RCPA Examinations in Anatomical pathology - Questions ... - Rcpa.tv

Exam Update 

2008 

Anatomical Pathology 

10.3.06

Myths, Smoke and Mirrors 

The big myth is that information about training and examinations is 

not available from the Board of Censors 

The “smoke and mirrors” appears to come from individuals who have 

not made any attempt to access the available information 

The following slides show the material available to supervisors and 

candidates, compiled from information supplied predominantly by 

the efforts of Members of the Board of Censors 

10.3.06

Available Information 

What is the Board of Censors and what is the Board’s 

mandate? 

• Available Information 

– Generic 

• RCPA Articles of Association 

10.3.06


RCPA ARTICLES OF ASSOCIATION 

BOARD OF CENSORS 

Appointment and Powers 

45. The Council shall have the power from time to time to appoint censors 

to constitute a Board of Censors for the purpose of inquiring into and 

testing the qualifications of candidates for membership of the College 

and to appoint a Chairman of the Board of Censors. The Council may 

make by-laws defining the powers of the Board of Censors and the 

Chairman thereof and prescribing rules for its procedure 

Council May Exercise Powers Where no Board of Censors 

46. At any time when there shall not be a Board of Censors in existence 

the Council may exercise and perform any powers duties and 

functions conferred or imposed on the Board of Censors by these 

Articles. The Council may from time to time co-opt not more than three 

additional Fellows of the College to be members of the Council for the 

purpose of exercising the last mentioned powers duties and functions. 

10.3.06

Available Information (cont.) 

Policy Manual – Guidelines 

• Admission to Fellowship by Viva Examination Alone 

• Assessment of Training Programs for Accreditation of RCPA 

Training: Process for Assessment of Adequate Staffing Levels 

• Joint Training Programs with the Royal Australasian College of 

Physicians 

• Interview of Overseas Trained Specialists 

10.3.06


Policy Manual - Policies 

• Appointment to Major Committees 

• Assessment of Overseas Trained doctors and Overseas Trained 

Specialists in australia and new Zealand 

• Examinations for Overseas Trained Specialists Incorporating Timing 

of Part II Examinations 

• Interrupted and Part-time Training 

• Repeat Examinations 

• Selection of Examiners for the College 

10.3.06


Policy Manual - Roles and Responsibilities 

• Chief Examiners and Associate Chief Examiners 

• Ombudsman for Trainees 

• Registrar and Deputy Registrar 

Policy Manual - Terms of Reference 

• Board of Censors 

• Training and Exams - Accredited Labs 

• 2007 Lab Audit Form 

10.3.06


Training and Exams - Accredited Labs 

• Accredited Laboratories for RCPA Training 

• Plus all forms for accreditation for individual disciplines 

• Step Guide: Assessment of labs seeking accreditation to train 

Registrars of the RCPA and renewal of lab accreditation Jan 2008 

• The Board of Censors have full business meetings in March, July and 

November of each year. The dates for 2008 are 17 March, 14 July and 

24 November. 

10.3.06


Training and Exams - Exam Information 

• Anatomical Pathology Part I Candidates Instructions 

• Anatomical Pathology Part I Candidates Slides proforma 

• Anatomical Pathology Part II Candidates Instructions 

• APII Part II Practical and Slides candidates instructions 

• Anatomical Pathology Part II Slides proforma 

• AP Exam Presentation 2004 

• Presentation on AP exams at Pathology Update 2003 (192 kb) 

• AP exam presentation 2005 (536 kb) 

• Information given at Pathology Update 2005, re AP exams and 2004 Part II slides 

• AP Exams Update - March 2007 

• RCPA June 2007 Exam Venues 11 May07 

• RCPA November Examination Timetable 

10.3.06


Training and Exams - Forms 

• Annual Registration and Exam Information 2008 

• Annual Registration and Exam Information 2008 

• Application for Annual Registration 2008 

• Autopsy Assessment Form (AP Trainees) 

• College Information 2008 

• Confirmation of Completion of Supervisors Module 

• Draft Exam Timetable 2008 as at 2Jan08 

• Examination Application 2008 

• Examination Application Information 2008 

• Fellowship Application Form 2007/8 

• Selection of Examiners 

10.3.06


Training and Exams - Past Exam Papers 

• Anatomical Pathology Part 1 Written Exams - 2006 

• Anatomical Pathology Part I Written Exam 2005 

• Anatomical Pathology Part I Written Exam Paper 2004 

• Anatomical Pathology Part I Written Exams 1999 - 2003 

• Anatomical Pathology Part II Forensic Slant 2005 

• Anatomical Pathology Part II Slant 2001 

• Anatomical Pathology Part II Slant Past Exams 

• Anatomical Pathology Part II Slant 2004 

• Anatomical Pathology PartII Slant 2006 

• Diploma of Cytopathology Written Exam 2001 

• Diploma of Forensic Medicine Exams 2001 - 2003 

10.3.06


Training and Exams - Policies 

• Acceptance of Australian Trained International Medical Graduates onto RCPA Training Programs in Australia 

• Admission to Fellowship by Viva Examination Alone 

• Appointment of Pathology Registrars 

• Assessment of Overseas Trained Specialists seeking Medical Registration in Australia or New Zealand via the Australian Medical Council and the Medical Council of New 

Zealand Processes 

• Candidates in Training and Sitting Examinations in Countries without College Representation 

• Information for Trainees in countries without a regional councillor or corresponding felow 

• Clinical Privilege Guidelines for Forensic Pathology Registrars 

• Clinical Privileges for Pathology Trainees 

• Complaints in Relation to Examinations 

• Discrimination and Harassment 

• Training and Exams - Policies 

• Eligibility for Retrospective and Prospective Accreditation of Training 

• Exam Exemption Guidelines 5 March 2007 

• Examination Candidates in Need of Consideration for Illness, Accident, Disability or Compassionate Grounds 

• Examination Papers on the Website 

• Examination Venues 

• Examination Venues July 2001 (94kb) 

• Fees Associated with Failure to Attend an Examination, Withdrawal from Sitting Examination, Exemption from Examination, Repeat Examination and Late Applications 

