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10. Pathology and Oncology MCQs

Practice Set 31 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 601

Topic: 10. Pathology and Oncology

A 30-year-old pregnant female presents with a slowly enlarging, painless mass in her abdominal wall. Biopsy reveals uniform spindle-shaped cells with abundant collagen, positive for beta-catenin. What is the current recommended first-line management?

. Immediate wide surgical excision
. Active surveillance
. Neoadjuvant radiation therapy
. Amputation
. Systemic doxorubicin

Correct Answer & Explanation

. Active surveillance

Explanation

The diagnosis is desmoid fibromatosis, frequently associated with pregnancy or trauma and characterized by beta-catenin mutations. Active surveillance is the current first-line management, as many tumors spontaneously arrest or regress.

Question 602

Topic: 10. Pathology and Oncology

A 28-year-old male presents with a painful soft tissue mass near his knee joint with stippled calcifications. Biopsy demonstrates a biphasic spindle cell and epithelial cell pattern. Which cytogenetic abnormality is characteristic?

. t(11;22)
. t(X;18)
. t(12;16)
. t(2;13)
. MDM2 amplification

Correct Answer & Explanation

. t(X;18)

Explanation

The clinical picture and biphasic histology are diagnostic of synovial sarcoma. This tumor is classically associated with the t(X;18)(p11;q11) chromosomal translocation, resulting in the SYT-SSX fusion gene.

Question 603

Topic: 10. Pathology and Oncology

What is the single most significant prognostic factor for overall survival in a patient newly diagnosed with conventional high-grade osteosarcoma?

. Tumor size greater than 8 cm
. Histologic subtype
. Presence of distant metastasis at diagnosis
. Serum alkaline phosphatase levels
. Degree of tumor necrosis following neoadjuvant chemotherapy

Correct Answer & Explanation

. Presence of distant metastasis at diagnosis

Explanation

The presence of distant metastasis at the time of diagnosis is the most critical prognostic factor for overall survival in osteosarcoma. Without metastasis, 5-year survival is 60-70%, dropping to less than 20% if metastasis is initially present.

Question 604

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with a permeative diaphyseal lesion of the fibula demonstrating an "onion-skin" periosteal reaction. Cytogenetic testing of the biopsy specimen is most likely to reveal which of the following translocations?

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

Correct Answer & Explanation

. t(11;22)

Explanation

Ewing sarcoma is classically associated with the t(11;22) translocation, which fuses the EWS gene on chromosome 22 with the FLI1 gene on chromosome 11. This specific translocation is found in approximately 85% of Ewing sarcoma cases.

Question 605

Topic: 10. Pathology and Oncology

A 26-year-old male presents with a slow-growing, painful mass in the plantar aspect of his foot. Radiographs show fine, stippled calcifications within the soft tissue. Biopsy demonstrates a biphasic pattern of epithelial and spindle cells. What is the most likely diagnosis?

. Liposarcoma
. Synovial sarcoma
. Rhabdomyosarcoma
. Epithelioid sarcoma
. Clear cell sarcoma

Correct Answer & Explanation

. Synovial sarcoma

Explanation

Synovial sarcoma often presents in young adults as a slow-growing mass in the extremities (especially the foot and ankle) with punctate calcifications on radiographs. The biphasic histology and t(X;18) translocation are diagnostic hallmarks.

Question 606

Topic: 10. Pathology and Oncology

A 65-year-old male presents with a destructive, lytic lesion in the proximal femur. Biopsy confirms metastatic clear cell renal carcinoma. Prophylactic stabilization is planned. Which of the following preoperative interventions is most critical for this specific primary tumor?

. Neoadjuvant external beam radiation
. Initiation of systemic chemotherapy
. Preoperative selective arterial embolization
. Administration of denosumab
. Placement of an inferior vena cava (IVC) filter

Correct Answer & Explanation

. Preoperative selective arterial embolization

Explanation

Metastatic renal cell carcinoma and thyroid carcinoma lesions are notoriously hypervascular and carry a severe risk of massive intraoperative hemorrhage. Preoperative selective arterial embolization 24-48 hours before surgery is critically indicated.

Question 607

Topic: 10. Pathology and Oncology

According to Mirels' criteria for predicting impending pathologic fractures, which of the following clinical or radiographic characteristics assigns the highest possible point value (3 points)?

