Practice questions Pathology of parathyroid gland/MEN


Practice questions

Pathology of parathyroid gland/MEN
© Jun Wang, MD, PhD

1. Use this case for the next five questions. A 58-year-old woman presents with abdominal pain for 2 weeks. She has had intermittent vomiting, diarrhea, fatigue and vague bone pains for 2 months. She has a history of invasive ductal carcinoma of left breast with axillary lymph node metastasis at age 48 that was treated with surgery and chemotherapy. Physical examination reveals no significant abnormalities, except signs of previous surgery. Laboratory test reveals serum calcium at 12.3 mg/dl (normal 8.5-10.2 mg/dl), phosphorus at 1.7 mg/dl (normal 2.5-4.5 mg/dl) and alkaline phosphatase at 575 U/L (normal 30-120 U/L). Other routine laboratory tests, including CBC and urinalysis, are within normal range. Radiologic studies reveals multiple well circumscribed lytic bone lesions at both hands and mandible. What is the appropriate next test?
A. Bone marrow biopsy
B. Immunofixation for serum proteins
C. Intact parathyroid hormone
D. MRI for breast
E. Parathyroid hormone related peptide

2. A 58-year-old woman presents with abdominal pain for 2 weeks. She has had intermittent vomiting, diarrhea, fatigue and vague bone pains for 2 months. She has a history of invasive ductal carcinoma of left breast with axillary lymph node metastasis at age 48 that was treated with surgery and chemotherapy. Physical examination reveals no significant abnormalities, except signs of previous surgery. Laboratory test reveals serum calcium at 12.3 mg/dl (normal 8.5-10.2 mg/dl), phosphorus at 1.7 mg/dl (normal 2.5-4.5 mg/dl) and alkaline phosphatase at 575 U/L (normal 30-120 U/L). Other routine laboratory tests, including CBC and urinalysis, are within normal range. Radiologic studies reveals multiple well circumscribed lytic bone lesions at both hands and mandible.

Additional test reveals an intact parathyroid hormone at 1125 pg/ml (normal 15-65 pg/ml). What is the diagnosis?
A. Metastatic breast cancer
B. Primary hyperparathyroidism
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism


3. A 58-year-old woman presents with abdominal pain for 2 weeks. She has had intermittent vomiting, diarrhea, fatigue and vague bone pains for 2 months. She has a history of invasive ductal carcinoma of left breast with axillary lymph node metastasis at age 48 that was treated with surgery and chemotherapy. Physical examination reveals no significant abnormalities, except signs of previous surgery. Laboratory test reveals serum calcium at 12.3 mg/dl (normal 8.5-10.2 mg/dl), phosphorus at 1.7 mg/dl (normal 2.5-4.5 mg/dl) and alkaline phosphatase at 575 U/L (normal 30-120 U/L). Other routine laboratory tests, including CBC and urinalysis, are within normal range. Radiologic studies reveals multiple well circumscribed lytic bone lesions at both hands and mandible.

Additional test reveals an intact parathyroid hormone at 1125 pg/ml (normal 15-65 pg/ml). What is the appropriate next test?
A. Bone lesion biopsy
B. Bone marrow biopsy
C. Immunofixation for serum proteins
D. Parathyroid hormone related peptide
E. Sestamibi scan

4. A 58-year-old woman presents with abdominal pain for 2 weeks. She has had intermittent vomiting, diarrhea, fatigue and vague bone pains for 2 months. She has a history of invasive ductal carcinoma of left breast with axillary lymph node metastasis at age 48 that was treated with surgery and chemotherapy. Physical examination reveals no significant abnormalities, except signs of previous surgery. Laboratory test reveals serum calcium at 12.3 mg/dl (normal 8.5-10.2 mg/dl), phosphorus at 1.7 mg/dl (normal 2.5-4.5 mg/dl) and alkaline phosphatase at 575 U/L (normal 30-120 U/L). Other routine laboratory tests, including CBC and urinalysis, are within normal range. Radiologic studies reveals multiple well circumscribed lytic bone lesions at both hands and mandible. Additional test reveals an intact parathyroid hormone at 1125 pg/ml (normal 15-65 pg/ml). Sestamibi scan reveals a hot spot at lower anterior neck. What is most likely the cause of her condition?
A. Chronic renal disease
B. Metastatic breast cancer to bones
C. Multiple myeloma
D. Parathyroid adenoma
E. Parathyroid hyperplasia

