Bone Tumors and Tumor-like Lesions — MCQs
Which of the following conditions is not typically associated with an underlying malignancy?
What is the most common primary bone tumor in adults?
Ewings sarcoma clinically mimics -
Giant cells are a prominent characteristic feature of which of the following conditions?
Which bone tumor involves the epiphysis?
Maffucci syndrome:
X-ray appearances of osteosarcoma are all except -
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 statement is incorrect about the pathology of the bone tumor?
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?
Bone Tumors and Tumor-like Lesions Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following conditions is not typically associated with an underlying malignancy?
- A. Paget disease of vulva
- B. Paget disease of anal region
- C. Paget disease of bone (Correct Answer)
- D. Paget disease of nipple
Explanation: ***Paget disease of bone*** - While Paget disease of bone can rarely undergo **malignant transformation** into **osteosarcoma**, it is itself a disorder of excessive bone remodeling and **not directly an underlying malignancy** like the other Paget diseases [2]. - The primary concern in Paget disease of bone is metabolic bone changes and potential complications like fractures, rather than being a superficial manifestation of internal cancer [2]. *Paget disease of nipple* - This condition is almost always associated with an **underlying ductal carcinoma in situ** or invasive adenocarcinoma of the breast [1]. - The epidermal changes are a manifestation of malignant cells migrating from the underlying breast tissue [1]. *Paget disease of vulva* - While it can occur as a primary intraepithelial neoplasm (adenocarcinoma in situ), approximately 20-30% of cases are associated with an **underlying invasive adenocarcinoma**, either vulvar or originating from other sites such as the colon, bladder, or urethra. - Its presence necessitates a thorough search for associated malignancies. *Paget disease of anal region* - Similar to vulvar Paget disease, it can be a primary intraepithelial adenocarcinoma, but it frequently is associated with an **underlying adenocarcinoma** of the colon, rectum, or anal glands. - Evaluation for an internal malignancy is crucial when this diagnosis is made. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1061-1062. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1191-1194.
Question 2: What is the most common primary bone tumor in adults?
- A. Chondrosarcoma (Correct Answer)
- B. Ewing's sarcoma
- C. Adamantinoma
- D. Osteogenic sarcoma
Explanation: ***Chondrosarcoma*** - **Chondrosarcoma** is the **most common primary malignant bone tumor in adults**, typically affecting older individuals (over 40-50 years) [1]. - It arises from **cartilage-producing cells** and is characterized by the production of malignant cartilage matrix [1]. - Common sites include pelvis, femur, and shoulder girdle [2]. *Osteogenic sarcoma* - **Osteogenic sarcoma** (osteosarcoma) is the most common primary malignant bone tumor in **children and adolescents**, not adults overall [1]. - There is a second peak incidence in older adults, often associated with **Paget's disease** or prior radiation. - It arises from osteoblasts and produces immature bone (osteoid). *Adamantinoma* - **Adamantinoma** is a rare, low-grade malignant bone tumor that almost exclusively occurs in the **tibia**. - It has a characteristic biphasic histologic pattern with epithelial and osteofibrous components. *Ewing's sarcoma* - **Ewing's sarcoma** is the second most common primary malignant bone tumor in **children and young adults** (ages 5-25 years). - It is a highly aggressive tumor with specific chromosomal translocation t(11;22) and composed of **small round blue cells**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1204. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674.
Question 3: Ewings sarcoma clinically mimics -
- A. Osteochondroses
- B. Heterotopic ossification
- C. Osteomyelitis (Correct Answer)
- D. Osteosclerosis
Explanation: ***Osteomyelitis*** - **Ewing's sarcoma** can clinically mimic **osteomyelitis** due to similar symptoms like **bone pain**, **swelling**, **fever**, and **leukocytosis**. - Both conditions can present with a periosteal reaction, such as an **onion-skin appearance** on X-ray, making differentiation challenging without further investigation. *Osteochondroses* - **Osteochondroses** are a group of disorders affecting **growth plates** or **epiphyseal centers**, commonly seen in children and adolescents, and are associated with repetitive trauma or vascular compromise. - While they can cause pain, they typically lack systemic symptoms like fever and do not show rapid destructive changes or soft tissue masses commonly associated with Ewing's sarcoma. *Heterotopic ossification* - **Heterotopic ossification** involves the formation of new bone in soft tissues where it normally does not exist, often following trauma, surgery, or neurological injury. - It is typically a localized process of abnormal bone growth and does not commonly present with systemic symptoms like fever or aggressive destructive lesions characteristic of Ewing's sarcoma. *Osteosclerosis* - **Osteosclerosis** refers to an abnormal increase in bone density, which can be localized or generalized, and is often a sign of various metabolic, genetic, or neoplastic conditions. - While some bone tumors can cause osteosclerotic changes, Ewing's sarcoma is typically an **osteolytic** or mixed lesion, and osteosclerosis itself does not mimic the aggressive clinical presentation of Ewing's sarcoma.
Question 4: Giant cells are a prominent characteristic feature of which of the following conditions?
