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10. Pathology and Oncology MCQs

Practice Set 50 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 981

Topic: 10. Pathology and Oncology

A 60-year-old patient with a known history of lung cancer develops new back pain. MRI shows an epidural mass compressing the spinal cord at T10. There is no neurological deficit beyond mild sensory changes. What is the most appropriate treatment strategy for optimal local control and quality of life?

. Emergent surgical decompression and stabilization
. High-dose systemic chemotherapy
. Palliative radiation therapy alone
. Stereotactic body radiation therapy (SBRT)
. Conservative management with analgesics

Correct Answer & Explanation

. Stereotactic body radiation therapy (SBRT)

Explanation

Correct Answer: DFor patients with good performance status, limited epidural compression, and radiosensitive tumors (like lung cancer), SBRT has emerged as a preferred treatment modality. SBRT delivers high-dose, highly conformal radiation in fewer fractions, offering excellent local control with less toxicity compared to conventional external beam radiation, and can often spare patients from extensive surgery, especially if they have mild or no neurological deficits. Emergent surgery is reserved for severe or rapidly progressing neurological deficits, spinal instability, or radioresistant tumors. Conventional radiation is an option but SBRT offers better local control. Chemotherapy is systemic, not primary for local compression, unless very chemosensitive tumor. Conservative management is inappropriate for spinal cord compression.

Question 982

Topic: 10. Pathology and Oncology

Which of the following characteristics is most consistent with a diagnosis of vertebral hemangioma on MRI?

. T1 hypointense, T2 hyperintense lesion with homogeneous enhancement
. T1 hypointense, T2 hyperintense lesion with associated dural tail sign
. T1 hyperintense, T2 hyperintense lesion with characteristic 'polka dot' or 'corduroy' sign on axial and sagittal T1/T2 images, respectively
. T1 hypointense, T2 hypointense lesion with dense sclerotic margins
. Expansile lytic lesion with cortical breach and soft tissue mass

Correct Answer & Explanation

. T1 hyperintense, T2 hyperintense lesion with characteristic 'polka dot' or 'corduroy' sign on axial and sagittal T1/T2 images, respectively

Explanation

Correct Answer: CVertebral hemangiomas are benign vascular tumors of the spine. On MRI, they are characteristically T1 hyperintense and T2 hyperintense due to their high fat content within the vascular channels. The 'polka dot' appearance on axial CT (due to thickened vertical trabeculae separated by fatty marrow) and the 'corduroy' sign on sagittal radiographs are classic, which correlate to high signal areas on MRI. Other options describe meningiomas (dural tail), blastic metastases (sclerotic), or aggressive malignant lesions (expansile lytic).

Question 983

Topic: 10. Pathology and Oncology

What is the most common primary malignant tumor of the spine in adults?

. Osteosarcoma
. Chondrosarcoma
. Chordoma
. Ewing's Sarcoma
. Multiple Myeloma

Correct Answer & Explanation

. Multiple Myeloma

Explanation

Correct Answer: EMultiple Myeloma is the most common primary malignant tumor involving bone in adults, and the spine is a frequently affected site. It is a hematologic malignancy characterized by the proliferation of plasma cells. While chordoma, osteosarcoma, chondrosarcoma, and Ewing's sarcoma are also primary malignant bone tumors of the spine, they are individually much rarer than multiple myeloma. Ewing's sarcoma is more common in adolescents and young adults.

Question 984

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with knee pain and swelling. Radiographs reveal a sunburst periosteal reaction in the distal femoral metaphysis. Biopsy confirms osteosarcoma. What is the standard first-line systemic chemotherapeutic regimen for this condition?

. Ifosfamide and etoposide
. Vincristine, doxorubicin, and cyclophosphamide
. Methotrexate, doxorubicin, and cisplatin (MAP)
. Imatinib mesylate
. Paclitaxel and carboplatin

Correct Answer & Explanation

. Methotrexate, doxorubicin, and cisplatin (MAP)

Explanation

The standard neoadjuvant and adjuvant chemotherapy regimen for high-grade osteosarcoma consists of Methotrexate, Doxorubicin (Adriamycin), and Cisplatin (MAP). Vincristine, doxorubicin, and cyclophosphamide are typically utilized for Ewing sarcoma.

