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10. Pathology and Oncology MCQs

Practice Set 274 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 5461

Topic: 10. Pathology and Oncology

Which of the following types of spinal metastases is typically considered 'radioresistant,' making surgical debulking or stabilization a more critical component of treatment?

. Breast cancer metastasis
. Prostate cancer metastasis
. Lymphoma metastasis
. Renal cell carcinoma metastasis
. Multiple myeloma

Correct Answer & Explanation

. Renal cell carcinoma metastasis

Explanation

Renal cell carcinoma metastases are notoriously radioresistant, meaning they respond poorly to conventional external beam radiation therapy. In contrast, breast and prostate cancers, lymphoma, and multiple myeloma are generally considered radiosensitive. For radioresistant tumors, surgical options like decompression and stabilization become more critical, especially in the presence of neurological deficits or spinal instability, often followed by stereotactic body radiation therapy (SBRT) if possible.

Question 5462

Topic: 10. Pathology and Oncology

A 6-year-old child presents with progressive kyphosis and a painful scoliosis. Radiographs show a lytic, expansile lesion of the T7 vertebral body with 'blown out' appearance. Biopsy confirms an Aneurysmal Bone Cyst (ABC). What is the preferred treatment for an active, symptomatic ABC of the spine?

. Observation and serial imaging
. Intralesional corticosteroid injection
. Embolization followed by curettage and bone grafting
. External beam radiation therapy
. Systemic chemotherapy

Correct Answer & Explanation

. Embolization followed by curettage and bone grafting

Explanation

Aneurysmal Bone Cysts are benign, but locally aggressive, highly vascular lesions. The standard of care for symptomatic or active ABCs of the spine typically involves pre-operative selective arterial embolization to reduce blood loss, followed by thorough intralesional curettage and bone grafting or cement augmentation. Observation is for quiescent lesions. Corticosteroid injections are less effective for large spinal ABCs. Radiation therapy is generally avoided in children due to the risk of radiation-induced malignancy and growth disturbance, used only in select, unresectable cases. Chemotherapy is not indicated.

Question 5463

Topic: 10. Pathology and Oncology

In the context of spinal cord tumors, what anatomical location generally carries the worst prognosis due to surgical complexity and high risk of neurological deficit?

. Extradural
. Intradural-extramedullary
. Intramedullary
. Sacral
. Conus Medullaris

Correct Answer & Explanation

. Intramedullary

Explanation

Intramedullary spinal cord tumors (within the spinal cord substance itself) typically carry the worst prognosis in terms of surgical morbidity and potential for permanent neurological deficit. Their intimate relationship with neural tracts makes complete resection challenging without causing further damage. Extradural and intradural-extramedullary tumors, while serious, generally allow for safer surgical dissection planes. Sacral and conus medullaris locations are challenging but generally have better functional outcomes than intramedullary tumors of the cervical or thoracic cord.

Question 5464

Topic: 10. Pathology and Oncology

A 68-year-old patient with no prior cancer history presents with rapidly progressive back pain, bilateral leg weakness, and urinary incontinence. MRI shows a destructive lesion of the L3 vertebral body with significant epidural compression and pathological fracture. A CT-guided biopsy is pending. What is the most appropriate initial management step while awaiting biopsy results?

. Immediate surgical decompression and stabilization
. Initiate broad-spectrum antibiotics
. Administer high-dose intravenous corticosteroids and arrange emergent MRI if not already done, then surgical consultation
. Start systemic chemotherapy
. Strict bed rest and pain medication

Correct Answer & Explanation

. Administer high-dose intravenous corticosteroids and arrange emergent MRI if not already done, then surgical consultation

Explanation

The patient presents with signs of acute spinal cord compression (rapidly progressive neurological deficits, bladder dysfunction, pathological fracture, epidural compression). The immediate priorities are to stabilize neurological function and obtain definitive diagnosis. High-dose corticosteroids are critical to reduce cord edema. Although a biopsy is pending, the clinical urgency of cord compression necessitates immediate intervention regardless of precise tumor type, guided by imaging. Surgical decompression and stabilization is a strong consideration, but the first medical step is steroids and a definitive plan based on imaging. Antibiotics are for infection, chemotherapy is for systemic disease, and bed rest is insufficient.