- A. Osteoclastoma (Correct Answer)
- B. Chondroblastoma
- C. Chordoma
- D. Osteitis fibrosa cystica
Explanation: ***Osteoclastoma*** - Also known as **giant cell tumor of bone**, it is characterized by the presence of numerous **multinucleated giant cells** [1]. - These giant cells are derived from **osteoclasts**, indicating the aggressive nature of this tumor [1]. *Osteitis fibrosa cystica* - While it may show giant cells, they are less prominent and often associated with **hyperparathyroidism** affecting the bone. - This condition primarily involves **bone resorption** and **cyst formation**, not defined by giant cell formation. *Chordoma* - Chordomas are typically composed of **bizarre cells** with a characteristic **mucous** stroma and do not predominantly contain giant cells. - They arise from **notochord remnants**, primarily found in the axial skeleton, rather than from bone cells. *Chondroblastoma* - This tumor primarily features **chondroblasts** and small cellular components, not giant cells. - It is usually seen in young adults and commonly involves the **epiphyses of long bones**, showing a different histological pattern. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1205-1206.
Question 5: Which bone tumor involves the epiphysis?
- A. Osteosarcoma
- B. Giant cell tumor (Correct Answer)
- C. Ewing's sarcoma
- D. Multiple myeloma
Explanation: ***Giant cell tumor*** - **Giant cell tumor (GCT)**, also known as osteoclastoma, characteristically arises in the **epiphysis** [1] or **metaphysis** of long bones in adults. - It is a benign but locally aggressive tumor that often presents with pain, swelling, and reduced range of motion in the affected joint [1]. *Osteosarcoma* - **Osteosarcoma** typically arises in the **metaphysis** of long bones, particularly around the knee (distal femur, proximal tibia). - It is a highly malignant primary bone tumor characterized by the production of **osteoid** by tumor cells [2]. *Ewing's sarcoma* - **Ewing's sarcoma** most commonly affects the **diaphysis** of long bones or flat bones (e.g., pelvis, scapula, ribs). - It is characterized by small, round, blue cells and often presents with pain, swelling, and systemic symptoms like fever. *Multiple myeloma* - **Multiple myeloma** is a malignancy of **plasma cells** that primarily affects the **bone marrow** and can cause widespread osteolytic lesions. - It typically presents in older adults and affects bones with active marrow, such as the vertebrae, ribs, skull, and pelvis, rather than being localized to the epiphysis as a primary bone tumor. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1205-1206. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674.
Question 6: Maffucci syndrome:
- A. Multiple osteochondromas
- B. Multiple osteochondromatosis with hemangiomas
- C. Multiple Giant cell tumor
- D. Multiple enchondromatosis with hemangiomas (Correct Answer)
Explanation: ***Multiple enchondromatosis with hemangiomas*** - **Maffucci syndrome** is a rare, non-hereditary disorder characterized by the presence of multiple **enchondromas** (benign cartilaginous tumors) and **hemangiomas** (benign vascular tumors). - The enchondromas typically affect the long bones and can lead to skeletal deformities and fractures, while the hemangiomas can be soft tissue or visceral. *Multiple osteochondromas* - This description typically refers to **multiple hereditary exostoses** (MHE), a distinct genetic condition. - In MHE, the bone lesions are **osteochondromas**, which are bone spurs capped with cartilage, rather than enchondromas that form within the bone. *Multiple osteochondromatosis with hemangiomas* - This accurately describes the presence of **hemangiomas** but identifies the bone lesions as **osteochondromas** instead of enchondromas. - The presence of osteochondromas would point towards a different diagnosis like MHE, even with co-occurring hemangiomas. *Multiple Giant cell tumor* - **Giant cell tumors (GCTs)** are generally solitary, benign, but locally aggressive bone tumors, not typically seen as multiple lesions in the context of a syndrome like Maffucci. - They also differ histologically and clinically from enchondromas.
Question 7: X-ray appearances of osteosarcoma are all except -
- A. Sunray appearance
- B. Codman's triangle
- C. Soap-bubble (Correct Answer)
- D. Periosteal reaction
Explanation: ***Soap-bubble*** - This appearance is characteristic of a **giant cell tumor**, which is a benign but locally aggressive bone tumor, often found in the **epiphysis** of long bones. - It results from multiple lucencies due to tumor cells eroding into the bone, creating a multicystic appearance. *Sunray appearance* - This describes **spicules of new bone** projecting outwards from the cortex, perpendicular to the bone surface, often seen in aggressive osteosarcomas. - It is a classic radiographic sign indicating **ossification within the soft tissue mass** of the tumor. *Codman's triangle* - This refers to an **elevated periosteum** forming a triangular area of new bone, indicating that the tumor has lifted the periosteum off the cortical surface of the bone. - It is a non-specific sign of primary bone tumor but is commonly associated with aggressive lesions like **osteosarcoma**. *Periosteal reaction* - This is a general term for the **formation of new bone** in response to periosteal irritation or elevation, which can be seen in various conditions including infection, trauma, and tumors. - In osteosarcoma, a periosteal reaction is a key finding, often presenting as a **spiculated, lamellated, or Codman's triangle pattern**, indicating an aggressive lesion.
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 statement is incorrect about the pathology of the bone tumor?
- A. Tumor has distinct margin
- B. Tumor arises from epiphyseal to metaphyseal region
- C. Eccentric lesion
- D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)
Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.
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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