RCPA Anatomical Pathology Fellowship Exam 2026 Study Guide: What You Actually Need to Know

This is a working guide for anatomical pathology trainees sitting the RCPA Anatomical Pathology Fellowship Exam in the next twelve months. It covers format, the IHC and molecular thinking the college rewards, synoptic reporting expectations, realistic timelines, and the failure modes that catch otherwise capable candidates. PRIMEX started in 2025 when an anaesthetic trainee at a regional NSW hospital built study tools for the ANZCA Primary. It now covers 21 colleges because trainees from each specialty asked us to build for them. The RCPA Anatomical Pathology Fellowship Exam curriculum on PRIMEX is maintained against the college's published syllabus, with topic mapping reviewed for accuracy.

What the Fellowship Examination actually is

The RCPA Anatomical Pathology Fellowship Examination is the part-two summative assessment for trainees in the Royal College of Pathologists of Australasia anatomical pathology training program. It sits at the end of training and tests integrated competence across surgical pathology, cytopathology, frozen section work, immunohistochemistry interpretation, molecular diagnostics and synoptic reporting. It is a high-stakes barrier exam, not a knowledge survey, and the marking reflects that.

• Components: Part I Written (MCQ and SAQ covering general pathology, organ system pathology, IHC and tumour classification), Part II Written (extended clinical scenarios integrating histological descriptions with diagnosis and management), Practical (glass slide interpretation with systematic reporting), and Viva (histological scenarios with clinicopathological correlation, frozen section communication, MDT-style integrated cases)
• Sequencing: candidates must pass the written components before being eligible to sit the practical and viva at later sittings; check the current trainee handbook on the RCPA website for sequencing requirements at your year of training
• Sittings: typically once to twice per year, with practical and viva components scheduled around an end-of-year window, as of 2026; check the RCPA website for the current calendar
• Pass mark: the college does not publish a fixed standardised pass mark; candidate performance is reviewed against examiner standards with psychometric oversight on each sitting, and tier-graded results are communicated post-exam
• Pass rate: historical pass-rate data published in college reports has hovered around the 60% range for the integrated fellowship, varying by sitting and component; the RCPA publishes pass rates per sitting in its annual reports
• Day-of logistics: the written paper has, at recent sittings, used a paper-based format under invigilation at nominated centres; the practical and viva are conducted on glass slides at college venues with examiners. Check the most recent candidate guide on the college site for the current sitting's logistics, permitted materials and ID requirements

The exam tests integrated competence, not isolated facts. A typical viva case will move from systematic reporting on a slide, to differential diagnosis with reasoning, to IHC panel construction with positive and negative markers, to molecular tests with indications, to staging and synoptic reporting, to clinicopathological correlation. Knowing each individually is not the same as moving cleanly between them under examiner pressure.

What the college actually tests

The RCPA Anatomical Pathology curriculum, as set out in the Trainee Handbook January 2025, maps to 237 numbered learning objectives across 7 curriculum sections. The PRIMEX curriculum tracker mirrors this structure exactly:

• 1.1 Foundation Knowledge and Skills: normal tissue recognition, physiology and pathophysiology, genetics, staining principles, cytology, IHC, immunofluorescence, FISH, PCR and NGS principles. The literacy layer the rest of the exam is built on.
• 1.2 to 1.4 Specimen Management and Analysis: accession, processing, storage, retrieval, cut-up, block selection, frozen section, electron microscopy, gross and microscopic analysis, clinicopathological correlation. The practical layer.
• 1.5 to 1.6 Reporting and Patient Follow-up: developing professional opinions on nature, causation, severity and likely sequelae; written reports; synoptic reporting against RCPA structured protocols; patient monitoring and follow-up. The reporting layer that the synoptic component of the written exam tests directly.
• 2. Laboratory Management: leadership, quality management, patient safety, workplace health and safety, regulation, resource utilisation, informatics and digital pathology. Examined particularly through scenario-based written questions and viva probes on quality and discordance.
• 3. Research and Scholarship: evidence appraisal, research methodology, scholarly contribution. Tested where it intersects with clinical decision-making.
• 4. Professional Qualities: communication, ethics, cultural safety (including Aboriginal and Torres Strait Islander health perspectives), self-care, professionalism. Threaded across the viva and woven into vignettes about communication with surgeons and clinicians.
• Appendix 13 Core Molecular Competencies: the molecular tests candidates must know how to order, interpret and act on. Examined directly in IHC and molecular question stems and woven into MDT-style integrated cases.

Underneath the 237 LOs, the PRIMEX index for RCPA AP carries 131 organ-system and discipline topic areas spanning the breadth of surgical pathology and cytopathology. The exam draws across this whole spread. You are expected to handle general pathology principles fluently, then move through the organ-system pathology that dominates the written and practical components.

