Bone Tumors — MCQs

Bone Tumors Indian Medical PG Practice Questions and MCQs

Question 11: What is the commonest extradural spinal tumor?

A. Neurofibroma
B. Glioma
C. Meningioma
D. Metastasis (Correct Answer)

Explanation: **Explanation:** The spinal column is the most common site for skeletal metastasis, and **Metastasis** is the overall commonest extradural spinal tumor. These tumors typically reach the vertebrae via the hematogenous route (often through Batson’s venous plexus). The most frequent primary sources are cancers of the breast, prostate, lung, and kidney. **Analysis of Options:** * **D. Metastasis (Correct):** Approximately 95% of spinal tumors are extradural, and the vast majority of these are metastatic. They typically involve the vertebral body and can lead to pathological fractures or cord compression. * **A. Neurofibroma:** This is the most common **intradural-extramedullary** tumor. While it can occasionally have an extradural component (forming a "dumbbell" shape), it is not as common as metastatic disease. * **C. Meningioma:** This is the second most common **intradural-extramedullary** tumor, typically found in the thoracic spine of middle-aged women. * **B. Glioma:** These (specifically ependymomas and astrocytomas) are **intramedullary** tumors, meaning they arise within the substance of the spinal cord itself. **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Location:** * **Extradural (95%):** Metastasis (Most common), Chordoma, Multiple Myeloma. * **Intradural-Extramedullary:** Neurofibroma (Most common), Meningioma. * **Intramedullary:** Ependymoma (Most common in adults), Astrocytoma (Most common in children). * **Winking Owl Sign:** On a spinal X-ray, the disappearance of a pedicle due to metastatic destruction is a classic radiological sign. * **MRI** is the gold standard investigation for suspected spinal cord compression.

Question 12: Arrange the following tumors according to the increasing age they affect: 1. Ewings sarcoma 2. Osteosarcoma 3. Osteoclastoma 4. Multiple Myeloma

A. 2-3-1-4
B. 1-2-3-4 (Correct Answer)
C. 4-2-1-3
D. 1-2-4-3

Explanation: The age of presentation is a high-yield diagnostic clue in orthopaedic oncology. Bone tumors follow a predictable chronological pattern based on skeletal maturity and cellular activity. ### **1. Explanation of the Correct Sequence (1-2-3-4)** The correct order follows the natural progression from childhood to old age: * **Ewing’s Sarcoma (5–15 years):** Primarily affects children and young adolescents. It arises from neuroectodermal cells in the diaphysis of long bones. * **Osteosarcoma (10–25 years):** The most common primary malignant bone tumor, peaking during the adolescent growth spurt (puberty) when osteoblastic activity is maximal. * **Osteoclastoma (Giant Cell Tumor) (20–40 years):** Occurs after epiphyseal closure in young adults. It is a characteristic epiphyseal tumor. * **Multiple Myeloma (>50–60 years):** A plasma cell dyscrasia and the most common primary bone malignancy overall in adults, rarely seen before age 40. ### **2. Why Other Options are Incorrect** * **Option A & C:** These place Osteosarcoma or Multiple Myeloma before Ewing’s Sarcoma. Ewing’s is classically the "youngest" malignant bone tumor in this list. * **Option D:** This incorrectly places Multiple Myeloma before Osteoclastoma. Multiple Myeloma is a disease of the elderly, whereas GCT (Osteoclastoma) is a disease of the "skeletally mature" young adult. ### **3. NEET-PG High-Yield Clinical Pearls** * **Ewing’s Sarcoma:** Look for "Onion-peel" periosteal reaction and $t(11;22)$ translocation. * **Osteosarcoma:** Look for "Sunburst" appearance and Codman’s triangle; usually involves the metaphysis. * **Osteoclastoma:** Characterized by "Soap-bubble" appearance on X-ray; it is the only tumor that consistently involves the **epiphysis**. * **Multiple Myeloma:** Look for "Punched-out" lytic lesions and a "M-spike" on serum electrophoresis. **Note:** Bone scans are usually negative in Multiple Myeloma (cold scan).

