OITE

1. OITE DR. Elfatori October / 11 / 2006

2. A 15 year old boy is diagnosed with a high grade osteogenic sarcoma, imaging studies reveal a 6cm lesion of the right humerus and no regional distant spread of the disease .what is the current American joint commission on cancer stage of the disease ? 1) IA. 2) I B. 3) II A. 4) II B. 5) III .

3. A 15 year old boy is diagnosed with a high grade osteogenic sarcoma, imaging studies reveal a 6cm lesion of the right humerus and no regional distant spread of the disease .what is the current American joint commission on cancer stage of the disease ? 1) IA. 2) IB. 3) IIA. 4) IIB. 5) III.

4. Pathological fractures that occur secondary to metastatic carcinoma most frequently involve what long bone location? 1) Distal femur. 2) proximal humerus. 3) proximal femur. 4) humeral diaphysis.

5. Pathological fractures that occur secondary to metastatic carcinoma most frequently involve what long bone location? 1) Distal femur. 2) proximal humerus. 3) proximal femur. 4) humeral diaphysis.

6. The femur is the mostly likely long bone to be affected by metastasis .the proximal third is involved in 50% of the caseses, with introchonteric region accounting for 20% because the developmental of bone metastasis is a dynamic process,it is important to stabilize as much of the bone as possible. Tip of the chosen fixation device should pass the lesion by a least twice the diameter of the femur. • AAOS instructional course lectures ,volume 53,2004.

7. A 41 year old man report a lump in his axilla . Coronal T1-T2 weighted MRI scan are shown in figures a and b. A biopsy specimen is shown in figures c. immunohistochemistery reveals that the tumor stains positive for vimentin and epithelial membrane antigen .What is the most likely diagnosis? 1) Liposarcoma. 2) Malignant fibrous histiocytoma. 3) Synovial sarcoma. 4) Leiomyosarcoma.

10. A 41 year old man report a lump in his axilla. coronal T1-T2 weighted MRI scan are shown in figures a and b. A biopsy specimen is shown in figures c. immunohistochemistery reveals that the tumor stains positive for vimentin and epithelial membrane antigen .What is the most likely diagnosis? 1) Liposarcoma. 2) Malignant fibrous histiocytoma. 3) Synovial sarcoma. 4) Leiomyosarcoma.

11. Thompson, Roby C. Jr MD *; Garg, Ashima MD *; Goswitz, Joseph MD **; Cheng, Edward Y. MD *; Clohisy, Denis R. MD *; Dusenbery, Kathryn MD + • Title Synovial Sarcoma: Large Size Predicts Poor Outcome.[Article] • Source Clinical Orthopaedics & Related Research. 373:18-24, April 2000. • Abstract A consecutive series of 38 patients with synovial sarcoma diagnosed and treated in a consistent fashion from 1976 to 1994 was reviewed for prognostic variables. The histologic specimens were reviewed and confirmed by one pathologist. There was a minimum 4-year followup for all surviving patients and no patients were lost to followup. The treatment protocol consisted of surgical excision with a wide or radical margin and limb preservation when possible. In those patients in whom the surgical margin was undefined or was less than a wide margin, perioperative radiation therapy was used. Four patients presented with metastatic disease and all died of their disease. Thirty-four patients had localized disease at presentation. Variables considered in stratifying outcomes included histologic grade, histologic subtype, surgical margin, presence or absence of local recurrence, age, and size of tumor. Of the 34 patients without metastasis there was a strong statistical association between size of tumor and survival: 17 patients with tumors less than 5 cm in diameter had a 100% survival, 12 patients with tumors 5 cm to 10 cm had a 75% survival, and five patients with tumors greater than 10 cm had a 20% survival..

12. Which of the following sarcomas is the most commonly found in young adult ? 1) Chondrosarcoma. 2) Malignant fibrous histiocytoma. 3) Liposarcoma. 4) Synovial sarcoma. 5) Fibrosarcoma.

