10. Pathology and Oncology MCQs

A 55-year-old male with a history of renal cell carcinoma presents with intractable mechanical back pain that worsens significantly with standing.

MRI of the thoracic spine reveals a metastatic lesion at T8 causing epidural spinal cord compression (ESCC grade 2) with deformation of the thecal sac but no cord signal change. The patient is neurologically intact. According to the Neurologic, Oncologic, Mechanical, and Systemic (NOMS) framework, what is the most appropriate management?

A 72-year-old woman with a history of osteoporosis presents with severe, progressive back pain three months after a minor fall. Initial radiographs at the time of injury were read as normal. Current radiographs demonstrate a T12 compression fracture with an intravertebral vacuum cleft on extension views. What is the most likely diagnosis?

A 62-year-old man presents with chronic lower back pain and new-onset bowel/bladder dysfunction. Imaging reveals a large, destructive, midline sacral mass.

Biopsy confirms the diagnosis of chordoma. Which of the following statements regarding the treatment and prognosis of this lesion is most accurate?

A 58-year-old woman with a history of metastatic renal cell carcinoma presents with progressive back pain and mild bilateral lower extremity weakness (motor strength 4/5). MRI demonstrates an isolated L2 vertebral body metastasis with significant epidural extension and spinal cord compression. The patient has a life expectancy of greater than 12 months. What is the most appropriate treatment paradigm?

A 58-year-old male with a history of renal cell carcinoma presents with acute-onset bilateral lower extremity weakness (3/5 hip flexion, 4/5 knee extension), saddle anesthesia, and urinary retention. MRI reveals an extensive T8 metastatic lesion with high-grade epidural spinal cord compression (ESCC). What is the most appropriate next step in management?

A 60-year-old woman with a history of breast cancer presents with progressive mechanical back pain. Standing radiographs and MRI reveal a lytic metastatic lesion at T10 involving the vertebral body and left pedicle. The lesion occupies 60% of the vertebral body height. She has kyphosis of 15 degrees at this level, and pain is reproducible with loading and relieved by lying down. According to the Spinal Instability Neoplastic Score (SINS), which of the following features contributes most to classifying this lesion as unstable?

A 62-year-old woman presents with severe, unrelenting mid-back pain and progressive lower extremity weakness. She has a history of renal cell carcinoma. Imaging reveals a solitary lytic lesion at T12 with severe collapse of the vertebral body and bony retropulsion causing severe spinal cord compression. Oncology determines her expected survival is greater than 12 months. Which of the following treatment strategies is most appropriate?

A 60-year-old man with an established history of metastatic prostate cancer presents with rapidly progressive bilateral lower extremity weakness, sensory deficits, and urinary retention over the last 48 hours. MRI reveals an anterior metastatic lesion at T8 causing severe anterior spinal cord compression. He has a Karnofsky Performance Status of 80 and an expected survival of greater than 6 months. What is the most appropriate initial surgical management?

A 33-year-old man with symptomatic plantar fibromatosis (Ledderhose disease) fails orthotics and steroid injections and undergoes surgical excision. What is the most common complication following surgical intervention for this condition?

A 19-year-old male presents to the trauma bay after a high-speed motor vehicle collision complaining of severe pain at the base of his neck, dysphagia, and a choking sensation. The medial end of the right clavicle is not palpable anteriorly. A CT scan of the chest confirms a posterior sternoclavicular dislocation. As the surgical team prepares for closed reduction in the operating room, which of the following specialist teams must ideally be immediately available?

A 15-year-old boy presents with progressive knee pain and a destructive, bone-forming lesion in the distal femoral metaphysis. A core biopsy confirms the diagnosis of high-grade, conventional osteosarcoma. Which of the following genetic alterations is most consistently associated with the underlying pathogenesis of this tumor?

A 12-year-old girl is evaluated for thigh pain and a low-grade fever. Radiographs reveal a permeative, diaphyseal lesion in the femur with a prominent 'onion skin' periosteal reaction. A biopsy shows sheets of monotonous small round blue cells. The primary translocation associated with this condition results in a fusion protein that acts as an aberrant transcription factor. Immunohistochemistry is most likely to show strong, diffuse membranous staining for which of the following markers?

A 14-year-old boy presents with a rapidly expanding, painful lesion in the proximal tibia. Radiographs show an eccentric, expansile, lytic lesion with a thin cortical shell. MRI reveals multiple fluid-fluid levels. Biopsy demonstrates blood-filled spaces lacking endothelial lining, separated by cellular fibrous septa containing multinucleated giant cells. Which of the following molecular abnormalities is considered the primary driver of this lesion?

A 28-year-old woman complains of a painless, slow-growing mass at the posterior aspect of her knee. Radiographs reveal a dense, heavily ossified mass arising from the posterior surface of the distal femur. A radiolucent cleft separates part of the tumor from the underlying cortex. Histology shows low-grade malignant spindle cells between well-formed, thick bone trabeculae. What is the typical genetic amplification found in this condition?

A 55-year-old man presents with dull, aching shoulder pain. Radiographs reveal a large medullary cartilaginous lesion in the proximal humerus with 'rings and arcs' calcification and significant endosteal scalloping. Core needle biopsy shows increased cellularity, binucleate chondrocytes, and myxoid changes in the hyaline stroma. Recent molecular studies show that this malignancy shares a specific genetic mutation with benign solitary enchondromas. Which of the following genes is most likely mutated?

A 10-year-old boy presents for orthopedic evaluation. He has multiple palpable bony protuberances around his knees, ankles, and shoulders, short stature, and a progressive valgus deformity of his left knee. A skeletal survey confirms multiple osteochondromas. The genetic mutation most likely responsible for his condition leads to a direct defect in which of the following biological processes?

A 24-year-old man presents with a deep, slow-growing soft tissue mass in his thigh. MRI shows a heterogeneous mass adjacent to, but not within, the knee joint capsule. Biopsy reveals a biphasic tumor containing both epithelial and spindle cell components. Which of the following chromosomal translocations is considered diagnostic for this sarcoma?

A 16-year-old boy experiences severe, throbbing leg pain that is consistently worse at night and dramatically relieved by taking ibuprofen. Radiographs demonstrate a diaphyseal cortical thickening in the anterior tibia with a 5-mm radiolucent nidus. The intense pain associated with this specific bone lesion is primarily mediated by the local overproduction of which of the following substances?

A 15-year-old boy is diagnosed with conventional high-grade osteosarcoma of the distal femur. He undergoes neoadjuvant chemotherapy followed by wide surgical resection. Which of the following factors is considered the most significant prognostic indicator for long-term survival in this patient?

A 12-year-old boy presents with progressive mid-thigh pain and swelling. Radiographs show a permeative diaphyseal lesion with an 'onion-skin' periosteal reaction. Biopsy reveals uniform small round blue cells. Cytogenetic analysis of this tumor is most likely to show which of the following translocations?