Evaluation and Staging of Bone Tumors — MCQs
Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
Most sensitive modality for detecting bone metastases
What is the best imaging modality for detecting early osteomyelitis?
A young girl presented with swelling of right thigh, with history of trauma 2 months back. Now she presents with swelling at mid-shaft of femur & low grade fever. ESR is mildly raised. X-ray shows a laminated periosteal reaction. Next line of investigation would be:
Biopsy of a clinically suspicious lesion is negative. The most appropriate treatment is
Classification system of bone tumors is -
True about bone tumor is:
What is the radiological feature characteristic of osteosarcoma?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
A 7-year-old child presents with a lesion in upper tibia. X-ray shows radiolucent area with Codman's triangle and sunray appearance. Diagnosis is
Evaluation and Staging of Bone Tumors Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
- A. T4 N3 MX
- B. T4 N1 M1
- C. T4 N0 M0
- D. T3 N3c MX (Correct Answer)
Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).
Question 2: Most sensitive modality for detecting bone metastases
- A. Bone scan
- B. PET-CT
- C. Plain radiograph
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **MRI**, especially **whole-body MRI (WB-MRI)**, has the **highest sensitivity (90-100%)** for detecting bone metastases among all imaging modalities. - It directly visualizes **bone marrow changes** before cortical bone destruction occurs, allowing for earlier detection than other modalities. - Excellent for detecting both **lytic and sclerotic lesions** and provides superior soft tissue contrast for assessing marrow involvement. - Particularly sensitive for **spine and pelvic metastases**, and whole-body protocols enable comprehensive skeletal assessment. *PET-CT* - **PET-CT with 18F-FDG** is highly sensitive for detecting metabolically active lesions and provides whole-body assessment with both metabolic and anatomical information. - However, its sensitivity varies by primary tumor type and is **limited for sclerotic/osteoblastic metastases** which may not be FDG-avid. - While excellent for many malignancies, it has **lower sensitivity than MRI** for pure bone metastases detection, particularly in low-metabolism lesions. *Bone scan* - **Bone scan (Tc-99m MDP)** detects increased osteoblastic activity and has been the traditional screening tool with good sensitivity (62-89%). - Effective for detecting osteoblastic lesions and provides whole-body skeletal survey at relatively low cost. - However, it is **less sensitive than MRI** and can miss purely lytic metastases or early marrow involvement before osteoblastic response occurs. *Plain radiograph* - **Plain radiographs** require significant bone mineral loss (30-50%) to visualize lesions, making them the **least sensitive modality** for bone metastases. - Useful for assessing established lesions and complications like pathological fractures, but inadequate for screening or early detection.
Question 3: What is the best imaging modality for detecting early osteomyelitis?
- A. CT scan
- B. X-ray
- C. MRI (Correct Answer)
- D. Bone scintigraphy
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is considered the **gold standard** for detecting early osteomyelitis due to its excellent soft tissue contrast and ability to visualize **bone marrow edema**, which is an early sign of infection. - It can identify changes within **3-5 days** of infection onset, much earlier than other modalities. *CT scan* - While useful for showing **bone destruction**, cortical integrity, and sequestra, **CT scans** are less sensitive than MRI for detecting early marrow edema. - Its ability to diagnose osteomyelitis is usually delayed until significant **bony changes** have occurred, typically around 1-2 weeks. *X-ray* - **Plain radiographs** are often the initial imaging study but are **insensitive** for early osteomyelitis, showing changes only after 10-14 days or more. - Early findings on X-rays can be subtle, such as **periosteal elevation** or **soft tissue swelling**, but frank bone destruction is a late finding. *Bone scintigraphy* - **Bone scintigraphy** (e.g., technetium-99m) is sensitive for detecting increased bone turnover associated with infection but lacks **specificity**, as it can be positive in other conditions like trauma or tumors. - While it can detect changes earlier than X-rays, typically within 2-3 days, it cannot clearly differentiate infection from other processes, and its spatial resolution is poor compared to MRI.
