Introduction Metastatic cancer is the most common reason for a destructive bone lesion in adults carcinomas that commonly spread to bone include breast lung thyroid renal prostate Epidemiology incidence bone is the third most common site for metastatic disease (behind lung and liver) demographics metastatic bone lesions are usually found in older patients (> 40 yrs) locations common sites of bony metastatic lesions include spine > proximal femur > humerus most common site of mets is thoracic spine 2nd most common site of mets is proximal femur proximal femur is also the most common site of fracture secondary to metastatic bone lesions 65% nonunion rate 50% in femoral neck, 20% pertrochanteric, 30% subtrochanteric Pathophysiology mechanism of bone destruction osteolytic bone lesions caused by tumor induced activation of osteoclasts occurs through the RANK, RANK ligand (RANKL), osteoprotegrin pathway PTHrP positive breast cancer cells activate osteoblastic RANKL production osteoblastic bone metastases due to tumor-secreted endothelin 1 Associated conditions metastatic hypercalcemia a medical emergency symptoms include see presentation below treatment hydration (volume expansion) loop diuretics bisphosphonates Prognosis median survival in patients with metastatic bone disease thyroid: 48 months prostate: 40 months breast: 24 months kidney: variable depending on medical condition but may be as short as 6 months lung: 6 months Principles of Metastasis Mechanism of metastasis tumor cell intravasation E cadherin cell adhesion molecule (CAM) on tumor cells modulates release from primary tumor focus into bloodstream PDGF promotes tumor migration avoidance of immune surveillance target tissue localization chemokine ligand 12 (CXCL12) in the stromal cells bone marrow acts as homing chemokine to certain tumor cells and promote targeting of bone attaches to target organ endothelial layer via integrin cell adhesion molecule (expressed on tumor cells) extravasation into the target tissue uses matix metalloproteinases (MMPs) to invade basement membrane and ECM induction of angiogenesis via vascular endothelial growth factor (VEGF) expression genomic instability decreased apoptosis thrombospondin inhibits tumor growth Mechanism of vascular spread Batson's vertebral plexus valveless venous plexus of the spine that provides a route of metastasis from organs to axial structure including vertebral bodies, pelvis, skull, and proximal limb girdles arterial tree metastasis mechanism by which lung and renal cancer spread to the distal extremities Mechanism of bone lysis oncogenic cell releases cytokines IL-6, IL-11, PTHrP, TGF-beta PTHrP and TGF-beta activate osteoblasts osteoblasts secrete RANKL, that binds to RANK on osteoclasts and activates osteoclasts Mechanism of bone sclerosis (prostate and breast mets) prostate cancer cells secrete endothelin 1 (ET-1) ET-1 binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts ET-1 decreasesWNT suppressor DKK-1 activates WNT pathway, increasing osteoblast activity Symptoms Symptoms pain may be mechanical pain due to bone destruction or tumorigenic pain which often occurs at night pathologic fracture occurs at presentation in 8-30% of patients with metastatic disease metastatic hypercalcemia confusion muscle weakness polyuria & polydipsia nausea/vomiting dehydration Physical exam neurologic deficits caused by compression of the spinal cord in metastatic disease to the spine Evaluation Workup for older patient with single bone lesion and unknown primary includes imaging plain radiographs in two planes of affected limb CT of chest / abdomen / pelvis technetium bone scan to detect extent of disease myeloma and thyroid carcinoma are often cold on bone scan - evaluate with a skeletal survey labs CBC with differential ESR basic metabolic panel LFTs, Ca, Phos, alkaline phosphatase serum and urine immunoelectrophoresis (SPEP, UPEP) biopsy in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to rule out a primary bone lesion should not treat a bone lesion without tissue diagnosis of the lesion metastatic adenocarcinoma not identified by CT of the chest, abdomen, and pelvis is most likely from a small lung primary tumor Imaging Radiographic recommended views AP and lateral of involved area findings purely lytic or mixed lytic/blastic lesions lung, thyroid, and renal