Thyroid Carcinoma

Thyroid Carcinoma

Q. 1 Thyroid carcinoma associated with hypocalcemia is

 A Follicular carcinoma

 B

Medullary carcinoma

 C

Anaplastic carcinoma

 D

Papillary carcinoma

Q. 1

Thyroid carcinoma associated with hypocalcemia is

 A

Follicular carcinoma

 B

Medullary carcinoma

 C

Anaplastic carcinoma

 D

Papillary carcinoma

Ans. B

Explanation:

Answer is B (Medullary Carcinoma)

Medullary carcinoma of thyroid secretes calcitonin and this causes reduction in calcium levels.


Q. 2

FNAC is useful in all the following types of thyroid carcinoma except

 A

Papillary

 B

Follicular

 C

Anaplastic

 D

Medullary

Ans. B

Explanation:

Answer is B (Follicular)

FNAC is the investigation of choice in discrete thyroid swellings.

FNAC cannot distinguish between a Follicular Adenoma and a Follicular Carcinoma as this distinction is dependant not on cytology but on histological criteria such as capsular and vascular invasion. FNAC thus cannot be used to diagnose Follicular carcinomas.

Conditions that may be diagnosed by FNAC are : 

  1. Papillary carcinoma
  2. Medullary carcinoma
  3. Anaplastic carcinoma
  4. Lymphoma
  5. Thyroiditis
  6. Colloid nodules

Q. 3 FNAC is not useful in which of the following thyroid carcinoma:

March 2012

 A Medullary carcinoma

 B

Follicular carcinoma

 C

Papillary carcinoma

 D

Lymphoma

Ans. B

Explanation:

Ans: B i.e. Follicular carcinoma

Thyroid carcinoma

  • Thyroid conditions that may be diagnosed by FNAC include colloid nodules, thyroiditis, papillary carcinoma, medullary carcinoma, anaplastic carcinoma & lymphoma
  • FNAC cannot distinguish between a benign follicular adenoma & follicular carcinoma, as this distinction is dependent not on cytology but on histological criteria, which include capsular & vascular invasion

Q. 4 Medullary carcinoma thyroid all EXCEPT:

March 2013

 A Contains amyloid

 B

TSH dependent

 C

Secretes calcitonin

 D

Patients should be screened for RET point mutation on chromosome 10

Ans. B

Explanation:

Ans. B i.e. TSH dependent

The rate of growth of papillary carcinoma thyroid may be stimulated by TSH

Thyroid medullary Ca/ MTC

  • 80% cases are sporadic,
  • 20% are familial (MEN-Ha or MEN-Hb),
  • MTC is the first abnormality expressed in MEN-Ha/ Ilb,
  • Stroma of MTC shows material with staining properties of amyloid,
  • MTC can be diagnosed by demonstrating calcitonin within the MTC cells (on immuno-histochemical studies),
  • Total thyroidectomy is the TOC

Q. 5 True regarding Papillary carcinoma of thyroid is:

March 2008

 A Undifferentiated carcinoma

 B

Blood-borne metastasis is commoner

 C

Excellent prognosis

 D

Capsulated

Ans. C

Explanation:

Ans. C: Excellent prognosis

Papillary carcinoma is a relatively common well-differentiated thyroid carcinoma.

Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive. In fact, these tumors may spread easily to other organs. Papillary tumors have a propensity to invade lymphatics but are less likely to invade blood vessels.

Papillary carcinoma appears as an irregular solid or cystic mass in a normal thyroid parenchyma. They are very seldom encapsulated

Thyroid cancers are more often found in patients with a history of low- or high-dose external irradiation. Papillary tumors of the thyroid are the most common form of thyroid cancer to result from exposure to radiation.

The life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients than for patients who are older than 45 years of patients with papillary cancers, about 11% present with metastases outside the neck and mediastinum.

FNAB is considered the best first-line diagnostic procedure for a thyroid nodule; FNAB is a safe and minimally invasive procedure.

Surgery is the definitive management of thyroid cancer, and various types of operations may be performed.