Question 13: Which of the following is true regarding osteosarcoma?

A. It occurs because of proliferation of osteoclasts.
B. Sunray appearance in X-ray indicates new bone formation. (Correct Answer)
C. It mainly affects males in the 5th or 6th decade.
D. Lymphatic metastasis is most common.

Explanation: **Explanation:** **Osteosarcoma** is the most common primary malignant bone tumor in children and young adults. 1. **Why Option B is Correct:** The characteristic **"Sunray" or "Sunburst" appearance** on X-ray is a classic radiological sign. It occurs due to a rapid, aggressive periosteal reaction. As the tumor grows, it lifts the periosteum and stimulates the formation of thin bony spicules (calcified osteoid) perpendicular to the bone surface. This represents **new bone formation** within the soft tissue component of the tumor. 2. **Why Other Options are Incorrect:** * **Option A:** Osteosarcoma is characterized by the proliferation of malignant mesenchymal cells that produce **osteoid** (immature bone). It is a tumor of **osteoblasts**, not osteoclasts. * **Option C:** It has a bimodal age distribution but primarily affects the **2nd decade of life** (10–20 years). A smaller second peak occurs in the elderly, usually secondary to Paget’s disease or radiation. * **Option D:** Like most sarcomas, osteosarcoma spreads primarily via the **hematogenous route**. The **lungs** are the most common site of metastasis. Lymphatic spread is rare (occurring in <5% of cases). **High-Yield NEET-PG Pearls:** * **Location:** Most common at the **metaphysis** of long bones (especially around the knee: distal femur and proximal tibia). * **Radiological Signs:** Look for **Codman’s Triangle** (lifting of the periosteum) and the Sunray appearance. * **Gold Standard Investigation:** Biopsy. * **Serum Marker:** Elevated **Alkaline Phosphatase (ALP)** and LDH levels correlate with tumor burden and prognosis. * **Treatment:** Neoadjuvant chemotherapy → Limb salvage surgery → Adjuvant chemotherapy.

Question 14: Which of the following statements is NOT true about Chondroblastoma?

A. Shows a chicken wire appearance
B. Also known as Codman's tumor
C. Typically an epiphyseal tumor
D. Is treated by chemotherapy (Correct Answer)

Explanation: **Explanation:** **Chondroblastoma** is a rare, benign, but locally aggressive primary bone tumor. The correct answer is **D** because Chondroblastoma is **not treated by chemotherapy**. As a benign lesion, the standard treatment is **surgical (extended curettage and bone grafting)**. Chemotherapy is reserved for malignant systemic tumors, which Chondroblastoma is not. **Analysis of Options:** * **Option A (Chicken wire appearance):** This is a classic histopathological hallmark. It refers to the fine, lace-like pattern of calcification surrounding individual chondroblasts. * **Option B (Codman’s tumor):** Chondroblastoma is eponymously known as Codman’s tumor, named after Ernest Amory Codman who first characterized it in the 1930s. * **Option C (Epiphyseal tumor):** This is one of the few tumors that characteristically arise in the **epiphysis** (or apophysis) of long bones in skeletally immature patients. **High-Yield Clinical Pearls for NEET-PG:** * **Age Group:** Typically occurs in the 2nd decade of life (10–20 years), before the closure of the growth plate. * **Common Sites:** Proximal humerus (most common), distal femur, and proximal tibia. * **Radiology:** Appears as a well-defined, eccentric, lytic lesion in the epiphysis with a thin sclerotic rim. * **Histology:** Features "cobblestone" appearance of polyhedral chondroblasts and characteristic **chicken-wire calcification**. * **Differential Diagnosis:** Giant Cell Tumor (occurs in adults after physis closure) and Clear Cell Chondrosarcoma.

Question 15: What is the recommended management plan for osteogenic sarcoma of the lower end of the femur?

