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10. Pathology and Oncology MCQs

Practice Set 18 of 351

This practice set contains high-yield board review questions covering key concepts in 10. Pathology and Oncology. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 341

Topic: 10. Pathology and Oncology

A 55-year-old man presents with a painful proximal humerus mass. Imaging shows a lytic lesion with intralesional 'popcorn' calcifications. Biopsy confirms conventional chondrosarcoma. What is the most appropriate primary treatment?

. Systemic chemotherapy alone
. Neoadjuvant chemotherapy followed by wide resection
. Primary radiation therapy
. Wide surgical resection
. Intralesional curettage and bone grafting

Correct Answer & Explanation

. Wide surgical resection

Explanation

Conventional chondrosarcoma is largely resistant to both chemotherapy and radiation. The mainstay of treatment is wide surgical resection to achieve negative margins.

Question 342

Topic: 10. Pathology and Oncology
A 77-year-old man is referred to the respiratory clinic with a cough, stridor, and a hoarse voice. He is noted on X-ray to have a lung mass, and biopsy confirms squamous-cell carcinoma of the bronchus. On examination, his BP is 125/72 mmHg, pulse is 74/min, and he has atrial fibrillation. There are coarse crackles and wheeze on auscultation of the chest. Investigations: Hb 12.6 g/dL, WCC 10.0 × 10^9/L, PLT 200 × 10^9/L, Na+ 135 mmol/L, K+ 4.2 mmol/L, Creatinine 128 μmol/L, Ca++ 2.88 mmol/L. Laryngoscopy: Left vocal cord palsy. Which of the following is the greatest contra-indication to surgery?
. Atrial fibrillation
. Creatinine 128 μmol/L
. His age (77 years)
. Hypercalcaemia
. Vocal cord palsy

Correct Answer & Explanation

. Vocal cord palsy

Explanation

Correct Answer: E. Vocal cord palsy. The vocal cord palsy implies recurrent laryngeal nerve injury, and the most likely explanation for this is invasion by the underlying bronchial carcinoma. As such, the tumour is almost certainly not amenable to surgery.

Question 343

Topic: 10. Pathology and Oncology
A 60-year-old hairdresser complains that, after an attack of flu last year, she has been more breathless than usual when taking her evening walk. She has also felt short of breath when climbing the stairs. She has become concerned that she has a cardiac problem. She has lost about 6.4 kg (14 lbs) in weight during the last year. She has smoked 20 cigarettes per day for 45 years but does not drink alcohol. Other than an occasional paracetamol for headache, she is on no regular medication. On examination she was apyrexic and had bilateral clubbing. No lymphadenopathy was seen. Her jugular venous pressure was not raised and heart sounds were normal. Bibasal inspiratory crepitations were audible. No pedal oedema was seen. Bilateral reticular shadowing, mostly on the bases, was seen on the chest X-ray. Routine bloods were normal, except for an ESR of 35 mm in the 1st hour. Her high-resolution computed tomography scan showed probable fibrosis, most marked in the basal region. Respiratory function tests showed a restrictive ventilatory defect. Bronchoalveolar lavage showed an increased number of cells – neutrophils and macrophages – but no malignant cells. An open-lung biopsy showed an exudate of intra-alveolar macrophages with patchy interstitial fibrosis. What is the likely diagnosis?
. Chronic left heart failure
. Extrinsic allergic alveolitis
. Idiopathic pulmonary fibrosis
. Lymphangitis carcinomatosis
. Sarcoidosis

Correct Answer & Explanation

. Idiopathic pulmonary fibrosis

Explanation

Correct Answer: C. Idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF), synonymous with cryptogenic fibrosing alveolitis (CFA), is a progressive and usually fatal disease of unknown cause characterized by sequential acute lung injury with subsequent scarring and end-stage lung disease. It is most commonly seen between the ages of 50 and 60 years. A history of progressive breathlessness on exertion in the absence of wheeze is typical. Lung function tests show a restrictive picture. The histological pattern in IPF is that of usual interstitial pneumonia (UIP).

