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10. Pathology and Oncology MCQs

Practice Set 8 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 141

Topic: Bone Tumors

A 15-year-old girl presents with progressive back pain. Imaging shows an expansile, multiloculated, osteolytic lesion in the posterior elements of L3. MRI demonstrates distinct fluid-fluid levels within the lesion. What is the most likely diagnosis?

. Simple bone cyst
. Aneurysmal bone cyst
. Osteoblastoma
. Giant cell tumor
. Chondroblastoma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts (ABCs) in the spine classically involve the posterior elements in adolescents. The hallmark MRI finding is fluid-fluid levels representing blood products of different ages.

Question 142

Topic: 10. Pathology and Oncology

Which of the following primary spine tumors typically arises from remnants of the primitive notochord?

. Ependymoma
. Chordoma
. Osteoblastoma
. Chondrosarcoma
. Ewing sarcoma

Correct Answer & Explanation

. Chordoma

Explanation

Chordomas arise from embryonic notochordal remnants. They occur most frequently at the ends of the axial skeleton, specifically the sacrococcygeal region and the spheno-occipital skull base.

Question 143

Topic: Bone Tumors

A 50-year-old patient with known multiple myeloma presents with severe, localized thoracic back pain. Plain films show a compression fracture of T8 without retropulsion, and MRI shows no neural compression. The patient has failed 6 weeks of conservative management. What is the most appropriate intervention for pain relief?

. Open reduction and internal fixation
. Kyphoplasty or Vertebroplasty
. Laminectomy
. En bloc vertebrectomy
. Intrathecal morphine pump

Correct Answer & Explanation

. Kyphoplasty or Vertebroplasty

Explanation

In cases of painful pathologic vertebral compression fractures without neural element compression that fail conservative care, vertebral augmentation (kyphoplasty or vertebroplasty) provides excellent and rapid pain relief.

Question 144

Topic: 10. Pathology and Oncology

A 25-year-old female presents with a sacral mass. Biopsy reveals mononuclear stromal cells and uniformly distributed multinucleated giant cells. The stromal cells represent the neoplastic component. What is the most common spinal location for this tumor?

. Cervical vertebral body
. Thoracic posterior elements
. Lumbar pedicle
. Sacrum
. Coccyx

Correct Answer & Explanation

. Sacrum

Explanation

The histology describes a Giant Cell Tumor (GCT) of bone. When GCTs occur in the spine, the sacrum is by far the most common location.

Question 145

Topic: Soft Tissue Tumors & Metastasis

Which of the following genetic syndromes is most strongly associated with the development of multiple spinal hemangioblastomas?

. Neurofibromatosis Type 1
. Neurofibromatosis Type 2
. Von Hippel-Lindau disease
. Tuberous Sclerosis
. Li-Fraumeni syndrome

Correct Answer & Explanation

. Von Hippel-Lindau disease

Explanation

Von Hippel-Lindau (VHL) disease is an autosomal dominant condition characterized by the formation of multiple hemangioblastomas in the central nervous system, including the brain and spinal cord, as well as renal cell carcinomas.

Question 146

Topic: Bone Tumors
A 68-year-old man presents with a pathologic fracture of the L4 vertebra. Laboratory evaluation reveals a monoclonal spike on serum protein electrophoresis and hypercalcemia. Which of the following radiographic features is typically absent in this disease process?
. Lytic bone lesions
. Osteopenia
. Reactive bone sclerosis
. Vertebral body collapse
. Cold spots on a bone scan

Correct Answer & Explanation

. Reactive bone sclerosis

Explanation

Multiple myeloma is characterized by purely lytic lesions without reactive bone sclerosis. Because there is no osteoblastic response, bone scans are typically "cold" or false-negative in myeloma.

Question 147

Topic: 10. Pathology and Oncology

What is the classic neurological presentation differentiating an intramedullary spinal tumor from an extramedullary spinal tumor early in the disease course?

