesicular steatosis

- AIH – plasma cells

Portal tract inflammation, lymphocytes and macrophages, rarely neutrophils and

eosinophils. Bridging necrosis – fibrosis

Alcoholic-

Steatosis, swelling/necrosis, Mallory bodies, neutropihls and fibrosis

Haemochromatosis-

Golden yellow haemosiderin granules in periportal hepatocytes – Perls +ve – inflammation

absent but still toxic to hepatocytes

Wilson –

Fatty change, acute hepatitis – chronic – cirrhosis, visualise Cu deposition with orcein (Cu
associated protein)

α1-AT –

D-Pas resistant globules in cyt

PBC –
Small duct fibrosis/cirrhosis, tracts – lymphocytes, macrophages, plasma cells, granulomas –
cirrhosis

PSC –

Lymphocytes, atrophy of bile ducts, periductal fibrosis

Aetiology – anencephaly, spina bifida

Neural tube defects;

Anencephaly – malformation of anterior end of neural tube – absent brain/calvarium

Spina bifida – occulta, meningeal outpouch = meningomyelocele, can become secondarily

infected. Pt may have bladder, bowel, motor and sensory deficit. aFP elevated, due to folate
deficiency

Renal TNM

Paediatric renal tumour

Metastasising leg lesion – 24 yr old woman

Builder with tumour, most likely cause

Definition of emphysema

Leiomyomas

Clonal process with multiple genetic mechanisms. Sharply circumscribed, grey/whorled cut
surface. Large ones may have red degeneration. Mitoses scarce, whorled smooth muscle
cells, oval nuclei, bipolar processes

Adrenal Tumour
Cortical – Adenoma, majority incidental, well circumscribed, if functioning adjacent gland
atrophic, yellow surface. Carcinoma is rare, LiFraumeni & Beckwith-Wiedemann syndrome,
>20cm, metastasise and invade

Medulla, phaeochromocytoma, vary in size, vascular tumour, haemorrhagic and necrotic.

Polygonal to spindle cells in zellballen, nuclei salt and pepper. No grading system.
Sustentacular cells S100+ve

MEN Syndrome

GIST

Renal dialysis, risk of PM

Granulomas in bone marrow

TB, fungal, sarcoid, lymphoma, HIV (poorly organised), Histoplasmosis, tumour, foreign
body, rheumatoid, CMV

Young woman, post cervical LN

CIN 1 – risk of getting SCC

Mesothelioma immuno

Male lung tumour, chest wall pain

SIDS

Dysplastic naevus

Melanoma precursor, flat macule, pebbly, dark centre. Irregular border, non-sun exposed.
Common in heritable syndrome. Compound naevus with abnormal growth, fusion of nests,
lentiginous hyperplasia, cytological atypia, pigment incontinence, fibrosis around ridges
(lamellar). Shouldering.

Gene losses in colorectal cancer

Renal tumour prognosis

CD30 and embryonal tumours

Ovarian tumour immuno

Cavernous haemangioma in a baby

Breast lesion – radial lesion

Breast carcinoma

FNA pleomorphic adenoma

Smear storage times

Slide labelling

Signs of ICP

Urate crystals

Cystitis microscopy
Back to top

Lymphomas – a quick guide

Non-Hodgkins

Aggressive

Diffuse Large B-cell lymphoma

Often a transformation from a less aggressive lymphoma, causing diffuse nodal replacement
with large cells.

CD45 CD19 CD20 +ve (i.e. b-cells)

Ig +ve and CD99a

2 types, germinal centre (CD10 and bcl-6 +ve) and post germinal centre (Mum-1 +ve)

There is an intravascular type – aggressive and a primary effusion type which is often in HIV
+ve patients

Burkitts

Highly aggressive, extranodal or leukaemic, monomorphic medium sized B-cells, basophilic

cytoplasm, numerous mitoses and apoptotic bodies. Myc translocation (chrom 8)
8q24:14q32. EBV – endemic type, some sporadic cases and some occur in immunodeficient.
At risk from tumour lysis syndrome
Pan B markers, IgM, CD10, bcl-6 +ve, but negative for CD5, CD23, Tdt, bcl-2.

Ki67 – 100%

Precursor T and B

B tends to be leukaemic, T tends to be lymphoma. Primitive cells, high N:C ratio, fine
chromatin. Effaced node.

B – CD19, PAX-5, Tdt +ve, ki67 high, t 9:22

T – CD2, CD3, CD4, CD 5, CD 8, Tdt +ve

Non-Aggressive

Follicular

Nodular in appearance (recapitulating GC). Graded by the number of centroblasts, more =

worse, the other cell type present is the centrocyte.