• Guidelines for Invigilators – Examination Procedure 

• Interview of Overseas Trained Specialists 

• Joint Training Programs with the Royal Australasian College of Physicians 

• Laboratory Accreditation for Training Programs 

• Limitation on the Number of Examination Attempts and Length of Time Examination Passes Remain Valid 

• Mentoring for Trainees 

• Occupational Trainees in Australia 

• Ownership and Confidentiality of Examination Materials 

10.3.06


Information for Trainees, invigiltors and examiners 

• Payment of Fees for Retrospective Accreditation 

• Plagiarism and Cheating in Examinations 

• Repeat Examinations 

• Retention of Examination Materials 

• Retraining 

• Selection of Examiners for the College 

• Selection of Examiners for the College - October 2001 (92kb) 

• Selection of Trainees 

• Supervision of Training 

• Timing of Part II Examinations in Anatomical Pathology with Particular Regard to Exemptions and OTS Candidates 

• Training Determinations, Examination Exemptions 

• Training in an Unpaid Position 

• Training Limitation 

• Training time credits (Retrospective time) 

• Viva Examinations 

10.3.06


Training and Exams - Publications 

• A Career in Pathology 

• AMC Accreditation Final Report 

• AMC Accreditation Final Report - appendices 

• Draft Induction Manual for Supervisors 

• Guide for Supervisors 

• RCPA Trainee Handbook 

• 2007 Trainee Handbook 24 September 

• Overall Results of Trainee Survey 2003 

• Supervisor's report for Trainees in Anatomical Pathology 

• Supervisor's report form 

10.3.06


10.3.06

What’s s Current ? 

• Forensic Pathology has its own examination system 

• No slants at Part ll Anatomical pathology examinations 

• Proposed introduction of (non mandatory) Diplomas at 

Post-Fellowship level to demonstrate advanced 

competency in selected sub-specialties 

specialties 

10.3.06

No More Slanted Part II Exams in 

AP – Post Fellowship Diplomas 

What’s s it mean ? 

Proposed 

• If you have not already registered for a Part ll slant then you must 

sit the AP Part l and Part ll Exams to proceed to Fellowship 

• It is proposed that post-Fellowship Diplomas, such as the Diploma 

in Cytopathology will also be offered in Neuropathology* and 

Paediatric Pathology* 

‣ May be sat at any regular exam round 

‣ Candidates are proposed for Diplomas by 2 Fellows 

recognised as specialists in the particular area* 

*These proposals have still to be formulated, together with a 

curriculum, and ratified by the Board of Censors and Council 

10.3.06

Examinations in Anatomical Pathology 

CURRENT 

EXAMINATION 

FORMAT AND 

MARKING 

PROCEDURES 

10.3.06

To avoid confusion (and to also avoid repetitive 

questions) – please note the following:- 

• The time allowed for the first practical examinations is 4 hours . 

• Change of format for marking practical examinations - examiners mark each question 

separately. This will avoid previous answers from a candidate having any influence on the 

marks for the next case 

• Autopsy assessment - the autopsy assessment is a stand alone component attempted any 

time after the first 15 months of training – the assessment must be satisfactorily completed 

before the Board of Censors will recommend the conferring of Fellowship lowship by Council 

• Exemptions for any one phase of the Part 1 examination are only valid for one year 

• Exemptions for any one component of the Part 2 examination are ordinarily o 

only valid to 

the next examination 

10.3.06

Examinations in AP 

The aims of the current examinations are: - 

Part I 

• the main assessment hurdle with candidates expected 

to approach but not reach the standard required for 

the Part II 

Part II 

• more of an ‘exit’ exam 

• a continued assessment of safe and unsupervised 

practice of AP at the specialist level 

10.3.06

Current Examination Format in AP 

Part I 

• One written paper 

• One 4 hour histopathology slide examination 

• Special practical examination 

• Two 20-minute 

vivas 

Part II 

• Casebook 

• One 4 hour histopathology slide examination 

• One 2 hour cytopathology examination (12 cases) 

• Two 20-minute 

vivas 

All – Autopsy assessment, 2005 onwards 

10.3.06

Part I 


Phase 1 

• One three-hour hour essay-type written paper comprising 5 compulsory questions 

• A four-hour practical examination of 20 cases consisting entirely of surgical and 

autopsy pathology 

Sat at around the same time, in regional venues, as at present 

Successful candidates will be invited to the Phase 2 

10.3.06

Part I 


Phase 2 

• A three-hour hour practical examination including any of the following:- 

frozen sections, cytology, small biopsies, special stains, 

immunoperoxidase, , immunofluorescence photographs, electron 

micrographs and macrophotographs (12 stations) 

Sat at the same venue as the oral. 

Candidates rotate at regular intervals through a series of stations 

• Two 20-minute oral examinations 

10.3.06

The Written Examination 

• What do we tell the examiners?

Sample portions of Letter To 

Examiners – Part l, 2005 

Dear Dr, 

Thank you for agreeing to mark a question in the Part I Anatomical al Pathology Written 

Examination. The examination will be held Friday 10 June. You have h 

been assigned 

question 1: 

1. A 74-year 

year-old male with severe chronic obstructive airways disease 

presents with abdominal discomfort and is found on imaging to have a 

thickening in his terminal ileum and retroperitoneal lymphadenopathy. athy. After 

assessment he is found to be a poor risk for general anaesthetic and open 

biopsy. The radiologists have been asked to obtain material from m his 

peritoneal lymph nodes under imaging guidance. 

You are called by the radiologist on duty and asked for advice as to the 

specimens you would prefer to maximise the chance of reaching a definitive 

diagnosis. 

State what advice you would give, considering the possible differential 

diagnoses, including the reasons for each type of specimen you would w 

require. 

How would you handle and distribute each of the specimens once they t 

are 

collected?

Instructions to Examiners 

“ In setting the paper we have 

attempted to move away from 

questions requiring only 

factual knowledge and have 

tried to introduce questions 

that require the candidate to 

apply that knowledge.”

Some of the points we had in mind when setting 

question 1 included: 

• The differential diagnosis to be considered including possible 

infectious causes (Mycobacterial( 

infection, Yersinial infection, 

Slamonella etc.), inflammatory causes including Crohn’s disease) 

and neoplastic disorders in this situation (lymphoma etc.) 

