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.
Jevremovic (page 292)
1. Flow cytometry immunophenotyping of bone marrow aspirates in chronic
myeloid malignancies is
A. definitively diagnostic.
B. not useful.
C.essential.
D. complementary to clinical, morphologic, and genetic studies.
2. What is the preferred cell type for flow cytometry immunophenotyping in
chronic myeloid neoplasms?
A.Blasts
B.Lymphocytes
C.Monocytes
D.Eosinophils
3. The quantitative approach in flow cytometry immunophenotyping
A. relies on visual recognition of clusters and/or relational patterns.
B. is instrument independent.
C. is easy to implement.
D. is observer independent.
4. Qualitative approach in flow cytometry immunophenotyping
A. is highly reproducible.
B. relies on visual recognition of clusters and/or relational patterns.
C. utilizes mean fluorescence intensity.
D. is easy to implement.
5. Normal CD34-positive myeloid blasts are
A. always positive for CD7.
B.CD45bright
C. Heterogeneous on CD13/HLA-DR plot
D.CD117-negative
Welsh (page 307)
1. Digibind can reverse cardiac toxicity from toxins produced by plants, but it is
not used for the botanical extract produced by which of the following?
A.Oleander
B. Lily of the valley
C.Foxglove
D. Willow bark
2. LOCI digoxin assay utilizes an antibody directed against digoxin. What is the
antibody?
A. Mouse monoclonal antibody
B. Sheep polyclonal antibody
C. Rabbit polyclonal antibody
D. Goat polyclonal antibody
3. Poisoning with lily of the valley can be indirectly identified by LOCI digoxin
assay. What is the lowest concentration tested that can be detected by
apparent digoxin concentration?
A. 10 ng/mL
B. 100 ng/mL
C. 250 ng/mL
D. 1 µg/mL
4. Convallatoxin interferes with serum digoxin measurement using LOCI
digoxin assay by falsely decreasing or increasing digoxin value (negative/
positive interference). The positive interference is observed beginning at what
concentration of convallatoxin?
A. 10 ng/mL
B. 100 ng/mL
C. 250 ng/mL
D. 1 µg/mL
5. Digibind neutralizes convallatoxin in vitro. This can be monitored by measuring
free digoxin because convallatoxin bound to
A. albumin does not pass through the filter.
B. albumin passes through the filter but does not cross-react with antibody.
C. Digibind does not pass through the filter.
D. albumin and convallatoxin bound to Digibind do not pass through the filter.
Frank (page 313)
1. Tumor resection is recommended for intraductal papillary mucinous
neoplasm when high-risk features, such as cyst size >3 cm, main duct
involvement, and elevated carcinoembryonic antigen levels, have been
identified. What percent of these cysts are noted to demonstrate a nonmalignant
diagnosis following resection?
A. Approximately 5%
B. Approximately 20%
C. Approximately 50%
D. Approximately 80%
2. Mesothelin, a differentiation antigen, is not observed in which of the
following pancreatic tumors?
A. Intraductal papillary mucinous neoplasm
B. Serous cystadenoma
C. Mucinous cystadenoma
D. Mucin-secreting pancreatic adenocarcinoma
© American Society for Clinical Pathology
3. Mesothelin, in the context of pancreatic cysts, is important to study for what
reason?
A. The function of mesothelin is very well understood in the context of cysts.
B. As in pancreatic adenocarcinoma, its expression may serve as a potential therapeutic
target.
C. Irrespective of the type of cyst, expression of mesothelin will aid in distinguishing
cystic from noncystic tumors.
D. Mesothelin expression is similar in all pancreatic cysts.
4. Diffuse and intense mesothelin staining was found in about 86% of which of
the following?
A. Serous cystadenoma
B. Benign pancreatic ductal epithelium
C. Adjacent gastric and duodenal mucosa
D. Pancreatic adenocarcinoma
5. Diffuse mesothelin expression is more frequently observed in neoplastic
epithelium of which of the following?
A. Intraductal papillary mucinous neoplasm
B. Mucinous cystic neoplasm
C. Adjacent gastric and duodenal mucosa
D. Serous cystadenoma
Am J Clin Pathol 2014;142:419-422
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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.
Nelles (page 331)
1. Platelet activation in the heparinized sample for Platelet Mapping may result
in what?
