SKIN, MSK, 22(liver, gallbladder), [12]-[13] (nasopharyngeal carcinoma and sarcodoisis v TB & [14-15] emphysema and lung cancer types. exam style

A 7-year-old child is brought to the clinic for evaluation of a pigmented lesion present since birth. The lesion measures approximately 3 cm in diameter. Given the size of the lesion, how would it be classified, and what syndrome could it potentially be associated with?

Medium congenital naevus; Neurocutaneous melanosis

The lesion would be classified as a medium congenital naevus (1.5 to <20 cm). It could potentially be associated with neurocutaneous melanosis, a syndrome in which melanocytic naevi are associated with leptomeningeal melanocytosis or melanoma.

A 45-year-old fair-skinned man presents with a rapidly enlarging mole on his back that has become painful and itchy. On examination, the lesion has irregular borders and variegated colors. A biopsy reveals malignant cells with large nuclei and prominent “cherry red” eosinophilic nucleoli, growing in poorly formed nests throughout the epidermis and in expansile dermal nodules. Describe the primary prognostic factor for this malignancy.

a) Tumor diameter
b) Presence of ulceration
c) Breslow thickness
d) Number of mitotic figures

Breslow thickness

The microscopic findings are characteristic of melanoma, which includes malignant cells growing as poorly formed nests or as individual cells at all levels of the epidermis (pagetoid spread) and in expansile dermal nodules. Melanoma cells have large nuclei with irregular contours, clumped chromatin at the nuclear membrane periphery, and prominent “cherry red” eosinophilic nucleoli. The primary prognostic factor for melanoma is the Breslow thickness, which measures the depth of invasion in millimeters from the top of the granular cell layer of the epidermis to the deepest point of tumor penetration.

A 60-year-old farmer presents with a red, scaling plaque on his forearm that has been slowly enlarging. A biopsy shows highly atypical cells at all levels of the epidermis with nuclear crowding and disorganization. Describe the clinical and histological features of the in situ form of this disease and identify the major risk factor.

a) Sharply defined, red scaling plaque; chronic sun exposure
b) Pearly papule with telangiectasia; genetic predisposition
c) Ulcerated nodule; arsenic exposure
d) Pigmented lesion with irregular borders; intense intermittent sun exposure

Sharply defined, red scaling plaque; chronic sun exposure

The clinical presentation is typical of squamous cell carcinoma in situ, which appears as sharply defined, red, scaling plaques. Histologically, this condition is characterized by highly atypical cells at all levels of the epidermis, with nuclear crowding and disorganization. The major risk factor for squamous cell carcinoma is chronic exposure to sunlight.

A 70-year-old male presents with a nodular lesion on his lower lip that is ulcerated and has variable scaling. Biopsy shows penetration of the basement membrane by atypical squamous cells. What is the diagnosis, and what are the typical microscopic features of this condition?

a) Melanoma; pagetoid spread and cherry red nucleoli
b) Basal cell carcinoma; palisading nuclei and retraction artifact
c) Invasive squamous cell carcinoma; penetration of the basement membrane by atypical cells
d) Actinic keratosis; atypical cells confined to the basal layer

• Invasive squamous cell carcinoma; penetration of the basement membrane by atypical cells

The diagnosis is invasive (infiltrating) squamous cell carcinoma. Typical microscopic features include penetration of the basement membrane by atypical squamous cells, with varying degrees of differentiation. Well-differentiated squamous cell carcinoma shows keratin pearls and well-defined cellular borders with prominent eosinophilic cytoplasm, while poorly differentiated squamous cell carcinoma demonstrates marked nuclear pleomorphism, necrosis, and mitosis.

A 55-year-old woman presents with a pearly papule on her nose, which has visible dilated sub-epidermal blood vessels (telangiectasia). Biopsy reveals tumor cells resembling the basal cell layer of the epidermis, with peripheral palisading of nuclei and separation from the stroma creating a cleft. Identify the condition and the underlying pathogenetic mechanism.

Basal cell carcinoma; dysregulation of the Hedgehog pathway

The condition is basal cell carcinoma. The underlying pathogenetic mechanism involves dysregulation of the Hedgehog signaling pathway. The microscopic features include tumor cells resembling the normal basal cell layer of the epidermis, peripheral palisading of nuclei, and retraction artifact (cleft formation) between the tumor nests and the surrounding stroma.

