Endocrine Surgery Practice Questions

Q: In the early postoperative period after excision of a pheochromocytoma, which complication is least likely?

Hypertension. **Explanation:** The primary hemodynamic challenge in the early postoperative period following pheochromocytoma excision is **hypotension**, not hypertension. Once the tumor is removed, the sudden withdrawal of high levels of circulating catecholamines, combined with a chronically constricted vascular bed and potential down-regulation of adrenoceptors, leads to profound vasodilation and a drop in blood pressure. Therefore, **Hypertension (Option B)** is the least likely complication. * **Infection (Option A):** Like any major abdominal or retroperitoneal surgery, surgical site infections (SSI) are a standard postoperative risk. * **Atelectasis (Option C):** This is the most common respiratory complication in the first 24–48 hours post-surgery, especially in procedures involving upper abdominal incisions or prolonged anesthesia. * **Bleeding (Option D):** The adrenal glands are highly vascular, and the proximity to major vessels (IVC on the right, renal vein on the left) makes postoperative hemorrhage a recognized risk. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Pheochromocytoma:** Episodic headache, sweating, and tachycardia. * **Pre-operative Preparation:** Always start **Alpha-blockers first** (e.g., Phenoxybenzamine) for 10–14 days, followed by Beta-blockers. Starting Beta-blockers first can cause an unopposed alpha-agonistic effect, leading to a hypertensive crisis. * **Post-op Hypoglycemia:** Removal of the tumor eliminates catecholamine-induced inhibition of insulin; patients must be monitored for rebound hyperinsulinemia and hypoglycemia. * **Fluid Management:** Aggressive volume expansion is required post-excision to counteract the expanded vascular space.

Q: Regarding follicular carcinoma of the thyroid, which of the following statements is true?

It spreads primarily through the hematogenous route.. **Explanation:** **1. Why Option C is Correct:** Follicular Thyroid Carcinoma (FTC) is characterized by its tendency for **hematogenous (blood-borne) spread**. Unlike Papillary Thyroid Carcinoma (PTC), which spreads via lymphatics, FTC cells invade blood vessels. This leads to distant metastases, most commonly to the **lungs and bones** (often presenting as osteolytic, pulsating bone lesions). **2. Why the Other Options are Incorrect:** * **Option A:** **Papillary Carcinoma** is the most common type of thyroid cancer (approx. 80-85%), whereas Follicular Carcinoma is the second most common (approx. 10-15%). * **Option B:** FTC is **not** readily diagnosed by Fine Needle Aspiration Cytology (FNAC). FNAC cannot distinguish between a benign follicular adenoma and a follicular carcinoma because the diagnosis of malignancy depends on identifying **capsular or vascular invasion**, which requires histological examination of the entire nodule. * **Option D:** FTC is typically a **solitary lesion**. Multifocality is a hallmark feature of Papillary Thyroid Carcinoma, not Follicular Carcinoma. **3. NEET-PG High-Yield Pearls:** * **Hürthle Cell Carcinoma:** A variant of FTC; it is less likely to take up iodine and has a higher rate of lymph node metastasis compared to typical FTC. * **Risk Factor:** FTC is more common in areas of **iodine deficiency** (endemic goiter belts). * **Tumor Marker:** **Thyroglobulin** is used to monitor for recurrence post-total thyroidectomy. * **Management:** Total thyroidectomy followed by Radioactive Iodine (RAI) ablation is the standard for tumors >1 cm or those with vascular invasion.

Q: Lymphatic spread is most commonly seen with which type of thyroid cancer?

