Bone Tumors Practice Questions

Q: Expansile pulsating secondary metastasis is a feature of which of the following?

Renal cell carcinoma. **Explanation:** The correct answer is **Renal cell carcinoma (RCC)**. **1. Why Renal Cell Carcinoma is correct:** Expansile, osteolytic, and **pulsating** skeletal metastases are characteristic of highly vascular tumors. RCC is the most common cause of such lesions. The "pulsatile" nature occurs because these metastases are extremely hypervascular; the high blood flow within the lesion transmits the arterial pulse, which can sometimes be felt on clinical palpation or heard as a bruit. On imaging, these appear as "blow-out" lytic lesions. **2. Why the other options are incorrect:** * **Basal Cell Carcinoma (BCC):** BCC is a locally invasive skin cancer that rarely metastasizes to distant organs or bones. * **Osteogenic Sarcoma (Osteosarcoma):** This is a primary bone tumor, not a secondary metastasis. While it is vascular, it typically presents with bone formation (osteoid) and a "sunburst" periosteal reaction rather than expansile pulsatile secondary deposits. * **Carcinoma of the Prostate:** This is the classic cause of **osteoblastic (sclerotic)** metastases. These lesions are dense and radio-opaque, not expansile or pulsatile. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Pulsatile Bone Metastases:** **"R-T-C"** (Renal cell carcinoma, Thyroid carcinoma—specifically follicular variety, and Choriocarcinoma). * **Most common source of bone metastasis in males:** Prostate cancer. * **Most common source of bone metastasis in females:** Breast cancer. * **Most common site for bone metastasis:** Spine (Vertebral column). * **Imaging of choice:** While Bone Scan (Technetium-99m MDP) is used for screening, it may show a **"cold lesion"** in pure lytic tumors like RCC or Multiple Myeloma. MRI is more sensitive for detecting early marrow involvement.

Q: A 22-year-old male presents with pain and swelling over the distal radius. X-ray shows an expansile lytic lesion in the metaphysis. Fine needle aspiration (FNA) reveals a bloody aspirate with hemosiderin-laden macrophages. What is the most likely diagnosis?

Aneurysmal bone cyst. ***Aneurysmal bone cyst*** - Aneurasymal bone cysts (ABCs) typically present as **expansile, soap-bubble lytic lesions** located in the **metaphysis** of long bones in patients under 30. - Diagnostic aspiration characteristically yields a **bloody fluid** and cytology shows **hemosiderin-laden macrophages** within fibrous septa, rather than solid tumor tissue. *Giant cell tumor* - Although GCT is a lytic lesion in young adults, it is primarily located in the **epiphysis** extending to the articular surface, not restricted to the metaphysis. - Histopathology would show a high concentration of **multinucleated giant cells** and mononuclear stromal cells rather than predominantly blood and macrophages. *Chondroblastoma* - Chondroblastomas are almost exclusively found in the **epiphysis** or apophysis of long bones, making a purely metaphyseal location unlikely. - Characteristic biopsy findings include **chondroblasts** and a unique **"chicken-wire" calcification** pattern, which are absent in this presentation. *Osteosarcoma* - Osteosarcoma usually presents with a mix of lytic and **sclerotic areas** accompanied by aggressive periosteal reactions like the **Codman triangle**. - Fine needle aspiration would show **pleomorphic malignant cells** and the presence of **neoplastic osteoid**, which contrasts with the benign bloody aspirate typical of an ABC.

Q: A 20-year-old male patient presented with localized pain, which is gradual in onset and worsened over time. X-ray showed the following finding. What is the diagnosis?

Osteosarcoma. ***Osteosarcoma*** - The X-ray shows a classic **sunburst appearance**, which represents spiculated periosteal new bone formation radiating outwards, a hallmark of osteosarcoma. - This diagnosis is supported by the patient's age (peak incidence in adolescence/young adulthood) and the tumor's location in the **metaphysis** of a long bone (distal tibia). *Ewing sarcoma* - This tumor typically presents with a lytic lesion and a lamellated, **"onion-skin" periosteal reaction**, which is different from the sunburst pattern seen here. - Ewing sarcoma most commonly arises in the **diaphysis** (shaft) of long bones or in flat bones like the pelvis. *Chondrosarcoma* - This is a malignant cartilage-forming tumor that typically affects older adults (usually >40 years), making it less likely in a 20-year-old. - Radiographically, it is characterized by **"ring-and-arc"** or **"popcorn" calcifications** within the tumor matrix, which are absent in this image. *Gout* - Gout is a form of inflammatory arthritis, not a bone tumor, and would present with acute joint pain and swelling rather than a gradual mass effect. - Radiographic findings in chronic gout include characteristic **"punched-out" erosions** with overhanging edges, which are completely different from the aggressive, bone-forming lesion shown.

