Soft Tissue Tumors — MCQs
What is the best imaging modality for detecting early osteomyelitis?
Which of the following statements about desmoid tumors is incorrect?
Most common malignant tumor of the heart in adults
Which of the following soft tissue sarcomas does not typically have a propensity for lymphatic spread?
The image shows a wrist deformity and an X-ray of a bone lesion near the distal radius. Based on the clinical and radiological features, what is the most likely diagnosis?
What is the treatment of choice in desmoid tumors?
Which of the following is the most frequent tumor of the bone in the hand:
A child 10 yrs of age presents with a mass on his left thigh. The mass seems to be arising from the diaphysis of the femur and involving the soft tissue of the thigh. The child is having fever also. Give your most probable diagnosis -
Which of the following is not a characteristic of malignant lesions?
A 15-year-old boy is injured while playing cricket. X-rays of the leg rule out a possible fracture. The radiologist reports the boy has evidence of aggressive bone tumor with both bone destruction and soft tissue mass. The bone biopsy reveals a bone cancer with neural differentiation. Which of the following is the most likely diagnosis?
Soft Tissue Tumors Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: Which of the following statements about desmoid tumors is incorrect?
- A. Show infiltrative growth pattern
- B. Often seen below the umbilicus
- C. More common in women
- D. Highly radiosensitive (Correct Answer)
Explanation: ***Highly radiosensitive*** - This is the **INCORRECT** statement and hence the correct answer to this question. - Desmoid tumors are **radioresistant**, not radiosensitive, meaning they do not respond well to radiation therapy. - Radiation therapy is typically reserved for cases where surgery is not feasible or for local control after incomplete resection, but it is not highly effective as a standalone treatment. - The radioresistant nature is an important clinical characteristic that influences treatment planning. *Often seen below the umbilicus* - This statement is **correct** about desmoid tumors. - Desmoid tumors frequently arise from the **anterior abdominal wall**, with a common location being below the umbilicus, particularly in postpartum women. - Abdominal wall desmoids are strongly associated with **pregnancy** and trauma, and can be locally aggressive. *Show infiltrative growth pattern* - This statement is **correct** about desmoid tumors. [1] - Desmoid tumors are characterized by their **locally aggressive** and infiltrative growth pattern, often invading adjacent tissues like muscle, fascia, and neurovascular structures. [1] - This infiltrative nature makes complete surgical resection challenging and contributes to a high rate of **local recurrence** (up to 20-40% after surgery). - Despite their aggressive local behavior, desmoid tumors do not metastasize. *More common in women* - This statement is **correct** about desmoid tumors. - Desmoid tumors show a **female predominance**, particularly affecting women during their reproductive years (ages 25-40). - This gender predilection is linked to **hormonal influences**, with increased risk during **pregnancy** and the postpartum period. - The association with estrogen is further supported by occasional tumor regression after menopause. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 691-692.
Question 3: Most common malignant tumor of the heart in adults
- A. Cardiac Sarcoma (Correct Answer)
- B. Paraganglioma
- C. Rhabdomyoma
- D. Lipoma
Explanation: ***Cardiac Sarcoma*** - **Cardiac sarcomas** are the most common type of **primary malignant tumor** of the heart in adults, accounting for about 95% of primary malignant cardiac tumors. - **Angiosarcoma** is the most common subtype (approximately 33-50% of all cardiac sarcomas), typically originating from the **right atrium**. - These tumors are highly aggressive with rapid growth, early metastasis, and poor prognosis. - They commonly present with right-sided heart failure, pericardial effusion, or constitutional symptoms. *Rhabdomyoma* - **Rhabdomyomas** are the most common **primary cardiac tumors in infants and children** (60-80% of pediatric cardiac tumors), not adults. - These tumors are **benign** and strongly associated with tuberous sclerosis. - They often spontaneously regress after birth. *Lipoma* - **Lipomas** are **benign tumors** composed of mature adipocytes and account for about 10% of benign cardiac tumors. - They are typically asymptomatic and found incidentally. - They are not malignant and therefore not relevant to this question about malignant tumors. *Paraganglioma* - **Paragangliomas** (pheochromocytomas of the heart) are rare neuroendocrine tumors. - They are typically **benign** (though can be locally invasive) and may be hormonally active, causing catecholamine-related symptoms. - They represent less than 1% of cardiac tumors and are not the most common malignant cardiac tumor.
Question 4: Which of the following soft tissue sarcomas does not typically have a propensity for lymphatic spread?
