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10. Pathology and Oncology MCQs

Practice Set 5 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 81

Topic: Bone Tumors

When an osteoid osteoma occurs in the spine, it can involve all of the following except:

. Facets
. Transverse processes
. Pedicles
. Rib heads adjacent to thoracic vertebrae
. Vertebral body

Correct Answer & Explanation

. Vertebral body

Explanation

When an osteoid osteoma occurs in the spine, involvement of the posterior elements of the vertebra is typical and includes: Lamina Pedicles Transverse processes Facets Rib heads adjacent to thoracic vertebrae

Question 82

Topic: Bone Tumors

Typical histologic features of an osteoid osteoma include all of the following except:

. C hondrocytes in an arrangement similar to that of a physis
. Nidus composed of haphazardly arranged network of osteoid trabeculae
. Varying degrees of mineralization with greatest mineralization in the center of the lesion
. Osteoblasts rimming the trabeculae
. Vascularized spindle cell stroma

Correct Answer & Explanation

. C hondrocytes in an arrangement similar to that of a physis

Explanation

The histologic features of an osteoid osteoma include the following: Nidus composed of haphazardly arranged network of osteoid trabeculae Varying degrees of mineralization with greatest mineralization in the center of the lesion Loose fibrovascular connective tissue between trabeculae Osteoblasts rimming the trabeculae Vascularized spindle cell stroma

Question 83

Topic: Bone Tumors

Treatment of a vertebral osteoid osteoma includes all of the following except:

. Surgical excision/curettage of the nidus
. En-bloc resection
. Observation if symptoms are mild
. Aspirin/salicylates/nonsteroidal anti-inflammatory drugs (NSAIDs)
. Radiofrequency ablation

Correct Answer & Explanation

. En-bloc resection

Explanation

Treatment of osteoid osteomas in the spine include the following: Aspirin/salicylates/NSAIDs Administered for up to 2 years Successful in up to 50% cases Radiofrequency ablation (RFA) Usually computed tomography-guided Clinical success rates as high as 97% have been reported with 1 to 2 treatments Surgical excision of the nidus/curettage Necessary when aspirin/salicylates/NSAIDs cannot be tolerated for long periods of time and RFA is not possible or unsuccessful Can usually be accomplished through a posterior approach En-bloc resection or a more radical procedure play no role in management

Question 84

Topic: Bone Tumors

Typical symptoms of a spinal osteoblastoma include all of the following except:

. Torticollis
. Painful scoliosis
. Stiffness
. Diskogenic pain
. Radicular symptoms

Correct Answer & Explanation

. Diskogenic pain

Explanation

The most common symptoms of spinal osteoblastomas include: Pain Usually the first and most common presenting symptom Night pain is not as common as it is with osteoid osteomas Night pain is not as common as it is with osteoid osteomas Painful scoliosis Torticollis Stiffness Radicular symptoms usually due to mass effect

Question 85

Topic: 10. Pathology and Oncology

Which of the following is the most common region of the spine affected by metastatic disease:

. Craniocervical junction
. Cervical region
. Thoracic region
. Lumbar region
. Sacral region

Correct Answer & Explanation

. Thoracic region

Explanation

The thoracic spine is the most common site of metastatic disease. This has been attributed to the watershed zone being located in the low thoracic region.

Question 86

Topic: 10. Pathology and Oncology

Which of the following is the most common complaint at time of presentation in patients with metastatic spine disease:

. Difficulty with balance
. Difficulty with urination
. Night sweats
. Pain during the night
. Numbness in the lower extremities

Correct Answer & Explanation

. Pain during the night

Explanation

The most common manifestation of metastatic disease is persistent pain. Pain is most marked at night and aggravated by movement. History of trauma is usually absent. Pain is followed by weakness of the lower extremities, sensory loss, and bladder and bowel changes.

Question 87

Topic: 10. Pathology and Oncology

Which of the following methods is the standard in diagnosing vertebral metastatic disease:

. Plain radiography demonstrating lytic lesion
. C omputed tomography with bony destruction respecting adjacent vertebral levels
. Magnetic resonance imaging with typical destructive lesion characteristics
. Tissue biopsy
. There is no standard of care in diagnosing vertebral metastasis.

Correct Answer & Explanation

. Tissue biopsy

Explanation

The only definitive method of determining the presence and nature of metastatic tumor is vertebral biopsy. Computed tomography-guided biopsy of the spine provides an accurate access to the lesion. Open biopsy is indicated when image guided biopsy is not feasible or non-diagnostic. Differential diagnosis mainly involves spinal infections, osteoporosis, disk disease, and multiple myeloma.

