Tumor-Like Lesions of Bone — MCQs
Radiographically, the lesion shown in the image could be:
Elderly female present with pain and swelling in the thigh. Xray shows multiple lytic lesions in distal femur with no periosteal reaction. Aspirate from the swelling shows homogenous serosanguinous fluid with RBCs. Which investigation can confirm the diagnosis?
A five-year-old girl is brought to a pediatrician because she is developing breasts. Physical examination shows large hyperpigmented macules with irregular margins on one side of her back. Which of the following bony abnormalities would most likely be associated with these symptoms?
Following are seen in fibrous dysplasia EXCEPT
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 patient with GCT, which of the following is false?
Most common benign tumor of bone?
Most common site of adamantinoma of the long bones is -
A patient presents with pain in the thigh, relieved by aspirin. X-ray shows a radiolucent mass surrounded by sclerosis. Diagnosis is ?
Excretory urography should be cautiously performed in
Tumor-Like Lesions of Bone Indian Medical PG Practice Questions and MCQs
Question 1: Radiographically, the lesion shown in the image could be:
- A. Cherubism
- B. Garre's osteomyelitis (Correct Answer)
- C. Fibrous dysplasia
- D. Osteosarcoma
Explanation: ***Garre's osteomyelitis*** - The radiographs show **periosteal new bone formation** resembling an **"onion skin"** appearance, which is characteristic of **Garre's osteomyelitis** (chronic osteomyelitis with proliferative periostitis). - This condition is typically a **reaction to low-grade chronic infection** or irritation, often seen in the periosteum of the mandible. *Cherubism* - Cherubism is a **fibro-osseous lesion** characterized by bilateral, symmetric enlargement of the jaws, giving a "cherubic" appearance. - Radiographically, it presents as **multilocular radiolucencies** with poorly defined borders, usually in children. *Fibrous dysplasia* - Fibrous dysplasia is a developmental anomaly where normal bone is replaced by **fibrous tissue and immature bone**. - Radiographically, it often has a **"ground glass" appearance** or a "peau d'orange" texture, differentiating it from the periosteal reaction seen in the image. *Osteosarcoma* - Osteosarcoma is a **malignant bone tumor** that typically shows a mix of osteolytic and osteoblastic areas, often with a **"sunburst" or "spiculated" periosteal reaction**. - While it involves periosteal reaction, the pattern and typical aggressive nature differ from the more layered and milder appearance of Garre's osteomyelitis.
Question 2: Elderly female present with pain and swelling in the thigh. Xray shows multiple lytic lesions in distal femur with no periosteal reaction. Aspirate from the swelling shows homogenous serosanguinous fluid with RBCs. Which investigation can confirm the diagnosis?
- A. S. PTH levels
- B. S. Calcium levels
- C. CD1a IHC
- D. Biopsy (Correct Answer)
Explanation: ***Biopsy*** - A biopsy is the **definitive diagnostic tool** for establishing the presence of malignant cells that would cause lytic lesions and serosanguinous fluid in an elderly patient. - The findings of **multiple lytic lesions** in an elderly patient, coupled with serosanguinous fluid, strongly suggest a primary bone tumor or metastatic disease, which can only be confirmed histologically. *S. PTH levels* - **Elevated PTH** levels are indicative of **hyperparathyroidism**, which can cause bone resorption and lytic lesions (osteitis fibrosa cystica). - However, in this case, the fluid aspirate points towards a more localized, possibly neoplastic process rather than a systemic metabolic bone disorder as the primary concern. *S. Calcium levels* - **Hypercalcemia** can be associated with lytic bone lesions, particularly in cases of malignancy (e.g., **multiple myeloma** or **metastatic cancer**). - While supportive, calcium levels alone are insufficient to **confirm the specific diagnosis** of the underlying cause of the lytic lesions. *CD1a IHC* - **CD1a immunohistochemistry** is primarily used to diagnose **Langerhans cell histiocytosis**, a condition typically seen in children and young adults. - Given the patient's age and the imaging findings of multiple lytic lesions, Langerhans cell histiocytosis is an unlikely diagnosis, making CD1a IHC not the primary or confirming investigation.
Question 3: A five-year-old girl is brought to a pediatrician because she is developing breasts. Physical examination shows large hyperpigmented macules with irregular margins on one side of her back. Which of the following bony abnormalities would most likely be associated with these symptoms?