Question 5465

Topic: 10. Pathology and Oncology

A 75-year-old female presents with T7 vertebral body collapse and severe pain. Biopsy confirms metastatic breast cancer. She has mild weakness but no cord compression. Her SINS score is 10. What is the most appropriate management approach?

. Observation and pain management
. Emergent surgical decompression and stabilization
. Palliative external beam radiation therapy (EBRT) alone
. Stereotactic Body Radiation Therapy (SBRT) to T7
. Systemic chemotherapy alone

Correct Answer & Explanation

. Stereotactic Body Radiation Therapy (SBRT) to T7

Explanation

The SINS score of 10 indicates indeterminate instability, meaning surgical consultation is warranted but not necessarily emergent. With mild weakness and no cord compression, SBRT is an excellent option for local control and pain relief for metastatic breast cancer, which is generally radiosensitive. SBRT offers superior local control and often prevents progression to overt instability compared to conventional EBRT, especially for single-level disease. Surgical decompression is not immediately indicated without severe cord compression or rapidly progressing deficits. Observation is insufficient for a SINS 10 and collapsed vertebra. Systemic chemotherapy treats the disease systemically, not the local instability or pain.

Question 5466

Topic: 10. Pathology and Oncology

Which of the following histological features is characteristic of a chordoma?

. Small round blue cells with high mitotic activity
. Plasmacytoid cells forming sheets
. Physaliferous cells arranged in cords and lobules within a myxoid matrix
. Spindle cells with palisading nuclei
. Cartilaginous matrix with entrapped chondrocytes

Correct Answer & Explanation

. Physaliferous cells arranged in cords and lobules within a myxoid matrix

Explanation

The hallmark histological feature of a chordoma is the presence of physaliferous cells. These are large, vacuolated cells, often arranged in cords and lobules within a prominent myxoid (mucinous) extracellular matrix. This appearance reflects their notochordal origin. Small round blue cells are seen in Ewing's sarcoma and lymphoma. Plasmacytoid cells are seen in multiple myeloma. Spindle cells with palisading nuclei are characteristic of schwannomas. Cartilaginous matrix with entrapped chondrocytes characterizes chondrosarcoma.

Question 5467

Topic: 10. Pathology and Oncology

Which of the following would be an absolute contraindication for proton beam therapy for a spinal tumor?

. Large tumor volume (> 5 cm)
. Prior conventional radiation therapy to the same area
. Presence of metallic instrumentation adjacent to the tumor
. Age greater than 70 years
. Significant neurological deficit requiring immediate decompression

Correct Answer & Explanation

. Significant neurological deficit requiring immediate decompression

Explanation

Proton beam therapy is an advanced form of radiation that can deliver highly conformal doses while sparing surrounding critical structures, often used for tumors like chordomas or chondrosarcomas. However, it is a planned therapy that takes time. A significant neurological deficit requiring immediate surgical decompression is an absolute contraindication for delaying treatment for any radiation therapy, including proton beam. Other options are typically relative contraindications or challenges that can often be overcome (e.g., metallic artifacts can be managed with specific planning, prior radiation is a consideration but not absolute contraindication if re-irradiation is planned carefully, age is not a direct contraindication, large tumor volume is often an indication for, not contraindication against, advanced radiation techniques).

Question 5468

Topic: 10. Pathology and Oncology

Which of the following is the most common extradural primary tumor of the spine in adolescents and young adults, often presenting with bone pain, fever, and weight loss?

. Osteosarcoma
. Chondrosarcoma
. Ewing's Sarcoma
. Osteoid Osteoma
. Multiple Myeloma

Correct Answer & Explanation

. Ewing's Sarcoma

Explanation

Ewing's Sarcoma is a highly malignant primary bone tumor primarily affecting children, adolescents, and young adults. It typically presents with localized pain, swelling, and systemic symptoms such as fever, weight loss, and fatigue, mimicking infection. The spine is an uncommon but recognized site. Osteosarcoma and chondrosarcoma are more common in older adults or have different age peaks. Osteoid osteoma is benign. Multiple myeloma is a disease of older adults.