CD20, CD79a, i.e. B-cell. For the non-aggressive B cell lymphomas, marker CD23, CD10, CD5
are the useful 3. CD10 and CD23 are positive in follicular along with bcl-2 and sometimes 6.
CD5 is negative as is CD43. Low ki-67. t(14:18)

Marginal Zone

Primary nodal disease is rare, often extranodal (H.pylori related)/MALT. May transform.
Vague nodularity (expansion of mantle zone) population of small heterogenous
lymphocytes.

CD20, CD79a, bcl-2 +ve, CD43+/-. And negative for the big 3 – CD5, CD10, CD23. Also bcl-6 –
ve.

Mantle Cell

Nodular or diffuse architecture, centrocyte-like cells. Prognosis is related to ki-67

CD20, CD79a, CD5, CD43, cyclin D1 +ve

CD23, CD10, Tdt –ve

T(11:14) – IgH:cyclin D1
Is really an aggressive lymphoma, but is non-blastic.

CLL/SLL

Monomorphic small round cells, proliferation centres of larger paler cells –

paraimmunoblasts

CD20, CD79a, CD5, CD23, CD43, IgM, CD38 +ve

CD10 –ve. Zap70 indicates mutated state

Lymphoplasmacytic

Rare, IgM paraprotein, (Waldenstroms) indolent but incurable. Lymphocyte-like and

plasmacytoid cels.

CD45, CD79a, CD38, IgM, bcl-2 +ve

CD5, CD10, CD23, bcl-6 -ve CD43 var

Hairy Cell

Elderly males with splenomegaly. Pale cytoplasm, nuclei stand apart (fried egg)

CD20, CD79a, CD11c, CD103, cyclin D1 (50-70%), TRAP +ve

CD5, CD10, CD23, CD43 –ve

Hodgkins Lymphoma

90% in isolated node groups.

Classical

• Nodular sclerosis – birefringent collagen bands

• Mixed cellularity

• Lymphocyte Depletion

• Lymphocyte Rich

Hodgkins cells/R-S cells, CD45-ve, CD15/30+ve

Nodular lymphocyte predominant – large nodulas, monotonous background of
lymphocytes, popcorn/L&H cells – CD45+ve, bob1/oct2 +ve.

Back to Top

TNM (5 or 6)

A quick guide to the common tumours

Salivary

T1 - <2cm, T2 – 2-4cm, T3 - >4cm or extraparenchymal extension, T4a – skin/mandible/facial

nerve, T4b – skull/carotid

N1 – single node <3cm, N2 – single node 3-6cm, N3 - >6cm

Thyroid (5th TNM)

T1 - <1cm, T2 – 2-4cm, T3 - >4cm, T4 – extrathyroid extension or anaplastic

Age <45 papillary/follicular – any T – stage I, M1 – stage II

Oesophageal

T1 – lamina propria, T2 – muscularis propria, T3 – adventitia, T4 – adjacent structures

Stomach

T1 – lamina propria, T2a, muscularis propria, T2b – subserosa, T3 – serosa, T4 – adjacent

structures

N1 – 1-6, N2 – 7-15, N3 - >15

Colon/Rectum
T1 – submucosa, T2 – muscularis propria, T3 – subserosa, T4 – serosa/organs

N1 – 1-3, N2 - >4

Lung

T1 - <3cm, T2 - >3cm/main bronchus/visceral pleura/obstructive pneumonia – hilum

T3 – chest wall/diaphragm/mediastinal pleura/<2cm from carina/lung pneumonia

T4 – Mediastinum/heart/vessels/oesophagus/trachea/multiple tumours in same

lobe/malignant effusion

N1 – ipsilat nodes, N2 – ipsilateral mediastinal nodes, N3 – contralateral nodes

Skin

T1 - <1mm, T2 – 1-2mm, T3 – 2-4mm, T4 - >4mm (a- no ulcer, b-ulcer)

Clark levels – I-epidermis, II – into papillary, III – fills papillary, IV – into reticular, V –fat

Breast

T1 - <2cm (Tmic - <0.1cm, a – 0.1-.5cm, b – 0.5-1cm, c – 1-2cm), T2 – 2-5cm, T3 - >5cm, T4 –

chest wall/skin/oedema/inflammatory)

