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Soft Tissue Tumors & Metastasis MCQs

Practice Set 2 of 6

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

Question 21

Topic: Soft Tissue Tumors & Metastasis
A 75-year-old woman notes a slowly enlarging mass in the right anterior thigh. Her medical history is significant only for hypertension. An MRI scan of her thigh is shown in Figures 60a through 60d. Which of the following surgical margins is the most appropriate for removal of this lesion?
. Radical
. Wide
. Marginal
. Intralesional
. Contaminated

Correct Answer & Explanation

. Marginal

Explanation

The patient has a large deep anterior thigh mass that has imaging characteristics of mature fat. Intramuscular lipomas are effectively treated with marginal resections with very low recurrence rates. Large lipomas often have small amounts of intralesional signal changes frequently representing trapped muscle fibers and do not necessitate more extensive margins.

Question 22

Topic: Soft Tissue Tumors & Metastasis

Histologic evaluation of a symptomatic mass excised from the third intermetatarsal space of a 45-year-old woman reveals marked perineural fibrosis, endoneurial edema, and demyelination of nerve fibers. What is the most likely diagnosis?

. Schwannoma
. Neurofibroma
. Morton's neuroma
. Ganglion cyst
. Plantar fibromatosis

Correct Answer & Explanation

. Morton's neuroma

Explanation

The histologic findings of perineural fibrosis, local vascular changes, and endoneurial edema are characteristic of Morton's neuroma. It is an entrapment neuropathy causing a reactive degeneration, rather than a true neoplasm.

Question 23

Topic: Soft Tissue Tumors & Metastasis

A 42-year-old male is diagnosed with a large, deep intramuscular myxoid liposarcoma of the thigh. Molecular analysis of the tumor is most likely to reveal which of the following genetic alterations?

. t(X;18)(p11;q11)
. t(12;16)(q13;p11)
. t(9;22)(q22;q12)
. t(2;13)(q35;q14)
. MDM2 amplification

Correct Answer & Explanation

. t(12;16)(q13;p11)

Explanation

Myxoid liposarcoma is characterized by the t(12;16)(q13;p11) translocation, which creates the FUS-DDIT3 fusion protein. It is uniquely highly sensitive to radiation therapy. MDM2 amplification is characteristic of well-differentiated and dedifferentiated liposarcomas.

Question 24

Topic: Soft Tissue Tumors & Metastasis

Figures 34a through 34c show an axial proton density (spin echo long TR, short TE) image, a sagittal inversion recovery (STIR) image, and a sagittal T1-weighted (short TR, short TE) image of the left thigh. What is the most likely diagnosis?

. Soft-tissue foreign body
. Lipoma
. Hematoma
. Pyomyositis
. Liposarcoma

Correct Answer & Explanation

. Hematoma

Explanation

The images reveal a region of increased signal within the rectus femoris muscle with mild, ill-defined surrounding edema. The presence of high intensity signal on the T1-weighted image favors acute blood, in this case associated with a rectus femoris muscle tear or fatty tissue. However, because of fat suppression, a fatty lesion or lipoma would be dark on STIR, rather than bright as in this image. Most foreign bodies are low intensity signal and if small, are difficult to evaluate with MRI. The lack of adjacent subcutaneous soft-tissue edema or surrounding fluid makes pyomyositis an unlikely diagnosis.

Question 25

Topic: Soft Tissue Tumors & Metastasis

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Sports Medicine 2007 Practice Questions: Set 3 (Solved) - Figure 8

. Baker's cyst
. Torn medial meniscus
. Patellofemoral pain syndrome
. Lipoma
. Ganglion cyst of the cruciates

Correct Answer & Explanation

. Ganglion cyst of the cruciates

Explanation

Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker's cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T1- and T2-weighted images. A lipoma would be bright on the T1-weighted image only. Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.

Question 26

Topic: Soft Tissue Tumors & Metastasis

Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation. The supraspinous fossa shows normal muscle bulk. What is the most likely cause of this condition?

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 18

. Neurofibroma of the suprascapular nerve
. Ganglion cyst of the suprascapular notch
. Ganglion cyst of the spinoglenoid notch
. Lipoma of the suprascapular notch
. Lipoma of the spinoglenoid notch

Correct Answer & Explanation

. Ganglion cyst of the spinoglenoid notch

Explanation

Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder. Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch. The majority of ganglion cysts found in the shoulder are related to tears of the labrum. When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach. Several authors have shown the value of arthroscopy in the treatment of this condition. It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum. Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery. Open cyst excision through a posterior approach is also an acceptable method of treatment. Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging. J Shoulder Elbow Surg 1993;2:110-114. Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia. Clin Orthop 1982;166:185-187.

Question 27

Topic: Soft Tissue Tumors & Metastasis

A 75-year-old woman notes a slowly enlarging mass in the right anterior thigh. Her medical history is significant only for hypertension. An MRI scan of her thigh is shown in Figures 60a through 60d. Which of the following surgical margins is the most appropriate for removal of this lesion?

