Metastatic Bone Disease — MCQs

10 questions

An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl

Skeletal metastasis is common in:

Most sensitive modality for detecting bone metastases

Which of the following is true about bone metastasis?

In the context of bone metastasis, which of the following bones is least likely to be a site of metastasis?

In prostatic metastasis, the site most commonly involved is which one?

Distant bone metastases can be best detected by which of the following imaging techniques?

All of the following produce osteoblastic secondaries except:

A 60 -year-old female presents with pain in her back of recent onset, which has become severe of late. During the course of investigations, she was found to have lytic lesions in the vertebrae and ribs. Which of the following organs should be carefully screened now for detecting the primary cause of these lesions?

Q10

Clinical examination of a symptomatic patient shows a Sister Mary Joseph nodule. It is most commonly associated with which of the following?

Metastatic Bone Disease Indian Medical PG Practice Questions and MCQs

Question 1: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl

A. Vertebral compression fracture
B. Metastatic carcinoma
C. Osteoporosis
D. Multiple myeloma (Correct Answer)

Explanation: ***Multiple myeloma*** - The combination of **osteolytic lesions** (bone pain, tenderness), **hypercalcemia** (confusion, thirst), **anemia** (Hb 69 g/dl, pallor), and **renal insufficiency** (confusion, thirst from dehydration) is highly suggestive of **multiple myeloma** [1]. - This plasma cell malignancy leads to excessive production of monoclonal antibodies and bone destruction [1]. *Vertebral compression fracture* - While **thoracic spine tenderness** and osteolytic lesions could be a component, it doesn't fully explain the systemic symptoms such as **anemia**, **confusion**, and **hypercalcemia**. - A simple compression fracture would not account for the profound **anemia** (Hb 69 g/dl) seen in this patient. *Metastatic carcinoma* - While metastatic carcinoma can cause **osteolytic lesions**, **anemia**, and sometimes **hypercalcemia**, the specific constellation of symptoms, particularly the severity of anemia and rapid progression, makes **multiple myeloma** a more fitting diagnosis. - Absence of primary tumor indicates that it is not a metastatic disease [1]. *Osteoporosis* - **Osteoporosis** can cause vertebral fractures and bone pain but typically does not lead to **osteolytic lesions**, **severe anemia**, or **hypercalcemia** [2]. - The bone changes in osteoporosis are primarily due to decreased bone density, not destructive lesions [2].

Question 2: Skeletal metastasis is common in:

A. Hepatoma
B. Cancer stomach
C. Cancer pancreas
D. Cancer breast (Correct Answer)

Explanation: ***Cancer breast*** - **Breast cancer** is one of the most common primary malignancies that metastasize to bones (part of the classic **"osteophilic pentad"**: breast, prostate, lung, kidney, and thyroid) [1]. - Preferentially metastasizes to **axial skeleton** including the **spine**, **pelvis**, and **ribs**. - Bone metastases from breast cancer can be **osteolytic**, **osteoblastic**, or mixed, often causing pain and **pathological fractures**. - Approximately **70% of patients with advanced breast cancer** develop bone metastases. *Hepatoma* - **Hepatocellular carcinoma (HCC)**, or hepatoma, commonly metastasizes to the **lungs** and regional lymph nodes via hematogenous spread [2]. - While bone metastases can occur, they are **uncommon** (occurs in <5% of cases), much less frequent than with breast, prostate, or lung cancers [1]. - Bone involvement often indicates advanced disease. *Cancer stomach* - **Gastric cancer** primarily metastasizes to nearby **lymph nodes**, the **liver**, and the **peritoneum** (Krukenberg tumor to ovaries, Sister Mary Joseph nodule). - Bone metastases from gastric cancer are **relatively rare**, occurring in less than 10-15% of cases, and represent a poor prognostic sign. - Not among the common cancers with bone tropism [1]. *Cancer pancreas* - **Pancreatic cancer** frequently metastasizes to the **liver** (most common), **peritoneum**, and **lungs**. - Bone metastases are **uncommon** in pancreatic cancer (<5% of cases), typically indicating widespread disease and a very poor prognosis. - Not part of the osteophilic group of cancers [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 671-672. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 282.

