Endocrine Surgery Practice Questions

Q: Prophylactic thyroidectomy is indicated for which of the following conditions?

Multiple Endocrine Neoplasia (MEN) 2B syndrome. **Explanation:** **Why Option B is Correct:** Prophylactic thyroidectomy is the standard of care for patients with **Multiple Endocrine Neoplasia (MEN) 2A and 2B** due to the 100% penetrance of **Medullary Thyroid Carcinoma (MTC)**. In MEN 2B, MTC is particularly aggressive, appearing earlier in life and metastasizing rapidly. Current guidelines (ATA) recommend prophylactic total thyroidectomy **within the first year of life** (ideally by 6 months) for infants identified with the *RET* proto-oncogene mutation associated with MEN 2B. **Why Other Options are Incorrect:** * **A. Hashimoto’s Thyroiditis:** This is an autoimmune condition managed primarily with levothyroxine. Surgery is only indicated if there is a suspicion of lymphoma or compressive symptoms. * **C. Riedel’s Thyroiditis:** A rare systemic IgG4-related sclerosing disease. Management is medical (Tamoxifen, Steroids). Surgery is technically difficult due to dense fibrosis and is reserved only for relieving tracheal compression (wedge resection of the isthmus). * **D. Graves’ Disease:** An autoimmune hyperthyroidism. While thyroidectomy is a definitive treatment option (especially for large goiters or suspicious nodules), it is **therapeutic**, not prophylactic. **High-Yield Clinical Pearls for NEET-PG:** * **MEN 2A:** Prophylactic thyroidectomy is recommended by **age 5**. * **Screening:** The most sensitive screening tool for MEN 2 syndromes is genetic testing for **RET proto-oncogene** mutations. * **Tumor Marker:** Post-operative monitoring for MTC recurrence is done via serum **Calcitonin** and CEA levels. * **Order of Surgery:** In MEN 2 patients, always rule out or treat **Pheochromocytoma** before performing thyroid surgery to prevent a hypertensive crisis.

Q: A 30-year-old lady who underwent near-total thyroidectomy for papillary carcinoma two years ago is found to have multiple, discrete, mobile, left deep cervical lymph nodes measuring 1 to 1.5 cm in size during follow-up. What is the ideal treatment for this patient?

Iodine 131 ablation. **Explanation:** The management of recurrent or metastatic Papillary Thyroid Carcinoma (PTC) depends on the size and extent of the disease. In this patient, the presence of multiple, small (1–1.5 cm), discrete, and mobile lymph nodes two years after a near-total thyroidectomy indicates regional recurrence. **1. Why Iodine-131 (RAI) Ablation is Correct:** Papillary carcinoma is an iodine-concentrating tumor. Following a near-total or total thyroidectomy, any residual thyroid tissue or microscopic/small-volume nodal disease is best managed with **Radioactive Iodine (I-131) therapy**. It effectively targets and destroys occult or small metastatic deposits that are difficult to clear surgically. In clinical practice, if nodes are small and multiple, RAI is the preferred first-line systemic approach to achieve "biochemical cure." **2. Why Other Options are Incorrect:** * **Modified Radical Neck Dissection (MRDN):** This is indicated for clinically significant, bulky, or fixed lymphadenopathy (usually >2 cm) or when nodes fail to respond to RAI. For small, mobile nodes, surgery is often deferred in favor of RAI to avoid the morbidity of re-exploration. * **Thyroxine Therapy:** While suppressive doses of T4 are mandatory post-thyroidectomy to keep TSH low, it is an adjuvant treatment, not a primary treatment for active nodal recurrence. * **External Irradiation:** This is reserved for palliative care in elderly patients with unresectable, iodine-refractory disease or rapidly progressive anaplastic transformation. **Clinical Pearls for NEET-PG:** * **Investigation of Choice for Recurrence:** Serum Thyroglobulin (Tg) levels and Neck Ultrasound. * **Gold Standard for Nodal Mapping:** Contrast-enhanced CT (without IV contrast if RAI is planned) or USG-guided FNAC. * **RAI Requirement:** Patients must have a high TSH (>30 mIU/L) and a low-iodine diet before I-131 administration for maximum uptake.

Q: What is the primary treatment for Medullary Carcinoma of the thyroid?

Surgery only. **Explanation:** Medullary Thyroid Carcinoma (MTC) arises from the **parafollicular C-cells**, which are neuroendocrine in origin and derived from the neural crest. Unlike follicular cells, C-cells do not concentrate iodine; therefore, MTC is inherently resistant to radioactive iodine therapy and is generally poorly responsive to chemotherapy and external beam radiation. **1. Why "Surgery only" is correct:** Surgery is the only curative treatment for MTC. The standard of care is **Total Thyroidectomy** with **Central Compartment Neck Dissection (Level VI)**. This is because MTC is frequently multicentric (especially in familial cases/MEN 2 syndromes) and has a high propensity for early lymphatic spread. **2. Why other options are incorrect:** * **Radiotherapy and Chemotherapy (A & B):** MTC is relatively radioresistant and chemoresistant. These modalities are reserved only for palliative care or unresectable local recurrence, not as primary treatment. * **Radioiodine Ablation (D):** This is a major "distractor." Since MTC originates from C-cells (not follicular cells), it does not take up Iodine-131. Radioiodine is used for Differentiated Thyroid Cancers (Papillary and Follicular) but has **no role** in MTC. **Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **Calcitonin** (used for diagnosis, screening, and monitoring recurrence) and CEA. * **Genetic Screening:** All patients with MTC must be screened for **RET proto-oncogene** mutations to rule out MEN 2A/2B. * **Pre-op Rule Out:** Always exclude **Pheochromocytoma** (via urinary/plasma metanephrines) before surgery to prevent a hypertensive crisis during anesthesia. * **Prophylactic Surgery:** In RET mutation carriers, prophylactic thyroidectomy is performed based on the specific codon mutation risk.

