Anatomical Pathology. Part I Introduction and Review 2017

Transcription

1 Anatomical Pathology Part I Introduction and Review 2017

2 Anatomical Pathology Part I Examination what does it focus on? Common diagnosable conditions Rare/not-so-common but classic entities Emphasis on cases that occur in real life/ in a routine setting Balance between neoplastic and non-neoplastic conditions, including normal histology The days when exam consisted mainly of soft tissue tumours are well and truly over

3 Anatomical Pathology Part I Examination Written paper Slides Duration 3hrs15min 4hrs15min Grading Pass (i.e. at least 3 questions passed) Fail (i.e. more than 2 question 2 failed) Pass = no more than 4 corrected * wrong Fail = more than 4 corrected wrong (i.e. > 20%) (* calculated after statistical analysis, eg 2 b/lines cases amount to 1 wrong case; variation between markers often needs remarking by 2 additional markers; final decision at discretion of CEXs) Hurdle factor Most people pass (but difficulties encountered in 2015 and 2016 exams!) This is and always has been the hurdle... Number of examiners At least two, up to 4 or 5; final decision by CEX At least 2, up to 6; final decision up to CEX

4 Anatomical Pathology Part I Examination Written paper General format: 5 questions to be answered in essay style One autopsy related question One procedure related question (cut up, frozen section, FNA performance or any how to do.. question) One short notes question with 3-5 sub questions, often covering newer developments and techniques Marking by at least 2 examiners, fail and borderline papers will be remarked by 2-3 additional examiners, final decision (pass or fail) at discretion of CEXs

5 Anatomical Pathology Part I Examination Written paper Some basic recommendations: Visual presentation of written answer is significant Write legibly An essay typically consists of an introduction, a main body of discussion and a conclusion Headings and subheadings may be useful

6 Anatomical Pathology Part I Examination Written paper Some basic recommendations...continued: Lists and tables may be very useful if integrated into an essay but may be irritating when used on their own without sufficient comment/explanation Written paper does not only assess knowledge (MCQs might be better at that!) BUT also ability to formulate an opinion in a comprehensible manner Write legibly

7 Anatomical Pathology Part I Examination Written paper only results Year Passrate % % % Written examination is still an IMPORTANT part of the exam! Surprisingly in 2015 and 2016 some candidates failed the written only (but passed slides). Comments from examiners suggest that some candidates find it hard to formulate an intelligible, well-laid out answer that examines/discusses the issue Organize written/essay practice exams at home!

8 Anatomical Pathology Part I Examination Written paper - Marking

9 Anatomical Pathology Part I Examination Written paper - Marking Clear Pass = 3 passed questions Overall Fail = More than 2 failed questions A borderline mark counts as ½ Fail. Anything in between will be remarked and looked at closely (e.g. discrepancies between markers etc)

10 Written exam which questions caused problems???

11 Problem Question: Q3 A 45-year-old woman had bilateral adrenal masses noted on CT scan. A. Discuss the differential diagnoses of the adrenal tumours in this patient. B. Outline the morphological features and ancillary tests (including molecular tests) that are relevant to the diagnosis and management of this patient. Expected response to include: A. Metastatic tumours carcinomas, lymphoma and melanoma; bilateral cortical nodules/adenomas; bilateral phaeochromocytoma; bilateral myelolipomas, etc B. Immmunohistochemical markers appropriate chromogranin, CD56, lymphoid markers, melanin A, etc For metastatic melanoma braf;, lymphoma - rearrangements, flow cytometry; lung carcinoma EGFR; phaeochromocytoma RET, SDHB and others

12 Anatomical Pathology Part I Examination Borderline category The Borderline category for the slide and written exam as a FINAL MARK is abolished, i.e. there will be either a fail or pass in the Part I examination Borderline is only used as an interim mark that triggers further work for examiners (additional examiners, discussion between Chief Examiners etc) *

13 Anatomical Pathology Part I Examination Written paper Comments from examiners reflecting on 2015 and 2016 written papers (Here: a cytology related question as an example..):. most candidates answered the question from book knowledge or first principles and that very few of them had any practical cytology experience when presenting for the part I exam. The candidates could reproduce complex tables of IPx differential diagnoses but very few had any concept of basic cytomorphology Frustratingly for the marker, many candidates continue to write in disjointed note form making it very hard to appreciate whether the author has truly addressed the question at hand using point notation format, the lack of any logical connection between written statements made the assessment of the answers a form of augury as I tried to scry the entrails of the thought or idea scattered on the answer page Clearly for generation Y the sentence is of historical interest only!

14 Anatomical Pathology Part I Examination Written paper A POOR EXAMPLE

15 Anatomical Pathology Part I Examination Written paper A GOOD EXAMPLE

16 Anatomical Pathology Part I Examination GOOD and BAD EXAMPLES ( reactive vs malignant mesothelial cells )

17 Anatomical Pathology Part I Examination The (dreaded) slide examination... the same old rules still apply!!! Common diagnosable conditions Has the trainee had exposure to routine diagnostic work? Can the trainee recognize NORMAL morphology? Can the trainee recognize basic patterns and entities? Can the trainee differentiate between benign and malignant in common (routine) cases? Remember: There will be a balance of neoplastic and non-neoplastic pathology - and even normal stuff!