  • Lobectomy with isthmectomy
  • Subtotal thyroidectomy

This is a near-total thyroidectomyPatients younger than 40 years who have papillary thyroid carcinoma nodules that are smaller than 1 cm, well-defined, minimally invasive, and isolated may be treated with hemithyroidectomy and isthmectomy

  • Total thyroidectomy

Perform a total thyroidectomy (removal of all thyroid tissue but preserving the contralateral parathyroid glands) in patients who are older than 40 years with papillary carcinoma and in any patient with bilateral disease Compared with most cancers the prognosis in differentiated thyroid carcinoma is excellent.


Q. 6 Amyloid deposition is seen in which type of carcinoma thyroid:  

September 2009

 A Follicular

 B

Anaplastic

 C

Anaplastic

 D

Medullary

Ans. D

Explanation:

Ans. D: Medullary

Medullary tumors have an ominous histologic pattern, with solid masses of cells with large vesicular nuclei. There may be considerable associated fibrosis, and deposits of amyloid are a helpful diagnostic point.

These tumors are entities distinct from the undifferentiated cancers and medullary carcinomas have a much better prognosis.

Medullary thyroid carcinoma (MTC) is associated with amyloid deposition in the surrounding tissues. Full-length calcitonin is the sole constituent of amyloid in MTC.


Q. 7 All of the following are true regarding medullary carcinoma of thyroid except:     

March 2010

 A Total thyroidectomy is done

 B

Parafollicular cells involved

 C

TSH dependent

 D

Releases calcitonin

Ans. C

Explanation:

Ans. C: TSH dependent

Medullary tumors are the third most common of all thyroid cancers (about 5 to 8 percent).

Unlike papillary and follicular thyroid cancers which arise from thyroid hormone producing cells, medullary cancer of the thyroid originates from the parafollicular cells (also called C cells) of the thyroid.

These C cells make a different hormone called calcitonin.

High levels of serum calcitonin and carcinoembryonic antigen are produced by many medullary tumours.

Levels falls after resection and rise again with recurrence making it a valuable tumour marker in the follow-up of patients with this disease

This cancer has a much lower cure rate than does the “well differentiated” thyroid cancers (papillary and follicular), but cure rates are higher than they are for anaplastic thyroid cancer.

  • Sporadic- Accounts for 80% of all cases of medullary thyroid cancer.

They are typically unilateral and there are no associated endocrinopathies (not associated with disease in other endocrine glands.

Peak onset 40 – 60. Females outnumber males by 3:2 ratio.

One third will present with intractable diarrhea. Diarrhea is caused by increased gastrointestinal secretion and hypermotility due to the hormones secreted by the tumor (calcitonin, prostaglandins, serotonin, or VIP).

  • MEN H-A (Sipple Syndrome). Multiple Endocrine Neoplasia Syndromes are a group of endocrine disorders. Sipple syndrome has bilateral medullary carcinoma or C cell C cell hyperplasia, pheochromocytoma and hyperparathyroidism.

This syndrome is inherited and is due to a defect of a gene (DNA) which helps control the normal growth of endocrine tissues.

This inherited syndrome is passed on to all children who get the gene (inherited in an autosomal dominant fashion). Males and females are equally affected. Peak incidence of medullary carcinoma in these patients is in the 30’s.

  • MEN II-B. This syndrome also has medullary carcinoma and pheochromocytoma, but only rarely will have hyperparathyroidism. Instead these patients have an unusual appearance which is characterized by mucosal ganglioneuromas (tumors in the mouth) and a Marfanoid habitus.

Inheritance is autosomal dominant as in MEN II-a, or it can occur sporadically (without being inherited). MEN II-B patients usually get medullary carcinoma in their 30’s, and males and females are equally effected.

As with MEN II-A, pheochromocytomas must be detected prior to any operation. The idea here is to remove the pheochromocytoma first to remove the risk of severe hypertensive episodes while the thyroid or parathyroid is being operated on.

  • Inherited medullary carcinoma without associated endocrinopathies. This form of medullary carcinoma is the least aggressive. Like other types of thyroid cancers, the peak incidence is between the ages of 40 and 50. Involvement of lymph nodes occurs in 50-60% of cases of MCT and blood-borne metastases are common. They are not TSH dependent and do not take up radioactive iodine

Treatment is by total thyroidectomy and either prophylactic or therapeutic resection of the central and bilateral cervical lymph nodes.


