Cytopathology

Cytopathology Indian Medical PG Question 1: Fine Needle Aspiration Cytology (FNAC) is NOT conclusive in which one of the following thyroid swellings?

• A. Papillary carcinoma thyroid
• B. Follicular carcinoma thyroid (Correct Answer)
• C. Thyroiditis
• D. Medullary carcinoma thyroid

Cytopathology Explanation: ***Follicular carcinoma thyroid*** - FNAC cannot definitively distinguish between a **follicular adenoma** and a **follicular carcinoma** [1]. - This is because the diagnosis of follicular carcinoma relies on the presence of **capsular invasion** or **vascular invasion**, which can only be assessed on **histopathological examination** of the resected specimen, not cytology [1]. *Papillary carcinoma thyroid* - FNAC is highly effective in diagnosing papillary carcinoma due to characteristic **nuclear features** such as **Orphan Annie eye nuclei**, nuclear grooves, and intranuclear inclusions [3]. - These distinct cytological findings allow for a confident diagnosis without needing to assess invasion [3]. *Thyroiditis* - FNAC is typically conclusive for diagnosing various forms of thyroiditis (e.g., Hashimoto's thyroiditis, subacute thyroiditis). - It identifies characteristic inflammatory cells, giant cells, and changes in follicular cells consistent with the diagnosis. *Medullary carcinoma thyroid* - Medullary thyroid carcinoma can be reliably diagnosed by FNAC due to its characteristic **polygonal or spindle-shaped cells**, **amyloid deposition**, and presence of **calcitonin** in the aspirate [2]. - Immunocytochemical staining for calcitonin further confirms the diagnosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, p. 1099.

Cytopathology Indian Medical PG Question 2: Radiation exposure can lead to which type of thyroid carcinoma?

• A. Lymphoma
• B. Papillary carcinoma (Correct Answer)
• C. Medullary carcinoma
• D. Follicular carcinoma

Cytopathology Explanation: ***Papillary carcinoma*** - Papillary thyroid carcinoma is strongly associated with **radiation exposure**, particularly during childhood [1]. - It is the most prevalent type of thyroid cancer and typically has a **good prognosis** [1]. *Lymphoma* - Thyroid lymphoma is rare and generally not linked to **radiation exposure**; it often presents as a **rapidly enlarging goiter**. - It is more commonly associated with **autoimmune thyroiditis**, not primary radiation effects. *Follicular carcinoma* - Follicular carcinoma shows a correlation with **iodine deficiency** rather than radiation exposure [1]. - Its presentation is more subtle, compared to the classical association of **radiation with papillary carcinoma**. *Medullary carcinoma* - Medullary thyroid carcinoma is primarily linked to **familial syndromes** like MEN 2 and not radiation exposure. - It arises from **parafollicular C cells**, making it clinically distinct from radiation-related types. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1098-1099.

Cytopathology Indian Medical PG Question 3: Which statement is incorrect about the pathology of the bone tumor?

• A. Tumor has distinct margin
• B. Tumor arises from epiphyseal to metaphyseal region
• C. Eccentric lesion
• D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)

Cytopathology Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.

Cytopathology Indian Medical PG Question 4: The histological grade best correlates with the prognosis in which one of the following malignancies?

• A. Soft tissue sarcoma (Correct Answer)
• B. Melanoma
• C. Colonic adenocarcinoma
• D. Prostate cancer

