Surveillance Protocols — MCQs
Which of the following is not true about osteosarcoma?
Avascular necrosis of the hip, investigation of choice -
Distant bone metastases can be best detected by which of the following imaging techniques?
A young marathon runner is participating in a marathon competition. After running for a short distance, he develops progressive, activity-related pain at the anteromedial aspect of the tibia which was mild to start with, but increased on further running. X-ray was normal. The doctor ordered a bone scan. What is the likely diagnosis?
Most common site of osteogenic sarcoma is:
What is the most appropriate treatment for a soap bubble appearance at the lower end of the radius?
Which of the following are features of Gorham's disease (Disappearing Bones)?
Onion peel appearance on radiograph is not seen in which of the following conditions?
Chemotherapy of Ewing's sarcoma includes all except?
Codman's triangle is seen in which of the following conditions?
Surveillance Protocols Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not true about osteosarcoma?
- A. Seen in the metaphyseal region of the long bones
- B. Lung metastasis is common
- C. Secondary osteosarcoma is seen in older age groups
- D. Most commonly arises in the epiphyseal region (Correct Answer)
Explanation: ***Most commonly arises in the epiphyseal region*** - This statement is **FALSE** - osteosarcoma most commonly arises in the **metaphyseal region** of long bones, particularly around the knee (distal femur, proximal tibia) and proximal humerus [1]. - The metaphysis is the region where bone growth is most active, which explains why osteosarcoma preferentially occurs there. - The epiphysis (growth plate region) is **not** the typical location for osteosarcoma. *Seen in the metaphyseal region of the long bones* - This is **TRUE** - osteosarcoma characteristically arises in the **metaphyseal regions** of long bones, especially around the knee and proximal humerus where growth is most active [1]. *Lung metastasis is common* - This is **TRUE** - the lungs are the most common site of distant metastasis in osteosarcoma, occurring in up to 80% of patients who develop metastatic disease [1]. - Pulmonary metastasis significantly impacts prognosis and treatment [1]. *Secondary osteosarcoma is seen in older age groups* - This is **TRUE** - while primary osteosarcoma affects children and young adults (peak 10-20 years), **secondary osteosarcoma** occurs in older patients, typically arising in association with Paget's disease, prior radiation therapy, or bone infarcts [1]. **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.
Question 2: Avascular necrosis of the hip, investigation of choice -
- A. CT
- B. USG
- C. XRAY
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the **most sensitive and specific** imaging modality for detecting **avascular necrosis (AVN)** of the hip in its early stages. - It can identify subtle changes in **bone marrow edema** and **necrotic areas** before they are visible on X-rays. *CT* - **Computed Tomography (CT)** can show bone changes in later stages of AVN, such as **subchondral collapse** and **sclerosis**. - However, it is **less sensitive** than MRI for early detection and identifying bone marrow changes. *USG* - **Ultrasound (USG)** is generally **not used** for the diagnosis of avascular necrosis of the hip. - It may be useful in detecting **joint effusions** but cannot visualize the bone marrow or early necrotic changes. *XRAY* - **X-rays** are often the initial investigation, but they are typically **normal in the early stages** of avascular necrosis. - Significant changes, such as **crescent sign**, **subchondral collapse**, and **flattening of the femoral head**, only become visible in **later stages** when considerable damage has already occurred.
Question 3: 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 4: A young marathon runner is participating in a marathon competition. After running for a short distance, he develops progressive, activity-related pain at the anteromedial aspect of the tibia which was mild to start with, but increased on further running. X-ray was normal. The doctor ordered a bone scan. What is the likely diagnosis?
- A. Shin splint (Correct Answer)
- B. Nutcracker fracture
- C. Lisfranc fracture
- D. Jones fracture
Explanation: ***Medial Tibial Stress Syndrome (Shin Splints)*** - **Anteromedial tibial pain** in a runner that starts mild and **worsens with activity** is the classic presentation of medial tibial stress syndrome. - **Normal X-ray** with **bone scan** ordered indicates suspected **periosteal inflammation** and microtears in the tibial cortex, which are hallmarks of this overuse injury. *Nutcracker fracture* - This is a **cuboid bone fracture** in the foot caused by high-energy compression, not tibial pathology. - Pain would be in the **midfoot**, not the anteromedial tibia, and would be **visible on X-ray**. *Lisfranc fracture* - Involves **tarsometatarsal joint disruption** in the midfoot from trauma or twisting injuries. - Pain occurs in the **midfoot region**, not the tibia, and fracture-dislocation would be **evident on X-ray**. *Jones fracture* - This is a **fifth metatarsal base fracture** causing **lateral foot pain**, not tibial pain. - Would present with **point tenderness** over the lateral foot and be **clearly visible on X-ray**. The combination of **exercise-induced anteromedial tibial pain**, **normal radiographs**, and the need for **bone scan** confirmation makes medial tibial stress syndrome the most likely diagnosis in this marathon runner.