A. Surgery alone
B. Chemotherapy and radiotherapy
C. Radiotherapy, amputation, and chemotherapy
D. Chemotherapy and limb salvage surgery (Correct Answer)

Explanation: **Explanation:** Osteogenic sarcoma (Osteosarcoma) is the most common primary malignant bone tumor in children and young adults, typically occurring at the metaphysis of long bones (most commonly the distal femur). **1. Why Option D is Correct:** The current "Gold Standard" for managing Osteosarcoma is a **multimodal approach**. This involves: * **Neoadjuvant Chemotherapy:** Administered before surgery to shrink the primary tumor and treat micrometastases (which are present in 80-90% of patients at diagnosis). * **Surgical Resection:** With modern imaging and chemotherapy, **Limb Salvage Surgery (LSS)** is now possible in 80-90% of cases, replacing amputation. * **Adjuvant Chemotherapy:** Administered post-operatively to ensure complete eradication of systemic disease. **2. Why Other Options are Wrong:** * **Option A (Surgery alone):** Before the era of chemotherapy, surgery alone had a 5-year survival rate of only 10-20% due to inevitable pulmonary metastasis. * **Option B & C (Radiotherapy):** Osteosarcoma is a **radioresistant** tumor. Radiotherapy is only used for palliation or in sites where surgical resection is impossible (e.g., certain spinal or pelvic lesions). Amputation (Option C) is now reserved only for cases where the neurovascular bundle is involved or a functional limb cannot be reconstructed. **3. High-Yield Clinical Pearls for NEET-PG:** * **Age:** Bimodal distribution (10–20 years; >60 years associated with Paget’s disease). * **X-ray Findings:** Sunburst appearance and Codman’s triangle (periosteal reaction). * **Biochemical Marker:** Elevated **Alkaline Phosphatase (ALP)** and LDH correlate with tumor burden and prognosis. * **Most Common Site of Metastasis:** Lungs (via hematogenous spread). * **Most Common Subtype:** Conventional intramedullary osteosarcoma.

Question 16: Which bone pathology do patients with Maffucci syndrome and Ollier disease present with?

A. Osteochondroma
B. Enchondromas (Correct Answer)
C. Ewing's sarcoma
D. Osteosarcoma

Explanation: **Explanation:** The correct answer is **Enchondromas**. Both Ollier disease and Maffucci syndrome are non-hereditary skeletal disorders characterized by **multiple enchondromas** (enchondromatosis). Enchondromas are benign hyaline cartilage tumors that develop within the medullary cavity of bones, typically involving the small bones of the hands and feet. * **Ollier Disease:** Characterized by multiple enchondromas with an asymmetrical distribution. It carries a significant risk (approx. 25-30%) of malignant transformation into chondrosarcoma. * **Maffucci Syndrome:** Characterized by multiple enchondromas associated with **soft tissue hemangiomas** (often appearing as blue nodules on the skin). This syndrome has a higher risk of malignancy, including chondrosarcoma and visceral cancers (e.g., ovarian or liver). **Analysis of Incorrect Options:** * **A. Osteochondroma:** These are cartilage-capped bony outgrowths (exostoses) seen in **Hereditary Multiple Exostoses (HME)**, not Ollier or Maffucci. * **C & D. Ewing’s Sarcoma / Osteosarcoma:** These are primary malignant bone tumors. While patients with enchondromatosis are at increased risk for secondary malignancies, the defining pathology of these syndromes is the benign enchondroma. **NEET-PG High-Yield Pearls:** * **Genetics:** Both conditions are associated with somatic mutations in **IDH1 or IDH2** genes. * **Radiology:** Enchondromas show a "popcorn calcification" or "rings and arcs" pattern on X-ray. * **Clinical Tip:** If a patient with known Ollier disease presents with new-onset pain or rapid growth of a lesion, suspect transformation to **Chondrosarcoma**.

