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Question 1
Correct
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Which of the following is the most accurate test for the diagnosis of primary syphilis?
Your Answer: Dark-field microscopy
Explanation:Primary syphilis is transmitted via sexual contact. Lesions on genitalia, called a chancre occur after an asymptomatic incubation period of 10-90 days (average 21 days) after exposure. This chancre is a typically solitary (can be multiple), firm, painless, ulceration over the skin at the point of exposure to spirochete, seen on penis, vagina or rectum. It heals spontaneously after 4-6 weeks. Local lymphadenopathy can be seen.
Diagnosis is made by microscopy of fluid from lesion using dark-field illumination, taking care to not confuse with other treponemal disease. Screening tests include rapid plasma regain (RPR) and Venereal Diseases Research Laboratory (VDRL) tests. False positives are known to occur with these tests and can be seen in viral infections like hepatitis, varicella, Epstein-Barr virus, tuberculosis, lymphoma, pregnancy and IV drug use. More specific tests should therefore be carried out in case these screening tests are positive.
The Treponema pallidum hemagglutination assay (TPHA) and the fluorescent treponemal antibody absorption (FTAABS) test are based on monoclonal antibodies and immunofluorescence and are more specific. However, they can too show false positives with other treponemal diseases like yaws or pinta. Other confirmatory tests include those based on enzyme-linked immunoassays.
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This question is part of the following fields:
- Pathology
- Urology
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Question 2
Correct
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An abnormal opening of the urethra on the under surface of the penis (ventral surface) is known as:
Your Answer: Hypospadias
Explanation:Hypospadias is the condition where the urethra opens along the underside or ventral aspect of penile shaft. First-degree hypospadias is seen in 50-75% cases, where the urethra open on the glans penis. Second-degree hypospadias is seen in 20% cases where the urethra opens on the shaft, and third-degree in 30% cases with the urethra opening on the perineum. The severe cases are usually associated with undescended testis (cryptorchidism) or chordee, where the penis is tethered downwards and not completely separated from the perineum.
It is a common male genital birth defect but varying incidences are noted in different countries. There is no obvious inheritance pattern noted. No exact cause has been determined, however several hypotheses include poor response to androgen, or interference by environmental factors.
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This question is part of the following fields:
- Pathology
- Urology
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Question 3
Correct
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If a 68-year-old man is diagnosed with a testicular seminoma that reaches the tunica albuginea and involves the tunica vaginalis, with retroperitoneal lymph nodes greater than 5cm, LDH 1.4 times the reference levels, β-hCG 4250 mIU/ml and AFP 780 ng/ml, what's the clinical stage in this case?
Your Answer: Stage IIC
Explanation:According to the AJCC, the clinical staging for testicular seminoma is:
Stage IA: T1 N0 M0 S0
Stage IB: T2/3/4 N0 M0 S0
Stage IC: any T N0 M0 S1/2/3
Stage IIA: any T N1 M0 S0/1
Stage IIB: any T N2 M0 S0/1
Stage IIC: any T N3 M0 S0/1
Stage IIIA: any T any N M1a S0/1
Stage IIIB: any T any N M0/1a S2
Stage IIIC: any T any N M1a/1b S3.
The patient in this case has IIC stage -
This question is part of the following fields:
- Pathology
- Urology
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Question 4
Incorrect
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Which of the following is the most common germ cell tumour of the testis affecting an adult male?
Your Answer: Embryonal carcinoma
Correct Answer: Seminoma
Explanation:Germ cell tumours represent 90% of primary tumours arising in the testis. They are broadly divided into seminomas and non-seminomas. Seminomas are the most common testicular germ cell tumour seen in 40% cases. The other non-seminomatous histological subtypes include embryonal (25%), teratocarcinoma (25%), teratoma (5%) and pure choriocarcinoma (1%).
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This question is part of the following fields:
- Pathology
- Urology
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Question 5
Correct
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Digital rectal examination of a 75-year old gentleman who presented to the surgical clinic with urinary retention revealed an enlarged, nodular prostate. PSA was found to be elevated, favouring the diagnosis of prostatic malignancy. Which of the given options is the most common malignant lesion affecting the prostate gland?
Your Answer: Adenocarcinoma
Explanation:Prostatic adenocarcinoma is the commonest solid malignancy and non-dermatological cancer in men above 50 years age. Increasing in incidence with age and the highest risk seen in the black population. About 75% of cases are seen in men over 65 years. Other tumours affecting the prostate include undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma, but these occur less commonly. Sarcomas usually affect children. Hormones play a role in the aetiology of prostate adenocarcinoma unlike the other types. Intraepithelial neoplasia is considered a precursor of invasive malignancy.
