Fair Game Flashcards
(260 cards)
1
Q
Case 56
What do you do with CT contrast and Metformin to avoid contrast-induced nephropathy?
A
Hold Metformin for 48 hours
Check blood for signs of CIN
Restart if all is well
2
Q
Case 56
What do you when there is CT contrast extravasation in the arm?
A
Elevate the arm Cold compress Call Surgeon - Lg vol high-osmolar contrast w necrosis - Neuromuscular dysfunction - Compartment Syndrome
3
Q
Case 56
When does the severity of the soft tissue injury peak after contrast extravasation in an extremity?
A
48 hours
4
Q
Case 56
How do you treat hives (urticaria) if Benadryl isn’t working?
A
Consider
- Cimetidine
- Epinephrine
5
Q
Case 56
How do you treat a contrast reaction of hypotension with bradycardia?
A
Atropine
- Vasovagal reaction!
6
Q
Case 56
How do you treat a contrast reaction of hypotension with tachycardia?
A
Trendelenburg position
IV fluids
Epinephrine
7
Q
Case 56
How do you treat a contrast reaction of dyspnea?
A
Oxygen
Beta-agonist inhalants
8
Q
Case 57
Name three causes of Medullary Nephrocalcinosis
A
Hyperparathyroidism
Renal Tubular Acidosis
Medullary sponge kidney
- typically unilateral
9
Q
Case 57
Is renal function impaired with Medullary Nephrocalcinosis?
A
No (particularly if it is reversed) Unless - Severe, long-standing hypercalcemia and/or - Renal tubular acidosis
10
Q
Case 57
What is the most common complication of Medullary Nephrocalcinosis?
A
Urolithiasis
11
Q
Case 58
What GU tract anomalies are associated with ureteral duplication?
A
UPJ Obstruction
Hydronephrosis
Ureterocele
Ureterovesical reflux
12
Q
Case 58
What is the Weigert-Meyer rule?
A
Upper pole ureter
- Inserts inferior and medial to the lower pole ureter
Upper pole moiety
- Obstructs
Lower pole moiety
- Refluxes
- Causes lower pole atrophy
13
Q
Case 59
What is the conventional treatment for emphysematous pyelonephritis?
A
Radical nephrectomy
Drainage / Abx is Insufficient
14
Q
Case 59
What type of patients are predisposed to emphysematous pyelonephritis?
What is the most common organism?
A
Diabetics
E. coli
15
Q
Case 60
What mechanism causes a horseshoe kidney?
A
Arrest of cranial migration of the kidney by the IMA
Abnormal contact of the developing metanephric tissues
16
Q
Case 60
What are common complications associated with horseshoe kidneys?
A
Nephrolithiasis
UPJ obstruction
Duplication anomalies
Recurrent infection
Higher susceptibility to renal injury from trauma
TCC (slight increase in incidence from urinary stasis)
17
Q
Case 61
Dx of a solid, enhancing renal mass?
A
RCC
Oncocytoma
Lipid-poor angiomyolipoma
Metastasis
18
Q
Case 61
What percentage of angiomyolipomas have no identifiable fat on CT or MRI?
What complication is AML associated with?
A
5%
Spontaneous Hemorrhage
19
Q
Case 62
What percentage of angiomyolipomas are associated with tuberous sclerosis?
A
20%
20
Q
Case 62
What size of an AML increases risk of bleeding?
What causes the tumor to bleed?
How do you deal with a nonhemorrhagic AML?
A
> 4cm
Small aneurysms develop in arteries supplying AML’s
Prophylactic excision, ablation, or embolization
21
Q
Case 63
A patient with multiple AML’s likely has?
A
Tuberous sclerosis
21
Q
Case 63
Three skin lesion associated with Tuberous Sclerosis?
A
Adenoma sebaceum (Adenofibroma)
Nevus depigmentosus
Cafe au lait spots
22
Q
Case 63
What percentage of tuberous sclerosis patients have AML?
A
80%
23
Q
Case 63
What are the 6 primary features of tuberous sclerosis?
(This to me is more of a neuroradiology question!)
A
Cortical tubers Giant cell astrocytoma Calcified subependymal nodules Retinal astrocytoma Facial angiofibromas Ungual fibromas
24
Case 64
| What other renal masses besides angiomyolipoma can contain fat?