18 Anatomical Pathology Part I Examination The (dreaded) slide examination... the same old rules still apply!!! Rare/not-so-common but classic entities (and diagnosable) Can the trainee recognize those classic lesions that he may come across a few times a year? Classic ones: Nodular fasciitis, Malakoplakia, Hodgkin lymphoma and its variants, Naevus sebaceous 2015 exam!). Infections (CMV, Amoebi, Fungi etc)

19 Anatomical Pathology Part I Examination The (dreaded) slide examination... the same old rules still apply!!! Organize your thoughts and answer before you start writing Write legibly Organize your report for each slide as you would in your routine work; separate categories visually (use paragraphs!) : Slide identification on top, history Microscopic Comment/discussion - if necessary UNDERLINE your preferred diagnosis (DO NOT use highlighter please for technical reasons

20 Anatomical Pathology Part I Examination The (dreaded) slide examination... Right answer: Correct diagnosis/bottomline, with limited number of auxiliary tests where appropriate or necessary If not sure provide limited differential BUT YOU MUST state your preferred diagnosis

21 Anatomical Pathology Part I Examination The (dreaded) slide examination... Wrong answer Borderline answer Incorrect diagnosis / bottomline and poor description (i.e. correct diagnosis not mentioned) or Correct diagnosis buried among long list of other possible or impossible diagnoses Correct diagnosis buried among long list of inappropriate auxiliary tests (i.e. lots of IHC for straightforward cases ) wrong answer, but close (correct diagnosis mentioned and discussed in report) Correct diagnosis discussed among limited list of other diagnoses Correct diagnosis discussed among limited list of appropriate auxiliary tests

22 Anatomical Pathology Part I Examination How I mark slide papers Up to 80 papers to mark!!! Preliminary horizontal assessment: Go through papers first and see how each case was handled (range of answers, degree of difficulty etc) Look at bottomline/underlined diagnosis: If correct next case! If incorrect go through report and discussion in detail, compare to other candidates answers, re-read etc??still worth borderline

23 Anatomical Pathology Part I Examination The (dreaded) slide examination... Some examples, some good and some not so good...

24 Anatomical Pathology Part I Examination not great

25 Anatomical Pathology Part I Examination not fanatastic..

26 Anatomical Pathology Part I Examination excellent!!!

27 Anatomical Pathology Part I Examination The (dreaded) slide examination...some tips Read the history (there are no tricks!) Maybe come up with possible differentials based on history alone (i.e. spend some time thinking about the clinical info ) Look at the entire slide with naked eye and scanning lense Do not 2 nd guess the examiner! ( it s an exam, so this normal looking menstrual endometrium on the slide must be something else may be small cell cancer of the endometrium??? )

28 Anatomical Pathology Part I Examination The (dreaded) slide examination...more tips Diagnosis or differential diagnosis (with your preferred diagnosis! You need to commit to a diagnosis (i.e. underline your preferred option) even if you are unsure! Limit your lists of differentials to 3 or 4 options; don t include any possibility that you could possibly think or have heard of (but regard as unlikely) Don t leave it up to the examiner to pick the correct diagnosis hidden somewhere in a list of 10 or more!

29 Anatomical Pathology Part I Examination The (dreaded) slide examination... More tips Write in a professional manner 2. Commit!

30 Anatomical Pathology Part I Examination The (dreaded) slide examination...more tips Use a comment or discussion to explain your limited differential diagnosis; Explain why you want to do the histochemical, immunohistochemical or any other additional studies and what they will show with regards to your differentials! If you provide long lists and tables of everything (diagnoses, tests etc) you are telling us that you are very unsure and basically do not know! Don t write in every answer that you would show the case to a senior colleague that is a given for difficult cases!

31 Anatomical Pathology Part I Examination The (dreaded) slide examination...more tips If and when you know the diagnosis straight away, be grateful and move on to the next slide! Most cases are we believe! straightforward and diagnosable esp in Part I! Reserve (long) comments and differential diagnoses for those few cases where you really are not 100% sure (just like in real life) No need and in fact counterproductive for comments, differentials etc for the straightforward (and in fact majority of) cases the examiner may think you are not really sure

32 Marking procedure: Anatomical Pathology Part I Examination The (dreaded) slide examination... At least 2 examiners, may be up to 6 to 8 (incl CEX) Examiners are given detailed instructions as to how to mark / what kind of answer is expected for a clear pass in each slide to maintain consistency! Final decision up to CEX Statistical analysis Pass mark determined by combination of factors, not just total number of failed slides but other variables (e.g. average number of correct slides, AR; and average corrected number of wrong slides, CW, - a reflection of variation between examiners, slides marked as b/line etc)

33 Statistical Review of Part I 2012 to 2016 Slide exam Year No of candidates Pass rate in %

34 Anatomical Pathology Part I Examination Regarding feedback... Individual feedback in the past has not led to better outcomes Knowing how to approach the exam and knowing what the examiners are looking for more useful than listing correct and incorrect slides Confusion and frustration if individual cases are compared (selective memory of what was written and its context!) Remember: Slides will change, the correct approach will not!

