Endocrine Pathology Practice Questions

Q: A patient presents with a mass in the front of the neck, along with odynophagia and dyspnea. Histopathology reveals tumor cells positive for TTF-1, synaptophysin, and chromogranin, and there is evidence of amyloid deposition. What is the most likely diagnosis?

Medullary thyroid carcinoma. ***Medullary thyroid carcinoma*** - The tumor cells are positive for **Synaptophysin** and **Chromogranin**, confirming their **neuroendocrine origin** from the parafollicular C cells [1][2]. - The characteristic finding of **amyloid deposition** is due to the precipitation of stored pro-hormone (primarily **calcitonin**) produced by these C cells, which is highly diagnostic for MTC [2]. *Papillary thyroid carcinoma* - While positive for TTF-1, it is characterized by distinctive nuclear features such as **Orphan Annie eye nuclei** and **nuclear grooves**. - It does **not** exhibit neuroendocrine differentiation (Synaptophysin/Chromogranin negative) or **amyloid deposition**. *Follicular thyroid carcinoma* - This tumor consists of follicular cells and is diagnosed by the demonstration of **capsular** or **vascular invasion**. - It is **negative** for neuroendocrine markers and **lacks** the pathognomonic **calcitonin-derived amyloid**. *Anaplastic thyroid carcinoma* - This is highly malignant and rapidly growing, often presenting with severe compression symptoms, but is histologically characterized by undifferentiated **spindle and giant cells**. - It is typically **negative** for specific neuroendocrine markers and TTF-1 expression is often lost; **amyloid deposits are not a feature**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1102-1103. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.

Q: Osteitis fibrosa cystica is a feature of

hyperparathyroidism. ***Correct: Hyperparathyroidism*** - **Osteitis fibrosa cystica** is a classic bone manifestation of **severe primary hyperparathyroidism**, resulting from excessive **parathyroid hormone (PTH)** [1]. - **PTH** causes increased bone resorption, leading to fibrous tissue replacement, cystic changes, and **brown tumors** (osteoclast-rich lesions with hemosiderin deposition) [1], [2]. - This represents advanced skeletal disease in hyperparathyroidism, though now rare due to early detection [1]. *Incorrect: Milk-alkali syndrome* - This syndrome is characterized by **hypercalcemia**, **metabolic alkalosis**, and **renal insufficiency** due to excessive intake of calcium and absorbable alkali. - It does not cause osteitis fibrosa cystica, which is a specific bone lesion requiring prolonged elevated **PTH**. *Incorrect: Rickets* - **Rickets** is a disorder primarily affecting children, characterized by defective bone mineralization leading to soft and weakened bones. - It is caused by **vitamin D deficiency** or resistance and manifests as bone deformities (bowing, rachitic rosary), not cystic bone lesions. *Incorrect: Hyperthyroidism* - **Hyperthyroidism** can lead to generalized **osteopenia** or **osteoporosis** due to increased bone turnover, but it does not cause osteitis fibrosa cystica. - The bone changes in hyperthyroidism are diffuse and distinct from the focal cystic lesions seen in excessive **PTH** activity. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1105-1106. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1194.

Q: The following is a histopathological image of thyroid pathology. What is the diagnosis?

Medullary carcinoma of thyroid. ***Medullary carcinoma of thyroid*** - This image shows sheets and nests of **polygonal to spindle-shaped cells**, which are characteristic of medullary thyroid carcinoma, especially when mixed with an **amyloid stroma** (seen as amorphous eosinophilic material) [2]. - The presence of **neuroendocrine features** and the production of **calcitonin** are hallmarks of these C-cell tumors [1], [2]. *Papillary carcinoma of thyroid* - Characterized by **papillary architecture**, **ground-glass (Orphan Annie eye) nuclei**, nuclear grooves, and intranuclear cytoplasmic inclusions. - These features are not prominently seen in the provided image. *Follicular carcinoma of thyroid* - Defined by an invasive growth pattern of **well-differentiated follicular cells** forming follicles, with either capsular or vascular invasion [2]. - The image does not show classic follicular architectural patterns or clear evidence of invasion in the absence of a capsule. *Anaplastic carcinoma of thyroid* - This is a highly aggressive and undifferentiated tumor with **marked pleomorphism**, bizarre giant cells, and high mitotic activity [2]. - While there is some pleomorphism, the overall pattern and cellular morphology in the image are more consistent with medullary carcinoma than the extreme anaplasia. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1102-1103. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-431.