Question 344

Topic: 10. Pathology and Oncology
A 50-year-old woman presents to the respiratory clinic with symptoms of increasing shortness of breath and a chronic cough. She was originally diagnosed by her GP as having asthma, but has had no significant response to a salbutamol inhaler. There has been slow weight loss over the past 6 months and problems with night sweats. On examination her BP is 155/72 mmHg, pulse is 70/min and regular. There are scattered crackles on auscultation of the chest. There is erythema nodosum and erythematous plaques resembling psoriasis. Investigations: Hb 12.2 g/dL, WCC 10.9 x 10^9/L, PLT 192 x 10^9/L, ESR 62 mm/1st hour, Na+ 138 mmol/L, K+ 4.3 mmol/L, Creatinine 120 μmol/L, CXR: Bilateral hilar lymphadenopathy. You suspect sarcoid. Which of the following is the best way to confirm the diagnosis?
. Bronchoalveolar lavage
. CT thorax
. Kveim test
. Serum ACE
. Skin biopsy

Correct Answer & Explanation

. Skin biopsy

Explanation

Correct Answer: E. Skin biopsy. Skin biopsy of one of the plaques is potentially very useful and is likely to confirm the presence of non-caseating granulomas. An alternative diagnostic route could be via endobronchial and transbronchial biopsies.

Question 345

Topic: 10. Pathology and Oncology
An 18-year-old man presents with a gradual onset of pallor, weakness, lethargy, dry cough, and occasional haemoptysis. There are no extrapulmonary features. His chest X-ray shows diffuse pulmonary infiltrates. Lung biopsy shows no vasculitic changes and no evidence of immunoglobulin or complement deposition. His gas transfer factor (TLCO) is found to be elevated. Renal function is normal. What is the most likely diagnosis?
. Behçet's disease
. Goodpasture syndrome
. Granulomatosis with polyangiitis
. Idiopathic pulmonary haemosiderosis
. Systemic lupus erythematosus

Correct Answer & Explanation

. Idiopathic pulmonary haemosiderosis

Explanation

Correct Answer: D. Idiopathic pulmonary haemosiderosis. Idiopathic pulmonary haemosiderosis tends to occur in younger people and is characterised by pallor, weakness, lethargy, dry cough, and occasional haemoptysis. There are no abnormal immunological features. Gas transfer is elevated as blood is already in the alveolar space. Behçet’s disease is incorrect as there is no history of orogenital ulceration. Goodpasture syndrome is incorrect as there are no extrapulmonary features or abnormal immunological features. Granulomatosis with polyangiitis is incorrect due to the lack of sinusitis or renal disease. Systemic lupus erythematosus (SLE) is unlikely given the lack of extrapulmonary features.

Question 346

Topic: 10. Pathology and Oncology

A 47-year-old woman presents with a chronic cough, weight loss and haemoptysis. She is a lifelong non- smoker and has previously been completely well, on no regular medication. On examination she looks thin and her body mass index (BMI) is 20 kg/m2. Her blood pressure is 132/70 mmHg and her pulse is 80 bpm and regular. General respiratory and abdominal examination is unremarkable.

Investigation:

Hb 12.4 g/dl

WCC 7.8 x 109/l

PLT 211 x 109/l

Sodium 139 mmol/l

Potassium 4.4 mmol/l

Creatinine 110 µmol/l Albumin 31 g/l (normal range 37-49 g/l) Alanine aminotransferase (ALT) 231 U/l (5-35 U/l) A chest X-ray shows a right upper-lobe tumour with hilar extension. Bronchoscopy was performed but no biopsies were obtained (washings negative so far). Which of the following is the most likely diagnosis?

