Bone Tumors Practice Questions

Q: All of the following are true about Ewing's sarcoma, EXCEPT

Common in 4th decade. ***Common in 4th decade*** - Ewing's sarcoma is most common in **children and adolescents**, typically presenting between 10 and 20 years of age, making it rare in the fourth decade. - It is the **second most common primary bone tumor** in children, after osteosarcoma. *Responds well to radiotherapy* - Ewing's sarcoma cells are highly **radiosensitive**, making radiotherapy a crucial component of its multimodal treatment. - Both **local control** and **palliation** can often be achieved with radiation therapy, even in metastatic disease. *Grows in diaphysis of long bones* - Ewing's sarcoma characteristically arises in the **diaphysis (shaft)** or metadiaphysis of long bones, such as the femur and tibia. - The tumor's origin in the diaphysis is a key distinguishing feature from other bone tumors that often originate in the metaphysis. *Has onion peel appearance on radiograph* - The classic radiographic sign of Ewing's sarcoma is a **multilaminated periosteal reaction**, which creates a characteristic **"onion peel" appearance** due to new bone formation. - This appearance reflects the aggressive nature of the tumor, as it repeatedly breaches the cortex, stimulating new layers of periosteal bone.

Q: A 28-year-old lady presented with wrist pain. X-ray of the wrist shows a lytic eccentric lesion in the lower end of the radius with a soap bubble appearance. What is the next plan of management?

Biopsy of the lesion. ***Biopsy of the lesion*** - A definitive **diagnosis is crucial** before any surgical intervention for a bone lesion, especially one with a characteristic appearance like "soap bubble." Biopsy will confirm the nature of the lesion, ruling out malignancy and guiding treatment. - The presented lesion, with its **lytic, eccentric, soap-bubble appearance** in the lower radius of a young adult, is highly suggestive of a **giant cell tumor (GCT)**. However, other diagnoses like chondroblastoma or aneurysmal bone cyst (ABC) can also mimic this appearance. *Extended curettage with phenol* - This is a treatment option for certain benign aggressive bone tumors like **giant cell tumors** after diagnosis, not the initial diagnostic step. - Performing this procedure without a **histological diagnosis** could lead to inappropriate treatment for other possible lesions. *Bone curettage and bone grafting* - This is a surgical treatment method typically used for **benign bone tumors** to remove the lesion and fill the defect, but it is performed after a definitive diagnosis. - **Performing it blindly** without knowing the exact pathology carries the risk of inadequate treatment or unnecessary surgery for a lesion that might require different management. *Extended curettage with phenol and bone grafting* - This comprehensive treatment often follows a **confirmed diagnosis** of an aggressive but benign bone tumor like GCT to minimize recurrence. - It is not the **initial diagnostic step** and carries risks if the underlying pathology is not accurately identified.

Q: A 19-year-old male has a small circumscribed sclerotic swelling over the diaphysis of femur, likely diagnosis is:

Osteoid osteoma. ***Osteoid osteoma*** - A **small, circumscribed sclerotic swelling** on the diaphysis of the femur in a young male is highly classic for an **osteoid osteoma**. - This benign bone tumor is characterized by a small, radiolucent nidus surrounded by dense sclerotic bone, often causing nocturnal pain relieved by NSAIDs. *Giant cell tumor* - Typically found in the **epiphyseal-metaphyseal regions** of long bones, particularly around the knee, in individuals aged 20-40 years. - Presents as an **osteolytic (radiolucent)** lesion, not slerotic, and can be locally aggressive. *Osteosarcoma* - A highly malignant tumor that typically arises in the **metaphysis** of long bones, especially around the knee, in adolescents and young adults. - Radiographically, it often shows a mixture of **sclerotic and lytic lesions**, with characteristic features like a **sunburst pattern** or **Codman's triangle**. *Ewing sarcoma* - Most commonly affects the **diaphysis of long bones** and flat bones in children and young adults. - Radiographically, it often presents with an **"onion-skin" periosteal reaction** due to layers of new bone formation, and it is typically an aggressive, lytic lesion.

Q: True about osteoid osteoma is

Radiolucent zone surrounded by sclerosis. ***Radiolucent zone surrounded by sclerosis*** - A characteristic radiological feature of **osteoid osteoma** is a small, central **radiolucent nidus** (the tumor itself) surrounded by a dense area of reactive **sclerosis**. - This **sclerosis** is the body's response to the tumor, attempting to wall it off. *Onset before the age of 10 years* - **Osteoid osteoma** typically presents in individuals between **10 and 20 years of age**, with a peak incidence in the second decade of life. - While it can occur at any age, presentation before age 10 is less common. *Night pain not relieved by salicylates* - The classic pain associated with **osteoid osteoma** is **worse at night** and (importantly) **dramatically relieved by NSAIDs**, particularly salicylates such as aspirin. - Pain *not* relieved by salicylates would argue against this diagnosis. *Bone scan shows decreased uptake* - A **bone scan** would typically show **increased uptake** in the area of an **osteoid osteoma** due to the intense osteoblastic activity and increased blood flow within the lesion. - Decreased uptake would be highly unusual and suggest other pathologies.