```
Angiomyolipoma
Rarely
- Lipoma
- Liposarcoma
- Wilms' tumor (dedifferentiated)
- RCC that engulfs adjacent renal hilar fat
```
25
Case 65
| Define a Bosniak I renal cyst and how do you manage it?
Simple cyst
- No follow-up
- Round
- Imperceptible wall
26
Case 65
| Define a Bosniak II renal cyst and how do you manage it?
Minimally complex
| - No follow-up
27
Case 65
| Define a Bosniak IIF renal cyst and how do you manage it?
```
Minimally complex: 6 month follow-up
>3cm
>3 septa that are thicker or nodular
Thick calcification
Hyperdense but nonenhancing
```
28
Case 65
| Define a Bosniak III renal cyst and how do you manage it?
Indeterminate
- 25-45% malignant
- Partial nephrectomy/RFA
- Multiple thick septations
- Coarse calcifications
- Hyperdense and enhancing
29
Case 65
| Define a Bosniak IV renal cyst and how do you manage it?
Malignant
- Partial or total nephrectomy
- Solid and enhancing mass
- Cystic or necrotic components
30
Case 66
| What renal tumor do patients with horseshoe kidneys more commonly have?
TCC
- Related to renal stasis
No increase in RCC incidence
31
Case 66
| Why should you always perform an angiogram in patients who have horseshoe kidney and RCC?
Surgical planning
Almost always have
- Aberrant arterial supply
- Anomalous Venous drainage
32
Case 66
| What pathology occurs with increased incidence in the setting of horseshoe kidney?
Infections
Stones
UPJ Strictures
TCC
34
Case 67
| What are causes of spontaneous perinephric hemorrhage
```
Neoplasm (60%)
Complicated renal cyst
Vasculitis
Infarction
Infection
```
35
Case 68
| DDx on U/S of a solid, heterogenous, hyperechoic mass (4 lesions)?
Renal cell carcinoma
Oncyocytoma
AML
Metastasis
36
Case 68
| What differentiates Stage III from Stage IV RCC?
Stage III
- Regional lymph nodes
- Venous extension
Stage IV
- Direct invasion of adjacent organs (besides adrenal)
- Distant metastasis
37
Case 69
| What are four causes of renal vein thrombosis?
RCC
Hyper coagulable state
Dehydration
Glomerulonephritis
38
Case 69
| What has a better prognosis in Stage III RCC, venous extension or regional lymph node involvement?
Venous extension
39
Case 69
Why is it important to determine if renal venous tumor thrombosis with IVC thrombus extends above the level of the hepatic veins?
If it extends above the hepatic veins
- Abdominal incision isn't enough for resection
- Requires thoracoabdominal incision w/ cardiopulmonary bypass
40
Case 70
| What three diseases are associated with renal cysts and solid renal masses?
Tuberous sclerosis
von Hippel-Lindau Disease
Long-term dialysis
41
Case 70
| What are common manifestations of vHL Disease
```
Retinal angiomas
Renal cysts
RCC (clear cell variety)
Pancreatic cysts and cystic tumors
Cerebellar hemangioblastomas
```
42
Case 70
| A patient with multiple renal cysts. What helps differentiate the cause between ADPKD v. vHL Disease
If they have pancreatic cysts, it's most likely vHL.
Patients with ADPKD don't get pancreatic cysts
43
Case 71
| What tumors grow in the kidney in an infiltrative pattern?
Urothelial tumors (TCC or SCC)
Metastasis
Lymphoma
Infiltrative RCC
44
Case 71
| What are common causes of bilateral or multiple renal solid masses?
Metastasis
Oncocytoma
Lymphoma
AML
Multifocal RCC
45
Case 72
| What two renal lesions are common in patients with tuberous sclerosis?
AML
| Renal cysts
46
Case 73
| A solid renal mass with a central stellate scar (spoke-wheel on angiography) is diagnostic of an oncocytoma. T or F?
False
- Highly suggestive
- Not diagnostic
- May be RCC
This is a surgical lesion! Biopsy won't help. Take it out!
47
Case 74
| DDx of bilateral infiltrative renal lesions (tumors and nontumors)?
Metastasis
Lymphoma
Infarcts
Pyelonephritis
48
Case 75
| What are four ways that lymphoma involving the kidneys presents?