Question 88

Topic: 10. Pathology and Oncology

Which of the following is NOT an indication for surgical intervention in metastatic vertebral disease:

. Progressive neurologic deficit
. Poor prognosis
. Instability of the spine
. Uncontrollable pain
. Failure of radiation therapy

Correct Answer & Explanation

. Poor prognosis

Explanation

In patients with metastatic vertebral disease, indications for surgery include progressive neurologic deficit, instability of the spine, uncontrollable pain, and failure of radiation therapy. Surgical intervention can add significant morbidity while providing marginal improvement in longevity of a patient with an already poor prognosis.

Question 89

Topic: 10. Pathology and Oncology

A 45-year-old intravenous drug user presents with severe, unrelenting back pain and low-grade fever. MRI reveals fluid in the L3-L4 disc space with endplate destruction and bone marrow edema. The patient is neurologically intact. What is the most appropriate next step in management?

. Immediate initiation of broad-spectrum empiric antibiotics
. Emergent anterior decompression and fusion
. CT-guided needle biopsy of the disc space
. Corticosteroid injection for pain relief
. Laminectomy

Correct Answer & Explanation

. CT-guided needle biopsy of the disc space

Explanation

In a hemodynamically stable patient without neurologic deficits, a tissue diagnosis via CT-guided biopsy should be obtained prior to initiating antibiotics to ensure directed therapy for vertebral osteomyelitis/discitis.

Question 90

Topic: 10. Pathology and Oncology

A 68-year-old man with a history of prostate cancer presents with mid-thoracic back pain. AP radiograph shows an absent left pedicle at T8 (the "winking owl" sign). Which of the following is the most likely diagnosis?

. Multiple myeloma
. Metastatic disease
. Osteosarcoma
. Osteoid osteoma
. Eosinophilic granuloma

Correct Answer & Explanation

. Metastatic disease

Explanation

The "winking owl" sign indicates pedicle destruction, which is a classic radiographic sign of metastatic spine disease. Prostate cancer is a common primary source for blastic or lytic spinal metastases.

Question 91

Topic: 10. Pathology and Oncology

A 60-year-old male with metastatic lung cancer presents with a rapid 24-hour onset of bilateral leg weakness and bowel incontinence. MRI shows a large epidural tumor mass compressing the thoracic spinal cord. According to the Patchell trial criteria, the preferred immediate management is:

. High-dose intravenous steroids followed by observation
. Emergent surgical decompression and spinal stabilization
. Emergent conventional radiation therapy alone
. Systemic targeted chemotherapy
. Lumbar puncture for definitive CSF cytology

Correct Answer & Explanation

. Emergent surgical decompression and spinal stabilization

Explanation

For solid tumors causing acute malignant epidural spinal cord compression with progressing neurologic deficits, direct surgical decompression and stabilization provides superior functional preservation compared to radiation therapy alone.

Question 92

Topic: 10. Pathology and Oncology

A 54-year-old man presents with low back pain and lower extremity weakness. Imaging shows a solitary lesion located in the conus medullaris with enhancement after administration of gadolinium. The most likely diagnosis is:

. Epidermoid cyst
. Lymphoma
. Meningioma
. Ependymoma
. Astrocytoma

Correct Answer & Explanation

. Ependymoma

Explanation

Ependymomas are the most common intramedullary tumor in adults and are found with equal prevalence in middle-aged men and women. They are most prevalent in the caudal regions of the spinal cord around the conus medullaris and filum terminale. Epidermoid cysts and dural-based meningiomas are extramedullary tumors. Astrocytomas are most commonly found in the lower cervical region, and a patient presents with neck pain and upper extremity deficits.

Question 93

Topic: 10. Pathology and Oncology

Which of the following diagnostic modalities is used most often to evaluate suspected malignant astrocytomas of the spinal cord:

. History and physical examination is often sufficient to make the diagnosis.
. Imaging characteristics of malignant astrocytomas on magnetic resonance imaging (MRI) are specific enough to make the diagnosis.
. Malignant astrocytoma of the spinal cord is a clinical diagnosis and is only confirmed after post-mortem tissue evaluation.
. An open biopsy with tissue evaluation is the only way to make the diagnosis.
. C omputed tomography with a myelogram

Correct Answer & Explanation

. An open biopsy with tissue evaluation is the only way to make the diagnosis.

Explanation

Clinically, early symptoms of intramedullary tumors are nonspecific. Almost all intramedullary tumors show contrast uptake. Even though there are specific MRI characteristics to each tumor, enough variability and overlap exists in their radiologic appearance that histological examination is still required for definitive diagnosis.

Question 94

Topic: 10. Pathology and Oncology

The most effective treatment for malignant intramedullary tumors of the spinal cord is:

. Surgical excision
. Radiation therapy
. Chemotherapy
. Surgical excision followed by a combination of chemotherapy and radiation therapy.
. Neither a single treatment modality nor a combination of treatment modalities has proven effective in significantly improving mortality.

