AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
Reid (page 168)
1. Which of the following is most supportive of a diagnosis of intraductal
papillary mucinous neoplasm (IPMN)
A. Mutations of the von Hippel-Lindau (VHL) gene
B. Mutations of GNAS
C. Mutations of β-catenin
D. Mutations of DAXX and ATRX genes
A. Diffuse nuclear positivity for p53 supports the diagnosis of pancreatic neuroendocrine
tumor.
B.Strong nuclear staining with p53 is supportive of a diagnosis of pancreatic ductal
adenocarcinoma.
C. Loss of DAXX and ATRX immunostaining supports the diagnosis of acinar cell carcinoma.
D. Nuclear positivity for E-cadherin supports the diagnosis of pancreatoblastoma.
2. A 25-year-old woman presents with vague abdominal pain and a 5.0-cm cystic
pancreatic tail mass composed of vague papillary groups lined by overlapping
epithelial cells with vesicular nuclei, powdery chromatin, and longitudinal nuclear
grooves. The diagnosis of solid pseudopapillary neoplasm is supported by
A. pure cytoplasmic positivity for β-catenin in tumor cells.
B. nuclear positivity for β-catenin in tumor cells.
C. KRAS mutation.
D. diffuse nuclear positivity for p53 in tumor cells.
4. Which of the following genetic syndromes increases the risk of pancreatic
ductal adenocarcinoma?
A. Multiple endocrine neoplasia type 1 (MEN1) syndrome
B. VHL syndrome
C. Familial atypical multiple mole melanoma syndrome
D. Neurofibromatosis type 1
3. Which statement is correct regarding the immunohistochemical diagnosis of
pancreatic neoplasms?
5. Which of the following genetic syndromes is not associated with pancreatic
neuroendocrine neoplasms?
A.MEN1
B.MEN2
C. VHL syndrome
D. Tuberous sclerosis complex
Sakandé (page 181)
1. Prior to implementation of an external quality assessment (EQA) program for
medical laboratories, what was the percentage of laboratories in Burkina Faso
that failed to meet the basic requirements for adequate functioning due to lack of
laboratory supplies, reagents, and equipment or to poor laboratory infrastructure?
A.>80%
B.50%-70%
C.40%-50%
D. <35%
2. As discussed in this paper, a study of a sub-Saharan region laboratory
practice disclosed that 55% of errors that accounted for unsatisfactory
proficiency testing were due to what?
A. Clerical errors
B. Methodological errors
C. Random errors
D. Technical problems
3. What was the main challenge faced in the implementation of the EQA
program in Burkina Faso, as described in this paper?
A. The lack of technical staff for the results analysis
B. The poor commitment of health authorities in the program
C. The poor participation of the targeted laboratories
D. Limited access to good quality EQA materials production
4. Reliability of transportation to deliver test materials in a timely fashion is
critical to success of an EQA program, and in Burkina Faso this necessitated
that test materials be delivered by what means?
A. Local postal distribution network
B.DHL
C. Special vehicles from the Ministry of Health
D. Private transport companies
5. What were the main lessons learned in the implementation of the EQA program?
A. An EQA program is an effective tool to identify and close poor performing laboratories.
B. A sustainable EQA program can only be implemented using external funding agencies.
C. Strong in-country government support can be crucial for the program acceptance.
D. A special focus should be on the statistical treatment of results in order to reinforce
the program.
Kibet (page 188)
1. Which one of the following preanalytic laboratory errors has the greatest
potential for patient harm?
A. Requisition error
B. Patient identification error
C. Sample re-collection
D. Delay in sample collection
2. Which one of the following is true about Six Sigma?
A. It was originally developed as a tool for measuring clinical outcome in hospitals.
B. Improvement is noted by a declining sigma value so that a negative number is desirable.
C. The values are based on a logarithmic scale.
D. A 50% decrease in error rate corresponds to a one sigma improvement.
3. Which one of the following would be considered an analytical error?
A. Failure to run an external quality assessment within the specified time
B. Mislabeled specimen
C. Sample mix-up
D. Failure to call a provider to report a critical value
4. Which one of the following programs has been established to support efforts
or strengthen national laboratory systems in developing countries?
