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10. Pathology and Oncology MCQs

Practice Set 19 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 361

Topic: 10. Pathology and Oncology

A 60-year-old man with known lung carcinoma presents with right thigh pain that is moderate with weight-bearing. Radiographs reveal a 2.5 cm lytic lesion in the peritrochanteric region, occupying about half the cortical diameter. According to Mirels' criteria, what is the most appropriate management?

. Observation with protected weight-bearing
. Chemotherapy alone
. Radiation therapy alone
. Prophylactic internal fixation
. Intravenous bisphosphonates alone

Correct Answer & Explanation

. Prophylactic internal fixation

Explanation

This patient has a Mirels' score of 10 (peritrochanteric = 3, moderate pain = 2, lytic = 3, size 1/3-2/3 = 2). A score of 9 or greater indicates a high risk of impending pathologic fracture, warranting prophylactic internal fixation.

Question 362

Topic: 10. Pathology and Oncology

You are referred a 68-year-old man who smokes 40 cigarettes per day and has had chronic cough for the past 6 months, increasingly associated with haemoptysis. He also has a dull ache on the left side of his chest, and his chest X-ray reveals a left hilar mass that is suspicious of bronchial carcinoma. You are considering radical radiotherapy in this man. Which of the following is the most significant contraindication to radical radiotherapy?

. Adenocarcinoma
. Forced expiratory volume in 1 s (FEV1) < 60%
. Malignant pleural effusion
. Superior vena caval obstruction
. Tumour adjacent to the hilum

Correct Answer & Explanation

. Malignant pleural effusion

Explanation

Correct Answer: C- Malignant pleural effusion Explanation Malignant pleural effusion Studies have shown that the presence of a malignant pleural effusion is predictive of poor outcome with radical radiotherapy. Adenocarcinoma Adenocarcinoma is incorrect. Adenocarcinoma is not a contraindication to radical radiotherapy. Forced expiratory volume in 1 s (FEV1) < 60% Forced expiratory volume in 1 s (FEV1) < 60% is incorrect. It was previously thought that patients with a forced expiratory volume in 1 s (FEV1) of less than 50% were at particular risk of post-radiotherapy pneumonitis, but it has been shown that some patients enrolled in radical radiotherapy trials with severe disease actually showed a small improvement in lung function. Superior vena caval obstruction Superior vena caval (SVC) obstruction is incorrect. SVC obstruction and position of the tumour adjacent to the hilum can increase surgical difficultly, but targeted radiotherapy might not be a problem in the majority of patients. Tumour adjacent to the hilum Tumour adjacent to the hilum is incorrect. Tumour adjacent to the hilum is not a contraindication to radical radiotherapy.

Question 363

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with progressive distal thigh pain. Radiographs show a destructive metaphyseal lesion with a "sunburst" periosteal reaction. A biopsy confirms high-grade intramedullary osteosarcoma. Following neoadjuvant chemotherapy, what is the most significant prognostic factor for long-term survival?

. Patient age at diagnosis
. Initial tumor volume
. Histologic response of >90% tumor necrosis
. Specific chemotherapeutic agents used
. Distance of the tumor from the joint line

Correct Answer & Explanation

. Histologic response of >90% tumor necrosis

Explanation

The degree of tumor necrosis following neoadjuvant chemotherapy is the most critical prognostic indicator in high-grade osteosarcoma. Greater than 90% necrosis indicates a strong response and significantly improves long-term survival rates.

Question 364

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with progressive knee pain. Radiographs reveal a metaphyseal lesion in the distal femur with a sunburst periosteal reaction and a Codman's triangle. A biopsy shows pleomorphic spindle cells producing malignant osteoid. What is the diagnosis?

. Ewing sarcoma
. Osteosarcoma
. Chondrosarcoma
. Giant cell tumor
. Non-ossifying fibroma

Correct Answer & Explanation

. Osteosarcoma

Explanation

Osteosarcoma typically presents in adolescents with a sunburst periosteal reaction and Codman's triangle. The histological hallmark is the production of malignant osteoid by pleomorphic mesenchymal cells.

Question 365

Topic: 10. Pathology and Oncology

A 16-year-old male complains of dull, aching pain in his distal femur that worsens at night. Radiographs show a destructive metaphyseal lesion with a "sunburst" periosteal reaction and a Codman triangle. Biopsy confirms high-grade osteosarcoma. What is the standard treatment protocol?

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy
. Wide surgical resection followed by radiation therapy
. Primary amputation without systemic therapy
. Definitive radiation therapy alone
. Neoadjuvant radiation therapy followed by intralesional curettage

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy

Explanation

The standard of care for high-grade conventional osteosarcoma includes neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage or amputation), and then adjuvant chemotherapy. This approach targets micrometastases and improves overall survival.

