Endocrine Surgery — MCQs
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Lateral aberrant thyroid is a node from which type of thyroid cancer?
A 75-year-old woman presents with mild congestive heart failure 6 weeks after a myocardial infarction. She has a past history of neck surgery for parathyroid adenoma 5 years ago. ECG shows slow atrial fibrillation. Serum calcium is 13.0 mg/dL and urinary calcium is 300 mg/24 hr. On examination, there is a small mass in the paratracheal position behind the right clavicle. What is the most appropriate management at this time?
Which of the following is false about viral thyroiditis?
Which of the following is true about anaplastic thyroid carcinoma?
An 80-year-old male presents with a rapidly enlarging neck mass and hoarseness of voice. He has a history of untreated papillary carcinoma of the thyroid. What is the likely diagnosis?
Goiter that appears along with toxic symptoms is classified as:
Which tumor marker is characteristic of Medullary Carcinoma of the thyroid?
A 30-year-old female patient presents with a complaint of a painless, hard anterior neck mass. Fine Needle Aspiration Cytology (FNAC) was inconclusive. An open thyroid biopsy was performed, which revealed a fibrous, woody, non-tender thyroid mass, mimicking carcinoma. What is the most likely diagnosis?
Most of the incidentalomas are:
Compared to follicular carcinoma, papillary carcinoma of the thyroid has which of the following features?
Endocrine Surgery Indian Medical PG Practice Questions and MCQs
Question 251: Lateral aberrant thyroid is a node from which type of thyroid cancer?
- A. Papillary cancer (Correct Answer)
- B. Follicular cancer
- C. Thyroid lymphoma
- D. Medullary cancer
Explanation: **Explanation:** The term **"Lateral Aberrant Thyroid"** is a historical misnomer. It refers to the presence of thyroid tissue in the lateral cervical lymph nodes. While it was once thought to be an embryological developmental anomaly, it is now established that this represents **metastatic spread from an occult Papillary Thyroid Carcinoma (PTC)**. **1. Why Papillary Cancer is Correct:** PTC is characterized by its strong tendency for **lymphatic spread** rather than hematogenous spread. In many cases, the primary tumor in the thyroid gland is so small (microcarcinoma) that it is clinically impalpable, while the first clinical presentation is an enlarged lateral cervical lymph node. Histologically, these nodes contain well-differentiated thyroid follicles or papillary structures, confirming the diagnosis of metastatic PTC. **2. Why Other Options are Incorrect:** * **Follicular Cancer:** This typically spreads via the **hematogenous route** (bloodstream) to bones and lungs. Lymph node involvement is rare (less than 10%). * **Thyroid Lymphoma:** This usually presents as a rapidly enlarging diffuse goiter, often in the background of Hashimoto’s thyroiditis, rather than isolated lateral nodal deposits. * **Medullary Cancer:** While it does spread to lymph nodes, the specific clinical entity of "lateral aberrant thyroid" is classically associated with the unique behavior of PTC microcarcinomas. **Clinical Pearls for NEET-PG:** * **Most common** thyroid malignancy: Papillary Carcinoma. * **Psammoma bodies** (calcified laminations) are a hallmark histological feature of PTC. * **Orphan Annie eye nuclei** and **nuclear grooves** are key cytological findings on FNAC for PTC. * **Treatment:** If a lateral aberrant thyroid is found, the patient requires a total thyroidectomy and a formal neck dissection.
Question 252: A 75-year-old woman presents with mild congestive heart failure 6 weeks after a myocardial infarction. She has a past history of neck surgery for parathyroid adenoma 5 years ago. ECG shows slow atrial fibrillation. Serum calcium is 13.0 mg/dL and urinary calcium is 300 mg/24 hr. On examination, there is a small mass in the paratracheal position behind the right clavicle. What is the most appropriate management at this time?