. Adenocarcinoma
. Bronchial carcinoid
. Large-cell carcinoma
. Small-cell carcinoma
. Squamous-cell carcinoma

Correct Answer & Explanation

. Adenocarcinoma

Explanation

Correct Answer: A- Adenocarcinoma Explanation Adenocarcinoma The peripheral nature of this tumour and the fact that the patient is a lifelong non-smoker make adenocarcinoma the most likely diagnosis. Because the primary tumour is peripheral it is quite possible that an initial bronchoscopy might be negative. It would be worth repeating the bronchoscopy in this case, although thoracoscopy or computed tomography-guided biopsy are other methods that could be used to obtain tumour material. Given the hilar lymphadenopathy, it is unlikely that this patient will be a candidate for surgery Bronchial carcinoid Bronchial carcinoid is incorrect. The weight loss is suggestive of an underlying malignancy. There are no symptoms to suggest metastatic carcinoid, therefore adenocarcinoma is more likely. Large-cell carcinoma Large-cell carcinoma is incorrect. Large-cell carcinoma is typically peripherally located, as in this case, but one would expect a history of smoking. Small-cell carcinoma Small-cell carcinoma is incorrect. A history of smoking would be expected in small-cell carcinoma. Squamous-cell carcinoma Squamous-cell carcinoma is incorrect. A history of smoking would be expected in squamous-cell carcinoma.

Question 347

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with progressive knee pain and a palpable mass over the distal femur. Radiographs demonstrate a mixed lytic/sclerotic lesion with periosteal elevation (Codman triangle). Biopsy confirms conventional high-grade osteosarcoma. What is the standard treatment sequence?

. Neoadjuvant chemotherapy, wide surgical resection, adjuvant chemotherapy
. Wide surgical resection followed by radiation therapy
. Radiation therapy alone
. Neoadjuvant radiation, wide surgical resection, adjuvant chemotherapy
. Amputation as the sole treatment

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, adjuvant chemotherapy

Explanation

The standard of care for conventional high-grade osteosarcoma involves neoadjuvant chemotherapy, followed by wide surgical resection (favoring limb salvage), and subsequently adjuvant chemotherapy. Osteosarcoma is generally considered radioresistant.

Question 348

Topic: 10. Pathology and Oncology

A 10-year-old boy presents with a 2-month history of pain and swelling in his left mid-thigh. Radiographs reveal a permeative lytic lesion in the diaphysis of the femur with an "onion skin" periosteal reaction. Histology shows small round blue cells. Which chromosomal translocation is commonly associated with this tumor?

. t(11;22)
. t(9;22)
. t(X;18)
. t(12;16)
. t(2;13)

Correct Answer & Explanation

. t(11;22)

Explanation

The clinical presentation and histology are classic for Ewing sarcoma, which typically affects the diaphysis of long bones. It is highly associated with the t(11;22) translocation, which results in the EWS-FLI1 fusion gene.

Question 349

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with a painful mass near his right knee. Radiographs reveal a poorly defined, destructive lesion in the distal femoral metaphysis with a "sunburst" periosteal reaction. Biopsy confirms osteosarcoma. What is the most significant prognostic factor for overall survival?

. Tumor size
. Histologic subtype
. Percentage of tumor necrosis following neoadjuvant chemotherapy
. Alkaline phosphatase level
. Age of the patient

Correct Answer & Explanation

. Percentage of tumor necrosis following neoadjuvant chemotherapy

Explanation

The most important prognostic factor in high-grade extremity osteosarcoma is the histological response to neoadjuvant chemotherapy. Achieving greater than 90% tumor necrosis correlates with significantly improved survival.

Question 350

Topic: Bone Tumors

A 9-year-old girl presents with fever, weight loss, and severe mid-shaft thigh pain. Radiographs show a permeative diaphyseal lesion of the femur with an "onion skin" periosteal reaction. What specific chromosomal translocation is diagnostic for this malignancy?

