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Bone Tumors MCQs

Practice Set 2 of 52

This practice set contains high-yield board review questions covering key concepts in Bone Tumors. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 21

Topic: Bone Tumors

When evaluating a patient with a suspected aneurysmal bone cyst (ABC), which of the following MRI findings is highly characteristic, though not entirely specific?

. Target sign
. Fluid-fluid levels on T2-weighted imaging
. Dural tail sign
. Salt-and-pepper appearance
. Double-line sign

Correct Answer & Explanation

. Fluid-fluid levels on T2-weighted imaging

Explanation

Fluid-fluid levels on T2-weighted MRI represent blood products of varying ages settling within the cystic spaces of an ABC. While characteristic of ABCs, they can also be seen in telangiectatic osteosarcoma and giant cell tumors.

Question 22

Topic: Bone Tumors

When an osteoid osteoma occurs in the spine, it can involve all of the following except:

. Facets
. Transverse processes
. Pedicles
. Rib heads adjacent to thoracic vertebrae
. Vertebral body

Correct Answer & Explanation

. Vertebral body

Explanation

When an osteoid osteoma occurs in the spine, involvement of the posterior elements of the vertebra is typical and includes: Lamina Pedicles Transverse processes Facets Rib heads adjacent to thoracic vertebrae

Question 23

Topic: Bone Tumors

Typical histologic features of an osteoid osteoma include all of the following except:

. C hondrocytes in an arrangement similar to that of a physis
. Nidus composed of haphazardly arranged network of osteoid trabeculae
. Varying degrees of mineralization with greatest mineralization in the center of the lesion
. Osteoblasts rimming the trabeculae
. Vascularized spindle cell stroma

Correct Answer & Explanation

. C hondrocytes in an arrangement similar to that of a physis

Explanation

The histologic features of an osteoid osteoma include the following: Nidus composed of haphazardly arranged network of osteoid trabeculae Varying degrees of mineralization with greatest mineralization in the center of the lesion Loose fibrovascular connective tissue between trabeculae Osteoblasts rimming the trabeculae Vascularized spindle cell stroma

Question 24

Topic: Bone Tumors

Treatment of a vertebral osteoid osteoma includes all of the following except:

. Surgical excision/curettage of the nidus
. En-bloc resection
. Observation if symptoms are mild
. Aspirin/salicylates/nonsteroidal anti-inflammatory drugs (NSAIDs)
. Radiofrequency ablation

Correct Answer & Explanation

. En-bloc resection

Explanation

Treatment of osteoid osteomas in the spine include the following: Aspirin/salicylates/NSAIDs Administered for up to 2 years Successful in up to 50% cases Radiofrequency ablation (RFA) Usually computed tomography-guided Clinical success rates as high as 97% have been reported with 1 to 2 treatments Surgical excision of the nidus/curettage Necessary when aspirin/salicylates/NSAIDs cannot be tolerated for long periods of time and RFA is not possible or unsuccessful Can usually be accomplished through a posterior approach En-bloc resection or a more radical procedure play no role in management

Question 25

Topic: Bone Tumors

Typical symptoms of a spinal osteoblastoma include all of the following except:

. Torticollis
. Painful scoliosis
. Stiffness
. Diskogenic pain
. Radicular symptoms

Correct Answer & Explanation

. Diskogenic pain

Explanation

The most common symptoms of spinal osteoblastomas include: Pain Usually the first and most common presenting symptom Night pain is not as common as it is with osteoid osteomas Night pain is not as common as it is with osteoid osteomas Painful scoliosis Torticollis Stiffness Radicular symptoms usually due to mass effect

Question 26

Topic: Bone Tumors

A 14-year-old girl presents with back pain and a palpable midline mass. Imaging shows a highly expansile, multicystic, radiolucent lesion involving the spinous process and lamina of L2. MRI demonstrates fluid-fluid levels within the cysts. What is the most likely diagnosis?

. Aneurysmal bone cyst
. Unicameral bone cyst
. Osteosarcoma
. Ewing sarcoma
. Hemangioma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts (ABCs) in the spine typically involve the posterior elements and appear as expansile, lytic lesions. MRI classically demonstrates fluid-fluid levels due to blood settling within the cystic spaces.

Question 27

Topic: Bone Tumors

A 62-year-old man presents with diffuse bone pain and fatigue. Radiographs show multiple punched-out lytic lesions in the skull and spine. A technetium-99m bone scan is performed. What is the expected finding on the bone scan?