are primarily lytic 60% of breast CA is blastic 90% of prostate CA is blastic cortical metastasis are common in lung cancer lesions distal to elbow and knee are usually from lung or renal primary CT scan helpful to identify metastatic lesions to the spine MRI useful to show neurologic compromise of the spine Studies Histology characteristic findings epithelial cells in clumps or glands in a fibrous stroma immunohistochemical stains positive Keratin CK7 (breast and lung cancer) TTF1 (lung cancer) Receptor status can provide therapeutic targets during concomitant medical management estrogen, progesterone, and HER2/neu receptor status is essential for treating metastatic breast cancer Treatment - General Nonoperative bisphosphonate therapy indications symptomatic care by preventing osteoclatic bone destruction technique IV pamidronate most commonly used chemotherapy, radiotherapy, and hormone therapy see table of treatment based on cancer type Operative stabilization of complete fracture, postoperative radiation goals of surgical treatment patient survives operation immediate full weightbearing implant survival > patient survival indications most complete fractures are treated if operative stabilization leads to improved quality of life technique fixation method depends on location See table of fixation methods by location postoperative radiation all patients require postop radiation unless death is imminent or area has previously been irradiated begin radiation therapy after surgery area of irradiation should include the entire fixation device (e.g. entire femur after intramedullary nailing of femoral lesion) prophylactic stabilization of impending fracture, postoperative radiation indications impending fx that meets criteria criteria for impending fractures preoperative embolization indications is indicated inpatients with renal cell carcinoma or thyroid carcinoma prior to operative intervention because these cancers are very vascular. Treatment - Proximal Femur Fractures Treatment operative cemented hemiarthroplasty indications intracapsular fracture use long stem if distal lesion present THA indications acetabular involvement cephalomedullary nail + currettage + cement pertrochanteric / subtrochanteric fractures Techniques prophylactic IM nailing of proximal femur lesions indications impending and complete peritrochanteric fractures that do not involve the femoral head technique statically locked cephalomedullary IM nail for peritrochanteric fractures hemiarthroplasty vs. total hip arthroplasty indications both impending and complete pathologic fractures of the femoral head and neck can be management with replacement arthroplasty Complications dislocation of prosthesis THA > hemiarthroplasty infection higher for THA and hemiarthroplasty than nails nonunion of fracture for cephallomedullary nails Differentials & Groups Malignant lesion in older patient(1) Multiple lesion in older patient(1) Epithelial glands on histology Benefits from Bisphonate therapy Treatment is wide resection and radiation(2) Metastatic bone disease • • • • • Myeloma • • • Lymphoma • • Chondrosarcoma • MFH / fibrosarcoma • Secondary sarcoma • Pagets disease • • Fibrous dysplasia • Synovial sarcoma • Hyperparathyroidism • Gomus tumor • Soft tissue sarcomas (3) • ASSUMPTIONS: (1) Older patient is > 40 yrs; (2) assuming no impending fracture (3) High-grade soft tissue sarcomas includes angiosarcoma, synovial sarcoma, liposarcoma, desmoid tumor, MFH/fibrosarcoma: exception is rhabdomysarcoma which is treated with chemotherapy and wide resection IBank Location Xray Xray CT B. Scan MRI MRI Histo(1) Case A prox femur Case B pelvis Case C hand (thyroid CA) Case D hand (lung CA) Case E femur (lung CA) Case F pelvis Case G renal CA (angio) (1) - histology does not always correspond to clinical case
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Endoprosthetic Reconstruction of Proximal Femur Malignant Lesion Orthobullets Team Pathology - Intramedullary Osteosarcoma Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Endoprosthetic Reconstruction of Proximal Humerus Orthobullets Team Pathology - Intramedullary Osteosarcoma Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Prophylactic Femoral Intramedullary Nailing Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Prophylactic IM Nailing of Humeral Shaft Impending Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Prophylactic Bipolar Hemiarthroplasty of the Hip Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Distal Femur Resection with Endoprosthetic Replacement Ahmed Siddiqi Pathology - Intramedullary Osteosarcoma