. t(11;22)(q24;q12)
. t(9;22)(q34;q11)
. t(X;18)(p11;q11)
. t(12;16)(q13;p11)
. t(2;13)(q35;q14)

Correct Answer & Explanation

. t(11;22)(q24;q12)

Explanation

Ewing sarcoma is classically associated with the t(11;22)(q24;q12) chromosomal translocation, resulting in the EWS-FLI1 fusion protein. It typically presents in the diaphysis of long bones with an "onion skin" appearance.

Question 351

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with a painful mass around his right knee. Radiographs reveal a lytic, destructive lesion in the distal femur metaphysis with a sunburst periosteal reaction. Biopsy confirms high-grade conventional osteosarcoma. Which of the following genetic alterations is most frequently associated with the pathogenesis of this tumor?

. t(11;22) translocation
. GNAS mutation
. TP53 and RB1 mutations
. USP6 gene rearrangement
. IDH1 mutation

Correct Answer & Explanation

. TP53 and RB1 mutations

Explanation

Conventional osteosarcoma is highly associated with mutations in tumor suppressor genes, particularly TP53 (Li-Fraumeni syndrome) and RB1 (hereditary retinoblastoma). t(11;22) is characteristic of Ewing sarcoma, while GNAS mutations are seen in fibrous dysplasia.

Question 352

Topic: 10. Pathology and Oncology

A 9-year-old girl presents with a permeative diaphyseal lesion in her left tibia with an associated large soft tissue mass. Biopsy reveals small round blue cells expressing CD99. The most likely cytogenetic abnormality involves a translocation that creates which of the following fusion proteins?

. EWS-FLI1
. SYT-SSX1
. PAX3-FKHR
. TLS-CHOP
. COL1A1-PDGFB

Correct Answer & Explanation

. EWS-FLI1

Explanation

Ewing sarcoma is characterized by the t(11;22)(q24;q12) translocation in 85% of cases, resulting in the EWS-FLI1 fusion protein. CD99 is a highly sensitive but non-specific cell surface marker for this tumor.

Question 353

Topic: 10. Pathology and Oncology

A 45-year-old man presents with severe generalized bone pain and muscle weakness. Labs reveal severe hypophosphatemia, normal serum calcium, and elevated alkaline phosphatase. A small benign mesenchymal tumor is discovered in his thigh. Secretion of which of the following substances by the tumor is responsible for his metabolic bone disease?

. Parathyroid hormone-related peptide (PTHrP)
. Fibroblast growth factor 23 (FGF23)
. RANK ligand (RANKL)
. Transforming growth factor beta (TGF-beta)
. Osteocalcin

Correct Answer & Explanation

. Fibroblast growth factor 23 (FGF23)

Explanation

Tumor-induced osteomalacia (oncogenic osteomalacia) is a paraneoplastic syndrome caused by tumors that secrete FGF23. FGF23 inhibits renal phosphate reabsorption and decreases 1-alpha-hydroxylase activity, leading to hypophosphatemia and osteomalacia.

Question 354

Topic: 10. Pathology and Oncology
An 82-year-old man living alone in a bungalow came to the clinic complaining of feeling generally unwell for about the last 3–4 months and of losing about 9.5 kg (21 lbs) in weight during this period. On further enquiry, he said he had been having night sweats for the last month. He also has a past history of angina and arthritis and was on medication. On examination, he did not look well. He was pyrexic but had no lymphadenopathy. Bibasal crepitus on the lower zone was heard on chest auscultation. He had hepatosplenomegaly and clubbing. Investigations showed: white cell count 12.3 × 10^9/l (neutrophils 52%, lymphocytes 39%), haemoglobin 9.1 g/dl, and all other routine investigations normal. A chest X-ray showed 1- to 2-mm-diameter miliary shadows all over the lung fields. The Mantoux test was negative. No bacteria grew in a sputum culture. What is the probable cause of the illness and the X-ray finding?
. Bacterial endocarditis
. Miliary tuberculosis
. Mycoplasma pneumonia
. Sarcoidosis
. Staphylococcal pneumonia

Correct Answer & Explanation

. Miliary tuberculosis

Explanation

Miliary tuberculosis is caused by a diffuse, widely disseminated spread of tubercle bacilli via the bloodstream. In older patients, it is difficult to diagnose and is universally fatal if left untreated. Miliary tuberculosis presents with a gradual onset of vague ill health, loss of weight, and then fever. Hepatosplenomegaly is seen in advanced disease. Chest X-ray reveals small, 1- to 2-mm lesions. The Mantoux test is negative in up to half of patients with severe disease.