Q: An 8 yr old child is having fever with pain and swelling in mid thigh. On Xray lamellated appearance and Codman's triangle is present. Histopathologic examination shows small round cells positive for MIC-2. What is the most likely diagnosis?

Ewings sarcoma. ***Ewings sarcoma*** - The combination of **fever with pain and swelling** in a child, **lamellated (onion-skin) periosteal reaction**, **Codman's triangle** on X-ray, and **small round cells positive for MIC-2 (CD99)** on histopathology is classic for Ewing's sarcoma. - This highly aggressive bone tumor primarily affects children and young adults, often presenting with systemic symptoms and a diaphyseal or metadiaphyseal location in long bones. *Chondrosarcoma* - This tumor is characterized by the production of **cartilage matrix** and typically affects older adults (40-70 years old), not children. - Radiographically, it often shows **calcifications with rings and arcs** within a lucent lesion, and histopathology reveals chondrocytes, not small round cells positive for MIC-2. *Chondroblastoma* - Chondroblastoma is a rare, **benign cartilage tumor** that typically occurs in the **epiphysis of long bones** in adolescents and young adults. - It usually presents as a well-defined lytic lesion and does not typically show lamellated periosteal reactions or positive MIC-2 staining, nor does it commonly present with fever. *Osteosarcoma* - While osteosarcoma is also an aggressive bone tumor affecting children and adolescents, it is characterized by the production of **osteoid (immature bone)**. - Radiographically, it often presents with a **"sunburst" pattern** due to spiculated periosteal reaction and a **Codman's triangle**, but histopathology shows malignant osteoblasts, not small round cells positive for MIC-2.

Q: True statements about hemangioma of bone: a) Mostly symptomatic b) Peak incidence in 5th decade c) Constitute 1-1.5% of total bone tumors d) Overgrowth of bone occurs

bd. ***bd*** - **Overgrowth of bone** can occur in response to the presence of a hemangioma, particularly in vertebral bodies. - The peak incidence of bone hemangiomas is indeed in the **5th decade**, though they can be found at any age. *ac* - Hemangiomas of bone are generally **asymptomatic** and are often incidental findings. - While they are benign tumors, they constitute a relatively **small percentage** of bone tumors, with 1-1.5% being a reasonable estimate. *ab* - As mentioned, bone hemangiomas are typically **asymptomatic**, not mostly symptomatic. - The **peak incidence in the 5th decade** is correct. *ad* - Hemangiomas of bone are usually **asymptomatic**, not mostly symptomatic. - **Overgrowth of bone** is a recognized feature, especially in vertebrae. *c* - While hemangiomas do constitute a small percentage of total bone tumors, this option is incomplete as **overgrowth of bone** and **peak incidence in the 5th decade** are also true statements.

Q: Osteomyelitis can mimic which of the following tumor?

Ewing sarcoma. ***Ewing sarcoma*** - Both osteomyelitis and Ewing sarcoma can present with **fever**, **pain**, **swelling**, and **elevated inflammatory markers**. - Radiographically, both conditions can show **periosteal reactions**, **bone destruction**, and **soft tissue masses**, making differentiation challenging without biopsy. *Chondroma* - Chondromas are **benign cartilage tumors** typically presenting as asymptomatic lesions or with mild pain if large. - They lack the inflammatory signs and rapid progression seen in osteomyelitis. *Osteoclastoma* - Osteoclastomas (also known as giant cell tumors of bone) are typically **lucent, aggressive lesions** found in the epiphysis of long bones, often presenting with pain and swelling. - While they can be aggressive, they generally do not present with the systemic inflammatory response or infectious signs characteristic of osteomyelitis. *None of the options* - This option is incorrect because Ewing sarcoma shares significant clinical and radiological features with osteomyelitis, making it a well-known mimic.