QUESTIONS 1 of 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ15.109) A 59-year-old women with known metastatic lung cancer presents with acute left hip pain with ambulation, as shown in Figure A. She previously underwent a right lung lobectomy 2 years ago, which has been complicated by chronic chest pain. Her oncologist predicts an estimated life expectancy of 12-18 months. She currently lives independently and walks for 2 hours per day. What would be the most appropriate treatment and rehabilitation plan? Tested Concept QID: 5794 FIGURES: A Type & Select Correct Answer 1 Observation; restrict activities with cane assistance as needed 1% (30/3169) 2 Radiation therapy; partial weight bearing with crutch assistance 1% (30/3169) 3 Prophylactic intramedullary nailing; non-weight bearing with crutch assistance 1% (45/3169) 4 Prophylactic intramedullary nailing; full weight bearing with cane assistance 95% (2996/3169) 5 Long stemmed total hip arthroplasty; full weight bearing with walker assistance and hip precautions 2% (51/3169) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.127) A 65-year-old community-ambulatory patient complains of constant left hip pain that affects her activities of daily living. Staging studies confirm multi-focal disease. Biopsy results are shown in Figure A. Recent radiographs are shown in Figures B and C. Life expectancy is estimated at 1 year. What is the most appropriate treatment option? Tested Concept QID: 4762 FIGURES: A B C Type & Select Correct Answer 1 Radiotherapy. 2% (59/3862) 2 Curettage, cemented dynamic hip screw fixation and radiotherapy. 1% (37/3862) 3 Curettage, cancellous bone grafting, cephalomedullary fixation and radiotherapy. 5% (179/3862) 4 Proximal femoral resection, replacement with allo-prosthetic composite and radiotherapy. 15% (580/3862) 5 Cemented hemiarthroplasty and radiotherapy. 77% (2981/3862) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.210) All of the following are known steps in the development of a malignant tumor with the ability to metastasize EXCEPT? Tested Concept QID: 3633 Type & Select Correct Answer 1 Increased apoptosis 87% (2070/2386) 2 Sustained angiogenesis 1% (26/2386) 3 Tumor cell intravasation 3% (66/2386) 4 Avoidance of immune surveillance 3% (62/2386) 5 Genomic instability 6% (155/2386) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ11.202) A 65-year-old male is seen for increasing thigh pain and a new femoral lesion seen by his oncologist. A current radiograph is shown in Figure A. He has a known diagnosis of lung carcinoma but no history of metastatic disease. What is the next most appropriate step in management of this patient? Tested Concept QID: 3625 FIGURES: A Type & Select Correct Answer 1 Biopsy 83% (2333/2817) 2 Intramedullary stabilization 2% (53/2817) 3 Intramedullary stabilization and send femoral reamings as biopsy 14% (391/2817) 4 Palliative chemotherapy 0% (9/2817) 5 Palliative radiotherapy 0% (10/2817) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ11.171) Endothelin 1 is known to be involved in which of the following disease processes? Tested Concept QID: 3594 Type & Select Correct Answer 1 Enchondroma formation 10% (316/3288) 2 Osteochondroma formation 5% (176/3288) 3 RANK ligand induced tumor lysis 17% (547/3288) 4 Osteoblastic bone metastases 64% (2095/3288) 5 Physeal bar formation 4% (132/3288) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.120) A 61-year-old female presents with a 6 month history of pain in the left hip and thigh. A hip radiograph is shown in Figure A. Serum protein electrophoresis is normal, and a bone scan shows increased uptake in the left femur only. A biopsy is taken and shown in Figure B. What is the most likely diagnosis? Tested Concept QID: 3214 FIGURES: A B Type & Select Correct Answer 1 Osteosarcoma 4% (114/3108) 2 Chondrosarcoma 4% (131/3108) 3 Primary lymphoma of bone 11% (333/3108) 4 Metastatic carcinoma 79% (2450/3108) 5 Multiple myeloma 2% (67/3108) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.214) You are seeing a 53-year-old female for 1 year of