Practice question II Pathology of thyroid

Practice question II 

Pathology of thyroid

© Jun Wang, MD, PhD


1. Use this case for the next three questions. A 39-year-old woman from mountain area of south America presents with slowly growing anterior neck mass for 13 years. She denies other symptoms. Her past medical history is unremarkable. She does not take iodized salt or any seafood. She has a family history of Hashimoto thyroiditis. Physical examination reveals a 12 cm lobulated mass at anterior neck, extending from chin to supra-sternal notch. No other abnormality is noted. Laboratory tests including thyroid functional are within normal ranges. No thyroid peroxidase antibody is identified. Sonographic examination reveals a diffusely enlarged thyroid glands without recognizable mass.  What is the diagnosis?
A. Diffuse simple goiter
B. Follicular adenoma
C. Graves disease
D. Hashimoto thyroiditis
E. Papillary thyroid carcinoma

2. A 39-year-old woman from mountain area of south America presents with slowly growing anterior neck mass for 13 years. She denies other symptoms. Her past medical history is unremarkable. She does not take iodized salt or any seafood. She has a family history of Hashimoto thyroiditis. Physical examination reveals a 12 cm lobulated mass at anterior neck, extending from chin to supra-sternal notch. No other abnormality is noted. Laboratory tests including thyroid functional are within normal ranges. No thyroid peroxidase antibody is identified. Sonographic examination reveals a diffusely enlarged thyroid glands without recognizable mass.  What is the cause of her clinical presentation?
A. Autoimmune reactions
B. Bacterial infection
C. Iodine deficiency
D. Ret mutation
E. Viral infections

3. A 39-year-old woman from presents with slowly growing anterior neck mass for 13 years. She denies other symptoms. Her past medical history is unremarkable. She does not take iodized salt or any seafood. She has a family history of Hashimoto thyroiditis. Physical examination reveals a 12 cm lobulated mass at anterior neck, extending from chin to supra-sternal notch. No other abnormality is noted. Laboratory tests including thyroid functional are within normal ranges. No thyroid peroxidase antibody is identified. Sonographic examination reveals a diffusely enlarged thyroid glands without recognizable mass.  What is the cause of her enlarged thyroid gland?
A. Activating antibodies against TSH receptor
B. Follicular hypertrophy due to chronic TSH stimulation
C. Malignant transformation of lymphocytes
D. Proliferation of parafollicular cells
E. Regenerative changes after follicular destruction by antibodies against thyroid peroxidase

 
4. A 48-year-old woman presents with an anterior neck mass for 6 months. The mass has not changed in size. She is otherwise healthy. Her past medical history is unremarkable. She has a 30 pack-year smoking history. She does not drink alcohol. Physical examination reveals a multilobular mass in the right lobe of her thyroid. No other abnormality is seen. Laboratory test results are within normal ranges. No autoantibodies are detected. Sonographic examination reveals a few nodular growths in her right thyroid. The left lobe and isthmus are unremarkable. Biopsies of these nodules reveals follicles with large variation in sizes. Many large follicles are seen. These follicles are lined by flat follicular cells without nuclear abnormality. No evidence of necrosis is seen. What is the diagnosis?
A. Follicular adenoma
B. Graves disease
C. Multinodular goiter
D. Squamous cell carcinoma
E. Thyroglossal duct cyst


5. A 47-year-old woman presents with nervousness, anxiety and palpitation for 3 months. She has lost 10 pounds since then, despite increased appetite. She has a history of iodine deficiency associated goiter 30 years ago. Her past medical history is otherwise unremarkable. Physical examination reveals a heart rate at 120 bpm, blood pressure at 150/90 mmHg, warm moist skin, staring gaze and hand tremor. Her thyroid is slightly enlarged. Laboratory tests reveal a TSH at 0.07 microIU/ml (normal 0.5-5 microIU/ml). No autoantibodies are detected. Sonographic examination reveals multiple nodular growths up to 1.5 cm in greatest dimension. Radioactive iodide scintiscan reveals multiple foci of increased uptake in her left lobe. Biopsy reveals follicles that are largely variable in sizes. Some follicular cells are columnar with finger like crowded growth. No nuclear abnormality is seen. The colloid in these follicles are paler. Other follicles are unremarkable. What is the diagnosis?
A. Granulomatous thyroiditis
B. Graves disease
C. Hashimoto thyroiditis
D. Thyroid follicular carcinoma
E. Toxic multinodular goiter