Correct Answer & Explanation

. Neither a single treatment modality nor a combination of treatment modalities has proven effective in significantly improving mortality.

Explanation

Despite treatment, a poor prognosis is given to patients with malignant intramedullary tumors. The median survival time for patients with cervical tumors is 3 to 6 months. Surgical excision, radiation, and chemotherapy are not found to significantly improve survival. Treatment is generally supportive.

Question 95

Topic: 10. Pathology and Oncology

A 50-year-old man presents with radicular pain. MRI shows an intradural, extramedullary 'dumbbell-shaped' mass causing widening of the C5-C6 neural foramen. The tumor is eccentric to the spinal cord. Which of the following is the most likely origin of this lesion?

. Ventral motor root
. Arachnoid cap cells
. Dorsal sensory root
. Ependymal lining
. Pia mater

Correct Answer & Explanation

. Dorsal sensory root

Explanation

Schwannomas are the most common benign nerve sheath tumors in the spine and classically arise from the dorsal (sensory) roots. They frequently grow through the neural foramen, creating a dumbbell shape.

Question 96

Topic: 10. Pathology and Oncology

A 65-year-old man presents with dull, aching lower back pain and bowel dysfunction. Imaging of the sacrum reveals a midline destructive lytic lesion with a large pre-sacral soft tissue mass. Histology demonstrates lobules of large cells with prominent intracytoplasmic vacuoles. Which of the following is the most appropriate treatment?

. Intralesional curettage and bone grafting
. Preoperative chemotherapy followed by curettage
. En bloc wide resection
. Definitive external beam radiation therapy
. Systemic immunotherapy

Correct Answer & Explanation

. En bloc wide resection

Explanation

Chordomas are locally aggressive malignant tumors arising from notochord remnants, classically presenting with physaliferous cells. En bloc wide resection is the treatment of choice to minimize local recurrence.

Question 97

Topic: 10. Pathology and Oncology

A 16-year-old boy presents with severe, progressive back pain that is worse at night and dramatically relieved by ibuprofen. Examination reveals a rigid scoliosis. Radiographs and CT show a 1.2 cm radiolucent nidus with surrounding sclerosis in the left pedicle of T10. The scoliosis convexity is most likely located:

. Away from the side of the lesion
. Toward the side of the lesion
. At the cervicothoracic junction
. Bilateral and alternating
. Independent of the lesion location

Correct Answer & Explanation

. Away from the side of the lesion

Explanation

Osteoid osteomas of the spine classically occur in the posterior elements and cause a painful, rigid scoliosis. The tumor is characteristically located on the concave side of the curve (convexity away from the lesion) due to asymmetric muscle spasm.

Question 98

Topic: Bone Tumors

A 14-year-old girl presents with back pain and a palpable midline mass. Imaging shows a highly expansile, multicystic, radiolucent lesion involving the spinous process and lamina of L2. MRI demonstrates fluid-fluid levels within the cysts. What is the most likely diagnosis?

. Aneurysmal bone cyst
. Unicameral bone cyst
. Osteosarcoma
. Ewing sarcoma
. Hemangioma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts (ABCs) in the spine typically involve the posterior elements and appear as expansile, lytic lesions. MRI classically demonstrates fluid-fluid levels due to blood settling within the cystic spaces.

Question 99

Topic: 10. Pathology and Oncology

A 55-year-old man presents with progressive back pain and lower extremity weakness. Imaging reveals a highly destructive, vascular lesion in the L1 vertebral body causing epidural compression. Biopsy confirms metastatic clear cell renal cell carcinoma. What is the most critical pre-operative step before surgical decompression?

. Neoadjuvant chemotherapy
. Preoperative angiographic embolization
. Bone marrow aspiration
. Methotrexate administration
. Prophylactic inferior vena cava filter

Correct Answer & Explanation

. Preoperative angiographic embolization

Explanation

Renal cell carcinoma and thyroid carcinoma metastases are notoriously hypervascular. Preoperative angiographic embolization is essential to reduce intraoperative blood loss during surgical decompression and stabilization.

Question 100

Topic: 10. Pathology and Oncology

A 60-year-old patient with known metastatic renal cell carcinoma presents with a Bilsky grade 3 epidural spinal cord compression at T8. The patient has mechanical back pain and progressive paraparesis. What is the best treatment paradigm?

. Primary conventional external beam radiation
. Systemic chemotherapy and bisphosphonates
. Surgical separation surgery followed by stereotactic body radiation therapy (SBRT)
. En bloc vertebrectomy
. Hospice care without intervention

Correct Answer & Explanation

. Surgical separation surgery followed by stereotactic body radiation therapy (SBRT)

Explanation

Renal cell carcinoma is radioresistant. For high-grade epidural cord compression (Bilsky grade 3), 'separation surgery' is indicated to decompress the spinal cord and create space, followed by targeted SBRT.

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