One of our readers sent in a nice quiz that he recently gave to his residents (from medicine, pediatrics and pathology) rotating through hematopathology. It will be posted in three installments so you can get through each part pretty quickly. Take a look and see how many you get right! Answers and explanations are at the end.

1. All of the following are common features of multiple myeloma EXCEPT:

A. Pathological fracture
B. Clonal plasma cells in bone marrow
C. Monoclonal protein in serum or urine
D. Clonal plasma cells in blood

2. Vitamin K dependent coagulation Factors include all of the following EXCEPT:

A. Factor II
B. Factor VII
C. Factor IX
D. Factor XI

3. Packed red blood cells are stored at :

A. 4 degrees centigrade
B. 16 degrees centigrade
C. 24 degrees centigrade
D. 36 degrees centigrade

4. Which of the following is a BCR-ABL tyrosine kinase inhibitor?

A. Imatinib
B. ATRA
C. Chlorambucil
D. Traztuzumab

5. Which of the following shows the ALK-NPM fusion protein?

A. Burkitt lymphoma
B. Anaplastic large cell lymphoma
C. Diffuse large B-cell lymphoma
D. Follicular lymphoma

6. Which of the following translocations is seen in acute promyelocytic leukemia (AML-M3)?

A. t(9;22)
B. t(11;14)
C. t(15;17)
D. t(8;14)

7. Adult patients with beta thalassemia minor have high levels of:

A. HbF
B. HbA2
C. HbE
D. HbS

8. Which of the following viruses is often responsible for transient aplastic crises in hemolytic anemia?

A. Hepatitis B virus
B. Adenovirus
C. Parvovirus B19
D. Hantavirus

9. The diagnosis of acute myeloid leukemia requires the presence of ____ % blasts in the blood or bone marrow.

A. 20%
B. 30%
C. 40%
D. 10%

10. If an anticoagulant is required in the first trimester of pregnancy, the drug of choice is:

A. Acitrom
B. Heparin
C. Warfarin
D. Aspirin

Scroll down for the answers…

1. D. Myeloma is characterized by accumulations of malignant plasma cells in the bone marrow (which stimulate osteoclasts to chew up bone, leading to painful osteolytic lesions). These plasma cells all make the same exact type of immunoglobulin, and you can see this in the serum (it’s called a monoclonal spike, or M spike). You almost never see myeloma cells in the blood for some reason. So D is wrong.

2. D. Vitamin K dependent factors are II, VII, IX and X (and proteins C and S).

3. A. This is just one of those things you have to memorize (if you’re taking path boards). Seriously. Can’t they think of any more cerebral questions? I mean, you can look this stuff up – why ask it on boards?

4. A. Imatinib (Gleevec) is an incredible drug that was developed for the treatment of chronic myeloid leukemia. It’s also useful in other malignancies, like gastrointestinal stromal tumor (GIST). It’s a BCR-ABL tyrosine kinase inhibitor. ATRA (all trans-retinoic acid) is used in acute promyelocytic leukemia. Chlorambucil is a nitrogen mustard alkylating agent used in chronic lymphocytic leukemia and other malignancies. Trastuzumab (Herceptin) is a monoclonal antibody that interferes with the HER2/neu receptor; it’s used for the treatment of breast cancer.

5. B. Anaplastic large cell lymphoma is characterized by a t(2;5)(p23;q35) that creates a fusion gene compoesd of nucleophosmin (NPM) and a receptor tyrosine kinase gene called anaplastic lymphoma kinase (ALK). This fusion gene encodes a constitutively activated tyrosine kinase that makes the tumor cells grow like crazy.

6. C. APL has a t(15;17). CML has a t(9;22) (the new 22 is called the Philadelphia chromosome). Mantle cell lymphoma has a t(11;14) (sometimes myeloma has this translocation). Burkitt lymphoma has a t(8;14).

7. B. In beta-thalassemia minor, patients have a diminished capability of making the beta chain of hemoglobin (one or both of the beta chain genes are not working right). So instead of the normal HbA (with two alpha and two beta chains), they make more HbA2 (with two alpha and two delta chains). We normally have a little of this hemoglobin around, but patients with beta thalassemia minor have much higher levels. 

8. C. Parvovirus B19 causes fifth disease (a childhood disease characterized by a facial rash). It also stops erythropoiesis – which isn’t such a big deal normally, unless you have a hemolytic anemia (in which case you can’t afford a break in erythropoiesis!).

9. A. In AML, at least 20% of the nucleated cells in the bone marrow and/or blood have to be blasts (or, in some types of AML, “blast-equivalents” – like the promyelocytes in acute promyelocytic leukemia). Any number less than 20% and you can’t call it AML (you’d probably end up calling it some kind of myelodysplastic syndrome).

10. B. Heparin is generally considered safe; aspirin and the others are not.