A. President’s Emergency Plan for AIDS Relief (PEPFAR)
B. Strengthening Laboratory Quality Improvement Process Towards Accreditation (SLIPTA)
C. South African National Accreditation System (SANAS)
D. National External Quality Assessment Service (NEQAS)
5. Hospitals in resource-poor areas such as sub-Saharan Africa seldom pursue
accreditation for what reason?
A. Qualified personnel are unavailable.
B. The use of laboratory testing is too limited to justify accreditation.
C. Syndromic and algorithmic approaches to disease are successful approaches to maintain lab quality.
D. Laboratory information systems are required, but laboratories do not have them.
DeMarco (page 204)
1. Hospital-acquired urinary tract infections (UTIs) comprise what proportion of
nosocomial infections?
A.10%
B.25%
C.40%
D.75%
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2. Which of the following has the greatest analytical sensitivity for the detection
of UTI?
A. Diafiltration matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS)
B. Urine culture
C. Flow cytometry with automated microscopy
D. Urine dipstick for nitrite detection
© American Society for Clinical Pathology
AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
3. MALDI-TOF MS clinical assays perform microbial identification by matching
the mass spectrum generated from the specimen in question to what?
A. The spectra from the positive controls on the MALDI plate
B. A library of fragment ions generated by tandem mass spectrometry of known isolates
C. A database of tryptic microbial peptides
D. A spectral database generated using known isolates
4. A technologist is performing the diafiltration MALDI-TOF MS test to identify a
microorganism from a patient’s urine specimen. To enable detection of Candida
albicans, which of the following steps is recommended?
A. Overlaying formic acid on the sample spot on the MALDI target plate
B. Using a fungal-specific diafiltration device
C. Increasing dilutions of the sample prior to testing to reduce turbidity
D. Decreasing the concentration of matrix applied to the MALDI target plate
5. A physician orders a diafiltration MALDI-TOF MS test for a patient with
a suspected UTI. In 2 hours the results are available, and the specimen is
positive for Klebsiella pneumoniae. What information is immediately available
that the physician can utilize as part of the decision process for selecting an
antimicrobial therapy?
A. Local antibiogram
B. Blood culture
C. Urine culture
D. Antibiotic susceptibility test
Vollmer (page 213)
1. Counts of things through a microscope are related to which of the following
probabilistic models?
A. Normal distribution
B. Lognormal distribution
C. Poisson distribution
D. c2 distribution
2. What is an unbiased way to count mitotic figures?
A. To use systematic random sampling
B. To pick one field at random and count it
C. To pick the “hot spot” and count it and contiguous fields
D. To count 10 microscopic fields
3. Finding no mitotic figures in a melanoma implies that the mitotic index is what?
A.Low
B. High, but missed
C. Unknown, but probably low
D. Unknown, but it depends on how many fields were sampled
4. The mitotic index derived from the “hot spot” method is likely to
A. underestimate the mitotic index for the whole tumor.
B. have nothing to do with the underlying mitotic index.
C. have nothing to do with the Poisson distribution.
D. overestimate the mitotic index for the whole tumor.
5. An unbiased estimate of the mitotic index for a melanoma is provided by
which of the following?
A. The mean mitotic count per field
B. The mean mitotic count per field divided by the microscopic field area
C. The “hot spot” count
D. The “hot spot” count divided by the microscopic field area
Luong-Player (page 219)
1. Which of the following markers is useful in differentiating low-grade renal
cell carcinoma (RCC) from benign renal tubules in a biopsy sample?
A.CD10
B.PAX8
C. Carbonic anhydrase (CA) IX
D.P504S
2. CA IX is frequently expressed in which of the following tumors?
A. Chromophobe RCC
B. Clear cell RCC
C.Seminoma
D. Breast carcinoma
3. Which of the following immunohistochemistry (IHC) panels is the most useful in
the distinction of intrahepatic cholangiocarcinoma from hepatocellular carcinoma?