Question 17: All the statements are true about exostosis, EXCEPT:

A. Growth continues after skeletal maturity (Correct Answer)
B. It is covered by cartilaginous cap
C. Malignant transformation may occur
D. A sexually transmitted disorder

Explanation: **Explanation:** **Exostosis (Osteochondroma)** is the most common benign bone tumor. It is a developmental anomaly where a portion of the epiphyseal growth plate becomes displaced and grows as a bony outgrowth covered by a cartilaginous cap. **1. Why Option A is the Correct Answer (The Exception):** The growth of an exostosis is strictly linked to the activity of the epiphyseal plate. Therefore, **growth typically ceases once skeletal maturity is reached** (when the growth plates close). If an osteochondroma begins to grow or becomes painful in an adult after skeletal maturity, it is a major "red flag" for malignant transformation into a chondrosarcoma. **2. Analysis of Other Options:** * **Option B:** True. By definition, an osteochondroma is a bony prominence covered by a **cartilaginous cap**. The thickness of this cap (usually <1 cm) is monitored; a cap thicker than 2 cm in adults suggests malignancy. * **Option C:** True. While rare in solitary lesions (<1%), **malignant transformation** can occur. The risk increases to 5-10% in patients with Hereditary Multiple Exostoses (HME). * **Option D:** True (in a specific context). While "Exostosis" usually refers to bone tumors, the term **"Genital Exostosis"** is an archaic/alternative name sometimes used for genital warts (Condyloma acuminatum), which are sexually transmitted. In the context of standard Orthopaedic MCQ patterns, this option is often included as a distractor or to acknowledge the dual nomenclature. **High-Yield Clinical Pearls for NEET-PG:** * **Direction of Growth:** The tumor always grows **away from the joint** (metaphyseal location). * **Radiological Feature:** Pathognomonic sign is **corticomedullary continuity** (the cortex and medulla of the tumor are continuous with the host bone). * **Common Site:** Lower end of the femur and upper end of the tibia (around the knee). * **Genetics:** Associated with mutations in **EXT1 and EXT2** genes.

Question 18: Ewing's sarcoma arises from which type of cells?

A. Totipotent cells
B. Blastemal cells
C. Neuroectodermal cells (Correct Answer)
D. Mesodermal cells

Explanation: ### Explanation **Correct Answer: C. Neuroectodermal cells** Ewing’s Sarcoma is a highly malignant primary bone tumor. Historically, its origin was debated, but modern immunohistochemistry and molecular studies have confirmed its **neuroectodermal origin**. It belongs to the **Ewing Family of Tumors (EFT)**, which includes Peripheral Primitive Neuroectodermal Tumors (PNET). These cells are derived from the neural crest. The tumor cells characteristically express **CD99 (MIC2 gene product)** on their surface and often show neural differentiation (e.g., Homer-Wright rosettes). **Why other options are incorrect:** * **A. Totipotent cells:** These are undifferentiated cells (like a zygote) capable of forming any cell type in the body. They are not the specific origin of Ewing’s. * **B. Blastemal cells:** These are primordial cells typically associated with embryonal tumors like Wilms’ tumor (nephroblastoma), not Ewing’s sarcoma. * **D. Mesodermal cells:** While most bone tumors (like Osteosarcoma) arise from mesenchymal/mesodermal lineages, Ewing’s is unique due to its neuroectodermal markers, distinguishing it from classic mesodermal bone cancers. --- ### High-Yield Clinical Pearls for NEET-PG: * **Genetics:** Associated with **t(11;22)** translocation, leading to the **EWS-FLI1** fusion gene (found in >90% of cases). * **Age & Site:** Most common in the first and second decades of life; typically involves the **diaphysis** of long bones (e.g., Femur). * **Radiology:** Characterized by a **"moth-eaten"** lytic appearance and **"onion-peel"** periosteal reaction. * **Histology:** Features **Small Round Blue Cells** that are **PAS positive** (due to cytoplasmic glycogen). * **Clinical Presentation:** Often mimics osteomyelitis (presents with pain, swelling, fever, and elevated ESR).

Question 19: An 8-year-old boy presents with a gradually progressing swelling and pain over the upper tibia for the past 6 months. An X-ray reveals an lytic lesion with sclerotic margins in the upper tibial metaphysis. What is the most likely diagnosis?

