Practice questions bone tumors

Practice questions

Bone tumors

© Jun Wang, MD, PhD

1. A 19-year-old man presents with worsening pain of his upper tibia. The pain was worse at night. He was hit at the same location two month ago during a baseball game. Physical examination and laboratory tests were unremarkable. X-ray examination reveal a well-defined 0.8 cm intracortical radiolucent area in the anterior tibia. The lesion was resected. Microscopic examination reveals thin, often interconnected spicules of bone. No inflammatory cells nor bone necrosis are seen. What is the most likely diagnosis?

A. Aneurysm bone cyst

B. Osteoblastoma

C. Osteoid osteoma

D. Osteomyelitis

E. Osteosarcoma

2. A 25-year-old female clerk presents with worsening pain of her lower back for 6 months. She tried aspirin but no relief was obtained. She has a history of left breast invasive ductal carcinoma at 3 years ago, and was treated with surgery and chemotherapy. She denies any history of trauma at her back. Physical examination and laboratory tests were within normal range. Radiology examinations reveal a 2.0 cm radiolucent lesion with irregular calcification in her vertebral body of L3. A CT guided biopsy was performed and reveals thin interconnecting woven bone trabeculae. Scattered osteoclasts are seen. No epithelial components nor inflammatory cells are seen. What is the most likely diagnosis?

A. Ewing sarcoma

B. Giant cell tumor of the bone

C. Metastatic invasive ductal carcinoma

D. Osteoblastoma

E. Osteosarcoma

3. An 18-year-old woman presents with painful swelling at her distal right thigh for 2 months. She used aspirin but the pain was not relieved. Her past history is unremarkable. Physical examination reveal a markedly swollen area at right distal thigh, extending to knee. Locomotion of left knee is slightly limited. X-ray reveals a 3.5 cm poorly defined osteolytic mass at the distal left femur with sclerotic reactions. The periosteum was raised. There are irregular calcification within the lesion. The lesion grows into peripheral soft tissue. Biopsy reveals sheets of pleomorphic cells with irregular nuclei and moderate amount of mitosis. Osteoid and cartilage are seen between the cells. Scattered inflammatory cells are seen. What is the most likely diagnosis?

A. Chrondrosarcoma

B. Osteoblastoma

C. Osteochondroma

D. Osteomyelitis

E. Osteosarcoma

4. A 12-year-old boy presents with progress pain at right knee. His has no history of trauma. His past history and family history are unremarkable. Physical examination reveals mild swelling above his right knee. No other abnormality is seen. X-ray examination reveal a poorly defined lytic masses with sclerosis at both distal femur and proximal tibia. The masses grow into surrounding soft tissue. Biopsy of the lesions reveals irregular bone woven bone trabeculae containing and lined by atypical cells with moderate to marked pleomorphism. Necrosis is focally seen. Further work up reveal additional lesions in his left humerus and left distal femur. Biopsies reveal similar findings as seen previously. Abnormality of what gene is most likely found in these lesions?

A. EX1

B. EWS

C. IDH1

D. p53

E. SYT

5. A 67-year-old man presents with worsening pain at left hip. He has a history of diffuse large B cell lymphoma involving mesentery lymph nodes 10 years ago and received chemotherapy. He has a history of Pagets disease of bone diagnosed 1 years ago, involving spine and femur. Physical examination is unremarkable. Radiology examination of the left hip reveals a 3 cm lytic bone mass with irregular calcification of the femoral head. Adjacent periosteum is raised. Biopsy of the mass reveal sheets of large atypical cells with osteoid and cartilage formation. Necrosis is focally seen. What is the most likely diagnosis?

A. Diffuse large B cell lymphoma

B. Chondrosarcoma

C. Ewing sarcoma

D. Osteoblastoma

E. Osteosarcoma

6. Use this case for the next two questions. A 6-year-old boy presents with a painful hard mass at above right knee. Radiological examination reveal a 2.5 cm pedunculated mass with stippled calcification attached to the femoral metaphysis. The mass was resected. Microscopic examination reveal a bony lesion with cartilage surface. The architectures are slightly distorted, but no atypia nor necrosis is seen. What is the most likely diagnosis?