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This question is part of the following fields:
- Pathology
- Urology
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Question 6
Correct
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A biopsy is performed on a 67-year-old-man with testicular seminoma; it reveals that the tumour affects the tunica vaginalis. The tumour stage in this case is:
Your Answer: T2
Explanation:The primary tumour staging for testicular seminoma is as follows, according to AJCC guidelines:
Tis: intratubular germ cell neoplasia (carcinoma in situ)
T1: tumour limited to testis/epididymis without vascular or lymphatic invasion; the tumour can invade into the tunica albuginea but not the tunica vaginalis
T2: tumour limited to testis/epididymis with vascular or lymphatic invasion or tumour extending through the tunica albuginea with involvement of the tunica vaginalis
T3: tumour invading the spermatic cord, with or without vascular/lymphatic invasion
T4: tumour invading the scrotum, with or without vascular/lymphatic invasion.
According to these guidelines, the tumour in this case has a T2 stage.
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This question is part of the following fields:
- Pathology
- Urology
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Question 7
Correct
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What's the nodal stage of a testicular seminoma if several lymph nodes between 2cm and 5cm are found?
Your Answer: N2
Explanation:According to the American Joint Committee on Cancer (AJCC) 2002 guidelines, the nodal staging of testicular seminoma is the following:
N0: no regional lymph node metastases
N1: metastasis with lymph nodes 2 cm or less in their greatest dimension or multiple lymph nodes, none more than 2 cm
N2: metastasis with lymph nodes greater than 2 cm but not greater than 5 cm in their greatest dimension, or multiple lymph nodes, any one mass greater than 2 cm, but not more than 5 cm
N3: metastasis with lymph nodes greater than 5 cm in their greatest dimension.
The patient in this case has N2 testicular seminoma. This TNM staging is extremely important because treatment options are decided depending on this classification.
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This question is part of the following fields:
- Pathology
- Urology
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Question 8
Correct
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Painful erections along with deviation of the penis to one side when erect are seen in which of the following conditions?
Your Answer: Peyronie’s disease
Explanation:Peyronie’s disease leads to development of fibrous plaques in the penile soft tissue and occurs in 1% of men, most commonly affecting white males above 40 years age. It is a connective tissue disorder named after a French surgeon, François de la Peyronie who first described it. Symptoms include pain, hard lesions on the penis, abnormal curvature of erect penis, narrowing/shortening, painful sexual intercourse and in later stages, erectile dysfunction. 30% cases report fibrosis in other elastic tissues such as Dupuytren’s contractures of the hand. There is likely a genetic predisposition as increased incidence is noted among the male relatives of an affected individual.
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This question is part of the following fields:
- Pathology
- Urology
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Question 9
Incorrect
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When a penile tumour invades the subepithelial connective tissue of the penis, what is its stage?
Your Answer: T2
Correct Answer: T1
Explanation:The TNM staging used for penile cancer is as follows:
TX: primary tumour cannot be assessed
T0: primary tumour is not evident
Tis: carcinoma in situ is present
Ta: non-invasive verrucous carcinoma is present
T1: tumour is invading subepithelial connective tissue
T2: tumour is invading the corpora spongiosum or cavernosum
T3: tumour invading the urethra or prostate
T4: tumour invading other adjacent structures.
In this case, the patient has a T1 tumour.
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This question is part of the following fields:
- Pathology
- Urology
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Question 10
Correct
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A patient with testicular seminoma has the following tumour markers: LDH 1.3 times the reference levels, β-hCG 4500 mIU/ml and AFP 875 ng/ml. What's the serum tumour marker stage in this case?
Your Answer: S1
Explanation:According to AJCC guidelines, the serum tumour marker staging is the following:
S0: marker studies within normal limits
S1: lactate dehydrogenase (LDH) less than 1.5 times the reference range, beta-human chorionic gonadotrophin (β-hCG) <5000 mIU/ml, and alpha-fetoprotein (AFP) <1000 ng/ml S2: LDH 1.5–10 times the reference range, β-hCG 5000–50,000 mIU/ml or AFP 1000–10,000 ng/ml S3: LDH greater than 10 times the reference range, β-hCG >50,000 mIU/ml or AFP >10,000 ng/ml.
According to this, the patient’s tumour belongs to the S1 stage.
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This question is part of the following fields:
- Pathology
- Urology
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