A 25-year-old woman with a family history of skin cancer presents with a new pigmented lesion that appeared over the past few months. The lesion is asymmetrical, with irregular borders, varying colors, and a diameter of 8 mm. Discuss the clinical criteria used to evaluate pigmented lesions for melanoma and the genetic mutations commonly associated with melanoma development.

a) ABCDE criteria; TP53 mutations
b) ABCDE criteria; BRAF or NRAS mutations
c) Breslow thickness; Hedgehog pathway mutations
d) Clark level; c-KIT mutations

ABCDE criteria; BRAF or NRAS mutations

A 65-year-old man with a history of significant sun exposure presents with a nodular lesion that has variable scaling and ulceration. Biopsy shows well-defined cellular borders, prominent eosinophilic cytoplasm, and keratin pearls. Identify the type and differentiation grade of this carcinoma, and discuss the primary molecular mutation involved in its pathogenesis.

a) Well-differentiated squamous cell carcinoma; TP53 mutation
b) Poorly differentiated squamous cell carcinoma; BRAF mutation
c) Basal cell carcinoma; Hedgehog pathway mutation
d) Melanoma; NRAS mutation

Well-differentiated squamous cell carcinoma; TP53 mutation

The lesion is a well-differentiated squamous cell carcinoma. The primary molecular mutation involved in its pathogenesis is TP53 mutation caused by UV light-induced DNA damage. Well-differentiated squamous cell carcinomas exhibit well-defined cellular borders, prominent eosinophilic cytoplasm, and keratin pearls.

A 60-year-old male with a history of mechanical joint injury presents with joint pain and stiffness. He is diagnosed with secondary osteoarthritis. What morphologic feature is typically observed in osteoarthritis?

a) Synovial hyperplasia
b) Eburnation of bone
c) Subcutaneous nodules
d) Pannus formation

Eburnation of bone

A 65-year-old man presents with knee pain and stiffness. Imaging shows subchondral cysts and bone sclerosis. Which type of arthritis does he likely have, and what are joint mice?

Osteoarthritis; fragments of cartilage in the synovial space

A 70-year-old woman presents with joint pain and stiffness that worsens throughout the day. Physical examination reveals bony enlargements at the distal interphalangeal joints. What are these enlargements called, and what is their underlying pathology?

Heberden nodes; osteophyte formation

A 40-year-old man with psoriasis presents with painful, swollen joints and nail pitting. Radiographs reveal a "pencil in cup" deformity. What is the most likely diagnosis, and what is a characteristic feature of this condition?

Psoriatic arthritis; sausage-shaped DIP joints

A young boy presents with arthritis, generalized lymphadenopathy, and hepatosplenomegaly. Which variant of rheumatoid arthritis is most likely, and what is it also known as?

Still disease; Juvenile rheumatoid arthritis

A 60-year-old male with long-standing rheumatoid arthritis develops pleural effusions and pulmonary involvement. What are these findings classified as, and what other extra-articular manifestations might be present?

Extra-articular manifestations; amyloidosis and vasculitis

A 50-year-old woman with a history of rheumatoid arthritis presents with ulnar deviation of her fingers and swan neck deformity. What are the key histological features you would expect to see in her affected joints?

Synovial hyperplasia and pannus formation

A 45-year-old female with rheumatoid arthritis presents with subcutaneous nodules and reports increased joint pain and swelling. Biopsy of the nodules shows central fibrinoid necrosis surrounded by palisading histiocytes. What are these nodules, and what is their significance?

Subcutaneous rheumatoid nodules; indicative of severe disease

A 35-year-old woman presents with symmetric joint pain, morning stiffness lasting over an hour, and fatigue. Laboratory tests reveal a positive serum rheumatoid factor. Which genetic marker is most commonly associated with her condition?

• HLA-DR4

A 36-year-old man presents with fever, weight loss, and night sweats. Physical examination reveals cervical lymphadenopathy and hepatosplenomegaly. A chest X-ray shows miliary nodules. Biopsy of a cervical lymph node shows granulomas with central caseation and Langhans giant cells. what is the most likely diagnosis?