6. Use this case for the next two questions. A 57-year-old woman presents with an anterior cervical mass, nervousness, anxiety and a 10 pound unintentional weight loss for 3 months. Her past medical history is unremarkable. Physical examination reveals a left thyroid nodule. No other abnormalities are noted. Laboratory tests reveal a TSH at 0.07 microIU/ml (normal 0.5-5 microIU/ml). Sonographic examination reveals a 2.5 cm solid nodule in her left thyroid. Thyroid scintigraphy studies confirmed hyperfunctioning status of this nodule. The background thyroid is unremarkable. Fine needle aspiration reveals microfollicles. Excisional biopsy is performed. This is a well circumscribe mass with glistening cut surfaces. Microscopically it is composed of packed small follicles lined by normal appearing follicular cells. Some cells have eosinophilic granular cytoplasm. No nuclear abnormality is noted. A fine capsule is found. There is no evidence of capsular or vascular invasion. What is the diagnosis?
A. Follicular adenoma
B. Follicular carcinoma
C. Graves disease
D. Hashimoto thyroiditis
E. Papillary carcinoma, follicular variant



7.  A 57-year-old woman presents with an anterior cervical mass, nervousness, anxiety and a 10 pound unintentional weight loss for 3 months. Her past medical history is unremarkable. Physical examination reveals a left thyroid nodule. No other abnormalities are noted. Laboratory tests reveal a TSH at 0.07 microIU/ml (normal 0.5-5 microIU/ml). Sonographic examination reveals a 2.5 cm solid nodule in her left thyroid. Thyroid scintigraphy studies confirmed hyperfunctioning status of this nodule. The background thyroid is unremarkable. Fine needle aspiration reveals microfollicles. Excisional biopsy is performed. This is a well circumscribe mass with glistening cut surfaces. Microscopically it is composed of packed small follicles lined by normal appearing follicular cells. Some cells have eosinophilic granular cytoplasm. No nuclear abnormality is noted. A fine capsule is found. There is no evidence of capsular or vascular invasion. What is the most likely causing her presentation?
A. Activating antibodies against TSH receptor associated hyperfunctioning of follicles
B. Destruction of follicular cells with abnormal release of thyroid hormone
C. Lack of negative feedback to pituitary TSH producing cells
D. Mutation of TSH receptor associated receptor hyperactivity


8. A 44-year-old woman presents with a slowly growing anterior neck mass. She is otherwise healthy. Physical examination reveal a mass in her right thyroid. Laboratory tests including thyroid function tests are within normal ranges. Sonographic examination reveals a single 1.5 cm well circumscribe right thyroid nodule. Fine needle aspiration reveals small clusters of follicular cells without significant nuclear abnormalities. Right hemithyroidectomy was performed. Grossly, this nodule is well demarcated with a fine capsule and glistening cut surfaces. Microscopically, this lesion is composed of packed small follicles lined by small follicular cells. No nuclear groove or inclusion are seen. There is no evidence of vascular and capsular invasion. What is the diagnosis?
A. Follicular adenoma
B. Follicular carcinoma
C. Graves disease
D. Hashimoto thyroiditis
E. Papillary carcinoma, follicular variant


9. Use this case for the next three questions. A 27-year-old woman presents with slowly growing anterior neck mass for 6 months. She does not have other symptoms. She has a history of multinodular goiter, diagnosed 2 years ago. Physical examination reveals a slightly enlarged thyroid glands with a few palpable nodules. Her laboratory tests results are within normal ranges. Sonographic examination reveal a few hypoechoic nodules. Fine needle aspiration reveals sheets of follicular cells with large overlapping nuclei. Some nuclei have nuclear grooves or intranuclear inclusions. What is the diagnosis?
A. Follicular adenoma
B. Follicular carcinoma
C. Hashimoto thyroiditis
D. Multinodular goiter
E. Papillary carcinoma