5. A 58-year-old woman presents with abdominal pain for 2 weeks. She has had intermittent vomiting, diarrhea, fatigue and vague bone pains for 2 months. She has a history of invasive ductal carcinoma of left breast with axillary lymph node metastasis at age 48 that was treated with surgery and chemotherapy. Physical examination reveals no significant abnormalities, except signs of previous surgery. Laboratory test reveals serum calcium at 12.3 mg/dl (normal 8.5-10.2 mg/dl), phosphorus at 1.7 mg/dl (normal 2.5-4.5 mg/dl) and alkaline phosphatase at 575 U/L (normal 30-120 U/L). Other routine laboratory tests, including CBC and urinalysis, are within normal range. Radiologic studies reveals multiple well circumscribed lytic bone lesions at both hands and mandible. Additional test reveals an intact parathyroid hormone at 1125 pg/ml (normal 15-65 pg/ml). Sestamibi scan reveals a hot spot at lower anterior neck. Bone lesion biopsy reveals thin trabeculae and slightly increased number of multinucleated cells. No inflammatory cells or epithelial cells are seen. No cytological atypia is noted. What is the diagnosis of the bone lesion?
A. Giant cell tumor of bone
B. Granulomatous osteomyelitis
C. Metastatic breast cancer
D. Osteitis fibrosa cystica
E. Osteosarcoma


6. A 52-year-old woman presents with bone pain, fatigue, depression and weakness for 3 weeks. She has a history of diabetes. Her family history is unremarkable. No significant abnormalities are noted per physical examination. Laboratory tests reveal a serum calcium of 12.5 mg/dl (normal 8.5-10.2 mg/dl), and an intact parathyroid hormone of 425 pg/ml (normal 15-65 pg/ml). Other laboratory tests results, including renal function tests, are within normal ranges. Neck sonographic examination reveal two enlarged parathyroid glands. Sestamibi scan is negative. The two parathyroid glands are removed. Microscopic examination reveals diffuse proliferation of cells with small round nuclei with a few adipose tissue. No necrosis nor invasion is noted. What is the most likely diagnosis?
A. Chronic renal disease
B. Parathyroid adenoma
C. Parathyroid carcinoma
D. Parathyroid hyperplasia
E. Secondary hyperparathyroidism


7. A 35-year-old woman presents with acute severe pain in her right index finger after it was caught in a door. Her past medical history is unremarkable. Physical examination reveals a markedly swollen and non mobile right finger. No other abnormality is noted. Radiologic examination fracture of right finger. In addition, subperiostieal bone absorption is noted in all other fingers. Laboratory tests are within normal range, except a serum calcium of 11.8 mg/dl (normal 8.5-10.2 mg/dl). What is the appropriate next test?
A. Bone biopsy of the phalanges
B. Bone marrow biopsy
C. Immunofixation for serum proteins
D. Intact parathyroid hormone
E. Parathyroid hormone related peptide


8. Use this case for the next three questions.  A 59-year-old man presents with intermittent muscular cramps for a year. He denies other symptoms. He has a history of diabetes and diabetic nephropathy for 15 years. His past medical history is otherwise unremarkable. No significant abnormalities are noted by physical examination. Laboratory tests reveal a serum glucose of 120 mg/dl (normal 70-110 mg/dl), calcium of 8.1 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 6.7 mg/dl (normal 2.5-4.5 mg/dl), parathyroid hormone of 550 pg/ml (normal 15-65 pg/ml), BUN of 35 mg/dl (normal 7-20 mg/dl), and creatinine of 1.8 mg/dl (normal 0.6-1.2 mg/dl). Urinalysis reveal 2+ proteinuria. What is the cause of his elevated parathyroid hormone?
A. Hypocalcemia
B. Hyperglycemia
C. Parathyroid adenoma
D. Parathyroid carcinoma
E. Proteinuria


9. A 59-year-old man presents with intermittent muscular cramps for a year. He denies other symptoms. He has a history of diabetes and diabetic nephropathy for 15 years. His past medical history is otherwise unremarkable. No significant abnormalities are noted by physical examination. Laboratory tests reveal a serum calcium of 8.1 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 6.7 mg/dl (normal 2.5-4.5 mg/dl), parathyroid hormone of 550 pg/ml (normal 15-65 pg/ml), BUN of 35 mg/dl (normal 7-20 mg/dl), and creatinine of 1.8 mg/dl (normal 0.6-1.2 mg/dl). What is the cause of his hypocalcemia?
A. Hypoparathyroidism
B. Nutritional deficiency
C. Pseudohypoparathyroidism
D. Reduced FGF23
E. Retention of phosphorus