• Specimens to consider requesting should include material for 

histopathological examination, microbiological examination, flow 

cytometry and immunohistochemistry 

• Discussion of handling of the specimens should include OH&S 

considerations 

• The candidates should be able to give advice as to the limitations of 

procedures including FNA biopsy and core biopsy techniques

• On receipt of this letter would you please liaise with your co- 

examiner re. the required content of the answer for this particular 

question – i.e. the minimum information you consider necessary 

for a pass. Between you, you may decide that further information, 

other than that which Tony Thomas and I have mentioned, should 

also be included. This is acceptable, but please correspond with us 

re. any extra information you think was necessary, after you have 

completed your marking. 

• After you have agreed on the content would you please mark the 

papers independently and keep a record of your original 

assessment to forward to us, together with an agreed assessment 

in the case of any major discrepancies. If there are major 

unresolved discrepancies a review of the candidate's paper by a 

third examiner may be necessary. We are requesting that you 

follow this procedure to fall in line with suggestions from the 

curriculum review and assessment outcomes thus far.

Question 2 

Write short notes on three of the following: 

The use of micro-arrays in defining tumour differentiation 

Implications of a diagnosis of serrated adenoma 

Flow cytometry and gene re-arrangement studies in the diagnosis of 

cutaneous lymphomas 

Micro-satellite instability in large bowel adenocarcinomas 

Electron microscopy in the diagnosis of soft tissue tumours

Question 3 

You are directed by the Coroner to perform an autopsy on the body y of 

a 38-year 

year-old male who has died following perforation of the 

oesophagus, followed by suppurative mediastinitis and septicaemia. 

a. 

Endoscopy four days prior to death showed an oesophageal ulcer and a 

biopsy revealed herpes virus inclusions in the squamous epithelium 

adjacent to the ulcer and fungal elements, presumed to be Candida 

sp., in the ulcer slough. 

Describe your approach to the autopsy under the following headings: 

- 

Possible differential diagnoses as to any underlying disease process you 

might expect to encounter; 

Occupational health and safety issues; 

Macroscopic examination; 

Specimen collection and examination: 

Potential microscopic findings in examination of lymph nodes.

Some of the points we had in mind 

when setting question 3 included: 

• Differential should include the range of conditions which might 

cause immunosuppression in this age group 

• Occupational health and safety Issues should include universal and a 

any special precautions for dealing with possible infectious material 

in the autopsy situation and in the handling of collected specimens 

ens 

• The macroscopic and microscopic examinations should include 

evidence of examination for possible factors related to acquisition ion of 

acquired immune deficiency and also related pathology, including 

infections. The possibility that the perforation is iatrogenic should s 

also be addressed 

• Lymph node examination should include features seen in HIV 

infection/AIDS and also other conditions in which immune 

compromise might be seen, including previously undiagnosed 

lymphoma etc.

Part II - Casebook 


From 2005: 

Only eight cases are required as outlined in the 

trainee handbook. (under review) 

**Please check the requirements as outlined in the Trainee Handbook** 

10.3.06



• At least two cases must have been handled during the 12 months 

immediately preceding the deadline for submission on 31st March in the 

year of the examination 

• Cases must be handled personally by the candidate as part of his or her 

training in the discipline 

• Cases cannot be used in any other casebook at any time or by any other 

candidate 

• Individual case reports in peer-reviewed reviewed journals, and paper or poster 

presentations during the period of training and for which the candidate is 

either the principal author or has had a significant input are acceptable; a 

a 

copy should be included with the casebook 

10.3.06



The aims of the casebook are to achieve: - 

• Content as set out in the Trainees’ handbook 

• A succinct presentation of no more than 10 pages with the discussion 

sion 

at least twice as long as the remainder of the presentation with 

• A bibliography in the order of 15 to 30 references and including 

recent peer-reviewed reviewed literature 

• Should include a comprehensive and critical appraisal of the cited 

literature 

and 

• High quality photomicrographs/illustrations 

The volume should be bound (spirax( 

binding OK) and submitted in 

duplicate 

10.3.06



Casebooks are assessed simply as: 

☺Satisfactory 

Unsatisfactory - revise and resubmit the same year 

Resubmission by 31st October for consideration and 

recommendation to BoC November meeting; otherwise 

by 31st March the following year 

Exam is incomplete until a pass grade is obtained 

PROPOSED CHANGE - It is proposed that Candidates not meeting the 

31st March deadline will be permitted to sit the Part 2 examination ion in 

the same year, but we will not guarantee your results will be ready by 

the end of the August exam cycle 

New cases will be necessary if not passed in the same year 

10.3.06

Part II - Practical 


• Include not only the recognition of commonplace and classical 

uncommon disorders, but also cases where the diagnosis may 

not be straightforward, and for which there may be no definite 

answer 

• Emphasis is now be placed on rational and scientific approach 

to differential diagnosis as part of problem-solving in AP 

• Consequently the number of cases is less than in the Part 1 

• The cases may include surgical and autopsy pathology 

• Sat in regional venues 

• The oral exam remains unchanged and comprises two 

20-minute 

vivas 

10.3.06

Part II - Cytopathology Practical 


12 cases to be completed in a 2 hour period 

Cases may include: - 

• Gynaecological (Pap.) cytology 

• FNA Cytology 

• Body fluid cytology 

• Exfoliative cytology 

• Sputum, urine etc. 

10.3.06

Part I and Part II practical 

examinations in AP 

• Cases are submitted by senior consultants from 

Departments around Australia, New Zealand, 

Singapore, Malayasia and Hong Kong 

• The practicals are designed to encompass a broad 

range of neoplastic and non-neoplastic 

neoplastic disorders 

• The suitability of material for each examination is 

assessed by a panel of senior consultants who are 

experienced examiners 

10.3.06

Marking of the Part I and Part II practical 


• Candidates’ answer books are identified by candidate number 

only and remain anonymous to individual examiners 

• An overall fail grade is usually the result of a number of errors. 

This may include too many misdiagnoses or a lesser number that 

are considered by the examiners to be ‘serious’ in the sense that 

misdiagnosis could impact adversely on patient management - 

NEVER BASED ON ONE CASE! 