- A. Rhabdomyosarcoma
- B. Synovial sarcoma
- C. Malignant Peripheral Nerve Sheath Tumor (MPNST) (Correct Answer)
- D. Epithelioid sarcoma
Explanation: ***Malignant Peripheral Nerve Sheath Tumor (MPNST)*** - **MPNSTs**, like most soft tissue sarcomas, primarily metastasize hematogenously to the lungs [3], and **lymphatic spread is rare** [1]. - Their origin from peripheral nerves explains their tendency for local invasion and distant blood-borne metastases rather than lymphatic involvement [1]. *Synovial sarcoma* - **Synovial sarcoma** is one of the soft tissue sarcomas that has a **higher propensity for lymphatic spread** compared to many others [2]. - While hematogenous spread is also common, clinicians should always assess regional lymph nodes when evaluating this type of tumor. *Rhabdomyosarcoma* - **Rhabdomyosarcoma** is a highly aggressive tumor, particularly in children, and frequently shows **lymphatic metastasis**, especially in parameningeal, genitourinary, and extremity sites. - Due to its high metastatic potential, regional lymph node involvement is a crucial prognostic factor. *Epithelioid sarcoma* - **Epithelioid sarcoma** is known for its **propensity for both regional lymphatic spread** and local recurrence. - The pattern of spread often mimics carcinomas, making thorough regional lymph node evaluation essential. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1250-1251. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1225-1226. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 282.
Question 5: The image shows a wrist deformity and an X-ray of a bone lesion near the distal radius. Based on the clinical and radiological features, what is the most likely diagnosis?
- A. Ewings Sarcoma
- B. Osteochondroma
- C. Giant Cell Tumor (GCT) (Correct Answer)
- D. Osteoid Osteoma
Explanation: ***Giant Cell Tumor (GCT)*** * The image shows a **lytic (lucid) lesion** located in the **epiphysis/metaphysis of the distal radius**, which is a classic presentation site for GCT. * GCTs are typically seen in individuals aged 20-40, often present with **pain, swelling, and reduced range of motion**, and can show a **soap bubble appearance** on X-ray even with cortical erosion as seen in the image. *Ewing's Sarcoma* * Ewing's Sarcoma commonly affects the **diaphysis of long bones** and may present with an **onion skin periosteal reaction**, none of which are clearly depicted. * It primarily affects children and young adults (5-20 years old), which does not align with the assumed adult presentation given the fused epiphysis. *Osteochondroma* * Osteochondromas are **bony prominences covered by cartilage** and grow **outward from the bone surface**, often away from the joint, unlike the intraosseous lytic lesion seen. * They typically appear as **pedunculated or sessile exostoses** and are benign growth plate abnormalities, not lytic lesions of the marrow cavity. *Osteoid Osteoma* * Osteoid osteomas are characterized by a **small lucent nidus** (usually <1.5 cm) surrounded by a significant margin of **sclerotic bone**, which is not seen here. * They classically cause **nocturnal pain** relieved by NSAIDs and are typically smaller than the lesion depicted, which appears expansile.
Question 6: What is the treatment of choice in desmoid tumors?
- A. Irradiation
- B. Wide excision (Correct Answer)
- C. Local excision
- D. Local excision following radiation
Explanation: ***Wide excision*** - For **desmoid tumors**, **complete surgical resection with clear margins** is the primary treatment of choice due to their infiltrative nature and high recurrence rates. - This approach aims to minimize local recurrence and prevent tumor progression, which can impact adjacent structures. *Irradiation* - **Radiation therapy** is typically reserved as an **adjuvant** treatment after surgery or for unresectable tumors, not as a primary standalone treatment. - While it can help reduce recurrence rates, it carries risks of **secondary malignancies** and local tissue damage. *Local excision* - **Local excision** alone is insufficient for desmoid tumors due to their **infiltrative growth pattern** and high propensity for **local recurrence** if positive margins remain. - It often leads to incomplete removal, necessitating further intervention and increasing the risk of tumor progression. *Local excision following radiation* - Combining local excision with initial radiation is not the preferred sequence; **wide surgical excision** is typically performed first. - Radiation might be considered preoperatively in specific cases to **reduce tumor size** or postoperatively for **positive margins**, but starting with local excision after initial radiation is not the standard primary management.
Question 7: Which of the following is the most frequent tumor of the bone in the hand:
- A. Hemangioma
- B. Ganglion cyst of the bone
- C. Enchondroma (Correct Answer)
- D. Synovioma
Explanation: ***Enchondroma*** - **Enchondromas** are the **most frequent benign tumors** of the bone in the hand, commonly arising from persistent hyaline cartilage rests within the medullary cavity. - They are typically discovered incidentally on radiographs and can present with pain if there's a **pathologic fracture**. *Hemangioma* - **Hemangiomas** are benign vascular tumors more commonly found in the **skull and vertebrae**, and less frequently in the hands. - While they can occur in bone, they are not the most common bone tumor in the hand. *Ganglion cyst of the bone* - An **intraosseous ganglion cyst** is a benign cystic lesion within the bone, typically communicating with a joint or tendon sheath. - While they can occur in the wrist and hand, they are less common than enchondromas as primary bone lesions within the digits. *Synovioma* - **Synovioma** (more accurately called **synovial sarcoma**) is a rare, malignant soft tissue tumor that typically arises near joints, bursae, or tendon sheaths, not primarily within the bone itself. - It is a highly aggressive tumor and not a frequent benign bone tumor of the hand.