N1 – 1-3, N2 – 4-9, N3 - >10

Cervix

T1 – confined to uterus

1a – microscopic

1a1 - <3mm vert, <7mm horiz

1a2 - >3mm <5mm vert, <7mm horiz

1b – macroscopic or >5mm vert, <7mm horiz

1b1 - <4cm

1b2 - >4cm

T2 – beyond uterus not to pelvic wall or lower 1/3 vagina without parametrial involvement

a – without parametrial involvement

 b – with parametrial involvement

T3 - Pelvic wall, lower 1/3 vagina

a – without hydronephrosis

b – with hydronephrosis

T4 – mucosa of bladder/rectum

Endometrium

T1 – confined to uterus

T1a – limited to endometrium

T1b - <1/2 myometrial thickness

Tlc - >1/2 myometrial thickness

T2 – cervix

T2a – endocervix

T2b – stromal invasion

T3a – serosa/adnexae/ascites

T3b – vagina

T3c/N1 – pelvic/paraaortic lymph nodes

T4 – bladder/rectal mucosa

Prostate

T1 – Clinically in apparent

1a - <5% TURP

1b - >5% TURP

1c – core +ve

T2 – Prostate confined

2a - <1/2 one lobe

2b - >1/2 one lobe

2c – both lobes
T3 – Capsular spread

3a – extracapsular

3b – seminal vesicle

T4 - bladder/sphincter/rectum/pelvic wall

Kidney

T1a - <4cm, T1b – 4-7cm, T2 - >7cm, T3a – adrenal/perinephric, T3b – vena cava below
diaphragm, T3c – vena cava above diaphragm T4 – Gerotas fascia

N1 – 1 node, N2 - >1 node

Bladder

T1 – subepithelail connective tissue, T2 – muscle a – inner ½, b – outer 1/2 , T3 – perivesical

tissue (a – micro, b – macro), T4a – ut/pros/vag, T4b – pelvic/abdo wall

Thanks to all those who have taken the part one and written down all the questions for
those of us who were yet to take the exam.

Back to Top
Oxford Questions Download the original attachment

The following are the questions from the Oxford Trainees from the Part One, some overlap
will occur with our own recollection. I do not know the names of the people that submitted
all the questions.

Sudden cardiac death. Young woman with normal hearing. No gross/microscopic cardiac
pathology during autopsy. Several family members also have sudden cardiac death.

Choices: Catecholamine mediated something , Long QT syndrome, atherosclerosis, HCM etc.

Answer I think is long qt.

Explanation:
long qt. two types –Romano Ward(autosm dominant, no deafness) the other I think
is something something Nielsen- with deafness, autosomal recessive

Description of some sort of intraendometrial polypoid growth, postmenopausal woman.

Prominent stroma, with glands showing ?various metaplasias?, with stromal
condensation.Then asks what is the likely eitiologic agent

I chose tamoxifen

Most common location for ectopic parathyroids. Dunno this one I

put thymus.

Crusty, brown, itchy skin lesions in a teenage boy. Nail abnormalities(vertical

alternating red, white stripes, V-shaped nick in the free edge) . Answer-
Dariers /Keratosis Follicularis

Description of renal biopsy. Thickened BM with breaks, spikes, holes. Complement

and IgG deposition. I think ans is Membranous GN

An NHS specific question(groan)A pathologist discovers that the

departmental breast tumour reporting is not conforming with the generally accepted
guidelines. He attempts to rectify this in a departmental meeting. Who is the person
ULTIMATELY responsible for the quality of the reporting . Choices are nhs chairman,
director of histopathology for that NHS trust, Clinical director for Pathology etc hated this
question.
Most important prognostic factor for Gastric Ca. Choices include depth of invasion, subtype
of gastric ca, presence of IM.

Most important prognostic factor for a buccal poorly diff SCC perineural invasion with 3
positive level 2 cervical lymph nodes (supraomohyoid neck disscn)
with extranodal extension. I chose EN extension. Other choices are lymph
node mets, perineural invasion, poorly differentiated subtype)

HPV –which of the following is low-risk subtype (found in a cervical

acetowhite area, microscopically only koilocytosis). What can I say, just have
to memorise the low and high risk subtypes.

Gene involved in clear cell RCC.

Gene involved in non polyposis coli.

Jejunal biopsy with villous atrophy, intraepithelial lymphocytosis,

increased lamina propria chronic inflamm cells. question is which serological marker is most
useful. FYI, there are two.

Lip lesion with bilayered bland epithelium, reddish chondromyxoid stroma ,

cystic spaces, channels etc I THINK ans is canalicular adenoma

Upper size limit for pN1mi (micromets) in breast carcinoma. Answer is 2mm

25 yr old man with AIDS, 5 months diarrhea. Small bowel bx, 2 micron , round specks
coating the villous surface. What is this? Ans=cryptosporidium.
A sidenote, microsporidium is intracellular.

