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10. Pathology and Oncology MCQs

Practice Set 9 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 161

Topic: 10. Pathology and Oncology

A 70-year-old male on chronic hemodialysis for 15 years develops severe neck pain and destructive lesions at the C5-C6 level on MRI, resembling an infection. Biopsy is negative for infection but reveals beta2-microglobulin amyloid deposition. This condition is known as:

. Charcot spinal arthropathy
. Destructive spondyloarthropathy
. Renal osteodystrophy
. Osteomalacia
. Brown tumor of hyperparathyroidism

Correct Answer & Explanation

. Destructive spondyloarthropathy

Explanation

Destructive spondyloarthropathy is a non-infectious complication seen in patients on long-term hemodialysis, driven by the deposition of beta2-microglobulin amyloid in the discs and facet joints, causing severe destruction mimicking osteomyelitis.

Question 162

Topic: 10. Pathology and Oncology

A spine MRI of an immunocompromised patient with back pain reveals vertebral body destruction sparing the disc space, with multiple small paraspinal abscesses. Biopsy shows broad, non-septate hyphae with right-angle branching. What is the diagnosis?

. Aspergillosis
. Candidiasis
. Mucormycosis
. Coccidioidomycosis
. Cryptococcosis

Correct Answer & Explanation

. Mucormycosis

Explanation

Broad, non-septate hyphae with right-angle branching are pathognomonic for Mucor species. Mucormycosis primarily affects severely immunocompromised patients, notably those with uncontrolled diabetes mellitus or hematologic malignancies.

Question 163

Topic: 10. Pathology and Oncology

In suspected spontaneous pyogenic spondylodiscitis with negative blood cultures, what is the approximate diagnostic yield of a single CT-guided percutaneous needle biopsy?

. 10-20%
. 30-40%
. 50-70%
. 85-95%
. 100%

Correct Answer & Explanation

. 50-70%

Explanation

The diagnostic yield of a single CT-guided needle biopsy for pyogenic spondylodiscitis is generally reported to be between 50% and 70%. If the initial biopsy is negative, repeat percutaneous biopsy or open biopsy may be necessary.

Question 164

Topic: 10. Pathology and Oncology

A patient with suspected native pyogenic vertebral osteomyelitis is hemodynamically stable and neurologically intact. Blood cultures are negative. A CT-guided biopsy is scheduled. What is the correct approach to antibiotic therapy?

. Start broad-spectrum empiric antibiotics immediately
. Wait for preliminary biopsy culture results before initiating antibiotics
. Administer a single prophylactic dose of Vancomycin prior to biopsy
. Start oral antibiotics and upgrade based on biopsy results
. Initiate anti-tuberculous therapy empirically until ruled out

Correct Answer & Explanation

. Wait for preliminary biopsy culture results before initiating antibiotics

Explanation

In a hemodynamically stable and neurologically intact patient with suspected vertebral osteomyelitis and negative blood cultures, antibiotics should be withheld until tissue or fluid is obtained via biopsy to maximize diagnostic yield.

Question 165

Topic: Bone Tumors

In children under the age of 5, what anatomical feature is primarily responsible for the pathophysiology of primary discitis, distinguishing it from adult vertebral osteomyelitis?

. A complete absence of blood supply to the vertebral endplates
. Direct communication between the spinal canal and the disc space
. A persistent notochordal remnant acting as a nidus
. The presence of vascular anastomoses traversing the cartilaginous endplate directly into the nucleus pulposus
. Increased permeability of the annulus fibrosus to venous drainage

Correct Answer & Explanation

. The presence of vascular anastomoses traversing the cartilaginous endplate directly into the nucleus pulposus

Explanation

Pediatric primary discitis occurs due to the presence of blood vessels that cross the cartilaginous endplate to supply the disc space in early childhood. These vessels regress around the age of 7 or 8, making adult isolated discitis rare.

