Endocrine Surgery Practice Questions

Q: The specimen shown below is:

MNG (Multinodular goiter). ***MNG (Multinodular goiter)*** - The specimen shows **multiple nodules** of varying sizes with **irregular cut surface** containing both **solid and cystic areas** with **colloid-filled spaces**. - Characteristic **heterogeneous appearance** with **fibrotic bands** separating nodules and absence of a **single dominant encapsulated mass**. *SNT (Solitary nodule thyroid)* - Would present as a **single well-defined nodule** within otherwise normal thyroid tissue, not multiple nodules. - The **cut surface** would show **uniform appearance** of a solitary mass, contrasting with the multinodular pattern seen here. *Adenoma thyroid* - Appears as a **single encapsulated nodule** with a **smooth, uniform cut surface** and **complete fibrous capsule**. - Lacks the **multiple nodules** and **heterogeneous appearance** characteristic of this specimen. *TG cyst (Thyroid cyst)* - Would show a **single cystic cavity** filled with **clear or hemorrhagic fluid** without solid nodular components. - Lacks the **multiple solid nodules** and **varied architectural pattern** evident in this multinodular specimen.

Q: What is tense and painful thyroiditis?

De Quervain thyroiditis. **Explanation:** The correct answer is **De Quervain thyroiditis (Subacute Granulomatous Thyroiditis)**. **Why it is correct:** De Quervain thyroiditis is classically characterized by a **painful, tender, and firm (tense)** thyroid gland. It is typically a post-viral inflammatory condition. The pain is often severe, localized to the anterior neck, and may radiate to the jaw or ears. On histology, it is characterized by **multinucleated giant cells** and granulomatous inflammation. Patients often present with an elevated ESR and a low radioactive iodine uptake (RAIU) due to follicular destruction. **Why the other options are incorrect:** * **Riedel thyroiditis:** Known as "woody" or "iron-hard" thyroiditis due to dense fibrous tissue replacement. While the gland is very hard and fixed, it is typically **painless**. * **Hashimoto thyroiditis:** The most common cause of hypothyroidism. It presents as a diffuse, rubbery, **painless** goiter. It is an autoimmune destruction mediated by antithyroid peroxidase (TPO) antibodies. * **Subacute lymphocytic thyroiditis:** Also known as "painless thyroiditis" or "silent thyroiditis." It often occurs postpartum and, as the name suggests, lacks the tenderness seen in De Quervain’s. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of De Quervain:** Painful neck swelling + Elevated ESR + Low Iodine Uptake. * **Treatment:** NSAIDs are the first-line treatment for pain; oral corticosteroids are used for refractory or severe cases. * **Biphasic Course:** It often starts with a transient hyperthyroid phase (leakage of preformed hormone) followed by a hypothyroid phase before returning to euthyroidism. * **Key Histology:** "Granulomas with Giant Cells" is the pathognomonic buzzword.

Q: Which of the following carcinomas shows a good response to radioiodine?

Follicular carcinoma. **Explanation:** The effectiveness of **Radioactive Iodine (RAI/I-131) therapy** depends on the expression of the **Sodium-Iodide Symporter (NIS)** and the degree of cellular differentiation. **Why Follicular Carcinoma (FTC) is the correct answer:** Follicular carcinoma is a well-differentiated thyroid cancer that retains the functional machinery of normal follicular cells. It has a high affinity for iodine uptake, often even more consistently than papillary carcinoma in metastatic settings. Because FTC tends to spread **hematogenously** (to lungs and bone), RAI is the mainstay for treating distant metastases, showing an excellent therapeutic response. **Analysis of Incorrect Options:** * **A. Papillary Carcinoma (PTC):** While PTC is also well-differentiated and responds to RAI, it primarily spreads via **lymphatics**. In a comparative context for NEET-PG, FTC is often highlighted for its superior reliance on RAI for managing systemic spread. However, both are "RAI-responsive." * **C. Anaplastic Carcinoma:** This is an undifferentiated tumor. It loses all functional characteristics of thyroid tissue, including the NIS protein, making it completely **resistant** to radioiodine. * **D. Medullary Carcinoma (MTC):** MTC arises from **Parafollicular C-cells**, which do not concentrate iodine. Therefore, RAI has no role in its management. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite for RAI:** Patients must have high TSH levels (>30 mIU/L) or receive recombinant TSH to maximize iodine uptake before therapy. * **Diagnostic vs. Therapeutic:** I-123 is preferred for imaging (diagnostic), while **I-131** is used for ablation (therapeutic) due to its high-energy beta-particle emission. * **Marker of Recurrence:** After total thyroidectomy and RAI ablation, **Serum Thyroglobulin** serves as the primary tumor marker for PTC and FTC.