. Intensely 'hot' diffuse skeletal uptake
. Superscan appearance
. Normal uptake or 'cold' spots in the areas of lytic lesions
. Increased uptake specifically localized to the appendicular skeleton
. Asymmetric uptake limited to the joints

Correct Answer & Explanation

. Normal uptake or 'cold' spots in the areas of lytic lesions

Explanation

Multiple myeloma characteristically lacks osteoblastic activity. Therefore, despite extensive lytic bone destruction, a standard technetium-99m bone scan often appears normal or shows 'cold' (photopenic) defects rather than increased uptake.

Question 28

Topic: Bone Tumors

Osteoblastoma and osteoid osteoma of the spine share similar histologic appearances. Which of the following clinical or radiographic features most reliably distinguishes an osteoblastoma from an osteoid osteoma?

. Location exclusively in the anterior vertebral body
. Lesion size greater than 2 centimeters
. Complete relief of pain with NSAIDs
. Presence of a dense reactive bone sclerosis out of proportion to the nidus
. Predominance in elderly females

Correct Answer & Explanation

. Lesion size greater than 2 centimeters

Explanation

Osteoblastoma is histologically identical to osteoid osteoma but is distinguished by a nidus larger than 1.5 to 2.0 cm. It is also less likely to be completely relieved by NSAIDs and has a higher tendency for local aggression.

Question 29

Topic: Bone Tumors

A 16-year-old girl presents with a rigid thoracic scoliosis and night pain relieved by ibuprofen. Imaging reveals a sclerotic lesion with a central lucent nidus in the left T9 pedicle. In which direction will the apex of her scoliosis typically point?

. Anteriorly, creating an extreme focal kyphosis
. Away from the side of the lesion
. Towards the side of the lesion
. Posteriorly, creating a focal lordosis
. Randomly, with no predictable correlation to the lesion side

Correct Answer & Explanation

. Away from the side of the lesion

Explanation

The lesion is an osteoid osteoma. Muscle spasm secondary to the inflammatory mediators (prostaglandins) released by the nidus causes a convex deformity, so the apex of the scoliosis points away from the side of the lesion.

Question 30

Topic: Bone Tumors

A 6-year-old boy complains of localized back pain. Lateral radiographs show complete collapse of the T8 vertebral body (vertebra plana) with preservation of the adjacent disc spaces. The most likely diagnosis is:

. Ewing sarcoma
. Osteosarcoma
. Eosinophilic granuloma
. Aneurysmal bone cyst
. Osteoid osteoma

Correct Answer & Explanation

. Eosinophilic granuloma

Explanation

Eosinophilic granuloma (Langerhans cell histiocytosis) is a classic cause of vertebra plana in children. The disc spaces are characteristically preserved, unlike in infectious discitis.

Question 31

Topic: Bone Tumors

A 22-year-old woman presents with severe back pain. MRI shows an expansile, multiloculated lytic lesion in the posterior elements of L3 with multiple fluid-fluid levels on T2-weighted sequences. The most likely diagnosis is:

. Aneurysmal bone cyst
. Giant cell tumor
. Osteoblastoma
. Chordoma
. Osteosarcoma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts (ABCs) typically arise in the posterior elements of the spine in young patients. The presence of fluid-fluid levels on MRI is a hallmark characteristic.

Question 32

Topic: Bone Tumors

A 16-year-old boy presents with severe thoracic back pain that is worse at night and completely relieved by ibuprofen. CT scan shows a 1 cm radiolucent nidus with surrounding sclerosis in the pedicle of T9. Which of the following is the most appropriate next step if conservative management fails?

. En bloc spondylectomy
. Radiofrequency ablation
. External beam radiation
. Chemotherapy
. Wide local excision

Correct Answer & Explanation

. Radiofrequency ablation

Explanation

The clinical picture is classic for an osteoid osteoma. If conservative management with NSAIDs fails, minimally invasive procedures such as CT-guided radiofrequency ablation (RFA) are the treatment of choice.

Question 33

Topic: Bone Tumors

A 15-year-old girl presents with progressive back pain. Imaging shows an expansile, multiloculated, osteolytic lesion in the posterior elements of L3. MRI demonstrates distinct fluid-fluid levels within the lesion. What is the most likely diagnosis?

. Simple bone cyst
. Aneurysmal bone cyst
. Osteoblastoma
. Giant cell tumor
. Chondroblastoma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts (ABCs) in the spine classically involve the posterior elements in adolescents. The hallmark MRI finding is fluid-fluid levels representing blood products of different ages.

Question 34

Topic: Bone Tumors

A 50-year-old patient with known multiple myeloma presents with severe, localized thoracic back pain. Plain films show a compression fracture of T8 without retropulsion, and MRI shows no neural compression. The patient has failed 6 weeks of conservative management. What is the most appropriate intervention for pain relief?

