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.
Rhea (page 5)
1. The laboratory reports a hemoglobin (Hb) A1c value of 5.1% on a patient with
symptomatic hyperglycemia. Assuming the sample is not a misidentification and
there is no laboratory error, which of the following is the most likely scenario?
A. The patient does not have diabetes based on the HbA1c result.
B. The patient has diabetes based on the HbA1c result.
C. The patient has a Hb variant affecting the HbA1c result.
D. The patient does not really have hyperglycemia.
2. Which of the following HbA1c methods recognizes the cis-diol groups of
glucose bound to Hb?
A.Immunoassay
B. Boronate affinity
C. Ion exchange high-performance liquid chromatography (HPLC)
D.Enzymatic
4. Which of the following Hb variants can result in a clinically misleading
HbA1c value?
A.HbAC
B.HbSC
C.HbAS
D.HbA0
5. Which is an example of a biological interference for HbA1c?
A.Coelution of a Hb variant with HbA1c when using capillary electrophoresis or ion
exchange HPLC
B. Altered RBC survival resulting in misinterpretation of HbA1c and average glycemia
C. A Hb β-chain mutation that alters the epitope recognized by HbA1c antibodies
D. A change in the charge of the Hb molecule that results in a split peak in HbA0 when
using ion exchange HPLC
3. What is HbA1c?
A. It is the most abundant component of Hb.
B. It is formed through an enzymatic reaction that results in glycation of HbA0 in direct
proportion to the amount of circulating glucose.
C. It is only used to diagnose diabetes.
D. It is used to monitor average glycemia in order to delay the onset and progression
of diabetic complications.
Abou Tayoun (page 17)
1. What does the “90/10” gap refer to?
A. The fact that 90% of all infections occur in just 10% of the world’s nations.
B. The fact that 90% of the world’s clean water is in only 10% of its nations.
C. The fact that 90% of research funding in genomics and health care development is
focused on the health needs of only 10% of the world’s population.
D. The fact that 90% of college-educated people are trained in only 10% of the world’s
countries.
2. Current state-of-the-art laboratory medicine is highly dependent on
complex platforms that typically
A. can run without access to regular electrical power sources.
B. can be operated automatically without trained laboratory personnel.
C. are optimized for small sample volumes.
D. require access to cold storage.
3. Challenges limiting the use of molecular diagnostics in resource-limited
areas include which of the following?
A. Lack of electricity and clean water
B. Lack of testing guidelines
C. Insufficient volume of cases to test new diagnostic devices
D. Availability of other diagnostic tools that are faster and more sensitive
4. In devising an accessible molecular test for the developing world, it is
essential to
A. develop and validate the test in an advanced laboratory infrastructure and then use
it in limited settings.
B.conceive challenges and implement potential solutions during the initial design
process.
C. plan for advanced training for personnel who will implement the device.
D. assume that any sample type and volume can be used.
5. Polymerase chain reaction–based molecular tests can achieve highest
impact in developing countries if what occurs?
A. They include fewer cycles of amplification.
B. They can use a lower annealing temperature.
C. They integrate all processes, including extraction, amplification, and detection, into a
sample-to-answer device.
D. They use shorter primers.
Hattori (page 43)
1. What is a specific method for detection of bloodstream infection?
A. WBC count
B. Body temperature
C. C-reactive protein
D. Blood culture
2. Procalcitonin level in patients with contaminated blood culture is
A. slightly but not significantly higher than that in patients with negative blood culture.
B. significantly higher than that in patients with negative blood culture.
C. not elevated significantly compared with that in patients with negative blood culture.
D. significantly lower than that in patients with negative blood culture.
3. Which statement correctly describes the evidence about time to positivity
(TTP) of a blood culture?
A. A short TTP is associated with a significantly higher mortality rate in patients with
Staphylococcus aureus bloodstream infection.
B. TTP is a useful marker to distinguish positive blood culture for gram-positive bacteria
from gram-negative bacteria.