Miliary tuberculosis

A 40-year-old woman presents with progressive dyspnea and chronic cough. She reports no significant occupational exposures or smoking history. Imaging reveals diffuse reticular opacities with a peri-bronchiolar distribution and small nodules. Biopsy shows non-caseating granulomas with a predominance of T lymphocytes and plasma cells. Which of the following is the most likely diagnosis?

• A) Idiopathic pulmonary fibrosis

• B) Sarcoidosis

• C) Hypersensitivity pneumonitis

• D) Granulomatosis with polyangiitis

• E) Cryptogenic organizing pneumonia

• Hypersensitivity pneumonitis

A 55-year-old man with a history of secondary tuberculosis presents with hemoptysis and chest pain. A CT scan shows extensive cavitary lesions in the upper lobes of the lungs. Which of the following is a characteristic microscopic finding in his lung tissue?

Caseating granulomas with Langhans giant cells

A 23-year-old woman presents with erythema nodosum, polyarthritis, and bilateral hilar lymphadenopathy. She also has hypercalcemia and increased serum angiotensin-converting enzyme levels. Which of the following microscopic findings is most likely seen in a lymph node biopsy?

pt has sarcoidosis.

Non-caseating granulomas with multinucleated giant cells

A 50-year-old man presents with fever, night sweats, and weight loss. A chest X-ray shows a cavitary lesion in the apex of the right lung. Sputum analysis reveals acid-fast bacilli. Which of the following histopathological findings is most characteristic of this patient's disease?

• A) Non-caseating granulomas

• B) Caseating granulomas

• C) Interstitial fibrosis

• D) Hyaline membranes

• E) Pleural plaques

• Caseating granulomas

A 35-year-old farmer presents with shortness of breath, cough, and fever. He reports being exposed to moldy hay. Bronchoalveolar lavage shows an increased number of CD4+ and CD8+ T lymphocytes. Histopathology reveals patchy mononuclear cell infiltrates, mainly lymphocytes, plasma cells, and epithelioid cells, with interstitial non-caseating granulomas in a peri-bronchiolar location. What is the most likely diagnosis?

• A) Sarcoidosis

• B) Hypersensitivity pneumonitis

• C) Pulmonary tuberculosis

• D) Idiopathic pulmonary fibrosis

• E) Chronic bronchitis

• Hypersensitivity pneumonitis

A 29-year-old African American woman presents with a 6-month history of dyspnea, cough, and fatigue. A chest X-ray shows bilateral hilar lymphadenopathy and diffuse reticular opacities. Laboratory findings reveal hypercalcemia and elevated serum angiotensin-converting enzyme levels. Which histopathological finding is most likely present in her lung tissue?

Non-caseating granulomas

A 45-year-old man from Southeast Asia presents with nasal obstruction, epistaxis, and a neck mass. Biopsy of the neck mass reveals sheets of undifferentiated cells with vesicular nuclei and prominent cytoplasm, along with numerous small lymphocytes. Immunohistochemistry is positive for cytokeratin 8, cytokeratin 19, EMA, and EBER (Epstein-Barr virus encoded RNA). What is the most likely diagnosis?

Nasopharyngeal carcinoma

A 62-year-old man with a 40-pack-year smoking history presents with shortness of breath, significant weight loss, and a barrel-shaped chest. Physical examination reveals labored breathing with pursed lips. His arterial blood gas shows mild hypoxia and respiratory acidosis. Which type of emphysema is most likely present in this patient?

• A) Centri-acinar emphysema

• B) Pan-acinar emphysema

• C) Distal acinar emphysema

• D) Irregular emphysema

Centri-acinar emphysema

This patient’s clinical presentation is typical of "pink puffers" seen in centri-acinar emphysema, which is commonly associated with heavy cigarette smoking. The destruction is more severe in the upper lobes.

A 28-year-old woman with a known deficiency in alpha1-antitrypsin presents with progressive dyspnea and fatigue. A CT scan of the chest shows uniformly enlarged airspaces throughout the entire lung, more severe at the lung bases. What is the most likely diagnosis?

Pan-acinar emphysema

Pan-acinar emphysema is characterized by the uniform enlargement of the entire acinus and is typically associated with alpha1-antitrypsin deficiency. It is most severe in the lower zones of the lungs.

