Basic Principles of Cytopathology — MCQs
Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing: Use posterior vaginal wall retractor Take the sample Make smear on a slide Fix the smear
On mammogram all of the following are the features of a malignant tumor except:
A 45-year-old man who works in a textile company visited hospital for routine health check-up. He prepares dyes in the company for the last 18 years. Which of the following investigation would you recommend for this patient?
Which is the best investigation for carcinoma of the head of pancreas?
A 45-year-old woman presents with a history of cervical erosion and spotting for the past 2 months. What is the next best step?
Which of the following is NOT classified as a small round cell tumor?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
Laparoscopy is the diagnostic procedure of choice for:
Name the cells marked as X in Pap smear.
Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
Basic Principles of Cytopathology Indian Medical PG Practice Questions and MCQs
Question 1: Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing: Use posterior vaginal wall retractor Take the sample Make smear on a slide Fix the smear
- A. 1,2,4,3
- B. 3,1,2,4
- C. 1,2,3,4 (Correct Answer)
- D. 2,1,3,4
Explanation: ***1,2,3,4*** - The correct sequence for collecting a Pap smear involves first **visualizing the cervix** using a posterior vaginal wall retractor, then **taking the sample** (e.g., using a broom or spatula and brush), followed by **making a smear on a slide** and finally **fixing the smear** to preserve the cells. - This sequential order ensures proper cell collection and preservation for accurate cytological examination. *1,2,4,3* - This option incorrectly places **fixing the smear** before **making the smear on the slide**. Cells must first be spread onto the slide before they can be fixed. - Fixing an un-smeared sample or attempting to smear after fixing would lead to an inadequate or damaged specimen. *3,1,2,4* - This sequence incorrectly starts with **making a smear on a slide** before any sample has been collected or the cervix visualized. - One cannot make a smear without first taking a sample and accessing the cervix via a retractor. *2,1,3,4* - This option incorrectly states that **taking the sample** occurs before **using a posterior vaginal wall retractor**. The retractor is essential for proper visualization and access to the cervix to obtain a quality sample. - Attempting to take a sample without proper visualization would lead to an inadequate or incorrect specimen collection.
Question 2: On mammogram all of the following are the features of a malignant tumor except:
- A. Spiculation
- B. High density
- C. Smooth margin (Correct Answer)
- D. Ill defined margin
Explanation: ***Smooth margin*** - A **smooth margin** on a mammogram is typically a feature of a **benign mass**, indicating that the lesion is well-defined and not invading surrounding tissues. - Malignant tumors usually exhibit **irregular, ill-defined, or spiculated margins** due to their invasive growth patterns. *Spiculation* - **Spiculation** is a **highly suspicious feature** of malignancy, characterized by sharp, radiating lines extending from the mass into the surrounding breast tissue. - It represents tumor invasion and desmoplastic reaction, indicating an aggressive growth pattern. *High density* - **High density** of a mass on mammography, appearing brighter than the surrounding breast tissue, is a **common feature of malignancy**. - This increased density is often due to higher cellularity or desmoplastic reaction within the tumor. *Ill-defined margin* - An **ill-defined margin** is a strong indicator of **malignancy** as it suggests infiltrative growth into adjacent tissues. - The borders of the mass are difficult to distinguish clearly from the surrounding breast parenchyma.
Question 3: A 45-year-old man who works in a textile company visited hospital for routine health check-up. He prepares dyes in the company for the last 18 years. Which of the following investigation would you recommend for this patient?
- A. Pulmonary function tests
- B. Complete blood count
- C. Liver function tests
- D. Urine examination (Correct Answer)
Explanation: ***Urine examination*** - Working in a textile company, especially with dyes, for 18 years significantly increases the risk of exposure to **aromatic amines**, which are established occupational carcinogens. - Exposure to **aromatic amines** is strongly linked to an increased risk of **bladder cancer**, making a periodic urine examination, including cytology, crucial for early detection. *Pulmonary function tests* - While textile workers can be exposed to **fibers and dusts** causing respiratory issues like byssinosis, the primary and most concerning risk associated with **dye exposure** is bladder cancer, not lung function impairment. - PFTs would be more relevant if there were specific respiratory symptoms or exposure to known **pneumoconiosis-causing contaminants**. *Complete blood count* - A CBC might detect hematological abnormalities, but it is not the most targeted or sensitive investigation for early detection of **dye-related occupational diseases**, particularly bladder cancer. - While some chemicals can affect blood cell production, the prominent carcinogenic risk here points elsewhere. *Liver function tests* - Some industrial chemicals can cause **liver toxicity**, but the most prominent and direct organ-specific cancer risk associated with long-term exposure to textile dyes containing aromatic amines is to the bladder. - LFTs would be relevant if there were signs or symptoms of **hepatic dysfunction**, but they don't address the primary cancer risk in this scenario.
