Bone and Soft Tissue Pathology Practice Questions

Q: Following are seen in fibrous dysplasia EXCEPT

No premalignant change. ***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.

Q: Chordoma can occur over all the following sites, except -

Rib. ***Rib*** - **Chordomas** originate from remnants of the **notochord**, which is primarily found along the **midline axial skeleton**. - Although the ribs are part of the axial skeleton, they develop from **somites and lateral plate mesoderm**, not from notochord remnants, making them an extremely unlikely site for chordoma. *Vertebral body* - The **vertebral bodies** are common sites for **chordomas** as they develop from notochordal remnants along the axial skeleton. - Approximately 15% of all chordomas occur in the mobile spine (cervical, thoracic, and lumbar vertebrae). *Clivus* - The **clivus**, located at the base of the skull, is a frequent site for **chordomas** due to the presence of notochordal tissue in this region. - **Clival chordomas** represent about 30-35% of all chordoma cases. *Sacrum* - The **sacrum** is the **most common site** for chordomas, accounting for over 50% of cases. - This is due to the significant presence of **notochordal remnants** in the sacrococcygeal region.

Q: Most common soft tissue sarcoma in children is

Rhabdomyosarcoma. ***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.

Q: Commonest malignancy of bones is -

Metastases. ***Metastases*** - **Metastatic tumors** are the most common malignancies found in bone, originating from primary cancers elsewhere in the body (e.g., breast, prostate, lung) [1], [3]. - While other options represent primary bone cancers, metastases significantly outnumber them due to the frequent spread of various carcinomas to bone [1], [3]. *Multiple myeloma* - This is a **primary bone marrow malignancy** involving plasma cells, but it is not a primary bone tumor in the strict sense. - While it causes extensive skeletal destruction, its overall incidence is less than that of metastatic bone disease from solid tumors [3]. *Ewing's sarcoma* - This is a **primary malignant bone tumor** that typically affects children and young adults [1]. - It is relatively rare compared to both metastatic disease and other primary bone tumors [1]. *Osteogenic sarcoma* - Also known as **osteosarcoma**, this is the most common primary malignant bone tumor, predominantly affecting adolescents and young adults [2]. - However, when considering all malignancies of bone, including metastatic disease, osteosarcoma's incidence is far lower than that of metastases [3]. **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. Bones, Joints, and Soft Tissue Tumors, p. 1202. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1198-1200.

Q: Bone tumor arising from epiphysis is?

Chondroblastoma. ***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.

Q: Select the type of bone disease which is most likely to be associated with genetically determined disorder in the structure or processing of type I collagen (SELECT 1 DISEASE)

Osteogenesis imperfecta. ***Osteogenesis imperfecta*** - This condition is primarily caused by **genetic defects** in the production of **type I collagen**, leading to fragile bones. - Due to these defects, bones are prone to **fractures** with minimal trauma. *Osteopetrosis* - Characterized by abnormally **dense bones** due to a defect in **osteoclast function**, not collagen structure [1]. - This leads to bones that are brittle and prone to fracture, but the underlying cause is different from collagen abnormalities [1]. *Osteomalacia* - This refers to the **softening of bones** due to impaired **mineralization**, most commonly from **vitamin D deficiency** or phosphate imbalance. - It does not involve a primary defect in the genetic structure or processing of type I collagen. *Osteitis fibrosa cystica* - This is a bone lesion caused by **severe hyperparathyroidism**, leading to excessive bone resorption and replacement by fibrous tissue and cysts. - It is an endocrine disorder affecting **calcium metabolism**, not a primary collagenopathy. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1188.

Q: In a patient with gouty arthritis, synovial fluid aspiration will show which of the following:

Monosodium urate crystals. ***Monosodium urate crystals*** - **Gouty arthritis** is pathognomonically characterized by the presence of **monosodium urate (MSU) crystals** in the synovial fluid [1]. - These crystals are typically **needle-shaped** and display **strong negative birefringence** under polarized light microscopy [1]. *Mononuclear leucocytosis* - While present in inflammatory conditions, a predominance of **mononuclear cells** is less typical for acute gout [1]. - **Pseudogout** or even some chronic arthritides are more likely to exhibit this pattern. *Calcium pyrophosphate crystals* - These crystals are characteristic of **pseudogout**, also known as **calcium pyrophosphate deposition disease (CPPD)** [2]. - They are typically **rhomboid-shaped** and show **positive birefringence** [2]. *Polymorphonuclear leukocytosis* - Although there is an inflammatory response with increased **polymorphonuclear leukocytes (PMNs)** in gout, their presence alone is not specific for gout [1]. - **Septic arthritis** also presents with a significant increase in PMNs, and the definitive diagnosis relies on identifying the specific crystals or infectious agents. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1218-1220. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 683-684.