• Candidates and supervisors should be reassured that the 

evaluation process is intended to be fair and impartial with 

crosschecks and balances at each phase of the assessment 

10.3.06

Marking of the Part I and Part II practical 


1st Examiner 

Pass 

2nd Examiner 

3rd Examiner 

Fail 

Progress to 

orals/2nd phase 

Borderline/ 

Discrepancies 

No progression to 

orals/2nd phase 

Pass 

Pass 

4th Examiner 

Borderline 

Reviewed 

Fail 

Fail 

Borderline 

10.3.06

The Autopsy Assessment in AP 

• This assessment can be undertaken any time after 15 

months of training and before awarding Fellowship 

• The assessment is a “stand alone” component in the 

overall assessment for qualification for Fellowship of 

the College in AP 

• The current guidelines and assessment form are as 

follows:- 

10.3.06

The Autopsy Assessment in AP 

• Two assessors required to substantiate competence in this area of assessment 

• Each assessor must independently complete a copy of the assessment form. 

A third combined and agreed assessment should also be submitted. 

• A depersonalised copy of the autopsy report must be forwarded, together t 

with the completed assessment sheets to the College office. 

• The autopsy must be assessed by : - 

– Departmental Autopsy Service supervisor 

and one of the following 

– RCPA Fellow (in AP or GP) (external to department) – preferred 

– RCPA Fellow (in AP or GP) other than the autopsy supervisor 

– Clinician involved in the case 

• The whole of the autopsy need not be observed by the assessors but b 

both 

assessors must be present at the introductory discussion, the demonstration 

of findings and assessment of key organ dissection. 

• The requirements for assessment are available on the RCPA web site in the 

form of an assessor’s s sheet 

10.3.06

Feedback on the performance and 

interpretation of the autopsy findings 

and the proposed recommendations 

of the assessors should be discussed 

with the candidate at the completion 

of the autopsy report 

10.3.06

Examinations in Anatomical Pathology 

QUESTIONS AND 

COMMENTS FOR 

DISCUSSION 

10.3.06

“Markers should be selected from a variety of 

departments and practices to reflect the diversity of 

pathological practice” 

They are: 

• At the end of the day, it is the content of the 

report and not the style which is of 

fundamental importance and it is this which 

forms the basis of a pass grade 

10.3.06

“Marking of essays is spread across Australia and argument 

that the slides are marked differently to expedite the process is i 

difficult to reconcile considering the time it takes to get results 

lts” 

• Since 1999, some borderline papers have been assessed by 

up to 5 different examiners in three different states and 

further reviewed by the Chief Examiners: this comment is 

not justified 

• The current system gives the candidate the best possible 

chance of progressing to the vivas and it is not appropriate 

to expedite results at the expense of candidates 

• It is not practicable or desirable to have 20 answers books 

per candidate and up to 20 different markers, or to have 

only a few candidates assessed by different examiners 

10.3.06

“If it is essential to keep the slide marking to one 

city why not rotate the city responsible annually?” 

• The Chief and Associate Chief Examiners are 

answerable to the Board of Censors and must be 

responsible for ensuring the maintenance of standards, 

impartiality and continuity from year to year 

• To annually rotate from city to city without the 

involvement of the Chief Examiners would result in 

variation of standards and possible loss of anonymity 

• cf. UK system where standards have in the past been 

vastly different from centre to centre. 

10.3.06

“What are the criteria for allowing candidates to be 

assessed on extra slides at the viva?” 

This applies to the Part II only ! 

• Candidates obtaining a borderline grade for the practical will be b 

required to report on extra slides at the time of the vivas 

• Candidates who fail the practical for the third time but who have 

achieved a pass grade or borderline result on a previous occasion, 

and whose incorrect answers on this last occasion do not exceed 

one third of the cases may be invited to report on extra slides at 

the vivas 

• Reducing the number of slides from 20 to 15 has led to a number 

of candidates who cannot be assessed as pass or fail despite having 

their papers marked by up to 5 examiners. These candidates are 

invited to report on extra slides at the vivas 

10.3.06

“A A recurring problem has been the general uncertainty 

about what is required in terms of the content and structure 

of a Pass answer.” 

• Perhaps the best guide, other than common 

sense, may be found by viewing previous 

Trainee Update Presentations, especially the 

“interactive” presentation from 2004. 

• This is available from the College Office 

10.3.06

“Sample answers and publication of answers to the 

slides would be helpful to both fail and pass candidates” 

• In the next part of this presentation we will 

consider cases from the 2007 Part ll first 

practical examination 

• We will show comments and/or answers on 

cases to give you an idea of what is expected 

10.3.06

Indication as to what is required for slide 

reporting in the practical examinations 

• Instructions to candidates are now issued with the 

acceptance letter for examination in addition to those 

provided at the time of the exam (Instructions to 

Candidates for the Special Part I practical are issued 

with invitation to participate in the vivas): 

– “The aim of this practical is to evaluate your ability 

as a pathologist to diagnose “a a slide” that is 

representative of a particular lesion(s) and, for Part 

II, to practice safe and unsupervised microscopy in 

AP at a specialist standard” 

10.3.06



– “It is in your interest not to waste time on overly long 

histological descriptions. You should describe the 

features (succinctly) and state how you would reach the 

appropriate diagnosis (if this is not obvious to you) 

– “For Part I, most cases represent examples of important 

and common diseases and classical less common 

disorders” 

– “For Part II, the cases include some that are 

straightforward and for which a definitive diagnosis can 

be made whilst others are more complex and for which 

there may be no straightforward answer. Here, the 

examiners seek to assess the capacity for an analytical 

and clinicopathological approach” 

10.3.06



– “Report on each case along the lines you would use in 

everyday practice, including a brief microscopic 

description of each slide. Whenever possible, identify 

the organ or tissue and emphasise any features you 

would need to highlight in your report to the referring 

clinician” 

– “If you are unsure as to the diagnosis, a differential 

diagnosis should be given and the means by which you 

arrive at your preferred diagnosis indicated” 

– “Differential diagnoses should be discriminating , 

reflect your microscopic description and should show 

discernment of the issues illustrated in the sections” 

10.3.06



Do not simply give a non-discriminating list of all 

potential differential diagnoses 

Do not simply give a list of potential special stains and/or 

immunoperoxidase studies without justification and an 

indication of the expected outcome 

Do not ‘second guess’ the examiners 

Write and indicate your preferred diagnosis clearly at the 

end of your report 

10.3.06

1“Are slides weighted?’ 