C. TTP is correlated with renal function.
D. TTP is correlated with duration of antibiotic treatment.
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4. Which statement best describes the optimum cut-off value of procalcitonin
for predicting a positive blood culture?
A.The optimal cut-off value of procalcitonin for predicting a positive blood culture
increases along with the deterioration of renal function.
B.The optimal cut-off value of procalcitonin for predicting a positive blood culture
decreases along with the deterioration of renal function.
C. The optimal cut-off value of procalcitonin for predicting a positive blood culture is not
changed with renal function.
D.The optimal cut-off value of procalcitonin for predicting a positive blood culture
decreases along with the deterioration of hepatic function.
5. What is the optimum cut-off value of procalcitonin for predicting a positive
blood culture in patients with an estimated glomerular filtration rate <30 mL/
min/1.73 m2?
A. 0.5 ng/mL
B. 1.0 ng/mL
C. 2.0 ng/mL
D. 2.5 ng/mL
© American Society for Clinical Pathology
12/10/13 11:16 AM
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.
Ho (page 62)
1. What is hemophagocytic lymphohistiocytosis (HLH) most likely associated
with?
A.Obesity
B. Epstein-Barr virus
C.Sarcoidosis
D.Myeloma
4. What is the criterion established by HLH-2004 for making the diagnosis
of HLH?
A.Dyspnea
B. Altered mental status
C. Bone pain
D. Elevated ferritin
2. Which laboratory test is most helpful in establishing the diagnosis of HLH?
A. Decreased level of soluble CD25
B. Low/absent natural killer cell activity
C. Elevated serum interleukin-6 levels
D. Leukocytosis with neutrophilia
5. Obtaining a bone marrow biopsy in the setting of clinical suspicion for HLH
is most useful in which of the following?
A. Finding an infectious etiology
B. Ruling out lymphoma and other infiltrative processes
C. Ruling in the diagnosis of HLH
D. Quantitating the number of hemophagocytic cells
3. What has the morphologic finding of hemophagocytosis in the marrow
been associated with?
A. Blood transfusions
B. High blood pressure
C.Pruritus
D.Hemolysis
Zhuang (page 72)
1. Spontaneous regression of nephrotic syndrome in patients with
membranous nephropathy associated with hepatitis B virus (HBV) infection
occurs in approximately what percent of patients?
A.1%
B.5%-10%
C.30%-60%
D.80%-90%
2. Which of the following types of renal injury is most commonly identified in
children with HBV-associated glomerulonephritis (HBV-GN)?
A. Membranoproliferative glomerulonephritis
B. Membranous nephropathy
C. Mesangial proliferative glomerulonephritis
D. IgA nephropathy
3. When comparing patients with HBV-GN who are normouricemic to those
with hyperuricemia, where are there significant differences?
A.Gender
B. Body weight
C. Serum triglycerides, cholesterol, and albumin
D. Age of patient
4. In HBV-GN patients, reduced glomerular filtration and decreased uric acid
excretion from renal tubules are the major causes of hyperuricemia. Given
the above information, how often does hyperuricemia happen to HBV-GN
patients with serum creatinine ≥132.6 μmol/L when glomerular filtration rate is
decreased by >50%?
A. 4 times more commonly than in patients with normal serum creatinine levels
B. 3 times more commonly than in patients with normal serum creatinine levels
C. 2 times more commonly than in patients with normal serum creatinine levels
D. At the same rate as in patients with normal serum creatinine levels
5. Hyperuricemia can impact many pathologic indices of HBV-GN patients;
which one of the following findings is not significantly increased in patients
with hyperuricemia?
A. Percentage of glomerular sclerosis
B. Membranous nephropathy
C. Degree of mesangial proliferation
D. Degree of tubulointerstitial injury
Minato (page 85)
1. What is the most reliable histologic criterion for the diagnosis of malignant
mesothelioma?
A. Cytologic atypia of mesothelial cells
B. Abnormal mitosis of mesothelial cells
C. Fat infiltration by mesothelial cells
D. Adenomatoid proliferation by mesothelial cells
2. What is the marker that has the lowest sensitivity in distinguishing between
malignant mesothelioma and reactive mesothelial cells?
