Endocrine Surgery Practice Questions

Q: Which of the following is NOT a feature of medullary carcinoma of the thyroid?

Constipation occurs. **Explanation:** Medullary Carcinoma of Thyroid (MCT) is a neuroendocrine tumor derived from the **parafollicular C-cells** of the thyroid. These cells are responsible for the secretion of **Calcitonin**. **Why Option D is the correct answer:** MCT is associated with **diarrhea**, not constipation. The tumor secretes high levels of Calcitonin, prostaglandins, and serotonin, which increase intestinal motility and lead to secretory diarrhea. This is a classic paraneoplastic feature of the disease. **Analysis of other options:** * **Option A:** MCT originates from the **ultimobranchial body** (parafollicular C-cells), which are neural crest in origin. This distinguishes it from papillary and follicular cancers, which arise from follicular cells. * **Option B:** A hallmark histological feature of MCT is the presence of **amyloid stroma**. This amyloid is formed by the deposition of pro-calcitonin molecules and stains positive with **Congo Red** (showing apple-green birefringence). * **Option C:** Approximately **20-25%** of MCT cases are familial, occurring as part of **MEN 2A, MEN 2B**, or Familial MCT (FMCT). These are associated with the **RET proto-oncogene** mutation. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Calcitonin (used for diagnosis and monitoring recurrence) and CEA. * **Genetics:** All patients with MCT must be screened for **RET mutations** and **Pheochromocytoma** (before thyroid surgery). * **Staining:** Positive for Calcitonin, Chromogranin, and Synaptophysin. * **Spread:** MCT spreads via both lymphatic and hematogenous routes. * **Treatment:** Total thyroidectomy with central compartment neck dissection is the standard of care. It is **not** sensitive to Radioiodine (I-131) therapy.

Q: A patient with multinodular goiter developed pain and difficulty in breathing. Which of the following types of thyroid carcinoma is most likely to cause this complication?

Anaplastic carcinoma. **Explanation:** The clinical presentation of a long-standing multinodular goiter (MNG) suddenly developing **pain, rapid enlargement, and obstructive symptoms** (dyspnea, dysphagia, or hoarseness) is a classic hallmark of **Anaplastic Thyroid Carcinoma (ATC)**. **1. Why Anaplastic Carcinoma is correct:** ATC is one of the most aggressive solid tumors in humans. It often arises from a pre-existing differentiated thyroid cancer or a long-standing MNG in elderly patients. Its hallmark is **rapid local invasion** into surrounding structures like the trachea (causing breathing difficulty), esophagus (dysphagia), and recurrent laryngeal nerve (hoarseness). The rapid growth stretches the thyroid capsule, leading to significant pain. **2. Why the other options are incorrect:** * **Papillary Carcinoma (B):** The most common thyroid cancer; it is typically slow-growing, painless, and spreads via lymphatics. It rarely causes acute respiratory distress unless in very advanced, neglected stages. * **Follicular Carcinoma (C):** Usually presents as a solitary "cold" nodule. It spreads hematogenously (to bones and lungs) and rarely causes acute local pressure symptoms or pain. * **Medullary Carcinoma (A):** Arises from parafollicular C-cells. While it can be aggressive, it does not typically show the explosive growth or acute painful presentation characteristic of ATC. **Clinical Pearls for NEET-PG:** * **Age Group:** ATC typically affects the elderly (6th–7th decade). * **Diagnosis:** Often requires **Core Needle Biopsy** or Incisional Biopsy because FNAC may only show necrosis or be inconclusive. * **Histology:** Shows spindle cells, giant cells, and pleomorphic cells. * **Prognosis:** Extremely poor; treatment is often palliative (tracheostomy for airway) as most cases are unresectable at presentation.

Q: What is the stage of an adrenocortical carcinoma measuring 6cm without invasion of surrounding structures?

Stage II Adrenocortical carcinoma. The staging of Adrenocortical Carcinoma (ACC) primarily follows the **ENSAT (European Network for the Study of Adrenal Tumors)** classification, which is the gold standard for NEET-PG. ### **Explanation of the Correct Answer** **Stage II** is defined as a tumor measuring **>5 cm** in its greatest dimension, which is confined to the adrenal gland (no invasion of surrounding fat or organs) and has no lymph node or distant metastasis (T2 N0 M0). Since the question specifies a **6 cm** tumor without invasion, it fits the criteria for Stage II. ### **Analysis of Incorrect Options** * **Stage I:** This stage is reserved for tumors measuring **≤5 cm** that are confined to the adrenal gland (T1 N0 M0). * **Stage III:** This stage involves local invasion into surrounding adipose tissue, adjacent organs (like the kidney or liver), or the presence of positive regional lymph nodes (T3/T4 or N1). * **Stage IV:** This stage is characterized by the presence of distant metastasis (M1), regardless of the tumor size or local invasion. ### **High-Yield Clinical Pearls for NEET-PG** * **ENSAT vs. AJCC:** ENSAT is preferred over AJCC because it better correlates with prognosis, particularly in distinguishing Stage III and IV. * **Imaging:** CT scan showing high unenhanced attenuation (>10 HU) and slow contrast washout is suspicious for ACC. * **Biopsy Contraindication:** Never perform a fine-needle aspiration (FNA) if ACC is suspected, as it carries a high risk of **capsular track seeding**. * **Treatment:** Radical surgical resection (R0) is the only curative treatment. **Mitotane** is the standard adjuvant therapy for high-risk patients.

