Endocrine Surgery Practice Questions

Q: A 50-year-old lady presents with a thyroid swelling diagnosed as papillary carcinoma. The mass measures 4 cm at its greatest diameter and invades strap muscles. Lymph node status is negative. What is the stage of the disease?

Stage I. ### **Explanation** The staging of **Differentiated Thyroid Carcinoma (DTC)**, which includes Papillary and Follicular types, is unique because it is heavily dependent on the **age of the patient** at the time of diagnosis. According to the **AJCC 8th Edition** TNM staging system: **1. Why Stage I is Correct:** For patients **younger than 55 years**, the staging is simplified into only two categories: * **Stage I:** Any T, Any N, **M0** (No distant metastasis). * **Stage II:** Any T, Any N, **M1** (Distant metastasis present). In this case, the patient is **50 years old** (under the 55-year cutoff). Although the tumor is 4 cm and invades strap muscles (T3b), and regardless of the lymph node status (N0), the absence of distant metastasis (M0) automatically classifies this as **Stage I**. **2. Why Other Options are Incorrect:** * **Stage II:** In patients <55 years, this is reserved only for cases with distant metastasis (e.g., lung or bone spread). In patients ≥55 years, Stage II involves T1/T2 with N1 or T3 tumors. * **Stage III & IV:** These stages **do not exist** for patients under the age of 55 in the AJCC 8th edition. They are only applicable to patients ≥55 years with advanced local invasion (T4) or distant metastasis. **3. NEET-PG High-Yield Pearls:** * **Age Cutoff:** The AJCC 8th edition increased the prognostic age cutoff from **45 to 55 years**. * **T3b Definition:** Invasion of **strap muscles only** (sternohyoid, sternothyroid, thyrohyoid, or omohyoid) is classified as T3b. * **Prognosis:** Papillary carcinoma has an excellent prognosis; patients <55 years have a near 0% 10-year mortality rate if they are M0. * **Anaplastic Carcinoma:** Always remember that Anaplastic thyroid cancer is considered **Stage IV** regardless of age or size at presentation.

Q: Which of the following is true regarding a solitary thyroid nodule?

Common in females. ### Explanation **Correct Option: D. Common in females** Solitary thyroid nodules (STN) are clinically common, and epidemiological studies consistently show a higher prevalence in women. The female-to-male ratio for thyroid nodules is approximately **4:1**. While nodules are more frequent in females, it is a high-yield clinical fact that a solitary nodule found in a **male** or at the extremes of age (very young or very old) carries a significantly higher risk of malignancy. **Analysis of Incorrect Options:** * **A. Thyroid-stimulating hormone receptor antibodies (TRAb):** These antibodies are the hallmark of **Graves' Disease**, which typically presents with diffuse toxic goiter rather than a solitary nodule. * **B. Lined by columnar epithelium:** This is a histological feature often associated with **Papillary Thyroid Carcinoma** (tall cell variant) or toxic goiters (hyperactive follicles), but it is not a defining characteristic of a solitary nodule itself, which can be a cyst, adenoma, or various types of carcinoma. * **C. Diffuse hyperplasia of the thyroid:** This describes a **Diffuse Goiter** (e.g., Graves' or physiological goiter). A solitary nodule is, by definition, a discrete swelling in an otherwise impalpable gland or a prominent nodule in a multinodular goiter. **Clinical Pearls for NEET-PG:** * **Initial Investigation of Choice:** Serum TSH. * **Gold Standard Investigation:** Fine Needle Aspiration Cytology (FNAC). * **Most Common Cause:** Colloid nodule/Dominant nodule of a Multinodular Goiter (MNG). * **Risk of Malignancy:** Approximately 5–15% of solitary nodules are malignant. * **Hot vs. Cold Nodules:** On radionuclide scanning, "Cold" nodules (non-functional) have a higher risk of malignancy compared to "Hot" (hyperfunctioning) nodules.

Q: Pemberton’s sign is elicited by which maneuver?