. Intramedullary tumors present early with severe radicular pain
. Intramedullary tumors present with a dissociated sensory loss
. Extramedullary tumors present with descending motor weakness
. Extramedullary tumors typically spare the corticospinal tracts
. Intramedullary tumors cause early unilateral hyperreflexia

Correct Answer & Explanation

. Intramedullary tumors present with a dissociated sensory loss

Explanation

Intramedullary tumors often damage the crossing spinothalamic tracts centrally, leading to a dissociated sensory loss (loss of pain and temperature with preserved light touch and proprioception). Extramedullary tumors typically present first with radicular pain due to nerve root compression.

Question 148

Topic: 10. Pathology and Oncology

A 45-year-old patient with breast cancer develops multilevel blastic and lytic spinal metastases. She is neurologically intact but complains of severe mechanical back pain upon standing, which is entirely relieved by lying down. Radiographs show instability at L2-L3. What is the most appropriate management?

. Radiation therapy alone
. High-dose corticosteroids
. Spinal stabilization surgery
. Chemotherapy alone
. Physical therapy and bracing

Correct Answer & Explanation

. Spinal stabilization surgery

Explanation

Mechanical back pain in the setting of metastatic disease with overt spinal instability is a structural problem that does not respond to radiation or systemic therapy. Surgical stabilization is required to allow upright mobilization and relieve pain.

Question 149

Topic: 10. Pathology and Oncology

The distinguishing phenotypic feature that differentiates a schwannoma from a neurofibroma is:

. The consistently hard and irregular surface of a schwannoma tumor
. The lack of a capsule around a neurofibroma tumor
. The presence of a dissection plane between the tissue and a schwannoma tumor
. Distinctly differing locations of occurrence along the spinal axis
. There is no phenotypic distinguishing characteristic that differentiates a schwannoma from a neurofibroma.

Correct Answer & Explanation

. The presence of a dissection plane between the tissue and a schwannoma tumor

Explanation

Nerve sheath tumors account for 25% of intradural spinal cord tumors in adults and can be further broken down into either schwannomas or neurofibromas. Schwannomas are more common than neurofibromas, most commonly occurring in patients 30 to 50 years of age, equally between the sexes. Most schwannomas arise in the dorsal nerve root. Neurofibromas, however, have a predilection to the ventral root. Both tumors primarily are intradural but as many as 10% to 15% can escape through the dura to form a dumbbell shape and exist as both an intradural and extradural tumor. Histologically, fibrous tissue and nerve fibers make up a neurofibroma. Grossly, neurofibromas appear as a fusiform enlargement of the nerve, making a clear distinction between tumor and nerve impossible. Macroscopically, schwannomas look like smooth globoid masses sitting on the nerve fiber and a clear resection plane is apparent.

Question 150

Topic: 10. Pathology and Oncology
What is the advantage of performing a magnetic resonance image (MRI) to evaluate spinal tumors?
. The post-contrast enhancement pattern is sensitive and specific in diagnosing malignant tumors.
. The diagnosis is often made based on imaging location of a tumor, thus avoiding the need for invasive tissue diagnosis.
. Magnetic resonance imaging is more sensitive than computed tomography (CT) myelography.
. Magnetic resonance imaging has no advantage as a diagnostic tool in evaluating spinal cord lesions.
. Magnetic resonance imaging is a helpful, adjunct diagnostic tool that can elucidate characteristics of spinal cord lesions and help narrow the differential diagnosis.

Correct Answer & Explanation

. Magnetic resonance imaging is a helpful, adjunct diagnostic tool that can elucidate characteristics of spinal cord lesions and help narrow the differential diagnosis.

