G.W.H. Stamp • N.A. Wright

Advanced Histopathology

Foreword by Colin L. Berry

Springer-Verlag London Berlin Heidelberg New York Paris Tokyo Hong Kong

G.W.H.Stamp, MBChB, MRCPath Clinical Research Fellow, Imperial Cancer Research Fund, Royal College of Surgeons, 35-43 lincoln's Inn Fields, London WC2A 3PN, UK and Honorary Consultant in Histopathology, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK

N.A.Wright, MA, DSc, MD, PhD, FRCPath Professor and Director, Department of Histopathology, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK and Associate Director and Head of Histopathology Unit, Imperial Cancer Research Fund, Royal College of Surgeons, 35-43 Lincoln's Inn Fields, London WC2A 3PN, UK

With contributions from:

Dr T. Clarke, MA, MBBChir, MRCPath, Senior Registrar in Histopathology, Royal Devon and Exeter Hospital, Exeter, Devon EX2 SAD, UK

Dr F. Barker, MA, MBBS, MRCPath, Senior Registrar in Histopathology and Dr M.B. Prentice, BMedSci, MBBS, FRCPathAust, Registrar in Histopathology Hammersmith Hospital, Du Cane Road, London W12 OHS, UK

ISBN-13:978-3-540-19589-4 e-ISBN-13:978-l-4471-1753-7 DOl: 10.1007/978-1-4471-1753-7

British Library Cataloguing in Publication Data Stamp, G.W.H. (Gordon W.H.), 1955-

Advanced histopathology. 1. Medicine. Histopathology I. Tide ll. Wright, N.A. (Nicholas Alcwyn), 1943- 611'.018 ISBN-13:978-3-540-19589-4

Library of Congress Cataloging-in-Publication Data Stamp, G. W. H. (Gordon W. H.). 1955-

Advanced histopathology/ G.W.H. Stamp and N.A. WrighL p. cm. ISBN-13:978-3-540-19589-4 (U.S. alk. paper)

1. Histology, Pathological-Examinations, questions, etc. 2. Histology, Pathological-Oudines, syllabi, etc. I. Wright, N. A. (Nick A.), 1943- ll. Tide. RB43.S73 1989 611' .018-dc20 89-26119

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Foreword

It is easy to be confident that an appropriate body of advice is available to candidates about the content of an examination once you have passed it. Prospectively, the Primary and Final Examinations of the Royal College of Pathologists will appear to most to involve the assimilation of what seems at the time an inexhaustible volume of data, and the recent change in the College examination system has not diminished this concern for the majority of candidates. The guidelines for training for the new Part I examination state that this is the "major hurdle of the MRCPath" and it is clear that it will determine whether candidates are suitable for training which will permit them to practise independently as consultants after Part II.

These general aims and objectives do not answer questions such as "How much do I need to know about glomerulonephritis?" or "Where do I stop with the lymphomas?" This text attempts to resolve the difficulty of knowing what standard to aim at, using College questions as its starting point. It concentrates on the essential basis of any single answer; many candidates for the new three-year examination will know more about individual topics than is stated here. However, it is the breadth of information required which is a feature of College examinations and this text should help with this problem.

There are a number of important additional points. You will not pass if you do not do an adequate post-mortem or present it clearly, if you do not know something about special techniques, if you have ignored cytology, or if you suppose surgical pathology can be learned by picture matching. Many slides are put into practical examinations to see how you think about problems - it is not necessary to know all the answers but you do have to behave sensibly when confronted with something difficult.

The Government White Paper on the National Health Service should have convinced you that it is important to know about management issues and to be able to evaluate your own work pattern critically (and financially). If you pass the

vi Foreword

examination(s) you can be confident that this phase of your training has been satisfactorily completed and that you have demonstrated a high standard of proficiency - an important achievement.

London October 1989

Colin L.Berry, PhD, FRCPath Professor of Morbid Anatomy

The London Hospital Medical College

Preface

We assume you have bought, or are thinking of buying, this book because you are faced, horribile dictu, with the Histopathology examinations of the Royal College of Pathologists, or some related ordeal.

If you have not taken the examination before, then, apart from advice from your seniors (who may not have taken the examination personally, being Grandfathers, or even worse, achieved their MRCPath status through research) and myth­ology prevalent among your peers, you will not know what to expect. If you have taken the examination, then you have obviously been failed, albeit by biased and intransigent examiners. Take comfort: help is on the way.

Following an initial discussion between Nick Wright and Colin Berry, it was decided to attempt a vade-mecum for prospective examination candidates. Gordon Stamp prepared the initial and final drafts, enlisting the substantial help of Fred Barker, Tom Clarke and Mark Prentice; Colin Berry's continuing guidance has been invaluable and without Susan Chandler, who deciphered our holographic offering, this book would not have been possible.