You want to demonstrate BOTH gram negs and gram positives using one stain.
Which of the following do you use. Ans: Brown-Hopps by process of elimination, since the
other choices were so ridiculous eg PAS, Warthin Starry, ZN, Gomori meth silver
(sidenote, after googling, I found that this stain stains
gram negs red and gram pos blue)

Examination of the ovarian hilus shows aggregates of glandlike structures lined by

bland nonciliated epithelium. What is this? Ans=rete ovarii.

Patient is s/p Hartmanns for perforated sigmoid diverticulum. Has bleeding and mucus from
rectal stump. Histo, fissuring, crypt abscesses, diffuse inflammation, crypt architecture
distortion. What is the cause of this ? Answer= lack of short chain fatty acids

Sudden death patient. Young woman. facial rash, joint pain, haematuria and some
other stuff. Skin biopsy done. Sudden death in hospital. Asked me what
is likely to be seen in the arterioles of the skin bx. My answer is fibrinoid necrosis, since I
think that the sudden death in hospital is due to malignant
hypertensive episode., secondary to lupus. Point: must know features of lupus skin, lupus
nephritis, and histologic difference between benign and malignant hypertension. Robbins
Review covers this in a few of their mcq I think.

Description of a ?decoy cell and EM showing some lattice array something or other.
Straightforward. Next

Elderly woman with A.Fib, Coronary artery dis, abdo pain, died. Autopsy-infarcted, dusky
small intestine, bloody ascetic fluid. What has happened-Inf mesenteric artery embolus DD
between oncocytoma and renal cell carcinoma which test I narrowed this down to using
EMA immuno and EM to detect mitochondria. I chose the EM for mitochondria.

Which mineral exposure causes granuloma-like lesion in lungs. I think ans s beryllosis.

Sudden death. Haemorrhage covering surface of medial temp lobe and frontal lobe. What is
likely to be seen on autopsy. I put berry aneurysm of anterior communicating artery.

Forensics laceration vs incised wound

Man with hypernatremia,

excess K+ excretion, what syndrome does he have- Conns
Man with 6cm adrenal tumour, no metastases. Histologically, occasional atypia,
necrosis with neutrophil infiltration, Which of the following is most predictive of
malignancy. Necrosis, size. Some other stuff. I put down necrosis.

Fat woman. 1.2cm endometrial stripe- bx shows well diff endometroid

adenoca. Which of the following hormones is most important in the
pathogenesis. Oestradiol or oestrone.????????

Description of a gastric erythematous patch vascular ectasia, minimal inflammatory cells,

upward growth ofmusc mucosae, foveolar hyperplasia What is the most
likely aetiology sounds like chemical gastritis/reactivegastropathy had to choose between
bile and pancreatic enzymes..???????

Baby with jaundice. Has bile ductile proliferation, feathery degen

of hepatocytes, large cell change, periportal oedema. What is this. Answer I think
is extrahepatic biliary obstruction.

Various lymphomas with their cytogenetic translocations and immuno stains. Two sets
of emqs for this!!

EMQ: Chest wall tumours- descriptions were purely immuno. Combination of

CAM, ema, vimentin, cd99, cd31, cd34 ttf1, calret, ck5and some weird thing called D34.
choices mesothelioma, scc lung, synovial sarc,malignant sft,, epithelioid angiosarc

Fast growing forehead mass, histology shows high nc ratio, nuclear molding,
finely granular chromatin, ttf1 neg, cd45 neg, ck20 pos, perinuclear dotlike CAM5.2 answer
is Merkel cell ca.

Positive p anca, hemoptysis some other things what is this. Ans churg strauss

Sudden death in a mentally retarded young boy. Faecal soiling of genitals, small
bruises on shins , torn oral frenulum, some other stuff. which of these is most likely due to
Non accidental injury . I chose torn oral frenulum
Testicular tumour. Description of fibrovascular cores with central vessel, papillae around it,
has varied solid, cystic pattern, areas resembling foetal liver, grossly yellowish , mostly solid
with some cystic areas too. Immuno cd30, cd117 plap neg, bhcg neg, afp pos.

Question about borderline serous tumour of ovary. Which is most important

prognostic factor: amount of psamomma bodies, degree of
papillary architecture, invasive peritoneal implants ovarian stromal microinvasion, degree of
cellular atypia

EMQ about various expected autopsy findings . Cant remember all of the choices- included
severe steatosis ( put this for a 40 year old binge drinker
who suddenly died), mild steatosis, micronodular cirrhosis

Then came the descriptions, the ones I remember are a toddler who died in his sleep,
autopsy shows various small bruises over shin, and some redness in the trachea, healed full
thickness burn over shoulder. None of the choices showed anything resembling child abuse
so I put (no other findings)

Various dead people, provisional diagnosis asphyxiation. Then gives

the crime scene, description of the patients past medical history. Then
a whole bunch of causes like positional asphyxia, foul play(scene
made to look like suicide). I remember some of the descriptions

a) man on floor , sky high blood alcohol, wedged between bed and cupboard.