Question 5469

Topic: 10. Pathology and Oncology

A patient with a history of prostate cancer presents with a T12 vertebral body lesion. Biopsy confirms metastatic adenocarcinoma. The lesion is primarily blastic. On MRI, it is typically:

. T1 hyperintense, T2 hyperintense
. T1 hypointense, T2 hypointense
. T1 isointense, T2 hyperintense
. T1 hyperintense, T2 hypointense
. T1 hypointense, T2 hyperintense with heterogeneous enhancement

Correct Answer & Explanation

. T1 hypointense, T2 hypointense

Explanation

Blastic metastases, such as those from prostate cancer (or sometimes breast), are characterized by increased osteoblastic activity. On MRI, these lesions typically appear T1 hypointense and T2 hypointense due to the replacement of normal fatty marrow with sclerotic bone and tumor cells, which have less free water. This contrasts with lytic lesions (e.g., renal cell, thyroid) that are often T1 hypointense and T2 hyperintense.

Question 5470

Topic: 10. Pathology and Oncology

Regarding Giant Cell Tumors (GCT) of the spine, which of the following statements is true?

. They are typically found in the pediatric population.
. They are always benign and never recur.
. They commonly involve the vertebral body and sacrum, with a higher recurrence risk after intralesional curettage.
. Chemotherapy is the mainstay of treatment.
. They are highly radiosensitive.

Correct Answer & Explanation

. They commonly involve the vertebral body and sacrum, with a higher recurrence risk after intralesional curettage.

Explanation

Giant Cell Tumors of Bone are locally aggressive benign tumors that commonly affect the epiphyses of long bones but can also involve the spine, particularly the sacrum and vertebral bodies. They are more common in young adults (20-40 years) after skeletal maturity. They have a high local recurrence rate, especially after intralesional curettage. Complete en bloc resection is ideal but often challenging in the spine. Denosumab (a RANK ligand inhibitor) is an important adjuvant therapy that can help in controlling the tumor, but chemotherapy is not the mainstay. They are not highly radiosensitive, and radiation is generally reserved for unresectable cases due to malignancy risk.

Question 5471

Topic: 10. Pathology and Oncology

A patient presents with a sacral mass. Biopsy reveals a chondrosarcoma. Surgical planning indicates that a wide en bloc resection will likely require a sacrectomy with significant neurological deficit (bowel/bladder/sexual dysfunction). What is the primary role of high-dose proton beam radiation therapy in this scenario?

. To serve as neoadjuvant therapy to shrink the tumor for a less extensive resection.
. To be the primary definitive treatment if surgery with clear margins is deemed impossible without unacceptable morbidity.
. To be given as adjuvant therapy after a marginal or intralesional resection.
. To provide palliative pain relief only.
. To induce tumor necrosis to allow for easier surgical curettage.

Correct Answer & Explanation

. To be the primary definitive treatment if surgery with clear margins is deemed impossible without unacceptable morbidity.

Explanation

Chondrosarcomas are generally considered radioresistant to conventional photon radiation. However, high-dose proton beam therapy, due to its ability to deliver high doses precisely, can be highly effective. If achieving wide surgical margins for a sacral chondrosarcoma would result in unacceptable morbidity (e.g., complete loss of bowel, bladder, and sexual function), proton beam therapy can be considered as the primary definitive treatment to achieve local control, often as a 'surgical alternative' where surgery is not feasible or would lead to unacceptably high morbidity. It can also be used adjuvant after marginal resection, or neoadjuvant, but its key role in radioresistant tumors like chondrosarcoma is as a potential primary definitive treatment.

Question 5472

Topic: 10. Pathology and Oncology

Which of the following conditions is most likely to present with 'skipping' or 'drop' metastases, often seen along the neuraxis in conjunction with a primary spinal cord tumor?