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.

Q: Which of the following statements regarding follicular cell carcinoma of the thyroid is true?

Hematogenous spread. **Follicular Thyroid Carcinoma (FTC)** is the second most common thyroid malignancy. Understanding its unique pathological behavior is crucial for NEET-PG. ### **Explanation of the Correct Option** * **A. Hematogenous spread:** Unlike Papillary Thyroid Carcinoma (PTC), which primarily spreads via the lymphatic system, FTC characteristically spreads via the **bloodstream (hematogenous)**. This occurs because the tumor cells invade thin-walled blood vessels. Consequently, distant metastases to the **lungs and bones** (often osteolytic) are more common than regional lymph node involvement. ### **Why the Other Options are Incorrect** * **B. Commonly multifocal:** FTC is typically a **solitary, encapsulated lesion**. Multifocality is a hallmark of Papillary Thyroid Carcinoma (PTC). * **C. Readily diagnosed by FNAC:** This is a classic "trap" question. FNAC **cannot** distinguish between a benign Follicular Adenoma and a malignant Follicular Carcinoma. Both show follicular cells on cytology. The diagnosis of malignancy requires histological evidence of **capsular or vascular invasion**, which can only be seen on a formal biopsy/resection. * **D. Most common carcinoma:** **Papillary Thyroid Carcinoma (PTC)** is the most common thyroid cancer (approx. 80-85%), whereas FTC accounts for about 10-15%. ### **High-Yield Clinical Pearls for NEET-PG** * **Risk Factor:** More common in **iodine-deficient** areas (unlike PTC, which is associated with radiation and iodine excess). * **Hürthle Cell Carcinoma:** A variant of FTC; it is more aggressive, less likely to take up radioactive iodine, and more likely to spread to lymph nodes. * **Molecular Marker:** Often associated with **RAS mutations** or **PAX8-PPARγ rearrangements**. * **Treatment:** Total thyroidectomy followed by Radioactive Iodine (RAI) ablation, as FTC cells usually retain the ability to concentrate iodine.

Q: What is the treatment for a brown tumor?

Parathyroidectomy. **Explanation:** A **Brown tumor** (osteitis fibrosa cystica) is not a true neoplasm but a reactive bone lesion caused by **Primary Hyperparathyroidism (PHPT)**. The underlying pathophysiology involves excessive secretion of Parathyroid Hormone (PTH), which stimulates osteoclastic activity. This leads to bone resorption and the replacement of marrow with vascular fibrous tissue and giant cells. The "brown" color is due to hemosiderin deposition from micro-hemorrhages. **Why Parathyroidectomy is the correct answer:** The definitive treatment for a brown tumor is addressing the source of excess PTH. Once the offending parathyroid adenoma or hyperplasia is surgically removed (**Parathyroidectomy**), PTH levels normalize, and the brown tumor typically undergoes spontaneous regression and mineralization over several months. **Why other options are incorrect:** * **A & B (Curettage/Surgical enucleation):** These are local treatments for true bone tumors (like Giant Cell Tumors). In the case of a brown tumor, local surgery is unnecessary and carries a risk of recurrence if the systemic hyperparathyroidism is not corrected. * **C (Intralesional steroids):** These are sometimes used for aneurysmal bone cysts or giant cell granulomas but have no role in treating the metabolic bone disease of hyperparathyroidism. **NEET-PG High-Yield Pearls:** * **Radiological Hallmark:** Subperiosteal bone resorption, most commonly seen on the **radial aspect of the middle phalanges**. * **Skull finding:** "Salt and pepper" appearance. * **Biochemical profile:** Elevated Serum Calcium, Elevated PTH, and Low Serum Phosphate. * **Differential Diagnosis:** Histologically, brown tumors are indistinguishable from **Giant Cell Tumors (GCT)**; always check serum calcium/PTH to differentiate.

