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path endocine system - formatted Flashcards

1
Q
  1. 55.APRIL02 A patient has a diagnosis of Addison’s disease. A CT of the abdomen is ordered. The most common causes of Addison’s disease are, in no special order;
  2. Autoimmune adrenalitis, infections (tuberculosis & fungal) and metastatic carcinoma
  3. Diabetes, autoimmune adrenalitis and infections (tuberculosis & fungal)
  4. Immune vasculitis, autoimmune adrenalitis and infections (tuberculosis & fungal)
  5. Diabetes, infections (tuberculosis & fungal) and metastatic carcinoma
  6. immune vasculitis, amyloid and haemochromatosis
A
  1. Autoimmune adrenalitis, infections (tuberculosis & fungal) and metastatic carcinoma
  • Autoimmune adrenalitis (∼60 - 70%)
  • Infectious processes (tuberculosis 10 - 25%, fungi)
  • Metastatic cancer – uncommon
  • Other causes:- AIDS, lymphoma, amyloid, sarcoid, haemochromatosis, haemorrhage
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2
Q
  1. 54.APRIL02 A 50-year-old man presents with hypertension. He has low serum potassium. The clinician wants the patient “screened”. This screening would best be targeted towards finding which of the following;
  2. Small (<2cm) solitary adrenal mass
  3. Bilateral adrenal hyperplasia
  4. Moderate to large 5cm+ solitary adrenal mass
  5. Solitary adrenal mass (35% of cases), or a mass in the abdominal sympathetic chain /para aortic plexus
  6. Solitary adrenal mass (90% of cases) but multiple or bilateral in 10% of variable size
A
  1. Small (<2cm) solitary adrenal mass
    * RY - ?if bilateral adrenal hyperplasia better answer of if adenoma their preferred answer. Most common cause of primary hyperadlosteronism is actually bilateral adrenal hyperplasia (~60%) followed by an adrenal adenoma (~35%). ?if CT best at looking for adenoma though (Big Robbins 9th Edition)

CCF - Agree with RY pg 1126 robbins. Also re:below (not sure who wrote) - Primary hyperaldo isnt synonymous w Conns. Conn syndrome is specifically an adrenal adenoma. Primary hyperaldo can be adrenal hyperplasia (most common) or Adenoma.

• Patient has Primary Hyperaldosteronism (Conn Syndrome).
o Hypertension with hypokalaemia
o Weakness, paraesthesia, visual disturbances, tetany due to hypokalaemia
o Increased total body sodium and extracellular volume → hypertension and cardiac decompensation
o Causes
• Adrenal adenoma - aldosterone secreting = Conn syndrome
• 80%
• F:M = 2:1
• 30s and 40s
• Bilateral idiopathic adrenal hyperplasia- 20%
• Uncommon
• Glucocorticoid suppressible hyperaldosteronism
• Adrenal carcinoma
• Familial variant

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3
Q
  1. 52.APRIL02 A patient has a clinical diagnosis of “secondary hyperparathyroidism” which of the following would be an UNEXPCTED finding
  2. Small kidneys
  3. Calcification in the stomach
  4. Well circumscribed lucencies in the bone
  5. Calcification in the mitral valve
  6. lntracerebral periventricular calcifications
A
  1. lntracerebral periventricular calcifications
  2. 52.APRIL02 A patient has a clinical diagnosis of “secondary hyperparathyroidism” which of the following would be an UNEXPECTED finding:
  3. Small kidneys (CRF)
  4. Calcification in the stomach (metastatic calcification in secondary renal osteodystrophy)
  5. Well circumscribed lucencies in the bone (brown tumours - Focal lytic bone lesions most frequent in mandible, ribs, pelvis, femora)
  6. Calcification in the mitral valve (metastatic calcification)
  7. lntracerebral periventricular calcifications

• Caused by any condition associated with a chronic depression in serum calcium level → compensatory overactivity of parathyroid glands
• Metastatic calcification may be seen in many tissues, including lungs, heart, stomach, and blood vessels
• Hyperparathyroidism: Scattered metastatic calcification in the brain has been recorded but is extremely rare. More common is extensive calcification in the falx and tentorium in patients with chronic renal failure and on long-term hemodialysis who have developed hyperparathyroidism
Causes
• CRF - most common
• Vitamin D deficiency
• Inadequate dietary calcium
• Steatorrhoea
• Osteomalacia
• Pseudohypoparathyroidism

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4
Q
  1. 53.APRIL02 A 38-year-old mother of five is receiving radioactive iodine for follicular carcinoma of the thyroid. Without knowing further details which best describes her prognosis;
  2. Poor; death by local disease within a year even without treatment
  3. Guarded: If local nodes are negative; 60% 5-year survival
  4. Good: If local nodes are negative; 80% 10 year survival
  5. Very Good: Overall 85 - 90% 5 year survival
  6. Excellent: Overall 90%+ 10 year survival
A

LJS edit: I don’t think 5 is correct. This is for papillary carcinoma, which has excellent prognosis even with nodal spread.
Follicular likes haematogenous spread and prognosis is poor with invasion. We don’t know whether she has invasion, so I would say 4. correct (taking into account the group that does poorly). 1,2,3 definitely wrong. Unless we are supposed to infer something from her having radioactive iodine rx (though Robbins says usual rx is thyroidectomy followed by radioactive iodine, so probably not)

**LW:
Agree with above.
Further general info:
–> Age is a significant prognostic factor for differentiated carcinoma such as follciular. The 10-year survival rate for patients with differentiated thyroid cancer is over 95 percent if the patient is less than 40 years of age.
–> Conversely, radioiodine is usally given after total thyroidectomy, in high-risk patients and in selected intermediate-risk patients, depending upon specific tumor characteristics (eg, clinically significant lymph node metastases outside of the thyroid bed, or other higher-risk features).
—> so, although her age is favourable, recieving radioactive iodine may suggest a higher risk, so likely dropping prognosis down from excellent (option 5), and maybe into option 4 of very good. (honestly tho…i have no idea)

  1. Excellent: Overall 90%+ 10 year survival•
  • The prognosis of a patient with thyroid cancer is related to the type of tumor.
  • The overall 10-year survival rates are 98% for papillary and 92% for follicular carcinomas.
  • Five per cent to 20% of patients have local or regional occurrences, and 10 to 15% have distant metastases.
  • In general, the prognosis is less favorable among elderly patients, patients with invasion of extrathyroidal tissues, and patients with distant metastases
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5
Q
  1. 50.APRIL02 A 76 year old man has a thrombosed jugular vein associated with a 5 cm thyroid mass. The latter was a non-specific 2cm thyroid mass on imaging only 2 months earlier, when he had staging for an apparent Dukes B carcinoma of the caecum. The thyroid mass is most likely to be;
  2. Papillary carcinoma of the thyroid
  3. Follicular carcinoma of the thyroid
  4. Anaplastic thyroid carcinoma
  5. Primary thyroid lymphoma
  6. Metastatic colon carcinoma
A
  1. Anaplastic thyroid carcinoma
  • Hard question, anaplastic carcinoma of the thyroid typically grows at fast rate and involves the elderly
  • Colonic metastases can occur though, according to articles.

*LW: unlikely to be colonic mets as Duke B doesn’t involve nodes, so extra abdominal mets would be very unlikely.