Q. 8 Which of the following is initial investigation of choice for a patient presenting with solitary nodule of thyroid:   

March 2005

 A

Thyroid function test

 B

FNAC

 C

Radionuclide scan

 D

MRI

Ans. B

Explanation:

Ultrasound is the preferred imaging modality for thyroid nodules, and the ultrasound guided fine needle aspiration biopsy (FNAB) is the preferred method of tissue. 


Q. 9

Percentage of cold thyroid nodules likely to be malignant:

 A

20%

 B

30%

 C

40%

 D

72%

Ans. A

Explanation:

Ans. 20%


Q. 10

Psammoma bodies are seen in all except ‑

 A

Seminoma

 B

Meningioma

 C

Papillary carcinoma of thyroid

 D

Papillary serous cystadenocarcinoma of the ovary

Ans. A

Explanation:

Ans. is ‘A’ i.e., Seminoma

Psammoma bodies represent a process of dystrophic calcification.

Single necrotic cells may constitute seed crystals that become encrusted by the mineral deposits. The progressive acquisition of outer layers may create lamellated configurations, called psammoma bodies because of their resemblance to grains of sand.

Psammoma bodies are seen in :

  • Papillary cancer of the thyroid
  • Meningioma
  • Papillary serous cystadenocarcinoma of the ovary

Q. 11 Medullary thyroid carcinoma is associated with‑

 A MEN I

 B

MEN II

 C

MEN III

 D

MEN IV

Ans. B

Explanation:

Ans. is ‘b’ i.e., MEN II

About 70% of tumors arise sporadically. The remainder occurs in the rsetting of MEN syndrome 2A or 2B or as familial tumors without an associated MEN syndrome (familial medullary thyroid carcinoma, or FMTC.


Q. 12 The histopathological picture of a patient suffering from carcinoma is shown below.The multiple,round figures seen in the image is due to a mineral deposition .It can be seen in all of the following conditions,except:

 A

Papillary thyroid carcinoma

 B

Adenocarcinoma of Lung

 C

Meningioma

 D

Squamous cell carcinoma of Tongue.

Ans. D

Explanation:

Ans:D.)Squamous cell carcinoma of Tongue.

The histopathological picture shows Psammoma Bodies.

Psammoma bodies

  • They are round microscopic calcific collections.
  • It is a form of dystrophic calcification.
  • Necrotic cells forms the focus for surrounding calcific deposition.
  • They have a lammelated concentric calcified structure, sometimes large enough to be seen on CT.
  • Psammoma bodies are found in a diverse group of tumours which include:
    • papillary thyroid carcinoma
    • papillary serous endometrial adenocarcinoma
    • meningioma
    • mesothelioma
    • serous cystadenocarcinoma of the ovary
    • adenocarcinoma of lung.

Q. 13 Identify the type of thyroid carcinoma shown in the photomicrograph below ? 

 A

Medullary.

 B

Anaplastic.

 C

Papillary.

 D

Large cell lymphoma.

Ans. C

Explanation:

Papillary carcinoma (PTC)is the most common form of well-differentiated thyroid cancer, and the most common form of thyroid cancer to result from exposure to radiation. Papillary carcinoma appears as an irregular solid or cystic mass or nodule in a normal thyroid parenchyma.

Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive. In fact, these tumors may spread easily to other organs. Papillary tumors have a propensity to invade lymphatics but are less likely to invade blood vessels.

The life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients than for patients who are older than 45 years.


Q. 14

Identify the thyroid carcinoma:

 A

Papillary Carcinoma

 B

Anaplastic Carcinoma

 C

Medullary Carcinoma

 D

Follicular Carcinoma

Ans. C

Explanation:

Ans:C.)Medullary Carcinoma

Image shows:Medullary carcinoma thyroid. Microscopy shows organoid pattern of oval tumour cells and abundant amyloid stroma.Amyloid shows congophilia which depicts apple-green birefringence under polarising microscopy.

Medullary Thyroid Carcinoma

  • Medullary carcinoma is a less frequent type derived from parafollicular or C-cells present in the thyroid and comprises about 5% of thyroid carcinomas.

MORPHOLOGIC FEATURES.

