Table Of ContentG.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 Colin L.Berry, PhD, FRCPath
October 1989 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 myth
ology 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 encourage
ment, 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, Gordon Stamp
September 1989 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
Introduction
The final part of the examination for membership of the Royal College of
Pathologists was introduced in 1962 in order to provide a professional quali
fication which would establish whether a candidate was capable of undertaking
the duties and responsibilities of a consultant. As such, the examination was
intended to be set at a relatively greater degree of difficulty than other profession
al examinations for membership of the other medical colleges, which are taken
relatively early in training, assessing suitability for training. The Primary examin
ation was designed to fulfill this role, success in which enabled candidates to
pursue more advanced training in registrar and senior registrar posts.
Naturally, over the years the examination has been refined and expanded with
the advances in histopathology and morbid anatomy, in common with most
medical and scientific disciplines, and it is true to say that a higher standard is
expected than say ten or fifteen years ago, especially with the emergence of a
more science-based approach to pathology which has greatly increased our
understanding of the pathogenesis of disease.
Unfortunately, little advice is available to prospective candidates and the onus
on preparation for the examination has remained largely up to the individual
concerned. This is to a large extent a consequence of the broad scope of skills and
knowledge expected of a modern pathologist, so that revision courses along the
lines of those offered for MRCP or PRCS examinations are impractical because
of the difficulties in organising the complex material required. It could, however,
be argued that the examination is intended to assess the results of five or more
years of training to a satisfactory level of competence in all respects, which could
not possibly be achieved during a 'crammer' course. Instead, individual courses
in aspects of histopathology, morbid anatomy or specialised disciplines such as
paediatric pathology are available, but they are not a compulsory requirement of
training, and attendance is selective, based on the trainee's perception of need,
measured against financial considerations and utilising a finite amount of study
leave.
As many candidates are not made aware of the format of the Final examination
during their junior appointments (especially if based overseas) it is not surprising
that many do not have an organised general training covering all important
aspects, which allows the practice and perfection of certain of the skills required.
This cannot be left until the last minute as part of the revision programme. For
instance, those who have tried to remove a spinal cord for the first time or made a
serious attempt to understand the classification of lymphomas in the few weeks
heading up to the examination will know the folly of leaving preparation too late.
Therefore it seemed obvious that an explanatory overview of both the examin
ation and preparation requirements, aimed at potential candidates, would be of
value, to enable the optimal planning of a training programme. As such we do not
intend to provide anything approaching a comprehensive account of disease
states, but instead suggest some approaches to the problems encountered during
the examination, with guidance to more detailed sources of information where
appropriate. Considerable emphasis is placed on the ability to provide clinically
useful information in a succinct, relevant fashion, the hallmark of a competent
histopathologist in routine hospital service and teaching commitments, as well as
in the examination.
A relatively informal style is used, since this is not designed to be a
conventional textbook of pathology. This may provoke some criticism from the
more intellectual reader, especially as it could be argued that the obvious is being
