Endocrine Pathology Practice Questions

Q: A biopsy from the parathyroid gland of a 55-year-old male, a known case of chronic kidney disease with hypertension and type II diabetes who recently developed bone pain, skin lesions, and recurrent kidney stones, is shown below. What is the most likely histopathological finding?

Water clear cells in parathyroid hyperplasia. ***Water clear cells in parathyroid hyperplasia*** - **Chronic kidney disease** leads to **secondary hyperparathyroidism** due to decreased **vitamin D activation** and **phosphate retention**, causing **parathyroid hyperplasia** with characteristic **water clear cells (wasserhelle cells)**. - These cells have **abundant clear cytoplasm** due to **glycogen accumulation** and **mitochondrial swelling**, commonly seen in **long-standing hyperparathyroidism** associated with **CKD**. *Water clear cells in parathyroid carcinoma* - **Parathyroid carcinoma** would show **capsular invasion**, **vascular invasion**, and **mitotic figures**, which are not typical in **secondary hyperparathyroidism** from CKD. - **Carcinoma** is extremely rare and usually presents with **severe hypercalcemia** and **rapid onset** symptoms, not the chronic progression seen with CKD. *Tuberculous parathyroiditis* - **TB parathyroiditis** would show **caseating granulomas**, **epithelioid cells**, and **Langerhans giant cells**, not water clear cells. - This condition is extremely rare and would present with **systemic TB symptoms** like **fever**, **weight loss**, and **night sweats**, which are absent here. *Parathyroid necrosis* - **Parathyroid necrosis** would show **tissue death**, **inflammatory infiltrate**, and **loss of normal architecture**, not hyperplastic changes. - This typically occurs in **acute conditions** like **infarction** or **severe hypocalcemia**, not in chronic progressive CKD with bone pain and stones.

Q: A patient presents with secondary adrenal masses. What is the most common primary site for such metastases?

Lung. **Explanation:** The adrenal glands are a highly vascularized site, making them the fourth most common site for hematogenous metastasis in the body (after the liver, lungs, and bones). **1. Why Lung is Correct:** **Lung cancer** is the most common primary malignancy to metastasize to the adrenal glands. Approximately 30-40% of patients with lung cancer will have adrenal involvement at the time of autopsy. Both Small Cell Lung Cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC), particularly **adenocarcinoma**, frequently spread to the adrenals. In clinical practice, when a unilateral or bilateral adrenal mass is found in a patient with a history of smoking or respiratory symptoms, lung cancer is the primary suspect. **2. Analysis of Incorrect Options:** * **Kidney (Renal Cell Carcinoma):** While RCC can spread to the adrenal gland (often via direct extension or venous routes), it is less common than lung-derived metastases. * **Breast:** Breast cancer is the second most common primary site for adrenal metastasis. While frequent, it statistically trails behind lung cancer. * **Stomach:** Gastrointestinal malignancies (Stomach, Colon) can metastasize to the adrenals, but they are significantly less common than thoracic or breast primaries. **3. Clinical Pearls for NEET-PG:** * **Bilateral Involvement:** Metastatic disease is the most common cause of bilateral adrenal masses. * **Imaging:** On CT, metastases typically show high unenhanced attenuation (>10 HU) and slow washout of contrast, unlike benign adenomas. * **Biopsy Rule:** Never perform a Fine Needle Aspiration (FNA) of an adrenal mass until **Pheochromocytoma** has been ruled out (via plasma/urine metanephrines) to avoid a life-threatening hypertensive crisis. * **Adrenal Insufficiency:** Clinical Addison’s disease is rare in metastasis unless >90% of both glands are destroyed.

Q: A patient presents with a 2 cm midline neck swelling. HPE reveals orphan annie eye nuclei. What is the most likely diagnosis?