. Upper extremity location
. Blastic radiographic appearance
. Lesion size < 1/3 of cortical diameter
. Severe pain
. Mild functional pain

Correct Answer & Explanation

. Severe pain

Explanation

Mirels' criteria scores location, pain, lesion size, and radiographic appearance on a scale from 1 to 3. Severe pain, a strictly osteolytic nature, lower extremity/peritrochanteric location, and a size > 2/3 of cortical diameter each score the maximum of 3 points.

Question 608

Topic: Bone Tumors
A 50-year-old male presents with deep shoulder pain. Radiographs reveal a radiolucent lesion in the proximal humerus with intralesional "rings and arcs" calcification and endosteal scalloping involving > 2/3 of the cortical thickness. What is the most appropriate definitive management?
. Neoadjuvant chemotherapy followed by curettage
. Radiation therapy alone
. Extended intralesional curettage with burring and cementation
. Wide surgical resection
. Observation with serial radiographs every 3 months

Correct Answer & Explanation

. Wide surgical resection

Explanation

The clinical presentation is classic for a primary conventional high-grade chondrosarcoma, indicated by the rings/arcs calcification and deep endosteal scalloping. Because conventional chondrosarcoma is resistant to both chemotherapy and radiation, wide surgical resection is the standard of care.

Question 609

Topic: 10. Pathology and Oncology
A 14-year-old male presents with left distal femoral pain and swelling. Imaging reveals a large metaphyseal lesion with cortical destruction and soft tissue extension. Biopsy confirms high-grade osteosarcoma. A whole-body PET-CT scan shows no distant metastases but highlights a separate, small, enhancing lesion within the same femur, proximal to the primary tumor. According to the 8th edition UICC staging criteria for bone sarcomas, what is the correct T-stage for this patient's primary tumor?
. T1
. T2
. T3
. Tx
. T4

Correct Answer & Explanation

. T3

Explanation

For bone sarcomas (like osteosarcoma), the 8th edition UICC T-staging system is as follows: T1 is for tumors ≤ 8 cm, T2 for tumors > 8 cm. T3 is specifically designated for discontinuous tumor foci in the primary bone, commonly known as 'skip lesions.' The description of a separate, enhancing lesion within the same femur proximal to the primary tumor perfectly fits the definition of a skip lesion, regardless of the primary tumor's size. Therefore, the T-stage is T3.

Question 610

Topic: 10. Pathology and Oncology
A 65-year-old male presents with a progressively enlarging, painless mass in his right thigh for 6 months. MRI reveals a 12 cm deep-seated, heterogeneous mass. Biopsy confirms high-grade pleomorphic undifferentiated sarcoma (PUS). Imaging of the chest, abdomen, and pelvis is negative for metastases, and lymph nodes are unremarkable. What is the correct UICC T-stage for this soft tissue sarcoma of the extremity?
. T1
. T2
. T3
. T4
. Tx

Correct Answer & Explanation

. T3

Explanation

For soft tissue sarcomas of the trunk and extremities, the 8th edition UICC T-staging is based primarily on tumor size: T1 for tumors ≤ 5 cm, T2 for tumors > 5 cm and ≤ 10 cm, and T3 for tumors > 10 cm. The described tumor is 12 cm, which places it in the T3 category. T4 is reserved for tumors of any size with invasion of major neurovascular structures, bone, joint, or visceral organs. Since invasion of these critical structures is not mentioned, T3 is the correct stage based on size alone.

Question 611

Topic: 10. Pathology and Oncology
In the context of the UICC staging system for musculoskeletal sarcomas, which factor is not a primary determinant of the Grade (G) component?
. Tumor cellularity
. Mitotic activity
. Extent of necrosis
. Pleomorphism
. Tumor size

Correct Answer & Explanation

. Tumor size

Explanation

The Grade (G) component in the UICC staging system for musculoskeletal sarcomas, particularly for soft tissue sarcomas (often using the FNCLCC system), is determined by histopathological features such as tumor differentiation, mitotic activity, and the extent of tumor necrosis. Pleomorphism and cellularity are aspects of differentiation. Tumor size, however, is a primary determinant of the T-stage (primary tumor extent), not the G-stage (histological grade). Therefore, tumor size is not a primary determinant of the Grade component.

Question 612

Topic: 10. Pathology and Oncology
A 28-year-old female is diagnosed with a high-grade synovial sarcoma in her left forearm. Staging workup reveals a single, isolated pulmonary nodule consistent with metastatic disease. There is no regional lymph node involvement. According to the 8th edition UICC staging for soft tissue sarcomas, what is the overall stage group?
. Stage IIB
. Stage III
. Stage IVA
. Stage IVB
. Stage IA

Correct Answer & Explanation

. Stage IVA

Explanation

The presence of distant metastases (M1) automatically upstages any sarcoma to Stage IV. For soft tissue sarcomas in the 8th edition UICC, M1 disease is classified as Stage IVA if there are no regional lymph node metastases (N0). If regional lymph node metastases (N1) are present alongside distant metastases, it would be Stage IVB. In this case, with M1 and N0, the overall stage is IVA.

