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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endocrine neoplasia
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