A. MOC31/CA IX/Arginase-1
B. mCEA/PAX8/CA IX
C. Glypican 3/HepPar1/Arginase-1
D.AFP/HepPar-1/CD10
4. Which of the following statements regarding CA IX is correct?
A. CA IX is never expressed in areas of tumor necrosis or immediately adjacent to the
necrotic areas.
B. CA IX is a nuclear transcription factor that plays a crucial role in cellular homeostasis,
adhesion, and proliferation.
C. Strong and diffuse CA IX staining is rarely seen in prostatic adenocarcinomas, lowgrade breast adenocarcinomas, and renal oncocytomas.
D. CA IX expression is not seen in papillary RCC.
5. Which of the following IHC panels is the most useful in differentiating clear
cell RCC from uterine clear cell carcinoma?
A.PAX8/VHL/HNF-1B/ER
B.PAX8/RCC/CK7/WT1
C. CK7/CD10/CA IX/RCC
D.VHL/RCC/ER/p53
Qian (page 226)
1. In non–small cell lung carcinoma (NSCLC) cells and interstitial tissue,
immunohistochemical staining for tumor necrosis factor superfamily member 13
(TNFSF13) reveals positive staining predominantly localized to the what?
A.Plasmalemma
B.Cytoplasm
C. Cytoplasmic membrane
D.Nucleus
2. In NSCLC tissues and matched peritumoral lung tissues, TNFSF13-positive
staining is predominantly localized to which?
© American Society for Clinical Pathology
A. Tumor cells
B. Interstitial tissue
C.Fibroblasts
D. Tumor cells and interstitial tissue
3 Overexpression of TNFSF13 in NSCLC cancer fibroblasts was associated with
what?
A. Tumor diameter
B. Histologic type
C. Lymph node metastasis
D. Gender and lower differentiation
Am J Clin Pathol 2014;141:292-295
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AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
4. Kaplan-Meier survival curves in NSCLC suggest that higher expression of
TNFSF13 in carcinoma cells is associated with what?
A. Shorter overall survival
B. Longer overall survival.
C. No difference in overall survival
D. Similar early survival differences with significant changes in late (>5 year) survival
5. Overexpression of TNFSF13 in patients with NSCLC is
A. more frequently high in squamous than in adenocarcinomas of lung.
B. highly associated with TNM cancer stage.
C. linked to poor overall survival when carcinoma cells are positive but when nearby
stromal cells are negative for expression of TNFSF13.
D. more commonly seen in older patients.
Lehman (page 234)
1. Which of the following is most suggestive of a diagnosis of IgG4-related skin
disease?
A. Patient history of IgG4-related pancreatitis, with a plasmacytic infiltrate in the skin
B. Skin biopsy showing storiform fibrosis, obliterative phlebitis, and lymphoplasmacytic
inflammation
C. Skin biopsy showing storiform fibrosis and many IgG4-positive plasma cells (225/highpower field [hpf])
D. Skin biopsy with storiform fibrosis and tissue IgG4/IgG ratio of 0.3
2. Which of the following excludes a diagnosis of IgG4-related skin disease?
A. Absence of tissue IgG4-positive plasma cells in skin biopsy
B. Normal serum IgG4 level
C. Tissue density of IgG4-positive plasma cells of 100/hpf in skin biopsy
D. Tissue IgG4/IgG ratio of 0.7 in skin biopsy
3. In which of the following conditions is the IgG4 subclass of autoantibodies
thought to be pathogenic?
A. Lupus panniculitis
B. Necrobiotic xanthogranuloma
C. Plasma cell balanitis
D. Pemphigus vulgaris
4. A 65-year-old man with a history of cholecystitis, pancreatitis, and
sialadenitis developed ill-defined erythematous papules on his flank. His
internist suspected IgG4-related disease as a unifying diagnosis. A skin biopsy
was performed, and the interpreting pathologist commented that 12 IgG4positive plasma cells per high powered field were observed in the most involved
areas. Which of the following statements is most accurate?
A.Correlation with serum IgG4 levels and biopsy findings from other organs or repeat
skin biopsy is recommended before determining whether he has IgG4-related disease.