Question 613

Topic: 10. Pathology and Oncology

Which of the following describes the M1a designation for bone sarcomas in the 8th edition UICC staging system?

. Distant metastasis to lung only
. Distant metastasis to bone only
. Distant metastasis to other sites (e.g., liver)
. Regional lymph node metastasis
. Peritoneal metastasis

Correct Answer & Explanation

. Distant metastasis to lung only

Explanation

Correct Answer: AIn the 8th edition UICC staging system for bone sarcomas (e.g., osteosarcoma, Ewing sarcoma), M1a specifically refers to distant metastasis to the lung only. M1b refers to distant metastasis to bone or other distant sites (e.g., liver, brain). This distinction can be important prognostically, as isolated lung metastases sometimes have a better prognosis and are amenable to surgical resection in select cases.

Question 614

Topic: 10. Pathology and Oncology

For patients with primary bone sarcoma, which of the following is the most significant factor influencing the prognosis of those with localized disease?

. Patient's age at diagnosis
. Tumor size
. Primary tumor location (axial vs. appendicular)
. Response to neoadjuvant chemotherapy (pathologic necrosis)
. Histological subtype

Correct Answer & Explanation

. Response to neoadjuvant chemotherapy (pathologic necrosis)

Explanation

Correct Answer: DWhile patient's age, tumor size, location, and histological subtype all have prognostic significance for localized bone sarcomas, the response to neoadjuvant chemotherapy, as measured by the percentage of tumor necrosis in the resected specimen, is consistently one of the most powerful and independent prognostic factors. A 'good response' (typically >90-95% necrosis) is strongly associated with improved event-free and overall survival. This is a key 'Nevin Insight' into evaluating the efficacy of systemic therapy. The other factors are important, but chemotherapy response integrates the biological aggressiveness of the tumor with the effectiveness of treatment.

Question 615

Topic: 10. Pathology and Oncology
A 25-year-old male with a 4 cm deep-seated fibrosarcoma of the forearm has a biopsy revealing high-grade features (G3). Staging studies are negative for regional lymph nodes (N0) and distant metastases (M0). According to the 8th edition UICC staging system for soft tissue sarcomas, what is the overall stage group?
. Stage IA
. Stage IB
. Stage IIA
. Stage IIB
. Stage III

Correct Answer & Explanation

. Stage IIB

Explanation

Let's break down the UICC 8th edition staging for soft tissue sarcomas of the extremity/trunk: T-stage: Tumor is 4 cm, so T1 (≤ 5 cm). N-stage: N0 (no regional lymph node metastases). M-stage: M0 (no distant metastases). G-stage: G3 (high grade). Mapping to Stage Groups: Stage I: G1/G2, T1/T2, N0, M0; Stage II: G3, T1, N0, M0 OR G1/G2, T3/T4, N0, M0; Stage III: G3, T2/T3/T4, N0, M0 OR any G, any T, N1, M0; Stage IV: Any G, any T, any N, M1. For a G3T1N0M0, the overall stage group is IIB.

Question 616

Topic: 10. Pathology and Oncology

Which of the following factors is considered the most critical independent prognostic indicator for survival in patients with localized high-grade soft tissue sarcoma of the extremity?

. Patient age at diagnosis
. Tumor size
. Histological subtype
. Deep versus superficial location
. Achieving negative surgical margins (R0 resection)

Correct Answer & Explanation

. Achieving negative surgical margins (R0 resection)

Explanation

Correct Answer: EWhile tumor size, grade, depth, and histological subtype are all important prognostic factors, achieving negative surgical margins (R0 resection) is arguably the most critical independent prognostic indicator for local control and, by extension, survival in patients with localized high-grade soft tissue sarcomas. Local recurrence significantly increases the risk of distant metastasis and complicates subsequent treatment. The inability to achieve R0 resection (i.e., R1 or R2 resection) is a strong negative prognostic factor. All other options influence prognosis but are often considered in conjunction with or secondary to the achievement of complete local excision.

Question 617

Topic: 10. Pathology and Oncology

Which of the following is considered the primary 'oncological' function of neoadjuvant (preoperative) chemotherapy in the treatment of high-grade osteosarcoma?