Question 3: Most sensitive modality for detecting bone metastases

A. Bone scan
B. PET-CT
C. Plain radiograph
D. MRI (Correct Answer)

Explanation: ***MRI*** - **MRI**, especially **whole-body MRI (WB-MRI)**, has the **highest sensitivity (90-100%)** for detecting bone metastases among all imaging modalities. - It directly visualizes **bone marrow changes** before cortical bone destruction occurs, allowing for earlier detection than other modalities. - Excellent for detecting both **lytic and sclerotic lesions** and provides superior soft tissue contrast for assessing marrow involvement. - Particularly sensitive for **spine and pelvic metastases**, and whole-body protocols enable comprehensive skeletal assessment. *PET-CT* - **PET-CT with 18F-FDG** is highly sensitive for detecting metabolically active lesions and provides whole-body assessment with both metabolic and anatomical information. - However, its sensitivity varies by primary tumor type and is **limited for sclerotic/osteoblastic metastases** which may not be FDG-avid. - While excellent for many malignancies, it has **lower sensitivity than MRI** for pure bone metastases detection, particularly in low-metabolism lesions. *Bone scan* - **Bone scan (Tc-99m MDP)** detects increased osteoblastic activity and has been the traditional screening tool with good sensitivity (62-89%). - Effective for detecting osteoblastic lesions and provides whole-body skeletal survey at relatively low cost. - However, it is **less sensitive than MRI** and can miss purely lytic metastases or early marrow involvement before osteoblastic response occurs. *Plain radiograph* - **Plain radiographs** require significant bone mineral loss (30-50%) to visualize lesions, making them the **least sensitive modality** for bone metastases. - Useful for assessing established lesions and complications like pathological fractures, but inadequate for screening or early detection.

Question 4: Which of the following is true about bone metastasis?

A. Most common secondary tumor in females is from breast (Correct Answer)
B. Higher serum levels of alkaline phosphatase
C. Bone metastases are often symptomatic
D. Prostate cancer produces only lytic lesions

Explanation: ***Most common secondary tumor in females is from breast*** - **Breast cancer** is the most common cause of skeletal metastases in women, frequently affecting the **axial skeleton** (spine, pelvis, ribs) [1]. - These metastases can be **osteolytic**, **osteoblastic**, or mixed, often leading to bone pain and pathological fractures. *Higher serum levels of alkaline phosphatase* - While **elevated alkaline phosphatase** can be seen in bone metastasis due to increased osteoblastic activity [2], it is not universally true for *all* bone metastases. - Many bone metastases, especially purely **lytic lesions**, may not significantly elevate alkaline phosphatase; instead, they might raise calcium levels. *Bone metastases are often symptomatic* - Bone metastases can be **asymptomatic** for extended periods, especially early in their development [2], only becoming symptomatic when significant bone destruction or nerve compression occurs [1]. - While pain is the most common symptom, **pathological fractures** and **spinal cord compression** can also be initial presentations [2]. *Prostate cancer produces only lytic lesions* - **Prostate cancer** characteristically produces **osteoblastic (bone-forming) metastases**, which appear as sclerotic lesions on imaging [2],[3]. - While rarely some lytic components can be present, the predominant feature is increased bone density. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 671-672. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 501-502. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 993-994.

Question 5: In the context of bone metastasis, which of the following bones is least likely to be a site of metastasis?

