Bone and Soft Tissue Pathology — MCQs

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?

Q297

Following are seen in fibrous dysplasia EXCEPT

Q298

Most common soft tissue sarcoma in children is

Q299

Which is the most common clinical feature of Ewing's sarcoma?

Q300

Bone tumor arising from epiphysis is?

Bone and Soft Tissue Pathology Indian Medical PG Practice Questions and MCQs

Question 291: What is the most common structural location within the bone for conventional chondrosarcoma?

A. Intramedullary (Correct Answer)
B. Juxtacortical
C. Epiphyseal
D. Periosteal

Explanation: ***Intramedullary*** - This is the **most common location** for conventional chondrosarcoma, accounting for approximately **75-85%** of cases [1]. - These tumors arise within the **medullary cavity** (central or intramedullary location) and grow expansively within the bone [1]. - They typically show lytic destruction with internal ring-and-arc or popcorn calcifications on imaging. - Conventional chondrosarcoma is synonymous with central or intramedullary chondrosarcoma [1]. *Periosteal* - Periosteal (surface) chondrosarcoma is a **rare subtype** accounting for only **1-2%** of chondrosarcomas. - These arise from the periosteum on the bone surface, not within the medullary cavity. - They have a better prognosis compared to conventional (intramedullary) chondrosarcoma. *Juxtacortical* - This refers to tumors arising at or near the **bone surface** (cortical region) [1]. - Peripheral/juxtacortical chondrosarcoma accounts for approximately **10-15%** of cases and is much less common than the central type. - Secondary chondrosarcoma arising from osteochondroma is an example of peripheral chondrosarcoma [1]. *Epiphyseal* - Chondrosarcoma **rarely arises in the epiphysis** of long bones. - Conventional chondrosarcoma typically involves the **metaphysis and diaphysis**, with predilection for flat bones (pelvis, ribs) and long bones (femur, humerus) [2]. - Epiphyseal location would be highly unusual for this 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. 1202-1204. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674.

Question 292: Osteoarthritis is associated with all of the following except -

A. Subchondral sclerosis
B. Ca++deposition in joint space (Correct Answer)
C. Osteophyte formation
D. Decreased joint space

Explanation: ***Ca++deposition in joint space*** - **Calcium pyrophosphate dihydrate (CPPD) crystal deposition** in the joint space is characteristic of **pseudogout**, not osteoarthritis [1]. - While some **calcification** may occur in osteophytes, direct **calcium crystal deposition** in the synovial fluid is not a primary feature of osteoarthritis [1]. *Subchondral sclerosis* - **Subchondral sclerosis** refers to the increased bone density that occurs beneath the cartilage in areas of stress in osteoarthritis. - This is a common radiological finding in osteoarthritis, reflecting the bone's response to increased mechanical load. *Osteophyte formation* - **Osteophytes** (bone spurs) are bony projections that form along the joint margins in osteoarthritis [2]. - They are a hallmark feature of the disease, resulting from the body's attempt to repair and stabilize the damaged joint [2]. *Decreased joint space* - **Decreased joint space** on radiographs is a classic sign of osteoarthritis, indicating loss of articular cartilage thickness [2]. - As the cartilage erodes, the distance between the bones within the joint decreases. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 683-684. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1210-1212.

Question 293: 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 294: True about bone tumor is:

A. Multiple myeloma is seen in more than 55 years of age and above (Correct Answer)
B. Osteoclastoma- fifth decade
C. Osteogenic sarcoma-fourth decade
D. Chondrosarcoma -first decade

Explanation: ***Multiple myeloma is seen in more than 55 years of age and above*** - **Multiple myeloma** is a plasma cell malignancy that predominantly affects older adults, with the median age of diagnosis being around **69 years** [1] - Its incidence significantly increases with age, making it rare before the age of 40 and most prevalent in those **over 55 years** [1][2] - This statement is **medically accurate** and represents the correct answer *Osteoclastoma - fifth decade* - **Osteoclastoma** (giant cell tumor of bone) typically occurs in young adults, primarily in their **20s to 40s** (2nd to 4th decade) - Peak incidence is in the **3rd-4th decade**, not the fifth decade - This statement is **incorrect** as fifth decade is an atypical presentation *Osteogenic sarcoma - fourth decade* - **Osteogenic sarcoma** (osteosarcoma) has a **bimodal age distribution** with peaks in adolescence (10-20 years, 2nd decade) and a smaller peak in older adults over 60 years - It is **uncommon in the fourth decade** (30s), which falls outside its primary age groups - This statement is **incorrect** *Chondrosarcoma - first decade* - **Chondrosarcoma** is a malignant cartilaginous tumor that predominantly affects older adults, typically in their **50s and 60s** (5th-6th decade) - It is **exceedingly rare in the first decade** of life (0-9 years), and its incidence significantly increases with age - This statement is **incorrect** **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] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-607.