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6
Q
  1. 51.APRIL02 The most common endocrine abnormality associated with MEN 1 (Multiple Endocrine Neoplasia I) is:
  2. Hyperprolactinemia
  3. Hypopituitarism
  4. Hyperparathyroidism
  5. Phaeochromocytoma
  6. Medullary Carcinoma of the thyroid
A
  1. Hyperparathyroidism
  2. Parathyroid
    • Primary hyperparathyroidism most common manifestation by age 40 – 50
    • Hyperplasia (more common) or multiple adenomas in 90-95%
    • Patients most often present with hypercalcaemia complications
  3. Pancreas
    • Islet cell lesions in 33% - most often adenomas, also carcinomas & hyperplasia
    • Responsible for most fatalities
    • Gastrin> insulin> serotonin> VIP, glucagon
    • Zollinger-Ellison syndrome, hypoglycaemia
    • Pancreatic malignancy causes 20% of deaths
  4. Pituitary
    • Adenomas in 10-15% - most commonly prolactinomas
    • Mostly non-functioning, occasionally present with mass effect
4.	Additional neoplasms described
•	Duodenal gastrinomas
•	C 
The 3Ps 
Parathyroids
pancreas,
pituitary glands
arcinoid tumours 
•	Thyroid and adrenocortical adenomas &amp; hyperplasia (20%)
•	Lipomas
•	Thymoma
•	Buccal Mucosa tumour
•	Colonic Polyposis
•	Menetrier disease
 
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7
Q
  1. 49.APRIL02 Which of the following most correctly describes the causes of hyperparathyroidism, from most frequent to least frequent?
  2. Parathyroid hyperplasia > single parathyroid adenoma > parathyroid carcinoma
  3. Single parathyroid adenoma > parathyroid hyperplasia > parathyroid carcinoma
  4. Single parathyroid adenoma > pituitary adenoma > parathyroid hyperplasia
  5. Parathyroid hyperplasia > pituitary adenoma > single parathyroid adenoma
  6. Parathyroid hyperplasia > single parathyroid adenoma > pituitary causes
A
  1. Single parathyroid adenoma > parathyroid hyperplasia > parathyroid
  • More than 95 % cases sporadic adenomas or hyperplasia
  • Some caused by inherited syndromes (MEN I & II)

• Parathyroid lesions
o Adenoma - 75-80%
o Primary hyperplasia (diffuse or nodular) - 10-15%
o Parathyroid carcinoma - <5%

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8
Q
  1. 20.02.13 What are the most common causes of hyperthyroidism in order of frequency? Rob p739
  2. Grave’s disease > toxic MNG > toxic adenoma
  3. Grave’s disease > toxic adenoma >toxic MNG
  4. Toxic MNG > Grave’s disease > toxic adenoma
  5. Grave’s disease > Hashimoto’s thyroiditis> toxic adenoma
  6. Pituitary adenoma > Grave’s disease> toxic MNG
A
  1. Grave’s disease > toxic MNG > toxic adenoma(85%/10%/4%)
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9
Q
  1. 20.03.76 MOST COMMON cause of hyperthyriodism is ? Rob p739
  2. Graves
  3. Hashimotos – Hashitoxicosis
  4. Ademona
  5. Cancer
A
  1. Graves (85%

Common of causes hyperthyroidism

  1. Grave’s (85%)
  2. Toxic Mutinodular Goitre (10%)
  3. Toxic adenoma (4%)
Uncommon causes of hyperthyroidism (1%)
1.	Acute/subacute thyroiditis
2.	Hyperfunctioning thyroid carcinoma
3.	Choriocarcinoma or hydatidiform mole
4.	TSH-secreting pituitary adenoma
5.	Neonatal thyrotoxicosis- a/w maternal Grave’s
6.	Struma ovarii
7.	Iodide-induced hyperthyroidism
8.	Iatrogenic (exogenous)
 
)
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10
Q
  1. 20.03.11 Increase risk of thyroid cancer LEAST LIKELY secondary to ? Rob p734
  2. In utero exposure to I131
  3. Father with thyroid cancer
  4. Mother with thyroid cancer
  5. MEN
  6. Hashimotos
A
  1. In utero exposure to I131
  2. 20.03.11 Increase risk of thyroid cancer LEAST LIKELY secondary to ? Rob p734
  3. In utero exposure to I131
  4. Father with thyriod cancer (MEN??)
  5. Mother with thyroid cancer (MEN??)
  6. MEN II – develop medullary carcinoma
  7. Hashimotos (can develop a B-cell nonhodgkins lymphoma)

• Low-dose radiation exposure from imaging studies has not been found to have a tumorigenic effect. Radiation targeting the thyroid gland (eg, iodine 131 [ 131 I] ablation of the thyroid gland) or high-dose external beam radiation therapy does not appear to increase the risk of papillary thyroid carcinoma. This is presumably because of the increased cell killing associated with these doses.

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11
Q
  1. Sep03.15 Which of the following are least likely to cause hyperthyroidism?
A

Common

  1. Grave’s (85%)
  2. Toxic Mutinodular Goitre (10%)
  3. Toxic adenoma (4%)

Uncommon (1%)

  1. Acute/subacute thyroiditis
  2. Hyperfunctioning thyroid carcinoma
  3. Choriocarcinoma or hydatidiform mole
  4. TSH-secreting pituitary adenoma
  5. Neonatal thyrotoxicosis- a/w maternal Grave’s
  6. Struma ovarii (ovarian teratomatous thyroid)
  7. Iodide-induced hyperthyroidism
  8. Iatrogenic (exogenous)
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12
Q
  1. Sep03.26 Atypical Scenario
  2. Craniopharyngioma in a 42 year old
  3. Anaplastic thyroid cancer in a 29 year old
  4. Bowel cancer in a 32 year old
A
  1. Anaplastic thyroid cancer in a 29 year old (elderly)
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13
Q
  1. Sep03.38 Hypoparathyroidism 1. Associated with adrenal …
A

primary (idiopathic) atrophy of glands

Surgical - accidental removal during thyroidectomy, radical LN dissection
Haemochromatosis
Haemorrhage, infection
External beam Radiation

Congenital absence - DiGeorge syndrome (thymic aplasia)
Autoimmune disease : 60% have autoantibodies directed against calcium-sensing receptor in gland may prevent release of PTH
• Rare familial hypoparathyroidism
o associated with chronic mucocutaneous candidiasis and primary adrenal insufficiency
 

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14
Q
  1. Sep03.50 FNA of the thyroid showed scant cells, and psamomma bodies
A

• Psammoma Bodies in Thyroid Papillary ca’s

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15
Q
  1. Sep03.57 Neuroblastoma, worse prognosis:
  2. Younger age
  3. N-myc amplification
  4. Triploid tumour

*AJL added some

A
  1. Sep03.57 Neuroblastoma, prognosis:
  2. N-myc amplification (worse prognosis)
  • Infants younger than 1 year of age have an excellent prognosis
  • The hyperdiploid or near-triploid tumors occurring in infants have a particularly good prognosis, whereas the near-diploid tumors occurring at any age tend to have an unfavorable outcome
  • Tumors with chromosome 1 deletions have a worse prognosis.
  • Amplification of N- myc oncogene worse prognosis
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16
Q
  1. Sep03.62 Least likely to cause hyperthyroidism.
  2. Graves disease
  3. Toxic multinodular goitre
  4. Toxic adenoma
  5. Hashimoto’s thyroiditis
A
  1. Hashimoto’s thyroiditis
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17
Q
  1. 20.02.14 Most common thyroid malignant tumours in order of frequency? Rob p735
  2. Papillary > follicular > Medullary> anaplastic
  3. Papillary > Medullary>follicular > anaplastic
  4. follicular > Papillary > anaplastic >Medullary
  5. follicular > Papillary > Medullary> anaplastic
  6. Medullary>Papillary > follicular > anaplastic
A
  1. Papillary > follicular > Medullary> anaplastic (Med Robbins 75-85% / 10-20% / 5% / <5%)

*LW:
“Papillary is most Popular, Followed by Follicular”