A. Overestimation of maximum amplitude due to fibrin alone (MAFibrin)
B. Reduced numbers of platelet microvesicles in the sample
C. Underestimates of percent adenosine diphosphate (ADP) and percent arachidonic acid
(AA) inhibition
D. Falsely increased platelet counts in the sample
2. Heparin induced thrombocytopenia type 1 is due to what?
A. Activation of the platelet ADP receptor by heparin
B. Immune-mediated activation of platelets by antibodies to heparin/platelet factor 4
complex
C. Direct activation of platelets by heparin alone though the GPIIb/IIIa receptor
D. Inhibition of AA
3. In the Platelet Mapping assay, reduced MAADP compared to MAThrombin in
subjects not on ADP receptor blockers is associated with which of the following?
A. Falsely reduced MAFibrin
B. Falsely increased percent ADP inhibition estimates
C. Falsely decreased percent AA estimates
D. Reduced thrombin inhibition by argatroban
4. In the Platelet Mapping assay, MAFibrin alone is measured how?
A. By adding reptilase to heparinized whole blood
B. By adding activated factor XIII to heparinized whole blood
C. By adding reptilase and activated factor XIII to heparinized whole blood
D. By adding thrombin to citrated blood
5. Correction by the addition of eptifibatide indicates that the falsely increased
MAFibrin values were due to what?
A. Unanticipated thrombin generation in the heparinized sample
B. Inhibition of ADP in the heparinized sample
C. Inhibition of AA in the heparinized sample
D. Platelet activation in the heparinized sample
Turakhia (page 339)
1. What is the prognosis of double-hit lymphoma with translocations involving
MYC and BCL2?
A. Similar to that of Burkitt lymphoma (BL)
B. Similar to that of diffuse large B-cell lymphoma (DLBCL), not otherwise specified
C. Superior to that of BL
D. Worse than that of BL or of DLBCL, not otherwise specified
2. As consequences of translocations involving MYC and BCL6, how are protein
levels affected?
A. Increased for MYC and BCL6
B. Increased for MYC, decreased for BCL6
C. Decreased for MYC, increased for BCL6
D. Decreased for MYC and BCL6
3. Clinical characteristics of double-hit lymphomas with translocations involving
MYC and BCL6 include which of the following?
A. Male predominance
B. Localized presentation
C. Advanced stage at presentation
D. Association with low-grade lymphomas
4. What is the karyotype of BL?
A. Complex, including translocations involving MYC
B. Complex, without translocations involving MYC
C. Simple, with translocations involving MYC
D. Simple, without translocations involving MYC
5. Most cases of double-hit lymphomas with translocations involving MYC and
BCL6 have an immunophenotype corresponding to what?
A. Germinal center B cells
B. Activated B cells
C.Plasmablasts
D. Reed-Sternberg cells
Flatley (page 347)
1. Prolymphocytic leukemia (PLL) is defined how?
A.Immature B-cell lymphoma in which prolymphocytes comprise more than 33% of
circulating B cells
B.Immature B-cell lymphoma in which prolymphocytes comprise more than 55% of
circulating B cells
C. Mature B-cell lymphoma in which prolymphocytes comprise more than 33% of circulating B cells
D.Immature B-cell lymphoma in which prolymphocytes comprise more than 55% of
circulating B cells
2. A 70-year-old man with several weeks of progressive fatigue and
splenomegaly (19 cm) without lymphadenopathy has a WBC count of 87 × 103/
µL (normal, 4.5-11 × 103/µL) with 90% lymphocytes, hemoglobin level of 10 g/
dL (normal, 14-17.5 g/dL), and a platelet count of 53 × 103/µL (normal, 150-450 ×
103/µL). Lymphocytes show round to slightly irregular nuclei, prominent central
nucleoli, and moderate amount basophilic cytoplasm. Flow cytometry analysis
reveals a monoclonal B-cell population, positive for CD5, CD19, CD20, and
surface l light chain and negative for CD10, CD23, and CD103. Which additional
test is necessary for a definitive diagnosis using current specimen?
A. BRAF mutation analysis
B. Complete cytogenetic karyotype
C. Fluorescence in situ hybridization (FISH) analysis for translocations involving MYC
and CCND1
D. IgH gene rearrangement by polymerase chain reaction
3. After CBC count and flow cytometry analysis results from question 1, a bone
marrow aspirate was submitted for karyotyping and FISH studies. H&E-stained
sections of bone marrow biopsy revealed markedly hypercellular bone marrow
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with diffuse lymphocytic infiltrates. The lymphocytes have prominent central
nucleoli and a moderate amount of clear cytoplasm with rare mitotic figures.