increasing knee pain. She is otherwise healthy. Based on the imaging studies below (Figures A-D), what is your diagnosis? Tested Concept QID: 600 FIGURES: A B C D Type & Select Correct Answer 1 Chondrosarcoma 25% (801/3234) 2 Giant cell tumor 19% (617/3234) 3 Multiple myeloma 3% (87/3234) 4 Chordoma 4% (135/3234) 5 Renal Cell Carcinoma 49% (1574/3234) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.162) Metastatic bony lesions that occur distal to the elbows or knees are most likely to originate from which one of the following primary organs? Tested Concept QID: 548 Type & Select Correct Answer 1 Breast 4% (105/2676) 2 Lung 79% (2101/2676) 3 Thyroid 10% (280/2676) 4 Gastrointestinal 3% (90/2676) 5 Prostate 3% (88/2676) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.172) A 69-year-old man with known metastatic lung cancer presents with a pathological fracture after a fall from standing height (Figure A). Which of the following options is the best choice for treating this fracture? Tested Concept QID: 833 FIGURES: A Type & Select Correct Answer 1 Total hip arthroplasty 1% (6/569) 2 Hemiarthroplasty 2% (10/569) 3 Sliding hip screw 1% (5/569) 4 Dynamically locked cephalomedullary nail 11% (61/569) 5 Statically locked cephalomedullary nail 84% (479/569) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ07.208) A 56-year-old female is referred for a second opinion after placement of an intramedullary nail through a presumed metastatic lesion in her proximal femur. Final biopsy results from the lesion show a high-grade chondrosarcoma and staging studies show this to be an isolated site of disease. What treatment should be recommended? Tested Concept QID: 869 Type & Select Correct Answer 1 Intramedullary nail removal and radiotherapy to the limb 3% (17/631) 2 Systemic chemotherapy and keep nail in place to prevent fracture 12% (77/631) 3 Wide proximal femoral resection and hemiarthroplasty followed by radiotherapy 22% (139/631) 4 Wide resection including hip disarticulation 61% (388/631) 5 Palliative care 1% (6/631) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ06.260) What is the most common cause for an aggressive lytic bone lesion in a patient above 40-years-old? Tested Concept QID: 271 Type & Select Correct Answer 1 Multiple myeloma 10% (195/2012) 2 Post-radiation sarcoma 0% (10/2012) 3 Metastatic bone disease 87% (1759/2012) 4 Paget's sarcoma 1% (12/2012) 5 Lymphoma 2% (32/2012) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ06.40) All of the following are necessary steps in bony metastasis of a malignant cell EXCEPT? Tested Concept QID: 151 Type & Select Correct Answer 1 Intravasation 7% (45/652) 2 Avoidance of immune surveillance 3% (18/652) 3 Target tissue localization 7% (45/652) 4 Induction of angiogenesis 3% (18/652) 5 Direct stimulation of osteoclasts 80% (519/652) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ06.84) A 65-year-old woman presents with elbow pain. Her radiograph is shown in the Figure A. The patient had a history of non-metastatic breast cancer 10 years ago which was treated successfully. Repeat mammogram, bone scan and CT scan of the chest, abdomen and pelvis demonstrate this to be an isolated lesion. What is the next most appropriate action in treatment? Tested Concept QID: 195 FIGURES: A Type & Select Correct Answer 1 Biopsy of lesion 95% (1647/1732) 2 Total elbow arthroplasty 1% (10/1732) 3 Currettage and bone grafting 3% (49/1732) 4 Percutaneous cement injection 0% (5/1732) 5 Radiofrequency ablation 0% (7/1732) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ06.109) A 53-year-old woman with a history of Paget's disease and bilateral total hip arthroplasties presents with left hip pain and dysuria. An AP pelvic radiograph and CT scan are shown in Figure A and B. What is the next most appropriate step in management? Tested Concept QID: 295 FIGURES: A B Type & Select Correct Answer 1 Revise the left hip total arthroplasty with a cemented stem 3% (36/1248) 2 Open reduction and internal fixation of the acetabular fracture 5% (61/1248) 3 Rest, IV bisphosphanates and follow-up in 6 weeks 9% (115/1248) 4 Radiation therapy 5% (61/1248) 5 Technetium Tc 99 and CT of the chest, abdomen and pelvis 77% (966/1248) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ05.186) A 51-year-old female with known metastatic breast cancer presents with