13. Which of the following sarcomas is the most commonly found in young adult ? 1) Chondrosarcoma. 2) Malignant fibrous histiocytoma. 3) Liposarcoma. 4) Synovial sarcoma. 5) Fibrosarcoma.

14. Soft tissue sarcomas occour at any age , although the majority are seen in patients older than age 40 years. Half of the soft tissue sarcomas occurring in children are rhabdomyosarcomas. In young adult , synovial sarcomas are more likely to be diagnosed than other types of soft tissue sarcomas. Twice as many soft tissue sarcomas occour in the lower extremities than in upper extrimities.(40% - 20% ). 30% in trunk,10% in head and neck. AAOS Instructional course lectures, volume 53,2004.

15. Which of the following is a true tumor? 1) Bone cyst 2) Fibrous dysplasia 3) Osteochondroma 4) Enchondroma 5) Nonosteogenic fibroma

16. Which of the following is a true tumor ? 1) Bone cyst 2) Fibrous dysplasia 3) Osteochondroma 4) Enchondroma 5) Nonosteogenic fibroma

17. A simple bone cyst (Synonym: unicameral bone cyst, solitary cyst) is a solitary cavity containing clear fluid originating in the metaphysis of growing children adjacent to the metaphyseal aspect of the growth plate. • Fibrous dysplasia is a developmental hamartoma in which areas of the skeleton fail to mature normally and remain indefinitely as immature, poorly mineralized trabeculae. • Exostosis (osteochondroma) is a hamartomatous outgrowth of cartilage from the peripheral aspect of the physeal plate that undergoes enchondral ossification. • An enchondroma is a benign, cartilaginous lesion that arises in the interior of the bone. • Non-ossifying fibroma (Synonym: fibrous cortical defect, fibrous metaphyseal defect, histiocytic fibroma) is a hamartomatous defect in the metaphyseal cortex of skeletally-immature adolescents. • (Enneking CD)

18. Figures a ,b show the radiograph and MRI scan of a 12 year old boy who has a pathological fracture through a right femoral osteogenic sarcoma . The patient undergoes an above knee amputation at the level of the line which of the following terms best characterizes the type of resection performed.? 1) intralesional. 2) Marginal. 3) Wide. 4) Radical. 5) Complete.

20. Figures a ,b show the radiograph and MRI scan of a 12 year old boy who has a pathological fracture through a right femoral osteogenic sarcoma . The patient undergoes an above knee amputation at the level of the line which of the following terms best characterizes the type of resection performed.? 1) intralesional. 2) Marginal. 3) Wide. 4) Radical. 5) Complete.

21. Malawer MM, sugarbaker PH:Musculoskeletal cancer surgery: Treatment of sarcoms and allied disease. • Menendez LR :orthopaedic knowledge update :musculoskeletal tumors. American academy of the orthopaedic surgons,2002.

22. Which of the following disorders most commonly places a patient at a risk for malignancy ? 1) McCune Albright syndrome 2) Ollier’s disease. 3) Mafucci syndrome. 4) Neurofibromatosis. 5) Hereditary multiple exostoses.

23. Which of the following disorders most commonly places a patient at a risk for malignancy ? 1) McCune Albright syndrome 2) Ollier’s disease. 3) Mafucci syndrome. 4) Neurofibromatosis. 5) Hereditary multiple exostoses

24. The malignant potential of enchondromatosis • HS Schwartz, NB Zimmerman, MA Simon, RR Wroble, EA Millar and M Bonfiglio • In a tri-institutional, retrospective study with long-term follow-up, forty-four patients who had multiple enchondromas were identified. Thirty-seven patients did not have hemangiomas (Ollier disease) and seven did (Maffucci syndrome). Of the thirty-seven patients who had Ollier disease, a low-grade chondrosarcoma developed in four; an astrocytoma, in one; and a granulosa-cell ovarian tumor, in one. In four of the seven patients who had Maffucci syndrome, there were six low-grade chondrosarcomas, one high-grade osteosarcoma, one pancreatic adenocarcinoma, one biliary adenocarcinoma, and one astrocytoma. None of the patients in either group died of the skeletal sarcoma, but four of five patients who had a non-skeletal malignant lesion died. From life-table analyses of these patients, we estimated that the incidence of secondary chondrosarcoma in patients who have Ollier disease is about 25 per cent at the age of forty years, and that malignant degeneration is almost a certainty in patients who have Maffucci syndrome. We concluded that periodic surveillance of the brain and abdomen for occult malignant lesions is indicated in patients who have enchondromatosis.