Perirenal space spread from retroperitoneum
Multifocal infiltrative renal masses
Diffuse renal infiltration
Solid renal mass (mimics RCC)
49
Case 75
| How can ureteral position help differentiate lymphoma from retroperitoneal fibrosis
Lymphoma
- Lateral ureteral displacement
RPF
- Medial ureteral displacement
49
Case 75
| What type of lymphoma involves the kidneys?
Non-Hodgkins Lymphoma
50
Case 76
| What helps differentiate a right perinephric abscess caused by a perforated duodenal ulcer from pyelonephritis?
Normal cortical enhancement is unusual in pyelonephritis
51
Case 77
| When you see a rim of enhancement around a renal cortical infiltrative abnormality, what is the likely diagnosis?
Renal infarct
The rim is caused by flow from the renal capsular artery
52
Case 78
| What causes a "faceless kidney," which is defined as a sold mass proliferating the renal sinus and obliterating its fat?
Transitional cell carcinoma
Squamous cell carcinoma less commonly
53
Case 79
| What is the mechanism of developing xanthogranulomatous pyelonephritis (XGP)?
Recurrent upper urinary tract infections
- E. coli or Proteus
Calculus formation
- Obstruction
Renal inflammation with lipid-laden histiocytes
Destruction and replacement of renal parenchyma
54
Case 79
| What patients are most susceptible to XGP?
Middle-aged women
| Diabetics
55
Case 80
| What mechanism causes a urinoma?
Laceration of the ureter at the UPJ
56
Case 80
| How is a urinoma treated non-surgically to allow the ureteral laceration to heal?
Percutaneous nephrostomy
| Ureteral stent
57
Case 80
| What is a Page kidney?
Renovascular hypertension
- Subcapsular fluid (or hematoma)
- > Compresses renal parenchyma
- > Underperfusion and ischemia
- > Triggers renal renin-angiotensin-aldosterone system
- -> HTN
58
Case 80
| What is a Goldblatt kidney?
Renovascular hypertension
| - Caused by renal artery stenosis or occlusion
59
Case 81
| What are two ways that a subcapsular hematoma can be distinguished from a hematoma in the peritoneal space?
Subcapsular hematoma deforms the renal shape
| - No fat plane between the hematoma and the kidney
60
Case 81
| Name 3 causes of a subcapsular hematoma
Trauma (blunt or biopsy)
Vasculitis
Vascular malformation
61
Case 82
| What are known complications of renal biopsy?
Hemorrhage Abscess
Hematuria Sepsis
AV fistula Page Kidney
62
Case 82
| What are 5 entities that are bright on T1 weighted MRI
Fat Methemoglobin
Melanin Gadolinium
Protein
63
Case 82
| What are two risk factors for post-biopsy bleeding?
Coagulopathy
| Severe hypertension
64
Case 83
| Besides RCC, Dehydration, and Hypercoagulability, what are other less common causes of renal vein thrombosis?
Sickle cell disease
Vasculitis
Amyloidosis
Lupus
65
Case 83
| What percentage of patients with renal vein thrombosis develop PE?
33%
66
Case 84
| What % of patients on long-term dialysis develop RCC?
7%
| RCC in these patients is typically less aggressive
67
Case 84
| What is also common in long-term dialysis patients?
Multiple renal cysts
68
Case 85
T/F
Bilateral orthotopic uretereoceles are not associated with other urinary tract anomalies.
True
| - Ectopic ureteroceles are however
69
Case 85
| Ureteroceles >2 cm have a higher risk of what complications?
Urinary stasis
Obstruction
Stone formation
Infection
70
Case 85
What is the maximum thickness of the radiolucent halo around an orthotropic ureterocele?
Failed resorption of what structure is the proposed cause of this abnormality?
2 mm
Chwalla's membrane
71
Case 86
| What is a ureterocele-like abnormality with an irregular wall surrounding its bulbous portion or a thick halo (>2mm)
Pseudoureterocele
72
Case 86
| What causes a Pseudoureterocele?
Ureteral stones
Edema from a recently passed ureteral stone
Manipulation of the UVJ
Bladder tumor blocking the ureteral orifice
73
Case 87
| What is an amputed calyx on an IVP or CT urogram?