Q: In which of the following is medullary thyroid cancer considered the most aggressive form?

Multiple endocrine neoplasia type IIb (MEN IIb). **Explanation:** Medullary Thyroid Cancer (MTC) arises from the parafollicular C-cells and is a hallmark of Multiple Endocrine Neoplasia (MEN) type 2 syndromes. The aggressiveness of MTC is directly linked to the specific germline mutation of the **RET proto-oncogene**. **Why MEN IIb is the correct answer:** MEN IIb is characterized by the **M918T mutation** in exon 16 of the RET gene. This specific mutation leads to the most aggressive biological behavior of MTC. In MEN IIb, MTC presents at a very young age (often in infancy), has a 100% penetrance, and metastasizes much earlier than in other forms. Due to this extreme virulence, prophylactic thyroidectomy is recommended within the **first year of life**. **Analysis of Incorrect Options:** * **MEN I (Wermer Syndrome):** This syndrome involves the "3 Ps" (Pituitary, Parathyroid, and Pancreas). It is **not** associated with Medullary Thyroid Cancer. * **MEN IIa (Sipple Syndrome):** While MTC is the most common feature of MEN IIa, it typically presents in the 2nd or 3rd decade of life and is less aggressive than the IIb variant. Prophylactic thyroidectomy is usually recommended by age 5. * **Sporadic Cases:** About 75% of MTC cases are sporadic. These generally present later in life (4th–6th decade) and are typically less aggressive than the syndromic MEN IIb variety. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **Calcitonin** is used for diagnosis and monitoring recurrence; **CEA** is a secondary marker. * **MEN IIb Phenotype:** Look for "Marfanoid habitus," mucosal neuromas (tongue/lips), and ganglioneuromatosis of the GI tract. * **Rule of Priority:** In any MEN 2 case, always exclude or treat **Pheochromocytoma** before performing thyroid surgery to prevent a hypertensive crisis. * **Staining:** MTC shows **Apple-green birefringence** under polarized light with Congo red stain due to amyloid deposition.

Q: A 50-year-old male presents with severe dyspnea following thyroid surgery. What is the treatment of choice?

Open the operative site. **Explanation:** The most common cause of acute respiratory distress immediately following thyroid surgery is a **tension hematoma** (post-operative hemorrhage). This occurs due to arterial bleeding (often from the superior thyroid artery) deep to the strap muscles. The accumulation of blood creates pressure that causes venous and lymphatic obstruction, leading to laryngeal edema and compression of the trachea. **Why "Open the operative site" is correct:** This is a surgical emergency. The immediate priority is to **decompress the neck** by opening the surgical incision and the underlying strap muscles at the bedside. This relieves the pressure on the airway, restores venous drainage, and allows the patient to breathe while being prepared for a formal re-exploration in the operating room to achieve definitive hemostasis. **Why other options are incorrect:** * **Tracheostomy:** This is a time-consuming procedure and technically difficult in a neck distorted by a large hematoma. It is not the first-line treatment for acute post-thyroidectomy airway obstruction. * **Cricothyroidotomy:** While an emergency airway procedure, it does not address the underlying cause (compression). Decompressing the hematoma is faster and more effective in this specific scenario. * **Wait and watch:** This is contraindicated as the condition can rapidly progress to total airway occlusion and cardiac arrest. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of post-op dyspnea (0-2 hours):** Tension hematoma. * **Most common cause of post-op dyspnea (after 24 hours):** Hypocalcemia (causing laryngospasm) or bilateral Recurrent Laryngeal Nerve (RLN) injury. * **Management Priority:** Always **Decompress first, Intubate second.** Do not wait for an anesthesiologist or transfer to the OR to open the wound if the patient is in distress.

Q: Which is the least common type of thyroid malignancy?

Anaplastic. **Explanation:** The frequency of thyroid malignancies follows a specific hierarchy based on their cellular origin and differentiation. **Anaplastic thyroid carcinoma (ATC)** is the correct answer as it is the rarest form, accounting for only **1–2%** of all thyroid cancers. It is an undifferentiated tumor, typically presenting in elderly patients as a rapidly enlarging neck mass with early local invasion and a very poor prognosis. **Analysis of Options:** * **A. Papillary (80–85%):** This is the **most common** type of thyroid malignancy. It is associated with radiation exposure and has the best prognosis. Characteristic features include Psammoma bodies and Orphan Annie eye nuclei. * **B. Follicular (10–15%):** The second most common type. It is characterized by hematogenous spread (unlike papillary, which spreads via lymphatics) and requires histological evidence of capsular or vascular invasion for diagnosis. * **C. Medullary (5%):** Arises from the parafollicular C-cells and secretes Calcitonin. It can be sporadic or associated with MEN 2A/2B syndromes. While less common than Papillary or Follicular, it is still more frequent than Anaplastic. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common overall:** Papillary Carcinoma. * **Least Common / Worst Prognosis:** Anaplastic Carcinoma. * **Most Common in Iodine-Deficient areas:** Follicular Carcinoma. * **Tumor Marker for Medullary:** Calcitonin (used for diagnosis and follow-up). * **Diagnosis:** FNAC can diagnose Papillary, Medullary, and Anaplastic, but **cannot** distinguish between Follicular Adenoma and Carcinoma (requires biopsy).

