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Bone Tumors MCQs

Practice Set 7 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 121

Topic: Bone Tumors

A 9-year-old boy presents with mild right arm pain after a minor fall. Radiographs are obtained.

Assuming the radiograph demonstrates a central, completely lytic metaphyseal lesion with a 'fallen leaf' sign, what is the most appropriate initial management?

. Wide en bloc resection
. Neoadjuvant chemotherapy followed by limb salvage
. Observation alone with no intervention
. Aspiration and injection of methylprednisolone
. Amputation

Correct Answer & Explanation

. Aspiration and injection of methylprednisolone

Explanation

A central, lytic metaphyseal lesion with a 'fallen leaf' sign is pathognomonic for a Unicameral Bone Cyst (UBC). The initial treatment of choice for symptomatic or fracture-prone UBCs is aspiration and corticosteroid injection.

Question 122

Topic: Bone Tumors

A 65-year-old man presents with severe back pain and anemia. A skeletal survey shows multiple lytic 'punched-out' lesions in the skull and spine. Which of the following laboratory findings is most specific for this condition?

. Elevated alkaline phosphatase
. Monoclonal spike on serum protein electrophoresis
. Decreased serum calcium
. Elevated C-reactive protein
. Positive HLA-B27

Correct Answer & Explanation

. Monoclonal spike on serum protein electrophoresis

Explanation

Multiple myeloma classically presents with lytic bone lesions, hypercalcemia, anemia, and renal involvement. A monoclonal M-protein spike on serum or urine protein electrophoresis is highly characteristic.

Question 123

Topic: Bone Tumors

A 19-year-old male complains of severe night pain in his right tibial diaphysis that is consistently and completely relieved by NSAIDs. Radiographs demonstrate a 1 cm radiolucent nidus surrounded by reactive sclerosis. If conservative management fails, what is the treatment of choice?

. En bloc resection
. Radiofrequency ablation (RFA)
. Radiation therapy
. Chemotherapy
. Amputation

Correct Answer & Explanation

. Radiofrequency ablation (RFA)

Explanation

The clinical and radiographic presentation is classic for an osteoid osteoma. If medical management with NSAIDs fails or is poorly tolerated, percutaneous Radiofrequency Ablation (RFA) is the definitive, minimally invasive treatment of choice.

Question 124

Topic: Bone Tumors

A 19-year-old male presents with severe, aching pain in his mid-tibia that classically worsens at night. He reports complete relief of symptoms within 30 minutes of taking aspirin. Radiographs reveal a cortical lucency surrounded by sclerosis. The central nidus of this lesion predominantly secretes high levels of which biochemical mediator?

. Interleukin-6
. Tumor Necrosis Factor-alpha
. Prostaglandin E2
. Leukotriene B4
. Substance P

Correct Answer & Explanation

. Prostaglandin E2

Explanation

The clinical presentation is classic for an osteoid osteoma. The central nidus produces a high concentration of Prostaglandin E2 (PGE2), which causes severe pain that is exquisitely sensitive to COX inhibitors like aspirin and NSAIDs.

Question 125

Topic: Bone Tumors
A 12-year-old boy is brought to the clinic by his concerned parents. The boy's forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well. The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelung's deformity and are concerned that the disease is now involving other areas of his body. You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The child's skeletal radiograph survey is also presented (Slide 2 and Slide 3). Which of the following areas is unlikely to be involved:
. Phalanges
. Pelvis
. Clavicle
. Femur
. Talus

Correct Answer & Explanation

. Clavicle

Explanation

The clavicle is a membranous bone, and osteochondromas do not arise in membranous bones.

Question 126

Topic: Bone Tumors

A 55-year-old male presents with deep, aching shoulder pain. Radiographs reveal a large, lytic lesion in the proximal humerus with intralesional 'popcorn' calcifications and endosteal scalloping. What is the most appropriate definitive management for a conventional high-grade lesion of this type?

. Extended intralesional curettage with adjuvant
. Neoadjuvant chemotherapy followed by wide resection
. Wide surgical resection alone
. Definitive external beam radiation therapy
. Radiofrequency ablation

Correct Answer & Explanation

. Wide surgical resection alone

Explanation

The presentation describes a conventional chondrosarcoma. Unlike osteosarcoma or Ewing sarcoma, conventional chondrosarcomas are generally resistant to chemotherapy and radiation, making wide surgical resection the primary treatment.