Q: Codman triangle is seen in

Osteosarcoma. ***Osteosarcoma*** - A **Codman triangle** is a **periosteal reaction** seen on X-rays, characterized by a triangular elevation of the **periosteum** away from the bone cortex due to rapid growth of a tumor. - **Osteosarcoma** is the **most classic** association with Codman triangle among aggressive bone tumors. - This is the **most common primary malignant bone tumor** and typically occurs in the metaphysis of long bones (around the knee). *Madura foot* - This is a chronic granulomatous infection of the foot (mycetoma), typically characterized by **multiple draining sinuses** and **granuloma formation**, not periosteal elevation. - Radiographically, it shows **soft tissue swelling**, **bone destruction**, and **osteomyelitis**, but not a Codman triangle. *Ewing's sarcoma* - This aggressive tumor **can also show Codman triangle** as it grows rapidly and elevates the periosteum. - However, it is **more characteristically** associated with an **"onion peel" periosteal reaction** (concentric layers of new bone formation). - While both tumors can show Codman triangle, **osteosarcoma remains the most classic association** in medical literature and exam questions. *Giant cell tumor* - This is a benign but locally aggressive tumor typically found in the **epiphysis** of long bones (after physeal closure). - Radiographically, it appears as an **eccentric, expansile, "soap bubble" lytic lesion** without a prominent periosteal reaction like a Codman triangle. - The tumor is **subarticular** and **non-sclerotic**, extending to the articular surface.

Q: Most common site of osteogenic sarcoma is:

Femur, lower end. ***Femur, lower end*** - The **distal femur** is the most common site for osteogenic sarcoma, accounting for approximately **40% of all cases** [1]. - This region, along with the **proximal tibia**, are the most frequent locations for this primary bone tumor [1]. *Tibia, lower end* - While osteogenic sarcoma can occur in the **tibia**, the **proximal end** is more commonly affected than the distal end. - The distal tibia is a less frequent site compared to the distal femur or proximal tibia. *Femur, upper end* - The **proximal femur** is a recognized site for osteogenic sarcoma, but it is less common than the **distal femur**. - Tumors in the proximal femur account for a smaller percentage of overall osteosarcoma cases. *Tibia, upper end* - The **proximal tibia** is the **second most common site** for osteogenic sarcoma, frequently affected after the distal femur [1]. - However, the question asks for the *most* common site, which remains the distal femur.

Question 1

All of the following are true about Ewing's sarcoma, EXCEPT

Accepted Answer

Common in 4th decade

Answer

Responds well to radiotherapy

Answer

Grows in diaphysis of long bones

Answer

Has onion peel appearance on radiograph

Question 2

Ewing's sarcoma is a PNET (Primitive Neuroectodermal Tumor) that develops in the diaphysis of a long bone. A child with Ewing's sarcoma is on radiotherapy and chemotherapy. Which of the following is a poor prognostic factor in Ewing's sarcoma?

Accepted Answer

Large tumor size (>8cm)

Answer

Age >15 years

Answer

Younger age

Answer

Axial/pelvic location

Question 3

A 28-year-old lady presented with wrist pain. X-ray of the wrist shows a lytic eccentric lesion in the lower end of the radius with a soap bubble appearance. What is the next plan of management?

Accepted Answer

Biopsy of the lesion

Answer

Extended curettage with phenol

Answer

Bone curettage and bone grafting

Answer

Extended curettage with phenol and bone grafting

Question 4

A 19-year-old male has a small circumscribed sclerotic swelling over the diaphysis of femur, likely diagnosis is:

Accepted Answer

Osteoid osteoma

Answer

Giant cell tumor

Answer

Osteosarcoma

Answer

Ewing sarcoma

Question 5

True about osteoid osteoma is

Accepted Answer

Radiolucent zone surrounded by sclerosis

Answer

Onset before the age of 10 years

Answer

Night pain not relieved by salicylates

Answer

Bone scan shows decreased uptake

Question 6

An 8 yr old child is having fever with pain and swelling in mid thigh. On Xray lamellated appearance and Codman's triangle is present. Histopathologic examination shows small round cells positive for MIC-2. What is the most likely diagnosis?

Accepted Answer

Ewings sarcoma

Answer

Chondrosarcoma

Answer

Chondroblastoma

Answer

Osteosarcoma

Question 7

True statements about hemangioma of bone: a) Mostly symptomatic b) Peak incidence in 5th decade c) Constitute 1-1.5% of total bone tumors d) Overgrowth of bone occurs

Accepted Answer

bd

Answer

ac

Answer

ab

Answer

ad

Answer

c

Question 8

Osteomyelitis can mimic which of the following tumor?

Accepted Answer

Ewing sarcoma

Answer

Chondroma

Answer

Osteoclastoma

Answer

None of the options

Question 9

Codman triangle is seen in

Accepted Answer

Osteosarcoma

Answer

Madura foot

Answer

Ewing's sarcoma

Answer

Giant cell tumor

Question 10

Most common site of osteogenic sarcoma is:

Accepted Answer

Femur, lower end

Answer

Tibia, lower end

Answer

Femur, upper end

Answer

Tibia, upper end

Bone Tumors — MCQs

Bone Tumors — MCQs

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