A. Insulin-like growth factor 2 messenger RNA binding protein 3 (IMP3)
B. Glucose transporter 1 (GLUT1)
C. Epithelial membrane antigen (EMA)
D.Desmin
3. What did study find to be the most reliable immunohistochemical support
for the diagnosis of malignant mesothelioma?
A. Positivity for IMP3
B. Positivity for EMA
C. Positivity for both IMP3 and GLUT1
D. Positivity for both EMA and CD146
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CME Questions_Jan14.indd 141
4. Although 9p21 deletion analysis by fluorescence in situ hybridization is a
specific method for detecting malignancy, the reported average sensitivity in
the diagnosis of malignant mesothelioma is how much?
A.60%
B.70%
C.80%
D.90%
5. Which marker was significantly less expressed in sarcomatoid than
in epithelioid and biphasic malignant mesothelioma compared with other
markers?
A.IMP3
B.GLUT1
C.EMA
D.CD146
Am J Clin Pathol 2014;141:140-143
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12/10/13 11:16 AM
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.
Hoffmann (page 94)
1. What is the hematologic sample most suitable for a limited panel strategy
for flow cytometry?
A. Metastatic carcinoma to the bone marrow
B. Staging bone marrow in a patient with non-Hodgkin lymphoma
C. A bone marrow sample from a patient with chronic myelogenous leukemia in chronic
phase
D. Bone marrow smear diagnostic of a plasma cell dyscrasia (>10% plasma cells with atypia)
2. Among the following clinical settings, which is the disease with the highest
likelihood of cytogenetic abnormalities in a bone marrow sample that has no
morphological abnormality on the smear and no flow cytometric abnormality
on a limited panel of markers?
A. Chronic myelogenous leukemia
B. Hodgkin lymphoma
C. Acute leukemia
D. Plasma cell dyscrasia
3. Limited flow cytometry strategies reduce utilization and simultaneously
maintain efficacy by how?
A. Conserving tissue samples in cases with high numbers of leukemic blasts
B. Triaging cases with high blast counts to the limited marker approach
C. Narrowly defining the flow cytometry markers used based on history and aspirate
smear findings
D. Encouraging other testing instead of flow cytometry.
4. When discussing the efficacy of a limited panel strategy for flow cytometry,
a reasonable approach is to do what?
A. Describe how only selected patient populations can benefit.
B. Explain there is no statistical difference in disease detection rate vs an initial full
panel screening.
C. Exclude cases of metastatic carcinoma.
D. Discuss the decreased accuracy of a limited panel strategy vs a full panel screening.
5. You examine a bone marrow sample from a patient with chronic anemia.
A limited flow cytometry panel reveals no clonal or aberrant populations, and
the marrow aspirate smears and biopsy reveal no morphologic abnormality.
What is the percentage likelihood that cytogenetics will reveal a clinically
significant abnormality?
A.0%
B.5%
C.10%
D.20%
DiCarlo (page 111)
1. In comparing preoperative clinical diagnosis with the histologic findings
after examining resection specimens from hip and knee joints, what is the
discrepancy in diagnosis?
A. Close to 0 for these specimen types
B. 10%-20% for total knee and hip specimens
C. 30%-40% for total knee and hip specimens
D. Over 50% for total knee and hip specimens
4. Regarding the diagnosis of subarticular fracture of either the hip or the
knee, which of the following statements is correct?
A. The clinical diagnosis is most commonly degenerative joint disease in both locations.
B. The clinical distinction from avascular necrosis is usually accurately made.
C. The region of necrosis is associated with fracture callus and may be superimposed
on the callus.
D. The failure to appreciate the diagnosis has clinical consequences.
2. Comparing diagnoses found in the knee and hip joints, which of the
following statements is correct?
A.The clinical diagnosis was less likely correct in cases of arthritis of the knee than
arthritis of the hip.
