Liver Pathology Questions. Matthew M. Yeh, MD, PhD. 1. Which of the following statements is true regarding hepatitis B?
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1 Liver Pathology Questions 2012 Matthew M. Yeh, MD, PhD 1. Which of the following statements is true regarding hepatitis B? A. Cirrhosis is not a prerequisite for the development of hepatocellular carcinoma. B. A patient infected with hepatitis C is less likely to develop chronic hepatitis than with hepatitis B. C. It is the most common cause for liver transplantation in the US. D. The finding of ground glass hepatocytes indicates the development of anti-hbs antibody. E. It is associated with mixed cryoglobulinemia. 2. There are several grading and staging schemes of chronic liver diseases in daily practice such as Batts and Ludwig, Ishak, and Metavir systems. They can be used in the following EXCEPT: A. Chronic hepatitis B B. Chronic hepatitis C C. Autoimmune hepatitis D. Primary biliary cirrhosis 3. Which of the followings best describe hepatitis C? A. It is a DNA virus B. The most common genotype in the US is genotype 3. C. Mild steatosis is common in chronic hepatitis C. D. Injury of the bile ducts in chronic hepatitis C is uncommon. E. Severe parenchymal injury in the hepatic lobule is common in chronic hepatitis C. 4. The followings are features of autoimmune hepatitis EXCEPT: A. Positive ANA and/or SMA antibodies B. Female predominance C. Hypergammaglobulinemia (IgG) D. Often with abundant plasma cells but minimal lobular inflammation E. Responsiveness to corticosteroid therapy 5. Which of the following statements is true? A. Sanded nuclei can be seen in chronic hepatitis C. B. Ground glass hepatocytes can be seen in chronic hepatitis C. C. Multinucleated giant hepatocytes are common in chronic hepatitis C. D. Marked interface hepatitis and severe lobular inflammation are hallmark features of chronic hepatitis C. E. Bile duct injury is a common finding in chronic hepatitis C. 1
2 6. Which of the following statements regarding primary biliary cirrhosis (PBC) is true? A. Florid duct lesion is typically a late manifestation. B. Loss of interlobular bile duct often leads to bile ductular reaction. C. PBC is characterized by elevated IgM. D. The pattern of PBC-associated cirrhosis is typically generalized cirrhosis. 7. Primary biliary cirrhosis: A. is commonly associated with inflammatory bowel disease, especially ulcerative colitis. B. predominantly affects middle aged men. C. typically overlaps with primary sclerosing cholangitis (PSC). D. is characterized by anti-nuclear antibody (ANA). E. is characterized by an immune response to mitochondrial antigens in the majority of the patients. 8. The following about primary sclerosing cholangitis is true: A. ERCP is the gold standard for its diagnosis. B. It affects only the small and medium-sized bile ducts. C. It is typically associated with anti-mitochondrial antigens. D. It is more common in women. E. It is more commonly associated with Crohn s disease than with ulcerative colitis. 9. The following is least likely associated with hepatocellular carcinoma? A. Primary biliary cirrhosis B. Chronic hepatitis C C. Chronic hepatitis B D. Wilson disease E. Hemochromatosis 10. The following statement regarding nonalcoholic steatohepatitis (NASH) is true: A. Neutrophilic infiltrates in the lobule are necessary for the diagnosis. B. Ballooned hepatocytes are necessary for the diagnosis. C. Mallory-Denk bodies (Mallory hyalines) are necessary for the diagnosis. D. Mallory-Denk bodies (Mallory hyalines) distinguish NASH from alcoholic steatohepatitis. E. Perivenular/pericellular (chicken-wire) fibrosis is necessary for the diagnosis. 11. Which of the following is associated with nonalcoholic steatohepatitis (NASH) EXCEPT: A. Obesity B. Hyperglycemia C. Type I diabetes D. Type II diabetes E. Hypertriglyceridemia 2
3 12. The typical histopathology of alcoholic liver disease includes the following EXCEPT: A. Steatosis B. Bile duct injury C. Ballooned hepatocytes D. Mallory-Denk bodies (Mallory hyalines) E. Centrilobular perivenular/pericellular fibrosis 13. The most common cancer in liver in the US is: A. Hepatocellular carcinoma B. Cholangiocarcinoma C. Metastatic carcinoma D. None of the above 14. The most common cancer in liver in the world is: A. Hepatocellular carcinoma B. Cholangiocarcinoma C. Metastatic carcinoma D. None of the above 15. The followings are risk factors of cholangiocarcinoma EXCEPT: A. Primary sclerosing Cholangitis B. Hepatolithiasis C. Liver fluke infections D. Oral contraceptive E. Choledochal cysts 16. Which of the following statement is true? A. The immunohistochemical staining pattern of cholangiocarcinoma and metastatic adenocarcinoma form the pancreas is very different. B. Chronic hepatitis B-associated hepatocellular carcinoma commonly arises in non-cirrhotic liver. C. Fibrolamellar carcinoma commonly arises in cirrhotic liver. D. Well-differentiated hepatocellular carcinoma and hepatocytic adenoma can be reliably distinguished in needle biopsy specimens. E. Monoclonal CEA is a useful antibody in diagnosing hepatocellular carcinoma (HCC), which highlights the unique canalicular pattern in the HCC cells. 17. Which is the most common cause of portal hypertension worldwide? A. Chronic hepatitis B infection B. Chronic hepatitis C infection C. Alcoholic liver disease D. Nonalcoholic fatty liver disease E. Schistosomiasis infestation 3