Question 4: Which is the best investigation for carcinoma of the head of pancreas?
- A. Transduodenal/transperitoneal sampling
- B. Guided biopsy
- C. ERCP
- D. EUS (Correct Answer)
Explanation: ***EUS*** - **Endoscopic ultrasound (EUS)** provides the highest resolution imaging of the pancreas and allows for **fine-needle aspiration (FNA)** of suspicious lesions, offering definitive tissue diagnosis. - Its ability to visualize small, early-stage tumors and regional lymph nodes makes it the **most accurate method for diagnosis and staging** of pancreatic head carcinoma. *Guided biopsy* - While a biopsy is necessary for definitive diagnosis, 'guided biopsy' is a broad term that doesn't specify the highly effective EUS guidance. - Other biopsy methods that are not guided by EUS may be less accurate and carry higher risks for pancreatic lesions. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is primarily a therapeutic procedure used for **biliary drainage** in cases of obstruction caused by pancreatic head tumors. - Although it can visualize ductal abnormalities and allow brush cytology, it is **less sensitive for direct tumor visualization** and tissue acquisition compared to EUS-FNA. *Transduodenal/transperitoneal sampling* - These are **invasive surgical approaches** for obtaining tissue samples, typically reserved when less invasive methods like EUS-FNA are unsuccessful or when intraoperative confirmation is needed. - They carry **higher risks** and are not considered the "best investigation" for initial diagnosis due to their invasiveness and potential for complications.
Question 5: A 45-year-old woman presents with a history of cervical erosion and spotting for the past 2 months. What is the next best step?
- A. LBC + HPV (Correct Answer)
- B. Pap smear + HSV
- C. Pap smear + HBV
- D. LBC + HSV
Explanation: ***LBC + HPV*** - Cervical erosion and spotting are concerning for **cervical intraepithelial neoplasia (CIN)** or **cervical cancer**, making **Liquid-Based Cytology (LBC)** the appropriate screening method. - **Human Papillomavirus (HPV) testing** is crucial as persistent high-risk HPV infection is the primary cause of cervical cancer and helps in risk stratification and management. *Pap smear + HSV* - A **routine Pap smear** (conventional cytology) is less sensitive than LBC for detecting abnormal cervical cells and is generally being phased out by LBC. - **Herpes Simplex Virus (HSV)** causes genital herpes and is not directly associated with cervical cancer, thus testing for it in this context is not the most appropriate immediate next step. *Pap smear + HBV* - As mentioned, a **routine Pap smear** is not the preferred method for cervical cancer screening compared to LBC. - **Hepatitis B Virus (HBV)** causes liver disease and is entirely unrelated to cervical pathology; therefore, testing for it would be irrelevant to the patient's symptoms. *LBC + HSV* - While **LBC** is the correct advanced cytology method, adding **HSV testing** is not indicated as HSV does not cause cervical cancer or intraepithelial lesions that present with cervical erosion and spotting. - Focus should be on identifying potential malignancy or pre-malignant changes with HPV co-testing, not sexually transmitted infections unrelated to cancer risk.
Question 6: Which of the following is NOT classified as a small round cell tumor?