Explanation

Although diagnosis and localization of spinal column tumors depends on a patient's history and physical examination, differentiation of intramedullary versus extramedullary location of a tumor relies primarily on image findings. The most common imaging modality is MRI. Lesion signal abnormalities, cerebral spinal fluid (CSF) capping, and cord or cauda equina displacement signify extramedullary masses, even without contrast. Gadolinium enhancement increases the sensitivity of the MRI, as almost all spinal cord tumors demonstrate some contrast enhancement. Although more sensitive than MRI, myelography and postmyelography CT are rarely used initially due to their invasive nature.

Question 151

Topic: Bone Tumors

A 45-year-old male presents with a spontaneous L1 compression fracture. He has no history of trauma, long-term steroid use, or known systemic medical conditions. What is the most critical next step in his medical workup?

. Routine Dual-energy X-ray absorptiometry (DEXA) scan only
. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)
. Genetic testing for COL1A1 mutations
. Serum calcitonin and carcinoembryonic antigen (CEA) levels
. HLA-B27 antigen testing

Correct Answer & Explanation

. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)

Explanation

A spontaneous vertebral compression fracture in a young or middle-aged male is highly suspicious for a secondary cause, particularly multiple myeloma. SPEP and UPEP are essential initial screening tools in this demographic.

Question 152

Topic: 10. Pathology and Oncology

An 80-year-old male presents with acute back pain. Imaging shows a pathological vertebral compression fracture.

Which of the following MRI findings is most indicative of a malignant compression fracture rather than a benign osteoporotic fracture?

. A straight or concave posterior vertebral body margin
. Involvement of the pedicle and posterior elements
. Bone marrow edema isolated to the anterior aspect of the vertebral body
. T2 hyperintensity confined strictly to the vertebral body
. Co-existing Schmorl's nodes

Correct Answer & Explanation

. Involvement of the pedicle and posterior elements

Explanation

Malignant compression fractures typically demonstrate pedicle or posterior element involvement, a convex (bulging) posterior vertebral body margin, and complete marrow replacement. Benign fractures typically spare the pedicles.

Question 153

Topic: Bone Tumors

A 68-year-old female presents with progressively worsening back pain 3 months after a minor fall. Radiographs show a T12 compression fracture with an intravertebral vacuum cleft that enlarges on an extension view. What is the most likely diagnosis?

. Multiple myeloma
. Kummell disease
. Vertebral osteomyelitis
. Discitis
. Paget disease

Correct Answer & Explanation

. Kummell disease

Explanation

Kummell disease is delayed post-traumatic avascular necrosis of a vertebral body following an ischemic insult. It is classically associated with an intravertebral vacuum cleft that dynamically changes in size with flexion and extension.

Question 154

Topic: 10. Pathology and Oncology

During the evaluation of a thoracic compression fracture, distinguishing between an osteoporotic etiology and a neoplastic process is critical. Which of the following radiographic findings is highly suspicious for a neoplastic etiology?

. Sparing of the pedicles
. Destruction of the pedicle
. Anterior wedging of the vertebral body
. Intravertebral vacuum cleft
. Generalized decreased bone mineral density

Correct Answer & Explanation

. Destruction of the pedicle

Explanation

Osteoporotic compression fractures typically spare the posterior elements, including the pedicles. Pedicle destruction, visible as the 'winking owl' sign on an AP radiograph, strongly suggests a metastatic or primary neoplastic process.

Question 155

Topic: 10. Pathology and Oncology



An elderly patient presents with severe back pain and the characteristic radiographic finding shown. Advanced imaging confirms a fluid-filled cleft within the vertebral body. Which of the following best explains the pathogenesis of this specific finding?

. Pyogenic infection of the intervertebral disc
. Avascular necrosis of the vertebral body
. Primary bone malignancy of the posterior elements
. Metastatic prostate cancer osteoblastic response
. Severe osteomalacia

Correct Answer & Explanation

. Avascular necrosis of the vertebral body

Explanation

The presence of an intravertebral vacuum cleft characterizes Kummell disease. This represents delayed avascular necrosis of the vertebral body, resulting from an ischemic insult following a prior compression fracture.