A. Chondroma

B. Chondrosarcoma

C. Ewing sarcoma

D. Osteochondroma

E. Osteosarcoma

7. A 6-year-old boy presents with a painful hard mass at above right knee. Radiological examination reveal a 2.5 cm pedunculated mass with stippled calcification attached to the femoral metaphysis. The mass was resected. Microscopic examination reveal a bony lesion with cartilage surface. The architectures are slightly distorted, but no atypia nor necrosis is seen.

A year later, the patient came back with additional mass at left ankle. Further work up reveals multiple masses at ribs, scapulae and pelvis. Excisional biopsies of the ankle and ribs reveal similar morphology as that seen in the right femoral metaphysis. Abnormality of what gene is most likely associated with these lesions?

A. EX1

B. EWS

C. HMGA2

D. RB

E. SYT

8. Use this case for the next two questions. A 20-year-old male student presents with a painful bruised left thumb after a fall. Radiology examination reveal a well demarcated radiolucent lesion of the first metacarpal, with associated with fracture. Emergency surgery was performed for curettage of the lesion. Microscopically this lesion is composed of hyaline cartilage with pushing borders. What is most likely the diagnosis?

A. Chondrosarcoma

B. Enchondroma

C. Osteochondroma

D. Osteoid osteoma

E. Osteosarcoma

9. A 20-year-old male student presents with a painful bruised left thumb after a fall. Radiology examination reveal a well demarcated radiolucent lesion of the first metacarpal, associated with fracture. Emergency surgery was performed for curettage of the lesion. Microscopically this lesion is composed of hyaline cartilage with pushing borders. Abnormality of what gene is most likely associated with these lesions?

A. EWS

B. EX1

C. FLI1

D. IDH1

E. RB

10. A 45-year-old man presents with painful left knee swelling for 4 months. Radiologic examinations reveal a lobulated ill-defined radiolucent mass at the metaphysis of distal left femur. Irregular calcified areas are seen. Biopsy of the lesion reveals bone trabecular entrapped in hyaline cartilage. The chondrocytes is slightly atypical. What is the most likely diagnosis?

A. Chondroma

B. Chondrosarcoma

C. Osteoblastoma

D. Osteochondroma

E. Osteosarcoma

11. Use this case for the next two questions. A 17-year-old boy presents with painful swelling of left knee for 2 months. He lives in a refugee camp and is being treated for tuberculosis. Radiologic examination reveals a well-defined expansile lytic lesion of the proximal tibia metaphysis. The lesion has a cystic appearance without significant bone formation. Biopsy reveal numerous large cells with multiple round nuclei, in a background of small to intermediate sized cell with round to oval nuclei. What is the most likely diagnosis?

A. Aneurysmal bone cyst

B. Bone tuberculosis

C. Burkitt lymphoma

D. Giant cell tumor

E. Osteosarcoma

12. A 17-year-old boy presents with painful swelling of left knee for 2 months. He lives in a refugee camp and is being treated for tuberculosis. Radiologic examination reveals a well-defined expansile lytic lesion of the proximal tibia metaphysis. The lesion has a cystic appearance without significant bone formation or sclerosis. Biopsy reveal numerous large cells with multiple round nuclei, in a background of small to intermediate sized cell with round to oval nuclei. What marker is expressed in these small cells?

A. CD3

B. CD20

C. Cyclin D1

D. OPG

E. RANKL

13. An 8-year-old girl presents with progressive proximal right leg pain and walking difficulty for 3 months. Physical examination reveals local tenderness, but no other significant abnormalities are seen. Radiologic examinations reveal a 3 cm well-defined radiolucent lesion at proximal tibia, involving both metaphysis and epiphysis. Biopsy of the lesion reveal fibrous tissue forming blood-filled cyst without endothelial lining. What is the most likely diagnosis?