Papillary thyroid carcinoma. ### Explanation The correct answer is **Papillary Thyroid Carcinoma (PTC)**. **1. Why Papillary Thyroid Carcinoma is Correct:** The presence of **"Orphan Annie eye nuclei"** is the pathognomonic histological hallmark of Papillary Thyroid Carcinoma. These are large, overlapping nuclei with a clear or ground-glass appearance due to finely dispersed chromatin. PTC is the most common type of thyroid malignancy (80–85%) and typically presents as a painless, slow-growing midline neck swelling (thyroid nodule). Other characteristic histological features include **Psammoma bodies** (laminated calcifications) and nuclear grooves. **2. Why the Other Options are Incorrect:** * **Medullary Thyroid Carcinoma (MTC):** Arises from parafollicular C-cells. Histology shows nests of cells in an **amyloid stroma** (stains with Congo Red). It is associated with MEN 2A and 2B syndromes. * **Toxic Nodular Goiter:** This is a functional (hyperthyroid) state characterized by follicular hyperplasia without malignant nuclear features. It presents with symptoms of thyrotoxicosis (tachycardia, tremors). * **Follicular Thyroid Carcinoma (FTC):** Diagnosis depends on demonstrating **capsular or vascular invasion**, which cannot be determined by FNA alone. It does not exhibit Orphan Annie eye nuclei. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common thyroid cancer:** Papillary Thyroid Carcinoma. * **Best Prognosis:** Papillary Thyroid Carcinoma. * **Route of Spread:** PTC spreads primarily via **lymphatics** (level VI nodes), whereas FTC spreads **hematogenously** (to bone/lungs). * **Risk Factor:** Prior exposure to ionizing radiation is strongly linked to PTC. * **Genetic Mutation:** Most commonly associated with **BRAF mutations** (specifically V600E) and RET/PTC rearrangements.

Question 1

A 65-year-old male with hypertension, diabetes, and heavy smoking history is brought to the emergency department with severe crushing chest pain radiating to the left arm. He is found unresponsive 48 hours after onset of chest pain and an autopsy is performed. The gross cardiac specimen at autopsy is shown (Image 2). Which of the following cellular events is the primary pathological process responsible for the gross appearance seen in this specimen at this time point?

Accepted Answer

A. Coagulative necrosis with preserved ghost outlines of cardiomyocytes and prominent neutrophilic infiltration

Answer

B. Early granulation tissue formation with ingrowth of capillaries, fibroblasts, and macrophage-predominant infiltrate replacing necrotic myocardium

Answer

C. Dense fibrous scar tissue replacing the infarcted zone with minimal residual inflammatory infiltrate

Answer

D. Hyperacute ischemic change with wavy fiber deformity, contraction band necrosis, and minimal inflammatory response

Question 2

Which of the following mechanisms is NOT responsible for complications in Diabetes Mellitus?

Accepted Answer

Chronic inflammation

Answer

Non-enzymatic glycosylation

Answer

Protein Kinase C activation

Answer

Disturbance in polyol pathway

Question 3

Insulin non-dependent diabetes mellitus correlates with which fat reserve?

Accepted Answer

Intra-abdominal fat

Answer

Lower body fat

Answer

Subcutaneous fat

Answer

Upper body fat

Question 4

A biopsy from the parathyroid gland of a 55-year-old male, a known case of chronic kidney disease with hypertension and type II diabetes who recently developed bone pain, skin lesions, and recurrent kidney stones, is shown below. What is the most likely histopathological finding?

Accepted Answer

Water clear cells in parathyroid hyperplasia

Answer

Water clear cells in parathyroid carcinoma

Answer

Tuberculous parathyroiditis

Answer

Parathyroid necrosis

Question 5

Osmotic damage is operative in all of the following complications of diabetes mellitus EXCEPT?

Accepted Answer

Insulin receptor deficiency

Answer

The formation of cataracts

Answer

Microaneurysms in retinal vessels

Answer

Peripheral neuropathy

Question 6

A patient presents with secondary adrenal masses. What is the most common primary site for such metastases?

Accepted Answer

Lung

Answer

Kidney

Answer

Breast

Answer

Stomach

Question 7

What is the most common tumor of the pineal gland?

Accepted Answer

Germinoma

Answer

Hemangioma

Answer

Teratoma

Answer

Embryonal Carcinoma

Question 8

A patient presents with a 2 cm midline neck swelling. HPE reveals orphan annie eye nuclei. What is the most likely diagnosis?

Accepted Answer

Papillary thyroid carcinoma

Answer

Medullary thyroid carcinoma

Answer

Toxic nodular goiter

Answer

Follicular thyroid carcinoma

Question 9

Psammoma bodies are typically found in which of the following conditions?

Accepted Answer

Papillary carcinoma of the thyroid

Answer

Follicular carcinoma of the thyroid

Answer

Medullary carcinoma of the thyroid

Answer

Anaplastic carcinoma of the thyroid

Question 10

Which of the following gene defects is associated with the development of medullary carcinoma of the thyroid?

Accepted Answer

RET Proto Oncogene

Answer

APC gene

Answer

Rb gene

Answer

BRCA 1 gene

Endocrine Pathology — MCQs

Endocrine Pathology — MCQs

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