- A. Repeat neck surgery
- B. Treatment with technetium-99 sestamibi scan
- C. Observation and repeat serum calcium in two months
- D. Ultrasound-guided ethanol injection of the mass (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Ultrasound-guided ethanol injection of the mass** The patient presents with **recurrent primary hyperparathyroidism** (hypercalcemia occurring >6 months after initial surgery) and symptomatic hypercalcemia (13.0 mg/dL). However, she is a **high-risk surgical candidate** due to a very recent myocardial infarction (6 weeks ago) and active congestive heart failure. In patients with recurrent hyperparathyroidism who are unfit for surgery, **minimally invasive non-surgical ablation** is the treatment of choice. **Ultrasound-guided ethanol injection (PEI)** or radiofrequency ablation can effectively reduce parathyroid hormone levels and normalize calcium without the risks of general anesthesia or the technical difficulty of re-operative neck surgery. **Why other options are incorrect:** * **A. Repeat neck surgery:** While surgery is the definitive treatment for hyperparathyroidism, it is contraindicated here due to the patient’s recent MI (high perioperative cardiac risk) and the technical challenges/complications associated with re-exploration. * **B. Treatment with Tc-99 Sestamibi scan:** Sestamibi is a **localization/diagnostic tool**, not a treatment modality. While it helps identify the ectopic or recurrent gland, it does not manage the hypercalcemia. * **C. Observation:** A serum calcium of 13.0 mg/dL is significantly elevated and potentially life-threatening (cardiac arrhythmias, renal crisis). Observation is inappropriate in symptomatic or severe hypercalcemia. ### NEET-PG High-Yield Pearls * **Persistent vs. Recurrent:** Persistent hyperparathyroidism occurs within 6 months of surgery (usually a missed gland); Recurrent occurs after 6 months of normocalcemia. * **Re-operative Surgery:** Carries a higher risk of recurrent laryngeal nerve injury and permanent hypoparathyroidism compared to the initial surgery. * **Localization:** For re-operative cases, **Sestamibi scan combined with SPECT/CT** or 4D-CT is the gold standard for localization. * **Medical Management:** If ablation is unavailable, **Cinacalcet** (a calcimimetic) can be used to lower calcium in patients unfit for surgery.
Question 253: Which of the following is false about viral thyroiditis?
- A. Self limiting
- B. Painful
- C. Initial hypothyroid state (Correct Answer)
- D. Raised ESR
Explanation: **Explanation:** Viral thyroiditis, also known as **De Quervain’s thyroiditis** or Subacute Granulomatous Thyroiditis, typically follows a viral upper respiratory tract infection. **Why Option C is False (The Correct Answer):** The hallmark of subacute thyroiditis is a **triphasic clinical course**. It begins with an **initial hyperthyroid state**, not hypothyroid. This occurs because the viral inflammation causes destruction of thyroid follicles, leading to the "leakage" of preformed thyroid hormones (T3 and T4) into the circulation. This is followed by a transient euthyroid phase, then a temporary hypothyroid phase as hormone stores are depleted, and finally, a return to normal function. **Analysis of Other Options:** * **Option A (Self-limiting):** Most cases resolve spontaneously within weeks to months. Treatment is usually supportive with NSAIDs or steroids for pain. * **Option B (Painful):** This is a classic clinical feature. Patients present with a **tender, painful thyroid gland**, often radiating to the jaw or ears. * **Option D (Raised ESR):** A markedly elevated Erythrocyte Sedimentation Rate (often >50–100 mm/hr) is a highly characteristic laboratory finding in De Quervain’s. **High-Yield Clinical Pearls for NEET-PG:** * **Radioactive Iodine Uptake (RAIU):** Characteristically **low/depressed** during the initial hyperthyroid phase (due to follicular damage and TSH suppression). * **Histology:** Features **multinucleated giant cells** and granulomatous inflammation. * **Treatment of choice:** NSAIDs for mild cases; Prednisone for severe pain. Beta-blockers can be used for thyrotoxic symptoms; antithyroid drugs (PTU/Methimazole) are **not** indicated as there is no excess synthesis.
Question 254: Which of the following is true about anaplastic thyroid carcinoma?
- A. It is common in the elderly.
- B. It is well encapsulated.
- C. It invades surrounding structures. (Correct Answer)
- D. Distant metastasis is common.
Explanation: Anaplastic Thyroid Carcinoma (ATC) is one of the most aggressive solid tumors in humans, characterized by rapid growth and extreme local invasiveness. **Explanation of the Correct Answer:** * **Option C (It invades surrounding structures):** The hallmark of ATC is its **aggressive local invasion**. By the time of diagnosis, the tumor typically extends beyond the thyroid capsule into the trachea, esophagus, recurrent laryngeal nerves, and carotid sheath. This leads to the classic presentation of a rapidly enlarging neck mass associated with "pressure symptoms" like dyspnea, dysphagia, and hoarseness. **Why the other options are incorrect:** * **Option A:** While ATC primarily affects the elderly (peak incidence in the 6th–7th decades), the question asks for the *most* defining characteristic. In competitive exams, "invades surrounding structures" is the definitive pathological feature that dictates its lethal prognosis. * **Option B:** ATC is **never encapsulated**. It is a highly undifferentiated, infiltrative malignancy. Encapsulation is more characteristic of benign follicular adenomas or some low-grade follicular carcinomas. * **Option D:** While distant metastasis (to lungs and bones) occurs in about 50% of cases, **local invasion** is the more immediate and consistent clinical feature that leads to mortality (often via airway obstruction) before distant spread becomes the primary issue. **High-Yield Clinical Pearls for NEET-PG:** * **Mutation:** Strongly associated with **p53 mutations** (loss of tumor suppressor function). * **Precursor:** Often arises from a long-standing differentiated thyroid cancer (usually Papillary or Follicular). * **Diagnosis:** Core needle biopsy or incisional biopsy is often required as FNA may only show necrosis or be non-diagnostic. * **Prognosis:** Extremely poor; median survival is approximately 3–6 months. * **Treatment:** Primarily palliative (tracheostomy for airway) as it is largely resistant to surgery, chemotherapy, and radiotherapy.