10. A 59-year-old man presents with intermittent muscular cramps for a year. He denies other symptoms. He has a history of diabetes and diabetic nephropathy for 15 years. His past medical history is otherwise unremarkable. No significant abnormalities are noted by physical examination. Laboratory tests reveal a serum calcium of 8.1 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 6.7 mg/dl (normal 2.5-4.5 mg/dl), parathyroid hormone of 550 pg/ml (normal 15-65 pg/ml), BUN of 35 mg/dl (normal 7-20 mg/dl), and creatinine of 1.8 mg/dl (normal 0.6-1.2 mg/dl). What is the diagnosis?
A. Hypoparathyroidsim
B. Primary hyperparathyroidism
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism


11. A 55-year-old man presents with fatigue, depression, abdominal pain, nausea and vomiting for 1 week. He has a history of end-stage kidney disease treated with dialysis, hypertension and hyperlipidemia. Physical examination are unremarkable. Laboratory test reveal serum calcium of 13.8 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 5.1 mg/dl (normal 2.5-4.5 mg/dl), BUN of 22 mg/dl (normal 7-20 mg/dl), creatinine of 1.5 mg/dl (normal 0.6-1.2 mg/dl) and intact parathyroid hormone of 778 pg/ml (normal 15-65 pg/ml). What is the diagnosis?
A. Hypoparathyroidsim
B. Primary hyperparathyroidism
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism

12. A 61-year-old asymptomatic man presents for diabetes follow up. He has a history of diabetes, diabetic nephropathy, hypertension, obesity and depression. Physical examination reveals no new abnormalities. Laboratory tests reveal serum calcium of 13.1 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 1.4 mg/dl (normal 2.5-4.5 mg/dl), and parathyroid hormone of 975 pg/ml (normal 15-65/ml). No other newly onset significant abnormalities are noted. Neck sonographic reveals a 3.1 cm ill-defined mass at the left lower pole of his thyroid. The mass is removed. Microscopically it is composed of cords or sheets of cells with small round nuclei infiltrating into pretracheal connective tissue. No colloid, amyloid nor significant nuclear abnormality is noted. What is the diagnosis?
A. Papillary carcinoma of thyroid
B. Parathyroid adenoma
C. Parathyroid carcinoma
D. Parathyroid hyperplasia
E. Thyroid medullary carcinoma

13. A 42-year-old woman presents with vomiting, abdominal pain and perioral numbness for 2 weeks. She has a history of recurrent muscle cramps for 5 years. Physical examination reveals irregular muscle contractions. Laboratory tests reveal a serum calcium of 5.6 mg/dl (normal 8.5-10.2 mg/dl), phosphorus of 7.0 mg/dl (normal 2.5-4.5 mg/dl), intact parathyroid hormone of 11.5 pg/ml (normal 15-65 pg/ml). What is the diagnosis?
A. Hypoparathyroidsim
B. Primary hyperparathyroidism
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism

14. A 3-year-old girl presents with facial twitching and hand spasms for 2 weeks. She denies other symptoms. Her height is at 3rd percentile, while her weight is at 87th percentile. She has a round face and the muscular tone of all limbs are increased. Laboratory tests reveal a serum calcium of 5.6 mg/dl (normal 8.5-10.2 mg/dl), intact parathyroid hormone of 187 pg/ml (normal 15-65 pg/ml). What is the diagnosis?
A. Hypoparathyroidsim
B. Primary hyperparathyroidism
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism

15. Use this case for the next three questions.  A 33-year-old man presents worsening epigastric abdominal pain, nausea, vomiting blood and diarrhea for 2 weeks. He has a history of pituitary prolactinoma at age 18. His has a family history of parathyroid hyperplasia and pituitary tumors. His initial laboratory tests are within normal ranges, except a serum calcium of 11.3 mg/dl (normal 8.5-10.2 mg/dl). Upper endoscopic examination reveals 3 ulcers at antrum and bulb of his duodenum, up to 1.5 cm in diameter. Abdominal CT reveals a 2.4 cm solid mass at pancreatic body. Additional laboratory test reveal an intact parathyroid hormone of 1120 pg/ml (normal 15-65 pg/ml) and gastrin of 950 pg/ml (normal 15-113 pg/ml). What is most likely the cause of his ulcer?
A. Gastrinoma
B. Helicobacter infection
C. Pseudohypoparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism

