Endocrine Surgery Practice Questions

Q: A patient with a thyroid nodule undergoes FNAC, which yields a result suggestive of follicular carcinoma. What is the most appropriate next step in management?

Hemithyroidectomy. ***Hemithyroidectomy*** - Fine-needle aspiration cytology (FNAC) cannot distinguish between **follicular adenoma** (benign) and **follicular carcinoma** (malignant) because the distinction requires histopathologic evidence of **capsular or vascular invasion**. - Therefore, a **hemithyroidectomy** (lobectomy) is the standard initial management to obtain a definitive tissue diagnosis while offering potential curative treatment if the lesion is benign or minimally invasive. *Total thyroidectomy* - This is not the initial procedure of choice because the majority of **follicular neoplasms** are eventually diagnosed as benign **adenomas**. - Total thyroidectomy is reserved for cases where histopathology confirms **invasive follicular carcinoma** or if there is clinical evidence of extensive multifocal disease. *Radioactive iodine therapy* - This therapy is used postoperatively for **differentiated thyroid cancer** (follicular or papillary) to ablate residual thyroid tissue or treat metastases, not as a primary management for a nodule. - It is never indicated when the diagnosis remains uncertain based solely on **FNAC** findings. *Repeat FNAC* - Repeating the FNAC is not helpful because it would likely yield the same **indeterminate result** (follicular neoplasm) and cannot evaluate for **invasion**. - Delaying surgical excision in a patient with a

Q: Which of the following statements is FALSE regarding medullary cancer of the thyroid?

These cancers take up Radioactive Iodine. ### Explanation **Medullary Thyroid Carcinoma (MTC)** arises from the **parafollicular C-cells**, which are neuroendocrine cells derived from the neural crest. This fundamental embryological origin is the key to understanding its clinical behavior and management. **Why Option D is the Correct (False) Statement:** Radioactive Iodine (RAI) uptake depends on the expression of the Sodium-Iodide Symporter (NIS), which is exclusive to follicular epithelial cells. Since MTC originates from C-cells (not follicular cells), these tumors **do not take up radioactive iodine**. Consequently, RAI ablation is not a therapeutic option for MTC, unlike papillary or follicular thyroid cancers. **Analysis of Other Options:** * **Option A (True):** C-cells naturally produce **Calcitonin**. Elevated serum calcitonin is a highly sensitive and specific tumor marker for MTC, used for both diagnosis and monitoring recurrence. * **Option B (True):** Approximately **20–25%** of MTC cases are familial, occurring as part of **MEN 2A, MEN 2B**, or Familial MTC (FMTC) syndromes, usually due to germline **RET proto-oncogene** mutations. The remaining 75–80% are sporadic. * **Option C (True):** Diarrhea occurs in about **30%** of patients, particularly in advanced or metastatic disease. It is caused by the hypersecretion of calcitonin, prostaglandins, or serotonin, which increases intestinal motility. **High-Yield Clinical Pearls for NEET-PG:** * **Amyloid Stroma:** Histologically, MTC is characterized by nests of cells separated by amyloid deposits (stained by Congo Red). * **CEA:** Carcinoembryonic Antigen is another important tumor marker for MTC. * **Screening:** All patients diagnosed with MTC must be screened for **RET mutations** and **Pheochromocytoma** (before surgery) to rule out MEN 2. * **Treatment:** The primary treatment is Total Thyroidectomy with central compartment neck dissection.

Q: Which of the following conditions can present with eye signs?