Question 156

Topic: Bone Tumors

When evaluating a patient with a suspected atraumatic osteoporotic compression fracture, obtaining which of the following laboratory values is critical to rule out multiple myeloma as a secondary cause?

. Alkaline phosphatase
. Serum protein electrophoresis (SPEP)
. C-reactive protein
. Thyroid stimulating hormone
. Prostate specific antigen

Correct Answer & Explanation

. Serum protein electrophoresis (SPEP)

Explanation

Multiple myeloma frequently presents with osteolytic lesions and pathological compression fractures that mimic osteoporotic fractures. Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) are essential screening tests to identify the characteristic monoclonal gammopathy.

Question 157

Topic: 10. Pathology and Oncology

A 72-year-old male with a history of prostate cancer presents with a T8 compression fracture. Which of the following MRI findings most strongly suggests a pathologic fracture rather than a benign osteoporotic fracture?

. Coexisting fractures at other thoracic levels
. Preserved pedicle signal on T1-weighted images
. Convex posterior vertebral body border with epidural extension
. Band-like edema adjacent to the fractured endplate
. Presence of an intravertebral vacuum cleft

Correct Answer & Explanation

. Convex posterior vertebral body border with epidural extension

Explanation

Pathologic fractures commonly feature a convex bulging of the posterior vertebral margin, epidural mass extension, and involvement of the pedicle. Benign osteoporotic fractures typically exhibit retropulsion with a straight or concave posterior margin and band-like subchondral edema.

Question 158

Topic: 10. Pathology and Oncology
A 45-year-old woman has pain in her right upper extremity and neck. The plain film is presented (Slide 1) as well as an axial post myelogram CT images (Slide 2, A & B). Her pain has not responded to nonsteroidal anti-inflammatory drugs or physical therapy. Which of the following is the most appropriate treatment?
. Needle aspiration of the C4-C5 intervertebral space
. 6-week course of antibiotics and bracing
. Needle biopsy of C4 or C5
. Mammography and technetium bone scan
. Anterior cervical diskectomy

Correct Answer & Explanation

. Anterior cervical diskectomy

Explanation

The axial post myelogram CT image shows a disk herniation, and the sagittal view shows prominent osteophytes. There is no evidence of an infection or a neoplasm. This patient is a candidate for anterior diskectomy and fusion.

Question 159

Topic: 10. Pathology and Oncology

Computerized tomography scans are efficacious for detecting which of the following conditions:

. Marrow changes
. Lytic lesion suspected on Plain L spine film
. Intrathecal abnormalities
. Instability patterns
. Intervertebral disk hydration

Correct Answer & Explanation

. Lytic lesion suspected on Plain L spine film

Explanation

Computerized tomography scans are excellent for assessing bone structure, especially in patients with metastatic bone disease and primary bone tumors of the spine. C omputerized tomography is useful for distinguishing between bone and soft tissue compression in neural compressive disorders.

Question 160

Topic: 10. Pathology and Oncology

A patient with established pyogenic vertebral osteomyelitis on MRI undergoes a CT-guided needle biopsy of the affected disc space, which returns negative for bacterial growth. What is the next most appropriate step in management if the patient remains hemodynamically stable but symptomatic?

. Start empiric broad-spectrum antibiotics immediately.
. Repeat the CT-guided biopsy or proceed to open biopsy.
. Perform an immediate anterior spinal fusion.
. Administer a course of high-dose oral corticosteroids.
. Discharge the patient with a 6-week course of oral antibiotics.

Correct Answer & Explanation

. Repeat the CT-guided biopsy or proceed to open biopsy.

Explanation

If initial cultures from a CT-guided biopsy are negative, a repeat CT-guided biopsy or an open/endoscopic biopsy is recommended before starting antibiotics, to ensure targeted antimicrobial therapy and prevent resistance.

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