The highest-yield content areas

From the published curriculum and the recurring patterns in trainee preparation, the following topic clusters appear reliably across written, practical and viva components, and are worth weighting your study toward.

• Lung carcinoma classification and IHC: the minimum panel of TTF-1, Napsin A, p40 and CK5/6 for adenocarcinoma versus squamous cell carcinoma versus small cell carcinoma; ALK, ROS1 and EGFR molecular testing indications; mesothelioma differentiation with calretinin, WT-1, CK5/6 and BAP1 loss. Lung is the most frequently examined organ in IHC questions.
• Colorectal carcinoma and Lynch syndrome workflow: mismatch repair IHC (MLH1, MSH2, MSH6, PMS2), MSI by PCR, BRAF V600E reflex testing for MLH1-deficient cases, MLH1 promoter hypermethylation, KRAS and NRAS for treatment selection. The expectation is the full algorithm, not just naming MMR proteins.
• Breast biomarker reporting: Allred and H-score for ER and PR (proportion plus intensity, with Allred 3 or higher considered positive per ASCO and CAP guidance), HER2 IHC scoring 0 to 3+ with FISH reflex on 2+ equivocal cases (FISH ratio 2 or higher, or average HER2 signals 6 or higher), Ki-67 thresholds, plus full Nottingham grading (tubule formation, nuclear pleomorphism, mitotic count). Examiners reward candidates who name the scoring system and apply it cleanly.
• Prostate Gleason and ISUP Grade Group: GG1 equals Gleason 6 (3+3), GG2 equals 3+4=7, GG3 equals 4+3=7, GG4 equals 8 (4+4 or 3+5 or 5+3), GG5 equals 9 to 10. Critical reporting elements per RCPA structured prostate protocol include grade group per core, percentage core involvement, percentage Gleason pattern 4 for GG2 and GG3, tertiary pattern if greater than 5%, perineural invasion and extracapsular extension. Calling Gleason 3+3=6 well-differentiated is a recurring examiner-flagged error.
• WHO 2021 CNS tumour classification: the IDH wild-type glioblastoma criteria (TERT promoter mutation, EGFR amplification, or chromosome 7 gain plus chromosome 10 loss); IDH-mutant astrocytoma graded 2 to 4 with CDKN2A homozygous deletion driving grade 4; oligodendroglioma defined by IDH mutation plus 1p/19q codeletion. Molecular features are diagnostic, not adjunctive.
• Endometrial TCGA molecular subtypes: POLE-ultramutated (best prognosis), MMR-deficient, NSMP (no specific molecular profile), and TP53-aberrant (worst prognosis). The college expects candidates to apply the ProMisE algorithm or equivalent and to integrate molecular findings with histological grade and stage.
• Frozen section and intraoperative communication: indications, limitations (follicular thyroid lesions, lymphoma classification, small biopsies, fatty tissue), how to convey uncertainty to a surgeon, when to defer to paraffin, the difference between "consistent with" and "confirmed" reporting language. This is a Section 1.5.4 competency examined explicitly in viva stations.

Appendix 13 of the trainee handbook deserves a separate read-through. It lists the molecular tests by MBS item number that candidates are expected to know how to order and interpret, including dual ISH for HER2 (MBS 73332 and 73342), ISH for MDM2 in liposarcoma (73374), FISH for ALK and ROS1 (73341 and 73344), FISH for MYC, BCL2, BCL6 and CCND1 in lymphoma, ISH for 1p/19q in glioma (73371), ploidy ISH for products of conception (73389), PCR for BRAF V600E, IDH1 R132H, EGFR and KRAS somatic variants, and HPV genotyping (73070 to 73075). MDT-style integrated cases probe this material directly.

How the written, practical and viva components are actually marked

The written exam rewards structured answers that map cleanly onto a marking schema. The practical and viva reward systematic, named-pattern reporting that does not skip steps under pressure. In both cases, structure beats prose flow.

