Biopsy Techniques — MCQs
What is the main contraindication for performing a liver biopsy?
A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
Which one of the following is not a principle followed in the management of missile injuries?
Investigation of choice for soft tissue sarcoma is -
Identify the given bone marrow biopsy instrument
Which of the following tumors is known for its potential for spontaneous regression?
What is the most effective management strategy for hemarthrosis?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
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 -
Biopsy Techniques Indian Medical PG Practice Questions and MCQs
Question 1: What is the main contraindication for performing a liver biopsy?
- A. Severe thrombocytopenia
- B. Liver hemangioma
- C. Presence of ascites
- D. Severe coagulopathy (Correct Answer)
Explanation: ***Severe coagulopathy*** - **Severe coagulopathy** is the main contraindication for liver biopsy due to a significantly increased risk of **hemorrhage** [1]. - A **prothrombin time (PT)** or **activated partial thromboplastin time (aPTT)** significantly prolonged beyond the normal range, or an **INR > 1.5**, should be corrected before the procedure [1]. *Severe thrombocytopenia* - While **thrombocytopenia** (platelet count <50,000/µL) does increase bleeding risk, it is often correctable with a **platelet transfusion** prior to biopsy, making it a relative rather than an absolute contraindication [1]. - The risk of major bleeding is typically lower with isolated thrombocytopenia compared to severe coagulopathy. *Liver hemangioma* - The presence of a **liver hemangioma** at the biopsy site is a contraindication as biopsying it can lead to massive hemorrhage. - However, if the biopsy can be performed safely away from the hemangioma, it is not an absolute contraindication to the procedure itself. *Presence of ascites* - **Ascites** can complicate a liver biopsy by increasing the risk of **peritoneal bleeding** and difficulty in targeting the liver [1]. - However, it is often manageable by draining the ascites or using imaging guidance, making it a relative contraindication rather than an absolute one [1].
Question 2: A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
- A. Long Intramedullary Nail (Correct Answer)
- B. External Fixator
- C. Dynamic Hip Screw
- D. Plate and Screws
Explanation: ***Long Intramedullary Nail*** - Provides **strong internal fixation** that can bear weight immediately, crucial for patients with a limited life expectancy due to metastatic disease. - Stabilizes the entire bone, preventing further **pathological fractures** in the diaphysis and allowing earlier mobilization and pain relief. *External Fixator* - Primarily used for **temporary stabilization** in severe open fractures or polytrauma, and not for definitive fixation of pathological fractures. - High risk of **pin tract infections** and patient discomfort, making it unsuitable for long-term management in cancer patients. *Dynamic Hip Screw* - Primarily used for **intertrochanteric hip fractures**, which are typically proximal femur fractures. - Less effective for **diaphyseal fractures** or for stabilizing bone weakened by metastatic disease along its entire length. *Plate and Screws* - While effective for some fractures, plates may not provide sufficient **load-bearing capacity** for extensively lytic or weakened bone in metastatic disease without extensive bone grafting. - Risk of **stress shielding** and subsequent re-fracture proximal or distal to the plate, especially when the intramedullary canal is compromised by tumor.
Question 3: Which one of the following is not a principle followed in the management of missile injuries?
- A. Excision of all dead muscles
- B. Removal of foreign bodies
- C. Leaving the wound open
- D. Removal of fragments of bone (Correct Answer)
Explanation: ***Removal of fragments of bone*** - While large, easily accessible bone fragments that are likely to cause future complications (e.g., nerve compression) might be removed, the general principle in missile injuries is **not to routinely remove all bone fragments**. - Small, embedded bone fragments often act as a scaffold for healing and may not pose a significant threat if sterile, and aggressive removal can cause further trauma. *Excision of all dead muscles* - This is a fundamental principle in the management of missile injuries to prevent **infection** and promote healing. - **Debridement** of all non-viable tissue, including dead muscle, is crucial to remove potential sources of bacterial growth and toxins. *Removal of foreign bodies* - This is also a crucial principle to prevent **infection**, **inflammation**, and potential long-term complications. - Foreign bodies like bullet fragments, clothing, or dirt can introduce bacteria and hinder wound healing. *Leaving the wound open* - This is a standard practice for most missile wounds, especially those with significant tissue damage or contamination, to allow for **drainage** and prevent **compartment syndrome**. - **Delayed primary closure** may be performed after a few days if the wound is clean and free of infection, but initial closure is generally avoided.
Question 4: Investigation of choice for soft tissue sarcoma is -
- A. CT
- B. MRI (Correct Answer)
- C. Ultrasound
- D. X-ray
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice for soft tissue sarcomas due to its superior **soft tissue contrast resolution**, allowing for detailed assessment of tumor size, location, and extent within muscle, fat, and neurovascular structures. - MRI is crucial for **surgical planning**, helping to define tumor margins and evaluate involvement of adjacent critical structures. *CT* - While CT scans can identify masses, they have **limited soft tissue contrast resolution** compared to MRI, making it less effective for precise delineation of soft tissue sarcomas. - CT is often used for **staging to detect metastatic disease**, particularly in the lungs, rather than for primary tumor characterization. *Ultrasound* - **Ultrasound** is a good initial screening tool for soft tissue masses due to its accessibility and lack of radiation, but it is **operator-dependent** and has limitations in assessing deep or large lesions. - It can help differentiate cystic from solid lesions and guide biopsies but **lacks the comprehensive detail** of MRI for definitive diagnosis and staging. *X-ray* - **X-rays** are primarily used to visualize **bone abnormalities** and are generally not effective for evaluating soft tissue masses unless there is associated calcification or bone erosion. - They provide **minimal information** regarding the internal structure or extent of a soft tissue sarcoma.