Q: A young girl presented with swelling in the neck which moves on deglutition. She complains of dyspnea and venous engorgement in the face. The clinician performed a test, and the name of this sign is:

Pemberton sign. ### Explanation **1. Why Pemberton Sign is Correct:** The clinical presentation describes a **Retrosternal Goiter**. When a large goiter extends into the superior mediastinum, it can cause a "thoracic inlet syndrome." The **Pemberton sign** is elicited by asking the patient to raise both arms above the head until they touch the sides of the face for 30–60 seconds. * **Mechanism:** This maneuver further narrows the thoracic inlet, causing the goiter to compress the internal jugular and subclavian veins against the clavicles/ribs. * **Clinical Findings:** Facial congestion, cyanosis, respiratory distress (stridor), and prominent neck veins. This confirms the presence of obstructive retrosternal extension. **2. Why the Other Options are Incorrect:** * **Lahey Test:** This is a physical examination technique used to palpate the thyroid gland. The clinician pushes the trachea to one side to make the contralateral lobe more prominent and easier to palpate. * **Crile Test:** Similar to the Lahey test, this involves palpating the thyroid gland by placing the thumb over the thyroid cartilage and asking the patient to swallow to feel for nodules or enlargement. * **Gifford Test:** This is an ocular sign seen in **Graves' ophthalmopathy**, characterized by difficulty in everting the upper eyelid. **3. High-Yield Clinical Pearls for NEET-PG:** * **Retrosternal Goiter Definition:** A goiter where >50% of the mass is below the thoracic inlet. * **Most Common Symptom:** Dyspnea (due to tracheal compression). * **Imaging of Choice:** CT scan (without contrast is preferred if radioactive iodine therapy is planned) to assess the extent of mediastinal involvement. * **Treatment:** Most retrosternal goiters can be removed via a standard cervical incision; a sternotomy is required in less than 5% of cases.

Question 1

Which of the following is NOT a feature of medullary carcinoma of the thyroid?

Accepted Answer

Constipation occurs

Answer

Arises from parafollicular cells

Answer

Amyloid infiltrate is present on histology

Answer

10-25% of cases are familial

Question 2

A patient with multinodular goiter developed pain and difficulty in breathing. Which of the following types of thyroid carcinoma is most likely to cause this complication?

Accepted Answer

Anaplastic carcinoma

Answer

Medullary carcinoma

Answer

Papillary carcinoma

Answer

Follicular carcinoma

Question 3

What is the approximate amount of thyroid tissue typically left on each side after a subtotal thyroidectomy?

Accepted Answer

4 grams on each side

Answer

4 grams on one side

Answer

6 grams on one side

Answer

6 grams on each side

Question 4

What is the stage of an adrenocortical carcinoma measuring 6cm without invasion of surrounding structures?

Accepted Answer

Stage II Adrenocortical carcinoma

Answer

Stage I Adrenocortical carcinoma

Answer

Stage III Adrenocortical carcinoma

Answer

Stage IV Adrenocortical carcinoma

Question 5

Which of the following statements about a solitary thyroid nodule are TRUE?

Accepted Answer

1, 2, and 3 are false, while 4 and 5 are true.

Answer

1, 2, and 3 are true, while 4 and 5 are false.

Answer

1, 3, and 5 are true, while 2 and 4 are false.

Answer

None of the statements are true.

Question 6

In which of the following is medullary thyroid cancer considered the most aggressive form?

Accepted Answer

Multiple endocrine neoplasia type IIb (MEN IIb)

Answer

Multiple endocrine neoplasia type I (MEN I)

Answer

Multiple endocrine neoplasia type IIa (MEN IIa)

Answer

Sporadic cases

Question 7

A 50-year-old male presents with severe dyspnea following thyroid surgery. What is the treatment of choice?

Accepted Answer

Open the operative site

Answer

Tracheostomy

Answer

Wait and watch

Answer

Cricothyroidotomy

Question 8

Which is the least common type of thyroid malignancy?

Accepted Answer

Anaplastic

Answer

Papillary

Answer

Follicular

Answer

Medullary

Question 9

Which of the following treatment modalities for papillary carcinoma is obsolete nowadays?

Accepted Answer

Berry picking of involved lymph nodes

Answer

Near total thyroidectomy

Answer

Modified radical neck dissection

Answer

Suppressive lifelong dose of L-thyroxine

Question 10

A young girl presented with swelling in the neck which moves on deglutition. She complains of dyspnea and venous engorgement in the face. The clinician performed a test, and the name of this sign is:

Accepted Answer

Pemberton sign

Answer

Lahey test

Answer

Crile test

Answer

Gifford test

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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