Fine Needle Aspiration Cytology — MCQs
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
What is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
A middle aged male patient presents with painless slow growing neck swelling. On examination, lymph nodes are positive. Surgery is done and biopsy is shown in the image below. Which of the following is false regarding the HPE findings?
A case of spontaneous pneumothorax comes to you. What will be the earliest treatment of choice?
A case of spontaneous pneumothorax comes to you what will be earliest t/t of choice :
A case of spontaneous pneumothorax with significant breathlessness comes to you. What will be the initial treatment of choice?
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Fine Needle Aspiration Cytology Indian Medical PG Practice Questions and MCQs
Question 1: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
Question 2: What is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
- A. I-123 scan
- B. Ultrasound (Correct Answer)
- C. Fine-needle aspiration (FNA) biopsy
- D. Thyroid function tests (TFTs)
- E. CT scan of the neck
Explanation: ***Ultrasound*** - **Ultrasound** is the initial investigation of choice for a solitary thyroid nodule (STN) because it can differentiate between **solid, cystic, or mixed lesions**, assess nodule size, and identify suspicious features (e.g., microcalcifications, irregular margins, internal vascularity). - It also helps to determine if there are other nodules not palpable on physical examination, allowing for a more complete assessment of the **thyroid gland**. *Fine-needle aspiration (FNA) biopsy* - **FNA biopsy** is the most accurate diagnostic tool for evaluating the malignant potential of a thyroid nodule, but it is typically performed *after* an initial ultrasound has characterized the nodule. - It requires guidance (often by ultrasound) to obtain an adequate sample for cytological analysis, making ultrasound a prerequisite for optimal FNA performance. *Thyroid function tests (TFTs)* - **TFTs (TSH, T3, T4)** are important for assessing the functional status of the thyroid gland (e.g., hyperthyroidism or hypothyroidism) and can provide context for the nodule. - However, TFTs do not directly evaluate the **morphology or malignant potential** of the nodule itself, making them less appropriate as an initial, stand-alone investigation for an STN. *I-123 scan* - An **I-123 scan** (radioactive iodine uptake and scan) is used to determine if a nodule is "hot" (hyperfunctioning/benign) or "cold" (non-functioning/potentially malignant). - It is typically reserved for cases where **TSH levels are suppressed**, suggesting a hyperfunctioning nodule, and is not the first-line imaging modality for initial characterization of all STNs. *CT scan of the neck* - **CT scan** can visualize thyroid nodules and assess for extrathyroidal extension or lymphadenopathy, but it is **not recommended as an initial investigation** for STN. - It involves **radiation exposure**, is more expensive than ultrasound, and provides **less detailed characterization** of nodule morphology compared to ultrasound, making it a less appropriate first-line modality.
Question 3: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Question 4: A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
- A. Incision biopsy (Correct Answer)
- B. Excision biopsy
- C. FNAC
- D. USG
Explanation: ***Incision biopsy*** - An **incision biopsy** is most appropriate for a large tumor (10 cm) to obtain a tissue diagnosis without performing a potentially morbid or disfiguring complete excision upfront. - It involves removing a representative section of the tumor for histopathological analysis, providing adequate tissue for diagnosis, grading, and subtyping. - This allows definitive treatment planning based on confirmed histopathology. *Excision biopsy* - **Excision biopsy** is generally reserved for smaller tumors (typically <3-5 cm) that can be completely resected with acceptable cosmetic and functional outcomes. - Excision of a 10 cm tumor on the thigh would be a significant surgical procedure, potentially causing substantial morbidity, without a prior definitive diagnosis. - Could compromise subsequent definitive surgery if margins are inadequate. *FNAC* - **FNAC (Fine Needle Aspiration Cytology)** provides only cytological diagnosis, which is insufficient for definitive diagnosis, grading, and subtyping of soft tissue tumors, especially sarcomas. - It misses crucial architectural features and tissue patterns needed for accurate classification. - May yield inadequate or non-diagnostic samples from large heterogeneous tumors. *USG* - **USG (Ultrasound)** is an imaging modality, not a tissue diagnosis procedure. - While useful for characterizing mass features (size, location, vascularity, solid vs cystic), it cannot provide histopathological diagnosis. - The question specifically asks for a procedure to "obtain a diagnosis," which requires tissue sampling for microscopic examination.
Question 5: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 6: A middle aged male patient presents with painless slow growing neck swelling. On examination, lymph nodes are positive. Surgery is done and biopsy is shown in the image below. Which of the following is false regarding the HPE findings?
- A. Spread is through lymphatics
- B. Nuclear features are the characteristic of this tumor
- C. FNAC is not diagnostic (Correct Answer)
- D. It has excellent prognosis
Explanation: ***Fine needle aspiration cytology (FNAC) is not diagnostic*** - FNAC can often provide significant insights, but in cases of **specific malignancies** or certain lesions, it may not yield definitive diagnoses [1]. - Diagnostic challenges arise as **cellular architecture** or certain **nuclear features** may not be appreciated in FNAC samples [1]. *It spreads quickly via lymphatics* - This condition can indeed spread via lymphatics, making it **aggressive** in nature [1]. - **Lymphatic spread** is a common pathway for many head and neck conditions, particularly malignancies [1]. *Excellent prognosis is associated with this condition* - While some conditions may have favorable prognoses, many midline neck lesions can have **serious implications** depending on their nature [1]. - Prognosis often varies widely and may not always be classified as **excellent** based solely on initial presentation [1]. *Nuclear characteristics are used for the identification* - Nuclear morphology is critical for identifying various **neoplastic conditions**, aiding in differentiation from benign lesions [1][2]. - Many pathologies, especially those involving **malignancy**, rely heavily on **nuclear features** for accurate diagnosis [1][2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101.