Question 355

Topic: 10. Pathology and Oncology

A 62-year-old man with a heavy smoking history is referred to the Chest Clinic after a mass is seen on his chest X-ray. Which of the following clinical features might indicate a possibility of curative surgical resection for bronchial carcinoma?

. Forced vital capacity (FVC) < 1.5 pre-operatively
. Hypercalcaemia
. Invasive superior vena cava (SVC) obstruction
. Ipsilateral malignant pleural effusion
. Left recurrent laryngeal nerve palsy

Correct Answer & Explanation

. Hypercalcaemia

Explanation

Correct Answer: B- Hypercalcaemia Explanation Hypercalcaemia Hypercalcaemia can be due to bony secondaries or to production of parathyroid hormone- (PTH)- like peptide by the tumour. If the hypercalcaemia is due to PTH-like peptide production, then the tumour might be operable. Forced vital capacity (FVC) < 1.5 pre-operatively Forced vital capacity (FVC) < 1.5 pre-operatively is incorrect. FVC of less than 1.5 essentially means there is unlikely to be sufficient reserve after pneumonectomy. Invasive superior vena cava (SVC) obstruction Invasive superior vena cava (SVC) obstruction is incorrect. The tumour is inoperable if there is invasive SVC obstruction, which occurs in 4% of cases, usually with small-cell carcinoma. Ipsilateral malignant pleural effusion Ipsilateral malignant pleural effusion is incorrect. The tumour is inoperable if there is malignant pleural involvement. Left recurrent laryngeal nerve palsy Left recurrent laryngeal nerve palsy is incorrect. The tumour is inoperable if there is left recurrent laryngeal nerve palsy (signifies mediastinal nodes).

Question 356

Topic: 10. Pathology and Oncology

A 64-year-old demolition worker presents to his GP with a severe, dull, right-sided chest pain. He first noticed it some months ago and he is now having particular problems with shortness of breath. Apparently he was given an asthma inhaler for shortness of breath around 2 years earlier. On examination he appears to have a right- sided pleural effusion and has finger clubbing. He admits to having been exposed to asbestos. On further questioning he says that his brother, who worked with him, died of ‘some sort of lung cancer’ around 2 years ago. X-ray confirms a right pleural effusion with evidence of pleural plaques elsewhere. What diagnosis would fit best with this clinical picture?

. Asthma
. Bronchial carcinoma
. Mesothelioma
. Rheumatoid arthritis
. Tuberculosis

Correct Answer & Explanation

. Mesothelioma

Explanation

Correct Answer: C- Mesothelioma Explanation Mesothelioma The clue to the answer here is the occupation, and the fact that a co-worker has already died of a cancer related to the chest. A restrictive lung defect, evidence of asbestosis, and now a painful pleural effusion would fit best with a diagnosis of mesothelioma. Diagnosis is confirmed by pleural biopsy. The median survival after diagnosis ranges from 12 to 21 months depending on staging. The cancer is poorly responsive to any form of intervention, however, and it is notable that a significant number of patients survive far less than 2 years. Asthma Asthma is incorrect. Asthma is not associated with pleural effusions or finger clubbing. Additionally, the presence of pleural plaques, chest pain and previous asbestos exposure make mesothelioma the most likely diagnosis. Bronchial carcinoma Bronchial carcinoma is incorrect. Although bronchial carcinoma can present with dyspnoea and a pleural effusion, the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis. Rheumatoid arthritis Rheumatoid arthritis is incorrect. Rheumatoid arthritis can be associated with pleural effusions but there is no mention of any joint symptoms, and the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis. Tuberculosis Tuberculosis is incorrect. Tuberculosis can present with a pleural effusion. However, there is no mention of contact with tuberculosis and there is no history of fevers or sweats. Furthermore, the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis.