B. Inflammatory disease was less prevalent in the hip than in the knee.
C.Subarticular fracture is the diagnosis that is least commonly missed clinically in
either the knee or the hip.
D. Inflammatory disease is always easily distinguished from degenerative disease.
5. Regarding the reporting of a pathologic diagnosis based on histologic
examination, which of the following statements is correct?
A.The histologic study of resection specimens does not provide information that may
lead to more meaningful prognostication.
B. The discovery and explication of subarticular fracture would have been made without
histologic examination given today’s radiographic capabilities.
C.The interest and perspective of the pathologist affect the accuracy and potential
value of the diagnosis rendered.
D. The correct diagnosis is usually not important, as the choice of surgical procedure and
the expected survival of the implant are not affected by the diagnosis.
3. Regarding the clinical reporting of avascular necrosis of either the hip or
the knee, which of the following statements is correct?
A. The clinical diagnosis is less reliable when made in the hip than in the knee.
B. The clinical distinction from subarticular fracture is rarely accurately made.
C. The infarcted region always shows subarticular and peripheral reparative callus.
D.In the knee, the correct diagnosis is less likely subarticular fracture than avascular
necrosis.
Swadley (page 119)
1. At immediate evaluation of an image-guided fine-needle aspiration
(FNA) of a liver mass, a cytopathologist identifies atypical and monotonous
discohesive cells with crush artifact and high nuclear/cytoplasmic ratios. The
cytopathologist astutely obtains material for cell block and flow cytometric
analysis. Final diagnosis reveals large B-cell lymphoma. The patient has
no known history of lymphoma and otherwise has no evidence of systemic
involvement. Which of the following represents the most likely clinical
presentation of this patient?
A. 54-year-old man with hepatitis C infection and a single, contrast-enhancing hepatic
lesion seen on computed tomography (CT) imaging studies
B. 45-year-old human immunodeficiency virus (HIV)–infected man with a CD4 count of
105 and multiple, hypointense hepatic lesions seen on CT imaging studies
C. 34-year-old HIV-infected woman with a CD4 count of 510 and multiple, hypointense
lesions seen on CT imaging studies
D.42-year-old woman with chronic hepatitis B infection and two contrast-enhancing
defined hepatic nodules on CT imaging studies
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2. Smear preparation of an abdominal FNA reveals a uniformly hypercellular
smear with scattered atypical individual cells with occasional cohesive
clusters arranged in rare rosettes and scant cytoplasm. Chromatin is fine and
evenly dispersed. A fibrillary background is present. The patient is 3 years old.
What is the most likely diagnosis?
A.Lymphoma
B. Small cell carcinoma
C.Neuroblastoma
D.Hepatoblastoma
3. Smear preparation of an FNA of a hepatic nodule reveals a monomorphic
population of large, atypical discohesive cells with scant cytoplasm, fine
chromatin, and nuclear crush artifact. Which of the following findings or
clinical features would most likely decrease your suspicion of hepatic
lymphoma (either primary or secondary)?
A. Male sex
B. Extensive history of smoking
C. Multiple hepatic lesions
D. Poorly managed HIV infection
© American Society for Clinical Pathology
12/10/13 11:16 AM
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. How is the relationship of chronic viral hepatitis infection in hepatic
lymphoma best defined?
A. As strong as that of HIV infection in primary hepatic lymphoma
B. Uncertain—chronic viral hepatitis infection is present in some cases of both primary
and secondary hepatic lymphoma, even in the absence of HIV infection in some cases
of secondary hepatic lymphoma
C. Uncertain—although chronic hepatitis B infection has been strongly associated with
development primary hepatic lymphoma in previous studies
D. Viral hepatitis infection appears to be protective against primary hepatic lymphoma
5. Which of the following statements regarding primary and secondary
lymphoma is most correct?
A. Primary hepatic lymphoma is more likely to occur in immunocompromised patients,
tends to have a large B-cell phenotype, and has a worse prognosis than secondary
hepatic lymphoma.