Abrupt cutoff of the infundibulum with minimal opacification of the calyces
74
Case 87
| DDx of an amputed calyx on an IVP or CT urogram
TCC
| TB
75
Case 88
What percentage of patients with calyceal TCC have synchronous tumors of the calyces?
Bladder?
25%
40%
76
Case 89
| What is the single most important risk factor for TCC?
Smoking
77
Case 89
| How does TCC typically present?
Hematuria (72%)
Dull pain (22%)
Renal colic due to obstruction
- Rare
78
Case 90
| What is a Goblet sign?
Ureteral dilation below a radiolucent filling defect
79
Case 90
| A "Goblet sign" is pathognomonic for what diagnosis?
Papillary TCC
80
Case 90
| What causes the ureter to dilate with a TCC giving the appearance of a goblet?
Long-standing, slowly growing polypoid mass that is continuously being pushed down by peristalsis
81
Case 91
| DDX of multiple ureteral filling defects on IVP
Uric acid stones Blood clots
Air bubbles Infectious debris (fungal)
Multifocal TCC (1/3 of patients) Sloughed papillae
82
Case 91
| What percentage of TCC is Papillary?
67%
83
Case 92
| Explain forniceal rupture related to a ureteral stone.
Spontaneous rupture of a calyceal fornix
Relief or "pop-off" valve reducing pressure
Contrast or urine extravasates into the perirenal space
84
Case 92
How does a fornix rupture present?
Is it an emergency?
Sudden relief of obstructive symptoms
It is a totally benign entity of no clinical significance
85
Case 93
T/F
Renal stones are the most common cause of transplant kidney hydronephrosis?
False
| Stones only account for 2% of post-transplant hydro
86
Case 93
| What are causes of transplant kidney hydronephrosis?
Anastomotic stricture
Blood clot
Ureteral edema
Pertransplant fluid collection (lymphoceles)
87
Case 93
How do you treat transplant kidney hydronephrosis?
Is the hydronephrosis symptomatic?
Percutaneous nephrostomy
Placement of a nephrovesical stent
No - painless in transplant kidney
88
Case 94
| What is the likely cause of hematuria in a patient with hematuria and large filling defect in the kidney on IVP?
TCC
RCC
Vascular malformation
89
Case 94
| What enzyme in urine leads to rapid change of pyelocalyceal blood clots?
Urokinase
90
Case 95
| How do you best diagnose a traumatic ureteral injury?
CT Abdomen/Pelvis with IV only
| Early and delayed images
91
Case 95
| What are typical CT findings of ureteral injury?
Normal renal enhancement
Medial perirenal contrast extrav
Nonopacification ipsilateral distal ureter
92
Case 95
| What is the best treatment for ureteral injury?
```
Percutaneous nephrostomy
Nephroureteral stent placement
Percutaneous urinoma drainage
NOT surgery
- They don't do as well
```
93
Case 96
| DDX for distal ureteral stricture
```
Extrinsic compression
->Tumor
Periureteral inflammation
-> Appendicitis, IBD, Endometriosis
Iatrogenic stricture
Infection
->TB or Schistosomiasis
Radiation
```
94
Case 96
| How do you treat distal ureteral stricture?
Stent placement
Balloon dilation
Surgical resection
95
Case 97
| What is a retrocaval ureter?
Abnormal course of the ureter posterior to the IVC
| - Caused from anomalous development of IVC
96
Case 97
| What defines medial displacement of the ureter?
The ureter courses medial to the L3 or L4 pedicle
97
Case 97
| DDX for medial displacement of the ureter
Retroperitoneal fibrosis
Retroperitoneal mass
Prior surgery
Retrocaval ureter
98
Case 98
| Where do most bladder tumors occur?
Posterolateral wall near the trigone
99
Case 98
| What are the most common bladder tumors
TCC: 90%
SCC: 5%
Adenocarcinoma: 2%
100
Case 98
| What predispose a patient to bladder squamous cell CA?
Schistosomiasis
Neurogenic bladder
Chronic Foley catheterization
101
Case 98
| What is the most important prognostic factor for bladder cancer
Depth of bladder wall invasion (T2 or T3)
| Treated with bladder cystectomy, not transurethral resection
102
Case 99
| What causes bladder diverticula to develop?
Chronic bladder outlet obstruction
103
Case 99
| What are common complications of bladder diverticula?
