SAMs Guidelines
DEVELOPING SELF-ASSESSMENT MODULES
TEST QUESTIONS
Ver. #2- 5.14.16
GUIDELINES FOR DEVELOPING SELF-ASSESSMENT
MODULES TEST QUESTIONS
The USCAP is accredited by the American Board of Pathology (ABP) to offer
Self-Assessment Modules (SAMs) credits for the purpose of meeting the
ABP requirements for Maintenance of Certification (MOC).
SAMs are a specific type of Category 1 CME required by the ABP as part of
its MOC Program. These activities may be used as Category 1 CME credits
to meet CME requirements for licensure and educational requirements of
other organizations.
In order to offer SAMs credits, a post-test is required. Attendees must
achieve a pass rate of 80% to be awarded SAMs credits for the course. The
ABP requires that persons taking the test be given immediate feedback,
so please provide a brief explanation and a reference(s) for the correct
answer(s). The test will be administered online through the USCAP website.
On the preceeding pages you will find several examples of SAMs questions.
The following criteria regarding composition of test questions reflect the
format used by the National Board of Medical Examiners and the American
Board of Pathology.
1.
The test question should be an important concept that is medically
(clinically) relevant. In addition, it should correlate to a particular learning
objective, and from the pathologists’ viewpoint be fair. 2.Since this will be an online test, you may wish to include one or two still
images (not virtual slides) for the question.
3.Where possible, the question should be written as a short clinical vignette
(stem). The stem should be answerable virtually without looking at the
choices. The focus should be on information of value and problemsolving rather than common knowledge.
4.The question should be stated as a positive rather than as a negative (i.e.,
avoid the “except” and “not” items). Avoid such terms as “commonly”,
“rarely”, “frequently”, “quite often”, “occasionally”, etc.
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Palm Springs, CA 92264
5.Answer choices should be in alphabetical order and approximately the
same length and type (there is a tendency to give more information
about the correct response and therefore make it longer).
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6.The question should generally have a “single best response” (definitive
answer) and have two “distractors” (incorrect answer).
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7.Questions should be multiple-choice, with 3 answers (A through C) and
should pose a clear question.
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Suite 201
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Phone | 706.733.7550
Fax | 706.733.8033
8.For the “correct answer” please provide a few sentences explaining why
the answer is correct. You must include a pertinent reference(s).
9. F
our questions per hour of instructional time (including Q & A) are
required.
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PAGE 1
SAMPLE QUESTIONS
1) Which of the following features has not been established as a risk factor for Barrett’s esophagus-related
adenocarcinoma?
A. The presence of dysplasia
B. Length of Barrett’s esophagus
√ C. Previous history of alcohol abuse
Explanation:
Q1. There are a number of risk factors which increase the risk of adenocarcinoma in patients with Barrett’s
esophagus. Increased patient age, increased length of Barrett’s esophagus, body mass index and the
presence of either low- or high-grade dysplasia are all well established risk factors. However, a previous
history of alcohol abuse has not been shown to significantly increase this risk.
Reference:
• Wilde CT, Hardle LJ. Reflux, Barrett’s oesophagus and adenocarcinoma: burning questions. Cancer
2003;3:676.
2) Which of the following statements regarding Barrett’s esophagus-related dysplasia is correct?
A. Up to 50% of patients ultimately progress to either low- or high-grade dysplasia within 5 years of initial
diagnosis
B. The presence of inflammation always precludes a diagnosis of dysplasia
√ C. Barrett’s esophagus, negative for dysplasia, is the most common diagnosis
Explanation:
Q2. Patients with Barrett’s esophagus are at increased risk of developing adenocarcinoma, although most
patients never progress along the dysplasia/adenocarcinoma sequence. Thus, the most common diagnosis
rendered is Barrett’s esophagus, negative for dysplasia. Only a small percentage of patients with low-grade
dysplasia ever progress to high-grade dysplasia or cancer and, in fact, a diagnosis of low- or high-grade
dysplasia does not always precede a diagnosis of adenocarcinoma. Many patients with Barrett’s esophagus
have ongoing active inflammation, making a diagnosis of dysplasia difficult, but not impossible.
Reference:
• Sampliner RE. A population prevalence of Barrett’s esophagus -- finally. Gastroenterology 2005;129:2101.
3) Which of the following statements regarding Barrett’s esophagus is true?
√
A. Goblet cells must be identified in a biopsy from an area of columnar-lined esophagus
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East
B. At least 2 cm of columnar-lined esophagus is required to make a diagnosis of Barrett’s esophagus
404 Town Park Blvd.
201C. The identification of cardiac and fundic-type mucosa is sufficient to render a diagnosis of Barrett’s
Suite
esophagus
Evans, GA 30809
Phone
| 706.733.7550
Fax | 706.733.8033
Explanation:
Q3. Barrett’s esophagus can be diagnosed if an endoscopic abnormality is seen (columnar-lined esophagus)
and goblet cells are identified in a biopsy taken from the area of endoscopic abnormality. Although cardiac
and fundic-type mucosa is frequently seen in patients with Barrett’s esophagus, it is not sufficient to render
this diagnosis, as goblet cells are necessary. Although an Alcian blue stain will confirm the presence of
acid mucin in goblet cells, this stain is not required for their identification. Intestinal metaplasia of the
gastroesophageal junction seems to be a multifactorial condition which is not necessarily indicative of
Barrett’s esophagus.