Q: A 20-year-old patient presents with painful swelling in the middle finger around the proximal phalanx. An X-ray was done, and it is shown below. What is the most likely diagnosis? ![img-14.jpeg](img-14.jpeg)

Enchondroma. ***Enchondroma*** - This is the most common primary bone tumor of the hand, typically found in the **phalanges** and **metacarpals** in patients aged 10-40, consistent with this case. - The X-ray shows a classic well-defined, centrally located, **lytic lesion** causing **endosteal scalloping** (thinning of the inner cortex) and expansile remodeling, which are characteristic features of an **enchondroma**. *Osteosarcoma* - **Osteosarcoma** typically arises in the **metaphysis** of long bones like the femur and tibia, and is very rare in the small bones of the hand. - Radiographically, it presents with aggressive features like **cortical destruction**, a soft tissue mass, and a **sunburst** or **Codman's triangle** periosteal reaction, which are absent in this image. *Ewing's sarcoma* - This is a highly malignant tumor that most commonly affects the **diaphysis** (shaft) of long bones and the pelvis; its occurrence in the hand is extremely rare. - It classically shows an aggressive, permeative or **moth-eaten** lytic lesion with a large soft tissue component and a characteristic **onion-skin** periosteal reaction. *Osteoclastoma* - Also known as a Giant Cell Tumor (GCT), it characteristically occurs in the **epiphysis** of long bones in skeletally mature individuals, most commonly around the knee. - The typical radiographic appearance is an eccentric, lytic lesion extending to the subarticular bone, often described as having a **"soap bubble"** appearance, which differs from the findings here.

Q: A 17-year-old boy presents to the clinic complaining of a painless lump on the lateral aspect of his left knee. The radiograph of the patient is shown below. Which of the following is the most likely diagnosis?

Osteochondroma. ***Osteochondroma*** - The radiograph displays a classic **bony exostosis** with a stalk (pedunculated) arising from the metaphyseal region of the distal femur, which is the pathognomonic appearance of an osteochondroma. - These are the most common benign bone tumors, typically presenting in adolescents as a painless, slow-growing mass near the **growth plates** of long bones, especially around the knee. *Enchondroma* - An enchondroma is a benign cartilaginous tumor that develops *within* the **medullary cavity** of a bone, not as an external projection. - They are most commonly found in the small bones of the hands and feet and appear as a lytic lesion with characteristic **"rings and arcs" calcification** on radiographs. *Chondroblastoma* - This is a rare benign cartilaginous tumor that characteristically arises in the **epiphysis** of long bones in skeletally immature patients. - Radiographically, it appears as a well-defined, lytic lesion, often with a thin **sclerotic rim**, located in the end of the bone, unlike the metaphyseal outgrowth seen here. *Giant cell tumor* - This is a locally aggressive tumor that typically affects the **epiphysis** of long bones in skeletally mature adults (age 20-40). - It appears as an eccentric, lytic lesion with a **"soap bubble"** appearance that extends to the subchondral bone, which is inconsistent with the presented image.

Q: A 17-year-old boy presents with a progressively increasing swelling over the tibia along with fever. Radiological examination reveals a Codman triangle and sunburst appearance. What is the most likely diagnosis?

Osteosarcoma. ***Osteosarcoma*** - This is the most common primary malignant bone tumor in adolescents, often presenting with pain and swelling, typically affecting the **metaphysis** of long bones (like the tibia). - The presence of the **Codman triangle** (periosteal elevation) and the **sunburst appearance** (spicules of bone radiating outwards) are pathognomonic radiological signs due to aggressive bone formation. *Ewing sarcoma* - While also affecting adolescents and associated with systemic features like **fever** (mimicking infection), its classic radiological sign is the **'onion-peel' (laminated) periosteal reaction**. - It typically involves the **diaphysis** of long bones or flat bones, unlike the metaphyseal involvement seen here. *Giant cell tumour* - This tumor usually affects slightly older adults (20-40 years) and predominantly involves the **epiphysis** of long bones. - Radiographically, GCT exhibits a non-sclerotic, **'soap bubble' appearance** (multiloculated lytic lesion) but does not feature the aggressive Codman triangle or sunburst pattern. *Chondrosarcoma* - This diagnosis is unlikely in a 17-year-old, as it typically presents in older adults (40-70 years). - The radiologic hallmark of chondrosarcoma is the presence of **ring-and-arc** or **'popcorn' calcifications** within the cartilaginous matrix, not the ossifying reactions seen in this case.