25. When a giant cell tumor of the bone arises in the axial skeleton what is the most common location? 1) Ribs. 2) Thoracic vertebra. 3) cervical posterior elements. 4) Lumber posterior elements. 5) Sacrum.

26. When a giant cell tumor of the bone arises in the axial skeleton what is the most common location? 1) Ribs. 2) Thoracic vertebra. 3) cervical posterior elements. 4) Lumber posterior elements. 5) Sacrum.

27. Low grade chondrosarcoma can best distinguished radiographically from benign enchondroma based on which of the following ? 1) increased tracer uptake on bone scan. 2) Endosteal erosion of one fourth of the inner cortex. 3) Stippled calcification. 4) increased radiolucency on follow-up radiographs. 5) Size of more than 5cm.

28. Low grade chondrosarcoma can best distinguished radiographically from benign enchondroma based on which of the following ? 1) increased tracer uptake on bone scan. 2) Endosteal erosion of one fourth of the inner cortex. 3) Stippled calcification. 4) increased radiolucency on follow-up radiographs. 5) Size of more than 5cm.

29. Enchondromas are always completely intraosseous. They are benign, do not grow and should not change rdiographically in adult ,if a presumed enchondroma changes on follow up radiographs it consider chondrosarcoma. radiographic changes is usually seen as decreasing calcification, or radiolucencies developing within the calcified lesion. calcification occurs in long standing resting cartilage. chondrosarcoma develops ,the malignant chondrocyte are actively dividing and do not calcify because all cartilage grows in lobules ,the radiolucencies are circular and often occour at the edge of the calcification. Weiner SD: Enchondroma and chondrosarcoma :clinical radiologic ,and histologic differentiation. AAOS instructional course ,volume53,204.

30. A 3 year old boy has back pain and is unable to walk A lateral radiograph is shown in figure a, and sagital and axial MRI scan are shown in figure b, c .low and high power biopsy specimens are shown in figure d and e, what is the most likely diagnosis? 1) Ewing’s sarcoma. 2) Langerhan’s cell histocytosis. 3) Giant cell tumor. 4) Bacterial osteomylitis. 5) Tuberculosis.

34. 12) A 3 year old boy has back pain and is unable to walk A lateral radiograph is shown in figure a, and sagittal and axial MRI scan are shown in figure b, c .low and high power biopsy specimens are shown in figure d and e, what is the most likely diagnosis? 1) Ewing’s sarcoma. 2) Langerhan’s cell histocytosis. 3) Giant cell tumor. 4) Bacterial osteomylitis. 5) Tuberculosis.

35. CLASSIFICATION BASED ON THE SELECTION OF SURGICAL STRATEGIES • J. S. Mehta, MS Orth, D Orth, MCh Orth, Orthopaedic Specialist Registrar • Kent and Sussex Hospital, Mt Ephraim, Tunbridge Wells TNG 8AT, Kent BR2 0YA, UK. • In spinal tuberculosis MRI can clearly demonstrate combinations of anterior and posterior lesions as well as pedicular involvement. We propose a classification system, using information provided by MRI, to help to plan the appropriate surgical treatment for patients with thoracic spinal tuberculosis. We describe a series of 47 patients, divided into four groups, based on the surgical protocol used in the management. Group A consisted of patients with anterior lesions which were stable with no kyphotic deformity, and were treated with anterior debridement and strut grafting. Group B comprised patients with global lesions, kyphosis and instability who were treated with posterior instrumentation using a closed-loop rectangle with sublaminar wires, and by anterior strut grafting. Group C were patients with anterior or global lesions as in the previous groups, but who were at a high risk for transthoracic surgery because of medical and possible anaesthetic complications. These patients had a global decompression of the cord posteriorly, the anterior portion of the cord being approached through a transpedicular route. Posterior instrumentation was with a closed-loop rectangle held by sublaminar wires. Group D comprised patients with isolated posterior lesions which required posterior decompression only.

