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SAMs Guidelines

DEVELOPING SELF-ASSESSMENT MODULES TEST QUESTIONS

Ver. #9- 07.03.18 GUIDELINES FOR DEVELOPING SELF-ASSESSMENT MODULES TEST QUESTIONS

USCAP is accredited by the American Board of Pathology (ABP) to offer Self- Assessment Modules (SAMs) credits for the purpose of meeting the ABP requirements for Continuing Certification (CC). All activities that offer SAMs also offer AMA PRA Category 1 Credit™. These activities may also be used to meet Continuing Medical Education (CME) requirements for licensure and educational requirements.

In order to offer SAMs credits, a post-test is required. Attendees must achieve a pass rate of 80% to be awarded SAMs credits for the course. The ABP requires that persons taking the test be given immediate feedback, so please provide a brief explanation and a reference(s) for the correct answer(s). The test will be administered online through the USCAP website.

Question Requirements

1. Test questions should address comprehension of concepts covered during the educational activity. The test question should be an important concept that is medically (clinically) relevant. In addition, it should correlate to a particular learning objective. 2. All questions must be multiple choice with three responses (correct answer plus two distractors). 3. True/false questions are not acceptable. 4. For the “correct answer” please provide a few sentences explaining why the answer is correct. 5. Please link a relevant learning objective to each question. Objectives may be used more than once. 6. Each question must include at least one reference. 7. Since this will be an online test, you may wish to include one or two still images (not virtual slides) for the question. 8. Four questions per hour of instructional time (including Q & A) are USAP es required. 500 South Palm Canyon Drive Suite 321 Palm Springs, CA 92264 Question Writing Tips Phone | 760.327.6777 Fax | 760.327.6477 1. An ideal question is one that can be answered without looking at the choices. Higher order questions that require interpretation, judgment, or USAP Es problem-solving are better than simple recall of information. 404 Town Park Blvd. Suite 201 2. Questions should be stated as a positive (do not use no, not, etc). Do Evans, GA 30809 not use “all of the following except.” Negatively-phrased questions can Phone | 706.733.7550 increase confusion rather than reinforcing educational messages. Fax | 706.733.8033 3. Answer choices should be approximately the same length and type (there is a tendency to give more information about the correct response and therefore make it longer). www.uscap.org 4. Do not use absolutes such as “all”, “none”, “always” and “never”. “All of the above” or “none of the above” are not acceptable choices.

On the following pages are examples of SAMs questions.

PAGE 1 SAMPLESAMPLE QUESTIONSQUESTIONS

1) Which of the following is a risk factor for Barrett’s -related ? √ A. Presence of dysplasia B. Previous history of alcohol use C. Age less than 30

Explanation: Q1. There are a number of risk factors which increase the risk of adenocarcinoma in patients with Barrett’s esophagus. Increased patient age, increased length of Barrett’s esophagus, body mass index and the presence of either low- or high-grade dysplasia are all well established risk factors. However, a previous history of alcohol abuse has not been shown to significantly increase this risk.

Learning Objective: Recognize the pathogenesis and epidemiology of Barrett’s esophagus.

Reference: • Wilde CT, Hardle LJ. Reflux, Barrett’s oesophagus and adenocarcinoma: burning questions. Cancer 2003;3:676.

2) Which of the following statements regarding Barrett’s esophagus-related dysplasia is correct? A. Up to 50% of patients ultimately progress to either low- or high-grade dysplasia within 5 years of initial diagnosis B. The presence of inflammation precludes a diagnosis of dysplasia √ C. Barrett’s esophagus, negative for dysplasia, is the most common diagnosis

Explanation: Q2. Patients with Barrett’s esophagus are at increased risk of developing adenocarcinoma, although most patients never progress along the dysplasia/adenocarcinoma sequence. Thus, the most common diagnosis rendered is Barrett’s esophagus, negative for dysplasia. Only a small percentage of patients with low-grade dysplasia ever progress to high-grade dysplasia or cancer and, in fact, a diagnosis of low- or high-grade dysplasia does not always precede a diagnosis of adenocarcinoma. Many patients with Barrett’s esophagus have ongoing active inflammation, making a diagnosis of dysplasia difficult, but not impossible.

Learning Objective: Recognize the diagnostic pitfalls in diagnosing Barrett’s esophagus and Barrett’s-related dysplasia.

Reference: • Sampliner RE. A population prevalence of Barrett’s esophagus -- finally. Gastroenterology 2005;129:2101.

PAGE 2 SAMPLESAMPLE QUESTIONSQUESTIONS

3) Which of the following statements regarding Barrett’s esophagus is true? √ A. Goblet cells must be identified in a biopsy from an area of columnar-lined esophagus B. At least 2 cm of columnar-lined esophagus is required to make a diagnosis of Barrett’s esophagus C. The identification of cardiac and fundic-type mucosa is sufficient to render a diagnosis of Barrett’s esophagus

Explanation: Q3. Barrett’s esophagus can be diagnosed if an endoscopic abnormality is seen (columnar-lined esophagus) and goblet cells are identified in a biopsy taken from the area of endoscopic abnormality. Although cardiac and fundic-type mucosa is frequently seen in patients with Barrett’s esophagus, it is not sufficient to render this diagnosis, as goblet cells are necessary. Although an will confirm the presence of acid in goblet cells, this stain is not required for their identification. Intestinal of the gastroesophageal junction seems to be a multifactorial condition which is not necessarily indicative of Barrett’s esophagus.