Question 366

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with right knee pain and swelling. Radiographs show a destructive, permeative metaphyseal lesion in the distal femur with a sunburst periosteal reaction and Codman's triangle. A core needle biopsy reveals malignant spindle cells producing unmineralized osteoid. What is the most appropriate definitive management strategy?

. Immediate above-knee amputation
. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy
. Wide surgical resection followed by local radiation therapy
. Primary radiation therapy and adjuvant chemotherapy
. Intralesional curettage, bone grafting, and adjuvant chemotherapy

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy

Explanation

The patient has a high-grade intramedullary osteosarcoma. Standard of care consists of neoadjuvant chemotherapy, followed by limb-salvage wide surgical resection (or amputation if limb salvage is not feasible), and adjuvant chemotherapy.

Question 367

Topic: 10. Pathology and Oncology

A 60-year-old man presents with a history of cough and weight loss. He has smoked 40 cigarettes a day since he was 17 years old. He describes recent darkening of his skin and the chest X-ray reveals a mass (suspicious for lung cancer) at the left hilum. What is the most likely histology?

. Adenocarcinoma
. Large-cell carcinoma
. Mesothelioma
. Small-cell carcinoma
. Squamous-cell carcinoma

Correct Answer & Explanation

. Small-cell carcinoma

Explanation

Correct Answer: D- Small-cell carcinoma Explanation Small-cell carcinoma Endocrine symptoms are seen in patients with lung cancer due to the syndrome of ectopic hormone secretion. Small-cell lung cancer and bronchial carcinoid tumours are both associated with ectopic adrenocorticotropic hormone (ACTH) secretion, which can cause increased skin pigmentation. In small-cell lung cancer, around 5% of cases are thought to manifest ectopic ACTH secretion. Adrenal metastatic spread should be excluded with appropriate imaging. Treatment of the clinical or biochemical abnormalities associated with endocrinopathies of non-endocrine origin is best directed at the primary disorder. In neoplastic disease, this might involve surgical excision, radiotherapy or chemotherapy. If the cancer cannot be targeted, symptomatic treatment should be given. Adenocarcinoma Adenocarcinoma is incorrect. Although adenocarcinoma could present as a hilar mass, it is not associated with ectopic ACTH production (that would explain the increased skin pigmentation). Large-cell carcinoma Large-cell carcinoma is incorrect. Although large-cell carcinoma could present as a hilar mass, it is not associated with ectopic ACTH production (that would explain the increased skin pigmentation). Mesothelioma Mesothelioma is incorrect. Mesiothelioma is a malignant pleural tumour that is related to asbestos exposure. It does not present as a hilar mass and is not associated with ectopic production of ACTH. Squamous-cell carcinoma Squamous-cell carcinoma is incorrect. Squamous-cell carcinomas are not associated with ectopic ACTH production; they are often associated with hypercalcaemia due to parathyroid hormone- related peptide secretion.

Question 368

Topic: 10. Pathology and Oncology

A 61-year-old woman with nephrotic syndrome comes to the Respiratory Clinic with increased shortness of breath over the past 2 months. A large, left-sided pleural effusion was first diagnosed by her GP at the the time of onset of symptoms, and he prescribed an increased dose of diuretics. Despite increased furosemide and peripheral oedema having resolved, the effusion is unchanged on chest X- ray. Which of the following is the most appropriate next step?

. Blind pleural biopsy
. CT thorax
. Diagnostic pleural aspiration
. Increased furosemide
. Therapeutic drainage

Correct Answer & Explanation

. Diagnostic pleural aspiration

Explanation

Correct Answer: C- Diagnostic pleural aspiration Explanation Diagnostic pleural aspiration In this situation, where peripheral oedema has resolved in response to increased diuretic therapy, although the effusion is unchanged, diagnostic pleural aspiration for cytology, protein, LDH, pH, gram stain, culture and sensitivity is most appropriate. Blind pleural biopsy Blind pleural biopsy is incorrect. Pleural biopsy could be considered, although this is usual post the aspiration results, and is undertaken under radiological guidance. CT thorax CT thorax is incorrect. A CT thorax may be appropriate here and should be considered particularly if diagnostic aspiration reveals the effusion is an exudate. Increased furosemide Increased furosemide is incorrect. Furosemide appears to have had no effect on the effusion thus far, despite resolving the peripheral oedema, so increasing the dose further without further investigation to establish the underlying aetiology of the effusion is inappropriate. Therapeutic drainage Therapeutic drainage is incorrect. Therapeutic drainage is not considered until the underlying diagnosis has been established.