• Systematic reporting wins. A practical or viva answer that runs specimen, macroscopic, microscopic (architecture, cell type, nuclear features, stroma, necrosis, mitoses, invasion, margins), IHC, molecular, integrated diagnosis with WHO classification and grade, then synoptic staging, will score even when the candidate is uncertain on the diagnosis itself.
• IHC panels need positive and negative markers. Naming three positive markers without justifying why each is on the panel and what the negative controls are is a recurring shortfall. Examiners want the panel construction reasoned, not the marker list recited.
• Numbers and thresholds. Allred 3 or higher, HER2 ratio 2 or higher, Ki-67 thresholds for grading neuroendocrine tumours, Nottingham mitotic count cut-offs per square millimetre, Breslow thickness in millimetres, Weiss criteria score, NAFLD Activity Score components. Specific numeric thresholds are expected to be stated, not waved at.
• Synoptic reporting. The RCPA structured pathology reporting of cancer protocols are the ground truth. Knowing which elements are mandatory for a colon, breast, prostate, lung, melanoma or endometrial resection report is examinable as a question in its own right.
• Time per question. In the written, allocate cleanly across the paper and stop on time per question. In the practical and viva, plan a 25-minute station as 3 minutes reading, 5 minutes systematic descriptive report, 5 minutes differential and IHC, 5 minutes molecular and integrated diagnosis, 7 minutes synoptic and clinicopathological correlation. Walk in with that pacing already drilled.

Common pitfalls that fail capable candidates

The pattern that breaks otherwise capable trainees in this exam is rarely a knowledge gap. It is structural and habit-driven. The microscopy and IHC are largely there, but the answer does not match what the marking schema rewards, or the candidate skips a step under examiner probing.

• Using p63 instead of p40 for squamous differentiation. p63 also stains myoepithelial and urothelial cells and is therefore less specific. The RCPA examiner reports note this explicitly.
• Calling Gleason 3+3=6 well-differentiated. The grade simply indicates the lowest ISUP group. It is not equivalent to well-differentiated in other grading systems and labelling it that way undersells malignancy.
• Missing the synchronous carcinoma when reporting an adenoma. Look for an invasive focus in a polypectomy specimen, assess depth of submucosal invasion, and report any margin involvement. Examiners pose this trap regularly.
• Skipping p57 for complete versus partial mole. p57 is a paternally imprinted, maternally expressed gene; it is absent in complete moles (androgenetic, no maternal genome) and positive in partial moles (triploid, with a maternal contribution). Failing to perform p57 on the initial workup of a suspected molar pregnancy is a flagged error.
• Diagnosing carcinoma versus mesothelioma without a balanced panel. EMA or pan-cytokeratin positivity alone does not separate the two. The expected answer pairs positive mesothelioma markers (calretinin, WT-1, CK5/6, D2-40) with negative carcinoma markers (CEA, CD15, MOC-31, BerEP4) and references BAP1 loss and MTAP deletion as supporting evidence.
• Frozen section communication failure. Reporting a frozen finding without conveying limitations, the difference between "consistent with" and "confirmed", and when a deferred diagnosis is necessary, costs candidates marks even when the histological call is correct.
• Light synoptic reporting. Writing a free-text descriptive report and ignoring the structured RCPA cancer protocol elements (margin distances in millimetres, lymph node yield, lymphovascular invasion, perineural invasion, named pathological staging by AJCC) is an avoidable loss of marks.
• Forgetting the Appendix 13 molecular layer. Listing the histology and IHC, and stopping there, skips the layer the curriculum explicitly examines. MDT-style integrated cases are the place this gets penalised most.

Cultural safety and professional qualities

Section 4 of the curriculum is not decorative. Cultural safety, communication and ethics LOs sit explicitly across the program and are reflected in viva probes about communication with clinicians, surgeons and patients, particularly where Aboriginal and Torres Strait Islander health perspectives intersect with reporting. The college expects candidates to consider patient context where it is relevant to the clinical question being asked, and to communicate findings without stigmatising language. Examiners notice it.

Practical material to keep in working memory:

• How you would communicate a complex or distressing diagnosis to a referring clinician, including what you would put in the report and what you would phone
• How to handle a discordance between frozen and paraffin findings, and the medicolegal documentation around it
• How to engage with cultural protocols around tissue handling, retention and return where relevant
• The audit and quality framework around discordant or unexpected findings (Section 2 LOs)

Realistic study timelines

Most trainees underestimate the integration burden of this exam. Knowing the histology is necessary, not sufficient. The exam rewards integrated reasoning under pressure, which takes months of slide work and structured practice, not a fortnight of cramming.

9 month run-up (recommended for first-time candidates)

• Months 1 to 2 (10 to 12 hours per week): read across the curriculum, working through the 237 LOs by section. Foundation knowledge and specimen management first, then organ-system pathology in blocks (lung, GI, breast, gynae, urological, skin, soft tissue, CNS, lymph node, endocrine). Build study notes as you go. Schedule the cross-cutting management, research and professional qualities LOs into this early phase so they do not crowd the back end.
• Months 3 to 4 (12 to 14 hours per week): deepen IHC panel construction and molecular literacy. Work systematically through Appendix 13. Begin written practice on individual SAQ stems and start glass slide review (one to two slides per week initially, building up).
• Months 5 to 6 (14 to 16 hours per week): full SAQ practice and structured slide review. Aim for one full SAQ paper per fortnight, marked against a schema. Move to two slides per slide-review session, with systematic reporting against a checklist. Begin to identify your own pattern of marking-point misses (under-IHC, under-synoptic, weak molecular justification).
• Months 7 to 8 (16 to 20 hours per week): timed full mock papers and viva-style practice. Aim for at least one full timed written paper per fortnight and weekly viva practice in pairs or with a supervisor. Address weak organ systems surfaced by the mocks. Refine systematic reporting until it is automatic.
• Final 4 weeks: taper to two timed papers and two viva sessions per week. Focus on the common pitfalls list, reread the synoptic protocols and IHC panels until they are reflexive. Sleep, exercise, no new content, no all-nighters.