2“Are there sudden death slides?” 

1 Yes, to a degree 

An error which would have led to unnecessary 

amputation is considered more serious than one which 

would not have affected the patient and this may be 

taken into account in overall performance 

2 No 

There have been no ‘sudden death’ slides during the 

term of office of the last two Chief Examiners and there 

will be none during the current Chief Examiner’s s term 

of office. 

10.3.06

Practical Examinations 

What are the examiners told ?

This is the overall format of the letter of 

Instructions sent to the practical examiners 

• Chief Examiner in Anatomical Pathology Telephone: (03) 92884551 

• Richard A Williams, MB BS, PhD, FRCPA, FHKCPath. International: 613 92884551 

• Department of Anatomical Pathology Fax: (03) 9288 4580 

• St. Vincent’s Pathology. 41 Victoria Pde., 

International: 613 9288 4580 

• Fitzroy, Vic. 3065 

email: williara@svhm.org.au 

• 

• 

Date 

• Dr 

• Department of Anatomical Pathology 

• Ground Floor 

• Dear , 

• Re: RCPA Part II Practical Examinations in Anatomical Pathology 

• Once again, many thanks for agreeing to mark the slides for the Part II practical examination held on Saturday 29th May. 

• Please find enclosed x sets of answers for y Candidates, a set of slides with accompanying examination question sheet and instructions 

to candidates and marking sheets. 

to candidates and marking sheets. I have attached a set of the case histories, together with an opinion 

(“diagnosis”)) for each case. Please feel free to disagree and assess accordingly. 

• We have made one change to the way the papers are to be marked this t 

year, in line with advice and recommendations from the 

curriculum review/assessment educational experts. We would ask that t 

the cases be marked “horizontally” rather than “vertically” this 

year. To this end we are forwarding the answer sheets bundled by question, rather than by candidate book – i.e. all slide 1 answers are 

bundled together and should be marked as a single group, before continuing to all of the slide 2 answers, etc. For each question/slide I 

have included a sheet for preliminary marks but also include the standard collation mark sheet for each individual candidate. Once all the 

marking has been completed, it may be easier to have your secretarial staff transfer the individual case marks and comments from the 

‘horizontal’ preliminary mark sheets to the standard (‘vertical( 

vertical’) ) individual candidate’s s final mark sheet. The College has agreed to 

reimburse your Department for this extra work time on receipt of an invoice.

letter of Instructions (cont.) 

As in the past we would ask you to mark each slide as ‘right’, ‘wrong’ or ‘borderline’ and once all the 

marking is completed, consider the overall number of slides ‘wrong’ or ‘borderline’ and the 

seriousness of errors in assessing whether an individual candidate has passed or failed. For the Part II we 

• As in the past 

have worked on over 3 ‘wrong’ answers (equivalent to over 20% wrong answers), or over 2 ‘wrong’ and 2 ‘borderline’ answers to be a fail grade depending on the 

seriousness of the errors. Although some weighting is given to the t 

seriousness of an error, we have not adopted the policy of a single 'sudden death slide'. 

Normally, for those cases where a differential diagnosis can be justified, provided the candidate has 

given an appropriate description and differential diagnosis, and can demonstrate that he/she would 

have arrived at the correct diagnosis through appropriate ancillary ary techniques, we would consider 

that answer to be at least ‘borderline’ if not ‘right’ even if the preferred diagnosis is wrong. 

• If appropriate, could you please make brief comments in the column provided for each case. This helps in formulating assessment reports and allows me to review 

individual slide box numbers in the event of discrepancies. Finally, for each candidate, could you give an overall opinion as to ‘pass’, ‘fail’ or ‘borderline’ based on the 

above criteria. 

• I hope I have not totally confused you as to the approach – much of it is commonsense although there are always those candidates dates that are ‘borderline’ no matter which 

way one assesses them. Could you also make a recommendation for those borderline candidates who you think may be taken onto the orals and shown extra slides at 

that time. 

• This year we have given an undertaking to have the results published by the end of July and have not bowed to the pressure of publishing same earlier because of the 

increase in the number of candidates presenting this year, however er we would appreciate the results back in time for Tony and myself to review any discrepancies and 

have the scripts re-marked if necessary. Thus it would be appreciated if the marking g could be completed as soon as possible to enable the scripts to be sent to further 

examiners as required. 

• Could you please return the mark sheets to us by courier as soon as possible at the following address:- 

• Chief Examiners in Anatomical Pathology Telephone: (08) 8204 4259 

• C/- Anthony C Thomas, MB BS, PhD, FRCPath, FRCPA International: 618 8204 4259 

• Department of Anatomical Pathology Fax: (08) 8374 1437 

• Flinders Medical Centre International: 618 8374 1437 

• Bedford Park, SA 5042 

email:Tony.Thomas@flinders.edu.au 

Tony.Thomas@flinders.edu.au 

• Thank you once again for undertaking this task. 

• Best wishes, 

• Richard Williams 

• Chief Examiner in Anatomical Pathology.

Part 2 Practical

Before we Start on the Part ll Cases 

• Don’t t second guess the examiners:-

Analytical Assessment of Cases 

• Don’t t try and diagnose “intuitively” 

• Become an “analytical” diagnostician

Case 1: Female 36 – suspicious 

lesion on mammography

Case 1: Female 36 – suspicious 

lesion on mammography 

• MICROSCOPIC 

• The breast tissue contains a well circumscribed invasive tumour. There is one component of the tumour where 

the cells are arranged in large nests separated by fibrous bands. . Within the cell nests there is a predominance of 

small basaloid cells many of which surround aggregates of eosinophilic homogeneous material. There are also 

true lumens present lined by cells with more abundant eosinophilic ic cytoplasm. Surrounding this area of nested 

tumour there are infiltrating small tubules, nests and trabeculae e of tumour cells. Again these consists of both 

basaloid cells and cells with more abundant eosinophilic cytoplasm surrounding true lumens. 