. Radical
. Wide
. Marginal
. Intralesional
. Contaminated

Correct Answer & Explanation

. Marginal

Explanation

The patient has a large deep anterior thigh mass that has imaging characteristics of mature fat. Intramuscular lipomas are effectively treated with marginal resections with very low recurrence rates. Large lipomas often have small amounts of intralesional signal changes frequently representing trapped muscle fibers and do not necessitate more extensive margins. Gaskin CM, Helms CA: Lipomas, lipoma variants, and well-differentiated liposarcomas (atypical lipomas): Results of MRI evaluations of 126 consecutive fatty masses. Am J Roentgenol 2004;182:733-739.

Question 28

Topic: Soft Tissue Tumors & Metastasis

According to the Seddon classification, a peripheral nerve injury characterized by complete disruption of the axon and myelin sheath, but with preservation of the surrounding endoneurial, perineurial, and epineurial connective tissue is termed:

. Neuropraxia
. Axonotmesis
. Neurotmesis
. Neurofibroma
. Wallerian degeneration

Correct Answer & Explanation

. Neuropraxia

Explanation

Axonotmesis involves the loss of axonal continuity while the structural connective tissue framework remains intact, allowing for spontaneous nerve regeneration at about 1 mm/day. Neuropraxia is a local conduction block without structural disruption.

Question 29

Topic: Soft Tissue Tumors & Metastasis

A 65-year-old man presents with a destructive, purely lytic lesion in the proximal humerus and a history of nephrectomy for renal cell carcinoma. He is scheduled for wide excision and prosthetic reconstruction. What is the most critical preoperative step to minimize intraoperative complications?

. Systemic chemotherapy
. Neoadjuvant radiation therapy
. Preoperative embolization of the lesion
. Bone marrow aspiration
. Administration of intravenous bisphosphonates

Correct Answer & Explanation

. Preoperative embolization of the lesion

Explanation

Renal cell and thyroid carcinoma bone metastases are notoriously hypervascular. Preoperative selective arterial embolization is critical to minimize massive, potentially life-threatening intraoperative hemorrhage.

Question 30

Topic: Soft Tissue Tumors & Metastasis
A 5-year-old boy is diagnosed with Chondroectodermal Dysplasia. In addition to skeletal and cardiac anomalies, the orthopedic surgeon should be aware of the ectodermal manifestations of this disease. Which of the following dermatological or appendageal findings is commonly associated with this syndrome?
. Plantar keratoderma
. Alopecia totalis
. Café-au-lait macules
. Hyperhidrosis
. Neurofibromas

Correct Answer & Explanation

. Plantar keratoderma

Explanation

The 'ectodermal' component of Chondroectodermal Dysplasia (Ellis-van Creveld syndrome) includes anomalies of the hair, dystrophic nails, ichthyoids, and plantar keratoderma. Café-au-lait macules and neurofibromas are associated with Neurofibromatosis.

Question 31

Topic: Soft Tissue Tumors & Metastasis
In addition to skeletal and cardiac abnormalities, patients with Ellis-van Creveld syndrome frequently exhibit ectodermal defects. Which of the following dermatological or ectodermal findings is commonly associated with this condition?
. Café-au-lait spots
. Plantar keratoderma
. Neurofibromas
. Port-wine stains
. Hypopigmented macules

Correct Answer & Explanation

. Plantar keratoderma

Explanation

Ectodermal manifestations of Ellis-van Creveld syndrome include dystrophic nails, anomalies of hair, ichthyoids, and plantar keratoderma.

Question 32

Topic: Soft Tissue Tumors & Metastasis
A patient presents with the foot deformities shown in the clinical and radiographic images. In addition to these skeletal findings, which of the following dermatological manifestations is commonly associated with this syndrome?
. Café-au-lait spots
. Plantar keratoderma
. Subcutaneous neurofibromas
. Port-wine stains
. Ash-leaf spots

Correct Answer & Explanation

. Plantar keratoderma

Explanation

The image demonstrates shortening of the digits of the toes and feet, characteristic of Ellis-van Creveld syndrome. Associated ectodermal and dermatological findings in this disease include ichthyoids, plantar keratoderma, anomalies of hair, and dystrophic nails.

Question 33

Topic: Soft Tissue Tumors & Metastasis
The clinical and radiographic images belong to a patient with chondroectodermal dysplasia. In addition to the skeletal anomalies shown, which of the following dermatological/ectodermal manifestations is commonly associated with this syndrome?
. Café-au-lait spots
. Plantar keratoderma
. Subcutaneous neurofibromas
. Port-wine stains
. Hypopigmented macules

Correct Answer & Explanation

. Plantar keratoderma

Explanation

Ellis-van Creveld syndrome (chondroectodermal dysplasia) is associated with several ectodermal anomalies. Alongside skeletal issues like shortening of the digits, patients frequently exhibit ichthyoids, plantar keratoderma, anomalies of the hair, and dystrophic nails.

Question 34

Topic: Soft Tissue Tumors & Metastasis

The "ectodermal" component of Chondroectodermal Dysplasia (Ellis-van Creveld syndrome) is classically manifested by which of the following physical findings?