Which pair of immunohistochemistry stains is necessary for definitive diagnosis?
A. Ki67 and p53
B. Bcl-2 and Bcl-6
C. Cyclin D1and SOX11
D. CD5 and CD10
4. The cytogenetic analysis of the bone marrow aspirate of the patient reported
the following karyotype: 46,XY,t(8;14)(q24.1;q32)[2]/46,XX[19]. FISH confirmed
t(8;14) MYC rearrangement, but no aberrations involving BCL2, BCL6, or CCND1
were identified. What is the final diagnosis?
A. Mantle cell lymphoma, leukemic phase
B. Hairy cell leukemia
C. Burkitt lymphoma, leukemic phase
D. B-cell PLL
5. Emerging data have shown that MYC gene aberrations are not limited to
Burkitt lymphoma. MYC aberrations have been shown to occur in many types
of B-cell lymphomas, with the prevalence estimated at 20%. So far, MYC
aberrations have been shown to occur as translocations, gene copy number
increase, increased mRNA accumulation, and highly expressed Myc protein
level. Which type of MYC abnormality is required but not limited to the diagnosis
of Burkitt lymphoma?
A. MYC translocation
B. Increase in MYC gene copy number
C. Increase in mRNA accumulation
D. High Myc protein expression
© 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.
Williams (page 355)
1. Use of which of the following tissue-marking dye (TMD) color combinations
would be optimal to ensure the individual colors are easily distinguished from
one another microscopically?
A. Red, yellow, blue, green
B. Green, black, orange, brown
C. Red, green, black, blue
D. Blue, green, red, violet
2. Which of the following statements is true regarding the reliability of TMD
through tissue processing?
A.All commercially produced TMDs reliably survive tissue processing with adequate
microscopic color fidelity.
B. Artists’ acrylic ink cannot reliably be used as a substitute for any color of commercial
TMD.
C. The use of an acid mordant, such as 5% acetic acid, changes the color of some commercial TMDs and artists’ acrylic ink.
D.Some commercially produced TMD and artists’ acrylic ink may change or lose their
color in routine tissue processing.
3. Which of the following statements is true regarding the microscopic color of
TMD or artists’ acrylic ink?
A.The microscopic colors red, orange, and yellow should never be used together or
individually.
B. Certain color combinations may lead to difficulty distinguishing specific colors microscopically with some manufacturers’ products but not others.
C. The apparent microscopic color of TMD or artists’ acrylic ink is never relevant if the
intended margin is described in the block legend.
D. All surgical pathology specimens should be marked with at least two colors of TMD
that are easily identified microscopically.
4. Based on the results of this study, which of the following should be considered
by surgical pathology laboratories using more than one color of TMD?
A. Ensure that gross room staff have access to the seven standard colors (black, green,
blue, red, orange, yellow, violet) of TMD for use in routine surgical pathology specimens.
B. Purchase multiple products from various manufacturers and have all products available for gross room staff to select from based on the preferences of individual pathologists within the department.
C. Restrict use of TMD to products that have been systematically tested and reviewed
simultaneously in their own laboratory and ensure pathologists are familiar with the
microscopic appearance of each approved product.
D.Restrict use of TMD to black only and define grossing protocols that adequately
sample specimens based on this restriction.
5. Which of the following statements is true regarding the red TMD color?
A. Red TMD color from most manufacturers (DMS, Daler-Rowney) survives routine tissue
processing.
B. Red TMD color is most effective when used in red/orange and red/violet color combinations.
C. Red TMD color can be safely and reliably used in routine practice when used with
black, green, and blue color combinations.
D. Red TMD from CDI and Daler-Rowney may not survive tissue processing with reliable
color integrity.
Larson (page 370)
1. European League Against Rheumatism (EULAR) criteria for a diagnosis of
Henoch-Schönlein purpura (HSP) require which of the following?
A. Palpable purpura
B. Renal involvement
C. Altered mentation
D. Localized abdominal pain with arthralgias
2. Compared to HSP in children, HSP in adults is
A. more apt to include palpable purpura as a sign.
B. more likely to progress to chronic renal failure.
C. more often associated with immunoglobulin (Ig) G deposition in vasculitic lesions.
D. a more common disease in adults than in children.
3. What is the positive predictive value (PPV) of immunofluorescence reported
in this article for vascular IgA in patients meeting EULAR criteria for HSP?