Q: A thyroid FNA shows 'bubble gum' colloid. Which nuclear feature would best support papillary thyroid carcinoma?

Ground glass nuclei. ***Ground glass nuclei*** - **Ground glass nuclei**, also known as **Orphan Annie eye nuclei** [1][2], are the most **characteristic and recognized nuclear feature** of **papillary thyroid carcinoma (PTC)** on FNA cytology. [1] - This appearance results from **fine, evenly dispersed chromatin** that gives the nucleus a clear, empty, or translucent appearance with a prominent nuclear membrane. [1] - Among the given options, this is the **single best feature** that would support a PTC diagnosis when 'bubble gum' colloid is present. *Nuclear grooves* - **Nuclear grooves** are a common and highly supportive feature of PTC, particularly when **prominent and numerous**. - However, as a **single finding**, they are less definitive than ground glass nuclei, as grooves can occasionally be seen in benign conditions (though usually less prominent). - In combination with other features, nuclear grooves are highly specific for PTC. *Prominent nucleoli* - **Prominent nucleoli** are more frequently associated with **follicular neoplasms**, **medullary thyroid carcinoma**, or anaplastic thyroid carcinoma. - Classical PTC typically has **inconspicuous nucleoli**, so prominent nucleoli would suggest an alternative diagnosis or a tall cell variant of PTC. *Salt and pepper chromatin* - **Salt and pepper chromatin** (finely stippled chromatin) is a classic cytological feature of **medullary thyroid carcinoma** (MTC). - This chromatin pattern reflects neuroendocrine differentiation and is distinct from the nuclear characteristics of PTC. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1098-1100. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430.

Q: Malignancy in a multinodular goiter is most often:-

Papillary carcinoma. ***Papillary carcinoma*** - **Papillary carcinoma** is the most common type of thyroid cancer, accounting for about 80-85% of all thyroid malignancies [1], [2]. - It often arises in the setting of multifocal disease or within a **multinodular goiter**, particularly when a dominant nodule undergoes malignant transformation [2]. *Anaplastic carcinoma* - **Anaplastic carcinoma** is a very aggressive and rare form of thyroid cancer, typically presenting as a rapidly growing neck mass in elderly patients [2]. - While it can occur in a multinodular goiter, it is far less common than papillary carcinoma and carries a much poorer prognosis [2]. *Follicular carcinoma* - **Follicular carcinoma** is the second most common type of thyroid cancer (10-15%) and is often difficult to distinguish from benign follicular adenomas without surgical excision [2]. - While it can be found in a multinodular goiter, **papillary carcinoma** is still statistically more frequent in this context [1]. *Medullary carcinoma* - **Medullary carcinoma** originates from the parafollicular C cells of the thyroid and accounts for about 1-2% of all thyroid cancers [2]. - It is often associated with inherited syndromes like **Multiple Endocrine Neoplasia type 2 (MEN2)** and is distinct from tumors arising from follicular cells within a multinodular goiter [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1098-1099. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430.

Q: Nesidioblastoma is due to hyperplasia of?

Beta cell. ***Beta cell*** - Nesidioblastoma is a rare pancreatic disorder characterized by the **hyperplasia of pancreatic islet beta cells**. - This over-proliferation of **insulin-producing beta cells** leads to excessive insulin secretion and recurrent hypoglycemia [2]. *Alpha cell* - Hyperplasia of **alpha cells** would primarily lead to an overproduction of **glucagon**, potentially causing hyperglycemia [1], [2]. - Nesidioblastoma is specifically linked to hypoglycemia due to excessive insulin. *D cells* - **D cells** (delta cells) in the pancreas produce **somatostatin**, which inhibits the secretion of insulin and glucagon [2]. - Hyperplasia of D cells would more likely dampen both insulin and glucagon effects rather than cause insulin-driven hypoglycemia. *Acinus* - The **acinus** refers to the exocrine portion of the pancreas, responsible for producing digestive enzymes [1]. - Nesidioblastoma originates from the **endocrine islet cells**, not the exocrine acinar cells. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 433-434. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1109, 1125.