Learning Objective: Recognize the diagnostic pitfalls in diagnosing Barrett’s esophagus and Barrett’s-related dysplasia.

Reference: • Hirota WK, Loughney TM, Lazis DJ, et al. Specialized , dysplasia and cancer of the esophagus and esophagogastric junction: prevalence and clinical data. Gastroenterology 1999;116:277.

4) This biopsy was procured from a 68-year-old male patient with long- standing gastroesophageal reflux disease. Which of the following statements is true?

A. These cells show composed predominantly of acid B. This focus is diagnostic of Barrett’s esophagus as long as it was procured from the tubular esophagus √ C. This change is commonly seen in the distal esophagus of Click slide image to enlarge patients with chronic gastroesophageal reflux disease

Explanation: Q4. This biopsy reveals columnar with distended “pseudogoblet cells,” which can be easily mistaken for true goblet cells. An Alcian blue/PAS stain would typically confirm the presence of PAS-positive neutral mucins in these cells. This change is frequently seen in biopsies procured from the distal esophagus in patients with chronic gastroesophageal reflux disease. The presence of this type of epithelium is not diagnostic in and of itself of Barrett’s esophagus.

Learning Objective: Discuss the role of the pathologic diagnosis in the clinical care of patients with Barrett’s esophagus.

Reference: 1. Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2008;103:788.

PAGE 3 SAMPLESAMPLE QUESTIONSQUESTIONS

5) Which of the following statements regarding columnar-lined esophagus is true? A. Columnar-lined esophagus without goblet cells has been established to have no malignant potential B. Columnar-lined esophagus with goblet cells lining more than 3 cm of the esophagus is found in up to 40% of adult U.S. patients √ C. Columnar-lined esophagus without goblet cells has an immunohistochemical staining pattern similar to columnar-lined esophagus with goblet cells for to CDX2 and Das1.

Explanation: Q5. Columnar-lined esophagus without goblet cells has been the subject of intense scrutiny over the past few years. Although initially believed to be completely benign, there is mounting evidence to suggest that columnar-lined esophagus without goblet cells might have premalignant potential, although the exact risk is not known. Immunohistochemically, this type of epithelium shows very similar staining characteristics to columnar-lined esophagus with goblet cells using antibodies to CDX2 and Das1. Several studies have found the longer the length of columnar-lined esophagus and the greater the number of biopsies obtained, the greater the probability of finding goblet cells.

Learning Objective: Recognize the diagnostic pitfalls in diagnosing Barrett’s esophagus and Barrett’s-related dysplasia.

Reference: • Hahn H, Blout PL, Ayub K, et al. Intestinal differentiation in metaplastic, non-goblet cell columnar epithelium in the esophagus. Am J Surg Pathol 2009;33:1006.

6) Which of the following statements is true regarding the image from a 72-year-old male with a long-standing history of Barrett’s esophagus? A. This biopsy reveals an intraepithelial proliferation  B. Up to 80% of patients with Barrett’s esophagus present with this finding at initial diagnosis √ C. This lesion can metastasize to lymph nodes

Click slide image to enlarge

Explanation: Q6. This biopsy shows invasion of individual cells into the , consistent with intramucosal adenocarcinoma. Although some patients with Barrett’s esophagus do present with this finding, most patients have no evidence of dysplasia or adenocarcinoma in their initial diagnostic biopsy. Because there are lymphatic channels in the esophageal mucosa, this lesion can metastasize to lymph nodes. Given this fact, definitive therapy (either endoscopic mucosal resection or esophagectomy with or without ablation therapy) is required. Although goblet cells may not be found in the surrounding mucosa, can “overrun” the surrounding Barrett’s mucosa such that goblet cells may not be found.

Learning Objective: Discuss the role of the pathologic diagnosis in the clinical care of patients with Barrett’s esophagus.

Reference: • Sabik JF, Rice TW, Goldblum JR, et al. Superficial esophageal carcinoma. Ann Thorac Surg 1995;60:896.

PAGE 4 SAMPLESAMPLE QUESTIONSQUESTIONS

7) Which of the following statements regarding Barrett’s esophagus is true? √ A. It is a complication of chronic gastroesophageal reflux disease B. It does not increase the risk of esophageal adenocarcinoma C. It is associated with eosinophilic esophagitis in up to 75% of cases

Explanation: Q7. The definition of Barrett’s esophagus has evolved over the years, but the 2008 American College of Gastroenterology recommendations require the presence of an endoscopic abnormality and the identification of goblet cells in a biopsy specimen from the endoscopic abnormality. This condition is known to be a complication of chronic gastroesophageal reflux disease and is also known to increase the risk of esophageal adenocarcinoma.

Learning Objective: Recognize the pathogenesis and epidemiology of Barrett’s esophagus.