Question 985

Topic: 10. Pathology and Oncology
A 45-year-old poorly controlled diabetic presents with exquisite pain in his lower leg out of proportion to exam findings, massive swelling, and advancing erythema. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is 8. Which of the following is the most critical next step in management?
. STAT MRI of the lower extremity with IV contrast
. Broad-spectrum IV antibiotics and close observation
. Immediate surgical exploration and radical fascial debridement
. Hyperbaric oxygen therapy
. Incisional biopsy for frozen section

Correct Answer & Explanation

. Immediate surgical exploration and radical fascial debridement

Explanation

Necrotizing fasciitis is a rapid, life-threatening surgical emergency. Immediate surgical exploration and radical debridement should never be delayed for advanced imaging in patients with high clinical suspicion.

Question 986

Topic: 10. Pathology and Oncology

An 11-year-old boy presents with progressive knee pain. Radiographs reveal a metaphyseal, mixed lytic and sclerotic lesion in the distal femur with a "sunburst" periosteal reaction.

Biopsy confirms high-grade conventional osteosarcoma. What is the standard of care for treatment?

. Wide surgical resection alone
. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy
. Radiation therapy followed by wide surgical resection
. Neoadjuvant chemotherapy and radiation therapy
. Amputation followed by radiation therapy

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy

Explanation

The standard treatment for high-grade, conventional osteosarcoma is neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage or amputation), and adjuvant chemotherapy. Osteosarcoma is generally considered radioresistant.

Question 987

Topic: 10. Pathology and Oncology

A 14-year-old girl presents with deep thigh pain and a palpable soft tissue mass. Radiographs show a permeative lytic lesion in the diaphysis of the femur with a prominent "onion skin" periosteal reaction. Genetic testing of the biopsy specimen is most likely to reveal which of the following translocations?

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

Correct Answer & Explanation

. t(11;22)

Explanation

This patient has Ewing sarcoma, classically associated with the t(11;22)(q24;q12) chromosomal translocation. This creates the EWS-FLI1 fusion protein, which acts as an aberrant transcription factor driving oncogenesis.

Question 988

Topic: 10. Pathology and Oncology

A 32-year-old female presents with activity-related knee pain. Radiographs reveal an eccentric, lytic lesion in the distal femoral epiphysis extending to the subchondral bone without a sclerotic margin. Histology shows multinucleated giant cells in a background of neoplastic mononuclear stromal cells. What is the standard first-line surgical treatment?

. Wide en bloc resection and modular endoprosthetic reconstruction
. Extended intralesional curettage, high-speed burring, and defect filling with bone cement
. Preoperative radiation followed by marginal excision
. Amputation
. Core needle biopsy followed by observation

Correct Answer & Explanation

. Extended intralesional curettage, high-speed burring, and defect filling with bone cement

Explanation

Giant cell tumors of bone are locally aggressive but generally benign. The standard treatment is extended intralesional curettage utilizing a high-speed burr and chemical/thermal adjuvants, followed by filling the defect with PMMA (bone cement).

Question 989

Topic: 10. Pathology and Oncology

A 15-year-old male presents with right distal femur pain. Radiographs reveal a metaphyseal lesion with a 'sunburst' periosteal reaction and Codman's triangle. Which of the following is the most appropriate management sequence?

. Wide surgical resection alone
. Neoadjuvant chemotherapy followed by wide surgical resection and adjuvant chemotherapy
. Radiation therapy followed by wide surgical resection
. Intralesional curettage, bone grafting, and adjuvant chemotherapy
. Amputation followed by radiation therapy

Correct Answer & Explanation

. Neoadjuvant chemotherapy followed by wide surgical resection and adjuvant chemotherapy

Explanation

Osteosarcoma is a highly malignant bone tumor typically requiring neoadjuvant chemotherapy, wide surgical margins, and adjuvant chemotherapy. This multimodal approach has significantly improved long-term survival rates compared to surgery alone.

Question 990

Topic: 10. Pathology and Oncology

A 35-year-old male with a history of intravenous drug use presents with severe back pain, fever, and an ESR of 95 mm/hr. MRI of the lumbar spine reveals fluid in the L3-L4 disc space with marrow edema in the adjacent vertebral bodies. Blood cultures are negative, and the patient is neurologically intact. What is the most appropriate next step in management?

. Immediate initiation of broad-spectrum intravenous antibiotics
. CT-guided needle biopsy of the disc space and endplates
. Emergent anterior debridement and interbody fusion
. Posterior laminectomy and epidural washout
. Outpatient prescription for 6 weeks of oral ciprofloxacin

Correct Answer & Explanation

. CT-guided needle biopsy of the disc space and endplates

Explanation

In a neurologically intact patient with suspected discitis/osteomyelitis and negative blood cultures, a CT-guided biopsy should be performed before initiating antibiotics to maximize the chance of identifying the causative organism. Starting empiric antibiotics prematurely can lead to negative cultures and difficult long-term management.