- A. Ewing's sarcoma
- B. Rhabdomyosarcoma
- C. Wilm's tumor (Correct Answer)
- D. Retinoblastoma
Explanation: ***All of the above*** - Small round cell tumors encompass a variety of neoplasms including **retinoblastoma** and **rhabdomyosarcoma** [1]. - They are characterized by **primitive, undifferentiated cells**, making this classification broad and inclusive of all mentioned tumors. *Retinoblastoma (a small round cell tumor)* - While retinoblastoma is indeed a **small round cell tumor** [1], this option fails to recognize the broader classification of tumors in the question. - It doesn't encompass other key tumors that can also be categorized under the **small round cell tumor** umbrella. *Wilm's tumor (not a small round cell tumor)* - Wilm's tumor is classified as a **nephroblastoma**, featuring a distinct morphology that does not fit into the small round cell category. - Typically presents as a **pediatric abdominal mass** with **triphasic pathology**, unlike small round cell tumors which have a more uniform appearance. *Rhabdomyosarcoma (a small round cell tumor)* - Although rhabdomyosarcoma is considered a **small round cell tumor** [1][2], this option too does not cover all tumors classified under this term. - It features **mesenchymal differentiation** and uniform round cells with little cytoplasm [2] rather than presenting a broad view, as requested by the question. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 483-484. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1224-1225.
Question 7: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Question 8: Laparoscopy is the diagnostic procedure of choice for:
- A. Ca rectum
- B. Endometriosis (Correct Answer)
- C. Ca cervix
- D. Ca uterus
Explanation: ***Endometriosis*** - Laparoscopy allows for direct visualization of **endometrial implants** outside the uterus, which is crucial for diagnosis and staging. - It also allows for **biopsy confirmation** and potential treatment (excision or ablation) of endometriotic lesions during the same procedure. *Ca rectum* - The primary diagnostic procedure for **rectal cancer** is usually **colonoscopy** with biopsy. - **Laparoscopy** may be used for staging **rectal cancer** but it is not the initial diagnostic procedure of choice. *Ca cervix* - The primary diagnostic procedure for **cervical cancer** is a **colposcopy** with directed biopsy of suspicious lesions. - **Laparoscopy** is not typically used for the initial diagnosis of **cervical cancer** but may be used for staging in advanced cases. *Ca uterus* - The primary diagnostic procedure for **uterine cancer** (endometrial cancer) is an **endometrial biopsy** or **dilation and curettage (D&C)**. - **Laparoscopy** may be used for surgical staging of **uterine cancer** but is not the initial diagnostic procedure.
Question 9: Name the cells marked as X in Pap smear.
- A. Superficial cells (Correct Answer)
- B. Intermediate cells
- C. Para-basal cells
- D. Basal cells
Explanation: ***Superficial cells*** - These cells are characterized by a **small, pyknotic nucleus** and abundant, clear cytoplasm, which is typical for the cells marked as X in a Pap smear [1]. - They are the most mature cells of the vaginal epithelium and are prominent in the **proliferative phase** of the menstrual cycle. *Intermediate cells* - These cells have a **larger, vesicular nucleus** compared to superficial cells and a more folded cytoplasm. - They are more prominent during the **luteal phase** and pregnancy due to progesterone influence. *Para-basal cells* - These cells are smaller with a **larger nucleus-to-cytoplasm ratio** and are typically seen in atrophic smears or in children and postmenopausal women. - They represent the **immature cells** of the vaginal epithelium. *Basal cells* - These are the **deepest layer** of the squamous epithelium and are rarely seen in a normal Pap smear unless there is significant epithelial damage or sampling from deeper layers. - They have a **large nucleus** and very little cytoplasm. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, p. 1010.
Question 10: Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
- A. E3
- B. E5
- C. E6 (Correct Answer)
- D. E7
Explanation: ***E6*** - **E6 oncoprotein is the HPV protein that specifically targets and degrades p53** through ubiquitin-mediated proteolysis [2]. - **p53 degradation** prevents apoptosis and allows cells with damaged DNA to survive and proliferate, a critical early step in malignant transformation [3]. - E6 works synergistically with E7 in cervical carcinogenesis, but **E6 is uniquely responsible for p53 inactivation** [1]. *E3* - HPV does not have a clinically significant E3 oncoprotein in the context of cervical cancer pathogenesis. - This is not a major viral oncoprotein involved in malignant transformation. *E5* - **E5 oncoprotein** plays a minor role in early infection by enhancing growth factor receptor signaling. - It does **not target p53** and is often lost during viral integration, making it less critical for malignant progression. *E7* - **E7 oncoprotein targets the retinoblastoma protein (Rb)**, not p53 [1]. - Rb inactivation releases E2F transcription factors, driving cell cycle progression [1]. - E7 and E6 work together, but **E7's specific target is Rb, not p53** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 334-335. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1006-1007. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 303-304.
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