Midterm Review (Lectures 1&2)

Done by:
Maan Alherbish
Abdullah Almousa
Aisha Alraddadi
Badour Alsalman
Maan Alherbish

Team Leaders:
Abdullah Alatar & Ghaida Alawaji

Endocrine Block

hbjhggygyhhhhhhsdffffff
(Hypo/Hyper)Thyroidism and Hashimoto's Thyroiditis
• The Thyroid gland is formed of 2 large lobes connected by
isthmus, it's regulated by Hypothalamus-Pituitary-Thyroid axis.
• Hypothyroidism:
-­‐ Caused by any structural or functional damage, leading
to dropped levels of secreted hormones. Can be
primary (Thyroidal disease) or Secondary (e.g. TSH
deficiency)
-­‐ Incidence is 0.1%, Affect women ten folds more than
men.
Primary causes include:
1. Developmental (Acquired mutations, e.g. PAX8, FOXE1,
TSH receptor mutations).
2. Surgery and Radioiodine therapy (Postablative)
3. Iodine deficiency (Most common cause of congenital
hypothyroidism).
4. Autoimmune (e.g. Hashimoto's Thyroiditis) Most common
cause of hypothyroidism in iodine-rich countries.
5. Congenital defects (e.g. Dyshormonogenetic goiter) less
common cause of congenital hypothyroidism.
Manifestations differ according to the age affected:
-­‐ Cretinism: Due to congenital hypothyroidism, patients
come with severe mental retardation and short stature.
-­‐ Myxedema: slowing of physical and mental activity,
mental sluggishness and overweight.
• Thyrotoxicosis: Hypermetabolic state caused by elevated
circulating levels of free T3 and T4.
Causes Explanation Examples
Associated with More common, Graves's
Hyperthyroidism hyperfunction of disease/Adenoma/
the thyroid gland. Multinodular
goiter/Pituitary
adenoma
Not Associated Any other cause Thyroiditis / Struma
with leads to high ovarii / Exogenous
Hyperthyroidism levels of the hormonal intake
thyroid hormones.

• Graves' disease: Autoimmune disorder characterized by

presence of Immunoglobulins against TSH-Receptor that
mimic the action of TSH.
-­‐ Other antibodies against Peroxisome and Thyroglobulin may
also be a finding.
• Thyroiditis: Inflammation of the thyroid gland.
Can be:
-­‐ Painful with Acute illness (Infectious, Subacute
granulomatous thyroiditis*).
Thought to be caused infectiously (Coxsackie, Mumps
viruses) More common in women (40-50)
-­‐ Painless with little inflammation (Subacute lymphocytic
and fibrous Thyroiditis).
• Hashimoto's Thyroiditis: Gradual thyroid failure by
autoimmune destruction of the thyroid gland (Against many
thyroidal autoantigens e.g. Peroxidase enzyme and
Thyroglobulin).
-­‐ Patients come with diffusely symmetrically enlarged
gland with Lymphocytic infiltration (Struma
Lymphomatosa).
-­‐ Female predominance of 10:1 to 20:1. Age 45-65.
-­‐ Morphology:
1. Gross features: Diffusely enlarged gland with pale,
yellow-tan and firm cut-surface.
2. Microscopic features: extensive infiltration of the
parenchyma by a mononuclear inflammatory infiltrate
containing small lymphocytes, plasma cells, and well-
developed germinal centers.
-­‐ Presence of what is called (Hürthle cells) with
eosinophilic granular cytoplasm containing numerous
mitochondria.
 Thyroid nodules and Neoplasms
• Thyroid Neoplasm could be Follicular-Adenoma (Benign) or
Carcinoma (Malignant). Benign neoplasms are more
common than malignant.
• The major subtypes of thyroid carcinoma are:
- Papillary carcinoma (> 85% of cases)
- Follicular carcinoma
- Medullary carcinoma
- Anaplastic carcinoma

• Follicular Adenoma and all subtypes of thyroid carcinoma

arise from follicular cells EXCEPT Medullary carcinoma from
parafollicular (c-cells).
•
• Benign neoplasms outnumber thyroid carcinomas by a ratio
of nearly 10:1.
- Solitary nodules, in younger male patient → neoplastic
- Nodules that highly uptake radioactive iodine (hot nodules)
→ benign

• Careful evaluation of the integrity of the capsule is critical in

distinguishing follicular adenomas from follicular carcinomas,
which demonstrate capsular and/or vascular invasion.
-­‐ Follicular adenomas: encapsulated mass lesion.
-­‐ Follicular carcinomas: invasion of capsule or blood
vessels.