Question 127

Topic: Bone Tumors

Prolonged nonsteroidal anti-inflammatory drugs (NSAIDs) cure which of the following lesions:

. Osteosarcoma
. Osteoid osteoma
. Osteoblastoma
. Osteochondroma
. None of the above

Correct Answer & Explanation

. Osteoid osteoma

Explanation

An average 33-month course of treatment with NSAIDs cures osteoid osteoma. The prostaglandin E2 in osteoid osteoma is likely the reason for this response.

Question 128

Topic: Bone Tumors

A 15-year-old male presents with worsening distal femur pain. Radiographs reveal a mixed lytic/sclerotic lesion with a "sunburst" periosteal reaction. Staging studies are performed. What is the most common site of metastasis for this primary bone tumor?

. Liver
. Brain
. Lungs
. Lymph nodes
. Spine

Correct Answer & Explanation

. Lungs

Explanation

The clinical and radiographic presentation is classic for osteosarcoma. The lungs are the most common site of initial metastasis for osteosarcoma, making chest CT a critical component of staging.

Question 129

Topic: Bone Tumors

A 15-year-old boy presents with progressive knee pain and swelling for 2 months. Radiographs of the distal femur show a mixed lytic and blastic lesion, cortical destruction, and a Codman triangle. After staging, what is the most appropriate next step in management?

. Immediate transfemoral amputation
. Wide surgical excision alone
. Neoadjuvant chemotherapy followed by wide excision
. Radiation therapy followed by wide excision
. Intralesional curettage and bone grafting

Correct Answer & Explanation

. Neoadjuvant chemotherapy followed by wide excision

Explanation

The clinical and radiographic findings are classic for osteosarcoma. The standard of care involves neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage), and subsequent adjuvant chemotherapy.

Question 130

Topic: Bone Tumors

A 16-year-old male presents with knee pain. Radiographs show an aggressive, bone-forming distal femoral metaphyseal lesion with periosteal reaction (Codman's triangle). Which is the most common site of metastasis for this suspected malignancy?

. Liver
. Brain
. Lungs
. Spine
. Lymph nodes

Correct Answer & Explanation

. Lungs

Explanation

The clinical and radiographic picture strongly suggests conventional osteosarcoma. The lungs are the most common site for distant hematogenous metastasis in osteosarcoma.

Question 131

Topic: Bone Tumors

Which of the following is the most frequent primary site of involvement for classic high-grade intramedullary osteosarcoma in the pediatric population?

. Proximal humerus
. Proximal femur
. Distal femur
. Proximal tibia
. Distal tibia

Correct Answer & Explanation

. Distal femur

Explanation

Osteosarcoma most commonly affects the metaphyses of long bones where growth is most active. The distal femur is the single most common site, followed by the proximal tibia and the proximal humerus.

Question 132

Topic: Bone Tumors

An 18-year-old male reports persistent deep shin pain that is significantly worse at night and rapidly relieved by ibuprofen. Imaging shows a 1.2 cm radiolucent nidus surrounded by dense sclerotic bone in the proximal tibial diaphysis. What is the most common minimally invasive treatment if conservative management fails?

. Cryotherapy
. En bloc surgical resection
. Radiofrequency ablation
. Intralesional corticosteroid injection
. External beam radiation

Correct Answer & Explanation

. Radiofrequency ablation

Explanation

The presentation is classic for an osteoid osteoma (nidus <1.5 cm, nocturnal pain relieved by NSAIDs). If medical management fails or the patient prefers definitive treatment, CT-guided radiofrequency ablation is the gold standard minimally invasive treatment.

Question 133

Topic: Bone Tumors

A 9-year-old boy presents with a pathologic fracture of the proximal humerus after a minor fall. Radiographs show a centrally located, lytic, expansile metaphyseal lesion with a dependent cortical fragment visible within the cavity. Which fluid is most likely to be obtained upon aspiration of this lesion?

. Purulent material
. Gross, unclotting blood
. Clear or serosanguinous fluid
. Chylous fluid
. Thick, viscous synovial fluid

Correct Answer & Explanation

. Clear or serosanguinous fluid

Explanation

The dependent cortical fragment is the fallen leaf sign, pathognomonic for a Unicameral Bone Cyst (UBC). Aspiration of a UBC typically yields clear or slightly serosanguinous fluid, distinguishing it from an aneurysmal bone cyst (ABC) which yields unclotting blood.