Cytopathology Explanation: ***Soft tissue sarcoma*** - **Histological grade is THE MOST IMPORTANT prognostic factor** for soft tissue sarcomas, more significant than size or depth in many cases. - The **FNCLCC (French Federation of Cancer Centers) grading system** is the gold standard, which grades tumors based on differentiation, mitotic count, and necrosis. - Grade directly predicts metastatic potential and survival - high-grade sarcomas have significantly worse prognosis than low-grade tumors [2]. - This is consistently emphasized in **WHO classification of soft tissue tumors** and oncology guidelines. *Colonic adenocarcinoma* - While histological grade (well, moderate, poorly differentiated) is assessed, **TNM staging** (particularly T stage - depth of invasion, and N stage - lymph node involvement) is far more important for prognosis. - Stage is the primary determinant of treatment and survival, not grade. *Melanoma* - Prognosis is primarily determined by **Breslow thickness** (tumor depth in mm), presence of **ulceration**, and **mitotic rate**. - Histological grade per se is not the primary prognostic factor - tumor thickness is paramount. *Prostate cancer* - Uses the **Gleason score/Grade Group system**, which assesses architectural patterns rather than traditional cytological differentiation [1]. - While the Gleason score is crucial, this is a specific grading system, not conventional "histological grade" as understood in general pathology. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 993-994. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 207-208.

Cytopathology Indian Medical PG Question 5: Which of the following is true about prostate cancer?

• A. Most common region involved is central zone
• B. It is not a hormone dependent cancer
• C. Most common type is squamous cell Carcinoma
• D. Grading is based on Gleason score (Correct Answer)

Cytopathology Explanation: ***Grading is based on Gleason score*** - The **Gleason score** is a widely used system to grade the aggressiveness of prostate cancer based on its microscopic appearance [1]. - It assesses the architectural patterns of the tumor, assigning a grade from 1 to 5 to the two most prevalent patterns, which are then summed to yield a final score (ranging from 2-10), indicating the **prognosis** and guiding treatment [1]. *Most common region involved is central zone* - The most common region for prostate cancer to develop is the **peripheral zone**, accounting for about 70-80% of cases [1]. - The **central zone** accounts for less than 5% of prostate cancers. *It is not a hormone dependent cancer* - Prostate cancer is largely a **hormone-dependent cancer**, with its growth stimulated by androgens like testosterone [1]. - **Androgen deprivation therapy (ADT)** is a cornerstone of prostate cancer treatment, demonstrating its dependency on hormones [1]. *Most common type is squamous cell Carcinoma* - The most common type of prostate cancer is **adenocarcinoma**, which originates from the glandular cells of the prostate [1]. - **Squamous cell carcinoma** of the prostate is exceedingly rare, accounting for less than 1% of all prostate malignancies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 988-994.

Cytopathology Indian Medical PG Question 6: A patient presents with a gingival lesion as shown in the image. What is the most likely diagnosis?

• A. Carcinoma alveolar margin
• B. Leukoplakia
• C. Hyperplastic candidiasis
• D. Fibrous epulis (Correct Answer)

Cytopathology Explanation: ***Fibrous epulis*** - The image shows a **focal, exophytic, firm, nodular growth** on the gingiva, which is characteristic of a **fibrous epulis** [1]. These are common reactive lesions caused by **chronic irritation or trauma** [1]. - They are typically **pink, well-demarcated**, and may be pedunculated or sessile, composed primarily of **fibrous connective tissue** [1]. *Carcinoma alveolar margin* - Malignant lesions like **carcinoma** often present with irregular, ulcerated, fungating, or infiltrative borders, and may be associated with **bleeding, pain, or rapid growth** [4]. - While it can occur at the alveolar margin, the lesion in the image appears more organized and smooth-surfaced, which is less consistent with a typical malignant presentation. *Leukoplakia* - **Leukoplakia** is characterized by a **white patch or plaque** that cannot be rubbed off and is not diagnosable as any other disease [3]. - The lesion in the image is a clearly defined, **flesh-colored, nodular mass**, not a flat white patch. *Hyperplastic candidiasis* - **Hyperplastic candidiasis** typically presents as **persistent white plaques** that are adherent to the mucosa and may have a **nodular or granular appearance** [2]. - While it can be firm, the overall presentation in the image, particularly the color and distinct fibrous-like texture, is less suggestive of candidal infection. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 735-736. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 736-737. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 344-345. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 739-741.