Keep this book beside you during your revision effort, take careful heed of the advice given, and behave in the examination in the manner suggested, and if you don't pass this time, then there is obviously something wrong with the examination system, and you should join the serried ranks of those who clamour for examination reform (again).

Unless you positively enjoy examinations, then you will certainly not be looking forward to the event. We hope that this book will to some extent allay your fears, give you encourage­ment, and help minimise your negative feelings.

We would like to take this opportunity of wishing you luck (an important ingredient in these examinations) and stay off the B-blockers.

London, September 1989

Gordon Stamp Nick Wr~ght

Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Preparation for the Examination ...................... 2 Pathology Textbooks and Journals .................... 3 Application for the Final Examination. . .. . . . ..... . . .. . 8

The Written Examination. . .. . . . . . . • .. • .. . . . . • • • • • . .. 9 General Preparation..... . . . .. . . . . .. . . . . .. . . . . ... . . . . 9 Essay Format. . .. . . . . .. . . . .... .. ...... . ..... . .. . . .... 10 Essay Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

MRCPath Essay Questions (1969-1989) ••.•..•••.••.•• 17

Sections 1. General Pathology........ .. . . . . .. . . . . .... . ... . . . . . 17 2. Neoplasia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 3. Lyrnphoreticular System. . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4. Alimentary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5. Cardiovascular and Respiratory Systems ............ 113 6. Endocrine System. . .. . . . . .. . ............ . . . .. . . ... 147 7. Renal Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 8. Central Nervous System...... . . .. . . . . .......... . .. 179 9. Osteoarticular Pathology....... ... .... ........ . . . .. 193 10. Reproductive System . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 207 11. Dermatopathology................................ 217 12. Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 223 13. Short Notes Questions . . . . . . . . . . . . . . . . . . . . . . . . . . .. 243

The Written Examination: Practical Aspects. . . . . . . . . . • 249

The Practical Examination •••.•••••.......•••..•.•••• 251 Introduction ........................................ 251 Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 252

x Contents

The Necropsy: Preparation to Examination Standard ........................... 252

The Necropsy: Procedures............................ 254 Removal of Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256

Systematic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 259 Presentation of the Post Mortem ........... . . . . . . . . . . . 274 Writing the Report .......................... '......... 275 Special Techniques .................................. 281 Paediatric and Neonatal Necropsies. . . . . . . . . . . . . . . . . .. 284

Surgical Pathology Slides. . . . • . • . • • • • • • • • • • • . . . . . . • • • 287 Recommended Approach to Examination of Sections. . . . 287 Assessment of the Clinical Information . . . . . . . . . . . . . . .. 287 Naked Eye Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 288 Writing the Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 289 Types of Cases Used in the Examinations.............. 289 Preparation for the Surgical Histopathology. . . . . . . . . . .. 291 Material Sources and their Utilisation for

Surgical Pathology Revision. . . . . . . . . . . . . . . . . . . . . . 293 Current Literature ........ " . ....... ..... . . . .. . . . .... 296 Routine Surgical Reporting . . . . . . . . . . . . . . . . . . . . . . . . . .. 296 Specialised Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 297

Cytology ................•...............••......... 299 General Principles in Examination Preparation . . . . . . . .. 299

Approach to Cytology Specimens . . . . . . . . . . . . . . . .. 300 Screening Technique. . .. . . . . .. . . . . .. . . . . . . . . . . ... 301 Cytological Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 301 Standards in Cytology . . . . . . . . . . . . . . . . . . . . . . . . . .. 302

Common Cytological Specimens in Examinations....... 304 Gynaecological. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Non-gynaecological. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 305

Surgical Dissection and Macroscopic Examination. • . .. 307 Preparation for Surgical Dissection. . . . . . . . . . . . . . . . . . .. 307 Special Stains ....................................... 308

Necropsy Histology.... .. . ... . . .. ... . . . .. . . . . ..... .. 310 Mounted Museum Specimens ('Pots').................. 311 Case Discussion or Clinico Pathological Correlations. . .. 312 Electron Micrographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 313

Cl)'ostat Sections................... ............... .. 317

Contents xi

The Viva Voce Examination................. . .. .•. •.. 325 Introduction..................................... . .. 325 The Examination Itself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 325 Notification of Results ............................... 327 Envoi............................................... 328

Appendix 1 Reference List of Major Texts......................... 329 Additional Reading/Reference List. . . . . . . . . . . . . . . . . . .. 330

Appendix 2 Teaching Courses in Histopathology and Morbid Anatomy........................................... 331

Appendix 3 Professional Societies and Associations . . . . . . . . . . . . . . .. 335

Regulations Regarding the Examinations for Membership (Medically qualified candidates) . . . . . . . . . . 336

Regulations Regarding the Examinations for Membership (Candidates without a medical qualification) . . . . . . . . . .. 338