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Oncology for FRCS (Tr & Orth)

Musculoskeletal oncology covers the assessment, staging and biopsy of a bone or soft-tissue lesion, the benign bone tumours and tumour-like lesions, the primary malignant bone tumours, soft-tissue tumours, and metastatic bone disease and myeloma. For most orthopaedic surgeons the practical skill is recognising the lesion that must not be touched before it has been discussed with a sarcoma service, and managing metastatic disease and impending fractures well. Questions typically give an age, a site within the bone and a radiographic description, and ask for the most likely diagnosis or the most appropriate next step.

75 questions in the bank · 1 topics Updated 11 November 2026

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Bone & soft-tissue tumours75

What the paper tends to test

Expect the age–site pairings: osteosarcoma in the metaphysis around the knee in adolescents, Ewing sarcoma in the diaphysis of children and young adults, giant cell tumour at the end of a long bone in the skeletally mature, chondrosarcoma in the pelvis and proximal femur of older adults.
Biopsy principles are a favourite: plan it with the unit that will do the definitive resection, use a longitudinal incision in the line of that resection, cross a single compartment and avoid contaminating neurovascular planes.
Staging questions use the Enneking system for benign (latent, active, aggressive) and malignant (grade, compartment, metastases) lesions.
Metastatic bone disease is tested through the work-up of an unknown primary and the decision to fix prophylactically, often using the Mirels score.
Soft-tissue lumps are asked through the features that require urgent referral: larger than 5 cm, deep to the fascia, enlarging, painful, or recurrent after excision.

Classic traps and discriminators

A solitary destructive bone lesion is not assumed to be a metastasis, even in a patient with a known carcinoma: it is staged and biopsied first, because nailing through a primary sarcoma contaminates the whole bone.
Conventional chondrosarcoma is treated by surgery; it responds poorly to chemotherapy and radiotherapy. Osteosarcoma and Ewing sarcoma are treated with neoadjuvant chemotherapy followed by resection.
Osteoid osteoma gives night pain that is characteristically relieved by non-steroidal anti-inflammatory drugs, with a small radiolucent nidus; a similar lesion larger than about 2 cm is an osteoblastoma.
Renal and thyroid metastases are highly vascular; pre-operative embolisation should be considered before open surgery through them.
A Mirels score of 9 or more supports prophylactic fixation; 8 is borderline and 7 or less is usually managed without surgery. The score is built from site, pain, lesion type and size.

Free oncology practice questions

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05Oncology·Bone & soft-tissue tumours

medium

A 14-year-old girl is seen at a bone sarcoma centre with a radiograph showing a permeative, sclerotic lesion of the proximal tibial metaphysis with a sunburst periosteal reaction. A biopsy is being arranged.

Which investigation is it most important to complete before the biopsy is performed?

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06Oncology·Bone & soft-tissue tumours

easy

A 60-year-old woman with breast cancer and multiple lytic bone metastases is admitted with confusion, thirst, constipation and vomiting. She is clinically dehydrated. Adjusted serum calcium is 3.6 mmol/L and creatinine is mildly raised.

What is the most appropriate initial treatment?

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Oncology questions, answered

What are the principles of biopsy for a suspected sarcoma?

Complete local and systemic staging first, then biopsy in or in agreement with the treating sarcoma unit. The track is placed so it can be excised with the specimen: a longitudinal incision or needle track in the line of the planned resection, through one compartment, away from neurovascular bundles, with careful haemostasis.

How does the Mirels score work?

It scores four features from 1 to 3 — site (upper limb, lower limb, peritrochanteric), pain (mild, moderate, functional), lesion type (blastic, mixed, lytic) and size (less than one third, one to two thirds, more than two thirds of the cortex) — for a total out of 12. A score of 9 or more indicates a high risk of fracture and supports prophylactic fixation.

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