Q: Which type of thyroid cancer is characterized by high aggressiveness and lethality?

Anaplastic. **Explanation:** **Anaplastic Thyroid Carcinoma (ATC)** is the correct answer because it is one of the most aggressive and lethal solid tumors in humans. Unlike differentiated thyroid cancers, ATC is characterized by rapid local invasion of neck structures (trachea, esophagus, and vessels) and early distant metastasis. It typically presents in elderly patients (6th–7th decade) as a rapidly enlarging neck mass, often leading to death within 6 months of diagnosis due to airway obstruction or systemic disease. **Analysis of Incorrect Options:** * **Papillary Thyroid Carcinoma (PTC):** This is the most common type of thyroid cancer. It has an excellent prognosis with a 10-year survival rate exceeding 90%. It typically spreads via lymphatics. * **Follicular Thyroid Carcinoma (FTC):** This is the second most common type. While more aggressive than Papillary (due to hematogenous spread to bones and lungs), it still carries a very favorable prognosis compared to Anaplastic. * **Medullary Thyroid Carcinoma (MTC):** Arising from parafollicular C-cells, it is of intermediate aggressiveness. While more lethal than PTC/FTC, it does not match the rapid fatality of ATC. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** ATC shows spindle, polygonal, or giant cells with frequent mitoses; it lacks any follicular or papillary architecture. * **Transformation:** ATC often arises from a pre-existing long-standing differentiated thyroid cancer (usually Follicular) or goiter. * **Markers:** ATC is often negative for Thyroglobulin and TTF-1, making diagnosis reliant on clinical presentation and biopsy. * **Treatment:** Most cases are unresectable at the time of diagnosis; palliative tracheostomy and radiotherapy are often the only options.

Question 1

Prophylactic thyroidectomy is indicated for which of the following conditions?

Accepted Answer

Multiple Endocrine Neoplasia (MEN) 2B syndrome

Answer

Hashimoto's thyroiditis

Answer

Riedel's thyroiditis

Answer

Graves' disease

Question 2

What is the treatment for parathyroid adenoma?

Accepted Answer

Removal of the adenoma

Answer

Calcitonin and steroid

Answer

Total parathyroidectomy and implantation in the arm

Answer

Total parathyroidectomy

Question 3

A 30-year-old lady who underwent near-total thyroidectomy for papillary carcinoma two years ago is found to have multiple, discrete, mobile, left deep cervical lymph nodes measuring 1 to 1.5 cm in size during follow-up. What is the ideal treatment for this patient?

Accepted Answer

Iodine 131 ablation

Answer

External irradiation to the neck

Answer

Thyroxine therapy

Answer

Modified radical neck dissection

Question 4

What is the primary treatment for Medullary Carcinoma of the thyroid?

Accepted Answer

Surgery only

Answer

Surgery and radiotherapy

Answer

Radiotherapy and chemotherapy

Answer

Radioiodine ablation

Question 5

Which of the following is not a feature of Riedel thyroiditis?

Accepted Answer

Fine needle aspiration cytology (FNAC) is the investigation of choice

Answer

Fibrosing condition

Answer

Fibrosing condition

Answer

Associated with retroperitoneal fibrosis

Question 6

Which type of thyroid cancer is characterized by high aggressiveness and lethality?

Accepted Answer

Anaplastic

Answer

Papillary

Answer

Follicular

Answer

Medullary

Question 7

Surgical removal of adrenal adenoma is indicated when their size is more than:

Accepted Answer

4 cm

Answer

2 cm

Answer

6 cm

Answer

10 cm

Question 8

A 26-year-old woman presents with a palpable thyroid nodule. Needle biopsy demonstrates amyloid in the stroma of the lesion. A cervical lymph node is palpable on the same side as the lesion. What is the preferred treatment?

Accepted Answer

Total thyroidectomy and modified neck dissection on the side of the enlarged lymph node.

Answer

Removal of the involved node, the isthmus, and the enlarged lymph node.

Answer

Removal of the involved lobe, the isthmus, a portion of the opposite lobe, and the enlarged lymph node.

Answer

Total thyroidectomy and irradiation of the cervical lymph nodes.

Question 9

A patient presents with a small solitary nodule in the right lobe of the thyroid. FNAC shows follicular adenoma. What is the best surgical management?

Accepted Answer

Right hemithyroidectomy

Answer

Enucleation

Answer

Subtotal thyroidectomy

Answer

Near-total thyroidectomy

Question 10

Which of the following are indications for surgery in a case of thyroid swelling?

Accepted Answer

Cosmetic, pressure symptoms, and swelling with symptoms

Answer

Cosmetic, pressure symptoms, and myxedema

Answer

Cosmetic, pressure symptoms, pain, and swelling with symptoms

Answer

All are indications for surgery

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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