Primary toxic goitre.. **Explanation:** The presence of infiltrative ophthalmopathy (true eye signs) is a hallmark feature of **Graves' Disease**, also known as **Primary Toxic Goitre** [1]. **1. Why Option A is Correct:** Primary toxic goitre (Graves' Disease) is an autoimmune disorder caused by TSH-receptor antibodies (TRAb) [1]. These antibodies react with receptors not only in the thyroid but also in the retro-orbital tissues. This leads to inflammation, accumulation of glycosaminoglycans, and adipogenesis, resulting in **Exophthalmos** (proptosis), chemosis, and ophthalmoplegia [1]. These are "true" infiltrative eye signs. **2. Why Options B and C are Incorrect:** * **Secondary Toxic Goitre (Toxic Multinodular Goitre):** This condition occurs when a pre-existing simple goitre becomes autonomous. It is a purely hypermetabolic state without an autoimmune component; therefore, it lacks infiltrative ophthalmopathy. * **Thyrotoxicosis:** This is a general clinical syndrome of excess thyroid hormone. While it can cause "lid lag" and "lid retraction" (due to sympathetic overactivity affecting the Levator palpebrae superioris), these are **non-infiltrative** signs. True proptosis and extraocular muscle involvement are exclusive to the autoimmune pathology of Graves', not thyrotoxicosis itself [1]. **Clinical Pearls for NEET-PG:** * **Dalrymple’s Sign:** Widened palpebral fissures (staring look). * **Von Graefe’s Sign:** Lid lag on downward gaze. * **Stellwag’s Sign:** Infrequent or incomplete blinking. * **Smoking** is the most significant modifiable risk factor for the progression of Graves' ophthalmopathy. * **Treatment:** Severe cases are managed with IV Methylprednisolone or orbital decompression surgery [1].

Q: What is the recommended treatment for papillary carcinoma of the thyroid with bony metastasis?

Near total thyroidectomy with radioiodine and radiotherapy. ### Explanation The management of differentiated thyroid cancers (DTC), specifically **Papillary Carcinoma Thyroid (PTC)** with distant metastasis, follows a multimodal approach aimed at both local control and systemic treatment. **Why Option D is Correct:** 1. **Near Total or Total Thyroidectomy:** This is the mandatory first step. Removing all normal thyroid tissue is essential to eliminate the source of thyroglobulin (a tumor marker) and, more importantly, to ensure that subsequent doses of radioactive iodine (RAI) are taken up by the metastatic bone lesions rather than the thyroid gland itself. 2. **Radioiodine (I-131) Therapy:** PTC is typically iodine-avid. RAI is the treatment of choice for distant metastases (lung and bone) after the primary gland is removed. 3. **Radiotherapy (EBRT):** Bone metastases in PTC are often osteolytic and carry a high risk of pathological fractures or spinal cord compression. External Beam Radiation Therapy (EBRT) is added for palliation, pain control, and to stabilize the metastatic site. **Analysis of Incorrect Options:** * **Options A & B:** These are incomplete. Surgery is the cornerstone of management for DTC, even in the presence of metastasis, to facilitate adjuvant therapies. * **Option C:** While it includes surgery and radiotherapy, it misses **Radioiodine**, which is the most specific systemic therapy for thyroid cancer cells. **NEET-PG High-Yield Pearls:** * **Most common site of metastasis in PTC:** Cervical lymph nodes (Level II, III, IV). * **Most common site of distant metastasis:** Lungs (more common than bone). * **Prognostic Scoring:** Use the **AMES** or **MACIS** criteria for PTC. * **Thyroglobulin (Tg):** Used as a postoperative tumor marker to monitor recurrence. * **Treatment of choice for Follicular Carcinoma with bone metastasis:** Also Total Thyroidectomy followed by RAI.

Q: What is the most common type of thyroid cancer?

Papillary carcinoma. **Explanation:** **Papillary Thyroid Carcinoma (PTC)** is the most common type of thyroid malignancy, accounting for approximately **80–85%** of all thyroid cancers. It is typically associated with radiation exposure and has an excellent prognosis. The diagnosis is characterized by distinct nuclear features such as **Orphan Annie eye nuclei** (clear nuclei), **Psammoma bodies** (laminated calcifications), and nuclear grooves. **Analysis of Options:** * **Follicular Carcinoma (Option B):** The second most common type (approx. 10–15%). It is more prevalent in iodine-deficient areas and spreads primarily via the **hematogenous route** (to bone and lungs), unlike PTC which spreads via lymphatics. * **Medullary Carcinoma (Option C):** Accounts for about 5% of cases. It arises from the **parafollicular C-cells** and secretes **Calcitonin**. It can be sporadic or associated with MEN 2A/2B syndromes (RET proto-oncogene mutation). * **Anaplastic Carcinoma (Option D):** The rarest (<2%) but most aggressive form. It typically presents in elderly patients as a rapidly enlarging neck mass with a very poor prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Route of Spread:** Papillary = Lymphatic (most common site: Level VI nodes); Follicular = Hematogenous. * **Investigation of Choice:** FNAC is the gold standard for thyroid nodules, but it **cannot** distinguish between follicular adenoma and follicular carcinoma (requires histopathology to see capsular/vascular invasion). * **Psammoma Bodies:** Most commonly seen in Papillary CA, Meningioma, and Serous Cystadenocarcinoma of the ovary. * **Treatment:** Total thyroidectomy is the mainstay for most cases >1cm, often followed by Radioiodine (I-131) ablation.