Question 255: An 80-year-old male presents with a rapidly enlarging neck mass and hoarseness of voice. He has a history of untreated papillary carcinoma of the thyroid. What is the likely diagnosis?
- A. Medullary thyroid cancer
- B. Hürthle cell carcinoma
- C. Papillary thyroid cancer
- D. Anaplastic thyroid cancer (Correct Answer)
Explanation: **Explanation:** The clinical presentation of an elderly patient with a **rapidly enlarging neck mass**, hoarseness (suggesting recurrent laryngeal nerve palsy), and a history of untreated differentiated thyroid cancer (DTC) is a classic "textbook" description of **Anaplastic Thyroid Cancer (ATC)**. **1. Why Anaplastic Thyroid Cancer is correct:** ATC is one of the most aggressive solid tumors. It typically occurs in the 7th–8th decades of life. Crucially, up to **20–30% of ATC cases arise from pre-existing differentiated thyroid cancers** (like Papillary or Follicular carcinoma) through a process of dedifferentiation. The rapid growth leads to compressive symptoms (dyspnea, dysphagia) and local invasion (hoarseness). **2. Why the other options are incorrect:** * **Medullary Thyroid Cancer (MTC):** Arises from parafollicular C-cells. While it can be aggressive, it does not typically present with this degree of explosive growth or arise from a prior papillary carcinoma. * **Hürthle Cell Carcinoma:** A variant of follicular cancer. While more aggressive than standard DTC, it follows a much slower clinical course than ATC. * **Papillary Thyroid Cancer (PTC):** This is the most common thyroid malignancy and generally has an excellent prognosis with slow growth. The sudden change in behavior in an 80-year-old indicates transformation rather than the primary PTC itself. **Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (often present at diagnosis). * **Histology:** Shows spindle cells, giant cells, or squamoid cells; IHC is often positive for **PAX-8**. * **Prognosis:** Extremely poor; most patients have Stage IV disease at presentation. * **Key Differential:** Thyroid Lymphoma (also presents as a rapidly enlarging mass, but usually associated with Hashimoto’s thyroiditis).
Question 256: Goiter that appears along with toxic symptoms is classified as:
- A. Primary thyrotoxicosis (Correct Answer)
- B. Secondary thyrotoxicosis
- C. Toxic nodule
- D. None of the above
Explanation: In endocrine surgery, the classification of thyrotoxicosis is based on the chronological relationship between the appearance of the goiter and the onset of toxic symptoms. ### **Explanation of the Correct Answer** **A. Primary Thyrotoxicosis:** This is defined as a condition where the **goiter and toxic symptoms appear simultaneously**. The most common cause is **Graves' Disease**, an autoimmune disorder where TSH-receptor antibodies stimulate the entire gland. Clinically, the goiter is typically diffuse, vascular, and associated with extrathyroidal manifestations like exophthalmos and pretibial myxedema. ### **Why Other Options are Incorrect** * **B. Secondary Thyrotoxicosis:** This occurs when toxic symptoms develop in a patient who has had a **pre-existing long-standing simple goiter** (usually for many years). It is typically seen in **Toxic Multinodular Goiter (Plummer’s Disease)**. Unlike primary thyrotoxicosis, it rarely presents with exophthalmos. * **C. Toxic Nodule:** This refers to a single autonomous hyperfunctioning nodule (solitary toxic adenoma) within an otherwise normal or suppressed gland. While it causes thyrotoxicosis, the term "Primary Thyrotoxicosis" is the broader, standard classification for the simultaneous onset of goiter and toxicity. ### **NEET-PG High-Yield Pearls** * **Primary Thyrotoxicosis (Graves'):** Diffuse goiter + Toxicity + Eye signs (Exophthalmos). * **Secondary Thyrotoxicosis (TMNG):** Pre-existing nodular goiter + Toxicity + No eye signs + Higher risk of cardiac arrhythmias (Atrial Fibrillation) in elderly patients. * **Marine-Lenhart Syndrome:** The coexistence of Graves' disease with functioning nodules. * **Jod-Basedow Phenomenon:** Iodine-induced hyperthyroidism, often seen when iodine is given to a patient with a pre-existing multinodular goiter.