Question 369

Topic: 10. Pathology and Oncology
A 60-year-old man presents to the clinic with a 6-month history of dyspnea on exertion and a non-productive cough. On examination, there is clubbing and crepitations are heard at the lung bases. Lung function tests show a reduced vital capacity and an increased ratio of the forced expiratory volume in 1 second to the forced vital capacity (increased FEV1/FVC). What is the most likely diagnosis?
. Bronchiectasis
. Carcinoma of the lung
. Chronic obstructive pulmonary disease
. Idiopathic pulmonary fibrosis
. Tuberculosis

Correct Answer & Explanation

. Idiopathic pulmonary fibrosis

Explanation

Idiopathic pulmonary fibrosis is the correct answer. This is a classical history of interstitial lung disease. Idiopathic pulmonary fibrosis (IPF) is a progressive disease characterized by sequential acute lung injury with subsequent scarring. Lung function tests show a restrictive picture (reduced vital capacity and increased FEV1/FVC ratio).

Question 370

Topic: 10. Pathology and Oncology
A 40-year-old man presents with a 2-month history of cough and breathlessness. He has also noticed haemoptysis, which he says has worsened gradually. On examination, he has bilateral basal crepitations. His chest X-ray shows diffuse shadowing. He has moderate renal failure. He is previously well and holds down a job as a solicitor. Which investigation would be most useful in obtaining a diagnosis?
. Bronchoscopy
. Computed tomography (CT) of the thorax
. Renal biopsy
. Sputum sample
. Ventilation/perfusion scan

Correct Answer & Explanation

. Renal biopsy

Explanation

Renal biopsy is the correct answer. Goodpasture syndrome consists of diffuse pulmonary haemorrhage and glomerulonephritis with linear deposition of antibodies (90% of which are directed against the alpha-3 chain of type IV collagen) along the glomerular basement membrane (GBM). Serological testing for anti-GBM antibodies and ANCA is crucial for confirming the diagnosis, and a renal biopsy is almost always warranted.

Question 371

Topic: 10. Pathology and Oncology
A 44-year-old woman presents with peripheral calcinosis, sclerodactyly, and oesophageal reflux. On further questioning, it transpires that she has also had worsening shortness of breath over the past few months and Raynaud's phenomenon when she goes out on a cold day or puts her hands into cold water. On examination, her blood pressure is 155/91 mmHg and her pulse is 92 bpm and regular. She has multiple telangiectasia and sclerodactyly with peripheral calcinosis. Auscultation of the chest reveals scattered crackles. Investigations show: haemoglobin 12.9 g/dl, white cell count 8.2 × 10^9/l, platelets 203 × 10^9/l, sodium 138 mmol/l, potassium 4.4 mmol/l, creatinine 134 µmol/l. Which of the following is the most likely pulmonary manifestation of this disorder?
. Bronchiectasis
. Irreversible obstructive lung defect
. Non-specific interstitial pneumonia
. Pulmonary haemorrhage
. Reversible obstructive lung defect

Correct Answer & Explanation

. Non-specific interstitial pneumonia

Explanation

Non-specific interstitial pneumonia (NSIP) is the correct answer. Scleroderma is associated with generalised interstitial lung disease. Case series and multiple lung biopsy reviews suggest that NSIP is the most usual pattern of fibrotic lung disease seen in scleroderma. NSIP is associated with a restrictive pattern on spirometry, not an obstructive one.

Question 372

Topic: Bone Tumors

A 16-year-old boy presents with severe night pain in his right tibia that is dramatically relieved by NSAIDs. Radiographs show a 7 mm radiolucent nidus surrounded by dense sclerotic bone. Which of the following is the most appropriate definitive management?

. Observation and prolonged NSAID therapy
. Radiofrequency ablation
. En bloc resection with margins
. Radiation therapy
. Intralesional chemotherapy

Correct Answer & Explanation

. Radiofrequency ablation

Explanation

The clinical presentation is classic for an osteoid osteoma. Radiofrequency ablation (RFA) is currently the gold standard and most appropriate definitive, minimally invasive treatment.

Question 373

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with progressive distal femur pain. Radiographs demonstrate a destructive lesion with a "sunburst" periosteal reaction and a Codman triangle. Which of the following gene mutations is most strongly associated with the pathogenesis of this tumor?

. t(11;22) translocation
. GNAS1 mutation
. p53 and Rb mutations
. IDH1 and IDH2 mutations
. EXT1 and EXT2 mutations

Correct Answer & Explanation

. p53 and Rb mutations

Explanation

Osteosarcoma is the most likely diagnosis given the clinical and radiographic findings. It is strongly associated with mutations in tumor suppressor genes, predominantly Rb (Retinoblastoma) and p53 (Li-Fraumeni syndrome).

