Question 1

A 48-year-old woman has a malignant lymphoma involving lymph nodes in

the para-aortic region. She is treated with a chemotherapeutic agent
which results in the loss of individual neoplastic cells through
fragmentation of individual cell nuclei and cytoplasm. Over the next 2
months, the lymphoma decreases in size, as documented on abdominal
CT scans. By which of the following mechanisms has her neoplasm
primarily responded to therapy?
A

Coagulative necrosis

Mitochondrial poisoning

Phagocytosis

Acute inflammation

Apoptosis

(E) CORRECT. The induction of individual cell death occurs in the process
of apoptosis. The drug effect is targeted primarily at the neoplastic cells,
not normal cells.

Question 2
A 53-year-old man has experienced severe chest pain for the past 6 hours.
On physical examination he is afebrile, but has tachycardia. Laboratory
studies show a serum troponin I of 10 ng/mL. A coronary angiogram is
performed emergently and reveals >90% occlusion of the anterior
interventricular (left anterior descending) artery. In this setting, an
irreversible injury to myocardial fibers will have occurred when which of
the following cellular changes occurs?
A

Glycogen stores are depleted

Cytoplasmic sodium increases

Nuclei undergo karyorrhexis

Intracellular pH diminishes

Blebs form on cell membranes

(C) CORRECT. Chromatin clumping is reversible, but dissolution of the

entire nucleus is not, and when the nucleus is lost, the cell will die. An
acute coronary syndrome with myocardial infarction is described here.
Question 3
While in a home improvement center warehouse buying paint, a 35-yearold man hears 'Look out below!' and is then struck on the leg by a falling
pallet rack, which strikes him on his left leg in the region of his thigh. The
skin is not broken. Within 2 days there is a 5 x 7 cm purple colour to the
site of injury. Which of the following substances has most likely
accumulated at the site of injury to produce a yellow-brown colour at the
site of injury 16 days later?
A

Lipofuscin

Bilirubin

Melanin

Hemosiderin

Glycogen

(D) CORRECT. The iron in the heme pigment from the red blood cells in the
hemorrhage beneath the skin is incorporated into hemosiderin granules
that impart the yellow to brown colour of the healing contusion (bruise)
from blunt force trauma.
Question 4
A 54-year-old man with a chronic cough has a squamous cell carcinoma diagnosed
in his right lung. While performing a pneumonectomy, the thoracic surgeon notes that
the hilar lymph nodes are small, 0.5 to 1.0 cm in size, and jet black in colour
throughout. Which of the following is the most likely cause for this appearance to the
hilar nodes?
A

Anthracotic pigment

Lipochrome deposits

Melanin accumulation

Hemosiderosis

Metastatic carcinoma

(A) CORRECT. The black colour comes from carbon pigments in dust particles
inhaled over the years, engulfed by macrophages, and sent via lymphatics to the
lymph nodes. It looks bad but does not compromise lung function. Smokers will have
more anthracosis.
Question 5
A 50-year-old woman with a history of unstable angina suffers an acute myocardial
infarction. Thrombolytic therapy with tissue plasminogen activator (tPA) is
administered to restore coronary blood flow. In spite of this therapy, the degree of
myocardial fiber injury may increase because of which of the following cellular
abnormalities?
A

Cytoskeletal intermediate filament loss

Decreased intracellular pH from anaerobic glycolysis

Increased free radical formation

Mitochondrial swelling

Nuclear chromatin clumping

Reduced protein synthesis

(C) CORRECT. Such toxic oxygen radicals are released from neutrophils when blood
flow is restored following ischemia. This is a reperfusion injury. Overall, there is likely
to be more good than harm to restoration of blood flow.
Question 6
A 12-year-old boy has had multiple episodes of ear pain accompanied by fever. On
examination his right tympanic membrane is red and bulging with yellow exudate.
Laboratory studies of the exudate show culture positive for Hemophilus influenzae. A
year later he has conductive hearing loss on the right, and a head CT scan shows a
mass in the right middle ear. Which of the following materials is most likely to be
seen in the tissue curetted from his middle ear?
A

Lipofuscin pigment

Russell bodies

Neutrophil granules

Cholesterol crystals

Anthracotic pigment

(D) CORRECT. An inflammatory mass persisted, with cellular necrosis, and the lipid
from the cell membranes is broken down and cholesterol crystals form. The boy has
the complication of otitis media known as a cholesteatoma
Question 7
A 43-year-old man has complained of mild burning substernal pain following meals
for the past 3 years. Upper GI endoscopy is performed and biopsies are taken of an
erythematous area of the lower esophageal mucosa 3 cm above the
gastroesophageal junction. There is no mass lesion, no ulceration, and no
hemorrhage noted. The biopsies show the presence of columnar epithelium with
goblet cells. Which of the following mucosal alterations is most likely represented by
these findings?
A

Dysplasia

Hyperplasia

Carcinoma

Ischemia

Metaplasia

(E) CORRECT. Metaplasia is the substitution of one tissue normally found at a site
for another. The esophageal stratified squamous epithelium undergoes metaplasia in
response to the ongoing inflammation from reflux of gastric contents. This is
common in the lower esophagus with gastroesophageal reflux disease (GERD).
Question 8
A 71-year-old woman had the loss of consciousness that persisted for over an hour.
When she becomes arousable, she cannot speak nor move her right arm. A cerebral
angiogram revealed an occlusion to her left middle cerebral artery. Months later, a
computed tomographic (CT) scan shows a large 5 cm cystic area in her left parietal

lobe cortex. This CT finding is most likely the consequence of resolution from which
of the following cellular events?
A