A. Osteogenic carcinoma
B. Osteoclastoma
C. Brodie's abscess (Correct Answer)
D. Ewing's sarcoma

Explanation: ### Explanation **Correct Answer: C. Brodie's abscess** **Why it is correct:** Brodie’s abscess is a form of **subacute or chronic osteomyelitis**. It typically presents in children and young adults (most commonly males) as a localized, dull aching pain and swelling. The classic radiological hallmark is a **lytic lesion with well-defined sclerotic margins**, representing the body's attempt to wall off the infection. It most frequently involves the **metaphysis** of long bones, with the **tibia** being the most common site. **Why other options are incorrect:** * **A. Osteogenic Sarcoma (Osteosarcoma):** This is a highly malignant tumor characterized by bone destruction and new bone formation. Radiologically, it typically shows a "Sunburst appearance" or "Codman’s triangle" rather than well-defined sclerotic margins. * **B. Osteoclastoma (Giant Cell Tumor):** This usually occurs in a slightly older age group (20–40 years). Crucially, it is an **epiphyseal** lesion that is "eccentric" and has a "soap-bubble appearance" without sclerotic margins. * **D. Ewing’s Sarcoma:** This is a malignant tumor of the **diaphysis** (shaft). It typically presents with systemic symptoms (fever, high ESR) and an "onion-peel" periosteal reaction on X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogen:** *Staphylococcus aureus* is the most common organism isolated. * **Pathognomonic sign:** A "cloaca" or a "tortuous channel" leading to the growth plate may sometimes be seen. * **Differential Diagnosis:** Often confused with Osteoid Osteoma; however, Osteoid Osteoma has a smaller nidus (<2cm) and pain is characteristically relieved by NSAIDs/Aspirin. * **Treatment:** Surgical curettage and antibiotics.

Question 20: According to a newer hypothesis, Ewing's sarcoma arises from which part of the bone?

A. Epiphysis
B. Diaphysis
C. Medullary cavity (Correct Answer)
D. Cortex

Explanation: **Explanation:** **1. Why Medullary Cavity is Correct:** Traditionally, Ewing’s sarcoma was described as a tumor of the **diaphysis** (shaft) of long bones. However, modern pathological and radiological hypotheses emphasize that the tumor originates within the **medullary cavity** (bone marrow space). It arises from primitive neuroectodermal cells or mesenchymal stem cells located in the marrow. As the tumor grows, it permeates the Haversian canals to reach the subperiosteal space, creating the characteristic "onion-skin" periosteal reaction. **2. Why Other Options are Incorrect:** * **Diaphysis (Option B):** While this is the most common *location* along the longitudinal axis of the bone, it describes the anatomical region rather than the specific tissue of origin. Newer hypotheses focus on the intramedullary start of the lesion. * **Epiphysis (Option A):** This is the site for tumors like Giant Cell Tumor (GCT) or Chondroblastoma. Ewing’s sarcoma rarely involves the epiphysis primarily. * **Cortex (Option D):** Primary cortical tumors are rare (e.g., Osteoid Osteoma). Ewing’s sarcoma involves the cortex secondarily via destruction and permeation from the medulla. **3. Clinical Pearls for NEET-PG:** * **Genetics:** Associated with **t(11;22)** translocation involving the **EWS-FLI1** gene. * **Radiology:** Characterized by a **"moth-eaten"** appearance and **"onion-peel"** periosteal reaction. * **Histology:** Shows **Small Round Blue Cells**; PAS positive (due to glycogen) and **CD99 (MIC2)** positive. * **Clinical Presentation:** Often mimics osteomyelitis (fever, raised ESR, local pain). * **Most common site:** Femur (overall), but it is the most common tumor of the **flat bones** (pelvis) in children.

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Classification of Bone Tumors

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Benign Bone Tumors

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Malignant Primary Bone Tumors

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Metastatic Bone Disease

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Tumor-Like Lesions of Bone

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Soft Tissue Tumors

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Evaluation and Staging of Bone Tumors

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Biopsy Principles

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Limb Salvage Surgery

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Amputation for Bone Tumors

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Adjuvant Therapies

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Surveillance and Follow-up

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Bone Tumors — MCQs

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