Question 257: Which tumor marker is characteristic of Medullary Carcinoma of the thyroid?
- A. TSH
- B. Calcitonin (Correct Answer)
- C. T3, T4 and TSH
- D. Alpha Feto protein
Explanation: **Explanation:** **Medullary Thyroid Carcinoma (MTC)** originates from the **Parafollicular C-cells** of the thyroid gland. These cells are derived from the neural crest and are responsible for the secretion of **Calcitonin**, a hormone that lowers blood calcium levels. Therefore, Calcitonin serves as a highly specific and sensitive tumor marker for the diagnosis, screening, and monitoring of recurrence in MTC. **Analysis of Options:** * **Option B (Calcitonin):** Correct. Elevated serum calcitonin is the hallmark of MTC. Additionally, **Carcinoembryonic Antigen (CEA)** is another important marker used for monitoring this specific tumor. * **Option A & C (TSH, T3, T4):** These are markers of thyroid functional status (hypo/hyperthyroidism). While they may be used to monitor patients with differentiated thyroid cancers (like Papillary or Follicular) on suppressive therapy, they are not diagnostic markers for the tumor itself. * **Option D (Alpha-Fetoprotein):** This is a tumor marker for Hepatocellular Carcinoma (HCC) and certain germ cell tumors (Yolk sac tumors), not thyroid malignancies. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Approximately 25% of MTC cases are familial, associated with **MEN 2A and 2B** syndromes due to **RET proto-oncogene** mutations. * **Histology:** Characterized by **amyloid stroma** (demonstrated by Congo Red stain showing apple-green birefringence). * **Prophylaxis:** In patients with known RET mutations, prophylactic thyroidectomy is recommended. * **Note:** Unlike Papillary or Follicular cancers, MTC does **not** concentrate iodine; therefore, Radioiodine (I-131) therapy is not effective.
Question 258: A 30-year-old female patient presents with a complaint of a painless, hard anterior neck mass. Fine Needle Aspiration Cytology (FNAC) was inconclusive. An open thyroid biopsy was performed, which revealed a fibrous, woody, non-tender thyroid mass, mimicking carcinoma. What is the most likely diagnosis?
- A. De Quervain's thyroiditis
- B. Riedel's thyroiditis (Correct Answer)
- C. Hashimoto's thyroiditis
- D. None of the above
Explanation: ### Explanation **Correct Answer: B. Riedel’s Thyroiditis** Riedel’s thyroiditis is a rare form of chronic thyroiditis characterized by the replacement of thyroid parenchyma with **dense fibrous tissue**. This fibrosis often extends beyond the thyroid capsule into adjacent neck structures (muscles, trachea, nerves). * **Clinical Presentation:** It typically presents as a **"stony hard" or "woody"** painless mass that mimics thyroid carcinoma. * **Diagnosis:** FNAC is often inconclusive because the dense fibrous tissue is difficult to aspirate. A definitive diagnosis usually requires an **open biopsy** to differentiate it from anaplastic carcinoma or lymphoma. * **Pathology:** It is now considered part of the **IgG4-related systemic sclerosing diseases**, often associated with retroperitoneal fibrosis, sclerosing cholangitis, or mediastinal fibrosis. --- ### Why the other options are incorrect: * **A. De Quervain's Thyroiditis (Subacute Granulomatous):** This typically presents following a viral prodrome with a **painful, tender** thyroid gland and elevated ESR. It does not present with a "woody" hard mass. * **C. Hashimoto's Thyroiditis:** This is the most common cause of hypothyroidism. While the gland may be firm and bosselated, it is not "stony hard" or invasive. Histology shows lymphocytic infiltration and **Hurthle cells**, not dense fibrosis extending to neck muscles. --- ### NEET-PG High-Yield Pearls: * **"Woody/Stony hard" thyroid** = Riedel’s Thyroiditis or Anaplastic Carcinoma. * **Key Association:** IgG4-related disease (Retroperitoneal fibrosis is the most common association). * **Treatment:** Tamoxifen and Corticosteroids are the mainstays. Surgery (Isthmusectomy) is performed only to relieve tracheal compression. * **Differential Diagnosis:** Must rule out **Anaplastic Carcinoma**; however, Riedel’s usually occurs in younger patients (30–50s) compared to the elderly population affected by anaplastic cancer.