. To reduce the size of the tumor to facilitate limb-salvage surgery.
. To evaluate the tumor's sensitivity to chemotherapy for postoperative regimen adjustment.
. To treat micrometastatic disease not detectable by conventional imaging.
. To alleviate pain and improve functional status prior to surgery.
. To sterilize the tumor margins to prevent local recurrence.

Correct Answer & Explanation

. To treat micrometastatic disease not detectable by conventional imaging.

Explanation

Correct Answer: CWhile neoadjuvant chemotherapy can reduce tumor size (facilitating limb salvage) and alleviate pain, its primary oncological function in high-grade osteosarcoma is to treat micrometastatic disease that is presumed to be present at diagnosis, even if not detectable on imaging. Osteosarcoma has a high propensity for early systemic spread. Preoperative chemotherapy aims to eradicate these micrometastases, thereby improving overall survival. Evaluating tumor sensitivity (pathological response) is a crucial secondary benefit, as it guides adjuvant therapy. Sterilizing tumor margins is an indirect benefit if the tumor shrinks, but achieving clear surgical margins remains paramount, and chemotherapy doesn't guarantee margin sterility.

Question 618

Topic: 10. Pathology and Oncology

What is the primary significance of a biopsy tract in the surgical management of musculoskeletal sarcomas?

. It determines the appropriate type of systemic chemotherapy.
. It is the preferred site for placement of drains after definitive surgery.
. It must be completely excised en bloc with the primary tumor during definitive surgery.
. It is a reliable indicator of tumor grade.
. It is often left open to allow for subsequent radiation therapy.

Correct Answer & Explanation

. It must be completely excised en bloc with the primary tumor during definitive surgery.

Explanation

Correct Answer: CThe biopsy tract (the path created by the biopsy needle or incision) is considered to be potentially contaminated with tumor cells. Therefore, for proper oncologic management and to minimize the risk of local recurrence, the biopsy tract must be completely excised en bloc with the primary tumor during definitive surgery. This ensures that any 'seeded' tumor cells are removed. Failing to do so can lead to local recurrence along the tract. It does not determine chemotherapy, is not preferred for drains, is not a reliable indicator of tumor grade, and is not left open for radiation.

Question 619

Topic: 10. Pathology and Oncology

A 68-year-old male with a history of prostate cancer status post prostatectomy presents with increasing left shoulder pain and weakness for the past three months. X-rays show a lytic lesion in the proximal humerus. Laboratory tests reveal elevated serum calcium. What is the most appropriate next step in management?

. Initiate immediate chemotherapy.
. Refer for radiation therapy to the left shoulder.
. Biopsy the humeral lesion.
. Prescribe NSAIDs and physiotherapy.
. Perform surgical fixation with methyl methacrylate augmentation.

Correct Answer & Explanation

. Biopsy the humeral lesion.

Explanation

Correct Answer: CGiven the patient's history of prostate cancer and a new lytic lesion with hypercalcemia, metastatic disease to the humerus is highly suspected. While radiation and surgical fixation may be part of the treatment plan, a definitive diagnosis through biopsy is crucial to confirm metastasis and guide subsequent oncological management. Elevated serum calcium also suggests bone involvement. NSAIDs and physiotherapy are insufficient for a suspected malignancy. Immediate chemotherapy without definitive diagnosis is not standard practice.

Question 620

Topic: 10. Pathology and Oncology

A 16-year-old male presents with a 6-month history of localized pain in his proximal tibia, which is worse at night and consistently relieved by over-the-counter NSAIDs. Physical examination reveals localized tenderness. Radiographs show a small, lucent nidus (less than 1.5 cm) surrounded by a dense sclerotic reaction in the tibial cortex. What is the most likely diagnosis?

. Osteosarcoma
. Ewing's sarcoma
. Osteoid osteoma
. Enchondroma
. Fibrous dysplasia

Correct Answer & Explanation

. Osteoid osteoma

Explanation

Correct Answer: CThe clinical presentation of localized pain, worse at night, and classically relieved by NSAIDs (due to prostaglandin production within the nidus) in an adolescent, combined with radiographic findings of a small lucent nidus surrounded by dense cortical sclerosis, is pathognomonic for an osteoid osteoma. This is a benign bone tumor. Osteosarcoma and Ewing's sarcoma are malignant tumors with more aggressive radiographic features and different pain patterns. Enchondromas are typically asymptomatic and found in the medullary cavity of small bones. Fibrous dysplasia has a different radiographic appearance and clinical course.

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