summary Metastatic Disease of the Extremity is a malignant pathologic process that is the most common cause of destructive bone lesions in the extremities of adult patients. Diagnosis is made with plain radiographs of the affected limb including the joint above and below the lesion. In patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to rule out a primary bone lesion. Treatment is aimed at controlling pain, maintaining patient independence, and preventing fractures. Epidemiology Incidence bone is the third most common site for metastatic disease (behind lung and liver) Demographics Age >50-years-old Anatomic location most common sites of bony metastatic lesions include spine > proximal femur > humerus pathologic fractures secondary to metastatic disease most commonly occur in the proximal femur, followed by the proximal humerus 65% nonunion rate 50% in femoral neck, 20% pertrochanteric, 30% subtrochanteric acral (distal extremities) lesions are rare, but when present are most commonly from lung carcinoma lung primary is the most common for occult metastatic disease Risk factors carcinomas that commonly spread to bone include breast lung thyroid renal prostate mnemonic: BLT and a Kosher Pickle" Etiology Pathophysiology 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 matrix 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 lytic lesions osteolytic bone lesions "viscious circle" tumor cells secrete PTHrP which stimulates the release of RANKL from osteoblasts RANKL then binds to the RANK receptor on osteoclasts precursor cells differentiation to active osteoclasts occurs, which causes bony destruction TGF-B, ILGF-1, and calcium are released from resorbed bone, which stimulates tumor cells to release more PTHrP osteoblastic lesions prostate and breast cancer mets due to tumor-secreted endothelin-1(ET-1) binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts ET-1 decreases WNT suppressor DKK-1 activates WNT pathway, increasing osteoblast activity Associated conditions metastatic hypercalcemia a medical emergency symptoms include confusion muscle weakness polyuria & polydipsia nausea/vomiting dehydration treatment hydration (volume expansion) loop diuretics bisphosphonates Anatomy 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 Presentation 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 90% of pathologic fractures require surgery rarely have potential to heal 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 Imaging Radiographs recommended views plain radiographs in two planes of affected limb including the joint above and below the lesion findings destructive lesions may be lytic, mixed, or blastic (sclerotic) lung, thyroid, and renal are primarily lytic 60% of breast CA are blastic 90% of prostate CA are blastic cortical metastases are common in lung cancer lesions distal to elbow and knee are usually from lung or renal primary CT indications CT of chest / abdomen / pelvis shold be obtained to evaluate for a primary lesion in all patients >50-years-old with a single bone lesion CT of the lesion may also be obtained to evaluate containmnent within cortical boundaries Technetium bone scan indications may be used to indentify other skeletal lesions findings myeloma and thyroid carcinoma are often cold on bone scan because it evaluates osteoblastic activity evaluate with a skeletal survey Studies Labs CBC with differential ESR BMP LFTs PT, PTT electrolyte panel Ca, Phos, alkaline phosphatase serum and urine immunoelectrophoresis (SPEP, UPEP) multiple myelmoa PSA prostate CA LDH lymphoma Urinalysis renal CA Invasive studies 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 Histology characteristic findings epithelial cells in clumps or glands in a fibrous stroma immunostaining 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 Differential Differential of Metastatic Disease of Extremity Malignant lesion in older patient Multiple lesions in older patient Epithelial glands on histology Benefits from Bisphosphonate therapy Treatment is wide resection and radiation Metastatic bone disease o o o o o Myeloma o o o Lymphoma o o Chondrosarcoma o MFH / fibrosarcoma o Secondary sarcoma o Pagets disease o o Fibrous dysplasia o Synovial sarcoma o Hyperparathyroidism o Glomus tumor o Soft tissue sarcomas o Treatment Nonoperative bisphosphonate therapy indications used in lytic, blastic and mixed lesions outcomes reduces rates of skeletally related events decreased lysis and associated hypercalcemia Denosumab indications bone metastases from solid tumors and multiple myleoma outcomes superior to zoledronic acid in preventing skeletally related events radiation therapy indications palliation of pain and local tumor control outcomes renal cell carcinoma