Reference:
• Hirota WK, Loughney TM, Lazis DJ, et al. Specialized intestinal metaplasia, dysplasia and cancer of the
esophagus and esophagogastric junction: prevalence and clinical data. Gastroenterology 1999;116:277.
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SAMPLE QUESTIONS
4) T
his biopsy was procured from a 68-year-old male patient with longstanding gastroesophageal reflux disease. Which of the following
statements is true?
A. These cells show cytoplasm composed predominantly of acid
mucins
B. This focus is diagnostic of Barrett’s esophagus as long as it was
procured from the tubular esophagus
√C. This change is commonly seen in the distal esophagus of
patients with chronic gastroesophageal reflux disease
Click slide image to enlarge Explanation:
Q4. This biopsy reveals columnar epithelium with distended “pseudogoblet cells,” which can be easily
mistaken for true goblet cells. An Alcian blue/PAS stain would typically confirm the presence of PAS-positive
neutral mucins in these cells. This change is frequently seen in biopsies procured from the distal esophagus
in patients with chronic gastroesophageal reflux disease. The presence of this type of epithelium is not
diagnostic in and of itself of Barrett’s esophagus.
Reference:
1. Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology.
Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J
Gastroenterol 2008;103:788.
5) Which of the following statements is true regarding columnar-lined esophagus is true?
A. Columnar-lined esophagus without goblet cells has been established to have no malignant potential
B. Columnar-lined esophagus with goblet cells lining more than 3 cm of the esophagus is found in up to
40% of adult U.S. patients
√ C. Columnar-lined esophagus without goblet cells has an immunohistochemical staining pattern similar
to columnar-lined esophagus with goblet cells for antibodies to CDX2 and Das1.
Explanation:
Q5. Columnar-lined esophagus without goblet cells has been the subject of intense scrutiny over the past
few years. Although initially believed to be completely benign, there is mounting evidence to suggest that
columnar-lined esophagus without goblet cells might have premalignant potential, although the exact risk
is not known. Immunohistochemically, this type of epithelium shows very similar staining characteristics to
columnar-lined esophagus with goblet cells using antibodies to CDX2 and Das1. Several studies have found
the longer the length of columnar-lined esophagus and the greater the number of biopsies obtained, the
greater the probability of finding goblet cells.
USCAP East
404 Town Park Blvd.
Suite 201
Reference:
Evans,
GA 30809
• |H706.733.7550
ahn H, Blout PL, Ayub K, et al. Intestinal differentiation in metaplastic, non-goblet cell columnar epithelium
Phone
in the esophagus. Am J Surg Pathol 2009;33:1006.
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PAGE 3
SAMPLE QUESTIONS
6) W
hich of the following statements is true regarding the image from a
72-year-old male with a long-standing history of Barrett’s esophagus?
A. This biopsy reveals an intraepithelial proliferation
B. Up to 80% of patients with Barrett’s esophagus present with this
finding at initial diagnosis
√ C. This lesion can metastasize to lymph nodes
Click slide image to enlarge Explanation:
Q6. This biopsy shows invasion of individual cells into the lamina propria, consistent with intramucosal
adenocarcinoma. Although some patients with Barrett’s esophagus do present with this finding, most
patients have no evidence of dysplasia or adenocarcinoma in their initial diagnostic biopsy. Because there are
lymphatic channels in the esophageal mucosa, this lesion can metastasize to lymph nodes. Given this fact,
definitive therapy (either endoscopic mucosal resection or esophagectomy with or without ablation therapy)
is required. Although goblet cells may not be found in the surrounding mucosa, adenocarcinomas can
“overrun” the surrounding Barrett’s mucosa such that goblet cells may not be found.
Reference:
• Sabik JF, Rice TW, Goldblum JR, et al. Superficial esophageal carcinoma. Ann Thorac Surg 1995;60:896.
7) Which of the following statements regarding Barrett’s esophagus is true?
√A. It is a complication of chronic gastroesophageal reflux disease
B. It does not increase the risk of esophageal adenocarcinoma
C. It is associated with eosinophilic esophagitis in up to 75% of cases
Explanation:
Q7. The definition of Barrett’s esophagus has evolved over the years, but the 2008 American College of
Gastroenterology recommendations require the presence of an endoscopic abnormality and the identification
of goblet cells in a biopsy specimen from the endoscopic abnormality. This condition is known to be a
complication of chronic gastroesophageal reflux disease and is also known to increase the risk of esophageal
adenocarcinoma.
USCAP East
Reference:
404
Town Park Blvd.
Suite
201
• Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology.
Evans, GA 30809
Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J
Phone |Gastroenterol
706.733.7550 2008;103:788.