A 45-year-old man with a history of smoking and chronic bronchitis presents with sudden onset of chest pain and shortness of breath. A chest X-ray reveals a pneumothorax. Which type of emphysema is most likely to be associated with this complication?

Distal acinar emphysema

Distal acinar (para-septal) emphysema is associated with the formation of sub-pleural bullae, which can rupture and cause pneumothorax.

A 50-year-old man with a significant smoking history presents with a chronic productive cough and dyspnea. Physical examination reveals cyanosis and peripheral edema. Arterial blood gas analysis shows hypoxemia and hypercapnia. Which term best describes this clinical presentation?

Blue bloater

"Blue bloaters" are typically associated with chronic bronchitis, characterized by cyanosis, productive cough, hypoxemia, and hypercapnia.

A 35-year-old male non-smoker presents with progressive dyspnea and liver dysfunction. Liver biopsy shows cytoplasmic droplets within hepatocytes. Genetic testing reveals he is homozygous for the piZZ allele. Which lung pathology is he most likely to develop?

Pan-acinar emphysema

The piZZ allele of the alpha1-antitrypsin gene results in decreased activity of alpha1-antitrypsin, leading to pan-acinar emphysema and hepatic cirrhosis.

A 40-year-old man with a history of tuberculosis presents with shortness of breath. Imaging studies reveal large sub-pleural bullae predominantly in the upper lobes. He is diagnosed with bullous emphysema. What is the most likely underlying type of emphysema in this patient?

Distal acinar emphysema

Bullous emphysema can occur in any type of emphysema, but the association with upper lobe involvement and a history of tuberculosis suggests distal acinar (para-septal) emphysema.

A 60-year-old man with severe emphysema presents with subcutaneous crepitus on physical examination. Chest X-ray confirms air in the mediastinum and subcutaneous tissues. What is the most likely cause of his current condition?

Interstitial emphysema

Interstitial emphysema is characterized by the entrance of air into the connective tissue stroma of the lung, mediastinum, or subcutaneous tissue, often due to alveolar tears caused by increased pressures within the alveolar sacs.

A 45-year-old man presents with a solitary, pedunculated lesion in the large bronchi on bronchoscopy. Biopsy reveals a fibro-vascular stalk covered with squamous epithelium without atypias or mitoses. What is the most likely diagnosis?

• A) Solitary papilloma

• B) Multiple papilloma

• C) Squamous cell carcinoma

• D) Hamartoma

Solitary papilloma

Solitary papillomas in middle to advanced age patients are typically non-HPV associated and have a characteristic fibro-vascular stalk with squamous epithelium without atypias.

A 60-year-old man with a history of smoking presents with a solitary pulmonary nodule seen on a chest X-ray. Which feature would suggest a higher likelihood of malignancy?

• A) The patient is less than 35 years old

• B) The nodule is less than 3 cm in diameter

• C) The patient is over 50 years old

• D) The nodule is associated with pleural effusion

The patient is over 50 years old

The risk of malignancy in a solitary pulmonary nodule increases significantly in patients over 50 years old.

A 55-year-old man undergoes a chest CT scan for an unrelated issue, which reveals a round, peripheral lung lesion with a diameter of 3 cm. Biopsy shows nodules of cartilage intersected by epithelial clefts lined by ciliated columnar epithelium. What is the most likely diagnosis?

Hamartoma

Hamartomas, or adenochondromas, are characterized by nodules of connective tissue (commonly cartilage) intersected by epithelial clefts.

A 35-year-old woman presents with a persistent cough and hemoptysis. Imaging reveals a polypoid mass projecting into the bronchus. Histology shows uniform round nuclei with salt-and-pepper chromatin. What is the most likely diagnosis?

• A) Typical bronchial carcinoid

• B) Atypical bronchial carcinoid

• C) Small cell lung carcinoma

• D) Squamous cell carcinoma

Typical bronchial carcinoid

Typical bronchial carcinoids are characterized by low-grade malignancy, salt-and-pepper chromatin, and a polypoid growth pattern.

Which of the following statements about lung cancer epidemiology is true?

• A) Lung cancer is the second most common fatal cancer in men.