Cytopathology Indian Medical PG Question 7: In a patient with breast cancer, the following are poor prognostic factors except

• A. Aneuploid status
• B. Age less than 35 years
• C. High grade
• D. Absence of epidermal growth factor receptor (Correct Answer)

Cytopathology Explanation: ***Absence of epidermal growth factor receptor*** - The **absence of epidermal growth factor receptor (EGFR/HER1) overexpression** is associated with a **better prognosis** in breast cancer. - **EGFR overexpression** is more commonly seen in aggressive breast cancers, particularly **triple-negative breast cancers** (ER-negative, PR-negative, HER2-negative), and is associated with poor outcomes [2]. - When EGFR is absent or not overexpressed, the tumor tends to have less aggressive biological behavior. *Aneuploid status* - **Aneuploid status** (abnormal chromosome number) is a well-recognized **poor prognostic factor** in breast cancer, indicating genetic instability and aggressive tumor behavior [2]. - It is associated with **increased risk of recurrence** and poorer response to therapy. *Age less than 35 years* - **Younger age** (less than 35 years) at diagnosis is a **poor prognostic factor** for breast cancer. - This is often due to more aggressive tumor biology, **higher grade tumors**, hormone receptor negativity, and delayed diagnosis in younger women. *High grade* - A **high histological grade** (Grade III) indicates a more aggressive tumor with rapid cell division, marked nuclear pleomorphism, and poor differentiation, signifying a **poor prognosis** [1]. - High-grade tumors are more likely to metastasize and have higher recurrence rates. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 458-459. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1064-1066.

Cytopathology Indian Medical PG Question 8: All of the following are major subtypes of breast cancer based on Gene array analysis EXCEPT:

• A. Luminal A and Luminal B
• B. Triple negative
• C. Her-2 receptor positive
• D. Estrogen receptor positive (Correct Answer)

Cytopathology Explanation: ***Oestrogen receptor positive*** - While **estrogen receptor (ER) positivity** is a critical prognostic and predictive marker in breast cancer, it is a single marker, not a distinct intrinsic subtype encompassing broader genomic categorization [1]. - The intrinsic subtypes are based on gene expression profiles that cluster tumors into biologically distinct groups, such as Luminal A, Luminal B, HER2-enriched, and Basal-like (including Triple Negative) [3]. *Luminal A and Luminal B* - These are major intrinsic subtypes characterized by the expression of **hormone receptors** (ER and/or PR) and differing in their proliferation rates [2]. - **Luminal A** generally has high ER, low proliferation, and a good prognosis, while **Luminal B** often has higher proliferation (e.g., higher Ki-67) and a slightly worse prognosis [2]. *Triple negative* - This is a major intrinsic subtype (**Basal-like**) defined by the absence of **estrogen receptors (ER)**, **progesterone receptors (PR)**, and **HER2 overexpression** [1], [4]. - It often correlates with a more aggressive clinical course and specific treatment approaches [4]. *Her-2 receptor positive* - This is a major intrinsic subtype characterized by the **overexpression or amplification of the HER2 gene** [3]. - These cancers are often aggressive but respond well to targeted therapies like trastuzumab [3], [4]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1064-1066. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 10th ed. The Breast, pp. 1059-1060. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, p. 1060. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 258-259.

Cytopathology Indian Medical PG Question 9: Which of the following genetic syndromes are associated with brain tumours? 1. Neurofibromatosis type 1 2. Neurofibromatosis type 2 3. Tuberous sclerosis 4. Wiskott-Aldrich syndrome Select the answer using the code given below.

