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10. Pathology and Oncology MCQs

Practice Set 99 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 1961

Topic: 10. Pathology and Oncology

A 7-year-old girl has had a painful forearm for the past 2 months. Examination reveals fullness on the volar aspect of the forearm. Radiographs and an MRI scan are shown in Figures 42a through 42c. Biopsy specimens are shown in Figures 42d and 42e. What is the most likely diagnosis?

. Synovial sarcoma
. Liposarcoma
. Rhabdomyosarcoma
. Hemangioma
. Wilm's tumor

Correct Answer & Explanation

. Hemangioma

Explanation

The radiographs reveal phleboliths on the volar side of the forearm consistent with hemangioma. The MRI scan reveals a rather well-circumscribed in size, irregular in shape, intramuscular soft-tissue mass in the volar aspect of the distal right forearm within the flexor group musculature. The mass demonstrates heterogeneous mixed signal intensity in both T1- and T2-weighted sequences with increased signal intensity on the T1, suggesting fat within the tumor, typical of hemangioma. The postgadolinium-enhanced sequences demonstrate heterogeneous enhancement. The MRI findings are consistent with a soft-tissue hemangioma. Garzon M: Hemangiomas: Update on classification, clinical presentation and associate anomalies. Cutis 2000;66:325-328.

Question 1962

Topic: 10. Pathology and Oncology

A 45-year-old man reports right shoulder pain with overhead activities only. Figures 47a through 47d show the radiographs, bone scan, and MRI scan of a lesion of the proximal shoulder. What is the most appropriate treatment?

. Needle biopsy
. Incisional biopsy
. Curettage and grafting
. Observation
. En bloc resection

Correct Answer & Explanation

. Observation

Explanation

The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T2-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 1963

Topic: 10. Pathology and Oncology

An otherwise healthy 45-year-old man has a 3-cm subcutaneous mass on his anterior thigh that is presumed to be a lipoma. Removal of the mass is performed in the office of his primary care physician. Pathologic evaluation shows a high-grade malignant fibrous histiocytoma. Staging reveals no evidence of metastatic disease. Management at this time should consist of

. resection of the biopsy site and tumor bed, including the deep fascia and a portion of underlying muscle, and skin grafting.
. resection of the anterior compartment of the thigh and rotational flap, followed by radiation therapy.
. radiation therapy.
. chemotherapy and radiation therapy.
. observation.

Correct Answer & Explanation

. resection of the biopsy site and tumor bed, including the deep fascia and a portion of underlying muscle, and skin grafting.

Explanation

Resection of a previously excised soft-tissue sarcoma is recommended. Reoperation is recommended after removal of malignant tumors previously believed to be benign, as approximately one half of the patients will have residual tumor in the re-excised specimen. Observation is not indicated in most patients because local recurrence is likely. Radiation therapy alone may result in long-term local control but is felt to be less effective than reoperation. Chemotherapy and radiation therapy alone are not recommended. Wide excision is the most important factor for local disease control. Radiation therapy after surgical re-excision may also decrease the risk of local recurrence. Peabody TD, Monson D, Montag A, Schell MJ, Finn H, Simon MA: A comparison of the prognoses for deep and subcutaneous sarcomas of the extremities. J Bone Joint Surg Am 1994;76:1167-1173. Giuliano AE, Eilber FR: The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas. J Clin Oncol 1985;3:1344-1348. Lewis JJ, Leung D, Espat J, Woodruff JM, Brennan MF: Effect of resection in extremity soft tissue sarcoma. Ann Surg 2000;231:655-663.

Question 1964

Topic: 10. Pathology and Oncology

An 80-year-old woman notes a painless mass posterior to her left knee. MRI scans are shown in Figures 31a and 31b. What is the best course of action?

. Observation
. Medical management
. Needle biopsy
. Incisional biopsy
. Resection

Correct Answer & Explanation

. Observation

Explanation

The MRI scans show a popliteal cyst (Baker's cyst) in its most common location. The cyst emerges from the knee joint between the medial head of the gastrocnemius muscle and the tendon of the semimembranosus muscle. These images are diagnostic; therefore, no further work-up is indicated. Since the patient is asymptomatic, no treatment is necessary. Dlabach JA: Nontraumatic soft tissue disorders, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. Philidelphia, PA, Mosby, 2003, vol 1, pp 885-969.