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18
Q
  1. 20.03.78 Patient with increase calcitonin, MOST LIKELY diagnosis is ?
  2. Carcinoid
  3. Men IIa
  4. Medullary carcinoma thyroid
A
  1. Medullary carcinoma thyroid Hormonally active
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19
Q
  1. 20.03.77 Which is LEAST STRONGLY ASSOCIATED with being female?
  2. Graves
  3. Hashimotos
  4. SLE
  5. MS
  6. Rheumatoid
A
  1. MS (F:M 3:2
  2. 20.03.77 Which is LEAST STRONGLY ASSOCIATED which being female ?
  3. Graves (F:M 10:1)
  4. Hashimotos (F:M 20:1)
  5. SLE (F:M 10:1)
  6. MS (F:M 3:2)
  7. Rheumatoid (Danhert F:M 3:1 if <40 F:M 1:1 if >40 years / Robbins say F:M 5:1)
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20
Q
  1. 20.02.60 Hypertensive patient with hypokalaemia has CT for screening. Most likely looking for ?
  2. Adrenal mass <2cm
  3. Adrenal mass >5cm
  4. Bilateral adrenal enlargement
A
  1. Adrenal mass <2cm This patient has primary hyperaldosteronism –most common cause is Conn Syndrome with Adrenal adenoma (80%))
    * RY(GOAT) - actually most common cause for primary hyperalsosteronism is bilateral adrenal hyperplasia (Big Robins 9th edition).
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21
Q
  1. 20.02.16 Patient presents with Addison’s disease and hyponatremia, what is likely finding on CT ? Rob p748
  2. 2cm single adrenal mass
  3. Bilateral adrenal hyperplasia
  4. Moderate to large (+ 5cm) adrenal mass
  5. Bilateral adrenal masses
  6. Irregular shrunken glands with lipid-depleted cortex
A

Irregular shrunken glands with lipid-depleted cortex

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22
Q
  1. 20.02.17 Pheochromocytoma is associated with all of the following EXCEPT? Rob p751
  2. MEN I
  3. VHL
  4. TS
  5. NF1
  6. Sturge-Weber
A
  1. MEN I
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23
Q
  1. Sep03.21 Female, primary amenorrhoea, short stature. Pelvic ultrasound – no ovaries are seen. What is the most likely diagnosis?
  2. female hermaphrodism.
  3. Turners syndrome.
A
  1. Turners syndrome. (Atrophic ovaries- few fibrous strands = streak ovaries, Infertility and amenorrhoea )
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24
Q
  1. 20.02.15 A-16-year-old girl is referred for pelvic ultrasound as part of investigation of primary amenorrhoea. She is 140 cm in height and weighs 57kg. The most likely diagnosis would be:
  2. Polycystic ovaries
  3. Prolactin
  4. Dermoid
  5. Hypothalamic lesion
  6. Turner’s syndrome
A

? turners not here but probably was in exam

• Gonadal dysgenesis is characterized by Turner’s syndrome in which women preset with an XO karyotype, short stature (mean adult height 141 + 0.6 cm), primary amenorrhea, streak gonads, and sexual infantilism

25
Q
  1. 20.02.61 A 16yr old female 140cm in height and weight 57kg has primary amenorrhoea. Most likely cause ?
  2. Testicular feminisation
  3. Prolactinoma
  4. Anorexia
  5. Polycystic ovaries
  6. Turners syndrome
A
  1. Turners syndrome

• The most common cause of primary amenorrhea is delayed puberty due to some genetic factor that delays physical development. Being short is the most common sign of this, although sometimes a family history of delayed menstruation can indicate this situation. Time usually resolves the problem eg Turners

26
Q
  1. PATH2004 Paragangliomas
  2. paraganglioma, chemodectoma and carotid body tumours can be used interchangeably
  3. often adherent to vessels resulting in incomplete excision and recurrence of 10%
A

1: Paraganglioma, chemodectoma, carotid body tumours are interchangeable (with respect to paragangliomas within the carotid body location).

*LW:
Radiopaedia states, “Carotid body tumor, also known as a chemodectoma or carotid body paraganglioma, is a highly vascular glomus tumor that arises from the paraganglion cells of the carotid body”, which is further confirmed in Large Robbins.

Large Robbins states:

  • Paraganglia related to great vessels of head and neck…. infrequently release catecholamines, but because the cells that make up these lesions sense O2 and CO2 tensions within adjacent vessels, the tumours are also sometimes referred to as chemodectomas.
  • Tumors arising in the carotid body are designanted carotid body tumours
  • Tumors in the jugulotympanic body are referred to chemodectomas as these paraganglia sense oxygen and CO2 levels.

Robbins: Carotid body tumours: frequently recur after incomplete resection, with many metastasising.
Shamblin classification: types 2 and 3 are adherent to vessels.

  1. often adherent to vessels resulting in incomplete excision and recurrence of 10%
  • I think that it may have stated 10-40% in the exam see quote from robbins below:
  • Despite the infrequency and small size of paragangliomas, they are of great clinical importance because from 10 to 40% are malignant and recur after resection
  • Despite encapsulation, well developed or scant, they are often densely adherent to adjacent vessels and difficult to excise
27
Q
  1. PATH2004 Least likely to cause hyperthyroidism.
  2. Graves disease
  3. Toxic multinodular goitre
  4. Toxic adenoma
  5. Hashimoto’s thyroiditis
  6. Reidel’s Thyroiditis
  7. Subacute
  8. Viral thyroiditis
A
  1. Reidel’s Thyroiditis – F - rare disorder of unknown etiology characterised by extensive fibrosis; hard, firm thyroid mass. Thyroid function depends on the extent to which the normal thyroid gland has been replaced by fibrotic tissue. Most patients are euthyroid. Hypothyroidism is noted in approx 30% of cases. Very rarely can hyperthyroidism occur, but this is probably secondary to a coexisting condition.
  2. PATH2004 Least likely to cause hyperthyroidism. (TW) (–)
  3. Graves disease - T - most common cause of endogenous hyperthyroidism. Autoimmune disorder produced by autoantibodies to the TSH receptor.
  4. Toxic multinodular goitre - T
  5. Toxic adenoma - T - in a minority of cases adenomas may be hyperfunctional with autonomous secretion of thyroid hormone.
  6. Hashimoto’s thyroiditis - T - 5% do get initial hyperthroidism. In some cases it may be preceded by transient thyrotoxicosis. Autoimmune destruction of thyroid gland.
  7. Reidel’s Thyroiditis – F - rare disorder of unknown etiology characterised by extensive fibrosis; hard, firm thyroid mass. Thyroid function depends on the extent to which the normal thyroid gland has been replaced by fibrotic tissue. Most patients are euthyroid. Hypothyroidism is noted in approx 30% of cases. Very rarely can hyperthyroidism occur, but this is probably secondary to a coexisting condition.
  8. Subacute - T - both Granulomatous (de Quervain) and Lymphocytic forms of subacute thyroiditis have transient hyperthyroidism. Principle clinical manifestation of painless thyroidits is hyperthyroidism. Increased T3, T4, and reduced TSH.
  9. Viral thyroiditis- T - transient hyperthyroidism.
    Common
    • Grave’s (85%)
    • Toxic Mutinodular Goitre (10%)
    • Toxic adenoma (4%)
    Uncommon (1%)
    • Acute/subacute thyroiditis
    • Hyperfunctioning thyroid carcinoma
    • Choriocarcinoma or hydatidiform mole
    • TSH-secreting pituitary adenoma
    • Neonatal thyrotoxicosis- a/w maternal Grave’s
    • Struma ovarii (ovarian teratomatous thyroid)
    • Iodide-induced hyperthyroidism
    • Iatrogenic (exogenous)
28
Q
  1. PATH2004 DeQuervain macroscopic appearance
  2. Diffuse smooth symmetrical goitre
  3. Multiple nodules
  4. Bilateral or unilateral enlarged lobes
  5. Only microscopic changes
A
  1. Bilateral or unilateral enlarged lobes T – the gland may be unilaterally or bilaterally enlarged
  2. PATH2004 DeQuervain macroscopic appearance (–) (TW)
  3. Diffuse smooth symmetrical goitre - F - Hashimotos / Graves
  4. Multiple nodules - F - MNG
  5. Bilateral or unilateral enlarged lobes T – the gland may be unilaterally or bilaterally enlarged
  6. Only microscopic changes - F - subacute lymphocytic (painless) thyroiditis (“except for possible mild symmetric enlargement, the thyroid appears normal on gross inspection”).
    • The gland may be unilaterally or bilaterally enlarged and firm, with an intact capsule. It may be slightly adherent to surrounding structures.
    • In active inflammatory phase, scattered follicles may be disrupted and replaced by neutrophils forming microabscesses
    • Later = more classical aggregations of lymphocytes, histiocytes & plasma cells around damaged follicles
    • Multinucleated giant cells enclosing fragments of colloid, hence the designation granulomatous thyroiditis
29
Q
  1. PATH2004 Regarding pheos
  2. T2hyperintense
  3. Extra-adrenal pheos are less malignant than those associated with adrenal
  4. 2cm at Dx
A
  1. T2hyperintense
30
Q

Turners sydrome with Hurthle cells, which is true?