A. Femur
B. Humerus
C. Fibula (Correct Answer)
D. Spine

Explanation: ***Fibula*** - The **fibula** is not commonly involved in **metastatic disease**, primarily due to its low blood supply compared to other bones. - While it can occasionally show metastatic lesions, it's **rare** when compared to more commonly affected sites. *Humerus* - The **humerus** can be affected by metastasis, often from lung or breast cancers [1], as it is one of the long bones involved in **hematogenous spread**. - Common presentations include **lytic or blastic lesions**, which indicate bone damage from metastatic processes. *Femur* - The **femur** is frequently involved in metastatic lesions, particularly in patients with malignancies like **prostate or breast cancer** [1]. - Symptoms may include **pain** and **pathologic fractures** due to the weakening of the bone structure from metastasis [1]. *Spine* - The **spine** is a common site for metastases, especially from cancers such as **lung, breast, and prostate** [1]. - Bone scans often reveal **vertebral body lesions**, leading to complications like **spinal cord compression** [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 674-675.

Question 6: In prostatic metastasis, the site most commonly involved is which one?

A. Perivesical nodes
B. Obturator nodes (Correct Answer)
C. Pre-sacral nodes
D. Para-aortic nodes

Explanation: ***Obturator nodes*** - The **obturator nodes** are a primary site for metastatic spread from the prostate due to their close proximity and direct lymphatic drainage pathways. - Prostate cancer cells often spread via the **lymphatic system** to regional lymph nodes before disseminating to distant sites. **Perivesical nodes** * While also regional, perivesical nodes are less frequently the _initial_ or most common site of metastasis compared to the obturator and internal iliac nodes. * Lymphatic drainage from the prostate primarily follows pathways that lead to obturator and internal iliac nodes first. **Pre-sacral nodes** * Pre-sacral nodes are considered more distant regional nodes compared to the obturator nodes and are typically involved later in the metastatic process. * Their involvement often indicates a more advanced stage of nodal metastasis. **Para-aortic nodes** * Para-aortic nodes are considered distant metastases for prostate cancer, indicating widespread disease. * Metastasis to para-aortic nodes usually occurs after involvement of more proximal regional nodes like the obturator and internal iliac nodes.

Question 7: Distant bone metastases can be best detected by which of the following imaging techniques?

A. Bone scan (Correct Answer)
B. CT
C. Intravenous venogram
D. PET scan

Explanation: ***Bone scan*** - A **bone scan** is highly sensitive for detecting **osteoblastic activity**, which is characteristic of most bone metastases. - It involves injecting a **radioactive tracer** (usually technetium-99m methylene diphosphonate) that accumulates in areas of increased bone turnover, making it excellent for surveying the entire skeletal system. *PET scan* - While a **PET scan** (Positron Emission Tomography) can detect bone metastases, especially with **FDG-PET**, it is generally more expensive and may not be as sensitive for purely **osteoblastic lesions** as a bone scan. - Its primary role is often in assessing metabolic activity of the primary tumor and other distant soft tissue metastases. *CT* - **CT scans** (Computed Tomography) are excellent for assessing bone anatomy, cortical destruction, and soft tissue involvement, but they are generally less sensitive for detecting early or widespread **osseous metastatic disease** compared to a bone scan. - CT provides detailed anatomical information but may miss early **marrow involvement** that alters bone metabolism. *Intravenous venogram* - An **intravenous venogram** is an imaging technique used to visualize veins, primarily for detecting **thrombosis** or venous insufficiency. - It has no role in the detection of **bone metastases**, as it provides no information about bone structure or metabolic activity.