. Open reduction and internal fixation
. Kyphoplasty or Vertebroplasty
. Laminectomy
. En bloc vertebrectomy
. Intrathecal morphine pump

Correct Answer & Explanation

. Kyphoplasty or Vertebroplasty

Explanation

In cases of painful pathologic vertebral compression fractures without neural element compression that fail conservative care, vertebral augmentation (kyphoplasty or vertebroplasty) provides excellent and rapid pain relief.

Question 35

Topic: Bone Tumors
A 68-year-old man presents with a pathologic fracture of the L4 vertebra. Laboratory evaluation reveals a monoclonal spike on serum protein electrophoresis and hypercalcemia. Which of the following radiographic features is typically absent in this disease process?
. Lytic bone lesions
. Osteopenia
. Reactive bone sclerosis
. Vertebral body collapse
. Cold spots on a bone scan

Correct Answer & Explanation

. Reactive bone sclerosis

Explanation

Multiple myeloma is characterized by purely lytic lesions without reactive bone sclerosis. Because there is no osteoblastic response, bone scans are typically "cold" or false-negative in myeloma.

Question 36

Topic: Bone Tumors

A 45-year-old male presents with a spontaneous L1 compression fracture. He has no history of trauma, long-term steroid use, or known systemic medical conditions. What is the most critical next step in his medical workup?

. Routine Dual-energy X-ray absorptiometry (DEXA) scan only
. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)
. Genetic testing for COL1A1 mutations
. Serum calcitonin and carcinoembryonic antigen (CEA) levels
. HLA-B27 antigen testing

Correct Answer & Explanation

. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)

Explanation

A spontaneous vertebral compression fracture in a young or middle-aged male is highly suspicious for a secondary cause, particularly multiple myeloma. SPEP and UPEP are essential initial screening tools in this demographic.

Question 37

Topic: Bone Tumors

A 68-year-old female presents with progressively worsening back pain 3 months after a minor fall. Radiographs show a T12 compression fracture with an intravertebral vacuum cleft that enlarges on an extension view. What is the most likely diagnosis?

. Multiple myeloma
. Kummell disease
. Vertebral osteomyelitis
. Discitis
. Paget disease

Correct Answer & Explanation

. Kummell disease

Explanation

Kummell disease is delayed post-traumatic avascular necrosis of a vertebral body following an ischemic insult. It is classically associated with an intravertebral vacuum cleft that dynamically changes in size with flexion and extension.

Question 38

Topic: Bone Tumors

When evaluating a patient with a suspected atraumatic osteoporotic compression fracture, obtaining which of the following laboratory values is critical to rule out multiple myeloma as a secondary cause?

. Alkaline phosphatase
. Serum protein electrophoresis (SPEP)
. C-reactive protein
. Thyroid stimulating hormone
. Prostate specific antigen

Correct Answer & Explanation

. Serum protein electrophoresis (SPEP)

Explanation

Multiple myeloma frequently presents with osteolytic lesions and pathological compression fractures that mimic osteoporotic fractures. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) are essential screening tests to identify the characteristic monoclonal gammopathy.

Question 39

Topic: Bone Tumors

In children under the age of 5, what anatomical feature is primarily responsible for the pathophysiology of primary discitis, distinguishing it from adult vertebral osteomyelitis?

. A complete absence of blood supply to the vertebral endplates
. Direct communication between the spinal canal and the disc space
. A persistent notochordal remnant acting as a nidus
. The presence of vascular anastomoses traversing the cartilaginous endplate directly into the nucleus pulposus
. Increased permeability of the annulus fibrosus to venous drainage

Correct Answer & Explanation

. The presence of vascular anastomoses traversing the cartilaginous endplate directly into the nucleus pulposus

Explanation

Pediatric primary discitis occurs due to the presence of blood vessels that cross the cartilaginous endplate to supply the disc space in early childhood. These vessels regress around the age of 7 or 8, making adult isolated discitis rare.

Question 40

Topic: Bone Tumors

A 60-year-old female presents with insidious onset of persistent mid-thoracic back pain, worsened by recumbency. Laboratory results show hypercalcemia and elevated total protein. Radiographs reveal a lytic lesion in the T7 vertebral body. Which of the following is the most likely diagnosis?

. Metastatic breast carcinoma
. Multiple myeloma
. Osteosarcoma
. Chondrosarcoma
. Hemangioma

Correct Answer & Explanation

. Multiple myeloma

Explanation

Multiple myeloma is the most common primary malignancy of bone in adults. It classically presents with bone pain, hypercalcemia, lytic bone lesions, and elevated serum protein due to monoclonal gammopathy.

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