Question 5: Most common site of osteogenic sarcoma is:
- A. Tibia, lower end
- B. Femur, upper end
- C. Tibia, upper end
- D. Femur, lower end (Correct Answer)
Explanation: ***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 6: What is the most appropriate treatment for a soap bubble appearance at the lower end of the radius?
- A. Local excision
- B. Excision and bone grafting (Correct Answer)
- C. Amputation
- D. Radiotherapy
Explanation: ***Excision and bone grafting*** - A **soap bubble appearance** at the lower end of the radius is highly suggestive of a **giant cell tumor (GCT)**, which is locally aggressive and has a high recurrence rate after simple curettage. - **Excision of the tumor and filling the defect with bone graft** is the preferred treatment to reduce recurrence and maintain skeletal integrity. *Local excision* - While local excision might remove the visible tumor, **GCTs are known to recur frequently** (up to 50%) after intralesional treatments like simple curettage. - It does not adequately address microscopic extensions or the risk of **local aggressive behavior**. *Amputation* - **Amputation is an overly aggressive and unnecessary treatment** for a GCT, as it is a benign but locally aggressive tumor. - It would be considered only in rare cases of extensive soft tissue invasion or intractable recurrence, which is not implied by a "soap bubble appearance." *Radiotherapy* - **Radiotherapy is generally not the first-line treatment for GCTs** due to concerns about **malignant transformation** (osteosarcoma) in a small percentage of cases, especially with high doses. - It may be considered for unresectable tumors or recurrent lesions in difficult anatomical locations, or as an adjuvant.
Question 7: Which of the following are features of Gorham's disease (Disappearing Bones)?
- A. Progressive disappearance of bone associated with multiple hemangiomatosis or multiple lymphangiectasis
- B. Usually the progression involves contiguous bones, but occasionally multiple sites are affected
- C. Patients present with mild pain or with pathological fracture
- D. All of the above (Correct Answer)
Explanation: **Gorham’s Disease**, also known as **Vanishing Bone Disease** or Phantom Bone Disease, is a rare musculoskeletal condition characterized by the spontaneous, progressive destruction and resorption of bone tissue. ### **Explanation of Options** * **Option A:** The hallmark of Gorham’s disease is the proliferation of thin-walled vascular or lymphatic channels within the bone. This leads to **progressive osteolysis** (bone disappearance) associated with **hemangiomatosis** or **lymphangiectasis**. The bone is replaced by fibrous connective tissue. * **Option B:** The disease typically spreads across joints to involve **contiguous bones** (e.g., spreading from the humerus to the scapula or from one vertebra to the next). While localized, it can occasionally manifest in multiple non-contiguous anatomical sites. * **Option C:** The clinical presentation is often insidious. Patients may experience **dull aching pain**, localized swelling, or a **pathological fracture** following minor trauma. In severe cases involving the ribs or spine, it can lead to chylothorax. Since all statements accurately describe the pathophysiology, progression, and clinical presentation of the disease, **Option D (All of the above)** is the correct answer. ### **High-Yield Clinical Pearls for NEET-PG** * **Radiology:** Characterized by "tapering" of the ends of remaining bone (sucker-stick appearance) and eventual complete disappearance of the bone shadow. * **Key Feature:** Unlike most bone tumors, Gorham’s disease **crosses joint spaces** to involve adjacent bones. * **Biopsy:** Shows non-malignant proliferation of thin-walled vessels; there is a notable **absence of osteoclasts** (the resorption is mediated by the vascular tissue). * **Complication:** **Chylothorax** is a life-threatening complication if the disease involves the thoracic cage.
Question 8: Onion peel appearance on radiograph is not seen in which of the following conditions?
- A. Garre's osteomyelitis
- B. Ewing's sarcoma
- C. Osteogenic sarcoma
- D. Fibrous dysplasia (Correct Answer)
Explanation: **Explanation:** The "onion peel" appearance (lamellated periosteal reaction) is a radiographic sign caused by the rhythmic or episodic lifting of the periosteum, leading to the deposition of multiple concentric layers of new bone. **1. Why Fibrous Dysplasia is the Correct Answer:** Fibrous dysplasia is a benign fibro-osseous lesion where normal bone is replaced by fibrous tissue and immature trabeculae. It is an **intramedullary** process that does not typically involve the periosteum. Therefore, it does not produce a periosteal reaction. Its classic radiographic appearance is described as **"Ground-glass opacification"** with a well-defined "rind" of sclerotic bone. **2. Analysis of Incorrect Options:** * **Ewing’s Sarcoma:** This is the classic association for onion peel appearance. The aggressive nature of this tumor causes rapid, successive layers of periosteal bone formation. * **Garre’s Osteomyelitis:** Also known as Chronic Sclerosing Osteomyelitis with proliferative periostitis. It is a low-grade chronic infection (often in the mandible) that stimulates the periosteum to form reactive peripheral bone in a lamellated pattern. * **Osteogenic Sarcoma (Osteosarcoma):** While "Sunburst" and "Codman’s triangle" are more common, Osteosarcoma is a highly aggressive tumor that can occasionally present with a lamellated (onion peel) appearance depending on the rate of tumor growth. **Clinical Pearls for NEET-PG:** * **Onion Peel Appearance:** Seen in Ewing’s sarcoma, Garre’s osteomyelitis, Osteosarcoma, and sometimes Langerhans Cell Histiocytosis (LCH). * **Ground Glass Appearance:** Pathognomonic for Fibrous Dysplasia. * **Sunburst/Sunray Appearance:** Highly suggestive of Osteosarcoma. * **Codman’s Triangle:** Indicates an aggressive process (malignancy or subperiosteal abscess) lifting the periosteum rapidly.