Q: Which soft tissue sarcoma commonly gives rise to bone secondaries? (PGI June 2008)

Fibrosarcoma. **Fibrosarcoma** (Historical Answer) - This question reflects older teaching that fibrosarcoma has a propensity for bone metastases - However, **modern evidence** shows fibrosarcoma primarily metastasizes to **lungs (80-90%)**, with bone metastases being uncommon - Among soft tissue sarcomas, **clear cell sarcoma, alveolar soft part sarcoma, and synovial sarcoma** are more characteristically associated with bone metastases [1] - Note: This represents the historical answer from PGI 2008; current pathology references may provide different perspectives *Osteosarcoma* - **Osteosarcoma** is a **primary malignant bone tumor**, not a soft tissue sarcoma - It originates in bone and produces **osteoid matrix** by malignant cells - This option is clearly incorrect as it doesn't meet the question criteria *Neurofibroma* - A **benign tumor** of peripheral nerves composed of Schwann cells, fibroblasts, and mast cells - Being benign, it is **non-metastatic** and does not give rise to bone secondaries - This is not a sarcoma *Liposarcoma* - A malignant tumor of **adipose tissue**, classified as a soft tissue sarcoma [2] - Most commonly metastasizes to **lung and liver** - Bone metastases are uncommon, though **myxoid/round cell liposarcoma** subtype may have slightly higher bone metastatic potential than other subtypes [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. 1225-1226. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1222-1223.

Q: Which of the following is true about bone metastasis?

Most common secondary tumor in females is from breast. ***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 1

Following are seen in fibrous dysplasia EXCEPT

Accepted Answer

No premalignant change

Answer

Ground glass appearance on X-ray

Answer

Expanding rib lesions

Answer

Expanding lesions of maxilla

Question 2

Chordoma can occur over all the following sites, except -

Accepted Answer

Rib

Answer

Vertebral body

Answer

Clivus

Answer

Sacrum

Question 3

Most common soft tissue sarcoma in children is

Accepted Answer

Rhabdomyosarcoma

Answer

Myosarcoma

Answer

Liposarcoma

Answer

Sacrococcygeal teratoma

Question 4

Commonest malignancy of bones is -

Accepted Answer

Metastases

Answer

Multiple myeloma

Answer

Osteogenic sarcoma

Answer

Ewing's sarcoma

Question 5

Bone tumor arising from epiphysis is?

Accepted Answer

Chondroblastoma

Answer

Chondrosarcoma

Answer

Osteoid osteoma

Answer

Ewing's sarcoma

Question 6

Chondrocalcinosis is seen in -

Accepted Answer

Hypoparathyroidism

Answer

Ochronosis

Answer

Hypervitaminosis D

Answer

Rickets

Question 7

Select the type of bone disease which is most likely to be associated with genetically determined disorder in the structure or processing of type I collagen (SELECT 1 DISEASE)

Accepted Answer

Osteogenesis imperfecta

Answer

Osteopetrosis

Answer

Osteomalacia

Answer

Osteitis fibrosa cystica

Question 8

In a patient with gouty arthritis, synovial fluid aspiration will show which of the following:

Accepted Answer

Monosodium urate crystals

Answer

Calcium pyrophosphate crystals

Answer

Polymorphonuclear leukocytosis

Answer

Mononuclear leukocytosis

Question 9

Which soft tissue sarcoma commonly gives rise to bone secondaries? (PGI June 2008)

Accepted Answer

Fibrosarcoma

Answer

Osteosarcoma

Answer

Neurofibroma

Answer

Liposarcoma

Question 10

Which of the following is true about bone metastasis?

Accepted Answer

Most common secondary tumor in females is from breast

Answer

Higher serum levels of alkaline phosphatase

Answer

Bone metastases are often symptomatic

Answer

Prostate cancer produces only lytic lesions

Bone and Soft Tissue Pathology — MCQs

Bone and Soft Tissue Pathology — MCQs

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