• Follicular adenomas are the most common benign

neoplasms, while papillary carcinoma is the most common
malignancy.

• Extremely rare that thyroid neoplasms increase the

production of thyroid hormones (generally are
nonfunctional)
 Carcinomas
• Genetics:
Follicular → RAS Medullary → MEN-2, RET
Papillary → RET, NTRK1 or Anaplastic → P53
BRAF

1. Papillary Thyroid Carcinoma:

-­‐ The major risk factor is exposure to ionizing radiation.
-­‐ Between the ages of 25 and 50
-­‐ The first manifestation may be a mass in a cervical lymph
node
-­‐ Have an excellent prognosis
-­‐ Papillary carcinomas are recognized based on nuclear
features
-­‐ Morphology: Papillary structures, Orphan Annie nuclei and
Psammoma bodies.

2. Follicular Carcinomas:
-­‐ Between 40 and 60 years and More common in women (3:1)

3. Medullary Carcinomas:
-­‐ Neuroendocrine neoplasms derived from C cells.
-­‐ Measurement of Calcitonin plays an important role in the
diagnosis and postoperative follow-up of patients.
-­‐ About 70% of tumors arise sporadically and the remainder
occurs in the setting of MEN syndrome 2A or 2B
-­‐ Morphology: polygonal to spindle cells and Amyloid
deposition. (Detected by Congo red stain)

4. Anaplastic Carcinomas
-­‐ Undifferentiated tumors of the thyroid follicular epithelium.
-­‐ Lethal (100%).
-­‐ Older age group > 65 year.
-­‐ Morphology: composed of highly anaplastic cells → giant
cells, spindle cells and small cells.
 MCQs
1-A 46-year-old woman complains of increasing fatigue and muscle
weakness over the past 6 months. She reports an inability to
concentrate at work and speaks with a husky voice. The patient denies
drug or alcohol abuse. Physical examination reveals cold and clammy
skin, coarse and brittle hair, boggy face with puffy eyelids, and
peripheral edema. There is no evidence of goiter or exophthalmos.
Laboratory studies show reduced serum levels of T3 and T4. Which of the
following is the most likely underlying cause of these signs and
symptoms?
A. Amyloidosis of the thyroid
B. Hypothyroidism
C. Thyroid follicular adenoma
D. Multinodular goiter

2-A patient presents with signs of hyperthyroidism (thyrotoxicosis). To

investigate the matter, you measure the levels of T4 and TSH. If the
patient has a benign thyroid adenoma ("toxic nodule"), you can expect
the following results?
A. T4 elevated, TSH reduced
B. T4 reduced, TSH reduced
C. T4 elevates, TSH elevated
D. T4 reduced, TSH elevated

3-A patient presents with signs of hypothyroidism. To investigate the

matter, you measure the levels of T4 and TSH. If the patient suffers from
iodine deficiency, you can expect the following results?
A. T4 reduced, TSH reduced
B. T4 elevated, TSH reduced
C. T4 elevates, TSH elevated
D. T4 reduced, TSH elevated
4-The Exact cause of Hashimoto's thyroiditis is?
A. therapeutic radiation
B. thyroid resection
C. hypopituitarism
D. autoimmune destruction

5-In Grave's disease, enlargement of the thyroid gland is caused by?