16. A 33-year-old man presents worsening epigastric abdominal pain, nausea, vomiting blood and diarrhea for 2 weeks. He has a history of pituitary prolactinoma at age 18. His has a family history of parathyroid hyperplasia and pituitary tumors. His initial laboratory tests are within normal ranges, except a serum calcium of 11.3 mg/dl (normal 8.5-10.2 mg/dl). Upper endoscopic examination reveals 3 ulcers at antrum and bulb of his duodenum, up to 1.5 cm in diameter. Abdominal CT reveals a 2.4 cm solid mass at pancreatic body. Additional laboratory test reveal an intact parathyroid hormone of 1120 pg/ml (normal 15-65 pg/ml) and gastrin of 950 pg/ml (normal 15-113 pg/ml). What is most likely the diagnosis?
A. Metastatic parathyroid carcinoma to pancreas
B. Multiple endocrine neoplasia 1
C. Multiple endocrine neoplasia 2
D. Parathyroid hyperplasia
E. Pseudohypoparathyroidism

17. A 33-year-old man presents worsening epigastric abdominal pain, nausea, vomiting blood and diarrhea for 2 weeks. He has a history of pituitary prolactinoma at age 18. His has a family history of parathyroid hyperplasia and pituitary tumors. His initial laboratory tests are within normal ranges, except a serum calcium of 11.3 mg/dl (normal 8.5-10.2 mg/dl). Upper endoscopic examination reveals 3 ulcers at antrum and bulb of his duodenum, up to 1.5 cm in diameter. Abdominal CT reveals a 2.4 cm solid mass at pancreatic body. Additional laboratory test reveal an intact parathyroid hormone of 1120 pg/ml (normal 15-65 pg/ml) and gastrin of 950 pg/ml (normal 15-113 pg/ml). Mutation of what gene is likely to be associated with his condition?
A. Menin
B. NF-1
C. PAX8
D. PTEN
E. RET


18. Use this case for the next three questions.  A 32-year-old woman presents with swelling of anterior neck for 6 months. She denies other symptoms. She has a history of parathyroid hyperplasia at the age of 18. Physical examination reveals a firm mass at the left thyroid. Her laboratory tests are within normal range. Sonographic examination reveals a 3.8 cm well-circumscribed mass at the lower pole of her left thyroid lobe. The mass is resected. Microscopically it is composed of plasmacytoid cells containing granular eosinophilic cytoplasm and intermediate sized round nuclei with salt and pepper chromatin. Amyloid deposit was seen in the background. These cells are positive for calcitonin, but negative for thyroglobulin and parathyroid hormone. What is the diagnosis of the thyroid lesion?
A. Follicular adenoma
B. Medullary carcinoma
C. Papillary thyroid carcinoma
D. Parathyroid carcinoma
E. Plasmacytoma

19. A 32-year-old woman presents with swelling of anterior neck for 6 months. She denies other symptoms. She has a history of parathyroid hyperplasia at the age of 18. Physical examination reveals a firm mass at the left thyroid. Her laboratory tests are within normal range. Sonographic examination reveals a 3.8 cm well-circumscribed mass at the lower pole of her left thyroid lobe. The mass is resected. Microscopically it is composed of plasmacytoid cells containing granular eosinophilic cytoplasm and intermediate sized round nuclei with salt and pepper chromatin. Amyloid deposit was seen in the background. These cells are positive for calcitonin, but negative for thyroglobulin and parathyroid hormone. Mutation of what gene is likely to be associated with her condition?
A. Calcium-sensing receptor
B. Menin
C. NF-1
D. PAX8
E. RET

20. A 32-year-old woman presents with swelling of anterior neck for 6 months. She denies other symptoms. She has a history of parathyroid hyperplasia at the age of 18. Physical examination reveals a firm mass at the left thyroid. Her laboratory tests are within normal range. Sonographic examination reveals a 3.8 cm well-circumscribed mass at the lower pole of her left thyroid lobe. The mass is resected. Microscopically it is composed of plasmacytoid cells containing granular eosinophilic cytoplasm and intermediate sized round nuclei with salt and pepper chromatin. Amyloid deposit was seen in the background. These cells are positive for calcitonin, but negative for thyroglobulin and parathyroid hormone. What disorder the patient most likely has?
A. Familial thyroid papillary carcinoma
B. Multiple endocrine neoplasia 1
C. Multiple endocrine neoplasia 2
D. Multiple myeloma
E. Plasma cell leukemia


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