Raising of arms. **Explanation:** **Pemberton’s sign** is a clinical maneuver used to demonstrate latent **thoracic inlet obstruction**. It is most commonly seen in patients with a large retrosternal goiter, though it can also occur in cases of mediastinal tumors or superior vena cava (SVC) syndrome. **1. Why "Raising of arms" is correct:** The maneuver involves asking the patient to elevate both arms until they touch the sides of the face (Pemberton’s maneuver) and holding this position for 30–60 seconds. This action further narrows the thoracic inlet by pulling the clavicles and soft tissues upward. In the presence of a retrosternal mass, this "corks" the inlet, obstructing venous return. A **positive sign** is indicated by facial congestion, cyanosis, inspiratory stridor, or distended neck veins. **2. Why the other options are incorrect:** * **Swallowing:** This is used to assess the mobility of a thyroid swelling (thyroid moves upward with deglutition due to its attachment to the pretracheal fascia). * **Extrusion of tongue:** This is used to identify a **Thyroglossal cyst**, which moves upward upon tongue protrusion because it is connected to the hyoid bone/foramen caecum. * **Extension of neck:** While extension can make a cervical goiter more prominent, it is not the specific maneuver for Pemberton’s sign. **Clinical Pearls for NEET-PG:** * **Indication:** Retrosternal goiter is the #1 cause. * **Mechanism:** Venous congestion due to compression of the internal jugular and subclavian veins. * **Berry’s Sign:** Absence of carotid pulse due to encasement by thyroid malignancy (differentiates from benign goiter). * **Kocher’s Test:** Pushing on the lateral lobes of a goiter causing stridor (indicates tracheomalacia or compression).

Q: A patient operated for thyroid surgery for a thyroid swelling, later in the evening developed difficulty in breathing and swelling in the neck. What is the immediate management?

Open the wound sutures in the ward. ### Explanation **Correct Option: D. Open the wound sutures in the ward** The clinical presentation of respiratory distress and neck swelling immediately following thyroid surgery is a classic sign of a **tension hematoma**. This is a surgical emergency where bleeding (usually from a slipped ligature on the superior thyroid artery) accumulates deep to the investing layer of the deep cervical fascia. The pressure compresses the trachea and causes venous congestion, leading to laryngeal edema and rapid airway obstruction. The **immediate management** is to evacuate the hematoma to relieve the pressure. This must be done at the bedside (in the ward) by removing the skin sutures and opening the deep fascia. Waiting to transfer the patient to the operating theater can be fatal. **Why other options are incorrect:** * **A. Epinephrine injection:** Used for anaphylaxis or cardiac arrest; it does not address the mechanical compression of the airway. * **B. Tracheostomy:** While it secures the airway, it is technically difficult and time-consuming in a patient with a massive neck hematoma. Hematoma evacuation must precede or bypass the need for this. * **C. IV calcium gluconate:** This is the treatment for hypocalcemia (post-operative tetany), which typically presents 24–72 hours post-surgery with circumoral paresthesia and carpopedal spasm, not acute respiratory distress. **Clinical Pearls for NEET-PG:** * **Most common cause of post-thyroidectomy respiratory distress:** Tension hematoma (within the first 24 hours). * **Other causes:** Bilateral recurrent laryngeal nerve injury (presents immediately after extubation) and laryngeal edema. * **Sequence of Management:** 1. Open sutures at bedside $\rightarrow$ 2. Secure airway (intubation) $\rightarrow$ 3. Return to OR for formal hemostasis. * **Tracheomalacia:** A rare cause of collapse seen in long-standing large goiters where tracheal rings have weakened.

Q: Localization in insulinoma is best with which imaging modality?