• A. 1, 2 and 3 (Correct Answer)
• B. 1, 3 and 4
• C. 1 and 2 only
• D. 2, 3 and 4

Cytopathology Explanation: ***1, 2 and 3*** - **Neurofibromatosis type 1 (NF1)**, **Neurofibromatosis type 2 (NF2)**, and **Tuberous sclerosis (TSC)** are all well-established genetic syndromes associated with an increased risk of developing various brain tumors [1]. - NF1 is linked to **optic pathway gliomas**, NF2 to **schwannomas** and **meningiomas**, and TSC to **subependymal giant cell astrocytomas (SEGAs)** [1], [2]. *1 and 2 only* - This option is incomplete as it correctly identifies NF1 and NF2 but omits Tuberous sclerosis, which is also strongly associated with brain tumours [1]. - While NF1 and NF2 are major genetic risk factors for brain tumors, excluding TSC would be an inaccurate representation of conditions linked to these abnormalities [1]. *1, 3 and 4* - This option incorrectly includes **Wiskott-Aldrich syndrome (WAS)**, which is an **immunodeficiency disorder** and not typically associated with primary brain tumours. - Although WAS can lead to an increased risk of lymphomas, these are generally not considered primary brain tumors [1] in the context of genetic syndromes predisposing to such growths. *2, 3 and 4* - This option again incorrectly includes **Wiskott-Aldrich syndrome** while omitting **Neurofibromatosis type 1**, a significant genetic syndrome linked to brain tumors [1]. - Omitting NF1, a condition known for an increased risk of gliomas, renders this option incomplete and inaccurate. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 724-725. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1318-1319.

Cytopathology Indian Medical PG Question 10: A 16-year-old boy presents with pain and swelling around the knee for 3 months. X-ray of the affected region is shown below. What is the most likely diagnosis?

• A. Ewing's sarcoma
• B. Osteosarcoma (Correct Answer)
• C. Giant cell tumor
• D. Enchondroma

Cytopathology Explanation: ***Osteosarcoma*** - **Osteosarcoma** is the most common primary malignant bone tumor, typically affecting the **metaphysis** of long bones in adolescents and young adults [1,2]. - Radiographically, it often presents with a **sunburst appearance** or **Codman's triangle** due to periosteal reaction [1]. *Ewing's sarcoma* - **Ewing's sarcoma** is a malignant small round blue cell tumor, often presenting with an **onion-skin appearance** on X-ray due to lamellated periosteal reaction [3]. - It commonly affects the **diaphysis** of long bones and flat bones, and is associated with the **t(11;22) translocation** [3]. *Giant cell tumor* - **Giant cell tumor** is a benign but locally aggressive tumor, typically found in the **epiphysis** of long bones, especially around the knee [4]. - It is characterized by numerous **osteoclast-like giant cells** and has a characteristic **soap-bubble appearance** on imaging [4]. *Enchondroma* - **Enchondroma** is a benign cartilaginous tumor that arises within the **medullary cavity** of bone, most commonly in the small bones of the hands and feet [3]. - It is typically asymptomatic and discovered incidentally, often appearing as a **well-circumscribed lucent lesion** with calcifications [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1200-1202. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 671-672. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1205-1206.

Cytopathology Flashcard 1 of 7

Question: Class II PAP consists of CIN grade _____ and Bethesda grade ASCUS/inflammatory or HPV

Answer: inflammatory

Cytopathology Flashcard 2 of 7

Question: Can fine needle aspiration distinguish between thyroid follicular adenoma versus carcinoma?_____

Answer: No

Cytopathology Flashcard 3 of 7

Question: Liquid-based cytology is commonly used in cervical cancer screening in place of a _____ using a urine specimen

Answer: pap smear

Cytopathology Flashcard 4 of 7

Question: A pap smear with findings of _____ can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma

Answer: atypical glandular cells of undetermined significance (AGUS)

Cytopathology Flashcard 5 of 7

Question: High-grade dysplasia on pap smear is characterized by _____ nuclei (color) with a high nuclear:cytoplasmic ratio

Answer: dark

Cytopathology Flashcard 6 of 7

Question: _____ and cytokeratin 5/6 is a useful marker for the detection of Non-Small Cell Lung Cancers with squamous differentiation when used in cytologic pulmonary samples

Answer: p63

Cytopathology Flashcard 7 of 7

Question: Class V PAP consists of CIN grade _____ and Bethesda grade SCC

Answer: SCC