Liquefactive necrosis

Atrophy

Coagulative necrosis

Caseous necrosis

Apoptosis

(A) CORRECT. She had a 'stroke' with cerebral infarction and loss of brain tissue.
The brain undergoes liquefactive necrosis with infarction. As it resolves, macrophaes
remove the dead cells and debria, leaving a cystic area that forms in the region of
infarction.
Question 9
A 19-year-old woman gives birth to her first child. She begins breast feeding the
infant. She continues breast feeding for almost a year with no difficulties and no
complications. Which of the following cellular processes that began in the breast
during pregnancy allowed her to nurse the infant for this period of time?
A

Stromal hypertrophy

Epithelial dysplasia

Steatocyte atrophy

Ductal epithelial metaplasia

Lobular hyperplasia

(E) CORRECT. There is an increase in the breast lobules under hormonal influence,
primarily progesterone with pregnancy, to provide for lactation.
Question 10
An 84-year-old man dies from complications of Alzheimer disease. At autopsy, his
heart is small (250 gm) and dark brown on sectioning. Microscopically, there is light
brown perinuclear pigment with H&E staining of the cardiac muscle fibers. Which of
the following substances is most likely increased in the myocardial fibers to produce
this appearance of his heart?
A

Hemosiderin from iron overload

Lipochrome from 'wear and tear'

Glycogen from a storage disease

Cholesterol from atherosclerosis

Calcium deposition following necrosis

(B) CORRECT. Lipochrome (lipofuscin) deposition in myocardial cell cytoplasm is a

common finding, though ordinarily there are small amounts of it, and it has little effect
upon cardiac function. The 'brown atrophy' of the heart in this case is a rare finding.
Question 11
In an experiment, a series of immunohistochemical stains are employed to identify
different cellular components. One particular stain identifies the presence of
intermediate filaments within cells. This cytokeratin stain is most likely to be useful
for which of the following diagnostic purposes?
A

Cytoskeletal alterations indicate impending cell death

A neoplasm is determined to be a carcinoma

Contractile properties of the cells can be assessed

A history of chronic alcoholism can be confirmed

The degree of metaplasia or dysplasia can be assessed

(A) Incorrect. Cytoskeletal alterations occur with ischemia, but are not a useful
marker for such an event.
(B) CORRECT. Carcinomas are derived from epithelium and contain cytokeratins, while
sarcomas derived from mesenchymal cells contain vimentin
(C) Incorrect. Many cell types contain intermediate filaments
(D) Incorrect. Mallory's alcoholic hyaline can be observed by H&E staining. However, it is not
entirely specific for alcoholism

(E) Incorrect. Metaplasia and dysplasia are assessed by light microscopic

appearances with H&E staining.
Question 12
A 20-year-old woman had Goodpasture syndrome which progressed to chronic renal
failure. She is 165 cm tall and weighs 55 kg. She now has blood pressure
measurements in the range of 150/90 to 180/110 mm Hg, but does not regularly take
medications. Laboratory studies show her blood urea nitrogen is over 100 mg/dL and
she requires chronic dialysis. A chest x-ray shows an enlarged heart. The size of her
heart is most likely to be the result of which of the following processes involving the
myocardial fibers?
A

Hypertrophy

Fatty infiltration

Hyperplasia

Fatty degeneration

Edema

(A) CORRECT. The ongoing pressure load of the systemic hypertension led to
myocardial fiber hypertrophy and a heart that increased in size. Renal failure often
leads to hypertension, and vice versa.
(B) Incorrect. Fat in the heart does not increase in response to the increase in work
load from hypertension.
(C) Incorrect. Myocardial fibers do not undergo a significant degree of hyperplasia.
(D) Incorrect. Fatty degeneration of myocardium is typically the result of a toxic or
hypoxic injury.
(E) Incorrect. Myocardial edema is not a characteristic feature of myocardial injury or
increased work load. However, heart failure could lead to peripheral edema.
Question 13
A 29-year-old man goes on a snorkeling trip to Looe Key Marine Sanctuary and later
spends time on the beach at Bahia Honda State Park. The next day he has a darker
complexion. His skin does not show warmth, erythema, or tenderness. His skin tone
fades to its original appearance within a month. Which of the following substances
contributes the most to the biochemical process leading to these skin changes?
A

Iron oxide

Lipofuscin

Tyrosine

Homogentisic acid

Glycogen

(A) Incorrect. Heme containing iron as part of hemosiderin from breakdown of red
blood cells can impart a brownish colour, but this is typically local from trauma or
more global as part of an iron storage disease such as hemochromatosis. Iron oxide
is also used in tattoo pigments.
(B) Incorrect. Lipochrome (lipofuscin) is a 'wear and tear' pigment imparting a golden
brown appearance to granules in cells (such as myocytes or hepatocytes), but this is
not a feature of skin.
(C) CORRECT. The tanning process in skin is stimulated by ultraviolet light
exposure. Melanocytes have the enzyme tyrosinase to oxidize tyrosine to
dihydroxyphenylalanine in the pathway for melanin production. Natural skin tone is
related to the level of tyrosinase enzyme activity
(D) Incorrect. Homogentisic acid can be part of the process of the rare disease
alkaptonuria, in which a black pigment is deposited in connective tissues.
(E) Incorrect. Glycogen in quantity is starch-like and imparts a paler colour to organs
in which it is stored in excess. It does not involve the skin.