36. Figures a, b show the radiographs of a 34 year old man who has an enlarging mass over the left iliac crest . A biopsy specimen is shown in figure c, after the staging studies have been completed ,what is the next most appropriate step in management.? 1)observation with following in 3 months. 2) preoperative external beam radiation therapy. 3)curettage and cement. 5) wide excision.

39. Figures a, b show the radiographs of a 34 year old man who has an enlarging mass over the left iliac crest . A biopsy specimen is shown in figure c, after the staging studies have been completed ,what is the next most appropriate step in management.? 1)observation with following in 3 months. 2) preoperative external beam radiation therapy. 3)curettage and cement. 5) wide excision.

40. FRANCIS Y. LEE, M.D., HENRY J. MANKIN, M.D., GERTRUDE FONDREN, B.S., MARK C. GEBHARDT, M.D., DEMPSEY S. SPRINGFIELD, M.D.§, ANDREW E. ROSENBERG, M.D. and L. CANDACE JENNINGS, M.D., BOSTON, MASSACHUSETTS Background: The data on 227 patients who had been managed for a chondrosarcoma at one institution were reviewed to determine the nature of the lesions, the predictors of outcome, and whether there were any ways to change the treatment approaches to improve the results. Methods: The patients were followed for a mean duration of six years (range, three to twenty-five years). The mean age of the patients was forty-seven years (range, nine to eighty-four years). The most prevalent sites of the tumors were the femur (seventy-eight), the pelvis (fifty-one), and the humerus (thirty-nine). The tumors were divided into two groups according to histological grade. Eighty-six tumors (sixteen atypical enchondromas and seventy grade-1 chondrosarcomas) that were locally destructive but were associated with a low likelihood of metastasis were considered to be low-grade. The remaining 141 lesions, which were locally destructive, potentially metastatic, and capable of causing death, were thought to be high-grade. One hundred and three of these 141 lesions were grade 2, and thirty-eight were grade 3 (eighteen of the thirty-eight were grade 3 only, and twenty were both grade 3 and dedifferentiated). Two hundred and twenty-four patients were managed with resection and a limb-sparing procedure; the remaining three patients had an amputation. Postoperative adjuvant radiation was used for fifty-six patients; chemotherapy, for thirty-five; and both radiation and chemotherapy, for nineteen. Flow cytometric patterns were analyzed for 105 patients. Results: The patients who had a high-grade tumor were older than those who had a low-grade tumor (mean age [and standard deviation], 50 ｱ 17.0 years compared with 40 ｱ 15.9 years; p < 0.001). Pathological fracture, metastasis, local recurrence, and death were more prevalent in the group that had a high-grade lesion (p < 0.001).

41. A12 year old girl sustains a knee injury while playing soccer .Radiographs reveal the lesion show in figures a, Examination reveals mild effusion ,no tenderness, and a full knee range of motion. What is the next most appropriate step in management? 1) Repeat radiographs in 3 months. 2) MRI of thee distal femur. 3) Needle biopsy. 4) CT of the chest.

43. A12 year old girl sustains a knee injury while playing soccer .Radiographs reveal the lesion show in figures a, Examination reveals mild effusion ,no tenderness, and a full knee range of motion. What is the next most appropriate step in management? 1) Repeat radiographs in 3 months. 2) MRI of thee distal femur. 3) Needle biopsy. 4) CT of the chest.