Selective angiography. **Explanation:** Insulinomas are the most common functional neuroendocrine tumors (NETs) of the pancreas. They are typically small (<2 cm), solitary, and benign. The primary challenge in management is localization. **Why Selective Angiography is the Correct Answer:** While non-invasive imaging is performed first, **Selective Angiography** (specifically when combined with calcium stimulation) is historically and classically considered the most sensitive modality for localization. In the **Calcium Stimulation Venous Sampling (ASVS) test**, calcium gluconate is injected into the gastroduodenal, superior mesenteric, and splenic arteries. A rise in insulin levels in the hepatic vein identifies the specific anatomical region (head, body, or tail) of the tumor. It has a sensitivity of >90%, surpassing standard CT/MRI for small lesions. **Why Other Options are Incorrect:** * **A & B (CT/MRI):** These are the initial screening tests. However, because insulinomas are often very small and isodense with the pancreas, CT and MRI have lower sensitivity (approx. 40–70%). * **C (Somatostatin Receptor Scintigraphy/Octreoscan):** Unlike other NETs (like gastrinomas), only about 50% of insulinomas express somatostatin receptors (SSTR2). Therefore, Octreoscan is unreliable for insulinoma localization. **Clinical Pearls for NEET-PG:** * **Whipple’s Triad:** Symptoms of hypoglycemia, low plasma glucose (<50 mg/dL), and relief of symptoms after glucose administration. * **Gold Standard for Localization:** **Endoscopic Ultrasound (EUS)** is now the preferred *pre-operative* investigation (sensitivity 80–90%). * **Most Sensitive Overall:** **Intra-operative Ultrasound (IOUS)** combined with surgical palpation is the most accurate method (95–100% sensitivity) to locate the tumor during surgery. * **Medical Management:** Diazoxide is used to inhibit insulin release in unresectable cases.

Q: A 32-year-old male presents with a painless cervical lymph node. Lymph node biopsy reveals normal thyroid gland features, and the thyroid is clinically normal on palpation. What is the most likely diagnosis?

Papillary carcinoma thyroid. **Explanation:** The clinical presentation of "normal thyroid tissue" within a cervical lymph node is a classic description of **metastatic Papillary Carcinoma of the Thyroid (PTC)**. **1. Why Papillary Carcinoma is correct:** In the past, this presentation was mistakenly called "Lateral Aberrant Thyroid." However, it is now a fundamental surgical principle that **there is no such thing as a lateral aberrant thyroid.** Any thyroid tissue found in a cervical lymph node is considered a metastasis from a primary thyroid malignancy until proven otherwise. PTC is the most common thyroid cancer and is highly lymphophilic. It often presents as a "node-first" disease where the primary tumor in the thyroid gland is occult (too small to be felt on palpation), but the lymph node contains well-differentiated thyroid follicles that look "normal" under light microscopy. **2. Why other options are incorrect:** * **Lateral Aberrant Thyroid:** This is an obsolete term. Embryologically, the thyroid descends midline; lateral thyroid tissue is almost always metastatic PTC. * **Follicular Carcinoma:** This subtype typically spreads via the **hematogenous route** (blood) to bones and lungs, rather than the lymphatic route. * **Anaplastic Carcinoma:** This is a highly aggressive, undifferentiated tumor seen in elderly patients. It would show high-grade pleomorphism on biopsy, not "normal thyroid features," and usually presents as a rapidly growing, painful mass. **Clinical Pearls for NEET-PG:** * **Occult Primary:** PTC is the most common cause of an occult primary presenting as a cervical neck mass. * **Psammoma Bodies:** Look for these laminated calcifications in the pathology description of PTC. * **Orphan Annie Eye Nuclei:** The pathognomonic nuclear feature of PTC. * **Investigation of Choice:** Ultrasound-guided FNAC of the node and the thyroid gland.

Q: What percentage of cold nodules on thyroid scans are malignant?