. Spinal Meningioma
. Spinal Schwannoma
. Spinal Ependymoma
. Spinal Osteosarcoma
. Spinal Chordoma

Correct Answer & Explanation

. Spinal Ependymoma

Explanation

Spinal ependymomas, particularly the higher-grade anaplastic subtypes, are known for their propensity to spread via CSF pathways, leading to 'drop metastases' or 'skipping lesions' at distant sites along the spinal cord or brain. This phenomenon is less common with meningiomas or schwannomas, which are typically localized intradural-extramedullary lesions. Osteosarcoma and chordoma are extradural bone tumors and spread via different mechanisms (hematogenous or direct invasion).

Question 5473

Topic: 10. Pathology and Oncology
What is the most common histological subtype of spinal cord astrocytoma in adults?
. Pilocytic Astrocytoma
. Fibrillary Astrocytoma
. Anaplastic Astrocytoma
. Glioblastoma Multiforme
. Subependymoma

Correct Answer & Explanation

. Fibrillary Astrocytoma

Explanation

In adults, spinal cord astrocytomas are predominantly low-grade fibrillary astrocytomas (WHO Grade II). Pilocytic astrocytomas (WHO Grade I) are more common in children. Anaplastic astrocytomas (Grade III) and glioblastoma multiforme (Grade IV) are high-grade and rarer in the spinal cord compared to the brain. Subependymomas are typically benign ependymal tumors, distinct from astrocytomas.

Question 5474

Topic: 10. Pathology and Oncology

What is the primary utility of a whole-body FDG-PET/CT scan in the workup of a suspected spinal tumor?

. To precisely delineate the spinal cord anatomy for surgical planning.
. To identify the exact histological subtype of the tumor.
. To assess for multifocal disease or distant metastases in known malignancies, and sometimes to identify the primary tumor in unknown origin.
. To evaluate spinal stability and risk of pathological fracture.
. To differentiate between benign and malignant lesions based on metabolic activity.

Correct Answer & Explanation

. To assess for multifocal disease or distant metastases in known malignancies, and sometimes to identify the primary tumor in unknown origin.

Explanation

Whole-body FDG-PET/CT is highly valuable in oncology for assessing metabolic activity. Its primary utility in the context of spinal tumors is to stage known malignancies by detecting distant metastases or multifocal disease. In cases of suspected metastatic spinal tumor from an unknown primary, it can help identify the primary tumor site (e.g., lung, colon). While it can help differentiate benign from malignant lesions (malignant lesions typically show higher FDG uptake), and can be incorporated into surgical planning, its main strength is systemic staging and primary tumor identification for metastatic disease. MRI is superior for spinal cord anatomy; CT is better for bony detail and stability.

Question 5475

Topic: 10. Pathology and Oncology

A patient is diagnosed with a sacral chondrosarcoma. The tumor is large, involving multiple segments of the sacrum, and would require a high sacrectomy with complete loss of bowel and bladder function. The patient declines this highly morbid surgery. What alternative treatment modality offers the best chance for local control?

. Conventional external beam radiation therapy
. Systemic chemotherapy
. High-dose proton beam therapy
. Intralesional injection of sclerosing agents
. Palliative analgesics

Correct Answer & Explanation

. High-dose proton beam therapy

Explanation

Chondrosarcomas are generally considered radioresistant to conventional photon radiation, and chemotherapy has limited efficacy. For large, unresectable, or high-morbidity sacral chondrosarcomas where surgery is declined, high-dose proton beam therapy is considered the best alternative for local control. Proton therapy's unique Bragg peak allows for highly conformal dose delivery to the tumor while minimizing dose to adjacent critical structures, making it superior to conventional radiation for these tumors. Intralesional injections are not suitable for large chondrosarcomas.

Question 5476

Topic: 10. Pathology and Oncology

A 60-year-old male with a history of pancreatic cancer presents with new-onset back pain and recent onset of bilateral leg weakness. MRI shows a metastatic lesion at T10 with moderate spinal cord compression. His performance status is good (KPS 80). Which of the following factors would MOST strongly favor surgical decompression over radiation alone?