Q: 99. A 20-year-old male patient presents with a lesion in the wrist joint. The X-ray appearance is given below. What is the likely diagnosis?

Simple bone cyst. ***Simple bone cyst*** - The X-ray image shows a **lucent, well-defined lesion** in the diaphysis/metaphysis of the ulna, often seen in the proximal humerus or femur, but can occur in other long bones. - The lesion has a **thin, sclerotic rim** without significant periosteal reaction or cortical destruction, suggesting a benign, fluid-filled lesion like a simple bone cyst. *Osteoclastoma* - This typically presents as an **eccentric, expansile lytic lesion** in the epiphysis or metaphysis of long bones, often with a "soap bubble" appearance. - It usually occurs near the **knee or distal radius** but the lesion in the image lacks the characteristic aggressive features and epiphyseal involvement of osteoclastoma. *Adamantinoma* - This is a rare, malignant bone tumor that almost exclusively occurs in the **tibia**. - It presents as a **lytic, often multifocal lesion** with central sclerosis or cystic changes, which does not match the appearance or location of the lesion in the ulna. *Multiple myeloma* - This is a systemic malignancy causing **punched-out lytic lesions** in the axial skeleton (skull, spine, pelvis) and proximal long bones. - The appearance in the image is of a single, well-defined cyst, not the widespread, multiple lucencies typical of multiple myeloma.

Q: 101. Identify the bone tumor:

Ewing's sarcoma. *Ewing's sarcoma* - The image displays a **large lytic lesion** in the diaphysis/metaphysis of the tibia, with a **"onion skin" periosteal reaction** and possible soft tissue extension, which are characteristic radiological features of Ewing's sarcoma. - Ewing's sarcoma typically affects **children and young adults** and is known for its aggressive nature and diaphyseal involvement of long bones. *Osteosarcoma* - Osteosarcoma usually presents with a **sclerotic (bone-forming) lesion** and a **"sunburst" periosteal reaction** or Codman's triangle, not primarily a lytic lesion with onion-skinning. - While it also affects metaphyses of long bones and is common in adolescents, its radiological appearance often differs significantly from what is shown. *Giant cell tumor* - Giant cell tumors are typically **lytic lesions** found in the **epiphysis/metaphysis** of long bones, often described as a "soap bubble" appearance. - They do not typically show significant periosteal reaction or the widespread diaphyseal involvement seen in the image. *Enchondroma* - Enchondromas are **benign cartilaginous tumors** usually found in the medullary cavity of small bones of the hands and feet, or less commonly in long bones. - They appear as **well-circumscribed, lytic lesions** with chondroid matrix calcifications and do not typically cause aggressive periosteal reactions or extensive bone destruction.

Q: A 16-year-old boy presents with pain and swelling around the knee for 3 months. X-ray of the affected region is shown below. What is the most likely diagnosis?

Osteosarcoma. ***Osteosarcoma*** - **Osteosarcoma** is the most common primary malignant bone tumor, typically affecting the **metaphysis** of long bones in adolescents and young adults [1,2]. - Radiographically, it often presents with a **sunburst appearance** or **Codman's triangle** due to periosteal reaction [1]. *Ewing's sarcoma* - **Ewing's sarcoma** is a malignant small round blue cell tumor, often presenting with an **onion-skin appearance** on X-ray due to lamellated periosteal reaction [3]. - It commonly affects the **diaphysis** of long bones and flat bones, and is associated with the **t(11;22) translocation** [3]. *Giant cell tumor* - **Giant cell tumor** is a benign but locally aggressive tumor, typically found in the **epiphysis** of long bones, especially around the knee [4]. - It is characterized by numerous **osteoclast-like giant cells** and has a characteristic **soap-bubble appearance** on imaging [4]. *Enchondroma* - **Enchondroma** is a benign cartilaginous tumor that arises within the **medullary cavity** of bone, most commonly in the small bones of the hands and feet [3]. - It is typically asymptomatic and discovered incidentally, often appearing as a **well-circumscribed lucent lesion** with calcifications [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1200-1202. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 671-672. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1205-1206.