Q: All are true about the effect of thymectomy, EXCEPT:

Hypogammaglobulinemia usually responds to thymectomy.. ### Explanation **1. Why Option B is the Correct Answer (The Exception):** Hypogammaglobulinemia associated with a thymoma is known as **Good’s Syndrome**. This is a rare paraneoplastic syndrome characterized by thymoma, low circulating B-cells, and hypogammaglobulinemia. Unlike Myasthenia Gravis (MG), the immune deficiency in Good’s Syndrome is **not reversed by thymectomy**. Patients remain at high risk for recurrent infections and usually require lifelong intravenous immunoglobulin (IVIG) replacement. **2. Analysis of Other Options:** * **Option A:** Pure Red Cell Aplasia (PRCA) is associated with thymoma in about 5% of cases. Surgical removal of the thymus leads to hematologic remission in approximately **30-50%** of these patients. * **Option C:** This is a classic high-yield statistic. Approximately **10-15% of patients with MG** have an underlying thymoma. Conversely, about 30-45% of patients with a thymoma will have MG. * **Option D:** While thymectomy is more urgently indicated in thymoma (due to malignant potential), the **neuromuscular course of MG** (severity of weakness and response to medical therapy) does not differ significantly between those with a thymoma and those with non-thymomatous lymphoid hyperplasia. **3. Clinical Pearls for NEET-PG:** * **Most common mediastinal tumor:** Thymoma (specifically in the anterior mediastinum). * **Indications for Thymectomy in MG:** All patients with thymoma; and patients without thymoma who are between puberty and age 60 with generalized symptoms. * **Good’s Syndrome Triad:** Thymoma + Hypogammaglobulinemia + Low B-cells (Thymectomy does *not* help the B-cell count). * **Post-operative care:** Patients with MG are at risk of "Myasthenic Crisis" post-surgery; plasmapheresis is often used pre-operatively to optimize respiratory status.

Question 1

What is the standard incision used in thyroidectomy?

Accepted Answer

Collar incision

Answer

Barking incision

Answer

Kocher incision

Answer

Koebner incision

Question 2

The specimen shown below is:

Accepted Answer

MNG (Multinodular goiter)

Answer

SNT (Solitary nodule thyroid)

Answer

Adenoma thyroid

Answer

TG cyst (Thyroid cyst)

Question 3

What is tense and painful thyroiditis?

Accepted Answer

De Quervain thyroiditis

Answer

Riedel thyroiditis

Answer

Hashimoto thyroiditis

Answer

Subacute lymphocytic thyroiditis

Question 4

Which of the following carcinomas shows a good response to radioiodine?

Accepted Answer

Follicular carcinoma

Answer

Papillary carcinoma

Answer

Anaplastic carcinoma

Answer

Medullary carcinoma

Question 5

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

Question 6

Which of the following statements regarding follicular cell carcinoma of the thyroid is true?

Accepted Answer

Hematogenous spread

Answer

Commonly multifocal

Answer

Readily diagnosed by FNAC

Answer

Most common carcinoma of the thyroid

Question 7

What is the recommended treatment for papillary carcinoma of the thyroid with lymph node metastasis at level VI?

Accepted Answer

Total thyroidectomy plus central neck dissection

Answer

Total thyroidectomy

Answer

Total thyroidectomy plus radioiodine ablation

Answer

Total thyroidectomy plus radical neck dissection

Question 8

What is the treatment for a brown tumor?

Accepted Answer

Parathyroidectomy

Answer

Curettage

Answer

Surgical enucleation

Answer

Intralesional steroids

Question 9

During bilateral adrenalectomy, what is the appropriate timing for the intra-operative dose of hydrocortisone?

Accepted Answer

Excision of both adrenal glands

Answer

Opening the abdomen

Answer

Ligation of the left adrenal vein

Answer

Ligation of the right adrenal vein

Question 10

All are true about the effect of thymectomy, EXCEPT:

Accepted Answer

Hypogammaglobulinemia usually responds to thymectomy.

Answer

Thymectomy results in the resolution of pure red cell aplasia in approximately 30% of patients.

Answer

Patients with myasthenia gravis have a thymoma in 10-15% of cases.

Answer

The course of myasthenia gravis is not significantly different in patients with or without thymoma.

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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