B.Primary hepatic lymphoma is about as likely to occur in immunocompromised
patients, tends to have a large B-cell phenotype, and has a better prognosis than
secondary hepatic lymphoma
C.Primary hepatic lymphoma is about as likely to occur in immunocompromised
patients, has a more heterogeneous phenotype, and has a similar prognosis to secondary hepatic lymphoma.
D. Primary hepatic lymphoma is more likely to occur in immunocompromised patients,
tends to have a large B-cell phenotype, and has a similar prognosis to secondary
hepatic lymphoma.
Vollmer (page 128)
1. Overdiagnosis of thyroid cancers is suggested by which of the following?
A. Increasing incidence of nonfatal cancers
B. Decreasing incidence of fatal cancers
C. Constant incidence of fatal cancers
D.Increasing incidence of nonfatal cancers coupled with constant incidence of fatal
cancers
4. What characterizes subsequent survival of those with thyroid cancer who
survive 2 years?
A. 100% will survive
B. 90% will survive
C. 96% will experience survival that matches the general population
D. 100% will experience survival that matches the general population
2. When does the hazard function calculated for thyroid cancers in the
Surveillance, Epidemiology and End Results (SEER) data peak?
A. At 1 year after diagnosis
B. At 2 years after diagnosis
C. At approximately 4 months after diagnosis
D. At 10 years after diagnosis
5. Survival probability relative to that of the general population is called what?
A. Absolute survival
B. Differential survival
C. Population survival
D. Relative survival
3. Most (>50%) of fatalities that occur in thyroid cancer have happened by when?
A. 2 years after diagnosis
B. 2 months after diagnosis
C. 6 months after diagnosis
D. 1 year after diagnosis
Stemme (page 133)
1. On biopsy material the diagnostic term endometrial stromal tumor (EST) is
typically used. Why?
A. Mitotic rate cannot be reliably determined on biopsy, and so the distinction between
endometrial stromal nodule/sarcoma cannot be made.
B. A highly cellular leiomyoma cannot be excluded on biopsy, and so the nonspecific
diagnosis of EST is given.
C. On biopsy material tumor circumscription/invasion into the surrounding myometrium
typically cannot be evaluated. The distinction between an endometrial stromal nodule/sarcoma therefore cannot be made.
D. Most laboratories do not have fluorescence in situ hybridization probes for the JAZF1JJAZ1 translocation. Therefore endometrial stromal sarcoma cannot be diagnosed on
biopsy.
2. What is the most common indication for the endometrial biopsy, as
reported on the requisition?
A. Fibroid uterus
B.Bleeding
CTumor
DProlapse
3. You are reviewing an endometrial biopsy when you encounter a region
of aglandular stroma. Based on the findings in this article how should you
proceed?
© American Society for Clinical Pathology
CME Questions_Jan14.indd 143
A. Measure the linear dimensions of the aglandular stromal fragment. If the size is ≥5
mm then the fragment is suspicious for an endometrial stromal tumor. If the size is
≤4 mm or smaller then the finding is nonspecific (ie, fragments of that size were seen
in the control, nonsarcoma specimens).
B. Measure the linear dimensions of the aglandular stromal fragment. Even small fragments (eg, 2 mm in size) should be regarded as suspicious for endometrial stromal
tumor.
C.Evaluate the stromal fragment for mitotic activity. If the mitotic rate is >10 mitoses/10 high-power fields then it is diagnostic of an EST.
D. Evaluate the biopsy for lymphovascular invasion. This is diagnostic of EST.
4. What is the most helpful diagnostic clue to the presence of an endometrial
stromal tumor on biopsy?
A. The presence of necrosis
B. Increased mitotic rate
C. A large aglandular stromal fragment (size ≥5 mm)
D Invasion into the myometrium
5. What is the most common pitfall in recognizing an endometrial stromal
tumor?
A. Highly cellular leiomyoma
B. Excluding metastasis
C. Identifying lymphovascular invasion
D.Adenosarcoma
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