Question 295: All of the following are features of pyle disease except

A. Dental caries and mandibular prognathism
B. Mental retardation is a common feature
C. It is an autosomal recessive disease
D. It is an epiphyseal dysplasia (Correct Answer)

Explanation: ***It is an epiphyseal dysplasia*** - **Pyle disease** is a **metaphyseal dysplasia**, not an epiphyseal dysplasia, characterized by widening and deformity of the metaphyses of long bones. - The characteristic **"Erlenmeyer flask"** deformity affects the metaphyseal regions, making this statement the exception among the listed features [1]. *Dental caries and mandibular prognathism* - **Craniofacial anomalies** including **mandibular prognathism** (prominent jaw) are characteristic features of Pyle disease. - **Dental caries** commonly occur due to the associated developmental abnormalities affecting oral structures. *Mental retardation is a common feature* - **Intellectual disability** is frequently observed in patients with Pyle disease, distinguishing it from isolated bone dysplasias. - This neurological involvement reflects the systemic nature of the underlying genetic defect affecting multiple organ systems. *It is an autosomal recessive disease* - Pyle disease follows an **autosomal recessive inheritance pattern**, requiring two copies of the mutated gene for disease manifestation. - This inheritance pattern is important for **genetic counseling** and family planning considerations [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. 1188-1189.

Question 296: 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.

Question 297: 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 298: Most common soft tissue sarcoma in children is

A. Myosarcoma
B. Liposarcoma
C. Rhabdomyosarcoma (Correct Answer)
D. Sacrococcygeal teratoma

Explanation: ***Rhabdomyosarcoma*** - **Rhabdomyosarcoma (RMS)** is the most common soft tissue sarcoma in children [2], accounting for approximately 50% of all pediatric soft tissue sarcomas and 5-8% of all childhood cancers. - It arises from **primitive mesenchymal cells** [2] destined to differentiate into skeletal muscle, and can occur in various sites including head and neck, genitourinary tract, and extremities [3]. - Peak incidence is in children aged 2-6 years and adolescents aged 15-19 years [3]. *Sacrococcygeal teratoma* - This is a **germ cell tumor**, not a soft tissue sarcoma, and is the most common tumor in neonates [1]. - It is typically benign but can have malignant elements, often presenting as a mass in the sacrococcygeal region [1]. *Myosarcoma* - This is a general term for a malignant tumor of muscle, which includes **leiomyosarcoma** (smooth muscle) and **rhabdomyosarcoma** (skeletal muscle). - While rhabdomyosarcoma falls under this umbrella, it is the specific type that is most common in children, making "myosarcoma" too broad and non-specific. *Liposarcoma* - **Liposarcoma** is a malignant tumor of adipose tissue (fat) [3]. - While it is a common soft tissue sarcoma in adults, it is **rare in children** and typically occurs in older adults [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 482-483. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 481-482. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1222-1225.

Question 299: Which is the most common clinical feature of Ewing's sarcoma?

A. Pain (Correct Answer)
B. Fever
C. Limp
D. Palpable mass

Explanation: ***Pain*** - **Localized pain**, often increasing in intensity over time, is the most consistent and often the initial symptom of **Ewing's sarcoma**. - This pain is typically worse at night and may be mistaken for injury or other benign conditions in its early stages [1]. *Fever* - **Fever** can be a systemic symptom in Ewing's sarcoma, indicating inflammation or metastatic disease. - However, it is less common than pain as the initial presenting symptom and is not present in all cases. *Limp* - A **limp** frequently occurs when the tumor affects skeletal elements of the lower extremities or pelvis, leading to mechanical compromise or pain with weight-bearing. - While common, it is a secondary symptom often resulting from underlying pain or a mass, rather than the primary presenting feature. *Palpable mass* - A **palpable mass** is a significant finding in Ewing's sarcoma, especially as the tumor grows and expands beyond the bone cortex. - However, the mass is often preceded by localized pain and may not be detectable in deeply situated tumors until late stages. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 660-661.

Question 300: Bone tumor arising from epiphysis is?

A. Chondroblastoma (Correct Answer)
B. Chondrosarcoma
C. Osteoid osteoma
D. Ewing's sarcoma

Explanation: ***Chondroblastoma*** - **Chondroblastomas** are rare, benign cartilaginous tumors that characteristically arise in the **epiphysis** or apophysis of long bones. - They typically occur in individuals between the ages of 10 and 25 and often present with pain and swelling around the affected joint. *Chondrosarcoma* - **Chondrosarcomas** are malignant cartilaginous tumors that typically affect the **metaphysis or diaphysis** of long bones or flat bones, not the epiphysis. - They are more common in older adults and are characterized by destructive bone lesions and a cartilaginous matrix. *Ewing's sarcoma* - **Ewing's sarcoma** is a highly malignant tumor that primarily affects the **diaphysis** of long bones and flat bones like the pelvis, ribs, and scapula. - It most commonly occurs in children and young adults and is characterized by a "onion-skin" appearance on X-ray due to periosteal reaction. *Osteoid osteoma* - **Osteoid osteomas** are small, benign bone tumors characterized by a central nidus of osteoid and woven bone, typically found in the **cortex of long bones** (e.g., femur, tibia). - They are classically associated with nocturnal pain that is dramatically relieved by **NSAIDs** like aspirin, and they rarely involve the epiphysis. [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. 1205-1206.

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