. Blue sclerae and hearing loss
. Alopecia universalis
. Anhidrosis and hyperthermia
. Hypoplastic or absent nails and neonatal teeth
. Cafe-au-lait spots and neurofibromas

Correct Answer & Explanation

. Hypoplastic or absent nails and neonatal teeth

Explanation

Ectodermal manifestations in EVC include hypoplastic, thin, or absent finger and toenails, as well as dental anomalies like neonatal teeth, partial anodontia, and delayed tooth eruption.

Question 35

Topic: Soft Tissue Tumors & Metastasis

A 62-year-old man with a history of nephrectomy for renal cell carcinoma presents with a solitary lytic metastasis in the proximal femur causing an impending pathologic fracture. Prior to prophylactic internal stabilization, which adjunctive intervention is most critical to minimize perioperative surgical morbidity?

. Neoadjuvant systemic chemotherapy
. Preoperative external beam radiation therapy
. Preoperative selective arterial embolization
. Administration of high-dose systemic corticosteroids
. Intravenous bisphosphonates immediately prior to incision

Correct Answer & Explanation

. Preoperative selective arterial embolization

Explanation

Metastases from renal cell carcinoma and thyroid carcinoma are notoriously hypervascular. Preoperative selective arterial embolization 24-48 hours before surgical stabilization is strongly recommended to minimize massive, potentially life-threatening intraoperative blood loss.

Question 36

Topic: Soft Tissue Tumors & Metastasis
A 6-year-old girl is evaluated for an anterolateral bowing deformity of the tibia. Physical exam reveals axillary freckling and multiple Lisch nodules. According to the NIH diagnostic criteria for this condition, which of the following additional findings would independently satisfy a diagnostic criterion?
. At least 2 cafe-au-lait macules measuring >5mm
. Optic glioma
. A single discrete neurofibroma
. Bilateral vestibular schwannomas
. A positive family history in a second-degree relative

Correct Answer & Explanation

. Optic glioma

Explanation

The diagnosis of Neurofibromatosis Type 1 requires 2 or more clinical criteria. An optic glioma is one of the major criteria. The criteria require at least 6 café-au-lait spots, at least 2 neurofibromas (or 1 plexiform), and a positive family history must be in a first-degree relative.

Question 37

Topic: Soft Tissue Tumors & Metastasis

When attempting to differentiate lipoma arborescens from pigmented villonodular synovitis (PVNS) on MRI, which feature is highly specific for PVNS?

. Location in the suprapatellar pouch
. High signal intensity on T1-weighted images
. Low signal on T2-weighted images with blooming artifact on gradient-echo
. Suppression of signal on fat-saturated sequences
. Frond-like synovial projections

Correct Answer & Explanation

. Low signal on T2-weighted images with blooming artifact on gradient-echo

Explanation

PVNS is characterized by hemosiderin deposition, which appears as low signal on T2-weighted images and causes "blooming" artifact on gradient-echo (GRE) sequences. Lipoma arborescens lacks hemosiderin and follows fat signal.

Question 38

Topic: Soft Tissue Tumors & Metastasis

Which of the following joint conditions is most commonly associated with the development of secondary lipoma arborescens?

. Rheumatoid arthritis
. Osteoarthritis
. Pigmented villonodular synovitis
. Synovial chondromatosis
. Lyme disease

Correct Answer & Explanation

. Osteoarthritis

Explanation

While lipoma arborescens can be primary, it is most often a secondary, reactive process resulting from chronic synovial irritation. It is most frequently associated with underlying degenerative joint disease (osteoarthritis) or prior trauma.

Question 39

Topic: Soft Tissue Tumors & Metastasis

A 45-year-old male presents with chronic, painless, boggy swelling of the left knee. An MRI is obtained. Based on the likely diagnosis of Lipoma Arborescens, what is the classic MRI finding?

. Low signal on T1, high signal on T2, hyperintense on STIR
. High signal on T1, high signal on T2, complete suppression on fat-saturated sequences
. Low signal on T1, low signal on T2 with blooming artifact on gradient echo
. High signal on T1, low signal on T2, hyperintense on STIR
. Intermediate signal on T1 and T2 with avid contrast enhancement

Correct Answer & Explanation

. High signal on T1, high signal on T2, complete suppression on fat-saturated sequences

Explanation

Lipoma arborescens follows fat signal on all MRI sequences, showing high signal on T1 and T2, and complete signal loss on fat-suppressed (STIR or Fat-Sat) sequences. Blooming artifact would suggest Pigmented Villonodular Synovitis (PVNS).

Question 40

Topic: Soft Tissue Tumors & Metastasis

Lipoma arborescens is most frequently associated with which of the following underlying conditions?

. Rheumatoid arthritis
. Pigmented villonodular synovitis (PVNS)
. Degenerative joint disease (Osteoarthritis)
. Ankylosing spondylitis
. Systemic lupus erythematosus

Correct Answer & Explanation

. Degenerative joint disease (Osteoarthritis)

Explanation

While lipoma arborescens can be idiopathic, it is most commonly a reactive process associated with degenerative joint disease (osteoarthritis) or chronic mechanical irritation.

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