Question 8: A child 10 yrs of age presents with a mass on his left thigh. The mass seems to be arising from the diaphysis of the femur and involving the soft tissue of the thigh. The child is having fever also. Give your most probable diagnosis -
- A. Osteosarcoma
- B. Chondrosarcoma
- C. Ewing's sarcoma (Correct Answer)
- D. Malignant fibrous histiocytoma
Explanation: ***Ewing's sarcoma*** - **Ewing's sarcoma** commonly presents in children and adolescents, often involving the **diaphysis of long bones** like the femur. - The presence of a **soft tissue mass** and **fever** are characteristic systemic symptoms due to its aggressive nature and rapid growth. *Osteosarcoma* - While it is a common pediatric bone tumor, **osteosarcoma** typically arises in the **metaphysis** of long bones, not the diaphysis. - Systemic symptoms like fever are less common at presentation compared to Ewing's sarcoma unless there's significant metastatic disease. *Chondrosarcoma* - **Chondrosarcoma** is a malignant tumor of cartilage that usually affects older adults and rarely occurs in children. - It typically affects the **pelvis, shoulder, or long bones**, but a fever and involvement of the soft tissue with a diaphyseal origin are less classic presentation. *Malignant fibrous histiocytoma* - **Malignant fibrous histiocytoma** (now often termed undifferentiated pleomorphic sarcoma) is a tumor of adulthood, primarily affecting individuals over 40 years of age. - While it can involve deep soft tissues and bone, it is an extremely rare diagnosis in a 10-year-old child.
Question 9: Which of the following is not a characteristic of malignant lesions?
- A. Absence of encapsulation
- B. Ulcerated borders
- C. Pear-shaped (Correct Answer)
- D. Ill-defined borders
Explanation: ***Pear-shaped*** - A **pear-shaped** morphology is not a typical characteristic of malignant lesions; they usually present with irregular, ill-defined, or infiltrative shapes [1] - This shape is often associated with benign lesions (e.g., fibroadenoma) or specific types of cysts [2] - Malignant tumors characteristically have **irregular, asymmetric, or spiculated** contours [3] *Absence of encapsulation* - Malignant lesions typically lack a well-defined fibrous capsule, allowing them to **invade surrounding tissues** [1] - This characteristic distinguishes them from most benign tumors, which are often encapsulated [2] - The absence of encapsulation is a hallmark feature of malignant behavior *Ulcerated borders* - Ulceration is a common feature of advanced malignant lesions, indicating rapid growth and tissue destruction [3] - This occurs as the tumor outgrows its blood supply or invades superficial layers, leading to tissue breakdown - Surface ulceration is particularly seen in malignant tumors of skin, GI tract, and mucosal surfaces *Ill-defined borders* - Malignant lesions frequently have **irregular or ill-defined borders** due to their invasive and infiltrative growth patterns [2] - This lack of clear demarcation makes complete surgical removal challenging - On imaging and gross examination, poorly defined margins are a key indicator of malignancy **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 276-278. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 280. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 204-206.
Question 10: A 15-year-old boy is injured while playing cricket. X-rays of the leg rule out a possible fracture. The radiologist reports the boy has evidence of aggressive bone tumor with both bone destruction and soft tissue mass. The bone biopsy reveals a bone cancer with neural differentiation. Which of the following is the most likely diagnosis?
- A. Ewing's sarcoma (Correct Answer)
- B. Osteosarcoma
- C. Neuroblastoma
- D. Chondroblastoma
Explanation: ***Ewing's sarcoma*** - This is an aggressive bone tumor that commonly affects children and adolescents, characterized by **bone destruction** and a **soft tissue mass**. - A key diagnostic feature is its **neural differentiation**, often identified by the presence of a characteristic **t(11;22) translocation**. *Osteosarcoma* - While it is an aggressive bone tumor in adolescents, it primarily demonstrates **osteoid production** rather than neural differentiation [1]. [2] - X-rays typically show a **sunburst appearance** and **Codman's triangle**, which are not specified here [1]. *Neuroblastoma* - This is a pediatric malignancy of the **sympathetic nervous system** that can metastasize to bone, but it originates from neural crest cells and is not primarily a bone tumor. - While it shows neural differentiation, the primary tumor is usually in the **adrenal gland** or sympathetic ganglia, not directly arising from bone. *Chondroblastoma* - This is a rare, benign cartilaginous tumor typically found in the **epiphyses of long bones** in adolescents but is not generally aggressive or associated with neural differentiation. - It involves **cartilage formation**, which is distinct from the aggressive bone destruction and neural features described [2]. **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.
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