Papillary. **Explanation:** **Papillary Thyroid Carcinoma (PTC)** is the most common type of thyroid malignancy and is characterized by its propensity for **lymphatic spread**. Approximately 50–70% of patients have cervical lymph node involvement at the time of diagnosis. This occurs because PTC cells typically invade the rich lymphatic network of the thyroid gland rather than the blood vessels. **Analysis of Options:** * **Papillary (Correct):** It is the most common thyroid cancer and spreads primarily via lymphatics to the central (Level VI) and lateral neck nodes. * **Follicular:** This cancer is known for **hematogenous spread** (via the bloodstream). It tends to metastasize to distant sites like the lungs and bones because the tumor cells typically invade blood vessels rather than lymphatics. * **Medullary:** While MTC can spread to lymph nodes (often early), it is less common overall than Papillary. It is also associated with calcitonin secretion and MEN 2 syndromes. * **Lymphoma:** While it involves the lymphatic system, it is a primary malignancy of the lymphoid tissue itself, not a thyroid epithelial cancer that "spreads" via lymphatics in the same clinical context as PTC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common thyroid cancer:** Papillary (85%). * **Psammoma bodies:** Characteristic microscopic finding in Papillary carcinoma. * **Orphan Annie eye nuclei:** Classic nuclear feature of Papillary carcinoma. * **Prognosis:** Papillary has an excellent prognosis, while Anaplastic has the worst. * **Route of spread:** Papillary = Lymphatic; Follicular = Hematogenous.

Q: Which vessels supply a secondary retrosternal goitre?

Thyroid vessels. **Explanation:** The classification and surgical management of retrosternal goitres depend heavily on their embryological origin and blood supply. **1. Why Thyroid Vessels are Correct:** A **secondary retrosternal goitre** (the most common type, accounting for >95% of cases) originates in the neck from the thyroid gland. Due to negative intrathoracic pressure, gravity, and the constraints of the pretracheal fascia, the enlarging thyroid gland is "pushed" or "sucked" down into the superior mediastinum. Because it originates in the neck, it **retains its original blood supply** from the **superior and inferior thyroid arteries**. This is a critical surgical fact: most secondary goitres can be delivered through a standard cervical incision because their vascular pedicle is accessible from the neck. **2. Why Other Options are Incorrect:** * **Mediastinal vessels:** These supply **primary** retrosternal goitres (ectopic thyroid tissue), which are rare (<1%) and located entirely in the chest without a connection to the cervical thyroid. * **Arch of aorta & Bronchial vessels:** These do not provide the primary blood supply to thyroid tissue. While the *Thyroidea ima* artery (an anatomical variant) can arise from the aortic arch or brachiocephalic trunk, it is not the standard supply for a secondary goitre. **Clinical Pearls for NEET-PG:** * **Primary vs. Secondary:** Primary goitres are ectopic and supplied by intrathoracic vessels; Secondary goitres are migrations and supplied by cervical vessels. * **Surgical Approach:** Most secondary goitres can be removed via a **cervical incision**. A sternotomy is rarely required (<5%) unless the goitre is primary, malignant, or larger than the thoracic inlet. * **Definition:** A goitre is typically defined as retrosternal if more than 50% of its volume lies below the plane of the thoracic inlet.

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

Papillary. **Explanation:** Thyroid carcinomas are classified based on their histological origin. **Papillary Thyroid Carcinoma (PTC)** is the most common type, accounting for approximately **80–85%** of all thyroid malignancies. It typically presents as a slow-growing, painless thyroid nodule and has an excellent prognosis. It is associated with radiation exposure and specific genetic mutations like **BRAF** and **RET/PTC** rearrangements. **Analysis of Options:** * **A. Papillary (Correct):** It is the most frequent thyroid cancer. Key histological features include **Orphan Annie eye nuclei** (clear nuclei), **Psammoma bodies** (calcifications), and nuclear grooves. It spreads primarily via the **lymphatics**. * **B. Follicular:** The second most common type (approx. 10%). Unlike PTC, it spreads **hematogenously** (to lungs/bones) and is more common in iodine-deficient areas. * **C. Medullary:** Accounts for about 5% of cases. It arises from **Parafollicular C-cells** and secretes **Calcitonin**. It can be sporadic or part of MEN 2A/2B syndromes. * **D. Anaplastic:** Rare (<2%) but highly aggressive. It has the worst prognosis among thyroid cancers, often presenting in elderly patients with rapid local invasion. **High-Yield Clinical Pearls for NEET-PG:** * **Most common thyroid cancer:** Papillary. * **Most common thyroid cancer in children:** Papillary. * **Most common thyroid cancer post-radiation:** Papillary. * **Route of spread:** Papillary = Lymphatic; Follicular = Hematogenous. * **Diagnosis:** FNAC can diagnose Papillary, Medullary, and Anaplastic, but **cannot** distinguish between Follicular Adenoma and Carcinoma (requires biopsy to see capsular/vascular invasion).