Chronic ureteral obstruction
Stones
Infection
Tumor
104
Case 100
| What is an Indiana Pouch?
A urinary diversion
- Conduit of cecum and distal terminal ileum
- Prevents reflux and provides urinary continence
- No need for osmtomy bag with good capacity (0.5-1 L)
- Allows self-catheterization every 3-6 hours
105
Case 100
| What is the best CT technique for evaluating a urinary diversion?
Oral only or IV only
| - Allows separation of GI and GU tracts
106
Case 101
| What is a Koch Pouch?
Continent cutaneous urinary diversion
| Uses Terminal ileum
107
Case 101:
| What early complications occur with Koch Pouch?
Anastamotic leak
Dehydration
Sepsis
108
Case 101:
| What major late complications occur with Koch Pouch?
Struvite pouch stones
Afferent nipple stenosis
Reflux
109
Case 102
| What is The Parfait Sign on MRI?
3 layers seen in the bladder on postcontrast MRI
Top layer: Urine (long T1)
Middle layer: Mixture or urine and Gd (short T2)
Bottom layer: Gadolinium
110
Case 103
What is the most common cause of vesicovaginal (VV) fistula in the US?
World wide?
XRT
Obstetric trauma
111
Case 103
| What CT technique should be used to detect VV fistula?
IV contrast only
| Delayed images with 3-5mm thin sections
112
Case 104
| What are causes of a "pear-shaped" bladder?
Hematoma Urinoma
Lipomatosis IVC Obstruction
Lymphadenopathy Lymphocysts
113
Case 105
| Who typically gets pelvic lipomatosis...Sex and race?
African American Men
- Men 94%
- African American 2/3
Many are obese
114
Case 105
| What is the diagnosis if you see a pear-shaped bladder with multiple lobulated filling defects?
Pelvic Lipomatosis with Cystitis Glandularis
115
Case 106
| What are the major causes of hemorrhagic cystitis?
Chemical urotoxins (Cyclophosphamide)
Radiation
Immune-mediated injury (related to viruses)
116
Case 106
| What cancers is radiation cystitis most commonly related to
Prostate
| Cervical
117
Case 107
| Does cyclophosphamide treatment increases risk for cancer?
Yes
118
Case 107
| How do you treat cyclophosphamide cystitis?
Forced diuresis
Bladder irrigation
Mesna
119
Case 108
| What is the classic symptom with bladder herniation through the inguinal canal?
Two-stage voiding
120
Case 108
| An indirect inguinal hernia lies lateral to what artery?
Deep inferior epigastric artery
121
Case 108
| What are complications of a bladder hernia?
```
Hydronephrosis
Strangulation
Stone formation
VU Reflux
Inadvertent perforation in surgery
```
122
Case 109
| DDX for mural bladder calcification
Schistosomiasis - ascends to the bladder from the prostate
TB cystitis - descends to the bladder from the kidney
Radiation cystitis
Intravesical chemotherapy
Neoplasm - SCC from chronic Schistosomiasis
123
Case 109
| What is an imaging sign of malignant transformation in the bladder in a patient with mural calcification
Disruption of the calcification
124
Case 110
| What is an artificial urinary sphincter used for
Stress incontinence
Post-prostatectomy sphincter weakness
Kids with incontinence related to spinal dysraphism
125
Case 111
Who typically have Congenital urethral diverticula? M or F?
Who typically have Acquired urethral diverticula? M or F?
Boys - 98%
Women
126
Case 111
| What symptoms are seen with urethral diverticula?
Dyspareunia
Postvoid dribbling
UTI's
127
Case 111
| Urethral diverticula in women involve what segment?
The middle 1/3 dorsolaterally
| More common in African-American women
128
Case 112
| How do urethral diverticula occur in females?
Skene's glands posteriorly in the inferior urethra obstruct leading to more proximal diverticula (in the middle 1/3)
129
Case 112
| What is the most common tumor that develops in a urethral diverticulum?
Adenocarcinoma
130
Case 113
What are the 4 parts of the male urethra?
What separates the anterior and posterior portions of the male urethra?
```
Anterior
- Penile
- Bulbous
Posterior
- Membranous
- Prostatic
```
Urogenital diaphragm divides anterior from posterior
131
Case 113
| How is a urethral injury typically treated
Suprapubic catheter for 3-6 months
132
Case 113
Describe the most common urethral injury?