Q: Swelling of the thyroid gland that does not move with deglutition is/are:

All of the above. **Explanation:** The hallmark clinical sign of a thyroid swelling is that it **moves with deglutition** (swallowing). This occurs because the thyroid gland is enclosed by the **pretracheal fascia**, which attaches the gland to the laryngeal cartilages and the hyoid bone. When these structures move upward during swallowing, the thyroid moves with them. However, certain conditions can prevent this movement: 1. **Retrosternal Goiter (Option A):** When a goiter extends significantly into the mediastinum (thoracic inlet), it can become "wedged" or "impacted" behind the sternum. The bony cage of the thoracic inlet restricts the upward excursion of the mass during swallowing. 2. **Riedel’s Thyroiditis/Goiter (Option B):** This is a rare chronic inflammatory condition characterized by dense, "woody" fibrosis. The fibrosis extends beyond the thyroid capsule to involve adjacent structures like the strap muscles, trachea, and carotid sheath, effectively "tethering" the gland and preventing movement. 3. **Anaplastic Carcinoma (Option C):** This is a highly aggressive malignancy. It frequently exhibits extrathyroidal extension, infiltrating surrounding muscles, nerves, and fascia. This local invasion causes the gland to become fixed to the neck structures. **Clinical Pearls for NEET-PG:** * **Thyroglossal Cyst:** Moves with deglutition AND **protrusion of the tongue** (due to its attachment to the hyoid bone via the tract). * **Pemberton’s Sign:** Seen in retrosternal goiters; raising the arms above the head causes facial congestion and respiratory distress due to thoracic inlet obstruction. * **Hard/Woody Thyroid:** Differential includes Riedel’s Thyroiditis and Anaplastic Carcinoma. Riedel’s is typically seen in younger patients, while Anaplastic is seen in the elderly.

Q: A 21-year-old woman presents with a 3 cm node in the lower deep cervical chain on the left. Biopsy reveals normal thyroid tissue within a lymph node. What is the most likely diagnosis?

Papillary carcinoma of the thyroid. **Explanation:** The presence of "normal-looking" thyroid tissue within a cervical lymph node is a classic presentation of metastatic **Papillary Carcinoma of the Thyroid (PTC)**. This phenomenon occurs because PTC is a highly lymphophilic tumor that frequently spreads to regional lymph nodes. Even when the metastatic deposits appear histologically well-differentiated (resembling normal follicles), they are pathologically considered metastatic cancer. **Why the other options are incorrect:** * **Lateral Aberrant Thyroid:** This was an older anatomical theory suggesting that thyroid tissue could develop independently in the lateral neck. Modern embryology and pathology have debunked this; any thyroid tissue found lateral to the internal jugular vein or within a lymph node is considered metastatic PTC until proven otherwise. * **Subacute Thyroiditis & Hashimoto’s Disease:** These are inflammatory/autoimmune conditions of the thyroid gland. While they may cause reactive lymphadenopathy, they do not cause the migration of thyroid follicular cells into the lymphatic system. **NEET-PG High-Yield Pearls:** * **Orphan Annie Eye Nuclei:** The pathognomonic histological feature of PTC (large, pale, clear nuclei). * **Psammoma Bodies:** Laminated calcifications often seen in PTC. * **Route of Spread:** PTC spreads primarily via **lymphatics** (unlike Follicular Carcinoma, which spreads hematogenously). * **Prognosis:** Despite early lymphatic spread (even in young patients), PTC has an excellent long-term prognosis. * **Rule of Thumb:** Any thyroid tissue found in a cervical lymph node is **metastatic papillary carcinoma** until proven otherwise.

Q: A middle-aged female presents to the surgical OPD with a thyroid swelling. She has a history of Hodgkin's lymphoma. Which of the following thyroid malignancies is most likely to be suspected in this patient?