Question 1965

Topic: 10. Pathology and Oncology

A 40-year-old man has a palpable mass over the dorsum of the ankle. He reports no history of direct trauma but notes that he sustained a laceration to the middle of his leg 6 weeks ago. Examination reveals a 4-cm x 1-cm mass. T1- and T2-weighted MRI scans are shown in Figures 12a and 12b. An intraoperative photograph and biopsy specimen are shown in Figures 12c and 12d. What is the most likely diagnosis?

. Giant cell tumor of the tendon sheath
. Gouty tophi
. Aggressive fibromatosis
. Tendon rupture
. Synovial cell sarcoma

Correct Answer & Explanation

. Tendon rupture

Explanation

The findings are most consistent with a rupture of the anterior tibial tendon. The damaged area of tendon should be resected, followed by tendon reconstruction or tenodesis. The histology is not consistent with giant cell tumor of the tendon sheath, gout, or synovial sarcoma. Fibromatosis is characterized by a large number of spindle cells within the collagen background. Otte S, Klinger HM, Loreaz F, Haerer T: Operative treatment in case of closed rupture of the anterior tibial tendon. Arch Orthop Traum Surg 2002;122:188-190.

Question 1966

Topic: 10. Pathology and Oncology

Figures 5a and 5b show the radiograph and MRI scan of a patient who has severe mechanical neck pain but no neurologic problems. Biopsy and work-up show the lesion to be a solitary plasmacytoma. Treatment should consist of

. radiation therapy alone.
. en bloc resection and anterior fusion.
. chemotherapy and bone marrow transplant.
. posterior occipitocervical fusion and radiation therapy.
. en bloc anterior resection followed by posterior occipitocervical fusion.

Correct Answer & Explanation

. en bloc anterior resection followed by posterior occipitocervical fusion.

Explanation

Plasmacytoma is very sensitive to radiation therapy and given the complexity of the resection and complications of surgery in the given location, radiation therapy is preferred. However, the patient has clear loss of bony structural integrity, and resultant instability would persist even with tumor irradiation; therefore, posterior stabilization is warranted. Chemotherapy and bone marrow transplant are reserved for systemic disease with multiple myeloma. Corwin J, Lindberg RD: Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to multiple myeloma. Cancer 1979;43:1007-1013.

Question 1967

Topic: 10. Pathology and Oncology

A 64-year-old man with a history of metastatic lung cancer reports increasing right hip pain over the period of several months. Radiographs are shown in Figures 3a and 3b. Initial management should consist of

. intramedullary fixation.
. radiation therapy.
. embolization.
. segmental resection and proximal femoral replacement.
. chemotherapy.

Correct Answer & Explanation

. intramedullary fixation.

Explanation

The patient has lung cancer metastatic to the right proximal femur. The lesion is large, has destroyed a portion of the cortex, and involves the peritrochanteric region. All of these findings put the patient at high risk for pathologic fracture. The lesion is amenable to intramedullary fixation in the form of some type of reconstruction nail. Chemotherapy alone will not restore the bone stock. Given the extent of the lesion, radiation therapy, chemotherapy, or embolization will not prevent fracture. A proximal femoral replacement would be indicated in patients with bone destruction extending into the femoral head and neck. Bisphosphonates may diminish the risk of subsequent lesions but are not sufficient to treat this high-risk lesion. Radiation therapy should be given postoperatively to prevent further bone destruction.

Question 1968

Topic: 10. Pathology and Oncology

An open biopsy specimen of a radiodense distal clavicle lesion in a 12-year-old girl shows chronic polyclonal inflammatory cells without granuloma formation. Laboratory studies show that bacterial, fungal, and acid-fast bacillus cultures are negative. Subsequently, a similar lesion is noted in the fibula. The next most appropriate step in management should consist of

. antiviral therapy.
. IV broad-spectrum antibiotics.
. partial claviculectomy and fibulectomy.
. symptomatic relief with anti-inflammatory drugs.
. bone marrow aspiration and biopsy.

Correct Answer & Explanation

. symptomatic relief with anti-inflammatory drugs.

