Question 41#

Which one of the following translocations is associated with acute promyelocytic leukaemia?

A. t(15;17)

Correct Answer A: Acute promyelocytic leukaemia - t(15;17).

Acute promyelocytic leukaemia:
You are not normally expected to be able to differentiate the different subtypes of acute myeloid leukaemia (AML) for the MRCP. An exception to this is acute promyelocytic leukaemia (APML, the M3 subtype of AML).

The importance of identifying APML lies in both the presentation (classically disseminated intravascular coagulation) and management APML is associated with the t(15;17) translocation which causes fusion of the PML and RAR-alpha genes.

Features:

• Presents younger than other types of AML (average = 25 years old)
• DIC or thrombocytopenia often at presentation
• Good prognosis

Question 42#

Which one of the following features is least recognized in thrombotic thrombocytopenic purpura?

A. Fever

Correct Answer E: Livedo reticularis is not commonly seen in thrombotic thrombocytopenic purpura. It occurs more commonly in conditions such as antiphospholipid syndrome and cholesterol embolism.

Thrombotic thrombocytopenic purpura:
Pathogenesis of thrombotic thrombocytopenic purpura (TTP):

• Abnormally large and sticky multimers of von Willebrand's factor cause platelets to clump within vessels
• In TTP there is a deficiency of caspase which breakdowns large multimers of von Willebrand's factor
• Overlaps with haemolytic uraemic syndrome (HUS)

Features:

• Rare, typically adult females
• Fever
• Fluctuating neuro signs (microemboli)
• Microangiopathic haemolytic anaemia
• Thrombocytopenia
• Renal failure

Causes: 

• Post-infection e.g. urinary, gastrointestinal
• Pregnancy
• Drugs: cyclosporin, oral contraceptive pill, penicillin, clopidogrel, acyclovir
• Tumours
• SLE
• HIV

Question 43#

Which one of the following ethnic groups have an increased incidence of prostate cancer?

A. Afro-Caribbean

Correct Answer A: 

Prostate cancer: features:

Prostate cancer is the second most common cancer in adult males in the UK and is the most common malignant condition in men over 65 years. 

Risk factors:

• Increasing age
• Afro-Caribbean ethnicity

Features:

• Bladder outlet obstruction: hesitancy, urinary retention
• Haematuria, haematospermia
• Pain: back, perineal or testicular
• Digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

Question 44#

Which one of the following viruses is associated with nasopharyngeal carcinoma?

A. Adenovirus

Correct Answer D: 

Epstein-Barr virus: associated conditions:

Malignancies associated with EBV infection:

• Burkitt's lymphoma*
• Hodgkin's lymphoma
• Nasopharyngeal carcinoma
• HIV-associated central nervous system lymphomas
• The non-malignant condition hairy leukoplakia is also associated with EBV infection

*EBV is currently thought to be associated with both African and sporadic Burkitt's

Question 45#

Which one of the following would most suggests a leukaemoid reaction rather than chronic myeloid leukaemia?

A. Raised packed cell volume

Correct Answer D: 

Leukaemoid reaction:

The leukaemoid reaction describes the presence of immature cells such as myeloblasts, promyelocytes and nucleated red cells in the peripheral blood. This may be due to infiltration of the bone marrow causing the immature cells to be 'pushed out' or sudden demand for new cells.

Causes: 

• Severe infection
• Severe haemolysis
• Massive haemorrhage
• Metastatic cancer with bone marrow infiltration

A relatively common clinical problem is differentiating chronic myeloid leukaemia from a leukaemoid reaction.

The following differences may help: Leukaemoid reaction:

• High leucocyte alkaline phosphatase score
• Toxic granulation (Dohle bodies) in the white cells
• 'Left shift' of neutrophils i.e. three or less segments of the nucleus 

Chronic myeloid leukaemia:

• Low leucocyte alkaline phosphatase score