• Comment 

• The presence of small basaloid cells associated with more epithelial appearing cells and aggregates of eosinophilic 

material indicates an adenoid cystic carcinoma. The differential l diagnosis includes an infiltrating cribriform 

carcinoma and in places the clearing around some of the infiltrating ting nests raises the possibility of a micropapillary 

carcinoma. 

• Investigations 

• Alcian blue, , PAS, immunoperoxidase stains for oestrogen and progestagen receptors 

• The eosinophilic material present should show positive staining with Alcian blue and be negative for PAS with the 

true glandular lumina showing positive staining with PAS. Immunoperoxidase stains for oestrogen and 

progestagen receptors should be negative in adenoid cystic carcinoma with positive p 

staining in an infiltrating 

cribriform carcinoma and frequent positive staining in a micropapillary carcinoma. 

• SUMMARY/ Preferred diagnosis 

• Breast: Adenoid cystic carcinoma

Heart: Giant cell myocarditis

Case 3: Male 19 – cystic lesion in 

the right humeral head

Case 3: Male 19 – cystic lesion in 

the right humeral head 


• The biopsy consists of fragments of the tumour with focal peripheral eral reactive sclerosis and new 

bone formation. The tumour has a population of mononuclear cells s with admixed multinucleated 

giant cells. The mononuclear cells form sheets, have a moderate amount of eosinophilic 

cytoplasm and slightly elongated nuclei with longitudinal grooves. There are fragments of tissue 

showing the cells within a chondroid matrix. The chondroid matrix has a slightly more 

eosinophilic hue than normal cartilage. Focal calcification is occurring within the chondroid 

matrix. There is also area of fibrosis with haemosiderin containing macrophages and prominent 

thin walled vascular spaces that raise the possibility of previous trauma. 

• Comment 

• This histologic appearance favours the diagnosis of chondroblastoma.. oma.. The differential diagnosis 

based on the histology alone would include a giant cell tumour of bone, a chondromyxoid fibroma 

and an osteosarcoma. 

• Radiological assessment is essential with a bone tumour. Both giant g 

cell tumours and 

chondroblastomas occur at the epiphysis (the epiphyseal plate is open with chondroblastoma and 

is closed in giant cell tumour) and the chondromyxoid fibroma involves the metaphysis. 

Histologically the chondromyxoid fibroma also appears more myxoid. The giant cell tumour has 

mononuclear cells that lack the nuclear grooves and do not show reactive sclerosis at the 

periphery. An osteosarcoma will have pleomorphic cells in a sheetlike pattern that permeate the 

surrounding bone trabeculae. 

• SUMMARY 

• Right humeral head: Chondroblastoma

Case 4: Female 42 – right thyroid 

nodule

Case 4: Female 42 – right thyroid 

nodule 


• The thyroid contains an encapsulated follicular nodule. The follicular licular structures vary in size and 

there appears to be central cystic degeneration within the nodule. The cells are predominantly 

low cuboidal with round nuclei containing small inconspicuous nucleoli. Nuclear crowding and 

overlapping are not prominent. Nuclear clearing and nuclear grooves oves are not evident. Golden 

brown pigment is present in some of the follicular epithelial cells. The fibrous capsule varies in 

thickness and in one area there is extension of follicular structures tures into the capsule but not 

beyond. However in another area there is a finger-like projections of thyroid follicles which 

extends beyond the contours of the capsule into the surrounding thyroid. There still appears to 

be a small rim of fibrous tissue surrounding this extension. However the appearance is consistent 

with capsular invasion. Vascular invasion is unable to be identified. 

ified. 

• Comment 

• The presence of capsular invasion indicates that this is a minimally invasive follicular carcinoma. 

Examination of the remaining capsule of the follicular nodule and d further levels of the area of 

capsular invasion will be examined to determine if there is more extensive invasion into the 

surrounding thyroid gland. 

• SUMMARY 

• Thyroid: Minimally invasive follicular carcinoma.

Case 5: Male 38 – right 

retroperitoneal mass

Case 5: Male 38 – right 

retroperitoneal mass 


• The section shows predominantly adipose tissue with mild variation in the size of the 

adipocytes. . In places there is a suggestion of increased interstitial tissue sue comprising 

spindle cells between the adipocytes. . In other areas there are interlacing bundles of 

spindle cells. The spindle cells appear to show a degree of cytoplasmic vacuolation. 

Thick walled vessels are not prominent however there is a background of small 

capillaries and larger thin walled vessels. 

• Comment 

• The combination of fat, smooth muscle and slightly abnormal vessels els indicates an 

angiomyolipoma. Immunoperoxidase stains for S100 and HMB45 as well as muscle 

specific actin would help confirm this diagnosis as these lesions s show positive staining 

for HMB45 and to a lesser degree S100. The smooth muscle shows positive staining 

ing 

for muscle specific actin. This lesion may be seen in patients with tuberous sclerosis 

and clinical correlation is required 

• SUMMARY 

• Right retroperitoneal mass: Angiomyolipoma

Case 6:Female 29 – persistent 

bleeding post partum

Case 6:Female 29 – persistent 

bleeding post partum 


• The curettings consist of decidua and immature 

chorionic villi. Some of the villi show oedema of 

the stroma. Fetal blood vessels can be identified 

within the villi. There is no evidence of cistern 

formation, excessive trophoblastic proliferation 

or a dual population of villi. There is no evidence 

of gestational trophoblastic disease. 

• SUMMARY 

• Uterine curettings: Products of conception 

confirmed.

Case 7: Male 68 – left scrotal mass

Case 7: Male 68 – left scrotal mass 


• There is atrophic testis with sclerosed tubules, rete testis and paratesticular soft tissue with an 

infiltrate which consist predominantly of atypical lymphoid cells s and also includes occasional 

eosinophils. Within the soft tissue the infiltrate is associated d with fat necrosis and vessels with 

prominent endothelial cells. The cells appear to be of medium size s 

and in many cells the nuclei 

appear slightly convoluted. 