Question 374

Topic: 10. Pathology and Oncology

A 10-year-old girl presents with fever, weight loss, and severe pain in her mid-thigh. Radiographs show a permeative diaphyseal lesion with an "onion-skin" periosteal reaction. Which chromosomal abnormality is diagnostic for this condition?

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

Correct Answer & Explanation

. t(11;22)

Explanation

Ewing sarcoma typically presents in the diaphysis of long bones in children and is characterized by the t(11;22) chromosomal translocation. This creates the EWS-FLI1 fusion protein, which acts as an aberrant transcription factor.

Question 375

Topic: Bone Tumors

A 60-year-old man presents with back pain, anemia, and elevated creatinine. Radiographs reveal multiple punched-out lytic lesions in the skull and spine. Which laboratory finding is essential to confirm the diagnosis?

. Elevated serum alkaline phosphatase
. Monoclonal spike on serum protein electrophoresis
. Polyclonal gammopathy on serum protein electrophoresis
. Profound hypocalcemia
. Elevated parathyroid hormone levels

Correct Answer & Explanation

. Monoclonal spike on serum protein electrophoresis

Explanation

Multiple myeloma is diagnosed by the presence of a monoclonal spike (M-protein, usually IgG or IgA) on serum protein electrophoresis (SPEP). It is a plasma cell dyscrasia leading to lytic bone lesions, renal failure, anemia, and hypercalcemia.

Question 376

Topic: 10. Pathology and Oncology

A 30-year-old woman presents with knee pain. Radiographs reveal an eccentric, lytic lesion in the distal femoral epiphysis. Biopsy shows numerous multinucleated giant cells. Which cells in this tumor are the actual neoplastic cells driving the disease?

. Multinucleated giant cells
. Mononuclear stromal cells
. Osteoblasts
. Chondrocytes
. Macrophages

Correct Answer & Explanation

. Mononuclear stromal cells

Explanation

In a Giant Cell Tumor of bone, the spindle-shaped mononuclear stromal cells are the true neoplastic cells. They express high levels of RANKL, which recruits and stimulates normal macrophages to fuse into the characteristic reactive multinucleated giant cells.

Question 377

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with knee pain and a destructive, sunburst periosteal reaction in the distal femur on X-ray. Biopsy confirms osteosarcoma. Which of the following genetic abnormalities is most classically associated with this patient's condition if he has a familial syndrome?

. t(11;22) translocation
. t(X;18) translocation
. RB1 gene mutation
. APC gene mutation
. FGFR3 mutation

Correct Answer & Explanation

. RB1 gene mutation

Explanation

Mutations in the RB1 tumor suppressor gene are highly associated with the development of osteosarcoma, particularly in patients with hereditary retinoblastoma. The t(11;22) translocation is characteristic of Ewing sarcoma.

Question 378

Topic: 10. Pathology and Oncology

A 60-year-old female with a history of breast cancer presents with a pathologic subtrochanteric femur fracture. What scoring system is most commonly used to predict the risk of pathologic fracture in long bones with metastatic lesions?

. Tokuhashi score
. Tomita score
. Mirels score
. Enneking system
. Risser classification

Correct Answer & Explanation

. Mirels score

Explanation

The Mirels score evaluates the risk of pathologic fracture in long bones based on site, size, nature of the lesion (blastic vs. lytic), and pain. A score of 9 or higher generally indicates the need for prophylactic internal fixation.

Question 379

Topic: 10. Pathology and Oncology

A 65-year-old male smoker presents with a severe ache in his proximal humerus. Radiographs reveal a large lytic lesion. Laboratory workup shows hypercalcemia. Biopsy indicates a metastatic epithelial malignancy. Which primary lung cancer subtype is most frequently associated with hypercalcemia due to parathyroid hormone-related peptide (PTHrP) secretion?

. Small cell carcinoma
. Squamous cell carcinoma
. Adenocarcinoma
. Large cell carcinoma
. Bronchoalveolar carcinoma

Correct Answer & Explanation

. Squamous cell carcinoma

Explanation

Squamous cell carcinoma of the lung is a classic cause of paraneoplastic hypercalcemia mediated by the secretion of PTHrP. Small cell lung cancer is more typically associated with SIADH or ACTH production.

Question 380

Topic: 10. Pathology and Oncology

A 15-year-old boy is diagnosed with conventional high-grade osteosarcoma of the distal femur. Staging imaging is ordered. Which of the following is the most common site of initial distant metastasis for this tumor?

. Brain
. Liver
. Lungs
. Contralateral femur
. Regional lymph nodes

Correct Answer & Explanation

. Lungs

Explanation

The lungs are the most common site of initial distant metastasis for osteosarcoma, typically spreading hematogenously. CT of the chest is a mandatory component of staging.

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