Question 4: A young girl presented with swelling of right thigh, with history of trauma 2 months back. Now she presents with swelling at mid-shaft of femur & low grade fever. ESR is mildly raised. X-ray shows a laminated periosteal reaction. Next line of investigation would be:
- A. MRI (Correct Answer)
- B. Bone scan
- C. Blood count & CRP
- D. Biopsy
Explanation: ***MRI*** - An **MRI** is the most appropriate next step as it provides excellent detailed imaging of soft tissues and bone marrow, allowing better characterization of the **periosteal reaction**, identifying abscesses, and assessing the extent of bone involvement, crucial for differentiating between infection and tumor. - The presence of a **laminated periosteal reaction** (like an "onion peel") on X-ray, in conjunction with localized swelling and low-grade fever, is highly suggestive of subacute osteomyelitis or even some bone tumors like Ewing sarcoma, for which MRI is superior for defining the extent. *Bone scan* - A **bone scan** (technetium-99m) is sensitive for detecting increased bone turnover, which occurs in infections and tumors, but it is **non-specific**, meaning it cannot differentiate between these conditions. - While it could show increased uptake in the affected area, it would not provide the anatomical detail needed to characterize the lesion or guide further management as effectively as an MRI. *Blood count & CRP* - A **blood count and CRP** would provide information on systemic inflammation (e.g., leukocytosis, elevated CRP for infection), but these are **non-specific**. - While ESR is already mildly raised, these blood tests would confirm generalized inflammation but **cannot localize or characterize the lesion** in the bone, offering little diagnostic value for the specific problem at this stage without imaging. *Biopsy* - A **biopsy** is an invasive procedure and is typically performed after initial imaging studies like X-ray and MRI have characterized the lesion to guide the biopsy site and help determine the nature of the condition (e.g., infection vs. tumor). - Performing a biopsy as the immediate next step without detailed imaging to assess the extent and nature of the lesion would be premature and potentially less effective in diagnosis.
Question 5: Biopsy of a clinically suspicious lesion is negative. The most appropriate treatment is
- A. Repeat the biopsy for further evaluation. (Correct Answer)
- B. Monitor the patient closely for twelve months.
- C. Monitor the patient closely for three months.
- D. Reassure the patient that the lesion is benign.
Explanation: ***Repeat the biopsy for further evaluation.*** - A **clinically suspicious lesion** with a negative biopsy result warrants a repeat biopsy because a **false negative** is possible, especially if the initial sample was inadequate or not representative. - The principle "**never let the sun set on a clinically suspicious lesion**" applies here - clinical suspicion should override a negative biopsy result. - Repeating the procedure ensures accurate diagnosis, which is crucial for lesions with **malignant potential**. *Monitor the patient closely for twelve months.* - This approach is too **conservative** for a clinically suspicious lesion with a negative biopsy, as a malignancy could progress significantly within a year. - Waiting this long without a definitive diagnosis carries an **unacceptable risk** of delayed treatment for a potential cancer. *Monitor the patient closely for three months.* - While more proactive than waiting a year, **three months** is still too long for a clinically suspicious lesion if the biopsy result is unreliable. - Early detection and diagnosis are paramount for better outcomes in potentially **malignant lesions**. *Reassure the patient that the lesion is benign.* - This is **inappropriate** as it accepts the false negative biopsy result at face value and dismisses the clinical suspicion. - **Clinical judgment** should take precedence over a negative biopsy when a lesion remains suspicious. - This approach could lead to **catastrophic delays** in diagnosing malignancy.
Question 6: Classification system of bone tumors is -
- A. Enneking (Correct Answer)
- B. Edmonton
- C. TNM
- D. Manchester
Explanation: ***Enneking*** - The **Enneking staging system** is widely used for primary **bone tumors**, particularly sarcomas. - It classifies tumors based on their histological grade, local extension, and presence of metastases, which guides surgical planning and prognosis. *Edmonton* - The **Edmonton classification** is primarily used for **periprosthetic fractures** around hip and knee replacements. - It does not classify primary bone tumors but rather describes fracture patterns related to prosthetic implants. *TNM* - The **TNM (Tumor, Node, Metastasis)** classification is a general staging system used for many types of cancer, but it's not the primary system for bone tumors. - While applicable for some bone cancers, the **Enneking system** provides a more specific functional and anatomical assessment for limb-sparing surgery in bone sarcomas. *Manchester* - The **Manchester staging system** is primarily used for **lymphoma**, particularly Hodgkin lymphoma. - It describes the extent of lymph node involvement and extralymphatic disease, completely unrelated to bone tumors.