is not radio sensitive chemotherapy and hormone therapy see table of treatment based on cancer type Operative stabilization of complete fracture, postoperative radiation indications operative stabilization would lead to improved quality of life failure of nonsurgical treatment and pain 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 more than 50% destruction of the diaphyseal cortices permeative destruction of the subtrochanteric femoral region >50-75% destruction of the metaphysis persistent pain after irradiation therapy functional pain preoperative embolization indications renal cell carcinoma or thyroid carcinoma prior to operative intervention because these cancers are very vascular Techniques Bisphosphonate therapy technique both oral (clodronate) and IV (pamidronate, zoledronic acid) formulas avaliable complications osteonecrosis of the jaw Denosumab technique convenient subcutaneous dosing complications osteonecrosis of the jaw Radiation therapy technique external-beam radiation therapy given as multiple fractions or as a single fraction in high dose dosage adn fraction are determined by location, symptoms, and tumor volume Chemotherapy and hormone therapy technique dependent on primary lesion and receptor positivity Stabilization of complete and/or impending fractures, postoperative radiation technique dependent on location proximal humerus arthroplasty or open reduction internal fixation humeral diaphysis intramedullary nail femoral neck arthroplasty/endoprosthetic replacement total hip arthroplasty should be performed if there are acetabular lesions hemi-arthroplasty adequate if no acetabular involvement peritrochanteric cephalomedullary device with +/- cement femoral diaphysis statically locked cephalomedullary nail outcomes humerus length of resected segment related to functional outcome femur arthroplasty has significantly lower failure rates compared to IMN and ORIF higher dislocation rate with THA compared to hemiarthroplasty higher rates of infection seen with arthroplasty compared to nails Embolization technique preoperative emoblization perfomred for renal and thryoid cancers reduces intraoperative blood loss without adverse effects on healing 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 or as long as 4-5 years lung: 6-7 months
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Endoprosthetic Reconstruction of Proximal Femur Malignant Lesion Orthobullets Team Pathology - Intramedullary Osteosarcoma Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Endoprosthetic Reconstruction of Proximal Humerus Orthobullets Team Pathology - Intramedullary Osteosarcoma Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Prophylactic Femoral Intramedullary Nailing Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Prophylactic IM Nailing of Humeral Shaft Impending Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Prophylactic Bipolar Hemiarthroplasty of the Hip Orthobullets Team Pathology - Metastatic Disease of Extremity Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Distal Femur Resection with Endoprosthetic Replacement Ahmed Siddiqi Pathology - Intramedullary Osteosarcoma
QUESTIONS 1 of 61 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 59 60 61 Previous Next (OBQ20.198) A 67-year-old female presents to the ED with right hip pain after standing up from a chair and feeling a pop in her hip. She states she fell to the ground and was unable to bear weight after. Radiographs are shown in Figure A. She has a past medical history of hypertension, coronary artery disease and breast cancer, which was treated with lumpectomy 3 years prior. The fracture is deemed pathologic by the radiologist. What role do matrix metalloproteases play in this type of fracture? QID: 215609 FIGURES: A Type & Select Correct Answer 1 RANK-L activation to aid osteoclastogenesis 17% (206/1192) 2 Induction of angiogenesis 1% (8/1192) 3 Acidification of the extracellular matrix to aid in bony destruction 18% (217/1192) 4 Extracellular matrix degradation to aid cell invasion and metastases 61% (728/1192) 5 Acts as a chemokine to promote targeting of bone 2% (28/1192) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ20.21) Figure A is the AP radiograph of a 51-year-old male who presents to the ED after sustaining a fall in which he landed on his right shoulder. Given the appearance of the proximal humerus, a biopsy was obtained as demonstrated in Figure B. Which of the following is the most appropriate implant to treat this patient’s injury? QID: 215432 FIGURES: A B Type & Select Correct Answer 1 Proximal humerus locking plate after curettage and grafting 11% (143/1279) 2 Proximal humerus locking plate with fibular strut 2% (29/1279) 3 Antegrade humeral nail 