10. A 27-year-old woman presents with slowly growing anterior neck mass for 6 months. She does not have other symptoms. She has a history of multinodular goiter, diagnosed 2 years ago. Physical examination reveals a slightly enlarged thyroid glands with a few palpable nodules. Her laboratory tests results are within normal ranges. Sonographic examination reveal a few hypoechoic nodules. Fine needle aspiration reveals sheets of follicular cells with large overlapping nuclei. Some nuclei have nuclear grooves or intranuclear inclusions. Abnormality of what gene is likely to be associated with these findings?
A. Menin 1
B. PAX8
C. PTEN
D. RET
E. TSH receptor

11. A 27-year-old woman presents with slowly growing anterior neck mass for 6 months. She does not have other symptoms. She has a history of multinodular goiter, diagnosed 2 years ago. Physical examination reveals a slightly enlarged thyroid glands with a few palpable nodules. Her laboratory tests results are within normal ranges. Sonographic examination reveal a few hypoechoic nodules. Fine needle aspiration reveals sheets of follicular cells with large overlapping nuclei. Some nuclei have nuclear grooves or intranuclear inclusions. What is the most likely finding of this lesion?
A. Early metastasis
B. Local aggressiveness
C. Multifocality
D. Regression with iodine supplementation


12. Use this case for the next three questions. A 51-year-old woman presents with a large anterior neck mass for a year. She is otherwise asymptomatic. She has a history of clear cell type renal cell carcinoma 5 years ago, that was treated with nephrectomy. Physical examination reveals a 12 cm left thyroid mass. Fine needle aspiration reveals small clusters of follicular cells with slightly enlarged nuclei. Left hemithyroidectomy is performed. The mass is well circumscribed with a fine capsule. Microscopically, it is composed predominantly by small follicles. A few larger follicles are seen. The follicular cells a cuboidal, some with markedly enlarged very pale nuclei. Nuclear grooves and nuclear inclusions are seen. What is the diagnosis?
A. Follicular adenoma
B. Follicular carcinoma
C. Metastatic renal cell carcinoma
D. Multinodular goiter
E. Papillary carcinoma

13. A 51-year-old woman presents with a large anterior neck mass for a year. She is otherwise asymptomatic. She has a history of clear cell type renal cell carcinoma 5 years ago, that was treated with nephrectomy. Physical examination reveals a 12 cm left thyroid mass. Fine needle aspiration reveals small clusters of follicular cells with slightly enlarged nuclei. Left hemithyroidectomy is performed. The mass is well circumscribed with a fine capsule. Microscopically, it is composed predominantly by small follicles. A few larger follicles are seen. The follicular cells a cuboidal, some with markedly enlarged very pale nuclei. Nuclear grooves and nuclear inclusions are seen. Abnormality of what gene is likely to be associated with these findings?
A. Menin 1
B. PAX8
C. PTEN
D. RET
E. TSH receptor

14. A 51-year-old woman presents with a large anterior neck mass for a year. She is otherwise asymptomatic. She has a history of clear cell type renal cell carcinoma 5 years ago, that was treated with nephrectomy. Physical examination reveals a 12 cm left thyroid mass. Fine needle aspiration reveals small clusters of follicular cells with slightly enlarged nuclei. Left hemithyroidectomy is performed. The mass is well circumscribed with a fine capsule. Microscopically, it is composed predominantly by small follicles. A few larger follicles are seen. The follicular cells a cuboidal, some with markedly enlarged very pale nuclei. Nuclear grooves and nuclear inclusions are seen. What is next step of management?
A. Antithyroxin medication
B. Chemotherapy
C. Follow up
D. Radioiodine ablation
E. Removal of the rest of thyroid gland


15. Use this case for the next two questions. A 39-year-old woman presents with a slowly growing anterior neck mass for 6 months. She has a history of Hashimoto thyroiditis. Physical examination reveals a left thyroid mass. No other abnormality is identified. Sonographic examination reveals a 2.5 cm well circumscribed mass in a background of nodular appearing thyroid. Fine needle aspiration reveals small clusters of benign appearing follicular cells in a background of scant colloid. Left hemithyroidectomy was performed. Grossly this is a well demarcated capsulated solid growth. Microscopically this lesion is composed of predominantly packed small follicles lined by benign appearing follicular cells. A fine fibrous capsule is noted. Focally the capsule is discontinued with small follicles in both sides. What is the diagnosis?
A. Anaplastic carcinoma
B. Follicular adenoma
C. Follicular carcinoma
D. Multinodular goiter
E. Papillary carcinoma