20%. ### Explanation **Concept Overview:** Thyroid nodules are evaluated functionally using radionuclide scanning (Technetium-99m or Iodine-123). Nodules are classified based on their uptake of the isotope compared to the surrounding thyroid parenchyma: * **Hot (Hyperfunctioning):** Increased uptake; almost never malignant (<1%). * **Warm (Isfunctioning):** Normal uptake; low risk of malignancy. * **Cold (Hypofunctioning):** Decreased or absent uptake; these carry the highest risk of malignancy. **Why 20% is Correct:** Statistically, approximately **15% to 20%** of cold nodules are found to be malignant upon further investigation (FNAC/Histopathology). While most cold nodules (80-85%) are benign (e.g., colloid cysts, adenomas, or thyroiditis), the 20% malignancy rate is the standard high-yield figure used in surgical textbooks (like Bailey & Love and Sabiston) and medical examinations. **Analysis of Incorrect Options:** * **A (5%):** This represents the overall prevalence of malignancy in *all* thyroid nodules (including hot and warm), not specifically cold nodules. * **B (15%):** While some studies cite 15%, 20% is the more commonly tested upper limit for the risk associated with a solitary cold nodule. * **D (40%):** This significantly overestimates the risk. Even a cold nodule is more likely to be benign than malignant. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** FNAC is the gold standard for evaluating a thyroid nodule. Radionuclide scans are now secondary to Ultrasound and FNAC. * **Hot Nodule Rule:** A "hot" nodule is reassuring as it indicates a functioning adenoma (e.g., Toxic Adenoma/Plummer’s Disease) and rarely requires biopsy. * **Risk Factors:** The risk of malignancy in a cold nodule increases if the patient is male, very young ( 70 years), or has a history of neck irradiation.

Question 1

A 50-year-old lady presents with a thyroid swelling diagnosed as papillary carcinoma. The mass measures 4 cm at its greatest diameter and invades strap muscles. Lymph node status is negative. What is the stage of the disease?

Accepted Answer

Stage I

Answer

Stage II

Answer

Stage III

Answer

Stage IV

Question 2

What is the treatment for parathyroid hyperplasia?

Accepted Answer

Removal of 3 1/2 glands

Answer

Phosphate binders

Answer

Calcitonin

Answer

Enlarged glands to be removed

Question 3

Which of the following is true regarding a solitary thyroid nodule?

Accepted Answer

Common in females

Answer

Thyroid-stimulating hormone receptor antibodies (THR-Ab)

Answer

Lined by columnar epithelium

Answer

Diffuse hyperplasia of the thyroid

Question 4

Pemberton’s sign is elicited by which maneuver?

Accepted Answer

Raising of arms

Answer

Swallowing

Answer

Extrusion of tongue

Answer

Extension of neck

Question 5

A patient operated for thyroid surgery for a thyroid swelling, later in the evening developed difficulty in breathing and swelling in the neck. What is the immediate management?

Accepted Answer

Open the wound sutures in the ward

Answer

Epinephrine injection

Answer

Tracheostomy

Answer

IV calcium gluconate

Question 6

What is the most common nerve injury associated with thyroid surgery?

Accepted Answer

External branch of superior laryngeal nerve

Answer

Right recurrent laryngeal nerve

Answer

Left recurrent laryngeal nerve

Answer

Right internal laryngeal nerve

Question 7

Fine-needle aspiration cytology (FNAC) is the investigation of choice in which of the following thyroid conditions?

Accepted Answer

Anaplastic carcinoma

Answer

Papillary carcinoma

Answer

Medullary carcinoma

Answer

None of the above

Question 8

Localization in insulinoma is best with which imaging modality?

Accepted Answer

Selective angiography

Answer

Contrast computerized tomography

Answer

Magnetic resonance imaging

Answer

Somatostatin receptor scintigraphy

Question 9

A 32-year-old male presents with a painless cervical lymph node. Lymph node biopsy reveals normal thyroid gland features, and the thyroid is clinically normal on palpation. What is the most likely diagnosis?

Accepted Answer

Papillary carcinoma thyroid

Answer

Lateral aberrant thyroid

Answer

Follicular carcinoma thyroid with metastatic lymph nodes

Answer

Anaplastic carcinoma

Question 10

What percentage of cold nodules on thyroid scans are malignant?

Accepted Answer

20%

Answer

5%

Answer

15%

Answer

40%

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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