B) woman with depression. Hanging by neck from doorway, but no bruises, no

fractured hyoid, no C2 fracture, face pale, no petechiae.

C) Fat man, copd, heart disease, lying face down. Very congested face,
no laryngeal or hyoid fracture, but has strap muscle bruising. I chose plastic
bag asphyixiation.

35. Uses of various bones to the forensic pathologist. What bone you use to determine
gender, height, age, which bone easiest to get marrow from (to look for diatoms in case of
suspected river drowning)

36. Some urine cytology. Im only pretty sure I got the SCC (keratinous debris, blood,
oval refractile bodies with hooks at one end, and TCC for certain.Others were a bit
bewildering.
37. Autopsy appearance of brain (gross )appearance and a description of the traumatic
incident leading up to it. There was a MVA victim with multiple fractures, autopsy showed
diffuse petecial h’ge
in white matter. One other collapsed in street,
had tonsillar herniation and pontine h’ge on autopsy.

One was a man with worsening headaches and onset of mild dementia, sudden death.
Autopsy =various superficial cortical haemorrhages of various ages.

Also had young girl, unrestrained back seat, in MVA. Had no skull fractures, but autopsy
showed uncal herniation and upper brainstem petechial haemorrhages. (pretty sure this
was cerebral oedema,but
I chose EDH since there was no cerebral oedema. I suppose edh will also

Need to know features of DAI, SAH, EDH, SDH, hypertensive h’ge, Duret haemorrhages,

38. Various skin lesions, clinical, histo and sometimes IMF given. Must know the clinical,
light micro and imf(IF APPLICABLE) all these-Lichen planus, Derm
Herpetiformis, polymorphous light eruption, Epidermolyis bullosa congenita and acquisita,
lichen aureus and other pigmented purpuric dermatoses, Bullous pemphigoid,

Pemphigus vulgaris, foileaceous.

39. Oligodendroma-which of the following features most predictive of aggressive behaviour

40. More nhs BS- various buzzwords like clinical governance,

revalidation, clinical audit match them up with the official
bureaucratese translation. I had fun with this EMQ. Not.

41. Various nonneoplastic lung lesions-given age, gender, occupation, radiogic

and microscopic description. Some weird stuff like serum angiotensin
converting enzyme , something with eosinophilic macrophages

As far as I know, the choices included the usual fodder like nsip, uip,
lymhocytic interstitial lung dis, EAA, DIP, sarcoid, boop. Some other stuff I never heard of
like pseudolymphoma also came up.

42. description of various dead people’s hearts with congenital defect- what can I say must
know the congenital heart defects well. Includes ebsteins
, TOF, truncus, total anomalous pulmonary return, hypoplastic left heart, disruption of
aorta, transposition of great vessels, coarctation of aorta(this one was easy- a lot of good
clinical info also was given-rib notching, weak pedal
pulses, Turner syndrome)

43. Stillborn infant with brain/liver weight ratio of 6(increased), small for dates, normal
brain mass, enlarged liver. Cause? I put down cmv infection, but in retrospect I think answer
is preeclampsia. Must know TORCH infections and their clinical features well. Forgot
that cmv has microcephly, ventricular calcification etc. still not sure.

44. Sudden death in young woman 1 wk post partum, Normal vag delivery-healthy baby girl.
I put down amniontic fluid embolus

45. description of various brain degenerative diseases –clinical and pathological. Then have
to match up with the correct protein that is altered.

Caudate nucleus atrophy in young man, history of chorea, father also had chorea and died
at age 50.-Huntingtin Parkinson symptoms- alpha synuclein

Frontal lobe atrophy, inappropriate behaviour- tau protein I think?

Woman with myoclonus, triphasic EEG- donno what the answer to this is, I
put prion protein. Vaguely remember that CJD causes a distinctive EEG pattern.
MRCPath part 1 Autumn 2009

MCQ

1) A known alcoholic 45 year-old male was found dead outside a pub. Which of the
following suggest foul play? Laceration on the inside of lower lip.

No alcohol in blood test. Multiple bruises on arms and legs of varying ages.

Bruising at the back of the head. Skull fracture of occiput

2) A friend of yours is interested in applying for a medical examiner job. He asked you
for advice. Who hires the medical examiner?