Question 9: Chemotherapy of Ewing's sarcoma includes all except?
- A. Doxorubicin
- B. Dactinomycin
- C. Topotecan
- D. 5-Fluorouracil (Correct Answer)
Explanation: **Explanation:** Ewing’s Sarcoma is a highly malignant, small round blue cell tumor that is exquisitely sensitive to chemotherapy. The standard of care involves a multimodal approach (Chemotherapy + Surgery/Radiotherapy). **Why 5-Fluorouracil (5-FU) is the correct answer:** 5-Fluorouracil is an antimetabolite primarily used in the treatment of epithelial malignancies (GI tract, breast, and head/neck cancers). It has **no established role** in the management of Ewing’s Sarcoma. **Analysis of other options (The VAC-IE Regimen):** The current standard chemotherapy for Ewing's Sarcoma follows the **VAC-IE** protocol, which includes: * **Vincristine** * **Actinomycin D (Dactinomycin):** An antitumor antibiotic that inhibits RNA synthesis (Option B). * **Cyclophosphamide** * **Ifosfamide** * **Etoposide** * **Doxorubicin (Adriamycin):** An anthracycline that is a cornerstone in treating both Ewing’s and Osteosarcoma (Option A). * **Topotecan:** A Topoisomerase I inhibitor often used in second-line or salvage therapy for recurrent/refractory Ewing’s Sarcoma (Option C). **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Characterized by the **t(11;22)** translocation, leading to the **EWS-FLI1** fusion gene. * **Radiology:** Classic **"Onion-peel"** periosteal reaction. * **Histology:** Small round blue cells that are **PAS positive** (due to cytoplasmic glycogen) and express **CD99 (MIC-2).** * **Site:** Most common in the diaphysis of long bones (Femur is most common). * **Prognosis:** The most important prognostic factor is the presence of metastasis at the time of diagnosis (Lungs and Bone marrow are common sites).
Question 10: Codman's triangle is seen in which of the following conditions?
- A. Chondroblastoma
- B. Osteosarcoma (Correct Answer)
- C. Chondrosarcoma
- D. Giant Cell Tumor
Explanation: ### Explanation **Codman’s Triangle** is a classic radiological sign representing an aggressive **periosteal reaction**. It occurs when a rapidly growing lesion (usually a tumor) lifts the periosteum away from the bone, leaving a triangular area of new subperiosteal bone at the margin where the periosteum is still attached. #### Why Osteosarcoma is Correct: **Osteosarcoma** is the most common primary malignant bone tumor in adolescents. Because it is highly aggressive and grows rapidly, it frequently breaches the cortex and elevates the periosteum. This results in characteristic periosteal reactions: **Codman’s Triangle** and the **Sunburst (Spiculated) appearance**. #### Why Other Options are Incorrect: * **Chondroblastoma:** A benign, epiphyseal tumor typically seen in young patients. It usually presents as a well-defined lytic lesion with a "fluffy" or "popcorn" calcification, but lacks aggressive periosteal reactions. * **Chondrosarcoma:** While malignant, it often presents in older adults with "endosteal scalloping" and "ring-and-arc" calcifications. While it can show periosteal changes, it is less classically associated with Codman’s Triangle than Osteosarcoma. * **Giant Cell Tumor (GCT):** A "benign but locally aggressive" tumor located in the epiphysis (extending to the subchondral bone). It typically shows a **"Soap-bubble appearance"** and lacks a periosteal reaction because it expands the bone rather than lifting the periosteum abruptly. #### NEET-PG High-Yield Pearls: * **Codman’s Triangle** is not pathognomonic for Osteosarcoma; it can also be seen in **Ewing’s Sarcoma**, subacute osteomyelitis, and active hematomas. * **Ewing’s Sarcoma** is more classically associated with an **"Onion-skin"** (lamellated) periosteal reaction. * **Osteosarcoma** most commonly occurs around the knee (distal femur/proximal tibia) and is associated with a rise in **Serum Alkaline Phosphatase**.
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