Question 7: A case of spontaneous pneumothorax comes to you. What will be the earliest treatment of choice?
- A. ICD
- B. Wait and watch
- C. Needle aspiration (Correct Answer)
- D. IPPV
Explanation: ***Needle aspiration*** - For a spontaneous pneumothorax, especially if it is of moderate size or the patient is symptomatic, **needle aspiration** is often the earliest and least invasive treatment option. - This procedure removes air from the pleural space, allowing the lung to re-expand and relieving symptoms quickly. *ICD* - **Intercostal chest drain (ICD)** insertion is typically reserved for larger pneumothoraces, recurrent cases, or when needle aspiration is unsuccessful [1]. - It is a more invasive procedure than needle aspiration and is generally not the *earliest* treatment of choice for an initial, uncomplicated spontaneous pneumothorax [1]. *Wait and watch* - A "wait and watch" approach is appropriate only for very **small, asymptomatic spontaneous pneumothoraces** (e.g., <2 cm from the chest wall at the level of the hilum) [1]. - The question implies a case that "comes to you," suggesting the need for intervention rather than simple observation. *IPPV* - **Intermittent Positive Pressure Ventilation (IPPV)** is a form of mechanical ventilation used in patients with respiratory failure. - It is not a primary treatment for pneumothorax; rather, pneumothorax could be a complication of IPPV, or IPPV might be required if the pneumothorax leads to severe respiratory compromise, but it is not the initial intervention.
Question 8: A case of spontaneous pneumothorax comes to you what will be earliest t/t of choice :
- A. ICD
- B. Wait and watch
- C. IPPV
- D. Needle aspiration (Correct Answer)
Explanation: ***Needle aspiration*** - For a **spontaneous pneumothorax**, especially a first-time episode and if the patient is stable, **needle aspiration** is often the earliest and least invasive treatment choice. - It involves inserting a small-bore needle to remove air from the pleural space, allowing the lung to re-expand and alleviating symptoms. *ICD* - An **intercostal drain (ICD)** insertion is typically reserved for larger pneumothoraces, symptomatic cases, or when needle aspiration has failed. - It is a more invasive procedure compared to needle aspiration and carries a higher risk of complications. *Wait and watch* - A "wait and watch" approach is only appropriate for very small, asymptomatic pneumothoraces (usually less than 1-2 cm) in a stable patient. - Given the general presentation of "spontaneous pneumothorax," it suggests a need for intervention beyond just observation [1]. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** is a form of mechanical ventilation rarely used as the initial treatment for a spontaneous pneumothorax. - It is typically reserved for patients with severe respiratory compromise or those undergoing surgery, and positive pressure can worsen a pneumothorax if not managed carefully.
Question 9: A case of spontaneous pneumothorax with significant breathlessness comes to you. What will be the initial treatment of choice?
- A. ICD
- B. IPPV
- C. Wait and watch
- D. Needle aspiration (Correct Answer)
Explanation: ***Needle aspiration*** - **Needle aspiration** is the initial treatment of choice for a **spontaneous pneumothorax**, especially if it is large or causing significant symptoms, as it quickly relieves pressure. - This procedure involves inserting a small needle and catheter into the pleural space to evacuate air, allowing the lung to re-expand. *ICD* - **Intercostal chest drain (ICD)** insertion is typically reserved for larger pneumothoraces, those failing needle aspiration, or recurrent cases. - While effective, it is a more invasive procedure than initial needle aspiration. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** is a form of mechanical ventilation applied in cases of severe respiratory failure, not as an initial treatment for a stable spontaneous pneumothorax. - Administering positive pressure can worsen a pneumothorax if not carefully monitored and managed. *Wait and watch* - A "wait and watch" approach is only appropriate for very **small, asymptomatic spontaneous pneumothoraces** (typically < 1-2 cm from the chest wall). - For symptomatic or larger pneumothoraces, intervention is necessary to prevent further complications and improve respiratory function.
Question 10: Anaplasia is
- A. Changing one type of epithelium to another
- B. Nuclear chromatin
- C. Lack of differentiation (Correct Answer)
- D. Morphological changes
Explanation: ***Lack of differentiation*** - Anaplasia refers to a **loss of differentiation** in cells, making them more primitive and less specialized [1]. - It is often seen in **malignant tumors**, indicating a poor prognosis and aggressive behavior [1]. *Morphological changes* - While anaplasia involves **morphological changes**, this term is too broad and can relate to various cellular alterations, not exclusively anaplasia [1]. - Anaplasia specifically emphasizes **lack of differentiation**, distinct from general changes in cell appearance [1]. *Changing one type of epithelium to another* - This describes a process known as **metaplasia**, where one adult cell type transforms into another, not anaplasia. - Anaplasia signifies a **de-differentiation** rather than a change to a different epithelial type [1]. *Nuclear chromatin* - While changes in **nuclear chromatin** can occur in anaplastic cells, this does not define anaplasia itself [1]. - Anaplasia primarily refers to **loss of cell differentiation**, making this option insufficient to describe the concept [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 276-280.
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