44. Non -Ossifying Fibroma - Fibrous Cortical Defect • Non-ossifying fibroma (NOF) is a well circumscribed, solitary fibrous proliferation. This lesion is found mostly in children with 75% occurring in the second decade. The lesion is found in males more commonly than in females and may occur in as many as 35% of all children.' It is a non-neoplastic process that occurs in the juxtaepiphyseal region of the long bones. The most common site is the femur followed by the tibia .Clinically, non-ossifying fibromas are asymptomatic and are usually discovered as an incidental finding on x-ray. Occasionally, a larger lesion presents as a pathologic fracture. The classic scenario is a child who has a minor injury in a sports contest and a plain radiograph is taken in a local emergency room.  A lesion is seen and the child is referred to an orthopaedic surgeon for evaluation.  Generally, a careful history and physical examination will show that the child's pain is related to the nearby joint rather than the lesion, and that the pattern of the symptoms fits that which is expected in a sprain or strain injury.  If there was pain before the injury that seems to arise from the lesion, the diagnosis of NOF is highly suspect. Jaffe-Campanacci syndrome is a constellation of symptoms including multiple non-ossifying fibromas, cafe-au-lait spots, mental retardation, hypogonadism, ocular and cardiovascular abnormalities. Non-ossifying fibromas have a very typical appearance on x-ray. They are eccentric, multi-loculated sub-cortical lesions with a central lucency and a scalloped sclerotic margin. There is sometimes cortical thinning but no periosteal reaction. Serial x-rays will show the lesion migrating away  from the epiphyseal plate with time.  If the lesion is not eccentric, has no sclerotic rim, or is not multi-loculated, the diagnosis of  NOF is suspect and further evaluation is warranted.  Since these lesions may be treated by observation only without biopsy, the physician should be quite certain of the diagnosis before formulating a treatment plan.  If any doubt exists, the advice of an orthopaedic oncology specialist should be sought.  . Marks, KE and TW Bauer, Fibrous Tumors of Bone, Orthopaedic Clinics of North America, 20(3): July, 1989.JX / gX,, ,1 1/17/97

45. A 63year old man with a history of localized prostate cancer sustained a femoral subtrochanteric fracture in a motor vehicle accident. Radiographs reveal a transverse fracture through a lytic lesion. What is the most appropriate step in management? 1) Biopsy of the lesion. 2) Antegrade femoral nailing. 3) Retrograde femoral nailing. 4) open reduction and internal fixation with a fixed angled plate. 5) Long-stemmed cemented hemiarthroplasty.

46. A 63year old man with a history of localized prostate cancer sustained a femoral subtrochanteric fracture in a motor vehicle accident. Radiographs reveal a transverse fracture through a lytic lesion. What is the most appropriate step in management? 1) Biopsy of the lesion. 2) Antegrade femoral nailing. 3) Retrograde femoral nailing. 4) open reduction and internal fixation with a fixed angled plate. 5) Long-stemmed cemented hemiarthroplasty

47. The following basic types of the formation about musculoskeletal tumors need to be obtained prior to treatment: The pathological diagnosis ,is obtained by biopsy. The local extent of the tumor, the extent of distant spread of the tumor ,is obtained by clinical staging. Treatment of most musculoskeletal tumors in extremities, the surgeon need to know the interosseous and extra osseous (soft tissue) extent of the tumor and if the tumor has a metastasized ,because treatment of the primary tumor may need modified if disseminated disease is present. Diagnostic strategy of bone and soft tissue tumors .Micheal A simon. Henry Finn. AAOS inst.course lecture volme43.1994.

48. A 17 year old girl who noted low pain following a fall 1month ago now report discomfort in the spine position and increasing difficulty initiating urination. An AP radiograph is shown in figure a ,and sagitall T1 and coronal T2 weight MRI scan are shown in figures b ,c .A biopsy specimen is shown in figure d, What is the most likely diagnosis? 1) Chondroma. 2) Giant cell tumor. 3) Osteoblastoma. 4) Chondrosarcoma. 5) Malignant fibrous histiocytoma of bone.