Coroner’s office

Primary care trust

Ministry of Justice

Foundation hospital

GP

3) A woman died in the hospital after started on a course of penicillin. Anaphylaxis is

suspected. Which of the followings indicate anaphylaxis ?
Specific IgE to penicillin

Serum Tryptase

Mastocytosis

Serum IgE Level

4) A child with a lesion composed of cells positive for CD1a and S100.

Cat scratch disease

Langerhan’s histiocytosis

5) 27 yo man from Hong Kong has a neck lump. The cells show large nuclei with prominent
nucleoli with a syncytial growth pattern. Which of the following IHC would you perform?

S100, MelanA, CD15, CD30

6) A man was found dead lying face down on the kitchen floor in his own home with a chair
toppled. A pool of blood on the floor.

Incision wounds on the inner aspect of the left forearm, stab wound on the left chest and no
cut on the overlying T-shirt. Incision wounds on the outer aspect of the left forearm, stab
wound on the left chest and cut on the T-shirt.

7) A 32 yo female whose cervical smear was reported as moderate dyskaryosis and referred
for colposcopy. However, 6 months later, your department has not received any specimen.
You received a letter from the GP saying that this patient has moved. Who is responsible for
the cervical cytology result?

Central call/recall center

PCT

GP who took the smear

Foundation hospital
Pathologist reported the cytology

8) A mechanic who is
a part-time bodybuilder admitted with acute renal failure. He admitted
to drinking liquid from unlabelled bottle in the Gym. There are birefringent
crystals in the urine. Which of the following is the most likely cause?

Oxalate – Ethylene Glycol

Uric acid – metabolism of Taurin

9) An elderly farmer had a dispute with his neighbours. He was found dead at home. PM -
his lungs are solid with hemorrhage and consolidation. What is likely to be the cause?

Paraquat

Organophosphate

10) Lesion from the thigh of a man showing biphasic lesion composed of spindle cells and
epithelial cells forming glands.

Synovial sarcoma

11) A tumour in the small bowel with tumour cells positive for CD34 and CD117, what is it?

GIST

12) A female patient with breast carcinoma. What is the most important prognostic
feature?

Lymph node mets

Size of tumour

Type of tumour
13) Suspicious of GIST, CD117 not working, which other immuno would you use?

CD34

14) A bladder TCC invades deep into the muscularis mucosae, what is the stage?

T1a

T1b

T2

T3

T4

15) Post mortem MRI is most useful in which of the following situation?

Aortic dissection

Pulmonary embolism

16) Post-mortem of a patient with suspected MI 1 day prior to death, which is the most
useful test?

Loss of staining of the myocardium with TTC (Triphenyl Tetrazolium Chloride)

Histology sections of the myocardium

Stain with something??? Blue

17) Prostate needle biopsy show areas of small regular glands and areas of gland fusion
giving rise to cribriform appearance. Which is the most likely grade?

Gl 3+4
18) A young pregnant lady who was febrile and had a stillbirth. Which of the following is the
most likely sequence of event?

Ascending infection – chorioamnionitis

Placental previa

Placental rupture

19) Axillary sentinel lymph node biopsy for breast carcinoma. What is the best practice to
process the lymph nodes?

Slice 2mm thick, embed all and 1 H&E section.

Slice 2mm thick, embed all and panCK on all sections

Bisect the LN and embed all with 1 H&E section.

Bisect and submit one half of the LN with 1 H&E section.

20) Young man with enlarge neck node. LN shows high endothelial venules proliferation
and plasma cells. Patient has polyclonal hypergammaglobulinemia. Which is the
likely cause?

Angio-immunoblast T-cell lymphoma

Castleman disease

21) Young man with phaechromocytoma and a mass in the ?thyroid. which of the following
gene mutation is most likely?

RET

MEN1

RAS
22) A man with hypertension, hypokalemia and hypernatremia. (Conn’s syndrome) which is
the most likely finding?

1cm yellow tumour in the cortex of adrenal gland.

1cm yellow tumour in the medulla of adrenal gland.

23) A mother with type 1 diabetes. The baby was born with hypoglycaemia immediately,
why?

The islet cells of the baby continue to produce increased insulin after birth.

24) An afro-caribbean female with skin rash. Chest X-ray was done and a diagnosis was
made. What is the most likely diagnosis?

Sarcoidosis.

25) A 63yo female has

a negative cervical smear. She had a borderline smear 5 years ago but
since had 3 subsequent negative smear. What action should you take?