Question 134

Topic: Bone Tumors

A 20-year-old male reports right thigh pain worse at night and relieved by NSAIDs. CT scan shows a 7 mm radiolucent nidus surrounded by dense sclerosis in the proximal femur. Which of the following is the most appropriate definitive minimally invasive treatment?

. Observation alone
. Intralesional curettage and bone grafting
. Radiofrequency ablation
. Wide local excision
. External beam radiation

Correct Answer & Explanation

. Radiofrequency ablation

Explanation

The clinical and radiographic presentation is classic for an osteoid osteoma. Radiofrequency ablation is the gold standard minimally invasive definitive treatment, offering high success rates with low morbidity.

Question 135

Topic: Bone Tumors

A 62-year-old female presents with bone pain. Radiographs show multiple punched-out lytic lesions in her skull. Lab tests show hypercalcemia and anemia. Which diagnostic test is most specific for confirming the suspected underlying systemic diagnosis?

. Serum alkaline phosphatase level
. Bone scintigraphy (bone scan)
. Serum and urine protein electrophoresis
. Erythrocyte sedimentation rate
. C-reactive protein

Correct Answer & Explanation

. Serum and urine protein electrophoresis

Explanation

The presentation is classic for multiple myeloma (hypercalcemia, renal failure, anemia, and bone lesions). Serum and urine protein electrophoresis identifying a monoclonal spike (M-protein) is essential for diagnosis.

Question 136

Topic: Bone Tumors
A 50-year-old male presents with deep shoulder pain. Radiographs reveal a radiolucent lesion in the proximal humerus with intralesional "rings and arcs" calcification and endosteal scalloping involving > 2/3 of the cortical thickness. What is the most appropriate definitive management?
. Neoadjuvant chemotherapy followed by curettage
. Radiation therapy alone
. Extended intralesional curettage with burring and cementation
. Wide surgical resection
. Observation with serial radiographs every 3 months

Correct Answer & Explanation

. Wide surgical resection

Explanation

The clinical presentation is classic for a primary conventional high-grade chondrosarcoma, indicated by the rings/arcs calcification and deep endosteal scalloping. Because conventional chondrosarcoma is resistant to both chemotherapy and radiation, wide surgical resection is the standard of care.

Question 137

Topic: Bone Tumors
A 55-year-old female presents with shoulder pain. Radiographs show a large radiolucent lesion in the proximal humerus with "rings and arcs" calcification and endosteal scalloping > 2/3 of the cortical thickness. What is the most appropriate definitive management?
. Intralesional curettage and bone grafting
. Wide surgical resection and reconstruction
. Neoadjuvant chemotherapy followed by wide resection
. Primary radiation therapy
. Observation with serial radiographs

Correct Answer & Explanation

. Wide surgical resection and reconstruction

Explanation

The clinical and radiographic findings suggest a conventional chondrosarcoma. Because conventional chondrosarcomas are highly resistant to chemotherapy and radiation, wide surgical resection is the standard of care.

Question 138

Topic: Bone Tumors

A 7-year-old boy with Hereditary Multiple Exostoses (HME) is noted to have a progressively worsening genu valgum deformity. His parents ask about the underlying cause of this angular deformity. Which of the following best describes the primary mechanism?

. Premature fusion of the entire physis due to the osteochondroma.
. Overgrowth of the physis on the concave side of the deformity.
. Asymmetric growth arrest or tethering of a portion of the physis by the osteochondroma.
. Mechanical block to joint motion leading to compensatory bone remodeling.
. Increased vascularity around the osteochondroma stimulating localized bone growth.

Correct Answer & Explanation

. Asymmetric growth arrest or tethering of a portion of the physis by the osteochondroma.

Explanation

Correct Answer: CAcademic Rationale:Angular deformities and limb length discrepancies in Hereditary Multiple Exostoses (HME) are primarily caused byasymmetric growth arrest or tethering of a portion of the physisby the osteochondroma. Osteochondromas arise from aberrant cartilage cells that escape the growth plate. When these lesions are located near or involve the physis, they can physically tether or distort a segment of the growth plate, leading to localized growth retardation or arrest. This asymmetric growth disturbance results in progressive angulation (e.g., genu valgum if the lateral side of the distal femur or proximal tibia physis is affected) and potential limb length discrepancies.Option A (Premature fusion of the entire physis):While growth arrest occurs, it's typically asymmetric and partial, not a complete premature fusion of the entire physis, which would lead to more uniform shortening rather than angulation.Option B (Overgrowth of the physis on the concave side):This is incorrect. The growth disturbance typically involves retardation or tethering, not overgrowth, and it's the affected side of the ph physis (often the concave side of the developing deformity) that is inhibited.Option D (Mechanical block to joint motion):While large osteochondromas can cause mechanical impingement and limit joint motion, this is a separate complication and not the primary mechanism for progressive angular deformities of the long bones themselves.Option E (Increased vascularity stimulating growth):Increased vascularity is not a recognized mechanism for causing angular deformities in HME; in fact, growth retardation is the issue.