Question 166

Topic: 10. Pathology and Oncology

Which test is most specific for diagnosing spinal column infection:

. White blood count
. Erythrocyte sedimentation rate
. Carbon-reactive protein
. Blood culture
. Biopsy

Correct Answer & Explanation

. Biopsy

Explanation

Vertebral biopsy, either via open or computed tomography-guided means, is most specific even though false-negative rates for closed and open biopsies are 30% and 14%, respectively. A patients white blood count may be normal even in acute spinal infection. Although often elevated, erythrocyte sedimentation rate and carbon-reactive protein are nonspecific tests. Blood cultures are negative in more than 75% of patients.

Question 167

Topic: 10. Pathology and Oncology

A 60-year-old male with a history of prostate cancer presents with a T10 vertebral body collapse and a retropulsed fragment causing acute myelopathy. While differentiating this from a simple thoracic disc herniation, which MRI sequence is most helpful to distinguish tumor from benign osteoporotic collapse?

. T1-weighted imaging with gadolinium enhancement
. T2-weighted fat-suppressed imaging (STIR)
. Diffusion-weighted imaging (DWI)
. Gradient-echo (GRE) sequence
. Proton density imaging

Correct Answer & Explanation

. Diffusion-weighted imaging (DWI)

Explanation

DWI and Apparent Diffusion Coefficient (ADC) maps are highly specific for differentiating malignant from benign vertebral compression fractures. Malignant lesions typically show restricted diffusion.

Question 168

Topic: 10. Pathology and Oncology

A 58-year-old woman with a history of breast cancer presents with progressive mechanical back pain. MRI shows a metastatic lesion at T8. Her Spinal Instability Neoplastic Score (SINS) is calculated to be 15. What does this score indicate regarding her management?

. Indicates a stable lesion suitable for radiation therapy alone
. Indicates a purely osteoblastic lesion
. Indicates spinal instability warranting immediate surgical consultation for stabilization
. Mandates exclusive treatment with bisphosphonates
. Suggests a benign process requiring only observation

Correct Answer & Explanation

. Indicates spinal instability warranting immediate surgical consultation for stabilization

Explanation

The Spinal Instability Neoplastic Score (SINS) evaluates tumor-related spinal instability. A score between 13 and 18 indicates definite spinal instability, warranting surgical consultation for potential stabilization before or concurrently with oncologic treatment.

Question 169

Topic: 10. Pathology and Oncology

A 50-year-old woman with 3 months of low back pain recently discovers a hard, painless lump in her breast. Due to the back discomfort, she undergoes plain radiography and subsequently a computed tomography scan (below). The most likely diagnosis is:

. Osteomyelitis
. Osteoid osteoma
. Fracture
. Herniated nucleus pulposis
. Metastatic disease

Correct Answer & Explanation

. Metastatic disease

Explanation

The computed tomography scan reveals a destructive lesion involving the vertebral body extending into the pedicle in a patient with a suspected breast malignancy. This is a metastatic lesion until proven otherwise. This patient needs a thorough evaluation of her breast lesion, as well as her spine lesion, including biopsies. An osteoid osteoma is seen in a younger population and is seen on a computed tomography scan as a sclerotic round lesion.

Question 170

Topic: 10. Pathology and Oncology

A 35-year-old woman has been complaining of severe unrelenting mid to low back pain for the past 5 months. Conservative management, consisting of bed rest and nonsteroidal anti-inflammatory drugs (NSAIDs), has not decreased the intensity of her symptoms. She immigrated to the United States from Vietnam 6 months ago. Based on the sagittal magnetic resonance image below, the next step in her management is:

. Antibiotics with gram-positive coverage
. Surgical decompression and reconstruction
. Biopsy of the lesion to obtain a specimen for pathology
. C ontinued conservative management and observation
. Physical therapy for low back strengthening

Correct Answer & Explanation

. Biopsy of the lesion to obtain a specimen for pathology

Explanation

It is prudent to determine the underlying etiology of this lesion. Tuberculous spondylitis is increasing in frequency and must be suspected in people who emigrate from countries where tuberculosis is endemic. A biopsy of the region must be obtained in order to make the diagnosis of tuberculosis accurately or any other infectious and noninfectious causative agent in order to determine proper management.