Reference: • Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2008;103:788.

8) Which of the following statements regarding normal colon is true? √ A. Lamina propria cellularity decreases from the right colon to the B. Eosinophils are not a normal component of the lamina propria of the normal colon C. Normal colon shows fewer than 5 lymphocytes/100 epithelial cells throughout the entire colon

Explanation: Q8. The right colon has histologic differences from the left colon. In particular, there is a progressive decrease in the lamina propria cellularity as well as a progressive decrease in the number of surface epithelial lymphocytes as one moves from the to the rectum. There can be up to 10 lymphocytes per 100 epithelial cells or even more present in the right colon. The rectum also has far more goblet cells than other parts of the colon. Paneth cells can be present in the right colon but are not a normal component of the colon distal to the right colon.

Learning Objective: Recognize the characteristic gross and histologic features of ulcerative colitis and Crohn’s disease.

Reference: • Lazenby AJ. Collagenous and lymphocytic colitis. Semin Diagn Pathol 2005;22:295.

PAGE 5 SAMPLESAMPLE QUESTIONSQUESTIONS

9) Ulcerative colitis is characterized by which of the following? A. Frequent involvement of the proximal small bowel √ B. Features of chronicity, including basal plasmacytosis and glandular distortion C. Pyloric metaplasia is a consistent finding

Explanation: Q9. Ulcerative colitis typically begins in the rectum and continues proximally in a contiguous fashion to involve a variable portion of the colon. However, following medical therapy, ulcerative colitis can become a patchy disease. Although there can be involvement in parts of the upper GI tract, the proximal small bowel is not frequently involved (although it can be involved). Pyloric gland metaplasia is an inconsistent finding and is far more characteristic of Crohn’s disease. Ulcerative colitis invariably shows feature of chronicity, including basal plasmacytosis, glandular distortion and metaplasia.

Learning Objective: Describe the characteristic gross and histologic features of ulcerative colitis and Crohn’s disease

Reference: • Surawicz CM, Haggitt RC, Husseman M, et al. Mucosal biopsy diagnosis of colitis: acute self-limited colitis and idiopathic inflammatory bowel disease. Gastroenterology 1994;107:755.

10) Which of the following is true of ulcerative colitis? A. Frequent involvement of the terminal B. Transmural lymphoid aggregates √ C. Diffuse involvement of the rectosigmoid colon

Explanation: Q10. Crohn’s disease is a patchy disease that involves any portion of the , and frequently involves the terminal ileum. Characteristic histologic features include transmural lymphoid aggregates, non- necrotizing granulomas and pyloric gland metaplasia, among others. The rectum is frequently spared and, if the distal colon is involved, it is typically involved in a patchy fashion.

Learning Objective: Describe the characteristic gross and histologic features of ulcerative colitis and Crohn’s disease.

Reference: • Yantiss RK, Odze RD. Pitfalls in the interpretation of the non-neoplastic mucosal biopsies in inflammatory bowel disease. Am J Gastroenterol 2007;102:890.

PAGE 6 SAMPLESAMPLE QUESTIONSQUESTIONS

11) Which of the following is the most likely explanation for the changes seen in the image taken from the in a 25-year-old male with diarrhea? A. Granuloma secondary to Crohn’s disease B. Sarcoidosis √ C. Crypt rupture granuloma

Click slide image to enlarge

Explanation: Q11. This image shows evidence of neutrophil-mediated crypt injury with extravasation of mucin into the lamina propria causing a foreign body histiocytic response, also known as a crypt rupture granuloma. Although granulomas can be seen in a number of settings, including Crohn’s disease, sarcoidosis and a variety of infectious colitides (including Histoplasmosis), this image clearly shows the granuloma arising secondary to crypt rupture.

Learning Objective: Explain the diagnostic pitfalls in diagnosing IBD and IBD-related dysplasia.

Reference: • Pierik N, De Hertogh G, Vermeire S, et al. Epithelioid granulomas, pattern recognition receptors and phenotypes of Crohn’s disease. Gut 2005;54:233.

12) This image is from a specimen from a 32-year-old male with bloody diarrhea. Which of the following statements is correct? √A. Diffuse chronic mucosal changes would be an expected histologic finding B. The creation of an ileal pouch-anal anastomosis is contraindicated C. Transmural lymphoid aggregates would be an expected histologic finding

Click slide image to enlarge

Explanation: Q12. This colectomy shows involvement of the rectum which continues proximally in a contiguous fashion to involve much of the colon. The right colon appears to be grossly normal. The gross characteristics are entirely consistent with ulcerative colitis. As such, one would not expect transmural lymphoid aggregates or involvement of the terminal ileum since the cecum appears to be normal. Sections from the grossly involved mucosa would be expected to show diffuse chronic mucosal alterations. Ulcerative colitis (like Crohn’s disease) increases the risk of colorectal cancer.

Learning Objective: Discuss the clinical implications of a diagnosis of IBD or IBD-related dysplasia.

Reference: • Tanaka M, Riddell RH, Saito H, et al. Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn’s disease from ulcerative colitis. Scand J Gastroenterol 1999;34:55.

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