Review of the AP Part II Practical Examination. Dr David Clift Co Chief Examiner

Review of the AP Part II Practical Examination Dr David Clift Co Chief Examiner

General Remarks The part II practical examination involved 15 cases which were presented with sufficient clinical data to allow the well-prepared candidate to develop either an appropriately named shortlist of differential diagnoses or the target diagnosis as their preferred diagnosis. 2

General Remarks The process of selection and moderation of these exam questions was discussed earlier. As mentioned before, each candidate s answers were examined independently by three senior anatomical pathologists. 3

General Remarks After assessment and application of the normalising educational analytical calculations which I mentioned earlier candidates fell into three clear groups: Clear Pass Clear Fail Borderline 4

Strata of Candidates Group 1 the majority These candidates scored 80% or greater and were clear passes. Many of these candidates answered all cases correctly. 5

Strata of Candidates Group 2 a significant minority These candidates who scored less that 65%, and usually much less than that, were the clear Fail group of candidates. 6

Strata of Candidates Group 3 a small number of candidates This group scored between 70% and 80% in the May examination. All were offered the chance to resit the examination in August and most were successful at this second sitting. 7

No Sudden Death questions From the preceding data it should be obvious that there is no single case which determines whether a candidate passes or fails. The examination is set to canvass the candidate s knowledge across the spectrum of Anatomical Pathology recognising that even the best and most conscientious pathologist has unavoidable gaps in knowledge and experience. 8

Questions associated with poor performance As in previous years, in this examination more than half the questions were answered successfully by every candidate. In the case of those candidates who did not pass the examination at the first sitting it was the same cluster of questions which were poorly or wrongly answered. These are the cases which I will discuss today. 9

Question 1: Meningioma, WHO grade 2, with cerebral invasion Male 50 years. Dural tumour. Recognition of this tumour as a meningioma was essential. Incorrect grading and/or failure to recognise cerebral invasion was insufficient for a Pass but was accepted as a Borderline answer. 10

Question 1: Meningioma, WHO grade 2, with cerebral invasion A frequently suggested and incorrect answer was haemangiopericytoma/solitary fibrous tumour 11

Question 1: Meningioma, WHO Grade II, with cerebral invasion H&E 4x Tumour and Cortex H&E 10x Variable Cellularity 12

Question 2: Testicular atrophy with Leydig Cell hyperplasia Male 71 years. Right testis. The sections showed atrophy with Leydig Cell hyperplasia. The recognition of atrophy without comment on the Leydig cell population OR the interpretation of the Leydig cell population as primary neoplasia was considered a Borderline response. 13

Question 2: Testicular atrophy with Leydig Cell hyperplasia H&E 4x broad sclerosis and loss of normal tubular architecture H&E 10x sclerotic tubules and nests of hyperplastic Leydig cells 14

Question 2: Testicular atrophy with Leydig Cell hyperplasia Several candidates interpreted the changes as metastatic malignancy such as melanoma or hepatocellular carcinoma. 15

Question 5: Basal Cell adenoma of Salivary gland Male 45 years. Lump on left facial nerve. The sections showed the characteristic features of a basal cell or monomorphic adenoma of the parotid gland. 16

Question 5: Basal Cell Adenoma H&E 4x Native parotid tissue is deformed by a well circumscribed glandular proliferation 17

Question 5: Basal Cell Adenoma H&E 40x Well formed ductules with bilaminar epithelial linings No cribriform areas 18

Question 5: Basal Cell Adenoma The examining panel agreed that diagnoses of Pleomorphic Adenoma and Polymorphous Low Grade Adenocarcinoma constituted Borderline answers. Diagnoses of epithelial-myoepithelial carcinoma and adenoid cystic carcinoma or other entity were wrong. 19

Question 6: Metastatic malignant melanoma to the gallbladder Male 65 years. Right Upper Quadrant Pain Given the morphology, all the examiners agreed that there was little scope for other diagnosis. 20

Question 6: Metastatic Melanoma to the gallbladder These low power views highlight the first problem is to determine tissue site. 21

Question 6: Metastatic Melanoma to the gallbladder Smooth muscle from GB wall is seen. The tumour is epithelioid and necrotic. 22

Question 6: Metastatic Melanoma to H&E 10x the gallbladder This epithelioid tumour shows granular pigmentation of the large cells which have enlarged and prominently nucleolated nuclei. 23

Question 6: Metastatic Melanoma to the gallbladder A number of candidates stated quite confidently that there was no evidence of malignancy describing granulomatous processes. Other candidates described a range of malignancies other than malignant melanoma. 24

Question 13: Extraskeletal Mesenchymal Chondrosarcoma Male 37 years. Right deltoid muscle mass. As illustrated in the next slide, this lesion demonstrates the features of an extraskeletal mesenchymal chondrosarcoma. The age and site are quite typical. 25

Question 13: Mesenchymal Chondrosarcoma H&E 4x Lobulated tumour of variable density within soft tissue 26

Question 13: Mesenchymal Chondrosarcoma This had cellular areas with atypical small cells in a fine eosinophilic matrix. (H&E 40x) The next medium power images show chondroid areas and focal osseous metaplasia 27

Question 13: Mesenchymal Chondrosarcoma 28

Question 13: Extraskeletal Mesenchymal Chondrosarcoma The examiners agreed that dedifferentiated chondrosarcoma and chondroblastic osteosarcoma were borderline responses. A number of candidates handled the discussion of their differential diagnoses in this case poorly, sometimes excluding the target diagnosis or more often leaving a confused answer with unclear final resolution. 29

Question 14: Inflammatory Myofibroblastic Tumour Male 10 years. Mass between the bladder and the abdominal wall. The morphology is quite typical. The diagnoses of leiomyoma, neurofibroma and fibromatosis were regarded as Borderline 30

Question 14: Inflammatory Myofibroblastic Tumour H&E 4x: Views of margins of the tumour 31

Question 14: Inflammatory Myofibroblastic Tumour The spindle celled and sometimes fascicular nature of the tumour is seen here. The plasma cell infiltrate was evident, as in the flame figures centrally. 32

Question 14: Inflammatory Myofibroblastic Tumour This question was poorly answered with a significant number of candidates suggesting erroneous diagnoses of sarcoma. 33

Question 15: Necrotising Lymphadenitis (Kikuchi) Female 13 years, left neck mass. 34

Question 15: Necrotising Lymphadenitis (Kikuchi) At low and medium power the sections show reactive lymphoid follicles intermingled with irregular geographic areas of bland necrosis. 35

Question 15: Necrotising Lymphadenitis (Kikuchi) The lymphocyte population is morphologically normal. No neoplastic infiltrate is present. 36

Question 15: Necrotising Lymphadenitis (Kikuchi) Candidates who passed this question provided a diagnosis of Necrotising Lymphadenitis AND an accompanying clinicopathological workup. Borderline answers included Necrotising Lymphadenitis without workup and Cat Scratch Disease. 37

Question 15: Necrotizing Lymphadenitis There is no evidence of primary or secondary neoplasia in this section and to suggest haematolymphoid malignancy was wrong. 38

To those candidates attempting the Part II Practical Examination in 2019 you are best served by writing what you think - do not try to second guess the Examiners. On the day of the examination we wish you all calmness, excellent recall, and clear thinking! 39