Question 991

Topic: 10. Pathology and Oncology
During surgical debridement of a Gustilo-Anderson Grade IIIa open tibial fracture, the orthopedic surgeon encounters muscle tissue that is dark, lacks contractility, and does not bleed when cut. Based on the principles outlined in the case, what is the appropriate management for this muscle tissue?
. Leave it in situ and reassess in 24-48 hours.
. Excise it immediately as it is non-viable and implicated in infection.
. Irrigate it extensively with saline and apply a vacuum-assisted closure (VAC) device.
. Perform a biopsy to determine viability before making a decision.
. Cauterize the tissue to prevent further bleeding and contamination.

Correct Answer & Explanation

. Excise it immediately as it is non-viable and implicated in infection.

Explanation

Non-viable skin should be excised, but any skin that is of dubious viability may be left for later assessment/debridement, unlike necrotic muscle which is implicated in infection and must be removed. The description of the muscle tissue (colour, consistency, contractility, cut) aligns with the criteria used to assess muscle viability, indicating that it is necrotic. Necrotic muscle is a nidus for infection and must be removed during debridement.

Question 992

Topic: 10. Pathology and Oncology

A 52-year-old woman with a painful MOM hip resurfacing undergoes further imaging after elevated metal ion levels. The MRI scan with metal artifact reduction sequences (MARS) is shown below. Based on the images and the case, what is the most appropriate immediate next step in management?

. Initiate a course of anti-inflammatory medication and monitor symptoms.
. Refer for physical therapy to improve hip range of motion and strength.
. Schedule urgent revision surgery to the hip.
. Perform a biopsy of the mass to confirm the diagnosis of pseudotumour.
. Continue close observation with serial metal ion level measurements.

Correct Answer & Explanation

. Schedule urgent revision surgery to the hip.

Explanation

Correct Answer: CThe MRI (Figures 2.5a and 2.5b) demonstrates an intra-pelvic mass, which the examiner confirms was a pseudotumour, palpable clinically. When asked 'What are you going to do?', the candidate responds: 'This patient requires urgent revision surgery to the hip.' The candidate further stresses 'the importance of early revision surgery as the longer the MOM resurfacing implant is left in place the more extensive the soft tissue destruction will most likely be.'Option A and B are incorrect as conservative management is not appropriate for a symptomatic pseudotumour, especially one that is palpable and confirmed by MRI.Option D is incorrect. While a biopsy could confirm the diagnosis histologically, the clinical presentation, elevated metal ions, and characteristic MRI findings are sufficient for diagnosis and the case indicates immediate surgical intervention is required, not further diagnostic delay.Option E is incorrect. The patient has a confirmed, symptomatic pseudotumour. Continuing observation would delay necessary treatment and potentially lead to more extensive soft tissue destruction, as highlighted by the candidate.

Question 993

Topic: 10. Pathology and Oncology

A 16-year-old male presents with persistent knee pain, swelling, and a palpable mass in the distal femur. Radiographs show a lytic, destructive lesion with a 'sunburst' periosteal reaction and Codman's triangle in the metaphysis of the distal femur. A biopsy confirms osteosarcoma. Which of the following is the most important prognostic factor for this patient?

. Patient's age at diagnosis
. Location of the tumor (distal femur vs. proximal tibia)
. Response to neoadjuvant chemotherapy
. Presence of pulmonary metastases at diagnosis
. Tumor size

Correct Answer & Explanation

. Response to neoadjuvant chemotherapy

Explanation

Correct Answer: DThe most important prognostic factor in osteosarcoma is the response to neoadjuvant chemotherapy (percentage of tumor necrosis). A good histological response (typically >90% necrosis) is strongly correlated with improved overall survival and decreased recurrence rates. While the presence of pulmonary metastases at diagnosis (Stage IV disease) is a very poor prognostic indicator, theresponse to chemotherapyis a dynamic and critical factor in determining the effectiveness of treatment and guiding subsequent surgical and adjuvant therapy. Age, tumor location, and tumor size are less significant than the chemotherapy response.

Question 994

Topic: 10. Pathology and Oncology

A 68-year-old female with known Paget's disease presents with a new, rapidly enlarging, painful mass in her right proximal humerus. Radiographs show a destructive, permeative lesion with a wide zone of transition. What is the most likely diagnosis?