Q: Marker for pancreatic non-functional neuro-endocrine tumor is

Chromogranin-A. ***Chromogranin-A*** - **Chromogranin-A** is a glycoprotein found in the neurosecretory granules of various neuroendocrine cells, making it a reliable **general neuroendocrine tumor marker** [1]. - Elevated levels are particularly useful for detecting and monitoring **pancreatic non-functional neuroendocrine tumors**, which often lack specific hormonal symptoms. *CEA* - **Carcinoembryonic antigen (CEA)** is primarily used as a tumor marker for **colorectal cancer**, and less commonly for other adenocarcinomas like pancreatic adenocarcinoma. - It is generally **not a specific marker** for neuroendocrine tumors. *PSA* - **Prostate-specific antigen (PSA)** is a specific marker for **prostate cancer**, used for screening, diagnosis, and monitoring of this particular malignancy. - It has **no relevance** in the diagnosis or monitoring of pancreatic neuroendocrine tumors. *CD100* - **CD100** (also known as semaphorin-4D) is a membrane glycoprotein involved in immune cell regulation and has been implicated in certain cancers, such as those of **hematopoietic origin**. - It is **not used as a marker** for pancreatic non-functional neuroendocrine tumors. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 780-781.

Question 1

A 45-year-old male presents with a neck mass. Fine needle aspiration shows pleomorphic cells with grooved nuclei (coffee bean appearance), nuclear pseudoinclusions, and psammoma bodies. What is the most likely diagnosis?

Accepted Answer

Papillary thyroid carcinoma

Answer

Medullary thyroid carcinoma

Answer

Follicular thyroid carcinoma

Answer

Anaplastic thyroid carcinoma

Question 2

A patient presents with a mass in the front of the neck, along with odynophagia and dyspnea. Histopathology reveals tumor cells positive for TTF-1, synaptophysin, and chromogranin, and there is evidence of amyloid deposition. What is the most likely diagnosis?

Accepted Answer

Medullary thyroid carcinoma

Answer

Follicular thyroid carcinoma

Answer

Papillary thyroid carcinoma

Answer

Anaplastic thyroid carcinoma

Question 3

Osteitis fibrosa cystica is a feature of

Accepted Answer

hyperparathyroidism

Answer

milk-alkali syndrome

Answer

rickets

Answer

hyperthyroidism

Question 4

The following is a histopathological image of thyroid pathology. What is the diagnosis?

Accepted Answer

Medullary carcinoma of thyroid

Answer

Papillary carcinoma of thyroid

Answer

Follicular carcinoma of thyroid

Answer

Anaplastic carcinoma of thyroid

Question 5

A thyroid FNA shows 'bubble gum' colloid. Which nuclear feature would best support papillary thyroid carcinoma?

Accepted Answer

Ground glass nuclei

Answer

Nuclear grooves

Answer

Prominent nucleoli

Answer

Salt and pepper chromatin

Question 6

Malignancy in a multinodular goiter is most often:-

Accepted Answer

Papillary carcinoma

Answer

Anaplastic carcinoma

Answer

Follicular carcinoma

Answer

Medullary carcinoma

Question 7

Nesidioblastoma is due to hyperplasia of?

Accepted Answer

Beta cell

Answer

Alpha cell

Answer

D cells

Answer

Acinus

Question 8

Which of the following occurs in long standing goitre:

Accepted Answer

Follicular Ca

Answer

Medullary Ca

Answer

Papillary Ca

Answer

Anaplastic Ca

Question 9

Marker for pancreatic non-functional neuro-endocrine tumor is

Accepted Answer

Chromogranin-A

Answer

CEA

Answer

PSA

Answer

CD100

Question 10

A patient presents with neck swelling causing compression of the trachea and esophagus. Histopathological assessment reveals cell nests and pink extracellular amyloid stroma. What is the cell of origin of the tumor associated with these findings?

Accepted Answer

Parafollicular C cells

Answer

Hurthle cells

Answer

Follicular cells

Answer

Chief cells

Endocrine Pathology — MCQs

Endocrine Pathology — MCQs

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