• Comment: The infiltrate appears to be composed of atypical lymphoid cells s consistent with a 

lymphoma. The occasional eosinophils, the nuclear morphology and d the prominent endothelial 

cells raise the possibility a T-cell T 

lymphoma however flow cytometry and immunohistochemistry is 

required for further categorisation. 


• Check past history of patient 

• Check to see if tissue was sent for flow cytometry. 

• Immunoperoxidase stains; CD20, CD79a for B linage, CD3, CD43 for T linage also Bcl2, BcL6, 

CD5, CD10, CD30. If just CD43 positive also do MPO to assess for myeloid linage. 

• SUMMARY 

• Testis and paratesticular tissue: Non-Hodgkin's lymphoma; subclassification based on flow 

cytometry and immunoperoxidase results

Case 8: Female 35 – enlarging 

painful soft tissue mass in left foot

Case 8: Female 35 – enlarging 

painful soft tissue mass in left foot 


• There is a tumour present within a tendon or aponeurosis with adjacent skeletal muscle. The 

tumour shows central necrosis. The viable tumour consists of cells with large vesicular nuclei, 

prominent nucleoli and a moderate amount of eccentrically located d eosinophilic cytoplasm 

arranged in nests separated by fibrous septa. Focally there is streaming of cells within nests. 

The tumour is well circumscribed but not encapsulated. Mitotic figures are present. 

• Comment 

• The histologic appearance is that of a soft tissue malignant tumour. The location of the tumour 

and the histology would favour a clear cell sarcoma of tendon and d aponeurosis with a differential 

diagnosis which includes metastatic melanoma, synovial sarcoma, epitheloid sarcoma, malignant 

peripheral nerve sheath tumour and metastatic carcinoma. 


• Cytogenetic for characteristic t(12;22) of clear cell sarcoma 

• Immunoperoxidase stains: S100, HMB45, Leu7, NSE– positive in clear cell sarcoma . 

• Keratin, EMA, CD99, Bcl2 – positive in synovial sarcoma 

• CAM5.2, EMA, vimentin, , CD34 – positive in epitheloid sarcoma 

• S100 – variable positive in malignant peripheral nerve sheath tumour 

• AE1/AE3, CK5/6, CAM5.2 – positive in carcinoma 

• SUMMARY 

• Left foot: Clear cell sarcoma of tendon and aponeurosis

Case 9: Male 60 – left pleural mass

Case 9: Male 60 – left pleural mass 


• The entire section consists of tumour which is composed of interlacing bland cells with elongated 

cytoplasm consistent with fibroblasts. These are separated by collagen. c 

In places the collagen 

appears slightly oedematous and other areas compact. A scattering of mast cells is present 

throughout the tumour. No mitotic figures can be identified and there is no evidence of 

cytological atypia. 

• Comment 

• The histology favours a benign lesion of such as a solitary fibrous tumour of the pleura. The 

differential diagnosis may include a sarcomatoid mesothelioma, a monophasic synovial sarcoma 

and possibly a nerve sheath tumour however the histology does not t favour a malignant lesion. 


• CD 34 and BCL 2 would be performed and positivity would confirm the diagnosis of a solitary 

fibrous tumour. Immunoperoxidase stains for CK5/6 should be negative and if the positive would 

raise the possibility of a mesothelioma. Synovial sarcoma. may show s 

positive staining for 

keratin,EMA,bcl2 and CD99 and is usually negative for CD34. 

• SUMMARY 

• Left pleural mass: Solitary fibrous tumour

Case 10: Male 4 days old – 

neonatal liver failure and death

Case 10: Male 4 days old – 

neonatal liver failure and death 


• The hepatic architecture appears to have been intact with normal central vein - portal 

tract relationships. Geographic areas of acute hepatocellular necrosis n 

with very little 

inflammation are present. Within the areas of necrosis there are e degenerate cells 

with eosinophilic nuclear inclusions and marginated chromatin. These inclusions 

appear to be viral in nature. Cytoplasmic inclusions are unable e to be identified and 

the nuclei do not appear to the markedly enlarged. 

• Comment 

• The viral inclusions are consistent with herpes virus infection and 

immunohistochemistry for HSV 1 and HSV 2 as well as PCR for herpes es virus 1 and 

herpes virus 2 will be undertaken to confirm the nature of the virus. v 

The morphology 

of the infected cells is not typical for cytomegalovirus and the necrosis and the type 

of cells infected are not typical for parvovirus B 19 however immunohistochemistry 

munohistochemistry 

and PCR can also be undertaken to exclude these diagnoses. 

• SUMMARY 

• Liver: Herpes simplex virus infection.

Case 11: Female 52 – nausea, 

abdominal pain, iron deficiency 

anaemia

Case 11: Female 52 – nausea, 

abdominal pain, iron deficiency 

anaemia 


• There are five fragments of small intestinal mucosa 

present on the slide. Brunner’s s glands are evident in 

one of the fragments indicating that the biopsies are 

from the duodenum. The villi appear to be of normal 

length with normal villus crypt ratio. The surface 

epithelium and brush border are normal. There is no 

evidence of increased numbers of lymphocytes within 

the surface epithelium. There is no evidence of 

increased number of inflammatory cells the lamina 

propria. No Giardia can be identified. 

• SUMMARY 

• Histologically normal duodenal mucosa.

Case 12: Male 52 – burns on 

hands, tissue from thickened ulnar 

nerve

Case 12: Male 52 – burns on 

hands, tissue from thickened ulnar 

nerve 


• The submitted slide shows soft tissue containing an area of granulomatous 

inflammation. The inflammation is well circumscribed but not encapsulated, shows 

central necrosis and a peripheral rim of mononuclear cells including macrophages and 

lymphocytes. Residual peripheral nerve is unable to be identified. ed. Adjacent to this 

there is a small linear structure which appears to represent a small s 

nerve. This 

shows perineural and intraneural infiltration by lymphocytes. 

• Comment: Correlation of the histological findings of granulomatous inflammation 

and perineural inflammation with the clinical history of burns on hands and a 

thickened ulnar nerve is consistent with a diagnosis of leprosy involving the ulnar 

nerve. 


