Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Making Things Memorable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Chapter 1:  Pap Test Samples, Reporting & Ancillary Studies

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 2:  HPV Testing & Molecular Biology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Chapter 3:  Normal & Benign Pap Tests

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Chapter 4:  Pap Test Squamous Abnormalities

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Chapter 5:  Pap Test Glandular Abnormalities

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Chapter 6:  Pap Test Hyperchromatic Crowded Groups

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Chapter 7:  Cytology Techniques & Ancillary Studies in Nongynecologic Cytopathology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

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Chapter 8:  Abdominopelvic Washings

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Chapter 9:  Serous Effusions

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Chapter 10:  Cerebrospinal Fluid & Central Nervous System

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Chapter 11:  Urine Cytopathology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Chapter 12:  Lung & Respiratory Cytopathology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Chapter 13:  Lymph Nodes

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Chapter 14:  Salivary Gland

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Chapter 15:  Thyroid

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322

Chapter 16:  Liver

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

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Chapter 17:  Pancreas

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Chapter 18:  Breast

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

Chapter 19:  Soft Tissue & Bone

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Chapter 20:  Renal, Adrenal & Retroperitoneum

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

Chapter 21:  Gastrointestinal Tract & Bile Ducts

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

Chapter 22:  Pediatric Cytopathology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

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Preface The Quick Compendia have provided for many residents dense, high yield sources of pathology information useful for board study. As a result the texts have often been used by potential examinees to “cram” as much information as possible just prior to attempting to navigate the boards. There are certainly pros and cons to this approach. In a pragmatic sense many pathologists will never experience certain subspecialties again in their practice and have the desire to just pass the test. Not much has changed in the environment in which this Series originally arose. Residency programs are still uneven in their teaching (especially of clinical pathology) and both residents and established pathologists are looking for the means of broadening their knowledge of these disparate areas of the field. I’ve considered al the various feedback regarding earlier editions of the Quick Compendium Companions. Besides mentions of typos, one of the major criticisms was that the questions were

simply recall based. Read the Quick Compendium then test how much you remember with multiple choice questions in the Companion. This is true, and it is by design. As previously mentioned, the QC Companions were designed (again, for better or worse) as “cram” devices. I vividly remember those last few months, weeks, days before the exam—I wanted a fast and compact means of getting the last bits of information into my head, while revisiting the information I was most sure of already. A review book is not the best way to teach or learn the higher reasoning skills needed for questions that require the test taker to synthesize new concepts from established ones. Those abilities arise from the hands on application of the knowledge that residents glean during residency. The point of the Companions is to test your recall. Please don’t hesitate to contact me with any questions or suggestions, either through the online forum or via email ([email protected]) George Leonard, MD, PhD ASCP Quick Compendium Companion series editor

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Chapter 3

Normal & Benign Pap Tests 1.

The cells shown here represent which of the following?

A. B. C. D. E. 2.

intermediate cells superficial cells endometrial cells endocervical cells parabasal cells

The correct interpretation of this Pap test obtained from a 46‑year‑old female is:

A. B. C. D. E.

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hyperkeratosis parakeratosis low grade squamous intraepithelial lesion (LSIL) high grade squamous intraepithelial lesion (HSIL) squamous metaplasia

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3: Normal & Benign Pap Tests Questions 3.

The cells present in this ThinPrep Pap test represents which of the following?

A. B. C. D. E. 4.

These cells occur singly and in flat sheets. They have evenly distributed chromatin and smooth nuclear contours. They represent:

A. B. C. D. E.

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parakeratosis squamous metaplasia transitional cell metaplasia hyperkeratosis dysplasia

atypical parakeratosis parakeratosis transitional cell metaplasia endometrial cells squamous metaplasia

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3: Normal & Benign Pap Tests Questions 5.

The cells from this 32‑year‑old female’s Pap test represent an adequate sample. They are:

A. B. C. D. E. 6.

superficial cells endocervical cells hyperkeratotic cells intermediate cells endometrial cells

This photomicrograph of a liquid based Pap test depicts which of the following?

A. B. C. D. E.

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squamous metaplasia atypical parakeratosis pseudokeratosis parakeratosis hyperkeratosis

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3: Normal & Benign Pap Tests Questions 7.

The cells depicted in this image on a conventional Pap test from a 69‑year‑old female with a hysterectomy for high grade endometrial adenocarcinoma 20 years ago represent which of the following?

A. B. C. D. E. 8.

Which of the following represents this benign condition associated with multinucleated cells?

A. B. C. D. E.

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rectovaginal fistula IUD change repair herpes simplex virus cytomegalovirus

herpes simplex virus LSIL choriocarcinoma sarcoma radiation induced dysplasia

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3: Normal & Benign Pap Tests Questions 9.

This liquid based Pap test was obtained from a 54‑year‑old female. What is the correct interpretation?

A. B. C. D. E.

atrophy tubal metaplasia repair squamous metaplasia HSIL

10. Which of the following are present in this liquid based Pap test?

A. B. C. D. E.

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koilocytes ground glass chromatin multinucleation mitoses nuclear halos

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3: Normal & Benign Pap Tests Questions 11. A 31‑year‑old female went to the OB/GYN office for a routine screening Pap test. The cytologic findings observed are in this photomicrograph. What is the most appropriate next step in management for this patient?