- A. Excessive bony deposition with obliteration of marrow
- B. A combination of osteitis fibrosa cystica and osteomalacia
- C. A generalized thinning of bony spicules
- D. Multiple localized whorls of connective tissue (Correct Answer)
Explanation: ***Multiple localized whorls of connective tissue*** - This constellation of symptoms (precocious puberty, hyperpigmented macules with irregular margins, and bony abnormalities) is characteristic of **McCune-Albright syndrome** [1]. - The bony abnormality associated with McCune-Albright syndrome is **fibrous dysplasia**, which is characterized by the replacement of normal bone with **fibrous tissue** and immature woven bone, often described as localized whorls of connective tissue [1]. *A combination of osteitis fibrosa cystica and osteomalacia* - **Osteitis fibrosa cystica** is associated with severe **hyperparathyroidism**, leading to bone resorption and cyst formation. - **Osteomalacia** results from defective mineralization of bone due to **vitamin D deficiency** or phosphate wasting, neither of which comprehensively explains the given symptoms. *A generalized thinning of bony spicules* - This description is characteristic of **osteoporosis**, a condition of reduced bone mass and structural deterioration, leading to increased fracture risk. - Osteoporosis is typically seen in older adults and is not directly associated with precocious puberty or café-au-lait spots. *Excessive bony deposition with obliteration of marrow* - This describes **osteopetrosis** (Albers-Schönberg disease), a genetic disorder characterized by abnormally dense bones due to defective osteoclast function. - While it affects bone, its presentation does not include precocious puberty or hyperpigmented macules. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1208-1209.
Question 4: Following are seen in fibrous dysplasia EXCEPT
- A. No premalignant change (Correct Answer)
- B. Ground glass appearance on X-ray
- C. Expanding rib lesions
- D. Expanding lesions of maxilla
Explanation: ***No premalignant change*** - Fibrous dysplasia is a **benign condition** that does NOT undergo premalignant change [1]. - However, there is a small but definite risk of **malignant transformation** (not premalignant change), particularly to **osteosarcoma**, in about 0.5% of cases [1]. - This risk is higher in patients who have received **radiation therapy** for the condition. - **Key distinction**: Malignant transformation is different from premalignant change—fibrous dysplasia remains benign but can rarely transform directly to malignancy [1]. *Ground glass appearance on X-ray* - This is a **classic radiographic feature** of fibrous dysplasia, resulting from immature woven bone and fibrous tissue within the lesion [2]. - It describes the hazy, ill-defined radiodensity due to the lack of organized trabeculae. *Expanding rib lesions* - Fibrous dysplasia frequently affects the **ribs**, leading to their expansion and potential for pathological fractures [1]. - Rib involvement is particularly common in the **monostotic form** of the disease [1]. *Expanding lesions of maxilla* - The **maxilla** is a common site for fibrous dysplasia, especially in the **craniofacial form**. - Maxillary lesions can cause expansion, facial asymmetry, and dental abnormalities. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1208. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1208-1209.
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: A patient with GCT, which of the following is false?
- A. Defined margins
- B. Chemotherapy is the mainstay of treatment (Correct Answer)
- C. Epiphyseo-metaphyseal location
- D. Eccentric
Explanation: ***Chemotherapy is the mainstay of treatment*** - This statement is **false** because **Giant Cell Tumor of Bone (GCT)** therapy primarily involves **surgical resection**, with or without adjuvant therapies like **denosumab**. - **Chemotherapy** is generally *not* the first-line treatment for GCT, as these tumors respond poorly to it; it's usually reserved for cases of **metastatic GCT** or when other treatments fail. *Defined margins* - GCTs often present radiographically with **well-defined, non-sclerotic margins**, which indicates a lytic lesion that is often locally aggressive but typically doesn't invade widely. - While they are locally destructive, their borders are usually visible, helping distinguish them from other bone tumors. *Epiphyseo-metaphyseal location* - GCTs commonly originate in the **metaphysis** of long bones and **extend into the epiphysis** after the growth plate has closed. - This characteristic location near a joint is a classic diagnostic feature of GCT, especially in adults. *Eccentric* - GCTs typically arise **eccentrically** within the bone, meaning they originate off-center in the bone marrow cavity before expanding and thinning the cortex. - This eccentric growth pattern is a distinguishing feature, particularly in contrast to other bone tumors which might be centrally located.
Question 7: Most common benign tumor of bone?