Cystic hygroma
Hashimoto’s
Warthins tumour
Riedels thyroiditis
Parathyoid adenoma
A

Hashimoto’s - T - HT = chronic autmoimmune thyroid disorder characterised by slowly destructive lymphoid infiltrate of thyroid gland (and high circulating titres of antithyroid Abs). Occurs with increased frequency in patients with Down’s syndrome and Turner’s syndrome. Hürthle cells (oncycytes) are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).Note- increased risk in-> down’s-> Turners- Hurstle cells

**SCS added options to make this a question. Correct answer is Hashimoto.

  • Warthins - oncocytes present but not ass/w Turners.
  • Cystic hygroma are associated w Turners on antenatal imaging.
31
Q
  1. Anaplastic thyroid cancer prognosis
  2. Good
  3. Not so good
  4. Bad
  5. Really bad
  6. Shithouse
A
  1. Shithouse -

Malignant thyroid tumors: Papillary 75-85%, Follicular 10-20%, Medullary 5%, Anaplastic <5%.
Papillary - young (esp 20-40yo), female, lymphatic spread, calcification, orphan annie nuclei, irradiation, pasmmoma bodies. Px 10y survival 98%.
Follciular - any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion.
Medullary - any age (peak 20-30s for MEN, 40-50s sporadic), tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. Mor aggressive MENIIb.
Anaplastic - >60yo, locally invasive, 50% have goitre, 20% has Hx or previously more differentiated tumor (?develops from this ?due to p53 tumor suppressor gene loss). Px approx 100% mortality.

32
Q
  1. 55yo man - Oncocytes in biopsy specimen from solitary parotid cyst
  2. Benign pleomorphic adenoma
  3. Warthins
  4. HIV
  5. Type 1 branchial cleft cyst
  6. Mucoepidermoid
A
  1. Warthins - T - Warthins: 5th – 7th decades; M>F; 8 x risk in smoking, oncocytes p 772 old Robbins. Oncocytes are epithelial cells stuffed with mitochondria that impart the granular appearance to the cytoplasm.
  2. 55yo man - Oncocytes in biopsy specimen from solitary parotid cyst (TW)
  3. Benign pleomorphic adenoma - F - great histologic heterogeneity. Epithelial elements resembling ductal cells or myoepithelial cells.
  4. Warthins - T - Warthins: 5th – 7th decades; M>F; 8 x risk in smoking, oncocytes p 772 old Robbins. Oncocytes are epithelial cells stuffed with mitochondria that impart the granular appearance to the cytoplasm.
  5. HIV - F
  6. Type 1 branchial cleft cyst - F - fibrous walls, usually lined by stratified squamous or pseudostratified columnar epithelium underlaid by an intesne lymphocytic infiltrate.
  7. Mucoepidermoid - F - cords, sheets, or cystic configurations of squamous, mucous, or intermediate cells
33
Q
  1. DeQuervain thyroiditis macroscopic appearance
  2. Diffuse smooth symmetrical goitre
  3. Multiple nodules
  4. Bilateral or unilateral enlarged lobes
  5. Only microscopic changes
A
  1. Bilateral or unilateral enlarged lobes
  2. DeQuervain macroscopic appearance (TW)
  3. Diffuse smooth symmetrical goiter - F - Hashimotos / Graves
  4. Multiple nodules - F - MNG
  5. Bilateral or unilateral enlarged lobes
  6. Only microscopic changes - F - subacute lymphocytic (painless) thyroidits. AKA lymphocytic thyroiditis.

DeQuervains (AKA subacute (granulomatous) thyroiditis):

  • Self-limited granulomatous thyroiditis
  • Hyperthyroid then hypothyroid then euthyroid.
  • distinct histology characterised by GC formation / granulomata.
  • Recent viral infection (mumps, measles, flu adenovirus, coxsackievirus, echovirus).
  • Lobes can be normal sized or enlarged (uni-/bilateral). Regions of decreased echogenicity and decreased vascularity on USS.
  • Reduced uptake on NM study.
  • Typically middle aged women.
34
Q
  1. Phaeochromocytoma not a common location?
  2. Adrenal cortex.
  3. Adrenal medulla.
  4. Mediastinum.
  5. Bladder.
  6. Organ of Zuckerkandal.
A
  1. Adrenal cortex - F - adrenal medulla
  2. Phaeochromocytoma not a common location? (TW)
  3. Adrenal cortex - F - adrenal medulla
  4. Adrenal medulla - T - Approx 95% of catecholamine-secreting tumors are in the abodmen, of which 85-90% are intraadrenal (phaeochromocytoma) UTD.
  5. Mediastinum - T
  6. Bladder - T
  7. Organ of Zuckerkandal - T - Most common extraadrenal location
    Pheochromocytoma arises from pheochromocytes the predominant cells of the adrenal medulla, these cells were widespread in the fetal sympathetic chain but typically degenerate after birth.
    Radiographics: More than 90% of phaeochromocytomas are located within the adrenal glands, and 98% occur within the abdomen. Extraadrenal pheochromocytomas develop in paraganglionic chromaffin tissue of the sympathetic nervous system. They may occur anywhere from the base of the brain to the urinary bladder and are considered to be paraganlgiomas.
    Common locations for extraaadrenal pheochromocytomas include the organ of Zuckerkandl, bladder wall, retroperitoneum, heart, mediastinum, and carotid and glomus jugulare bodies.
    1% located in thorax, most paravertebral. Have been described in pericardium.
    Female reproductive organs have been described but extremely rare. AJR
35
Q
  1. CT request for patient with MEN 1 which are NOT features
  2. increased VMA.
  3. Increased parathormone.
  4. GI mass.
  5. Pituitary mass.
A
  1. increased VMA - F - (least correct) pheos seen with MEN 2A and 2B but not MEN 1. Can get carcinoids with MEN 1, and for this would test for urinary 5-HIAA (hydroxyindoleacetic acid) which is end product of serotonin metabolism - note however that carcinoids can produce other biogenic amines (ie Norepinephrine / dopamine) whose break down product is VMA.
  2. CT request for patient with MEN 1 which are features (TW)
  3. increased VMA - F - (least correct) pheos seen with MEN 2A and 2B but not MEN 1. Can get carcinoids with MEN 1, and for this would test for urinary 5-HIAA (hydroxyindoleacetic acid) which is end product of serotonin metabolism - note however that carcinoids can produce other biogenic amines (ie Norepinephrine / dopamine) whose break down product is VMA.
  4. Increased parathormone - T - primary hyperparathyroidism is the most common manifestation of MEN 1. Multiple gland involvement is typical. Hyperplasia more common than adenoma.
  5. GI mass - T - (this was previous remembered as false) pancreatic islet cell or gastrointestinal endocrine cell tumors become clinically apparent in approx 1/3rd patients with MEN1. Most common cause for symptomatic disease is Zollinger-Ellison. Duodenum is a common site for tumors (gastrinomas).
  6. Pituitary mass - T - clinically apparent (anterior) pituitary adenomas develop in approximately 15-20% of patients with MEN1 when sought by CT or MRI. Most common type of pituitary tumor in MEN1 is a prolactinoma, but a GH, ACTH, gonadotroph, and non-functioning tumors can also occur.
36
Q
  1. Which is not a feature of Zollinger-ellison?
  2. Hypervascular GI mass.
  3. Gastrinoma.
  4. Increased ulcers.
  5. Increased lymphoma in Gastric wall.
  6. Atrophic Gastritis.
A
  1. Increased lymphoma in Gastric wall. F - complications include: malignant islet cell tumour (in 60%), liver mets with continued gastric secretion, perforated DU/jejunal ulcer, oesoph stricture with reflux, obstruction, GI bleeding, gastric carcinoids (esp. in MEN1).
  2. Which is not a feature of Zollinger-Ellison? (GC)
  3. Hypervascular GI mass. T
  4. Gastrinoma. T - non-beta cell gastrin-secreting tumour of the pancreas
  5. Increased ulcers. T - multiple in 10%; solitary ulcer in 90%; recurrent or intractable; unusual locations (postbulbar).
  6. Increased lymphoma in Gastric wall. F - complications include: malignant islet cell tumour (in 60%), liver mets with continued gastric secretion, perforated DU/jejunal ulcer, oesoph stricture with reflux, obstruction, GI bleeding, gastric carcinoids (esp. in MEN1).
  7. Atrophic Gastritis. - ? - hypergastrinaemia causes gastric gland hyperplasia (mainly parietal cells in fundus).
    [Robbins; eMedicine]