16. A 39-year-old woman presents with a slowly growing anterior neck mass for 6 months. She has a history of Hashimoto thyroiditis. Physical examination reveals a left thyroid mass. No other abnormality is identified. Sonographic examination reveals a 2.5 cm well circumscribed mass in a background of nodular appearing thyroid. Fine needle aspiration reveals small clusters of benign appearing follicular cells in a background of scant colloid. Left hemithyroidectomy was performed. Grossly this is a well demarcated capsulated solid growth. Microscopically this lesion is composed of predominantly packed small follicles lined by benign appearing follicular cells. A fine fibrous capsule is noted. Focally the capsule is discontinued with small follicles in both sides. Abnormality of what gene is likely to be associated with these findings?
A. Menin 1
B. P53
C. PAX8
D. RET-PTC
E. TSH receptor


17. Use this case for the next three questions. A 37-year-old woman presents with slowly growing anterior neck mass for 3 months. Her past medical history is unremarkable. She has a family history of pheochromocytoma and parathyroid adenoma. Physical examination reveals a firm right thyroid mass. A few enlarged right cervical lymph nodes are noted. Her laboratory test results including thyroid function tests are within normal ranges. Sonographic examination reveals a 2 cm mass in the right thyroid. Fine needle aspiration reveals scattered atypical cells. The mass is resected. Microscopically, it has sheets of atypical cells with eccentric round nuclei and punctuate chromatin. Focally there are Congo red positive amorphous deposit. Per immunohistochemistry studies, these cells are negative for thyroglobulin. What is the diagnosis?
A. Anaplastic carcinoma
B. Follicular adenoma
C. Follicular carcinoma
D. Medullary carcinoma
E. Papillary carcinoma

18. A 37-year-old woman presents with slowly growing anterior neck mass for 3 months. Her past medical history is unremarkable. She has a family history of pheochromocytoma and parathyroid adenoma. Physical examination reveals a firm right thyroid mass. A few enlarged right cervical lymph nodes are noted. Her laboratory test results including thyroid function tests are within normal ranges. Sonographic examination reveals a 2 cm mass in the right thyroid. Fine needle aspiration reveals scattered atypical cells. The mass is resected. Microscopically, it has sheets of atypical cells with eccentric round nuclei and punctuate chromatin. Focally there are Congo red positive amorphous deposit. Per immunohistochemistry studies, these cells are negative for thyroglobulin. Abnormality of what gene is likely to be associated with these findings?
A. Menin 1
B. P53
C. PAX8
D. RET
E. TSH receptor

19. A 37-year-old woman presents with slowly growing anterior neck mass for 3 months. Her past medical history is unremarkable. She has a family history of pheochromocytoma and parathyroid adenoma. Physical examination reveals a firm right thyroid mass. A few enlarged right cervical lymph nodes are noted. Her laboratory test results including thyroid function tests are within normal ranges. Sonographic examination reveals a 2 cm mass in the right thyroid. Fine needle aspiration reveals scattered atypical cells. The mass is resected. Microscopically, it has sheets of atypical cells with eccentric round nuclei and punctuate chromatin. Focally there are Congo red positive amorphous deposit. Per immunohistochemistry studies, these cells are negative for thyroglobulin. What additional marker is likely to be elevated in her blood?
A. Antibody against thyroid peroxidase
B. Inhibitory antibody against TSH receptor
C. Calcium
D. Calcitonin
E. Parathyroid hormone


20. A 65-year-old man presents with a rapidly growing anterior neck mass and hoarse voice change for a month. He does not have other abnormalities. He has a history of cervical classical Hodgkin lymphoma 10 years ago that was treated with radiation therapy and chemotherapy. Physical examination reveals an immobile firm mass at the lower portion of anterior neck. Image studies reveal a poorly demarcated 9 cm mass arising from right thyroid. Biopsy of the mass reveals sheets of cells with marked pleomorphism. Scattered multinucleated cells are seen. Per immnuhistochemistry studies, these cells are positive for cytokeratin, but negative for thyroglobulin, CD30 and CD45. What is the diagnosis?
A. Anaplastic carcinoma
B. Follicular carcinoma
C. Hodgkin lymphoma
D. Medullary carcinoma
E. Pleomorphic sarcoma



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