Question 7: True about bone tumor is:
- A. Multiple myeloma is seen in more than 55 years of age and above (Correct Answer)
- B. Osteoclastoma- fifth decade
- C. Osteogenic sarcoma-fourth decade
- D. Chondrosarcoma -first decade
Explanation: ***Multiple myeloma is seen in more than 55 years of age and above*** - **Multiple myeloma** is a plasma cell malignancy that predominantly affects older adults, with the median age of diagnosis being around **69 years** [1] - Its incidence significantly increases with age, making it rare before the age of 40 and most prevalent in those **over 55 years** [1][2] - This statement is **medically accurate** and represents the correct answer *Osteoclastoma - fifth decade* - **Osteoclastoma** (giant cell tumor of bone) typically occurs in young adults, primarily in their **20s to 40s** (2nd to 4th decade) - Peak incidence is in the **3rd-4th decade**, not the fifth decade - This statement is **incorrect** as fifth decade is an atypical presentation *Osteogenic sarcoma - fourth decade* - **Osteogenic sarcoma** (osteosarcoma) has a **bimodal age distribution** with peaks in adolescence (10-20 years, 2nd decade) and a smaller peak in older adults over 60 years - It is **uncommon in the fourth decade** (30s), which falls outside its primary age groups - This statement is **incorrect** *Chondrosarcoma - first decade* - **Chondrosarcoma** is a malignant cartilaginous tumor that predominantly affects older adults, typically in their **50s and 60s** (5th-6th decade) - It is **exceedingly rare in the first decade** of life (0-9 years), and its incidence significantly increases with age - This statement is **incorrect** **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 616-618. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-607.
Question 8: What is the radiological feature characteristic of osteosarcoma?
- A. Sunray appearance (Correct Answer)
- B. Osteoid formation
- C. Periosteal new bone formation
- D. Cotton wool spots
Explanation: ***Sunray appearance*** - The **sunburst** or **sunray appearance** is a characteristic radiological feature of osteosarcoma, representing rapidly growing tumor spicules extending perpendicularly from the bone cortex. - This pattern is formed by **calcified tumor osteoid** radiating from the periosteum. *Periosteal new bone formation* - While osteosarcoma does involve periosteal new bone formation, this term is **too general** and can describe various bone conditions and tumors. - The specific pattern of new bone formation in osteosarcoma is better described by terms like "sunray" or "Codman's triangle", which are more diagnostic. *Cotton wool spots* - **Cotton wool spots** are seen in **Paget's disease of bone**, representing areas of sclerotic bone. - This appearance is not characteristic of osteosarcoma, which typically presents with destructive and proliferative bone changes. *Osteoid formation* - **Osteoid formation** is a histological hallmark of osteosarcoma, as it is a bone-forming tumor. - However, on radiology, the presence alone of osteoid is not a specific diagnostic feature; rather, it's the **pattern of osteoid mineralization** that defines the radiological appearance.
Question 9: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Question 10: A 7-year-old child presents with a lesion in upper tibia. X-ray shows radiolucent area with Codman's triangle and sunray appearance. Diagnosis is
- A. Osteosarcoma (Correct Answer)
- B. Osteoid Osteoma
- C. Ewing sarcoma
- D. Chondrosarcoma
Explanation: ***Osteosarcoma*** - The classic radiographic features of **Codman's triangle** (periosteal elevation) and **sunray appearance** (spiculated periosteal reaction) are highly characteristic of osteosarcoma. - This tumor commonly affects the **metaphysis of long bones** in children and young adults, with the distal femur and proximal tibia being frequent sites. *Osteoid Osteoma* - This is a **benign bone tumor** characterized radiographically by a small radiolucent **nidus** surrounded by a rim of dense sclerosis. - It does not present with Codman's triangle or sunray appearance and typically causes **nocturnal pain relieved by NSAIDs**. *Ewing sarcoma* - Ewing sarcoma often presents with an **"onion skin" periosteal reaction** (layers of new bone formation) due to its aggressive nature. - While it can be destructive and radiolucent, it typically does not classically exhibit the sunray appearance or a distinct Codman's triangle as prominently as osteosarcoma. *Chondrosarcoma* - Chondrosarcoma is a **malignant cartilaginous tumor** that usually affects older adults more commonly than children. - Radiographically, it often shows a **lobulated appearance** with **punctate or ring-and-arc calcifications** within the lesion, not the sunray or Codman's triangle findings.
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