4% (48/1279) 4 Reverse shoulder arthroplasty 8% (106/1279) 5 Proximal humerus replacement 74% (945/1279) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ19.25) A 48-year-old male is referred to your clinic for progressive left hip and thigh pain for the past three weeks. His pain is causing him to walk with a significant limp and he is no longer able to do his job as a carpenter. Two months ago, he found a lump in his neck, however, he never saw his doctor due to concerns about missing work. A radiograph obtained in your office is shown in Figure A. A biopsy slide obtained from the lesion is shown in Figure B. What is this patient's Mirel's score, and what would be the next best step in treatment? QID: 213927 FIGURES: A B Type & Select Correct Answer 1 Mirel score 5; Intramedullary nailing 4% (61/1362) 2 Mirel score 9; Radiation 3% (43/1362) 3 Mirel score 4; Observation 1% (12/1362) 4 Mirel score 10; Radiation 4% (54/1362) 5 Mirel score 12: Intramedullary nailing 87% (1185/1362) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.71) A 65-year-old man presents to your clinic as a referral for consideration of prophylactic treatment for an impending pathologic hip fracture. He was diagnosed with metastatic prostate cancer one month ago and most recently had his first course of chemotherapy. Which of the following is associated with this diagnosis as compared to other metastatic carcinomas? QID: 211883 Type & Select Correct Answer 1 Insensitivity to radiation therapy 14% (255/1760) 2 Comparable likelihood of pathologic fracture healing 41% (724/1760) 3 Primarily lytic lesions 9% (167/1760) 4 Increased skeletal related events (SREs) 30% (531/1760) 5 Worse median survival 4% (69/1760) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ18.163) A 65-year-old man with a 20-pack-year tobacco history and a remote history of small cell lung carcinoma presents with thigh pain and radiographs demonstrated in Figure A. He undergoes a full femur MRI and a CT chest, abdomen, and pelvis, both of which reveal no other areas of disease. What is the next best step in management? QID: 213059 FIGURES: A Type & Select Correct Answer 1 Open biopsy using an intermuscular interval 19% (351/1877) 2 Open biopsy using an intramuscular interval 61% (1144/1877) 3 Antegrade intramedullary nailing with reamings sent to pathology 10% (183/1877) 4 Proximal femoral replacement 9% (171/1877) 5 ORIF with plate and screws, followed by radiation 0% (8/1877) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ18.61) A 78-year-old man presents to your office with new onset right knee pain 3 years after total knee replacement. The pain is worse with weightbearing and he now has to use a cane. Ibuprofen initially gave him pain relief, but he now reports constant pain. Figure A and B represent his 1-year and 3-year (current) radiographs, respectively. ESR is 14, CRP 2.3, and an aspirate reveals 900 nucleated cells with a negative gram stain and negative leukocyte esterase. What is the best next step in management? QID: 212957 FIGURES: A B Type & Select Correct Answer 1 Bone scan to evaluate for component loosening 12% (222/1851) 2 2-stage revision arthroplasty for infection 2% (46/1851) 3 Revision of tibial component with metaphyseal sleeve and long stem 48% (897/1851) 4 CT chest, abdomen, and pelvis 35% (642/1851) 5 Observation of an osteolytic lesion 1% (17/1851) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ18.161) A 70-year-old man is scheduled to undergo a procedure to address a symptomatic left proximal femur solitary lesion. Plain radiographs are depicted in Figure A and histopathology in Figure B. Which of the following procedures is associated with improved survivorship in this patient? QID: 213057 FIGURES: A B Type & Select Correct Answer 1 Radiation therapy 6% (115/2056) 2 Chemotherapy 6% (127/2056) 3 Intramedullary stabilization 16% (320/2056) 4 Wide resection and proximal femoral replacement 71% (1465/2056) 5 Open reduction internal fixation with plates and screws 1% (20/2056) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ18SP.72) A 72-year-old 2-pack-per-day smoker presents to your office with increasingly severe right hip pain that is now exacerbated by any weight-bearing. Physical exam is significant an antalgic gait but otherwise a full painless range of motion, good strength, and an absence of neurologic symptoms. A radiograph is shown in Figure A. Metastatic work-up reveals a primary source. The histopathology is shown in Figure B. Which of the following is LEAST associated with the diagnosis? QID: 211894 FIGURES: A B Type & Select Correct Answer 1 Acral involvement 25% (549/2235) 2 High rate of complications with intralesional treatment requiring revision surgery 8% (176/2235) 3 