acute right thigh pain and inability to bear weight. A radiograph is shown in Figure A. A biopsy is performed that confirms metastatic breast cancer. What is the next step in management? Tested Concept QID: 1072 FIGURES: A Type & Select Correct Answer 1 Local radiation therapy 0% (7/1794) 2 Intramedullary nailing only 11% (204/1794) 3 Intramedullary nailing and chemotherapy 11% (194/1794) 4 Intramedullary nailing, radiation therapy to the tumor site, and chemotherapy 26% (471/1794) 5 Intramedullary nailing, radiation therapy to the entire femur, and chemotherapy 51% (907/1794) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ05.65) A 70-year-old man with a history of esophageal cancer presents to the emergency department with pain in his right femur. His right hip xray is shown in Figure A and B. His medical oncologist has estimated he has a life expectancy of less than 6 months. His activities are limited to walking around his house. Which of the following management options is most appropriate? Tested Concept QID: 951 FIGURES: A B Type & Select Correct Answer 1 Sliding hip screw 2% (13/665) 2 Cephalomedullary nail 90% (597/665) 3 Proximal femoral locking plate 2% (11/665) 4 Hemiarthroplasty 3% (23/665) 5 Proximal femoral replacement 2% (12/665) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ05.244) What is the most appropriate treatment for a 65-year-old female with a 100-pack-year tobacco history who presents with a new painful lytic lesion in her femoral diaphysis? Tested Concept QID: 1130 Type & Select Correct Answer 1 Antegrade femoral nailing with reamings sent to pathology for analysis 4% (73/1812) 2 Antegrade femoral nailing with adjuvant radiotherapy to the lesion 1% (26/1812) 3 Minimally invasive plating of the femur for stabilization and open cementation of the lesion 0% (9/1812) 4 Referral to medical oncology for chemo-radiotherapy 2% (32/1812) 5 Lesion biopsy with further treatment based on the results of the biopsy 92% (1659/1812) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ04.252) A 65-year-old patient without a history of cancer presents with thigh pain and a lytic lesion in the left femur. A CT scan of the chest, abdomen, and pelvis as well as a bone scan show this to be an isolated tumor. Biopsy confirms adenocarcinoma. What is the most likely primary source of this patient's tumor? Tested Concept QID: 1357 Type & Select Correct Answer 1 Gastrointestinal 12% (85/686) 2 Lung 64% (441/686) 3 Kidney 3% (20/686) 4 Prostate 9% (64/686) 5 Breast 11% (74/686) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ04.219) Which of the following correctly lists the life expectancy from least life expectancy to greatest life expectancy when a patient presents with metastatic carcinoma to bone? Tested Concept QID: 1324 Type & Select Correct Answer 1 Prostate < breast < thyroid < renal < lung 3% (25/825) 2 Renal < prostate < breast < thyroid < lung 2% (14/825) 3 Lung < renal < thyroid < breast < prostate 39% (324/825) 4 Thyroid < renal < lung < breast < prostate 5% (39/825) 5 Lung < renal < breast < prostate < thyroid 50% (415/825) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ04.150) A 62-year-old male with a 50-pack-year history of tobacco use presents with complaints of productive cough and increasing leg pain for the past 6 months. Proximal tibial radiographs are shown in Figures A and B, and are concerning for an impending pathologic fracture. CT of the chest, abdomen, and pelvis, and staging blood work are negative. MRI of the tibia shows a multi-focal cortically based lesion without significant soft tissue mass and whole body technetium bone scan shows this to be an isolated lesion. What is the next most appropriate step in management of this patient? Tested Concept QID: 1255 FIGURES: A B Type & Select Correct Answer 1 Intramedullary nailing of the tibia and send canal reamings to pathology 8% (155/1830) 2 Radiotherapy for palliative pain control as the risk for pathological fracture is very small 1% (12/1830) 3 Open incisional biopsy 84% (1546/1830) 4 Chemotherapy and surgical stabilization with intramedullary nailing of the tibia 2% (45/1830) 5 Radiotherapy and surgical stabilization with intramedullary nailing of the tibia 3% (62/1830) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept
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