Question 139

Topic: Bone Tumors

A 22-year-old male presents with a painful mass in the popliteal fossa. Imaging reveals a large osteochondroma. Doppler ultrasound shows extrinsic compression of the popliteal artery with turbulent flow. Which of the following is the most appropriate definitive management for this patient?

. Observation with serial Doppler ultrasounds.
. Administration of systemic anticoagulants.
. Surgical excision of the osteochondroma with vascular repair if necessary.
. Percutaneous ethanol ablation of the osteochondroma.
. Physical therapy to improve popliteal muscle strength.

Correct Answer & Explanation

. Surgical excision of the osteochondroma with vascular repair if necessary.

Explanation

Correct Answer: CAcademic Rationale:The presence of an osteochondroma causing extrinsic compression of the popliteal artery with turbulent flow indicates a significant vascular complication that can lead to ischemia, pseudoaneurysm, or thrombosis. This is a surgical emergency. The most appropriate definitive management issurgical excision of the osteochondromato relieve the compression, with concurrent vascular repair or reconstruction if the artery has been damaged (e.g., pseudoaneurysm formation, intimal injury). This approach addresses both the cause (osteochondroma) and the consequence (vascular compromise).Option A (Observation):Observation is inappropriate given the acute vascular compromise.Option B (Systemic anticoagulants):Anticoagulants might be used if thrombosis has occurred, but they do not address the underlying mechanical compression and risk of arterial injury.Option D (Percutaneous ethanol ablation):This is not a standard or effective treatment for large osteochondromas, especially those causing vascular compression.Option E (Physical therapy):Physical therapy is not indicated for a mechanical vascular compression caused by a bony lesion.

Question 140

Topic: Bone Tumors

A 15-year-old boy has a large, sessile osteochondroma of the distal ulna causing progressive ulnar deviation of the wrist and forearm rotation limitation (Madelung-like deformity). He is skeletally immature. What is the most appropriate surgical strategy to address this condition?

. Simple excision of the osteochondroma and observation for deformity correction.
. Excision of the osteochondroma combined with a corrective osteotomy and possibly guided growth of the radius/ulna.
. Proximal ulnar osteotomy to shorten the ulna without excising the osteochondroma.
. Radiation therapy to halt the growth of the osteochondroma and correct deformity.
. Arthrodesis of the distal radioulnar joint to stabilize the wrist.

Correct Answer & Explanation

. Excision of the osteochondroma combined with a corrective osteotomy and possibly guided growth of the radius/ulna.

Explanation

Correct Answer: BAcademic Rationale:When an osteochondroma, particularly in the distal ulna, causes significant angular deformity and functional limitation (like a Madelung-like deformity) in a skeletally immature patient, simple excision of the osteochondroma alone is often insufficient to correct the existing deformity. The most appropriate surgical strategy isexcision of the osteochondroma combined with a corrective osteotomy(e.g., of the ulna or radius) to realign the limb and, if significant growth potential remains, possibly guided growth (e.g., hemiepiphysiodesis) to modulate future growth and prevent recurrence of the deformity. This comprehensive approach addresses both the mass and the resulting skeletal malalignment.Option A (Simple excision and observation):Simple excision may relieve impingement but will not correct a pre-existing angular deformity. Observation would allow the deformity to persist or worsen.Option C (Proximal ulnar osteotomy without excision):This would address the length discrepancy but not the underlying osteochondroma or its potential for continued growth and recurrence of the deformity.Option D (Radiation therapy):Radiation therapy is not indicated for benign osteochondromas and carries risks of radiation-induced malignancy and growth disturbance.Option E (Arthrodesis of DRUJ):Arthrodesis is a salvage procedure that sacrifices motion and is not indicated as a primary treatment for a correctable deformity in a skeletally immature patient.

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