Q: 96. Spot the diagnosis: (Recent NEET Pattern 2016-17)

Aneurysmal bone cyst. ***Aneurysmal bone cyst*** - The image shows an **expansile, lytic lesion** in the metaphysis of the tibia, with a **thin sclerotic rim** and **soap bubble appearance**, which is characteristic of an aneurysmal bone cyst. - The lesion extends close to the **epiphyseal plate** but generally respects it, and the presence of internal trabeculations often gives it a multiloculated appearance. *Osteoblastoma* - This lesion is typically a **well-circumscribed, lytic lesion** often associated with a **sclerotic rim**, but it usually presents as a nidus greater than 2 cm, frequently in the spine or long bones, and is less expansile than what is seen here. - While it can be destructive, the **multiloculated, expansile appearance** with distinct fluid levels (not directly visible on plain X-ray but implied by "soap bubble") is not typical for osteoblastoma. *Osteoclastoma* - Also known as **Giant Cell Tumor of Bone**, this tumor is typically an **epiphyseal lesion**, extending to the subarticular bone, often described as an **expansile osteolytic lesion** without a sclerotic rim. - The lesion in the image is more metaphyseal and shows a well-defined sclerotic border with internal septations, not the typical "soap bubble" appearance of ABC or the purely lytic destructive nature of an osteoclastoma. *Chondrosarcoma* - Chondrosarcomas are malignant tumors characterized by the formation of cartilage, often presenting as **lytic lesions with calcifications** (popcorn or ring-and-arc patterns) and cortical destruction, but typically lack the multiloculated, expansile, "soap bubble" appearance of an aneurysmal bone cyst. - While they can be expansile, the **radiographic features** in the image, particularly the internal architecture and clear margination, are not typical for chondrosarcoma.

Question 1

Expansile pulsating secondary metastasis is a feature of which of the following?

Accepted Answer

Renal cell carcinoma

Answer

Basal cell carcinoma

Answer

Osteogenic sarcoma

Answer

Carcinoma of the prostate

Question 2

A 22-year-old male presents with pain and swelling over the distal radius. X-ray shows an expansile lytic lesion in the metaphysis. Fine needle aspiration (FNA) reveals a bloody aspirate with hemosiderin-laden macrophages. What is the most likely diagnosis?

Accepted Answer

Aneurysmal bone cyst

Answer

Giant cell tumor

Answer

Chondroblastoma

Answer

Osteosarcoma

Question 3

A 20-year-old male patient presented with localized pain, which is gradual in onset and worsened over time. X-ray showed the following finding. What is the diagnosis?

Accepted Answer

Osteosarcoma

Answer

Ewing sarcoma

Answer

Chondrosarcoma

Answer

Gout

Question 4

A 20-year-old patient presents with painful swelling in the middle finger around the proximal phalanx. An X-ray was done, and it is shown below. What is the most likely diagnosis? ![img-14.jpeg](img-14.jpeg)

Accepted Answer

Enchondroma

Answer

Osteosarcoma

Answer

Ewing's sarcoma

Answer

Osteoclastoma

Question 5

A 17-year-old boy presents to the clinic complaining of a painless lump on the lateral aspect of his left knee. The radiograph of the patient is shown below. Which of the following is the most likely diagnosis?

Accepted Answer

Osteochondroma

Answer

Giant cell tumor

Answer

Enchondroma

Answer

Chondroblastoma

Question 6

A 17-year-old boy presents with a progressively increasing swelling over the tibia along with fever. Radiological examination reveals a Codman triangle and sunburst appearance. What is the most likely diagnosis?

Accepted Answer

Osteosarcoma

Answer

Ewing sarcoma

Answer

Giant cell tumour

Answer

Chondrosarcoma

Question 7

99. A 20-year-old male patient presents with a lesion in the wrist joint. The X-ray appearance is given below. What is the likely diagnosis?

Accepted Answer

Simple bone cyst

Answer

Osteoclastoma

Answer

Adamantinoma

Answer

Multiple myeloma

Question 8

101. Identify the bone tumor:

Accepted Answer

Ewing's sarcoma

Answer

Osteosarcoma

Answer

Giant cell tumor

Answer

Enchondroma

Question 9

A 16-year-old boy presents with pain and swelling around the knee for 3 months. X-ray of the affected region is shown below. What is the most likely diagnosis?

Accepted Answer

Osteosarcoma

Answer

Ewing's sarcoma

Answer

Giant cell tumor

Answer

Enchondroma

Question 10

96. Spot the diagnosis: (Recent NEET Pattern 2016-17)

Accepted Answer

Aneurysmal bone cyst

Answer

Osteoblastoma

Answer

Osteoclastoma

Answer

Chondrosarcoma

Bone Tumors — MCQs

Bone Tumors — MCQs

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