. Chondrosarcoma
. Multiple myeloma
. Osteosarcoma
. Ewing sarcoma
. Metastatic carcinoma

Correct Answer & Explanation

. Osteosarcoma

Explanation

Osteosarcoma is the most common and devastating secondary malignancy arising in Pagetic bone, occurring in approximately 1% of patients. It typically presents with new-onset, severe pain and a rapidly enlarging mass.

Question 995

Topic: Bone Tumors

Which of the following pathognomonic radiographic signs is most characteristic of the advancing osteolytic wedge seen in the long bones of patients with Paget's disease?

. Sunburst periosteal reaction
. Blade of grass sign
. Nidus with surrounding sclerosis
. Shepherd's crook deformity
. Erlenmeyer flask deformity

Correct Answer & Explanation

. Blade of grass sign

Explanation

The "blade of grass" or "flame" sign represents the advancing V-shaped radiolucent edge of osteolysis in the long bones during the early lytic phase of Paget's disease.

Question 996

Topic: 10. Pathology and Oncology

A 65-year-old with long-standing Paget's disease presents with severe, new-onset progressive thigh pain. Radiographs demonstrate a destructive, lytic lesion in the femur with cortical breakthrough.

What is the most likely diagnosis?

. Multiple myeloma
. Chondrosarcoma
. Secondary osteosarcoma
. Ewing sarcoma
. Metastatic prostate cancer

Correct Answer & Explanation

. Secondary osteosarcoma

Explanation

A new, painful, destructive lytic lesion in a patient with a history of Paget's disease is highly suspicious for malignant transformation. The most common malignancy is secondary osteosarcoma, which carries a very poor prognosis.

Question 997

Topic: 10. Pathology and Oncology

A 78-year-old man with a 20-year history of polyostotic Paget's disease presents with a rapid onset of severe, unrelenting left hip pain. Radiographs reveal a new, aggressive lytic lesion in the left ilium with cortical destruction. What is the most likely diagnosis?

. Chondrosarcoma
. Ewing sarcoma
. Secondary osteosarcoma
. Multiple myeloma
. Metastatic prostate cancer

Correct Answer & Explanation

. Secondary osteosarcoma

Explanation

Malignant transformation occurs in approximately 1% of patients with Paget's disease, most commonly presenting as a highly aggressive secondary osteosarcoma. This complication must be suspected when a patient with Paget's develops sudden, severe pain and new destructive radiographic changes.

Question 998

Topic: 10. Pathology and Oncology

A 68-year-old male with a long-standing history of Paget's disease presents with a 3-month history of severe, unrelenting left thigh pain that wakes him up at night. Radiographs demonstrate a new, ill-defined destructive lytic lesion with cortical breakthrough within an area of thickened pagetic bone. What is the most likely diagnosis?

. Metastatic prostate carcinoma
. Secondary osteosarcoma
. Multiple myeloma
. Ewing sarcoma
. Chondrosarcoma

Correct Answer & Explanation

. Secondary osteosarcoma

Explanation

Secondary osteosarcoma is a rare but highly aggressive complication of Paget's disease (accounting for roughly 1% of patients). It typically presents with new, severe pain in previously stable pagetic bone and demonstrates destructive features on radiographs.

Question 999

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with a permeative lytic lesion in the diaphysis of his femur with an associated onion-skin periosteal reaction. Cytogenetic analysis reveals a t(11;22) translocation. Which of the following fusion proteins is highly characteristic of this tumor?

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

Correct Answer & Explanation

. EWS-FLI1

Explanation

The clinical and radiographic presentation is classic for Ewing sarcoma. The t(11;22) chromosomal translocation is found in approximately 85% of Ewing sarcomas and results in the EWS-FLI1 fusion protein.

Question 1000

Topic: 10. Pathology and Oncology

A 15-year-old male presents with persistent knee pain. Radiographs demonstrate a destructive, mixed lytic and sclerotic lesion in the distal femoral metaphysis with a sunburst periosteal reaction. Core needle biopsy confirms high-grade intramedullary osteosarcoma. What is the standard sequence of treatment?

. Primary amputation followed by radiation therapy
. Primary wide surgical resection alone
. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy
. Neoadjuvant radiation therapy followed by wide surgical resection
. Adjuvant chemotherapy followed by wide surgical resection

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy

Explanation

The standard of care for high-grade osteosarcoma is neoadjuvant (preoperative) chemotherapy, followed by wide surgical resection (limb salvage or amputation), and then adjuvant (postoperative) chemotherapy. Radiation plays a minimal role because osteosarcoma is highly radioresistant.

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