Explanation

The most likely diagnosis is chronic multifocal osteomyelitis. This is a culture-negative polyostotic disease that is most commonly found in young people. The treatment of choice is anti-inflammatory drugs. The pathology does not suggest eosinophilic granuloma. Antiviral therapy, broad-spectrum antibiotics, and surgical resection are not indicated for this disease.

Question 1969

Topic: 10. Pathology and Oncology

A 36-year-old woman with familial neurofibromatosis has an enlarging mass in the posterior thigh. The lesion has slowly increased in size and is now constantly painful. Pressure on the mass causes dysesthesias in the foot. Figures 44a through 44c show T1-weighted, STIR, and T1-weighted fat-saturated gadolinium scans, respectively. Figure 44d shows a PET scan. What does this lesion most likely represent?

. Peripheral nerve sheath tumor
. Malignant peripheral nerve sheath tumor
. Malignant fibrous histiocytoma
. Liposarcoma
. Synovial sarcoma

Correct Answer & Explanation

. Malignant peripheral nerve sheath tumor

Explanation

The images reveal a large mass in the posterior thigh arising from the sciatic nerve. The lesion is edematous, and the gadolinium image reveals rim enhancement, suggesting necrosis, given that the STIR image is not uniformly bright as would be seen in a cystic lesion. The PET scan has increased uptake, in this case a standard unit value (SUV) of greater than 2.0. These findings are all very suggestive of a malignant process. The history of neurofibromatosis makes a malignant peripheral nerve sheath tumor, or neurofibrosarcoma, the most likely diagnosis. The term "peripheral nerve sheath tumor" has replaced neurolemmoma and schwannoma. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 225-230.

Question 1970

Topic: 10. Pathology and Oncology

A 21-year-old man is referred for evaluation of a lesion in the left proximal femur that was discovered when he was undergoing an upper gastrointestinal series. He reports no hip or thigh pain. Radiographs are shown in Figures 64a and 64b. What is the best course of action?

. Observation
. Needle biopsy
. Incisional biopsy
. Curettage
. Wide resection

Correct Answer & Explanation

. Observation

Explanation

Melorheostosis is a rare disorder characterized by the classic radiographic appearance of flowing hyperostosis in a long bone. The hyperostosis may be on the periosteal or endosteal surface of the bone and frequently gives the appearance of wax falling down the side of a candle. The radiographs are diagnostic; therefore, no further work-up is indicated. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 87-102.

Question 1971

Topic: 10. Pathology and Oncology

An otherwise healthy 78-year-old woman has low back and buttock pain. Rectal examination reveals a large sacral mass. Figures 7a and 7b show a CT scan and a sagittal MRI scan of the lumbosacral spine. A biopsy specimen is shown in Figure 7c. What is the most likely diagnosis?

. Chondrosarcoma
. Chordoma
. Metastatic renal cell carcinoma
. Metastatic breast cancer
. Infection

Correct Answer & Explanation

. Chordoma

Explanation

A chordoma is a malignant neoplasm originating from remnants of the notochord. It is usually localized to the midline with 50% at the sacrococcygeal area, 35% at the skull base, and 15% at the mobile portion of the spine. Large vacuolated cells (physaliferous cells) are a characteristic of the tumor. Mindell ER: Chordoma. J Bone Joint Surg Am 1981;63:501-505.

Question 1972

Topic: 10. Pathology and Oncology

A 13-year-old boy has a painless "knot" over his left hip. History reveals that he injured his left hip playing soccer 4 months ago. A radiograph and MRI scan obtained at the time of injury are shown in Figures 7a and 7b. He is very active and is currently asymptomatic. A current radiograph is shown in Figure 7c. What is the next most appropriate step in management?

. Observation
. Anti-inflammatory medication
. Referral to a rheumatologist
. Biopsy
. Resection of the lesion

Correct Answer & Explanation

. Observation

Explanation

The diagnosis is myositis ossificans resulting from an injury. The initial radiograph reveals a small amount of mineralization in the soft tissues overlying the left hip. The MRI scan shows signal abnormality of the entire gluteus minimus muscle with a mineralized mass in the center. The current radiograph shows a lesion within the abductor musculature with mature ossification peripherally. The imaging studies are diagnostic and the patient is asymptomatic; therefore, the management of choice is observation with no further evaluation or treatment indicated. Miller AE, Davis BA, Beckley OA: Bilateral and recurrent myositis ossificans in an athlete: A case report and review of treatment options. Arch Phys Med Rehabil 2006;87:286-290.