6 month run-up (typical for trainees with strong base knowledge)

• Months 1 to 2 (15 to 18 hours per week): rapid curriculum sweep, prioritising the highest-yield clusters listed earlier. Do not aim for completeness, aim for coverage of the most-examined material. Begin slide review from week two.
• Months 3 to 4 (18 to 22 hours per week): structured SAQ and viva practice from week one. Single SAQ stems first, then full papers. Begin marked feedback (peer, supervisor, AI grader, registrar group). Two slide-review sessions per week.
• Month 5: three timed mock papers per fortnight and two viva sessions per week. Each followed by a debrief and a focused study session on the topics that scored worst.
• Month 6: taper, polish, sleep.

4 month run-up (high-risk, only viable with strong clinical base)

• Month 1 (20 to 25 hours per week): curriculum sweep with ruthless prioritisation. Skim what you already know, dwell on weak areas. Slide review and SAQ practice from week three.
• Month 2: two full mocks per week from day one, plus two viva sessions per week. Marking schema feedback every time.
• Month 3: three mocks and three viva sessions per week. Targeted gap-closure between mocks.
• Final month: two mocks and two viva sessions per week, taper to one of each in the last fortnight, sleep priority.

The single biggest mistake people make

You read across the entire curriculum, you build a notes folder that fills three lever-arch files, you can recite the WHO 2021 CNS classification in your sleep, and you walk into your first practice slide review at week 16 thinking the reporting will look after itself. It does not.

You sit down to a 25 minute glass slide station with a clinical history, gross description and microscopic description in front of you. You jump straight to the diagnosis (probably correct, in fact), then sketch out an IHC panel that misses the negative markers, then try to retrofit synoptic elements when the examiner asks you to staging. The marks are not where the diagnosis sits. They are where the systematic reporting structure shows up, where the IHC panel is built with positive and negative markers reasoned, where the molecular layer is named by Appendix 13 indication, and where the synoptic elements are recited without prompting.

The fix is to start systematic reporting at week 4, not week 16. Sit one glass slide per week from the beginning, even when the material is fresh and your reports are short. Get a marked schema back. Watch how examiners pattern-match. Drill the structure (specimen, macro, micro, IHC, molecular, integrated diagnosis, synoptic, clinicopathological correlation), not just the diagnostic call. The candidates who pass first time treat reporting structure as a separately trained skill, on its own timeline, alongside content study. The ones who treat structure as a final-month polish learn the hard way that you cannot retrofit a clean systematic approach into reporting habits that have already settled the wrong shape.

How PRIMEX helps

• Written grader: the PRIMEX RCPA Anatomical Pathology written grader generates RCPA-format MCQs and SAQs spanning general pathology, organ system pathology, IHC interpretation and tumour classification, marks each response against a structured marking schema with named-marker and named-threshold ticks, and returns a tier-graded result with a model answer at examiner standard.
• Curriculum tracker: all 237 RCPA Anatomical Pathology learning objectives across Foundation Knowledge, Specimen Management, Reporting, Laboratory Management, Research, Professional Qualities and Appendix 13 Molecular Competencies are checklisted in the app with progress saved locally, so you can see what you have covered and what still has a gap.
• Ask PRIMEX: ask any anatomical pathology question and get a structured answer drawn from the indexed study notes and curriculum mapping, fast enough to use during a slide review session without breaking flow.
• Viva simulator: AI-driven glass slide, frozen section, cytopathology and MDT integrated case stations with voice mode, examiner-style probing through systematic report, IHC panel construction, molecular indication and synoptic reporting. The same systematic structure that wins written marks reads cleanly back when you have been reporting it out loud.

Frequently asked questions

Related study guides

• RCPA Haematology 2026 Study Guide
• RANZCR Part 2 2026 Study Guide

Not affiliated with the Royal College of Pathologists of Australasia. The RCPA curriculum and exam structure are the intellectual property of the college; this guide is an independent commentary for trainee preparation. Always check the RCPA website for current sitting dates, format and policy.