No further smear

Repeat smear 3 months

Repeat smear 6 months

Repeat smear 12 months

26) Renal transplant patient with renal failure. The biopsy showed ‘Decoy cells’. What is
the likely cause?

BK virus (Polyoma virus)

27) Child with recurrent chest

infection, failure to thrive and died. What is the underlying disease?

Cystic fibrosis

28) Young man with ? accident, right arm/leg weakness, 6th nerve palsy. What is the
cause?

Transtentorial herniation

Hemorrhage on cerebellar surface

? cerebellar herniation

29) A miner’s lung with calcified fibrous nodules. Which minerals he was exposed to?

Silica

Coal

Asbestos?

30) Elderly man from England travel to visit his son in Scotland. He had COPD. Prior to
returning to England, his health deteriorated and he died in the hospital. His body was
returned to England. The coroner asked you to perform a second autopsy. However, you
discovered that no autopsy had been done in Scotland. What is the most likely
explanation?

The autopsy was performed on a wrong body

The fiscal has more discretion on patient die of old age

The fiscal is satisfied that the patient died of natural causes

31) Frozen section of parathyroid gland, surgeon wants to know whether it is an adenoma.
What would you tell the surgeon?
We can only tell them this is parathyroid tissue and need to assess the size of the other 3
parathyroid glands.

We can only tell them this is parathyroid tissue and need the frozen sections of the other 3
parathyroid glands.

32) Frozen section of a lymph node from neck. The patient was exposed to TB recently.
Surgeon wants to rule out TB with frozen section. What would you do?

Refuse to do the FS as it is inappropriate

Cut the specimen, do the FS and send small piece to microbiology.

Ask the surgeon to cut the specimen, send part to microbiology and the other part for FS

33) What is the normal size of parathyroid gland?

5mm, 37mg

1mm, 37mg

10mm, 37mg

5mm, 85mg

10mm, 250mg

34) FNA from neck lump showed 2 small clusters of follicles and debris. Which of the
following result is appropriate?

Thy 1

Thy 2

Thy 3

Thy 4

Thy 0
35) A male patient , post aortic aneurysm repair. Developed left sided abdominal pain
and died. Which of the following branch is most likely to have been blocked?

Inferior mesentery artery

Superior mesentery artery

Celiac artery

36) A young man with stomach GIST has a family history of tumours and multiple
subcutaneous nodules. Which of the following is the syndrome?

A) ??

37) In the case of diaphragmatic hernia, what is the most important prognostic factor?

A) Lung hypoplasia

38) Breast cancer axillary node clearance. There is a group of cells in the subcapsular
space. Which of the following immunostaining means that this group of cells is likely to be
benign.

S100

39) When you find that a specimen you are trimming is different from the description on
the request form, what would you do?

Check label and specimen pots.

40) In a liver biopsy, there are PAS positive globules in the hepatocytes, what is the
likely diagnosis?

á1 antitrysin difficiency.
41) A vulval lesion with large epithelial cells infiltrating the epidermis. These cells are CK7 –
ve, CK20+ve, CEA+ve and CDX2-ve. Diagnosis?

?Primary pagetoid disease

?Secondary pagetoid disease

42) What does “p” in pT1N2Mx mean?

Resection specimen

43) HOCM morphology, which gene is mutated?

44) Female with mastectomy for breast cancer. She also had chemo-
radiotherapy. Presented with a vascular breast lump. What is the likely diagnosis?

Post-radiotherapy angiosarcoma

45) 20 yo male with multiple skin lesions ? site. Histology shows cup-shaped lesion,
intracellular inclusion, extends to surface. What is the likely diagnosis?

Molluscum contagiosum

46) IVDU, pleural effusion.

“Maltese cross” seen in the effusion. What is the likely substance?

Starch

47) A patient with 47 XXY chromosome, what is the commonest ovarian tumour
EMQ

1) What is the likely precursor protein for amyloid deposition in the following conditions?

Cardiomegaly with waxy surface and plasma cells.

Rheumatoid arthritis

Haemodialysis - â2-microglobulin

Dementia.
2) Liver biopsy from following patients, what is the likely diagnosis?

IVDU, interface hepatitis, Orcein-positive granules in hepatocytes - Hepatitis B

Female with biopsy showing numerous plasma cells infiltration in the portal
tract. Autoimmune hepatitis

Middle aged female with biopsy showing lymphocytic infiltrates in the portal tracts
with loose granulomas - PBC

A man with chronic alcohol excess. Liver biopsy shows macro and microvesicular
steatosis and presence of Mallory’s bodies - Alcoholic hepatitis

Young patient with PERL’s +ve granules in hepatocytes and non-hepatocytes -

? Hemosiderosis / Hemochromatosis

3) Neurodegenerative disease, what is the likely diagnosis?