Question 8: All of the following produce osteoblastic secondaries except:

A. Carcinoma of Prostate
B. Carcinoma of Breast
C. Carcinoid tumors
D. Multiple myeloma (Correct Answer)

Explanation: ***Multiple myeloma*** - Multiple myeloma is a **plasma cell malignancy** that typically causes **osteolytic (bone-destroying) lesions** due to the activation of osteoclasts and inhibition of osteoblasts, rather than osteoblastic (bone-forming) metastases [1]. - The bone lesions are often described as **punched-out lesions** on imaging [1]. *Carcinoma of Prostate* - **Prostate cancer** is well-known for producing **osteoblastic (sclerotic)** bone metastases, characterized by new bone formation [2]. - This is mediated by factors secreted by prostate cancer cells that stimulate osteoblasts [2]. *Carcinoma of Breast* - **Breast cancer** metastases to bone can be **mixed osteoblastic and osteolytic**, but frequently present with an osteoblastic component, especially in advanced stages. - The type of bone lesion can be influenced by various signaling pathways between cancer cells and bone cells. *Carcinoid tumors* - **Carcinoid tumors**, particularly those of gastrointestinal origin, can cause **osteoblastic bone metastases**, sometimes presenting as sclerotic lesions. - While less common than prostate or breast cancer, they are recognized for their potential to induce bone formation. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 616-618. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 501-502.

Question 9: A 60 -year-old female presents with pain in her back of recent onset, which has become severe of late. During the course of investigations, she was found to have lytic lesions in the vertebrae and ribs. Which of the following organs should be carefully screened now for detecting the primary cause of these lesions?

A. Large intestine
B. Breast (Correct Answer)
C. Adrenal
D. Small intestine

Explanation: **Breast** - **Breast cancer** is a common primary malignancy in women that frequently metastasizes to bone, causing **lytic lesions** in the vertebrae and ribs [4]. - The patient's age (60-year-old female) and the presence of severe, recent-onset back pain with multiple lytic lesions strongly suggest metastatic disease [2], with **breast cancer** being a top differential [4]. *Large intestine* - While **colorectal cancer** can metastasize to bone, it typically causes mixed lytic and blastic lesions or predominantly blastic lesions, rather than purely lytic lesions. - Furthermore, the frequency of bone metastases from colorectal cancer is generally lower compared to breast or lung primary tumors [1]. *Adrenal* - Primary **adrenal tumors** (e.g., adrenal cortical carcinoma, pheochromocytoma) rarely metastasize to bone and are not a common cause of diffuse lytic bone lesions. - Bone metastases from adrenal cancers are much less frequent and typically associated with advanced, aggressive disease [3]. *Small intestine* - **Small bowel malignancies** (e.g., adenocarcinomas, neuroendocrine tumors) rarely metastasize to bone. - When they do, the pattern of bone involvement is variable but less commonly presents as widespread lytic lesions in the spine and ribs without other systemic symptoms.

Question 10: Clinical examination of a symptomatic patient shows a Sister Mary Joseph nodule. It is most commonly associated with which of the following?

A. Ovarian cancer
B. Stomach cancer (Correct Answer)
C. Colon cancer
D. Pancreatic cancer

Explanation: ***Stomach cancer*** - A **Sister Mary Joseph nodule** is a **periumbilical metastatic nodule**, most commonly associated with **gastric adenocarcinoma** due to its propensity for peritoneal spread. - While it can originate from other abdominal malignancies, stomach cancer is statistically the most frequent primary source of this metastatic sign. *Ovarian cancer* - Ovarian cancer can metasatasize to the peritoneum and sometimes cause Sister Mary Joseph nodules, but it is not the most common primary source [1]. - Instead, ovarian cancer more frequently presents with symptoms like **abdominal distension**, **pelvic pain**, or **ascites** [1]. *Colon cancer* - **Colorectal cancer** can also metastasize to the peritoneum, potentially leading to a Sister Mary Joseph nodule, though less commonly than gastric cancer [2]. - It often manifests with changes in **bowel habits**, **rectal bleeding**, or **unexplained weight loss** [2]. *Pancreatic cancer* - Pancreatic cancer can produce a Sister Mary Joseph nodule, particularly in advanced stages with **peritoneal dissemination**. - However, it is primarily known for other metastatic patterns and often presents with **jaundice** (if the head of the pancreas is affected) or **epigastric pain**.

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