Hypervascularity requiring pre-operative embolization 27% (610/2235) 4 Sensitivity to radiation and cytotoxic chemotherapy 29% (654/2235) 5 Variable median life expectancy, potentially as short as 6 months 10% (218/2235) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic 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? QID: 5794 FIGURES: A Type & Select Correct Answer 1 Observation; restrict activities with cane assistance as needed 1% (36/3608) 2 Radiation therapy; partial weight bearing with crutch assistance 1% (37/3608) 3 Prophylactic intramedullary nailing; non-weight bearing with crutch assistance 1% (50/3608) 4 Prophylactic intramedullary nailing; full weight bearing with cane assistance 94% (3407/3608) 5 Long stemmed total hip arthroplasty; full weight bearing with walker assistance and hip precautions 2% (60/3608) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic 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 (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? QID: 4762 FIGURES: A B C Type & Select Correct Answer 1 Radiotherapy. 2% (67/4271) 2 Curettage, cemented dynamic hip screw fixation and radiotherapy. 1% (40/4271) 3 Curettage, cancellous bone grafting, cephalomedullary fixation and radiotherapy. 5% (203/4271) 4 Proximal femoral resection, replacement with allo-prosthetic composite and radiotherapy. 15% (644/4271) 5 Cemented hemiarthroplasty and radiotherapy. 77% (3288/4271) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ11PA.100.1) A 54-year-old male presents to the emergency department after a sudden onset of pain and inability to use his right arm after pushing himself up from a chair. X-rays are obtained and demonstrated in Figures A & B. The patient denies other medical problems. He is subsequently admitted for continued workup including a CT chest/abdomen/pelvis, which does not demonstrate any relevant abnormalities. What would be the next best step of the options below? QID: 216567 FIGURES: A B Type & Select Correct Answer 1 Intramedullary nailing of humerus 6% (58/912) 2 Initiate radiation therapy to entire right arm 0% (1/912) 3 Plate and screw fixation of fracture 9% (83/912) 4 Discussion of hospice care 0% (3/912) 5 Core needle biopsy 84% (764/912) L 2 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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, however, the initial diagnostic workup over a year ago did not show any metastatic disease. What is the next most appropriate step in management of this patient? QID: 3625 FIGURES: A Type & Select Correct Answer 1 Biopsy 83% (2557/3097) 2 Intramedullary stabilization 2% (64/3097) 3 Intramedullary stabilization and send femoral reamings as biopsy 14% (431/3097) 4 Palliative chemotherapy 0% (12/3097) 5 Palliative radiotherapy 0% (12/3097) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ11OS.121.1) You are consulted to see a 67-year-old female with a new-onset inability to ambulate due to severe right hip pain. Her past medical history is significant for metastatic breast cancer. Radiographs demonstrate a peritrochanteric lytic lesion involving 40% of the cortical circumferential circumference. She has no radiographic evidence of osteoarthritis, acetabular involvement, or skip lesions. The oncology team feels her life expectancy is > 6 months. Which of the following is the recommended management correctly paired with her Mirel's score? QID: 210069 Type & Select Correct Answer 1 Hemiarthroplasty; Mirels' score of 11 59% (1091/1838) 2 Total hip arthroplasty; Mirels' score of 9 5% (98/1838) 3 Radiation and physical therapy; Mirels' score of 7 1% (20/1838) 4 Continued observation; Mirels' score of 11 1% (13/1838) 5 Cephalomedullary nail; Mirels' score of 8 33% (605/1838) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic 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? QID: 3633 Type & Select Correct Answer 1 Increased apoptosis 86% (2246/2605) 2 Sustained angiogenesis 1% (30/2605) 3 Tumor cell intravasation 3% (71/2605) 4 Avoidance of immune surveillance 3% (71/2605) 5 Genomic instability 7% (177/2605) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ11.171) Endothelin 1 is known to be involved in which of the following disease processes? QID: 3594 Type & Select Correct Answer 1 Enchondroma formation 10% (368/3846) 2 Osteochondroma formation 6% (217/3846) 3 RANK ligand induced tumor lysis 16% (617/3846) 4 Osteoblastic bone metastases 64% (2459/3846) 5 Physeal bar formation 4% (154/3846) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic 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? QID: 3214 FIGURES: A B Type & Select Correct Answer 1 Osteosarcoma 4% (135/3533) 2 Chondrosarcoma 4% (156/3533) 3 Primary lymphoma of bone 11% (394/3533) 4 