A. B. C. D. E.

colposcopic examination endometrial sampling HPV testing cervical biopsy routine Pap test in 3 years

12. This image represents a routine Pap test on a 29‑year‑old female. It is best interpreted as:

A. B. C. D. E.

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NILM, reactive cellular changes ASC-US atypical endocervical cells, favor neoplastic LSIL HSIL

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3: Normal & Benign Pap Tests Questions 13. A 39‑year‑old female had a routine Pap test. What is the correct interpretation of the cells depicted in this Pap test?

A. B. C. D. E.

repair atypical endocervical cells ASC-US HSIL IUD reactive change

14. This 62‑year‑old postmenopausal patient has a clinical history of squamous cell carcinoma of the cervix. She was treated with hysterectomy and radiation therapy. A follow-up Pap test was obtained in 6 months. These cells most likely represent?

A. B. C. D. E.

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herpes simplex virus LSIL radiation change folic acid deficiency reactive endocervical cells

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3: Normal & Benign Pap Tests Questions 15. Which of the following cytologic findings is present in this image?

A. B. C. D. E.

shift in vaginal flora cytolysis actinomycetelike organisms  Leptothrix  Candida species

16. This liquid based Pap test was obtained from a 35‑year‑old female with a malodorous vaginal discharge. These findings are most consistent with an infection from:

A. B. C. D. E.

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 Candida species herpes simplex virus cytomegalovirus  Gardnerella vaginalis  Trichomonas vaginalis

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3: Normal & Benign Pap Tests Questions 17. This liquid based Pap test was obtained from a 27‑year‑old female complaining of white vaginal discharge. These cytologic findings are consistent with which of the following infections?

A. B. C. D. E.

 Candida species herpes simplex virus cytomegalovirus  Gardnerella vaginalis  Trichomonas vaginalis

18. This squamous cell from the ectocervix is an immature cell that is round to oval and has dense cytoplasm. It has a nucleus that is usually 1/3 to 1/2 of the size of the cell. It is a(n): A. superficial cell B. intermediate cell C. parabasal cell D. basal cell E. endocervical cell 19. The majority of Pap tests are interpreted according to the 2001 Bethesda System as: A. NILM (negative for intraepithelial lesion or malignancy) B. ASC-US (atypical squamous cells of undetermined significance) C. LSIL (low grade squamous intraepithelial lesion) D. HSIL (high grade squamous intraepithelial lesion) E. ASC-H (atypical squamous cells, cannot exclude HSIL) 20. Glycogenated cells are often misinterpreted for which of the following? A. hyperkeratosis B. koilocytes C. herpes simplex virus D. parakeratosis E. squamous metaplasia 21. This benign thickening of the squamous epithelium in response to chronic irritation causes plaques of mature squamous cells without nuclei: A. squamous metaplasia B. dyskeratosis C. dysplasia D. parakeratosis E. hyperkeratosis

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3: Normal & Benign Pap Tests Questions 22. Dyskeratosis or atypical parakeratosis is considered an epithelial abnormality and should be reported as: A. NILM, reactive cellular changes B. ASC-US C. ASC-H D. LSIL E. HSIL 23. Which of the following can mimic HSIL due to nuclear irregularity? A. hyperkeratosis B. reactive cellular changes associated with trichomonads C. transitional cell metaplasia D. parakeratosis E. squamous metaplasia 24. Transitional cell metaplasia contains squamous cells with what cytologic characteristic? A. longitudinal nuclear grooves B. irregular nuclear contour C. irregular clumpy chromatin D. coarse chromatin E. high nuclear to cytoplasmic (N/C) ratio 25. Which of the following describes the condition when ciliated cells of the ectocervix are sampled? A. squamous metaplasia B. transitional cell metaplasia C. parakeratosis D. atrophy E. tubal metaplasia 26. Tubal metaplasia often can be confused morphologically with: A. ASC-US B. ASC-H C. parakeratosis D. LSIL E. HSIL 27. The detection of cilia is used to support a benign diagnosis, as cilia are typically lost with malignant tumors. This rare tumor is a ciliated carcinoma: A. leiomyosarcoma B. carcinoma of Müllerian duct origin C. spindle squamous cell carcinoma D. small cell undifferentiated carcinoma E. malignant mixed mesodermal tumor (MMMT) 28. This finding is commonly associated with high progesterone states such as contraception and postpartum: A. pseudokeratosis B. dyskeratosis C. hyperkeratosis D. parakeratosis E. tubal metaplasia

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3: Normal & Benign Pap Tests Questions 29. The small dark cells located at the center of exodus represent which of the following? A. endocervical cells B. stromal cells C. endometrial cells D. inflammatory cells E. squamous metaplastic cells 30. Endometrial cells that shed out of phase or after day 12 and are associated with actinomycetes may be due to which of the following? A. oral contraceptives B. intrauterine device (IUD) C. endometrial polyp D. endometritis E. Depo-Provera 31. High sampling at the time of performing a Pap test with an endocervical sampling device could result in the collection of which of the following? A. squamous metaplasia B. endocervical cells C. intermediate cells D. superficial cells E. lower uterine segment 32. Following total hysterectomy one may find glandular cells in a small percentage (