What is it's most common cause?
Type III
- Disrupted membranous and bulbous urethra
- Disrupted urogenital diaphragm and extravasation
MVC with pelvic fractures
133
Case 114
| What are three causes of a urethral diverticulum?
Infection
Trauma
Prolonged catheterization
134
Case 115
| DDX of an irregular urethra with stricture and filling defects
Carcinoma
- Predominantly SCC
Benign Conditions
- Papillary urethritis
- Nephrogenic adenoma
- Condylomata acuminata
- Amyloidosis
- Sarcoidosis
- Balanitis xerotica obliterans
135
Case 115
| What has a better prognosis, anterior v. posterior urethra carcinoma?
Anterior
135
Case 115
| Most commonly cited risk factor for SCC of the urethra?
Chronic urethral stricture of any cause
136
Case 116
Define septate uterus
How is it treated?
Divided by fibrous septum
- Convex, flat, or minimally indented
- Intercornual distance less than 4 cm
Treatment
- Hysteroscopic metroplasty
137
Case 116
Define bicornuate uterus.
How is it treated?
Divided by myometrial tissue
- Deeply concave fundus
- Horns are divergent
- Intercornual distance > 4cm
Treatment
- Abdominal metroplasty
138
Case 117
| What is typically associated with Polycystic Ovary Disease?
Infertility
Hirsutism
Obesity
Oligomenorrhea
139
Case 117
| How is POD diagnosed with LH/FSH?
LH/FSH ratio >2
140
Case 117
What are classic U/S findings in POD?
Are these imaging finding pathogmonic?
Enlarged hyperechoic ovaries
Multiple small peripheral follicles
- String of pearls
No
141
Case 118
| What are imaging findings of Ovarian Hyperstimulation?
Ovaries
- Enlarged
- Multiple large follicles
Associated Findings
- Ascites
- Pleural effusions
- Pericardial effusion
142
Case 118
| Who's at risk for Ovarian Hyperstimulation Syndrome?
```
Thin
Young
High Gonadotropins
High Estradiol levels
PCOD patients
```
143
Case 118
| What are complications of Ovarian Hyperstimulation?
```
Ovarian torsion
Rupture
- Hemorrhagic Cyst
DVT
PE
```
144
Case 119
What is suspected when you see a snowstorm appearance in the uterus?
What type of ovarian cysts are seen with this entity?
Complete hydatidiform mole
Theca Lutein Cysts
- Multilocular cysts
- Expand the ovary
- 2o to overstimulation (hCG)
145
Case 119
| How do patients with molar pregnancy present?
Rapid uterine enlargement
Hyperemesis
Vaginal bleeding
Markedly elevated hCG levels
146
Case 120
| DDx for postpartum patients with fever and lower abdominal pain?
```
Ovarian Vein Thrombosis
Appendicitis
Pyelonephritis
Endometritis
TOA
Acute Cholecystitis
```
147
Case 120
| What are the two most common causes of ovarian vein thrombosis?
Endometritis
| Oncologic surgery
148
Case 120
| What is the most likely side of ovarian vein thrombosis?
Right
149
Case 121
| Describe a Cesarean section scar on MRI
Focal disruption in the junctional zone along the ventral uterine corpus
Junctional zone is inner third of myometrium
150
Case 122
| What causes an ovarian mass with multiple thick septations, solid peripheral nodules, and ascites?
Ovarian Carcinoma
151
Case 122
| CA-125 is elevated in what 5 entities?
```
Ovarian neoplasm
- Elevated in 80% of pts
Uterine leiomyoma
Endometriosis
PID
Early pregnancy
```
152
Case 122
| What are imaging features of ovarian cancer?
```
Increased ovarian size (>7.5cm)
Solid component of the mass
Mural nodules
Internal papillary projections
Thickened septations
```
153
Case 122
| What are the four types of ovarian neoplasms
Epithelial
Germ cell
Sex cord-stromal
Metastasis
154
Case 123
| Where do ovarian cancer peritoneal implants typically go?
Pouch of Douglas
Ileocecal region
Right paracolic gutter
155
Case 123
| What is Pseudomyxoma peritonei?