Metastatic carcinoma 78% (2749/3533) 5 Multiple myeloma 2% (83/3533) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic 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? QID: 600 FIGURES: A B C D Type & Select Correct Answer 1 Chondrosarcoma 24% (890/3701) 2 Giant cell tumor 19% (717/3701) 3 Multiple myeloma 3% (104/3701) 4 Chordoma 4% (148/3701) 5 Renal Cell Carcinoma 49% (1820/3701) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic 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? QID: 548 Type & Select Correct Answer 1 Breast 4% (122/3082) 2 Lung 79% (2431/3082) 3 Thyroid 10% (314/3082) 4 Gastrointestinal 3% (102/3082) 5 Prostate 3% (99/3082) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 869 Type & Select Correct Answer 1 Intramedullary nail removal and radiotherapy to the limb 2% (23/928) 2 Systemic chemotherapy and keep nail in place to prevent fracture 12% (108/928) 3 Wide proximal femoral resection and hemiarthroplasty followed by radiotherapy 21% (194/928) 4 Wide resection including hip disarticulation 63% (588/928) 5 Palliative care 1% (10/928) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 833 FIGURES: A Type & Select Correct Answer 1 Total hip arthroplasty 1% (8/917) 2 Hemiarthroplasty 2% (19/917) 3 Sliding hip screw 1% (6/917) 4 Dynamically locked cephalomedullary nail 11% (102/917) 5 Statically locked cephalomedullary nail 84% (773/917) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ06.260) What is the most common cause for an aggressive lytic bone lesion in a patient above 40-years-old? QID: 271 Type & Select Correct Answer 1 Multiple myeloma 9% (221/2394) 2 Post-radiation sarcoma 0% (11/2394) 3 Metastatic bone disease 88% (2100/2394) 4 Paget's sarcoma 1% (16/2394) 5 Lymphoma 2% (42/2394) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.40) All of the following are necessary steps in bony metastasis of a malignant cell EXCEPT? QID: 151 Type & Select Correct Answer 1 Intravasation 7% (71/950) 2 Avoidance of immune surveillance 4% (36/950) 3 Target tissue localization 7% (64/950) 4 Induction of angiogenesis 3% (30/950) 5 Direct stimulation of osteoclasts 78% (741/950) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 195 FIGURES: A Type & Select Correct Answer 1 Biopsy of lesion 95% (1993/2098) 2 Total elbow arthroplasty 1% (14/2098) 3 Currettage and bone grafting 3% (62/2098) 4 Percutaneous cement injection 0% (5/2098) 5 Radiofrequency ablation 0% (7/2098) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 295 FIGURES: A B Type & Select Correct Answer 1 Revise the left hip total arthroplasty with a cemented stem 3% (54/1653) 2 Open reduction and internal fixation of the acetabular fracture 6% (93/1653) 3 Rest, IV bisphosphanates and follow-up in 6 weeks 10% (166/1653) 4 Radiation therapy 5% (77/1653) 5 Technetium Tc 99 and CT of the chest, abdomen and pelvis 76% (1249/1653) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 1130 Type & Select Correct Answer 1 Antegrade femoral nailing with reamings sent to pathology for analysis 4% (93/2166) 2 Antegrade femoral nailing with adjuvant radiotherapy to the lesion 2% (38/2166) 3 Minimally invasive plating of the femur for stabilization and open cementation of the lesion 1% (11/2166) 4 Referral to medical oncology for chemo-radiotherapy 2% (41/2166) 5 Lesion biopsy with further treatment based on the results of the biopsy 91% (1968/2166) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 1072 FIGURES: A Type & Select Correct Answer 1 Local radiation therapy 0% (8/2116) 2 Intramedullary nailing only 12% (248/2116) 3 Intramedullary nailing and chemotherapy 10% (219/2116) 4 Intramedullary nailing, radiation therapy to the tumor site, and chemotherapy 26% (555/2116) 5 Intramedullary nailing, radiation therapy to the entire femur, and chemotherapy 51% (1071/2116) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 951 FIGURES: A B Type & Select Correct Answer 1 Sliding hip screw 2% (23/1090) 2 Cephalomedullary nail 90% (980/1090) 3 Proximal femoral locking plate 1% (14/1090) 4 Hemiarthroplasty 4% (40/1090) 5 Proximal femoral replacement 2% (24/1090) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 1255 FIGURES: A B Type & Select Correct Answer 1 Intramedullary nailing of the tibia and send canal reamings to pathology 9% (183/2141) 2 Radiotherapy for palliative pain control as the risk for pathological fracture is very small 1% (15/2141) 3 Open incisional biopsy 84% (1796/2141) 4 Chemotherapy and surgical stabilization with intramedullary nailing of the tibia 3% (57/2141) 5 Radiotherapy and surgical stabilization with intramedullary nailing of the tibia 4% (79/2141) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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