72yo, haematology patient, right hand weakness, had a fit, rapidly deteriorated and died.

60yo, myoclonic fit.

Old man, dysarthria, poor swallowing, muscle loss - ? Motorneurone disease

Old man with memory loss, aggression, then became mute. Autopsy shows temporal
atrophy - ? Pick’s disease

Young woman, myoclonic seizure.

4) FNA cytology of neck lump?

Bizzare squamous cells

Lymphoid cells

Sheets of epithelial cells with lymphocytes

“Comet-shaped” cells

5) Infectious diseases.

young patient, been to Africa recently. Fever, loss of consciousness, intracellular

parasites. Plasmodium Falciparum Immunosuppressed patient with diarrhoea and weight
loss. Intestinal biopsy shows ZN +ve organisms. ? Mycobacterium avium intracellulare Can’t
remember history Entaemoeba histolytical Colectomy with cream color membrane like
material on the mucosal surface - Clostridium difficile

Immunosuppressed patient with cough. Found to have a well circumscribed mass in

lung. Aspergillus

6) Diarrhoea, what is the likely cause?

Woman been to Russia, 1 episode of diarrhoea and abdo pain. Then progressive weight
loss. Otherwise well. - Giardiasis

Old woman had some sort of surgery and started on ciprofloxacin. Watery
diarrhoea. - Pseudomembranous colitis

HIV +ve patient with chronic diarrhoea, weight loss and skin pigmentation. -
Whipples disease Post-op CABG, diarrhoea,
laparotomy shows dusky color large intestine - Ischaemic colitis

Thin woman with increased appetite, weight loss, hand tremor, diarrhoea. -
Hyperthyroidism

7) Polyps from intestine.

Pedunculated polyps with a tree like architecture -

Peutz-Jeghers polyp 5 yo girl with pedunculated

polyp - juvenile polyp Middle aged man with diarrhoea,

?polyp from the rectum -

Solitary rectal ulcer

Morphology description ?? Serrated adenoma

Can’t remember

8) Bone tumours.

Tumour distal femur, with bone covered by cartilage, stalk in continuity with the
marrow. Osteochondroma

Lesion in the knee, woke up at night with pain and helped by aspirin. X-ray shows
translucent nidus with peripheral sclerosis. Osteoid Osteoma

Can’t remember history Ewing’s sarcoma

Young female patient with lesion in the rib. There is no calcification. Microscopically, there
are fish-hook shaped bone trabeculae with interspersed fibrosis. Fibrous dysplasia

Young patient with lytic bone lesion in the jaw. There are multinucleated giant cells
and mononuclear cells positive for CD1a. Langerhan’s cell histiocytosis

9) Skin IF.

Linear IgG and C3 deposition along basement membrane - Bullous Pemphigoid

Focal deposit of IgA at the tips of dermal papillae - Dermatitis herpetiformis

IgA depositions in the vessel walls - Henoch-Schonlein Purpura

Ig G deposition with the epidermis in ‘Chicken-wire’ pattern - Pemphigus Vulgaris

Granular depositions of IgG along dermo-epidermal junction - Discoid Lupus Erythematosus

10) Cardiar anomalies- morphology descriptions, can’t remember, but answers below
should be correct, just read the chapter!

Ebstein anomaly
Hypoplastic left heart

Tetralogy of Fallot

Coarctation of aorta

Truncus Arteriosus

11) Cervical cytology – Infections:

Pear-shaped organisms - Trichomonas Vaginalis

Dordein Bacilli

IUCD user, hairy organisms -Actinomyces like organisms

Severe dyskaryosis with koilocytes, CIN3, which are the most likely organisms involve? - HPV
16, 18

Vaccination for HPV, what would you tell the patients - Virus like particles

12) Insignificant Gynae lesions seen on histology- Please read the books about

their morphology.

Microglandular hyperplasia

Walthard cell rest

Rete ovarii

Mesonephric remnant

Can’t remember

13) Prostate needle biopsy.

glands with epithelial cells containing pigments - Seminal vesicle

Glands with stratifications of epithelial cells - HG PIN

Description of ? Gleason 4 AdenoCA

Can’t remember the rest.

14) Breast pathology- Please read textbook for morphology descriptions:

Phyllodes

Hamartoma

Fibroadenoma

Metaplastic tumour

?? Adenoid cystic ca

15) Auto-antibodies.

Sjogren’s syndrome - Anti Ro

Coeliac disease - Anti TTG

Pulmonary hemorrhage and renal failure – Wegener’s - Anti PR3