• B) Lung cancer has a peak incidence at 45-55 years.

• C) Adenocarcinoma is the most common lung cancer in never-smokers.

• D) Small cell lung carcinoma is most common in non-smokers

Adenocarcinoma is the most common lung cancer in never-smokers.

A 60-year-old former uranium miner presents with a persistent cough and weight loss. He has a 40-pack-year smoking history. Which combination of factors most likely contributed to his lung cancer?

• A) Smoking and radium exposure

• B) Asbestos exposure and radium exposure

• C) Radon exposure and cigarette smoking

• D) Nickel exposure and asbestos exposure

Radon exposure and cigarette smoking

Uranium miners are exposed to radon, and cigarette smoking significantly increases the risk of lung cancer in combination with radon exposure.

A 58-year-old man with a 50-pack-year smoking history presents with facial swelling, cyanosis, and dilatation of veins in the neck. A CT scan reveals a peri-hilar mass. Which paraneoplastic syndrome is most likely associated with this type of lung cancer?

• A) Hypercalcemia

• B) SIADH

• C) Cushing's syndrome

• D) Carcinoid syndrome

Cushing's syndrome

Small cell lung carcinoma is associated with SIADH and ACTH-like activity leading to Cushing's syndrome.

A 50-year-old woman who never smoked presents with a peripheral lung mass. Genetic testing reveals an EGFR mutation. What is the most likely diagnosis?

Adenocarcinoma

Adenocarcinoma is the most common lung cancer in never-smokers and is often associated with EGFR mutations.

A 65-year-old man with a significant smoking history presents with a centrally located lung mass. Biopsy shows keratin pearls and intercellular bridges. What is the most likely diagnosis?

Squamous cell carcinoma

Squamous cell carcinoma is characterized by keratin pearls and intercellular bridges and is almost exclusively seen in smokers.

A biopsy of a lung mass in a smoker reveals small, round cells with high nuclear-to-cytoplasmic ratio and neuroendocrine features. Which immunohistochemical markers are most likely to be positive?

• A) TTF-1 and napsin A

• B) p63 and CK5/6

• C) Synaptophysin and chromogranin

• D) HER2 and ER

Synaptophysin and chromogranin

Small cell lung carcinoma typically shows immunopositivity for neuroendocrine markers such as synaptophysin and chromogranin.

A 55-year-old woman with a history of breast cancer presents with dyspnea. Imaging reveals multiple lung nodules. What is the most likely primary site of metastasis to the lung?

Breast cancer

Breast cancer is a common primary site for metastasis to the lung.

A 70-year-old man presents with facial swelling, cyanosis, and prominent veins in the neck and upper chest. Imaging shows a large mediastinal mass. Which lung cancer type is most likely responsible?

Small cell lung carcinoma

Superior vena cava syndrome is often caused by the compression or invasion of the superior vena cava by a central lung tumor such as small cell lung carcinoma.

A 40-year-old man presents with intermittent diarrhea, flushing, and cyanosis. Imaging reveals a lung mass. Which type of lung tumor is most likely responsible for his symptoms?

• A) Adenocarcinoma

• B) Squamous cell carcinoma

• C) Small cell lung carcinoma

• D) Bronchial carcinoid

Bronchial carcinoid

Bronchial carcinoids can produce hormones leading to carcinoid syndrome, characterized by intermittent diarrhea, flushing, and cyanosis.

A lung biopsy shows a poorly differentiated tumor with no evidence of glandular or squamous differentiation. The cells have large nuclei and prominent nucleoli. What is the most likely diagnosis?

Large cell carcinoma

Large cell carcinoma is a diagnosis of exclusion characterized by poorly differentiated cells with large nuclei and prominent nucleoli, without glandular or squamous differentiation.

A 65-year-old smoker with a lung mass presents with hypercalcemia. Which type of lung cancer is most likely responsible for this paraneoplastic syndrome?

• A) Small cell lung carcinoma

• B) Adenocarcinoma

• C) Squamous cell carcinoma

• D) Large cell carcinoma

Squamous cell carcinoma

Hypercalcemia as a paraneoplastic syndrome is most commonly associated with squamous cell carcinoma of the lung due to the production of parathyroid hormone-related protein (PTHrP).