A. constitutive activation of the Gs-protein as a result of a somatic
mutation
B. an antibody that stimulates TSH receptors
C. abnormally elevated TSH levels
D. a transport defect for iodine in the membrane of the follicular cell

6-A 40-year-old woman complains of chronic constipation and

anovulatory menstrual cycles for the last 8 months. Her vital signs are
normal. Physical examination reveals peripheral edema and a firm,
diffusely enlarged thyroid gland. Serum levels of T3 and T4 are
abnormally low. A thyroid biopsy is shown in the image. What is the
appropriate diagnosis?
A. Graves' disease
B. Hashimoto's thyroiditis
C. Lymphadenoid thyroiditis
D. Subacute (de Quervain) thyroiditis

7-A 43-year-old woman complains of low-grade fever and has a 3-day

history of pain in her neck. Physical examinations reveals a slightly
enlarged thyroid. A CBC is normal. A biopsy of the thyroid reveals
granulomatous inflammation and the presence of giant cells. What is
the appropriate diagnosis?
A. Graves' disease
B. Hashimoto's thyroiditis
C. Lymphadenoid thyroiditis
D. Subacute (de Quervain) thyroiditis
8-Patient has symptoms of hyperthyroidism. Which of the following best
summarizes the clinical symptoms expected in this patient?
A. Tremor, tachycardia, weight loss
B. Hyperpigmentation, weakness, hypotension
C. Nervousness, irritability, paresthesia, tetany
D. Dry skin, hypogonadism, fatigability

9-Which one of the following is the most susceptible group to be

affected by Hashimoto's Thyroiditis?
A. 20 Years old, male
B. 80 Years old, male
C. 50 Years old, female
D. 35 Years old, female

10-The appropriate reason behind the appearance of hypothyroid

manifestations between the episodes of hyperthyroidism in some
patients with Graves' disease is?
A. Presence of immunoglobulins that are directed to antigens other
than TSH receptor
B. Coexistence of TSH-receptor stimulating and inhibiting autoantibodies
C. Excessive levels of plasma TSI
D. None of these

11-The most common type of thyroid carcinoma is?

A. Papillary carcinoma
B. Follicular carcinoma
C. Medullary carcinoma
D. Anaplastic carcinoma

12-Young male came to the hospital with solitary nodule of the thyroid
.On examination with radioactive iodine, the nodule appear to be cold.
What is the most likely diagnosis?
A. Non neoplastic nodule
B. Neoplastic nodule, malignant nodule
C. Neoplastic benign nodule
13-The definitive diagnosis of thyroid adenoma by?
A. Gross examination
B. Careful histological examination
C. Radiological examination

14-Ionising radiation is the major risk factor for papillary carcinoma?

A. True
B. False

15-A 35 years old female comes to the hospital with cervical lymph
node enlargement, Microscopic examination shows finely deposit
chromatin (Orphan Annie eye) and pseudoinclusion, what is the most
likely diagnosis?
A. Papillary carcinoma
B. Follicular carcinoma
C. Anaplastic carcinoma
D. Medullary carcinoma

16-papillary carcinoma usually metastasize through lymphatics?

A. True
B. False

17-A 56 male have past history of well-differentiated thyroid carcinoma,

presents with swelling in his neck, biopsy was done and showed poor
differentiated pleomorphic giant cells. What is the most likely diagnosis?
A. Follicular carcinoma
B. Papillary carcinoma
C. Anaplastic carcinoma
C. Medullary carcinoma
18-In the patient described in Q7, what other microscopic fetters you
will observe?
A. Well-defined, intact capsule
B. Spindle cell with a sarcomatous appearance
C. Psammoma bodies
D. Orphan Annie eye

19-A 50 years old woman come to the hospital with sever goiter then
appear to have iodine deficiency .Histological examination of the
thyroid shows follicular cells invading the blood vessels. What is the most
likely diagnosis?
A. Papillary carcinoma
B. follicular carcinoma
C. Anaplastic carcinoma
D. Medullary carcinoma

20-In follicular thyroid carcinomas there is mutation in?

A. In the PI-3K/AKT signaling pathway
B. RET gene
C. P53 tumor suppressor gene

21-Medullary carcinoma derived from follicular epithelium?

A. True
B. False

22-A 36-year-old woman presents with swelling in her neck. Physical

examination reveals a non-tender nodule in the left lobe of the thyroid.
The thyroid nodule is found to be “cold” by radioiodine test. And a
section stained with Congo red reveals birefringent amyloid stroma.
What is the most likely the diagnosis?
A. Follicular carcinoma
B. Medullary carcinoma
C. Anaplastic carcinoma
D. Papillary carcinoma
Question 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Answer B A D D B B D A C B A B B A A A C B B A B B

Thank You & Good Luck