Question 259: Most of the incidentalomas are:
- A. Non-functioning adenoma (Correct Answer)
- B. Adrenocortical carcinoma
- C. Adrenal metastasis
- D. Pheochromocytoma
Explanation: **Explanation:** An **adrenal incidentaloma** is defined as an adrenal mass (≥1 cm) discovered serendipitously during radiologic imaging performed for reasons other than suspected adrenal disease. **1. Why Non-functioning Adenoma is Correct:** The vast majority of incidentalomas (approximately **75–80%**) are **clinically silent, non-functioning cortical adenomas**. These are benign lesions that do not secrete hormones in excess. Because they lack clinical symptoms, they remain undetected until imaging is performed for unrelated abdominal or thoracic complaints. **2. Analysis of Incorrect Options:** * **Adrenocortical Carcinoma (ACC):** While a critical diagnosis to exclude, primary malignancy is rare, accounting for less than 5% of incidentalomas. Size (>4 cm) and imaging characteristics (high Hounsfield units) are used to screen for this. * **Adrenal Metastasis:** These are common in patients with a *known* primary malignancy (e.g., lung or breast cancer), but in the general population presenting with an incidentaloma, benign adenomas are far more frequent. * **Pheochromocytoma:** These account for only about 5% of incidentalomas. However, because they can be life-threatening if missed, all patients with an incidentaloma must undergo biochemical screening (plasma or urinary metanephrines) regardless of symptoms. **Clinical Pearls for NEET-PG:** * **Initial Workup:** Every incidentaloma requires two assessments: **Hormonal activity** (Rule out Pheochromocytoma, Cushing’s, and Conn’s) and **Malignancy risk** (Size and CT attenuation). * **High-Yield Cut-off:** Lesions **>4 cm** or those with **CT attenuation >10 HU** (non-contrast) are suspicious for malignancy and often warrant surgical resection (Adrenalectomy). * **Most common functioning incidentaloma:** Subclinical Cushing’s syndrome (Autonomous Cortisol Secretion).
Question 260: Compared to follicular carcinoma, papillary carcinoma of the thyroid has which of the following features?
- A. More male preponderance
- B. Bilaterality (Correct Answer)
- C. Local recurrence is common
- D. Increased mortality
Explanation: **Explanation:** The correct answer is **Bilaterality**. Papillary Thyroid Carcinoma (PTC) is the most common thyroid malignancy and is characterized by its **multicentricity**. In approximately 20–80% of cases (depending on the study), PTC is found to be multifocal or bilateral within the thyroid gland, often due to intraglandular lymphatic spread. In contrast, Follicular Thyroid Carcinoma (FTC) is typically a solitary, encapsulated lesion. **Analysis of Options:** * **A. More male preponderance:** Incorrect. Both PTC and FTC are significantly more common in females (roughly a 3:1 ratio). * **C. Local recurrence is common:** Incorrect. While PTC can recur, it is generally considered to have an excellent prognosis with low recurrence rates if managed correctly. FTC, due to its hematogenous spread, often presents with distant metastases (bone/lung) rather than just local recurrence. * **D. Increased mortality:** Incorrect. PTC has a much better prognosis than FTC. The 10-year survival rate for PTC is >90%, whereas FTC has a higher mortality rate due to its tendency for early vascular invasion and distant spread. **NEET-PG High-Yield Pearls:** * **Spread:** PTC spreads via **lymphatics** (leads to "lateral aberrant thyroid" or cervical nodes); FTC spreads via **blood** (hematogenous). * **Histology (PTC):** Look for **Orphan Annie eye nuclei**, Psammoma bodies, and nuclear grooves. * **Diagnosis:** PTC can be diagnosed via FNAC; FTC **cannot** be diagnosed by FNAC (requires histological proof of capsular or vascular invasion). * **Risk Factor:** Prior radiation exposure is a major risk factor for PTC.
Practice by Chapter
Thyroid Nodules
Practice Questions
Thyroid Cancer
Practice Questions
Graves' Disease
Practice Questions
Thyroiditis
Practice Questions
Primary Hyperparathyroidism
Practice Questions
Secondary and Tertiary Hyperparathyroidism
Practice Questions
Adrenal Cortical Tumors
Practice Questions
Pheochromocytoma
Practice Questions
Adrenal Incidentalomas
Practice Questions
Multiple Endocrine Neoplasia
Practice Questions
Neuroendocrine Tumors
Practice Questions
Intraoperative Monitoring in Endocrine Surgery
Practice Questions
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