The symptoms of Zollinger-Ellison syndrome are secondary to hypergastrinemia, which causes hypertrophy of the gastric mucosa and leads to an increase in the number of parietal cells (as many as 6 times the reference range value) and increased maximal acid output. On its own, gastrin also stimulates acid secretion, resulting in increased basal acid secretion. The increased acid production leads to mucosal ulceration of the GI tract, diarrhea, or malabsorption. Malabsorption in patients with Zollinger-Ellison syndrome is usually multifactorial and is caused by direct mucosal damage (caused by increased stomach acid), inactivation of the pancreatic enzymes, and the precipitation of bile salts.

37
Q
  1. Autopsy of the thyroid in Hashimotos shows? which is false:
  2. Hurthle cells.
  3. Fibrosing nodules.
  4. Psammoma bodies.
A
  1. Fibrosing nodules - ?F - indicating Reidel thyroiditis? however there is a fibrosing variant (rare) of hashimotos
    * *LJS - Can have fibrosis (fibrosing variant) - but not extending beyond capsule of thyroid gland (ddx Reidel thyroiditis)
  2. Autopsy of the thyroid in Hashimotos shows? (TW)
  3. Hurthle cells - T - This is presumable the best single answer. Thyroid follicles are small and are lined in many areaas by epithelial cells with abundant eosinophilic, granular cytoplasm, termed Hürthle cells. Hürthle cells (oncycytes) are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).
  4. Fibrosing nodules - ?F - indicating Reidel thyroiditis? however there is a fibrosing variant (rare) of hashimotos.
    * *LJS - Can have fibrosis (fibrosing variant) - but not extending beyond capsule of thyroid gland (ddx Reidel thyroiditis)
  5. Psammoma bodies - T - Thyroid microcalcifications are psammoma bodies and are one of the most specific features of thyroid malignancy. They are found in all primary thyroid carcinomas, most commonly papillary. Also seen in benign conditions such as follicular adenoma and Hashimoto thyroiditis (Radiographics 2007). **LJS - Papillary carcinoma ass/w Hashimotos, might be getting at this.
38
Q
  1. Macroscopic features of Dequervians Thyroiditis
  2. Diffuse smooth symmetrical goiter.
  3. Multiple nodules.
  4. Bilateral or unilateral enlarged lobes.
  5. Only microscopic changes
A
  1. Bilateral or unilateral enlarged lobes
  2. Macroscopic features of Dequervians Thyroiditis: (TW)
  3. Diffuse smooth symmetrical goiter - F - Hashimotos / Graves
  4. Multiple nodules - F - MNG
  5. Bilateral or unilateral enlarged lobes
  6. Only microscopic changes - F - subacute lymphocytic (painless) thyroidits. AKA lymphocytic thyroiditis.
    DeQuervains (AKA subacute (granulomatous) thyroiditis): Self-limited granulomatous thyroiditis with distinct histology characterised by GC formation / granulomata. Probably viral links with previous viral infection (mumps, measles, flu adenovirus, coxsackievirus, echovirus).
    30-50yo. Women 5x > men.
39
Q
  1. Least likely to cause Hyperthyroidism?
  2. Graves disease.
  3. Toxic adenoma.
  4. Hashimotos thyroiditis.
  5. Riedels Thyroiditis.
  6. Subacute thyroiditis.
A
  1. Reidel’s Thyroiditis – F - rare disorder of unknown etiology characterised by extensive fibrosis; hard, firm thyroid mass. Thyroid function depends on the extent to which the normal thyroid gland has been replaced by fibrotic tissue. Most patients are euthyroid. Hypothyroidism is noted in approx 30% of cases. Very rarely can hyperthyroidism occur, but this is probably secondary to a coexisting condition.
  2. Least likely to cause Hyperthyroidism? (TW)
  3. Graves disease - T - most common cause of endogenous hyperthyroidism. Autoimmune disorder produced by autoantibodies to the TH receptor.
  4. Toxic adenoma - T - in a minority of cases adenomas may be hyperfunctional with autonomous secretion of thyroid hormone.
  5. Hashimotos thyroiditis - T - 5% do get initial hyperthroidism. In some cases it may be preceded by transient thyrotoxicosis. Autoimmune destruction of thyroid gland.
  6. Reidel’s Thyroiditis – F - rare disorder of unknown etiology characterised by extensive fibrosis; hard, firm thyroid mass. Thyroid function depends on the extent to which the normal thyroid gland has been replaced by fibrotic tissue. Most patients are euthyroid. Hypothyroidism is noted in approx 30% of cases. Very rarely can hyperthyroidism occur, but this is probably secondary to a coexisting condition.
  7. Subacute thyroiditis – T - principle clinical manifestation of painless thyroidits is hyperthyroidism. Increased T3, T4, and reduced TSH.
40
Q
  1. In regards to thyroid cancer