Q: Which metastatic sites are most common to the thyroid gland?

Lung. **Explanation:** Metastasis to the thyroid gland is an infrequent clinical finding but is increasingly identified in autopsy series. Among non-thyroidal primary malignancies, the **Lung** is the most common site of origin for thyroid metastases, followed closely by the kidney (Renal Cell Carcinoma) and the breast. * **Lung (Correct):** Large-scale autopsy studies consistently identify lung cancer as the most frequent primary source. This is attributed to the high incidence of lung cancer and its propensity for hematogenous spread. In clinical practice (symptomatic patients), Renal Cell Carcinoma is often the most common, but for the NEET-PG context, Lung is the established answer for overall frequency. * **Breast:** While breast cancer is a common source of metastasis to various organs, it typically ranks second or third behind lung and kidney in its frequency of spread to the thyroid. * **Brain:** Primary brain tumors rarely metastasize outside the central nervous system. Conversely, the thyroid frequently metastasizes *to* the brain (especially papillary and follicular types), but the reverse is not true. * **Gastrointestinal Tract:** While cancers of the colon or stomach can metastasize to the thyroid, they are significantly less common than thoracic or renal primaries. **High-Yield Clinical Pearls for NEET-PG:** * **Most common clinical presentation:** A rapidly enlarging, firm, painless thyroid mass in a patient with a known history of malignancy. * **Renal Cell Carcinoma (RCC):** Often presents with the longest latency period (metastasis may appear years after the primary tumor is treated). * **Diagnosis:** Fine Needle Aspiration Cytology (FNAC) is the gold standard, often requiring immunohistochemistry (IHC) to differentiate from primary thyroid medullary or anaplastic carcinoma. * **Prognosis:** Generally poor, as thyroid involvement usually signifies disseminated systemic disease.

Question 1

In the early postoperative period after excision of a pheochromocytoma, which complication is least likely?

Accepted Answer

Hypertension

Answer

Infection

Answer

Atelectasis

Answer

Bleeding

Question 2

Regarding follicular carcinoma of the thyroid, which of the following statements is true?

Accepted Answer

It spreads primarily through the hematogenous route.

Answer

It is the most common type of thyroid cancer.

Answer

It is readily diagnosed.

Answer

It is commonly multifocal.

Question 3

Lymphatic spread is most commonly seen with which type of thyroid cancer?

Accepted Answer

Papillary

Answer

Medullary

Answer

Follicular

Answer

Lymphoma

Question 4

All of the following are associated with Thyroid storm, EXCEPT:

Accepted Answer

Surgery for thyroiditis

Answer

Surgery for thyrotoxicosis

Answer

Stressful illness in thyrotoxicosis

Answer

I-131 therapy for thyrotoxicosis

Question 5

What is the preferred approach for a retrosternal goitre?

Accepted Answer

Transcervical approach

Answer

Transthoracic approach at the 2nd intercostal space

Answer

Transthoracic approach at the 4th intercostal space

Answer

Transsternal approach to the anterior mediastinum

Question 6

Which vessels supply a secondary retrosternal goitre?

Accepted Answer

Thyroid vessels

Answer

Mediastinal vessels

Answer

Arch of aorta

Answer

Bronchial vessels

Question 7

Thyroid storm is characterized by which of the following?

Accepted Answer

All of the above.

Answer

It is common in inadequately prepared patients for surgery and is accompanied by excess release of thyroid hormone.

Answer

Tachycardia, hyperpyrexia, dehydration, and hyperexcitability are seen.

Answer

It is a condition of hyperthyroidism accompanied by fever, CNS agitation, or depression.

Question 8

What is the most common type of thyroid carcinoma?

Accepted Answer

Papillary

Answer

Follicular

Answer

Medullary

Answer

Anaplastic

Question 9

Which metastatic sites are most common to the thyroid gland?

Accepted Answer

Lung

Answer

Breast

Answer

Brain

Answer

Gastrointestinal tract

Question 10

Thyroid storm after operation is due to?

Accepted Answer

Inadequate control of hyperthyroidism

Answer

Massive bleeding

Answer

Recurrent laryngeal nerve injury

Answer

Postoperative infection

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?