Fax | 706.733.8033
PAGE 4
SAMPLE QUESTIONS
8) Which of the following statements regarding normal colon is true?
√ A. Lamina propria cellularity decreases from the right colon to the rectum
B. Eosinophils are not a normal component of the lamina propria of the normal colon
C. Normal colon shows fewer than 5 lymphocytes/100 epithelial cells throughout the entire colon
Explanation:
Q8. The right colon has histologic differences from the left colon. In particular, there is a progressive decrease
in the lamina propria cellularity as well as a progressive decrease in the number of surface epithelial
lymphocytes as one moves from the cecum to the rectum. There can be up to 10 lymphocytes per 100
epithelial cells or even more present in the right colon. The rectum also has far more goblet cells than other
parts of the colon. Paneth cells can be present in the right colon but are not a normal component of the colon
distal to the right colon.
Reference:
• Lazenby AJ. Collagenous and lymphocytic colitis. Semin Diagn Pathol 2005;22:295.
9) Ulcerative colitis is characterized by which of the following?
A. Frequent involvement of the proximal small bowel
√B. Features of chronicity, including basal plasmacytosis and glandular distortion
C. Pyloric gland metaplasia is a consistent finding
Explanation:
Q9. Ulcerative colitis typically begins in the rectum and continues proximally in a contiguous fashion to
involve a variable portion of the colon. However, following medical therapy, ulcerative colitis can become a
patchy disease. Although there can be involvement in parts of the upper GI tract, the proximal small bowel
is not frequently involved (although it can be involved). Pyloric gland metaplasia is an inconsistent finding
and is far more characteristic of Crohn’s disease. Ulcerative colitis invariably shows feature of chronicity,
including basal plasmacytosis, glandular distortion and Paneth cell metaplasia.
Reference:
• Surawicz CM, Haggitt RC, Husseman M, et al. Mucosal biopsy diagnosis of colitis: acute self-limited colitis
and idiopathic inflammatory bowel disease. Gastroenterology 1994;107:755.
10) All of the following features are characteristic of Crohn’s disease except
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East
A. Frequent involvement of the terminal ileum
404 Town Park Blvd.
Suite
201B. Transmural lymphoid aggregates
Evans, GA 30809
√C. Diffuse involvement of the rectosigmoid colon
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Fax | 706.733.8033
Explanation:
Q10. Crohn’s disease is a patchy disease that involves any portion of the gastrointestinal tract, and frequently
involves the terminal ileum. Characteristic histologic features include transmural lymphoid aggregates, nonnecrotizing granulomas and pyloric gland metaplasia, among others. The rectum is frequently spared and, if
the distal colon is involved, it is typically involved in a patchy fashion.
Reference:
• Yantiss RK, Odze RD. Pitfalls in the interpretation of the non-neoplastic mucosal biopsies in inflammatory
bowel disease. Am J Gastroenterol 2007;102:890.
PAGE 5
SAMPLE QUESTIONS
11) W
hich of the following is the most likely explanation for the changes
seen in the image taken from the transverse colon in a 25-year-old male
with diarrhea?
A. Granuloma secondary to Crohn’s disease
B. Sarcoidosis
√C. Crypt rupture granuloma
Click slide image to enlarge Explanation:
Q11. This image shows evidence of neutrophil-mediated crypt injury with extravasation of mucin into the
lamina propria causing a foreign body histiocytic response, also known as a crypt rupture granuloma.
Although granulomas can be seen in a number of settings, including Crohn’s disease, sarcoidosis and a
variety of infectious colitides (including Histoplasmosis), this image clearly shows the granuloma arising
secondary to crypt rupture.
Reference:
• Pierik N, De Hertogh G, Vermeire S, et al. Epithelioid granulomas, pattern recognition receptors and
phenotypes of Crohn’s disease. Gut 2005;54:233.
12) This image is from a colectomy specimen from a 32-year-old male with
bloody diarrhea. Which of the following statements is correct?
√
A. Diffuse chronic mucosal changes would be an expected
histologic finding
B. The creation of an ileal pouch-anal anastomosis is
contraindicated
C. Transmural lymphoid aggregates would be an expected
histologic finding
Click slide image to enlarge Explanation:
Q12. This colectomy shows involvement of the rectum which continues proximally in a contiguous fashion
to involve much of the colon. The right colon appears to be grossly normal. The gross characteristics are
entirely consistent with ulcerative colitis. As such, one would not expect transmural lymphoid aggregates or
involvement
of the terminal ileum since the cecum appears to be normal. Sections from the grossly involved
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East
mucosa
would be expected to show diffuse chronic mucosal alterations. Ulcerative colitis (like Crohn’s
404 Town
Park Blvd.
disease) increases the risk of colorectal cancer.
Suite 201
Evans, GA 30809
Phone | 706.733.7550
Reference:
Fax
| 706.733.8033
• Tanaka M, Riddell RH, Saito H, et al. Morphologic criteria applicable to biopsy specimens for effective
distinction of inflammatory bowel disease from other forms of colitis and of Crohn’s disease from ulcerative
colitis. Scand J Gastroenterol 1999;34:55.
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