B. On the basis of the skin biopsy findings, a diagnosis of IgG4-related disease is confirmed.
C. On the basis of the skin biopsy findings, a diagnosis of IgG4-related disease is refuted.
D. Immunohistochemistry studies were not indicated in this case.
5. Which of the following conditions is most likely to display elevated tissue
levels of IgG4-positive plasma cells?
A. Lupus panniculitis
B.Morphea
C.Pemphigus
D.Scleroderma
Barron (page 239)
1. High-risk human papillomavirus (HPV)+ rate in patients with low-grade
squamous intraepithelial lesion/cannot exclude high-grade squamous
intraepithelial lesion (LSIL-H) is ____ the rate in patients with HSIL.
A. lower than
B. higher than
C. equal to
D. unknown compared to
2. High-risk HPV+ rate in patients with LSIL-H is ____ the rate in patients with LSIL.
A. lower than
B. higher than
C. equal to
D. unknown compared to
3. Follow-up histopathologic cervical intraepithelial neoplasia (CIN) 2/3+ rate
in patients with LSIL-H is ____ the rate in patients with high-grade squamous
intraepithelial lesion (HSIL).
A. lower than
B. higher than
C. equal to
D. unknown compared to
4. Follow-up histopathologic CIN 2/3+ rate in patients with LSIL-H is ____the
rate in patients with atypical squamous cells/cannot exclude HSIL.
A. lower than
B. higher than
C. equal to
D. unknown compared to
5. Which of the following would be an appropriate follow-up method for
patients with LSIL-H?
A. Reflex high-risk HPV testing
B. Loop electrosurgical excision procedure or cone biopsy
C. Colposcopy with biopsy
D. Repeat cytology in 1 year
Gibson (page 247)
1. Which of the following is an advantage of classical cytogenetic studies over
array-based karyotyping in lymphoid neoplasms?
A. Higher resolution compared to single nucleotide polymorphism (SNP) array analysis
B. Detection of uniparental disomy
C. Identification of interstitial deletions of less than 5 Mb in size
D. Ability to identify balanced chromosomal abnormalities
2. Array-based karyotyping using SNP arrays or array-based comparative
genomic hybridization may be particularly useful in the evaluation of lymphoid
neoplasms because these platforms
A. detect balanced translocations.
B. require less than 5% neoplastic cells to detect copy number abnormalities.
C. do not require dividing cells.
D. easily distinguish tumor subclones.
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3. Classical cytogenetic studies of a lymph node biopsy with marginal zone
lymphoma demonstrate 47,XX,+18 in three metaphase cells; however, the SNP
array studies do not. What is the most likely explanation for this discordant
result?
A. Insufficient proportion of neoplastic cells in the lymph node
B. SNP array analysis does not identify extra whole chromosomes
C. Spurious classical cytogenetic results due to a culture artifact
D. SNP analysis is best at identifying chromosomal deletions
4. Fluorescence in situ hybridization studies are more appropriate than SNP
array analysis in lymphoid neoplasms where
A. there are only 50% neoplastic cells.
B. the proliferative fraction is very low.
C. a chromosomal translocation is important.
D. copy number variations are important
© American Society for Clinical Pathology
AJCP Journal CME/SAM
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
To complete an exam, go to www.ascp.org/ajcpcme. Call 800.267.2727 for ASCP Customer Service.
5. Classical cytogenetic studies may detect numerical chromosomal
abnormalities not identified with SNP array analysis because the abnormality is
A. in a small proportion of cells that are very proliferative.
B. too small to be detected by SNP analysis.
C. too large to be detected by SNP analysis.
D. only in nonproliferative cells.
Harm (page 256)
1. In this study there were 66 sickle cell disease patients who were
alloimmunized. How many of the alloimmunized patients had at least one
alloantibody evanesce at some time during their transfusion history?
A. 6 (9%)
B. 20 (30%)
C. 42 (64%)
D. 58 (88%)
2. What percentage of alloimmunized sickle cell disease patients with at least
one evanesced antibody received RBC transfusions at nonindex hospitals (ie,
hospitals that did not originally identify the alloantibody)?