1. 20% of medullary thyroid cancer associated with MEN

A
  1. In regards to thyroid cancer: (TW)
  2. 20% of medullary thyroid cancer associated with MEN - T - ~80% of MTC are sporadic, the rest are familial as part of the MEN2 syndrome.
41
Q
  1. Phaeochromocytoma not associated with
  2. MEN
  3. VHL
  4. Sarcoidosis
  5. Can’t remember d
  6. Can’t remember e
A
  1. Sarcoidosis - F
  2. Phaeochromocytoma not associated with: (TW)
  3. MEN - T - MEN2A: P-M-P (pheochromocytoma, medullary carcinoma thyroid, phyerparathyroidism due to primary parathyroid hyperplasia). MEN2B / 3: M-P-MN (medullary carcinoma thyroid, pheo, mucosal neuromas / intestinal ganglioneuromas, marfanoid). Chromosome 10
  4. VHL - T - two primary familial disorders associated with pheochromocytoma, both autosomal dominant inheritance: vHL and MEN2. vHL phenotype: pheochromocytoma (frequently bilateral), paraganglioma (rarely), retinal angioma, cerebellar hemangioblastoma, epididymal cystadenoma, renal and pancreatic cysts, pancreatic neuroendocrine tumors, and renal cell carcinoma. Chromosome 3p25
  5. Sarcoidosis - F
  6. NF - T - AD, chromosome 17, Approx 2% of pts with NF1 develop catecholamine-secreting tumors (usually a solitary benign adrenal pheochromocytoma).
  7. Can’t remember e
42
Q
  1. 76 year old male for radiotherapy of thyroid lesion. Most likely?
  2. Anaplastic
  3. Follicular
  4. Medullary
  5. Papillary
  6. Lymphoma
A
  1. Anaplastic - T - surgery often not indicated as usually advanced disease. Locally advanced inoperable disease - combined XRT and chemotTX. If localized, complete resection should be attempted with postoperative combined modality therapy with radiation and chemotherapy for tumors that are resected completely (no extrathyroid spread). Hyperfractionated XRT (high ‘radical’ doses >Gy) appears to be associated with improved local control of disease.
  2. 76 year old male for radiotherapy of thyroid lesion. Most likely? (TW). Presuming they mean external beam and not I131.
  3. Anaplastic - T - surgery often not indicated as usually advanced disease. Locally advanced inoperable disease - combined XRT and chemotTX. If localized, complete resection should be attempted with postoperative combined modality therapy with radiation and chemotherapy for tumors that are resected completely (no extrathyroid spread). Hyperfractionated XRT (high ‘radical’ doses >Gy) appears to be associated with improved local control of disease.
  4. Follicular - F - Surgery + I131
  5. Medullary - F - Best treatment for MC is thyroidectomy and lymphadenectomy. Note that early studies found no survival benefit from ext beam XRT (ie path notes), however retrospective analysis showed XRT may prolong the interval until disease progression or recurrence in some patients. XRT useful for primary therapy if resection incomplete, and for adjuvant therapy. ChemoTx, transarterial chemoembolisation also can be used for advanced / residual disease.
  6. Papillary - F - surgery + I131
  7. Lymphoma - ?F (but also potentially true as well) - Pts with thyroid lymphoma should be staged like any other patient with lymphoma. Stage I or limited stage II - choid is between radiotherapy alone for indolent lymphoma, or combined XRT and chemoTx for aggressive histologies. Rate of local contral with 35-40Gy given in 4 weeks is excellent. Radiation therapy alone is adequate Tx for localized indolent lymphomas, such as MALT lymphoma or follicular lymphoma. Combined Tx for all patients with aggressive histiology thyroid lymphoma.
43
Q
  1. Which is true regarding (presumably thyroid) medullary carcinoma?
  2. 10-15% are associated with BRCA 1 or 2
  3. Age >65
  4. Calcification
A
  1. Calcification - T - coarse calcifications are the most common type of calcification in MTCs (Radiographics). Thyroid microcalcifications are psammoma bodies and are one of the most specific features of thyroid malignancy. They are found in all primary thyroid carcinomas, most commonly papillary.
  2. Which is true regarding medullary carcinoma? (TW)
  3. 10-15% are associated with BRCA 1 or 2 - F - think “Boobs, Bums, Booze, Babies”. Increased risk in Boobs: Breast (male and female); Bums: Colon (only minimal increase); Booze: Pancreatic cancer; Babies: Ovarian and Prostate cancer.
  4. Age >65 - F - generally peak incidence is 40-50yo, or younger (20-30yo) for familial types. Papillary (20-40yo). Follciular (40-50yo). Anaplastic (>60yo).
  5. Calcification - T - coarse calcifications are the most common type of calcification in MTCs (Radiographics). Thyroid microcalcifications are psammoma bodies and are one of the most specific features of thyroid malignancy. They are found in all primary thyroid carcinomas, most commonly papillary.
    In most patients with MTC, the disease has already metastasized at the time of diagnosis.
44
Q
  1. Which is true regarding primary hyperaldosteronism?
  2. Hyperkalaemia
  3. Solitary adenoma
  4. Hyponatraemia
  5. Metabolic acidosis
A
  1. Solitary adenoma - T - most common subtypes of primary adlosternoism are: aldosterone-producing adenoma; bilateral idiopathic hyperaldosteronism. Less common forms include: unilateral adrenal hyperplasia; bilateralhyperplasia; familial hyperaldosteronism; pure aldosterone-producing adrenocortical carcinoma and ectopic aldosterone-secreting tumors.
  2. Which is true regarding primary hyperaldosteronism? (TW)
  3. Hyperkalaemia - F - hypo. Aldosterone in kidney: increases number of open sodium channels in luminal membrane leading to increased sodium (cations) resorption, which makes the lumen electronegative, thereby creating an electrical gradient that favors secretion of cellular potassium into the lumen - resultant hypokalemia (however is an inconsistent finding).
  4. Solitary adenoma - T - most common subtypes of primary adlosternoism are: aldosterone-producing adenoma; bilateral idiopathic hyperaldosteronism. Less common forms include: unilateral adrenal hyperplasia; bilateralhyperplasia; familial hyperaldosteronism; pure aldosterone-producing adrenocortical carcinoma and ectopic aldosterone-secreting tumors.
  5. Hyponatraemia - F - increased sodium resorption (see ans. 1.). There may be mild hypernatremia only, due to the bodys regulatory mechanism: ADH released + thirst which maintains a stable sodium concentration.
  6. Metabolic acidosis - F - alkalosis. Increased urinary H= secretion mediated by hypokalemia (which directly increases bicarbonate resorption) and direct stimulatory effect of aldosterone on distal acidification. In a low K+ state: get a shift of K+ out of cells / exchanged for H+ which moves into cells to compensate.
    Classic presenting signs of primary aldosteronism are hypertension and hypokalemia.
    Added option 4.
45
Q
  1. VHL is associated with all of the following except…
  2. Papillary RCC
  3. Clear cell RCC
  4. 3p deletions
  5. Retinal angiomas
  6. Pheochromocytomas
A
  1. Papillary RCC - F - RCCs of predominant papillary, chromophobe, or oncocytic histology are not associated with vHL disease (UTD). pRCC is the 2nd most common subtype, and most common multifocal or bilateral renal tumor. Most pRCCs are sporadic.
  2. VHL is associated with all of the following except: (TW)
  3. Papillary RCC - F - RCCs of predominant papillary, chromophobe, or oncocytic histology are not associated with vHL disease (UTD). pRCC is the 2nd most common subtype, and most common multifocal or bilateral renal tumor. Most pRCCs are sporadic.
  4. Clear cell RCC - T - all vHL-associated RCCs are clear cell tumors, although these clear cell tumors may contain minor papillary components (usually <25% of the lesion).
  5. 3p deletions - T - vHL gene Ch 3p25. Specific germline mutations or deletions of the vHL gene can influence the clinical manifestations of vHL disease.
  6. Retinal angiomas - T - see below
  7. Pheochromocytomas - T - vHL phenotype: pheochromocytoma (frequently bilateral), paraganglioma (rarely), retinal angioma, cerebellar hemangioblastoma, epididymal cystadenoma, renal and pancreatic cysts, pancreatic neuroendocrine tumors, and renal cell carcinoma.
46
Q
  1. Phaeochromocytoma is not associated with…
  2. Nephritic syndrome
  3. Elevated VMA
  4. Headache
A
  1. Nephritic syndrome - F - proteinuria (usually not severe), hematuria (RBC casts), hypertension, uremia and variable renal insuffciency (azotemia, oliguria).
  2. Phaeochromocytoma is not associated with: (TW)
  3. Nephritic syndrome - F - proteinuria (usually not severe), hematuria (RBC casts), hypertension, uremia and variable renal insuffciency (azotemia, oliguria).
  4. Elevated VMA - T - VMA: vanillylmandelic acid is metabolite of norepinephrine, elevated in phaeo and neuroblastoma. If high clinical suspicion test 24hr urine and plasma metanephrines (plasma metanephrines probably superior test); if low clinical suspicion test 24hr urine. If positive then MRI or CT.
  5. Headache - T - classic triad of pheochromocytoma is 1) episodic headache, 2) sweating, 3) tachycardia. About 50% have paroxysmal hypertension; most of rest have what appears to be essential hypertension.
    Symptoms of phaeochromocytoma are cause by tumoral hypersecretion of norepinephrine, epihephrine and dopamine, although increased central sympathetic activity may also contribute.
47
Q
  1. Phaeochromocytomas are not associated with:
  2. VHL
  3. MEN 2
  4. Neurofibromatosis
  5. Sarcoidosis
A
  1. Sarcoidosis - F
  2. Phaeochromocytomas are not associated with: (TW)
  3. VHL - T - two primary familial disorders associated with pheochromocytoma, both autosomal dominant inheritance: vHL and MEN2. vHL phenotype: pheochromocytoma (frequently bilateral), paraganglioma (rarely), retinal angioma, cerebellar hemangioblastoma, epididymal cystadenoma, renal and pancreatic cysts, pancreatic neuroendocrine tumors, and renal cell carcinoma. Chromosome 3p25.
  4. MEN 2 - T - MEN2A: P-M-P (pheochromocytoma, medullary carcinoma thyroid, phyerparathyroidism due to primary parathyroid hyperplasia). MEN2B / 3: M-P-MN (medullary carcinoma thyroid, pheo, mucosal neuromas / intestinal ganglioneuromas, marfanoid). Chromosome 10. Sipple syndrome (MEN 2).
  5. Neurofibromatosis - T - AD, chromosome 17, Approx 2% of pts with NF1 develop catecholamine-secreting tumors (usually a solitary benign adrenal pheochromocytoma).
  6. Sarcoidosis - F
    Most catecholamine-secreting tumors are sporadic, however 15-20% have the disease as part of a familial disorder; in these patients it is more likely to be bilateral adrenal phaeo’s or paragangliomas.
    MEN 1 (Wermer): PPP (primary hyperparathyroidism, pituitary tumors, pancreatic neuroendocrine tumors.
48
Q
  1. Cancer Thyroid: (True or False)
    a. Follicular overlapping features with papillary
    b. Medullary Cancer amyloid deposits
    c. Paillary lymph node mets
    d. Follicular Hematogenous
    e. Female more common than male
A

a. Follicular overlapping features with papillary - F - follicular has variable architecture: typically microfollicular architecture with uniform cuboidal cells. No nuclear features of papillary carcinoma and no psamomma bodies.
* *note papillary is allowed to have some follicular features, but if any there are papillary features, gets called papillary (Robbins) (RY)