Question 357

Topic: 10. Pathology and Oncology

Which one of the following features is most characteristic of small-cell bronchial carcinoma?

. A history of prior asbestos exposure
. Cancer cell origin from small lymphocytes
. Has a relatively better prognosis than other bronchial cancers
. Hyponatraemia
. Surgery is often the only possible treatment

Correct Answer & Explanation

. Hyponatraemia

Explanation

Correct Answer: D- Hyponatraemia Explanation Hyponatraemia Syndrome of inappropriate antidiuretic hormone secretion (SIADH) resulting in hyponatraemia occurs in approximately 15% of patients with small-cell lung cancer. A history of prior asbestos exposure A history of prior asbestos exposure is incorrect. Asbestos exposure increases the risk of lung cancer but is most associated with pleural malignancy (malignant mesothelioma). Cancer cell origin from small lymphocytes Cancer cell origin from small lymphocytes is incorrect. Small-cell lung cancer is of neuroendocrine cell origin. Has a relatively better prognosis than other bronchial cancers Has a relatively better prognosis than other bronchial cancers is incorrect. The prognosis is very poor and survival beyond two 2 years is exceptional. Surgery is often the only possible treatment Surgery is often the only possible treatment is incorrect. By the time the diagnosis has been made the tumour is usually disseminated, so that surgery is seldom considered.

Question 358

Topic: Bone Tumors

A 70-year-old man presents with generalized fatigue, severe back pain, and hypercalcemia. Radiographs of his skull reveal multiple 'punched-out' lytic lesions. Serum protein electrophoresis shows an M-spike. Which of the following is the most definitive primary treatment for his skeletal disease?

. Wide resection of affected bones
. Empiric broad-spectrum antibiotics
. Surgical curettage and bone grafting
. Systemic chemotherapy and bisphosphonates
. Prolonged immobilization

Correct Answer & Explanation

. Systemic chemotherapy and bisphosphonates

Explanation

The clinical presentation is classic for multiple myeloma (CRAB criteria: hyperCalcemia, Renal involvement, Anemia, Bone lytic lesions). Treatment is primarily medical with chemotherapy and bisphosphonates, reserving surgery for impending or actual pathologic fractures.

Question 359

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with progressive pain in his left thigh. Plain radiographs show a permeative diaphyseal lesion in the femur with a multilamellated 'onion skin' periosteal reaction. A biopsy is performed. Which of the following chromosomal translocations is most characteristic of this tumor?

. t(11;22)
. t(9;22)
. t(X;18)
. t(12;16)
. t(2;13)

Correct Answer & Explanation

. t(11;22)

Explanation

The clinical and radiographic presentation is classic for Ewing sarcoma. Ewing sarcoma is genetically defined by the t(11;22) translocation, resulting in the EWS-FLI1 fusion protein in approximately 85% of cases.

Question 360

Topic: 10. Pathology and Oncology

A 45-year-old male immigrant presents with chronic back pain, night sweats, and a progressive kyphotic deformity. MRI reveals destruction of the T8 and T9 anterior vertebral bodies, sparing of the posterior elements, destruction of the intervening disc space, and a large paraspinal abscess. What is the most likely diagnosis?

. Metastatic carcinoma
. Multiple myeloma
. Tuberculous spondylitis
. Pyogenic spondylodiscitis
. Brucellosis

Correct Answer & Explanation

. Tuberculous spondylitis

Explanation

Tuberculous spondylitis (Pott's disease) typically involves the anterior vertebral body and crosses the disc space, leading to anterior wedging and a gibbus deformity. The presence of a paraspinal (cold) abscess strongly supports this diagnosis.

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