  • Grossly, the tumour may either appear as a unilateral solitary nodule (sporadic form),or have bilateral and multicentric involvement (familial form).
  • Cut surface of tumour in both forms shows well-defined tumour areas which are firm to hard, grey-white to yellow-brown with areas of haemorrhages and necrosis.
  • Histologically, the features are as under :
    • 1. Tumour cells: Like other neuroendocrine tumours (e.g. carcinoid, islet cell tumour, paraganglioma etc), medullary carcinoma of the thyroid too has a well-defined organoid pattern, forming nests of tumour cells separated by fibrovascular septa. Sometimes, the tumour cells may be arranged in sheets, ribbons pseudopapillae or small follicles. The tumour cells are uniform and have the structural and functional characteristics of C-cells.
    • 2. Amyloid stroma: The tumour cells are separated by amyloid stroma derived from altered calcitonin which can be demonstrated by immunostain for calcitonin.
      • The staining properties of amyloid are similar to that seen in systemic amyloidosis and may have areas of irregular calcification but without regular laminations seen in psammoma bodies.
    • 3. C-cell hyperplasia: Familial cases generally have C-cell hyperplasia as a precursor lesion but not in sporadic cases.

MAIN HISTOLOGIC TYPES OF THYROID CARCINOMA


Q. 15

Commonest thyroid tumor in MEN (multiple endocrine neoplasia) ‑

 A

Follicular

 B

Papillary

 C

Anaplastic

 D

Medullary

Ans. D

Explanation:

Ans. is ‘d’ i.e., Medullary 

  • Thyroid tumor is seen in MEN II, and is medullary carcinoma of thyroid.

Q. 16 A patient presented with swelling in the thyroid gland and also presented with cervical lymphadenopathy.Thyroid shows the following picture.What can be the most probable diagnosis?

 A

Papillary Carcinoma of Thyroid

 B

Medullary Carcinoma of Thyroid

 C

Hashimoto’s Thyroiditis

 D

Grave’s Disease

Ans. A

Explanation:

Ans:A.)Papillary Carcinoma of thyroid.

Image shows:

Papillary carcinoma of the thyroid. A–C, A papillary carcinoma with grossly discernible papillary structures. In this particular example,
well-formed papillae (B) are lined by cells with characteristic empty-appearing nuclei, sometimes termed “Orphan Annie eye” nuclei (C). D, Cells
obtained by fine-needle aspiration of a papillary carcinoma. Characteristic intranuclear inclusions are visible in some of the aspirated cells (arrows).


Q. 17

Medullary ca of thyroid is associated with increase in

 A

Calcitonin

 B

Thyroglobulin

 C

T3

 D

T4

Ans. A

Explanation:

Ans. is ‘a’ i.e., Calcitonin 

  • The cells of medullary carcinomas, similar to normal       cells, secrete calcitonin.
  • In some instance other hormones are secreted such as somatostatin, serotonin, and VIP.

Medullary carcinoma thyroid

  • Accounts for approximately 7% of malignant tumour of thyroid.
  • It arises from ultimobranchial bodies (from the parafollicular C cells derived from neural crest and not from thyroid follicles).
  • It contains amyloid stroma
  • Familial medullary carcinoms occurs in 25% of patients (Marfanoid habitus, Amyloidosis and Hirschsprung’s disease also occur in patients with familial medullary cancer).
  • Medullary carcinoma occurs in association with (MEN) syndrome.
  • All patients with medullary carcinoma of thyroid should be screened for RET point mutation on chromosome 10. 
  • Medullary Ca thyroid secretes calcitonin, this cause hypocalcemia. Calcitonin also acts as tumour marker. 
  • Involvement of lymph node is very common in medullary carcinoma. It is seen in 50-60% of cases.

Q. 18 Which type of thyroid carcinoma is classically associated with calcitonin induced amyloid deposition?

 A Papillary

 B

Follicular

 C

Anaplastic

 D

Medullary

Ans. D

Explanation:

Ans. is ‘d’ i.e., Medullary 

 


Q. 19

Calcitonin is a marker of

 A Prostate cancer

 B Medullary carcinoma of thyroid

 C

Pheochromocytoma

 D

Pancreatic cancer

Ans. B

Explanation:

Ans. is ‘b’ i.e., Medullary carcinoma of thyroid 


Q. 20

Which thyroid carcinoma has amyloid deposition‑

 A

Anaplastic

 B

Follicular

 C

Medullary

 D

Papillary

Ans. C

Explanation:

Ans. is ‘c’ i.e., Medullary 

  • Medullary carcinoma of thyroid has deposition of A cal amyloid (derived from calcitonin).


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