Question 1973

Topic: 10. Pathology and Oncology

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

. Aneurysmal bone cyst
. Giant cell tumor
. Brown tumor
. Pigmented villonodular synovitis
. Telangiectatic osteosarcoma

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

Aneurysmal bone cysts typically present as radiolucent lesions with an expansile remodeled cortex. The histologic appearance consists of blood-filled lakes surrounded by a benign lining that contains fibroblasts, giant cells, and hemosiderin. Although the other lesions are in the radiographic differential diagnosis, these histologic findings indicate an aneurysmal bone cyst. Bieselker JL, Marcove RC, Huvos AG, Mike V: Aneurysmal bone cyst: A Clinico-pathologic study of 66 cases. Cancer 1973;26:615.

Question 1974

Topic: 10. Pathology and Oncology

A 43-year-old woman has had pain in the left hip for the past 2 months. A radiograph, CT scan, MRI scan, and biopsy specimens are shown in Figures 16a through 16e. What is the most likely diagnosis?

. Osteosarcoma
. Osteochondroma
. Chondrosarcoma
. Chordoma
. Enchondroma

Correct Answer & Explanation

. Chondrosarcoma

Explanation

The imaging studies are consistent with a chondrosarcoma. The radiograph shows a radiolucent lesion in the pelvis, and there are stippled calcifications on the CT scan. The histology shows a low-grade cellular hyaline cartilage neoplasm with stellate, occasionally binucleated chondrocytes. Enchondroma has a more benign histologic appearance.

Question 1975

Topic: 10. Pathology and Oncology

A 12-year-old girl has had progressive left knee pain for the past 4 months. She reports that the pain is unrelated to activity, and she has no history of fever or recent infections. Examination reveals full range of motion of the knee but tenderness along the medial joint line. Plain radiographs and MRI scans are shown in Figures 39a through 39d. A biopsy specimen of the lesion is shown in Figure 39e. Treatment should include

. curettage.
. systemic antibiotics.
. observation and protected weight bearing.
. chemotherapy.
. radiation therapy.

Correct Answer & Explanation

. curettage.

Explanation

The lesion is a chondroblastoma. The plain radiographs show a well-defined radiolucent lesion in the distal femoral epiphysis of a skeletally immature patient. The margins are well defined, suggesting a benign growth. The epiphysis is an unusual location for bone tumors, except for chondroblastomas. Of all chondroblastomas, 95% are located within the epiphysis. The MRI scans show a punctate appearance that is commonly seen in cartilage lesions. The biopsy specimen shows a chondroid lesion with polygonal chondrocytes. These findings are consistent with a chondroblastoma. The natural history of chondroblastomas is for continued growth and bone destruction if left untreated. Treatment should consist of curettage, with or without the use of physical or chemical adjuvants, and bone grafting.

Question 1976

Topic: Bone Tumors

A 23-year-old man has had heel pain and fullness for the past several months. He reports that initially the pain was present only with activity, but more recently the pain has become constant. Figures 53a through 53d show a radiograph, a bone scan, and T2-weighted and gadolinium MRI scans. What is the most likely diagnosis?

. Chondroblastoma
. Fibrous dysplasia
. Simple bone cyst
. Aneurysmal bone cyst
. Giant cell tumor

Correct Answer & Explanation

. Aneurysmal bone cyst

Explanation

The imaging studies reveal an expansile lesion with the classic soap bubble appearance that involves most of the calcaneus. The bone scan reveals a very active lesion with intense uptake, and the MRI scans show the classic, loculated appearance of the lesion with multiple fluid-fluid levels. While it is important to rule out telangiectatic osteosarcoma, the most likely diagnosis is an aneurysmal bone cyst. While giant cell tumor might have a similar appearance, the multiple fluid levels in a expansile lesion strongly favor an aneurysmal bone cyst. Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.