35 Review of the 2016 Part I slide Exam

36 Summary of Slide examination Six difficult cases, 7 easy cases

37 2015 Part I slide Exam The cases 1. Metastatic small cell carcinoma (from lung) 2. Olfactory neuroblastoma 3. Cryptogenic organizing pneumonia (Bronchiolitis obliterans organizing pneumonia, BOOP) 4. Acute myocardial infarction 5. Collagneous colitis 6. Cholecystitis AND granulomatous arteritis 7. Diabetic nephropathy 8. Endometrioid carcinoma of ovary 9. Mucinous carcinoma of breast 10. Metastatic prostate carcinoma

38 2015 Part I slide Exam The cases 11. Nodular sclerosing Hodgkin Disease 12. Hirschsprung s disease 13. Hurthle cell adenoma of thyroid 14. Chondroid syringoma 15. Metastatic melanoma in thyroid 16. Chronic sclerosing sialadenitis/kuttner s tumour/igg4 sclerosing disease of salivary gland 17. Solitary fibrous tumour of thyroid 18. Brenner s tumour of ovary 19. Granular cell tumour of skin 20. Giant cell tumour of tendon sheath

39 Case 2: Olfactory neuroblastoma Hx: 39 year old male. Presented with 1 month of decreased vision, left facial numbness, loss of smell and swelling

40 Case 2: Olfactory neuroblastoma

41 Case 2: Olfactory neuroblastoma

42 Case 2: Olfactory neuroblastoma

43 Case 2: Olfactory neuroblastoma Many benign diagnoses inc. pituitary adenoma, glomangiona. paraganglioma and others (carcinoma, melanoma ec) About one third of candidates made correct diagnosis Please note history provided!!!

44 Case 3: Cryptogenic organizing pneumonia (Bronchiolitis obliterans organizing pneumonia, BOOP) Hx: 53 year old female. Persistent cough, bilateral lung opacities on CT

45 Cryptogenic organizing pneumonia (Bronchiolitis obliterans organizing pneumonia, BOOP)

46 Cryptogenic organizing pneumonia )

47 BOOP (bronchiolitis obliterans organizing pneumonia)

48 Cryptogenic organizing pneumonia ) Generally done poorly? Lack of exposure to medical lung biopsies Most common misdiagnosis was UIP

49 Case 6: Cholecystitis AND granulomatous arteritis Hx: 65 year old female. Cholelithiasis

50 Case 6: Cholecystitis AND granulomatous arteritis

51 Case 6: Cholecystitis AND granulomatous arteritis

52 Case 6: Cholecystitis AND granulomatous arteritis

53 Case 6: Cholecystitis AND granulomatous arteritis

54 Case 6: Cholecystitis AND granulomatous arteritis All candidates go the cholecystitis but Many missed the arteritis and/or granulomtous inflammation involving the deeper vessels No mention of vasculitis at all was considered a fail.

55 Case 10: Metastatic prostate carcinoma Hx: 83 year old male. Lower back pain

56 Case 10: Metastatic prostate carcinoma

57 Case 10: Metastatic prostate carcinoma

58 Case 10: Metastatic prostate carcinoma

59 Case 10: Metastatic prostate carcinoma Quite a few wrong and inappropriate diagnoses, inc chordoma, Rosai Dorfman disease, fibrous dysplasia, paraganglioma, osteosarcoma, seminoma) About half of the candidates got it right

60 Case 15: Metastatic melanoma in a parotid lymph node Hx: 38 year old male. Palpable lump right preauricular area.

61 Case 15: Metastatic melanoma in a parotid lymph node

62 Case 15: Metastatic melanoma in a parotid lymph node

63 Case 15: Metastatic melanoma in a parotid lymph node

64 Case 15: Metastatic melanoma in a parotid lymph node

65 Case 15: Metastatic melanoma in a parotid lymph node Many suggested benign diagnoses such as oncocytoma, paraganglioma, Warthins s tumour despite observing atypical features (pleomorphism, mitoses, melanin pgment) Malignant diagnoses included acinic cell carcinoma, hepatocellular carcinoma and others About 25% got it right

66 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease Hx: 45 year old female. Mass in left neck

67 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease

68 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease

69 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease

70 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease

71 Case 16: Chronic sclerosing sialadenitis/kuttner s tumour IgG4 sclerosing disease Popular diagnoses included lymphoma This was regarded borderline with the appropriate discussion and work up and a favoured diagnosis of bening chronic sialadenitis