A.0.9
B.0.6
C.0.3
D.0.1
4. A patient not meeting EULAR criteria with low clinical suspicion for HSP tests
strongly positive for vascular IgA. Given the PPV reported in this article, what is
the chance the patient actually has HSP?
A.88%
B.67%
C.48%
D.14%
5. Comparing reported immunofluorescence studies for vascular IgA in mixed
populations of children and adults compared to adults only, which of the
following statements is true?
A. The PPV is higher in the mixed group than in adults only.
B. The negative predictive value is higher in the mixed group than in adults only.
C. The sensitivity is higher in the mixed group than in adults only.
D. The specificity is higher in the mixed group than in adults only.
Barresi (page 375)
1. Colorectal carcinoma with micropapillary pattern is a tumor characterized by
which of the following?
A. Micropapillae with fibrovascular cores
B. Low incidence of nodal metastases
C. At least 50% of micropapillae
D.Clusters of neoplastic cells surrounded by clear spaces and showing inverted cell
polarity
2. What is micropapillary pattern characterized by?
A. MUC1 stain in the cell membrane towards the stromal pole
B. Absence of MUC1 stain
C. MUC1 stain in the cytoplasm
D. Presence of MUC2 stain
3. Poorly differentiated clusters in colorectal cancer are defined how?
A. Clusters of neoplastic cells composed of <5 cells
B. Clusters of neoplastic cells composed of ≥5 cells in the absence of glandular formation
© American Society for Clinical Pathology
C. Clusters of neoplastic cells in the invasive front of the tumor
D. An association with low incidence of nodal metastases
4. For grading of colorectal cancer, poorly differentiated clusters should be
counted how?
A. At the invasive front of the tumor
B. Under ×20 objective lens in the area with the highest number of clusters
C. By using D2-40 immunohistochemical stain
D. Under ×40 objective lens
5. E-cadherin immunohistochemical stain in colorectal cancer is normally seen
where?
A. In the cytoplasm
B. At the cell membrane
C. At the invasive front of the tumor
D. In tumor budding foci
Am J Clin Pathol 2014;142:419-422
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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.
Seo (page 384)
1. What is the gold standard test for the confirmative diagnosis of Mycobacterium
tuberculosis infection?
A. Nested polymerase chain reaction (PCR) of M tuberculosis
B. Microbiological culture
C. Real-time PCR for M tuberculosis
D.Histologic evaluation and special stains of formalin-fixed, paraffin-embedded (FFPE)
tissue
2. What is the major limitation of the microbiological culture test for detecting M
tuberculosis?
A. It takes a long time to obtain the result.
B. It has low specificity.
C. It cannot be performed on fresh samples.
D. It requires the presence of granulomas for microbial detection.
3. Which of the following is not the advantage of real-time PCR over the
other tests, including culture, nested PCR or acid-fast bacilli (AFB) staining for
detecting M tuberculosis?
A. The postamplification steps of gel electrophoresis are needed.
B. The possibility of contamination is high.
C. Quantification of DNA is possible.
D. All methods of real-time PCR give the most sensitive and specific results.
Behdad (page 398)
1. Which one of the following antigens was found most frequently on the
surface of plasma cell myelomas?
A.CD117
B.CD19
C.CD56
D.CD20
2. Which one of the following statements is correct based on this study?
A. CD20 and CD117 are frequently expressed by normal, polyclonal plasma cells.
B. Most neoplastic plasma cells express CD19.
C. CD56 is never expressed by normal, polyclonal plasma cells.
D. Clonal plasma cell populations usually retain expression of CD38.
3. Which one of the following statements regarding the 9-color analytic cocktail
described herein is correct?
A. There is less duplication of antibody reagents, lower instrument acquisition times per
case, and enhanced correlated analysis vs the same panel using 4- to 6-color cocktails.
B. It can only be performed on the instrument used in the current study.
4. A 34-year-old man presented with weakness of low extremities. A computed
tomographic scan revealed an osteolytic lesion suggesting infection or metastatic
carcinoma. The biopsy was performed and granulomas with abscess were
detected by histologic evaluation of FFPE tissue. The fresh tissue was not available.
What is the most sensitive test for diagnosis of tuberculosis in this situation?
A. Microbiological culture
B. Ziehl-Neelsen staining
C. Single-step PCR
D. Nested PCR
5. A 22-year-old woman with skin nodules is taking immunosuppressive
medicine for implanted kidney. The biopsy of skin lesion revealed inflamed
granulation tissue and abscess. The AFB staining showed several AFB but realtime PCR for M tuberculosis showed a negative result. What is the most possible
diagnosis and the most effective test for confirming the diagnosis?