Papillary thyroid cancer. **Explanation:** The correct answer is **Papillary Thyroid Cancer (PTC)**. The key clinical association in this question is the history of **Hodgkin’s lymphoma**. Patients treated for Hodgkin’s lymphoma often receive mantle field radiation therapy. **Ionizing radiation** is the most significant and well-established risk factor for the development of Papillary Thyroid Cancer. There is a long latency period (often 10–20 years) between radiation exposure and the appearance of the malignancy. **Analysis of Options:** * **Papillary Thyroid Cancer (Correct):** It is the most common thyroid malignancy overall and specifically the one most strongly associated with prior radiation exposure. * **Medullary Thyroid Cancer:** This arises from parafollicular C-cells and is primarily associated with genetic mutations (RET proto-oncogene) and MEN 2 syndromes, not radiation. * **Anaplastic Thyroid Cancer:** While aggressive, it typically presents in elderly patients and is not the primary malignancy linked to prior lymphoma-related radiation. * **Thyroid Lymphoma:** Although the patient has a history of Hodgkin’s lymphoma, primary thyroid lymphoma is rare and is most strongly associated with **Hashimoto’s thyroiditis**, not prior radiation. **Clinical Pearls for NEET-PG:** * **Most common thyroid cancer post-radiation:** Papillary Thyroid Cancer. * **Genetic association:** *BRAF* mutation is the most common mutation in PTC; *RET/PTC* rearrangements are specifically associated with radiation-induced PTC. * **Psammoma bodies:** Characteristic histological finding (laminated calcifications) in PTC. * **Orphan Annie eye nuclei:** Classic nuclear clearing seen on histopathology of PTC.

Question 1

A patient with a thyroid nodule undergoes FNAC, which yields a result suggestive of follicular
carcinoma. What is the most appropriate next step in management?

Accepted Answer

Hemithyroidectomy

Answer

Total thyroidectomy

Answer

Radioactive iodine therapy

Answer

Repeat FNAC

Question 2

Which of the following statements is FALSE regarding medullary cancer of the thyroid?

Accepted Answer

These cancers take up Radioactive Iodine

Answer

Secrete Calcitonin

Answer

20-25% are familial

Answer

Diarrhea is seen in 30%

Question 3

Which of the following conditions can present with eye signs?

Accepted Answer

Primary toxic goitre.

Answer

Secondary toxic goitre.

Answer

Thyrotoxicosis.

Answer

All of the above.

Question 4

Which of the following statements is not true regarding medullary thyroid carcinoma?

Accepted Answer

They comprise approximately 25% of all thyroid malignancies.

Answer

They are a type of neuroendocrine tumor.

Answer

They are associated with MEN 2A and 2B syndromes.

Answer

Tumor cells may secrete serotonin, ACTH, and VIP.

Question 5

What is the recommended treatment for papillary carcinoma of the thyroid with bony metastasis?

Accepted Answer

Near total thyroidectomy with radioiodine and radiotherapy

Answer

Radiotherapy

Answer

Radioiodine

Answer

Near total thyroidectomy with radiotherapy

Question 6

What is the most common type of thyroid cancer?

Accepted Answer

Papillary carcinoma

Answer

Follicular carcinoma

Answer

Medullary carcinoma

Answer

Anaplastic carcinoma

Question 7

Swelling of the thyroid gland that does not move with deglutition is/are:

Accepted Answer

All of the above

Answer

Retrosternal goiter

Answer

Riedel's goiter

Answer

Anaplastic carcinoma

Question 8

What is the standard incision used in thyroidectomy?

Accepted Answer

Collar incision

Answer

Barking incision

Answer

Kocher incision

Answer

Koebner incision

Question 9

A 21-year-old woman presents with a 3 cm node in the lower deep cervical chain on the left. Biopsy reveals normal thyroid tissue within a lymph node. What is the most likely diagnosis?

Accepted Answer

Papillary carcinoma of the thyroid

Answer

Subacute thyroiditis

Answer

Hashimoto's disease

Answer

Lateral aberrant thyroid

Question 10

A middle-aged female presents to the surgical OPD with a thyroid swelling. She has a history of Hodgkin's lymphoma. Which of the following thyroid malignancies is most likely to be suspected in this patient?

Accepted Answer

Papillary thyroid cancer

Answer

Medullary thyroid cancer

Answer

Anaplastic thyroid cancer

Answer

Thyroid lymphoma

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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