Large amounts of gelatinous material
-> Peritoneal cavity
Transformation of peritoneal mesothelium
- to a mucin-secreting epithelium
- after perforation of a mucinous
- cystadenoma or cystadenocarcinoma
156
Case 124
| What is Krukenberg Metastasis?
Mets to the ovary from GI adenoCA
- Stomach
- Colon
157
Case 124
| How do you differentiate Krukenberg Metastasis to the ovary from primary ovarian neoplasm
Krukenberg Mets:
- Solid
- Bilateral
- Present late
Primary Mets
- Cystic >10 cm
- Unilateral
- Present early
158
Case 125
| What is the DDX of a homogenous hypoechoic mass in the adnexa?
Ovarian fibroma
| Pedunculate uterine leiomyoma
159
Case 125
| What is Meig's Syndrome?
Ovarian fibroma
Ascites
Hydrothorax
160
Case 125
| What are the MRI characteristics of Ovarian Fibroma?
```
Well-circumscribed mass
Low T1
Low T2 unless
- edema
- degeneration
```
161
Case 125
T/F
Most Ovarian Fibromas are surgically removed.
Ovarian Fibromas secrete steroids.
True
- Rare malignant potential
False
162
Case 126
| What is the most common cause of ovarian torsion?
Benign cystic teratoma
Kids may get torsion without an underlying mass
163
Case 126
| What are the classic imaging findings of ovarian torsion?
```
Enlarged ovary
Complex, cystic or solid mass
Dilated fallopian tube with a thick wall
- see Case 129 image
Intraperitoneal fluid
Absent flow in the ovary
Twisted vascular pedicle
```
164
Case 126
T/F
Doppler flow in the ovary excludes torsion.
False
Ovaries have dual blood supply
Doppler is therefore of limited use in torsion
165
Case 127
| What should you consider in a patient with a mass presenting with severe, cyclical pelvic pain?
Endometriosis
166
Case 128
In US evaluation of an ovarian mass, what are the most important features for distinguishing between a benign and malignant ovarian mass?
Solid Elements
- Presence
- Echogenicity
167
Case 128
| What is the Pulsatility index on sonography?
(Peak systolic velocity - End diastolic velocity) /
| Mean velocity
168
Case 128
| What is the Resistive index on sonography?
(Peak systolic velocity - End diastolic velocity) /
| Peak systolic velocity
169
Case 128
| What features suggest that an ovarian mass as malignant?
Solid component
Flow in a septation or the solid component
Free fluid in a postmenopausal woman
Thick septation (>3mm)
170
Case 129
| What is the most likely cause of rapid or massive ovarian enlargement or edema?
Ovarian torsion
| - Partial or intermittent
171
Case 129
| What is the vascular supply of the ovaries?
Ovarian artery
- Branch of the aorta
Uterine artery
- Branch of the anterior trunk of the internal iliac artery
172
Case 130
| What is ovarian pexy and what is its indication?
Ovaries are attached to superior pelvic sidewall
| Removes the ovaries from radiation field in cervical CA
173
Case 131
| U/S showing enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas is likely?
Gestational Trophoblastic Disease
- Molar pregnancy
- Partial Mole
- Choriocarcinoma
174
Case 131
| DDX of an enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas
Gestational Trophoblastic Disease
Degenerated uterine leiomyoma
Endometrial proliferative disease
Degeneration of the placenta
175
Case 132
| What are four causes of a thickened endometrium in postmenopausal women?
```
Endometrial hyperplasia
Polyps
Carcinoma
Drugs
- Tamoxifen
- Estrogen replacement
```
176
Case 132
| What is the most common type of endometrial cancer?
Adenocarcinoma (70%)
177
Case 132
| What stage is endometrial cancer that invades the cervix
Stage IIB
178
Case 133
| What is the best way to assess endometrial cancer?
Transvaginal Ultrasound
179
Case 133
| What are risk factors for endometrial cancer?
```
Obesity
Diabetes
Nulliparity
Unopposed Estrogen
Tamoxifen therapy
History of Breast or colon CA
```
180
Case 134
| What is an adnexal mass that is T1 bright, T2 dark with no fat suppression on MRI?
Endometrioma
| - Chocolate cyst
181
Case 134
| What extrapelvic organs can have endometriosis?