- A. Osteoma
- B. Simple bone cyst
- C. Osteochondroma (Correct Answer)
- D. Osteoid osteoma
Explanation: ***Osteochondroma*** - This is the **most common benign bone tumor**, characterized by a bony spur with a cartilaginous cap. - It typically arises from the **metaphysis of long bones**, especially around the knee. *Osteoma* - Osteomas are **benign, slow-growing tumors** composed of mature compact or cancellous bone. - They are most commonly found in the **skull and facial bones**, not typically in long bones. *Simple bone cyst* - This is a **fluid-filled lesion** of bone, not a true neoplasm, frequently found in the metaphysis of long bones in children. - It is often discovered incidentally or after a **pathological fracture**. *Osteoid osteoma* - Characterized by a **small, benign bone tumor** with a central nidus of osteoid and trabecular bone, surrounded by reactive sclerotic bone. - It classically causes **nocturnal pain** that is relieved by NSAIDs.
Question 8: Most common site of adamantinoma of the long bones is -
- A. Tibia (Correct Answer)
- B. Ulna
- C. Fibula
- D. Femur
Explanation: ***Tibia*** - Adamantinoma is a rare, malignant bone tumor that has a strong predilection for the **tibia**, accounting for approximately 85-90% of cases in long bones. - It most commonly occurs in the **diaphysis of the tibia** but can also be found in the metaphysis. *Ulna* - While adamantinoma can rarely affect other long bones, the **ulna is not a common site** for its occurrence. - The incidence of adamantinoma in the upper extremities, including the ulna, is significantly lower compared to the tibia. *Fibula* - The **fibula is an uncommon site** for adamantinoma, with only a small percentage of cases reported in this bone. - When it does occur in the fibula, it usually involves the mid-diaphysis. *Femur* - The **femur is also a rare location** for adamantinoma, with only a handful of cases documented in medical literature. - The vast majority of adamantinomas consistently originate in the lower leg, particularly the tibia.
Question 9: A patient presents with pain in the thigh, relieved by aspirin. X-ray shows a radiolucent mass surrounded by sclerosis. Diagnosis is ?
- A. Osteoma
- B. Osteoclastoma
- C. Osteoblastoma
- D. Osteoid osteoma (Correct Answer)
Explanation: ***Osteoid osteoma*** - Characterized by **pain that is classically relieved by aspirin or NSAIDs**, due to high prostaglandin production within the lesion. - Radiographically, it appears as a **small radiolucent nidus (lesion) less than 2 cm**, surrounded by a dense sclerotic bone reaction. *Osteoma* - This is a **benign tumor of mature bone**, most commonly found on the skull and facial bones. - It typically presents as a **hard, solitary, immobile mass** and is usually asymptomatic, not causing pain relieved by aspirin. *Osteoclastoma* - Also known as a **giant cell tumor of bone**, it is a locally aggressive tumor. - It typically affects the **epiphysis and metaphysis of long bones** (e.g., around the knee) and is not characteristically relieved by aspirin. *Osteoblastoma* - This is a **larger variant of osteoid osteoma** (>2 cm), also bone-forming, but the pain is generally less responsive to aspirin, and it tends to be more aggressive. - It is more commonly found in the **spine and sacrum**, unlike the thigh in this case.
Question 10: Excretory urography should be cautiously performed in
- A. Bone metastases
- B. Neuroblastoma
- C. Leukemia
- D. Multiple myeloma (Correct Answer)
Explanation: ***Multiple myeloma*** - Excretory urography (intravenous pyelography or IVP) involves the administration of **iodinated contrast media**, which can precipitate **Bence Jones proteins** in the renal tubules, leading to or worsening **acute kidney injury** in patients with multiple myeloma. - Patients with multiple myeloma often have **pre-existing renal dysfunction** (myeloma kidney) due to light chain deposition, making them highly susceptible to contrast-induced nephropathy. *Bone metastases* - While bone metastases can be painful and may require imaging, they do not directly contraindicate excretory urography; the primary concern with IVP is renal function. - The presence of bone lesions itself does not increase the risk of **contrast-induced nephropathy** in the same way that proteinuria from multiple myeloma does. *Neuroblastoma* - Neuroblastoma is a **childhood cancer** affecting the adrenal glands or sympathetic nervous system, and it is not typically associated with a specific risk for contrast-induced nephropathy from excretory urography. - The primary diagnostic imaging for neuroblastoma often involves ultrasound, CT, or MRI, and while contrast may be used, the specific renal risk seen in multiple myeloma is not present. *Leukemia* - While some forms of leukemia can affect the kidneys, particularly through infiltration, it does not typically pose the same specific risk for **contrast-induced nephropathy** as multiple myeloma. - The renal manifestations in leukemia are generally different from the **light chain proteinuria** seen in multiple myeloma, which directly interacts with iodinated contrast.
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