A.95%
B.90%
C.45%
D.29%
3. How many of the 42 alloimmunized sickle cell disease patients with at least 1
evanesced antibody were admitted ≥20 times for transfusion at a nonindex hospital?
A. 38 (90%)
B. 20 (48%)
C. 12 (29%)
D. 4 (10%)
4. What is the advantage of a centralized transfusion service database over
regional transfusion registries?
A. The patient safety benefit of the centralized database is dependent on voluntary entry
by participating hospitals.
B. The patient’s alloantibody history, transfusion history, product modification requirements, and current type and screen results are all present in a single database that
is used for routine compatibility testing that is accessible at each hospital within the
centralized transfusion service network.
C. Central databases can be easily accessed and manipulated by hospitals outside of the
centralized transfusion service.
D. Central database data are better at predicting delayed transfusion reactions.
5. Why is it important to keep track of all (current and historical) alloantibodies
in sickle cell disease patients?
A. To prevent future alloimmunization
B. To prevent future episodes of antibody evanescence
C. To provide RBC transfusions that are compatible with all identified antibodies and help
prevent delayed hemolytic transfusion reactions
D. To maintain the proficiency of reference laboratory technologists
Cho (page 268)
1. Posttransplant lymphoproliferative disorder (PTLD) comprises abnormal B- or
T-cell proliferations in which setting?
A. Increased T-cell immune surveillance
B. Decreased T-cell immune surveillance
C. Increased B-cell immune surveillance
D. Decreased B-cell immune surveillance
2. What is the most suitable test for routine monitoring for PTLD development in
transplant recipients?
A. Cytomegalovirus (CMV) antigenemia assay
B. Whole blood Epstein-Barr virus (EBV) viral load
C. Whole blood CMV viral load
D. EBV-encoded small RNA (EBER) in situ hybridization in biopsy specimen
3. What are the two high-incidence periods most common for PTLD?
A. In the first month after transplantation and between 12 and 16 months posttransplant
B. In the first year after transplantation and >3 years posttransplant
C. 14-16 months posttransplant and >5 years posttransplant
D. 2-3 years posttransplant and >5 years posttransplant
4. Shorter latency periods for onset of PTLD were seen in patients with
A. solid organ transplants rather than hematopoietic stem cell transplants.
B. monomorphic PTLD.
C. polymorphic PTLD.
D. the lowest viral levels.
5. To avoid confounding differences in reference ranges between laboratories,
prediction of PTLD is best made by
A.quantitating the number of nuclei by EBER in situ hybridization and comparing the
change in nuclear staining over time.
B. measuring peak CMV antigen levels and rate of increase of CMV antigen.
C. measuring peak CMV viral load and rate of increase of CMV.
D. measuring peak EBV viral load and rate of increase of EBV.
Damlaj (page 288)
1. The majority of reported cases of ALECT-2 amyloidosis have been found in
which group?
A. Hispanic patients with renal involvement
B. Elderly patients with gastrointestinal involvement
C. Female patients with hepatic involvement
D. Human immunodeficiency virus–positive patients with cerebral involvement
2. ALECT-2 amyloidosis may be amenable to treatment with liver transplantation
because the protein
A. is only deposited in its wild-type form.
B. is found in a periportal distribution in the liver.
C. only deposits as amyloid after being mutated in the liver.
D. is produced exclusively by the liver.
3. Compared to immunohistochemistry techniques, laser microdissection and
mass spectrometry is
© American Society for Clinical Pathology
A. cheaper and more readily available.
B. more sensitive for detecting wild-type amyloid proteins.
C. more sensitive for detecting smaller amyloid proteins.
D. more sensitive for detecting AL but not AA amyloid subtypes.
4. What is the typical pattern of ALECT-2 type amyloid deposition?
A. Globular and congo red negative
B. Globular and congo red positive
C. Linear and congo red negative
D. Linear and congo red positive
5. ALECT-2 amyloid is the most common form of amyloidosis in which group?
A. Patients with renal amyloid
B. Patients with hepatic amyloid causing portal hypertension
C. Patients with non-AA, non-AL type proteins
D. Patients who fail to respond to immunosuppressive therapy
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