  1. Cancer Thyroid: (TW)
    a. Follicular overlapping features with papillary - F - follicular has variable architecture: typically microfollicular architecture with uniform cuboidal cells. No nuclear features of papillary carcinoma and no psamomma bodies.
    b. Medullary Cancer amyloid deposits - T - Medullary - any age (peak 20-30s for MEN, 40-50s sporadic), tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. More aggressive MENIIb
    c. Paillary lymph node mets - T - Papillary - young (esp 20-40yo), female, lymphatic spread, calcification, orphan annie nuclei, irradiation, pasmmoma bodies. Px 10y survival 98%.
    d. Follicular Hematogenous - T - Follciular - any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion
    e. Female more common than male - T: female predominance in early and middle aged adults presenting with thyroid cancer, and equal distribution in childhood and late adult years (LW).
49
Q
  1. Hashimotos – False
    a. Lymphocyte infiltrate is sine qua non
    b. Hurthle cell
    c. Autoimmune thyroiditis
    d. Granulosa
    e. Hyper functioning early
A

d. Granulosa - F - ?bad recall - not sure if this meant ‘granuloma’ in which case referring to subacute (granulomatous thyroiditis) AKA DeQuervain thyroiditis.

  1. Hashimotos – False (TW)
    a. Lymphocyte infiltrate is sine qua non - T - extensive infiltration of parenchyma by a mononuclear inflammatory infiltrate containing small lymphocytes, plasma cells, and well-developed germinal centers. The sine quq non is stromal infiltration by lymphocytes and variable numbers of plasma cells.
    b. Hurthle cell - T - Thyroid follicles are small and are lined in many areas by epithelial cells with abundant eosinophilic, granular cytoplasm, termed Hürthle cells. Hürthle cells (oncycytes) are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).
    c. Autoimmune thyroiditis - T - chronic autoimmune thyroid disorder characterised by a slowly destructive lymphoid infiltrate of the thyroid gland, variable thyroid function, and high circulating titres of antithyroid antibodies,
    d. Granulosa - F - ?bad recall - not sure if this meant ‘granuloma’ in which case referring to subacute (granulomatous thyroiditis) AKA DeQuervain thyroiditis.
    e. Hyper functioning early - T - transient hyperthyroid with increased T3/T4 and reduced TSH, later have reduced T3/T4 and elevated TSH.
50
Q
  1. CA Thyroid
    a. 20% MEN with medullary
    b. Follicular growth
    c. Papillary Hematogenous spread
    d. Follicular ill defined mass
    e. Medullary calcitonin
A

a and e

  1. CA Thyroid (JS)
    a. 20% MEN with medullary - T - 80% arise sporadically, the remaining 20% occur in the setting of MEN IIA or IIB or as familial tumours without an association with MEN
    b. Follicular growth - ???
    c. Papillary Hematogenous spread - F - foci of lymphatic invasion are often present but involvement of blood vessels is uncommon. Mets to local LN in half of cases.
    d. Follicular ill defined mass - F - present as a slowly enlarging painless nodule
    e. Medullary calcitonin - T - neuroendocrine neoplasms derived from parafollicular (C) cells which secrete calcitonin
51
Q
  1. Neuroendocrine neoplasm of the lungs – FALSE
    a. Small foci of neuro endocrine cells in a scar are inconsequential
    b. Carcinoid occur in alveolar cells and deviates rather than invading adjacent bronchi
    c. Mitotic rate, lymph node invasion and differentiation important to differentiate between typical and atypical carcinoid but this is difficult with a FNA
    d. Small cell is neuroendocrine tumour
A

b. Carcinoid occur in alveolar cells and deviates rather than invading adjacent bronchi - F - arise from K cells of bronchial mucosa and penetrate the bronchial wall to fan out producing the collar-button lesions

  1. Neuroendocrine neoplasm of the lungs – FALSE (JS)
    a. Small foci of neuro endocrine cells in a scar are inconsequential - T - can have benign tumorlets in areas of scarring or chronic inflammation
    b. Carcinoid occur in alveolar cells and deviates rather than invading adjacent bronchi - F - arise from K cells of bronchial mucosa and penetrate the bronchial wall to fan out producing the collar-button lesions
    c. Mitotic rate, lymph node invasion and differentiation important to differentiate between typical and atypical carcinoid but this is difficult with a FNA - T - I presume but can’t find anything about FNA diagnosis…
    d. Small cell is neuroendocrine tumour - T - contain neurosecretory granules similar to those found in Kulchitsky cells
52
Q
  1. 18 year old with a pancreatic neoplasm is most likely to be
    a. Intraductal mucinous papillary tumour
    b. Cystadenocarcinoma
    c. Solid pseudopapillary tumour
    d. Cystadenoma
A

c. Solid pseudopapillary tumour - T - most common in <35yo, 90% are female. Gross: large, usually encapsulated, hemorrhagic, necrotic, rarely multifocal; most common in tail of pancreas. Excellent prognosis after excision; mets in 4% (omentum, liver, LNs). [Path outlines; Dahnert]

  1. 18 year old with a pancreatic neoplasm is most likely to be: (GC)
    a. Intraductal mucinous papillary tumour - F - typically older patients.
    b. Cystadenocarcinoma - F - 40-60yo; mucinous tumour - large, thick-walled, usually in body + tail; eggshell Ca2+.
    c. Solid pseudopapillary tumour - T - most common in <35yo, 90% are female. Gross: large, usually encapsulated, hemorrhagic, necrotic, rarely multifocal; most common in tail of pancreas. Excellent prognosis after excision; mets in 4% (omentum, liver, LNs). [Path outlines; Dahnert]
    d. Cystadenoma - F - >60yo, 70% are female, associated with VHL.
53
Q
  1. The organ of Zuckerkandl is located
    a. In the bladder wall
    b. Near the origin of the inferior mesenteric artery
    c. At the carotid artery bifurcation
    d. In the adrenal gland
A

b. Near the origin of the inferior mesenteric artery - T - 2nd most common site of extra-adrenal pheochromocytoma (2-5%), after the paraaortic sympathetic chain (8%).

  1. The organ of Zuckerkandl is located: (GC)
    a. In the bladder wall - F - accounts for 1% of extra-adrenal pheochromocytomas.
    b. Near the origin of the inferior mesenteric artery - T - 2nd most common site of extra-adrenal pheochromocytoma (2-5%), after the paraaortic sympathetic chain (8%).
    c. At the carotid artery bifurcation - F - carotid body
    d. In the adrenal gland - F - pheochromocytomas occur in adrenal medulla. [Dahnert]
54
Q
  1. Which of the following is false regarding thyroid carcinoma?
    a. Papillary carcinoma is associated with lymph node metastases
    b. Medullary carcinoma is associated with MEN (20% attached to this stem)
    c. Follicular carcinoma appears as an ill-defined nodule
A

c. Follicular carcinoma appears as an ill-defined nodule - F - Follciular - Encapsulated tumor sometimes very difficult to differentiate from adenomas. Any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion. US: indistinguishable from benign follicular adenoma.