. Radiosensitive nature of pancreatic cancer
. Single-level metastatic disease
. Absence of significant pain
. Rapidly progressive neurological deficit
. Prior history of radiation to the same spinal segment

Correct Answer & Explanation

. Rapidly progressive neurological deficit

Explanation

Rapidly progressive neurological deficit is a critical indication for urgent surgical decompression. While radiation can be effective, it often has a slower onset of action and may not be sufficient to prevent irreversible neurological damage in cases of rapid decline. Pancreatic cancer is generally radioresistant, further favoring surgery. Single-level disease and good performance status make surgery more feasible. Prior radiation to the same segment would make re-irradiation risky or less effective, also favoring surgery. Absence of pain might make the decision more nuanced, but rapid neurological progression is paramount.

Question 5477

Topic: 10. Pathology and Oncology

Which histological finding is characteristic of a spinal osteosarcoma?

. Chondroid matrix with entrapped lacunae
. Small round blue cells with prominent vascularization
. Malignant spindle cells producing osteoid or immature bone
. Sheets of plasma cells with amyloid deposition
. Physaliferous cells in a myxoid background

Correct Answer & Explanation

. Malignant spindle cells producing osteoid or immature bone

Explanation

The defining histological characteristic of osteosarcoma is the direct production of osteoid (immature bone) or bone by malignant mesenchymal cells (spindle cells). Chondroid matrix is seen in chondrosarcoma. Small round blue cells are characteristic of Ewing's sarcoma. Sheets of plasma cells are for multiple myeloma. Physaliferous cells are for chordoma.

Question 5478

Topic: 10. Pathology and Oncology

For patients with solitary spinal metastases from a chemosensitive and radiosensitive tumor (e.g., lymphoma, myeloma), who have no neurological deficits and stable spine, what is generally considered the primary treatment?

. Surgical en bloc resection
. Palliative decompression
. Aggressive chemotherapy and/or radiation therapy
. Observation with serial MRI
. Kyphoplasty or vertebroplasty

Correct Answer & Explanation

. Aggressive chemotherapy and/or radiation therapy

Explanation

For solitary spinal metastases from chemosensitive and radiosensitive tumors (like lymphoma or multiple myeloma), systemic chemotherapy and/or radiation therapy (conventional or SBRT) are typically the primary treatment modalities, especially if there are no neurological deficits and the spine is stable. These tumors often respond well to non-surgical treatment, allowing for disease control without the morbidity of surgery. Surgical resection is usually reserved for radioresistant tumors, instability, or neurological compromise. Observation is insufficient for malignancy. Kyphoplasty/vertebroplasty are for pain from vertebral compression fractures, not primary tumor treatment.

Question 5479

Topic: 10. Pathology and Oncology

Which type of metastatic lesion to the spine is most commonly associated with a 'blastic' appearance on plain radiographs and CT scans?

. Renal Cell Carcinoma
. Thyroid Carcinoma
. Lung Carcinoma
. Prostate Carcinoma
. Multiple Myeloma

Correct Answer & Explanation

. Prostate Carcinoma

Explanation

Prostate carcinoma metastases are classically osteoblastic or 'blastic,' meaning they stimulate bone formation, leading to increased bone density visible on radiographs and CT. Breast cancer metastases can also be blastic, lytic, or mixed. Renal cell, thyroid, and lung carcinomas are typically lytic (bone-destroying). Multiple myeloma causes 'punched-out' lytic lesions without reactive sclerosis.

Question 5480

Topic: 10. Pathology and Oncology

Regarding intramedullary spinal cord astrocytomas, what is a key prognostic factor influencing surgical outcome and long-term survival?

. Patient's age at diagnosis
. Size of the associated syrinx
. Gross total resection (GTR) vs. subtotal resection (STR)
. Presence of hydrocephalus
. Pre-operative neurological status

Correct Answer & Explanation

. Gross total resection (GTR) vs. subtotal resection (STR)

Explanation

For both ependymomas and astrocytomas, the extent of surgical resection is the most critical prognostic factor. Gross total resection (GTR) is strongly associated with significantly improved long-term survival and reduced recurrence rates compared to subtotal resection (STR). While pre-operative neurological status influences initial morbidity, and age can play a role, the completeness of tumor removal is paramount for biological control. Syrinx size is a symptom, not a primary prognostic factor in itself for the tumor. Hydrocephalus is rare with spinal cord tumors unless secondary to CSF pathway obstruction.

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