A. Aneurysmal bone cyst

B. Giant cell tumor of bone

C. Fibrous dysplasia

D. Non-ossifying fibroma

E. Osteosarcoma

14. Use this case for the next three questions. A 25-year-old man presents with progressive distal right thigh pain for 6 months. The area starts to swell in the last 2 months. He has a history of acute T-cell lymphoblastic lymphoma at age 12. Physical examination reveal swelling of lower third of right thigh. Radiologic studies reveal a 5 cm ill-defined mass involving the lower portion of his right femur. The mass has radiating radio-opaque stripes, raised periosteum, and appears to infiltrate into peripheral muscles. Biopsy of the mass reveal sheets of cells with relatively round to oval dark nuclei and scant cytoplasm, separated by fibrous bands. These cells are positive for vimentin, but negative for CD45, desmin and cytokeratin. What is the most likely diagnosis?

A. Burkitt lymphoma

B. Ewing sarcoma

C. Hodgkin lymphoma, nodular sclerosis type

D. Ostersarcoma, small cell variant

E. Recurrent acute T-cell lymphoblastic lymphoma

15. A 25-year-old man presents with progressive distal right thigh pain for 6 months. The area starts to swell in the last 2 months. He has a history of acute T-cell lymphoblastic lymphoma at age 12. Physical examination reveal swelling of lower third of right thigh. Radiologic studies reveal a 5 cm ill-defined mass involving the lower portion of his right femur. The mass has radiating radio-opaque stripes, raised periosteum, and appears to infiltrate into peripheral muscles. Biopsy of the mass reveal sheets of cells with relatively round to oval dark nuclei and scant cytoplasm, separated by fibrous bands. These cells are positive for vimentin, but negative for CD45, desmin and cytokeratin. What additional marker will be positive in these tumor cells?

A. CD3

B. CD10

C. CD20

D. CD30

E. CD99

16. A 25-year-old man presents with progressive distal right thigh pain for 6 months. The area starts to swell in the last 2 months. He has a history of acute T-cell lymphoblastic lymphoma at age 12. Physical examination reveal swelling of lower third of right thigh. Radiologic studies reveal a 5 cm ill-defined mass involving the lower portion of his right femur. The mass has radiating radio-opaque stripes, raised periosteum, and appears to infiltrate into peripheral muscles. Biopsy of the mass reveal sheets of cells with relatively round to oval dark nuclei and scant cytoplasm, separated by fibrous bands. What genetic abnormality is most likely seen in these tumor cells?

A. t(2;8) involving PAX3

B. t(8;14) involving c-myc

C. t(9;22) involving ABL

D. t(11;22) involving EWS

E. t(X;18) involving SYT

17. A 45-year-old man presents with a slowly growing mass at the volar side of his proximal right thumb for a year. He is a farmer and the right thumb was cut a year ago when he was repairing his barn. He wrapped the wound by himself and no complications occurred. Radiologic examination reveal a well-defined mass within the soft tissue without involvement of the proximal phalanx. The mass was resected and reveal numerous cells containing many nuclei in a background of sheets of mononucleated cells and fibrosis. What is the most likely diagnosis?

A. Foreign body granulomatous changes

B. Ganglion cyst

C. Giant cell tumor of bone

D. Giant cell tumor of tendon sheath

E. Superficial fibromatosis

18. A 14-year-old boy presents with distal left thigh discomfort for 3 months. He fell during cross country running and had a bruise of his left knee 5 months ago. Radiologic examinations reveal a 5.2 cm well demarcated radiolucent area at his distal left femur. Biopsy reveal a fibrotic tissue with scattered multinucleated cells, without bone formation. What is the most likely diagnosis?

A. Fibrosarcoma

B. Fibrous dysplasia

C. Giant cell tumor of bone

D. Non-ossifying fibroma

E. Primary myelofibrosis

19. A 14-year-old boy from New Guinea presents with graduate painless right face swelling for 2 months. He has no other symptoms. He has no history of trauma. Physical examination reveal diffuse swelling of right face. No discrete mass is found. Radiologic examinations reveal a 3 cm well define largely radiolucent right maxilla lesion containing homogeneous matrix with intermediate attenuation. Biopsy of the lesion reveal largely fibrous matrix with irregular disconnected bone trabeculae. No significant cellular atypia is seen. What is the most likely diagnosis?

A. Burkitt lymphoma

B. Fibrous cortical defect

C. Fibrous dysplasia

D. Osteosarcoma

E. Primary myelofibrosis

Answers

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