4 18. Fibrolamellar variant of hepatocellular carcinoma A. is typically negative for Hep par 1. B. is typically negative for glypican-3. C. is not associated with any underlying liver disease. D. typically shows steatosis. E. typically occurs in young women of reproductive age. 19. The following statements are true EXCEPT: A. Focal nodular hyperplasia is characterized grossly by a central scar. B. Focal nodular hyperplasia is characterized by thick-walled arteries within the parenchyma. C. Ductular reaction and inflammatory cell infiltrates are classic features of focal nodular hyperplasia D. It is now generally accepted oral contraceptive is not the cause of focal nodular hyperplasia E. On liver biopsy, focal nodular hyperplasia may resemble cirrhosis. 20. Which serologic test results most likely confirm that a patient is chronically infected with hepatitis B? A. Hepatitis B surface antigen negative and anti-surface antibody positive B. Hepatitis B surface antigen positive and IgM anti-core antibody positive C. Hepatitis B surface antigen positive and IgM anti-core antibody negative D. Hepatitis B surface antigen negative and IgG anti-core antibody positive 21. What immunohistochemical stain helps to diagnose autoimmune pancreatitis A. IgM B. IgG C. IgG4 D. IgA 22. Which of the following neoplasm occurs predominantly in women except A. pancreatic mucinous cystic neoplasm B. intraductal papillary mucinous neoplasm of the pancreas C. solid pseudopapillary neoplasm of the pancreas D. hepatic adenoma 4
5 Answers to Liver Pathology Matthew M. Yeh, MD, PhD 1. A 2. D 3. C 4. D 5. E 6. C 7. E 8. A 9. D 10. B 11. C 12. B 13. C 14. A 15. D 16. B 17. E 18. C 19. B 20. C 21. C 22. B 5
6 Liver Pathology Matthew M. Yeh, MD, PhD Image Questions, ASCP Resident Review The hepatocytes in this image most likely contain which in their cytoplasm? A. Abundant mitochondria B. Abundant Golgi apparatus C. Hepatitis B surface antigen D. Mallory-Denk bodies (Mallory hyalines) E. Abundant abnormally folded Alpha-1-antrypsin globules Answer: C 6
7 2. What differential diagnosis comes to your mind with the findings in this image: A. Wilson disease B. Nonalcoholic steatohepatitis C. Alpha-1 antitrypsin deficiency D. Hemochromatosis E. Chronic hepatitis B Answer: D 7
8 3. What stain will be confirmative with the findings in this image: A. Perls iron stain B. Ubiquitin C. PAS with diastase D. Copper stain E. Anti-HBs antibody Answer: C 8
9 4. What is the most likely diagnosis in this liver biopsy? A. Herpes hepatitis B. Acute hepatitis B C. EBV hepatitis D. Adenovirus infection E. CMV hepatitis Answer: E 9
10 5. What is the least likely diagnosis from this micrograph? A. Amanita Phalloides hepatotoxicity B. Acetaminophen hepatotoxicity C. Methyldopa hepatotoxicity D. Ischemia E. Infection Answer: C 10
11 6. A micrograph of a liver specimen from a 25-year-old man. What is the most likely diagnosis? A. Focal nodular hyperplasia B. Cholangiocarcinoma C. Metastatic adenocarcinoma D. Fibrolamellar carcinoma E. Hepatocellular carcinoma arising in cirrhosis Answer: D 11
12 7. Liver biopsy from a 45-year-old man. What is the most likely diagnosis? A. Primary biliary cirrhosis B. Primary sclerosing cholangitis C. Autoimmune hepatitis D. Chronic hepatitis C E. Chronic hepatitis B Answer: B 12
13 8. Liver biopsy from a 50-year-old woman. What is the most likely diagnosis? A. Primary biliary cirrhosis B. Primary sclerosing cholangitis C. Autoimmune hepatitis D. Chronic hepatitis C E. Chronic hepatitis B Answer: A 13
14 8. What is the most likely diagnosis from this micrograph? A. Bile duct hamartoma B. Peribiliary gland hamartoma C. Cholangiocarcinoma D. Metastatic adenocarcinoma E. Biliary obstruction Answer: E 14
15 9. CD10 immunohistochemical stain is shown in this micrograph from a liver neoplasm. A polyclonal CEA stain also shows a similar pattern. What is the most likely diagnosis? A. Metastatic renal cell carcinoma B. Hepatocellular carcinoma C. Cholangiocarcinoma D. Follicular lymphoma Answer: B 15
16 10. What statement best describes the disease associated with these micrographs? A. The gold standard for diagnosis is ERCP. B. Confirmatory diagnosis relies on serum AMA. C. Its complication is the most common cause for liver transplantation in the US. D. Bile duct injury is rare E. Hepatocellular carcinoma is a common sequela irrespective of cirrhosis. Answer: C 16
17 11. A 45-year-old woman presents with abdominal discomfort for half a year. Surgery was performed for her pancreatic mass which grossly shows a cystic neoplasm. This micrograph shows the cystic epithelium with immunohistochemistry for progesterone receptor (PR). Other immunohistochemical stains are also positive EXCEPT A. ER B. alpha-sma C. HMB-45 D. alpha-inhibin E. vimentin Answer: C 17
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