A. The possible diagnosis is the infection of M tuberculosis, and mycobacterial culture
is recommended.
B. The possible diagnosis is the infection of nontuberculous mycobacterium, and real-time
PCR is recommended.
C. The possible diagnosis is the infection of nontuberculous mycobacterium, and mycobacterial culture of a new fresh aspirate from the lesion is recommended.
D. The possible diagnosis is the infection of M tuberculosis, and nested PCR is
recommended.
C. It cannot be modified to include additional or alternative surface markers.
D. It will require more cells per case than the same panel run using 4- to 6-color cocktails.
4. Which one of the following statements regarding minimal residual plasma cell
myeloma detection by flow cytometry in bone marrow aspirates is correct based
on this study?
A. It is negative when there is no detectable M protein in serum or urine.
B. It is rarely positive when the immunomorphologic evaluation of the core biopsy is negative.
C. It requires analysis of large numbers of bone marrow cells for optimal sensitivity.
D. It is more accurate than a morphologic differential count for determining plasma cell
percentage.
5. Which one of the following statements about minimal residual plasma cell
myeloma is correct?
A. Flow cytometry is the only technology available for such testing.
B. There is no clinical evidence that detection by flow cytometry has an impact on prognosis.
C. Dilute bone marrow aspirates are suitable for testing.
D. Consensus guidelines for minimal residual plasma cell myeloma testing by flow cytometry are under development.
Oberley (page 411)
1. You have been asked to develop an algorithm for flow cytometry testing for
possible lymphoproliferative disorders (LPDs) in your laboratory, with a goal of
decreasing the number of tests performed. The most pertinent retrospective data to
collect to determine antibody panel use and clinical data cutoffs are what?
A. Patient age, absolute lymphocyte count, and immunophenotype diagnosis
B. Patient age, WBC count, hemoglobin level, and clinical diagnosis
C. Absolute lymphocyte count, duration of lymphocytosis, and clinical diagnosis
D. Patient age, CBC values, spleen size, immunophenotype diagnosis, and B12 levels
2. When plotted on a receiver operating characteristic (ROC) curve, a criterion value
that provides 100% sensitivity and 100% specificity will be plotted where? A criterion
value that provides a 50% sensitivity and 50% specificity will be plotted where?
A. On the upper far right of the graph (perfect classification)/On the diagonal line (line of
no discrimination)
B. On the upper far left of the graph (perfect classification)/On the diagonal line (line of no
discrimination)
C. On the diagonal line (perfect classification)/On the upper far left of the graph (line of no
discrimination)
D. On the diagonal line (perfect classification)/On the upper far right of the graph (line of
no discrimination)
3. You have been asked to develop a screening test for LPD for patients
presenting with incidental lymphocytosis but no other blood abnormalities. What
is the most useful 6-color antibody screen combination?
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A.CD19/CD20/CD23/k/l/CD3
B.CD19/k/l/CD10/CD3/CD45
C.CD19/k/l/CD5/CD45/CD3
D.CD3/CD4/CD8/CD19/k/l
4. Which of the following patients would most likely have a lymphoproliferative
disorder?
A. 42-year-old woman with absolute lymphocyte count (ALC) of 5,100/µL, seen in clinic for
back pain; WBC count 1 year earlier reportedly normal (no data to review)
B. 61-year-old woman with ALC of 5,200/µL admitted with an acute myocardial infarct;
CBC count 2 months ago normal
C. 57-year-old man seen in clinic for routine check for hypertension; found to have ALC of
5,400/µL; 1 year ago ALC was 4,200/µL
D. 35-year-old with fevers and malaise; ALC of 6,500 µL; no prior CBC data
5. You institute a flow algorithm to cut down the number of flow tests performed
in your lab; patients with ALC <8,000/µL have limited studies, with further testing
added if monoclonal B cells are found. A review of the data after 4 months shows
that 50% of cases with ALC <8,000/µL have required additional flow testing. The
number of added reflex tests is interfering with lab work flow. What changes if
any would you consider?
A. No changes are needed, as the total number of flow tests has gone down.
B. Revise the ALC criterion of 8,000/µL to a lower figure so that less reflex testing is required.
C. Keep the criterion of 8,000/µL and add a second criterion of patient age.
D.Reevaluate the ALC criterion to increase the reflex rate to 70% and thus decrease
overall test number further.
© American Society for Clinical Pathology