Question 1977

Topic: 10. Pathology and Oncology

A 13-year-old boy has knee pain after sustaining a mild twisting injury while playing basketball 4 weeks ago. Radiographs and MRI scans are shown in Figures 24a through 24d, and biopsy specimens are shown in Figures 24e and 24f. Treatment should consist of

. neoadjuvant chemotherapy followed by surgical resection and reconstruction.
. chemotherapy followed by radiation therapy.
. IV antibiotics for 4 weeks, followed by oral antibiotics for 4 weeks.
. surgical resection and reconstruction followed by chemotherapy.
. radiation therapy alone.

Correct Answer & Explanation

. neoadjuvant chemotherapy followed by surgical resection and reconstruction.

Explanation

The imaging studies and histology are consistent with high-grade osteosarcoma. The standard treatment for osteosarcoma is neoadjuvant chemotherapy combined with wide surgical resection that can be performed with amputation or limb salvage depending on characteristics unique to each tumor and each patient. In most patients, limb salvage surgery can be performed with reconstruction using allografts and/or megaprostheses. Osteosarcoma is poorly responsive to radiation therapy. Chemotherapy alone, in the absence of appropriate surgery, has not proven effective. Simon MA, Springfield DS: Surgery for Bone and Soft-Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 265-274.

Question 1978

Topic: 10. Pathology and Oncology

A 19-year-old girl has had pain and swelling in the right ankle for the past 4 months. She denies any history of trauma. Examination reveals a small soft-tissue mass over the anterior aspect of the ankle and slight pain with range of motion of the ankle joint. The examination is otherwise unremarkable. A radiograph and MRI scan are shown in Figures 45a and 45b, and biopsy specimens are shown in Figures 45c and 45d. What is the most likely diagnosis?

. Osteogenic sarcoma
. Ewing's sarcoma
. Giant cell tumor of bone
. Aneurysmal bone cyst
. Metastatic adenocarcinoma

Correct Answer & Explanation

. Giant cell tumor of bone

Explanation

Giant cell tumors typically occur in a juxta-articular location involving the epiphysis and metaphysis of long bones, usually eccentric in the bone. The radiographs show a destructive process within the distal tibia and an associated soft-tissue mass. The histology shows multinucleated giant cells in a bland matrix with a few scattered mitoses. Osteosarcoma can have a similar destructive appearance but a very different histologic pattern with osteoid production. Ewing's sarcoma also can have a diffuse destructive process in the bone. The histologic pattern of Ewing's sarcoma is diffuse round blue cells. Aneurysmal bone cysts typically are seen as a fluid-filled lesion on imaging studies and have only a scant amount of giant cells histologically. Metastatic adenocarcinoma does not demonstrate the pattern shown in the patient's histology specimen. Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 198-199.

Question 1979

Topic: 10. Pathology and Oncology

A 13-year-old girl is diagnosed with a stage IIB osteosarcoma of the proximal tibia. Following neoadjuvant chemotherapy, local control should consist of

. wide resection and reconstruction.
. wide resection and radiation therapy.
. radiation therapy.
. curettage and bone grafting.
. observation.

Correct Answer & Explanation

. wide resection and reconstruction.

Explanation

Local control of osteosarcoma consists of wide resection and reconstruction. Radiation therapy is not recommended except in unresectable lesions or for palliation. Curettage and bone grafting result in intralesional resection with an unacceptable high rate of local recurrence. Chemotherapy alone is not adequate for local control. Simon M, Springfield D, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue. Philadelphia, PA, Lippincott Raven, 1998, p 274.

Question 1980

Topic: 10. Pathology and Oncology

A 12-year-old girl has had increasing left knee pain for the past 3 months. A radiograph is shown in Figure 75a, and low- and high-power photomicrographs are shown in Figures 75b and 75c. What is the most appropriate treatment?

. Chemotherapy alone
. Surgery alone
. Radiation therapy alone
. Chemotherapy and surgery
. Radiation therapy and surgery

Correct Answer & Explanation

. Chemotherapy and surgery

Explanation

The radiograph reveals an aggressive purely lytic lesion of the distal femoral metaphysis. There is no apparent matrix mineralization or periosteal reaction. The photomicrographs show a malignant spindle cell neoplasm in a storiform pattern. Based on these findings, the diagnosis is malignant fibrous histiocytoma of bone. At most institutions, patients with this tumor are treated similar to patients with osteosarcoma with multi-agent chemotherapy and surgery with wide margins (resection or amputation). Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 203-209.

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