• Immunoperoxidase stain for EMA and S100 may demonstrate residual perineurium 

and Schwann cells. A Wade-Fite 

stain or PCR for Mycobacterium leprae would be 

undertaken to confirm the presence of organisms. 

• SUMMARY 

• Ulnar nerve: Granulomatous inflammation consistent with leprosy.

Case 13: Male 65 – tumour at the 

base of urinary bladder

Case 13: Male 65 – tumour at the 

base of urinary bladder 


• There are multiple fragments of adenocarcinoma present. There is crush 

artefact. The carcinoma has a papillary and glandular pattern. The 

glandular and papillary structures are lined by columnar to pseudostratified 

columnar epithelium. Mitoses are numerous. No prostatic tissue can be 

identified. There is a fragment of smooth muscle and fibrous tissue 

consistent with bladder wall. 

• Comment 

• There is an adenocarcinoma present. At the base of the bladder this is 

more likely to represent a prostatic adenocarcinoma rather than a primary 

bladder adenocarcinoma. Immunoperoxidase stains for PSA and PAP would 

be performed. As the morphology of the tumour favours a prostatic ductal 

adenocarcinoma these would be expected to be positive to confirm the 

diagnosis. If the PSA and PAP are negative investigations to exclude the 

possibility of a metastatic adenocarcinoma (eg CEA) will be undertaken. 

• SUMMARY 

• Bladder: Large duct carcinoma of prostate

Case 14: Female 45 – left temporal 

lobe mass

Case 14: Female 45 – left temporal 

lobe mass 


• There is a thin layer of meninges overlying the cerebral cortex. There is a diffuse 

infiltrate of relatively uniform small cells with round nuclei throughout t 

the white 

matter and the overlying grey matter. These show cells show "satellitosis" around 

the cortical neurones and also condensation in the outer cortex. Most of the cells 

have poorly defined cytoplasm and the nuclei appear to be surrounded by a clear 

halo however some cells show an eccentric collection of eosinophilic ilic cytoplasm. An 

area of microcystic change is present. 

• Comment: The histology is of a diffuse glioma and the cellular morphology 

combined with the pattern of infiltration is consistent with an oligodendroglioma. The 

differential diagnosis may include a diffuse low grade glioma however on 

morphological grounds (diffuse infiltration of uniform cells with peinuclear clearing) 

this is less likely. 

• Investigations: FISH studies for allelic losses from chromosomes 1p and 19q 

should be undertaken and these may give prognostic indications as well as assistin 

confirmation of the diagnosis. 

• SUMMARY 

• Brain: Oligodendroglioma

Case 15: Female 40 – right orbital 

mass

Case 15: Female 40 – right orbital 

mass 


• The slide shows fibrous tissue infiltrated by a population of predominantly small lymphoid cells. 

The cells are atypical and have slightly irregular nuclei with minimal m 

discernible cytoplasm. There 

are scattered larger cells with vesicular nuclei and small nucleoli. No follicular structures or 

lymphoepithelial lesions can be identified. 

• Comment 

• The histologic appearance is that of a lymphoma. While this appears to be a small cell lymphoma 

and the location in the orbit favours an extra nodal marginal zone lymphoma further 

categorisation requires confirmation by flow cytometry and immunoperoxidase stains. 


• Check if tissue has been submitted for flow cytometry and confirm m a monoclonal population 

• Tissue for cytogenetics 

• Immunoperoxidase stains CD20, CD79a, CD21 and possibly CD43 would d be expected the positive 

in a MALT lymphoma and CD5, CD10 and Bcl6 would be expected to be negative. CD10 positivity 

combined with Bcl2 positive staining would favour involvement by follicular lymphoma (however 

no follicular structures can be identified in the slide examined) ) and positive staining for CD5 in 

combination with cyclinD1 positivity would favour a Mantle cell lymphoma. If the lymphoma is 

CD5 and CD23 positive small lymphocytic lymphoma is likely. 

• SUMMARY 

• Orbit: : Favour small B-cell B 

lymphoma; await further characterization

“At some point ….. Genuine regard must be given to the 

supervisors assessment of the candidate’s s qualities….” 

“So far it appears scant regard has been given ….. To the 

opinions of those who have worked closely with the candidate….” 

• Supervisor’s s reports are considered in borderline cases and at 

the oral examinations. 

• However: 

– The practical exam may highlight deficiencies not previously 

appreciated, but later accepted by the supervisor as being an area of 

concern. 

– With the present examination system, a candidate who has clearly failed 

the practical cannot be granted a pass on the say so of the supervisor and 

yet some supervisors have lobbied the previous Chief Examiners in this 

way 

– Many supervisor reports are cursory, and therefore not helpful, in their 

approach despite the new format of the report 

– Through personality clashes and supervision from a distance, some 

supervisors reports are unfair to and may be biased against the 

candidate. 

10.3.06

What’s s under consideration? 

• Supervisors reports/ongoing in house assessment 

• Trainee Diary – can this be used as an objective 

measure of some areas of competence? 

• Discussion of % weighting of continuing assessment 

towards the overall results for the examinations is 

underway. A figure of 25% of the total assessment has 

been proposed but the content and objective criteria to 

be used are still under discussion. 

10.3.06


• It must be acknowledged that, if this system is 

implemented, in any individual case where there is a 

marked discrepancy between an individual’s “in 

house” assessments and the results of formal 

examinations, the matter should be referred for 

appraisal to a panel formed by the Chief Examiner and 

chaired by the Chairman of the BoC. . Similarly, if there 

was continued significant discrepancy between the in 

house assessments from a single institution and the 

results of candidates in the formal examinations, then 

the institution and their assessment process should be 

formally reviewed. 

10.3.06


• Accreditation of supervisors – 

In line with AMC requirements consideration has to 

be given to formal accreditation of supervisors – the 

mechanism is under discussion but would necessarily 

include continuing updates to ensure familiarity with 

supervisors role/requirements and the assessment 

process. 

10.3.06

References for relevant information 

• Refer to the Latest Trainee Handbook, and 

all the other documents available on the 

College Web Site 

10.3.06

RCPA Examinations in Anatomical pathology - Questions ... - Rcpa.tv

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?