Question 171

Topic: 10. Pathology and Oncology

A 54-year-old diabetic male presents with 3 weeks of worsening back pain, fever, and elevated ESR. Sagittal MRI is provided below. Blood cultures are pending. Neurologically he is intact. What is the most appropriate next step in management?

. Immediate surgical debridement and fusion
. CT-guided needle biopsy
. Empiric broad-spectrum IV antibiotics
. Oral NSAIDs and bed rest
. Epidural steroid injection

Correct Answer & Explanation

. CT-guided needle biopsy

Explanation

In a hemodynamically stable patient with pyogenic spondylodiscitis and no neurologic deficit, establishing a microbiologic diagnosis via CT-guided biopsy is indicated before initiating antibiotics. Empiric antibiotics should only be started immediately if the patient is septic or has profound neurologic decline.

Question 172

Topic: Bone Tumors

A 60-year-old female presents with insidious onset of persistent mid-thoracic back pain, worsened by recumbency. Laboratory results show hypercalcemia and elevated total protein. Radiographs reveal a lytic lesion in the T7 vertebral body. Which of the following is the most likely diagnosis?

. Metastatic breast carcinoma
. Multiple myeloma
. Osteosarcoma
. Chondrosarcoma
. Hemangioma

Correct Answer & Explanation

. Multiple myeloma

Explanation

Multiple myeloma is the most common primary malignancy of bone in adults. It classically presents with bone pain, hypercalcemia, lytic bone lesions, and elevated serum protein due to monoclonal gammopathy.

Question 173

Topic: 10. Pathology and Oncology

A 16-year-old boy presents with painful scoliosis and night pain in his mid-back that is completely relieved by ibuprofen. Radiographs show a mild structural curve but no obvious destructive lesions. What is the most likely location of the suspected pathology?

. Anterior vertebral body
. Pedicle or posterior elements
. Intervertebral disc space
. Epidural space
. Anterior longitudinal ligament

Correct Answer & Explanation

. Anterior vertebral body

Explanation

The clinical presentation is classic for an osteoid osteoma, which frequently causes a painful, rigid scoliosis. These benign, prostaglandin-secreting bone tumors have a strong predilection for the posterior elements (pedicles, lamina, facets) of the spine.

Question 174

Topic: 10. Pathology and Oncology

A 14-year-old boy presents with a painful right-sided thoracic scoliosis. He reports that the pain is worse at night and dramatically improves when he takes ibuprofen. Neurological examination is normal. Radiographs demonstrate a 15-degree right thoracic scoliosis. If this curve is secondary to an underlying benign tumor, where is the lesion most likely located?

. Anterior vertebral body on the convexity of the curve
. Posterior elements (pedicle/lamina) on the concavity of the curve
. Intervertebral disc space at the apex
. Anterior vertebral body on the concavity of the curve
. Posterior elements (pedicle/lamina) on the convexity of the curve

Correct Answer & Explanation

. Posterior elements (pedicle/lamina) on the concavity of the curve

Explanation

The clinical presentation (night pain relieved by NSAIDs) is classic for an osteoid osteoma. In the spine, these lesions typically occur in the posterior elements and cause a painful, rigid scoliosis with the lesion located on the concavity of the curve due to asymmetric muscle spasm.

Question 175

Topic: 10. Pathology and Oncology

A 16-year-old male presents with a painful structural scoliosis. The pain is worse at night and is dramatically relieved by NSAIDs. Radiographs show a right thoracic curve. If an osteoid osteoma is responsible for this deformity, where is the lesion most likely located?

. On the convexity of the curve
. On the concavity of the curve
. At the exact apex of the vertebral body
. In the anterior longitudinal ligament
. Within the intervertebral disc

Correct Answer & Explanation

. On the concavity of the curve

Explanation

Osteoid osteomas in the spine cause severe muscle spasm on the side of the lesion, pulling the spine toward the tumor. Consequently, the lesion is typically found on the concavity of the scoliotic curve.