  1. Which of the following is false regarding thyroid carcinoma? (TW)
    a. Papillary carcinoma is associated with lymph node metastases - T - Papillary - young (esp 20-40yo), female, lymphatic spread, calcification, orphan annie nuclei, irradiation, pasmmoma bodies. Px 10y survival 98%.
    b. Medullary carcinoma is associated with MEN (? % attached to this stem) - T - Medullary - any age (peak 20-30s for MEN, 40-50s sporadic). Sporadic 80%. Tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. More aggressive MENIIb. Penetrance of medullary thyroid cancer in MEN2A is nearly 100%. MTC occurs in almost all MEN2b patients.
    c. Follicular carcinoma appears as an ill-defined nodule - F - Follciular - Encapsulated tumor sometimes very difficult to differentiate from adenomas. Any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion. US: indistinguishable from benign follicular adenoma.
55
Q
  1. Which is true regarding medullary carcinoma?
    a. 10-15% are associated with BRCA 1 or 2
    b. Age >65
    c. Calcification
A

*SCS: depends on if asking about breast ca or Thyroid cancer.
If thyroid: C
If breast: A

  • LW: Assuming thyroid medullary carcinoma:
  • Answer = C: calcification, occurs in medullary thyroid carcinoma, along with amyloid sheets.
  • No association with BRCA, and peaks 20-30s.

If in relation to medullary breast carcinoma:
a. 10-15% are associated with BRCA 1 or 2 - T - More frequent in women who inherit mutations of BRCA-1 gene. Up to 20% or breast cancers in BRCA1 carriers had Medullary histology, and up to 3% in BRCA2 carriers (JAMA 1998).

  1. Which is true regarding medullary carcinoma? (TW)
    a. 10-15% are associated with BRCA 1 or 2 - T - More frequent in women who inherit mutations of BRCA-1 gene. Up to 20% or breast cancers in BRCA1 carriers had Medullary histology, and up to 3% in BRCA2 carriers (JAMA 1998).
    b. Age >65 - F - medullary and medullary-like carcinomas occur more frequently in younger patients than other types of breast cancer (~35yo).
    c. Calcification - F - rounded soft tumor that grows rapidly. Necrosis is common and may result in cyst formation. Calcification is uncommon and DCIS is either very limited or not present.
56
Q
  1. A woman 3 months post partum presents with headache and hypopituitarism. Which is most likely?
    a. Empty sella
    b. Rathke cyst
    c. Lymphocytic hypophysitis
A

c. Lymphocytic hypophysitis - T - uncommon disorder that is initially characterized by lymphocytic infiltration and enlargement of the pituitary; this stage is followed by destruction of the pituitary cells. It most often occurs in late pregnancy or postpartum period. Affected patients typically present with headache. Preferential hypofunction of ACTH and TSH has been described, however diabetes insipidus, hyperprolactinemia, growth hormone excess, and associated autoimmune thyroiditis can occur.

  1. A woman 3 months post partum presents with headache and hypopituitarism. Which is most likely? (TW)
    a. Empty sella - F - empty sella syndrome may be assoc with visual field defects and occasionally with endocrine anomalies, such as hyperprolactinemia. Only rarely is it associated with hypopituitarism because sufficient functioning parenchyma is maintained (Robbins). UTD says: although some papers claim deficiences of 1 or more pituitary hormones (in primary empty sella) - the evidence for such deficiencies is not convincing; ie, there is no consistent evidence of an “empty sella syndrome”. If considering secondary ESS and Sheehan’s, see below.
    b. Rathke cyst - F
    c. Lymphocytic hypophysitis - T - uncommon disorder that is initially characterized by lymphocytic infiltration and enlargement of the pituitary; this stage is followed by destruction of the pituitary cells. It most often occurs in late pregnancy or postpartum period. Affected patients typically present with headache. Preferential hypofunction of ACTH and TSH has been described, however diabetes insipidus, hyperprolactinemia, growth hormone excess, and associated autoimmune thyroiditis can occur.
    Sheehan’s syndrome: Less common in developed countries. Typically pts have Hx of postpartum hemorrhage so severe as to cause hypotension and require transfusion of multiple units of blood. Severe hypopituitarism can be recognized during the 1st days or weeks after delivery by development of lethargy, anorexis, weight loss, and inability to lactate. Less severe hypopituitarism may be manifested in the wks and months after delivery. The mildest degrees of hypopituitarism may not be recognized for may years after the inciting event. Most patients have a small pituitary within a sella of normal size, sometimes read as an “empty sella” on MRI. More selective loss of the anterior pituitary lobe (supplied from low-pressure venous system) relative to the posterior pituitary which receives blood directly from arterial branches (less susceptible to ischaemic injury and is therefore usually not affected).
    Sheehan’s syndrome, causing secondary empty sella (ie option a.) - I don’t think would account for the 3/12 presentation (ie less severe Sheehan’s) with both headache and hypopit. ** but open for discussion **
57
Q
  1. What is true regarding primary hyperaldosteronism?
    a. Hyperkaelaemia
    b. Adenoma <2cm
    c. Adenoma >3cm
A

b. Adenoma <2cm - T - 80% of cases are caused by an adenoma in one gland (Conn syndrome). These are almost always solitary and small (<2cm). Other causes include primary adrenocortical hyperplasia or glucocorticoid suppressible hyperaldosteronism

  1. What is true regarding primary hyperaldosteronism? (JS)
    a. Hyperkaelaemia - F - Primary hyperaldosteronism is a group of syndromes characterised by excess aldosterone secretion, causing sodium retention and potassium excretion with resultant hypertension and hypokalaemia
    b. Adenoma <2cm - T - 80% of cases are caused by an adenoma in one gland (Conn syndrome). These are almost always solitary and small (<2cm). Other causes include primary adrenocortical hyperplasia or glucocorticoid suppressible hyperaldosteronism
    c. Adenoma >3cm
58
Q
  1. Which is not associated with Zollinger Ellison syndrome?
    a. Peptic ulcer disease
    b. Lymphoma in the gastric folds
    c. Atrophic gastritis
    d. Hypervascular pancreatic mass
    e. Gastrinoma
A

Both b and c

b. Lymphoma in the gastric folds - T - complications include: malignant islet cell tumour (in 60%), liver mets with continued gastric secretion, perforated DU/jejunal ulcer, oesoph stricture with reflux, obstruction, GI bleeding, gastric carcinoids (esp. in MEN1).
c. Atrophic gastritis - T causes a hypertrophic gastritis.

  1. Which is not associated with Zollinger Ellison syndrome? (JS)
    a. Peptic ulcer disease - F - multiple in 10%; solitary ulcer in 90%; recurrent or intractable; unusual locations (postbulbar).
    b. Lymphoma in the gastric folds - T - complications include: malignant islet cell tumour (in 60%), liver mets with continued gastric secretion, perforated DU/jejunal ulcer, oesoph stricture with reflux, obstruction, GI bleeding, gastric carcinoids (esp. in MEN1).
    c. Atrophic gastritis - T - Causes hypertrophic gastritis. Hypergastrinaemia causes gastric gland hyperplasia (mainly parietal cells in fundus).
    d. Hypervascular pancreatic mass - F - may arise in the pancreas, peripancreatic region or wall of the duodenum
    e. Gastrinoma - F - Cause of ZE in 90% of cases = non-beta cell gastrin-secreting tumour of the pancreas
  • RY - note: Presume this is the old format of q where there are multiple correct answers. Zollinger Ellison specifically causes a hypertrophic gastritis (not atrophic). Although if question was high gastrin levels then high gastrin can be seen in autoimmune atrophic gastritis. Zollinger Ellison is not associated with lymphoma (classic association for gastric lymphoma is chronic H pylori gastritis).
  • AJL good explanantion. I agree.
59
Q
  1. Phaeochromocytomas are not associated with:

a. VHL
b. MEN 2
c. Neurofibromatosis
d. Sarcoidosis

A

d. Sarcoidosis

CDHB Path (22 decks)

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