Question 5: Identify the given bone marrow biopsy instrument
- A. Jamshidi needle (Correct Answer)
- B. Salah needle
- C. Tru-cut needle
- D. Vim Silverman needle
Explanation: ***Jamshidi needle*** - The image displays a **Jamshidi needle**, characterized by its **tapered, beveled tip** designed to facilitate entry into the bone and procure an intact core of bone marrow. - This needle is widely considered the **gold standard** for bone marrow biopsy due to its effectiveness in obtaining high-quality trephine samples. *Salah needle* - A Salah needle is primarily used for **bone marrow aspiration**, not typically for a trephine biopsy, and it has a different design meant for aspirating liquid marrow. - It features a **shorter, sturdier design** with a sharp bevel, optimized for safely extracting marrow fluid. *Tru-cut needle* - The Tru-cut needle is primarily designed for obtaining **soft tissue biopsies** (e.g., liver, kidney, prostate) and is not typically used for bone marrow biopsies. - Its mechanism involves an inner cutting stylet and an outer cutting cannula, which is unsuitable for penetrating dense bone and retrieving a bone core. *Vim Silverman needle* - The Vim Silverman needle is also designed for **soft tissue biopsies**, similar to the Tru-cut, and not specifically for bone marrow. - It utilizes a split needle design to capture tissue, which is not appropriate for obtaining a solid bone marrow core.
Question 6: Which of the following tumors is known for its potential for spontaneous regression?
- A. Osteogenic sarcoma
- B. Malignant melanoma (Correct Answer)
- C. Retinoblastoma
- D. Cholangiocarcinoma
Explanation: ***Osteogenic sarcoma*** - Osteogenic sarcoma, or **osteosarcoma**, is a **malignant bone tumor** that typically does not resolve spontaneously and often requires aggressive treatment [1]. - It commonly presents with **pain and swelling** in long bones, and its prognosis is poor without intervention. *Retinoblastoma* - Retinoblastoma can exhibit **spontaneous regression**, especially in bilateral cases, where the tumor may shrink without treatment over time. - It primarily affects the **retina** in children, ideally diagnosed early to preserve vision and life. *Cholangio carcinoma* - Cholangio carcinoma is an aggressive form of **bile duct cancer** that does not resolve spontaneously and usually has a poor prognosis. - Symptoms typically include **jaundice** and bile duct obstruction, requiring surgical intervention. *Malignant melanoma* - Malignant melanoma is a highly aggressive skin cancer that does not undergo spontaneous resolution and often metastasizes quickly. - Early recognition is crucial for treatment, as it is associated with significant **morbidity and mortality**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674.
Question 7: What is the most effective management strategy for hemarthrosis?
- A. Immobilization with a P.O.P. cast
- B. Application of a compression bandage
- C. Needle aspiration to remove excess blood (Correct Answer)
- D. All of the options
Explanation: ***Needle aspiration to remove excess blood*** - **Aspirating the blood** from the joint effectively reduces intra-articular pressure, pain, and inflammation. - This procedure also helps prevent **synovial hypertrophy** and **cartilage damage** caused by the presence of blood in the joint. *Application of a compression bandage* - While helpful for reducing swelling and providing support, a **compression bandage alone** does not remove the accumulated blood. - It may alleviate some discomfort but does not address the underlying issue of **intra-articular blood accumulation**. *Immobilization with a P.O.P. cast* - **Immobilization** can help rest the joint and reduce pain, but it does not remove the blood from the joint space. - Prolonged immobilization can lead to **joint stiffness** and **muscle atrophy**, which are undesirable outcomes. *All of the options* - While compression and immobilization can be supportive measures, they are not the **most effective primary strategy** for managing hemarthrosis. - The direct removal of blood via **aspiration** is crucial for alleviating pressure and preventing long-term joint damage.
Question 8: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Question 9: A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
- A. Incision biopsy (Correct Answer)
- B. Excision biopsy
- C. FNAC
- D. USG
Explanation: ***Incision biopsy*** - An **incision biopsy** is most appropriate for a large tumor (10 cm) to obtain a tissue diagnosis without performing a potentially morbid or disfiguring complete excision upfront. - It involves removing a representative section of the tumor for histopathological analysis, providing adequate tissue for diagnosis, grading, and subtyping. - This allows definitive treatment planning based on confirmed histopathology. *Excision biopsy* - **Excision biopsy** is generally reserved for smaller tumors (typically <3-5 cm) that can be completely resected with acceptable cosmetic and functional outcomes. - Excision of a 10 cm tumor on the thigh would be a significant surgical procedure, potentially causing substantial morbidity, without a prior definitive diagnosis. - Could compromise subsequent definitive surgery if margins are inadequate. *FNAC* - **FNAC (Fine Needle Aspiration Cytology)** provides only cytological diagnosis, which is insufficient for definitive diagnosis, grading, and subtyping of soft tissue tumors, especially sarcomas. - It misses crucial architectural features and tissue patterns needed for accurate classification. - May yield inadequate or non-diagnostic samples from large heterogeneous tumors. *USG* - **USG (Ultrasound)** is an imaging modality, not a tissue diagnosis procedure. - While useful for characterizing mass features (size, location, vascularity, solid vs cystic), it cannot provide histopathological diagnosis. - The question specifically asks for a procedure to "obtain a diagnosis," which requires tissue sampling for microscopic examination.
Question 10: 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.
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