Question 176

Topic: Soft Tissue Tumors & Metastasis

A 10-year-old girl with Neurofibromatosis type 1 presents with a sharp, angular thoracic kyphoscoliosis (dystrophic curve) and progressive weakness in her hands. MRI shows a solid mass compressing the spinal cord at the apex of the curve. What is the most likely composition of the mass?

. Osteoblastoma
. Neurofibroma
. Meningocele
. Dural ectasia
. Ependymoma

Correct Answer & Explanation

. Neurofibroma

Explanation

In NF-1, sharp, dystrophic kyphoscoliotic curves can be complicated by intraspinal pathology. The most common cause of cord compression in this specific scenario is an enlarging neurofibroma or severe angular deformity.

Question 177

Topic: 10. Pathology and Oncology
A 6-year-old boy presents with a linear area of swelling in the region of the posterior paraspinous muscles. He has no history of weight loss or fevers. He also has bilateral great toe deformities consisting of valgus and shortening. The most likely diagnosis is:
. Multiple hereditary exostoses
. Ewing's sarcoma
. Osteosarcoma
. Fibrodysplasia ossificans progressiva
. Synovial sarcoma

Correct Answer & Explanation

. Fibrodysplasia ossificans progressiva

Explanation

Fibrodysplasia ossificans progressiva is characterized by linear swelling and progressive ossification from a posterior-central origin. Patients also have a characteristic shortened and valgus great toe. The natural history of this disorder is one of progressive ossification, and it eventually impairs nutrition.

Question 178

Topic: 10. Pathology and Oncology

A 7-year-old boy from Massachusetts presents with a massive, painless right knee effusion. He is afebrile and active. Joint aspiration yields a WBC count of 45,000 cells/mm3 (predominantly neutrophils), but Gram stain is negative. What is the most appropriate diagnostic test?

. Fungal cultures
. Synovial fluid PCR for Borrelia burgdorferi
. Serum Borrelia burgdorferi two-tiered serology
. Synovial biopsy for acid-fast bacilli
. Rheumatoid factor and ANA testing

Correct Answer & Explanation

. Serum Borrelia burgdorferi two-tiered serology

Explanation

Lyme arthritis typically presents as a large, relatively painless effusion in an endemic area. Two-tiered serum testing (EIA/IFA followed by Western blot) is the recommended diagnostic approach, as synovial fluid PCR often has lower sensitivity.

Question 179

Topic: 10. Pathology and Oncology

A 12-year-old boy presents with chronic, mild lower leg pain that worsens at night. Radiographs demonstrate a 2 cm radiolucent lesion in the distal tibial metaphysis with a thick rim of reactive sclerosis. Inflammatory markers are normal. What is the most likely diagnosis?

. Ewing sarcoma
. Osteoid osteoma
. Brodie's abscess
. Non-ossifying fibroma
. Chondroblastoma

Correct Answer & Explanation

. Brodie's abscess

Explanation

A Brodie's abscess is a subacute or chronic localized form of osteomyelitis, often presenting with mild symptoms and normal inflammatory markers. It classically appears as a well-defined lytic metaphyseal lesion with a sclerotic rim.

Question 180

Topic: 10. Pathology and Oncology

A 16-year-old male presents with dull, aching pain in his distal tibia for several months, typically worse at night. Radiographs show a well-circumscribed, radiolucent lesion with a thick sclerotic margin in the metaphysis. What is the most likely diagnosis?

. Osteoid osteoma
. Subacute osteomyelitis (Brodie's abscess)
. Non-ossifying fibroma
. Chondroblastoma
. Ewing sarcoma

Correct Answer & Explanation

. Subacute osteomyelitis (Brodie's abscess)

Explanation

A Brodie's abscess is a localized form of subacute or chronic osteomyelitis. It classically presents as a purely lytic metaphyseal lesion with a thick sclerotic rim on radiographs, most commonly affecting the tibia.

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