Lungs
- Catamenial ptx
CNS
182
Case 134
T/F
Endometriomas increase likelihood for torsion
False
| - adhesions
183
Case 134
T/F
MRI is the best modality to diagnose endometriosis
False
- Laparoscopy
- >best for diagnosis and staging
184
Case 135
| What is the continuum of PID?
```
Cervicitis
Endometritis
Salpingitis
Pelvic peritonitis
Tuboovarian abscess
- 1% of all PID patients get TOA's
```
185
Case 136
Uterine didelphys is a result of what?
What do you see?
Complete failure of fusion of the mullerian ducts
Two hemiuteri, with separate cervices and vagina
186
Case 136
| What can cause dilation of one of the uterine horns?
- Transverse vaginal septum
| - Cervical stenosis
187
Case 136
| Uterine didelphys and Septate uterus are associated with what renal anomaly?
Unilateral renal agenesis
188
Case 137
| What is the most important feature to distinguish bicornuate from a septate uterus?
External uterine fundal contour
Septate: Flat or convex
Bicornuate: Concave
189
Case 138
| How often does ovarian vein thrombosis occur in surgical oncology patients?
80%
190
Case 138
| What does ovarian vein thrombosis look like on MRI?
T1 dark
| T2 bright
191
Case 139
| Define adenomyosis
Aberrant ectopic endometrium within the myometrium
192
Case 139
| What are the imaging characteristics of Adenomyosis?
Junctional zone > 12mm
Ectopic endometrial glands
- T2 hyperintense foci
193
Case 140
During what phase of the menstrual cycle is the endometrium thickest?
What should it measure?
Secretory phase
8-12mm
194
Case 140
T/F
The longer a person takes Tamoxifen and the higher the dose, the greater the risk for endometrial hyperplasia or cancer.
In women treated with Tamoxifen, endometrial hyperplasia is the most common endometrial abnormality resulting in abnormal endometrial thickening.
True
- Especially > 5 years
False
- Endometrial polyps
195
Case 141
| What pelvic tumors can invade the bladder?
Cervical
Prostate
Urethra
Rectum
196
Case 142
T/F
Patients with endometrial leiomyoma are more likely to get endometrial carcinoma.
True
197
Case 142
T/F
Benign Leiomyomas can metastasize to the lungs.
True
198
Case 143
| DDX of a pregnant patient with pelvic pain
```
Subchorionic hematoma
Degenerating fibroid
Adenomyosis
Focal myometrial contractions
Solid adnexal mass
```
199
Case 143
| What complications are associated with fibroids in pregnancy?
```
Pain
Bleeding
Spontaneous abortion
Placental abruption
Fetal malposition
Mechanical obstruction of the uterus
```
200
Case 144
| What symptoms do patients with pelvic congestion syndrome present with?
```
Pelvic fullness
Pain
- better in AM
- worst at the end of the day
Dyspareunia
```
201
Case 144
| How is pelvic congestion syndrome treated?
```
Hormones
Laparoscopic ligation
Embolization
- Ovarian vein
- Internal iliac veins
```
202
Case 144
| Does embolization of pelvic congestion reduce fertility?
No
| - No effect on menstruation or fertility
203
Case 145
| DDX of an adrenal mass
```
Adenoma
- most common
- even in cancer pts
Metastasis
Hyperfunctioning Adrenal neoplasm
- Pheochromocytoma
- Cushing's syndrome
- Aldosteronoma
```
204
Case 146
| What causes an adrenal adenoma to drop off in signal on chemical shift MRI?
Phase cancellation
| - caused by the presence of both fat and water protons within the same voxel.
205
Case 147
For adrenal adenoma on dynamic CT
What absolute washout is diagnostic?
How is it calculated?
Absolute washout of 60%
(HU at dynamic CT - HU at 15 minute delayed) /
(HU at dynamic CT - HU at noncontrast CT) x 100
206
Case 147
For adrenal adenoma on dynamic CT
What relative washout is diagnostic?
How is it calculated?
Relative washout of 40%
(HU at dynamic CT - HU at 15 minute delayed) /
HU at dynamic CT x 100
207
Case 148
T/F
The spleen should be used as the control in evaluating an adrenal adenoma on in and out of phase imaging.
True
| Don't use the liver!
208
Case 148
| What % of adenomas do not demonstrate signal drop-off on out-of-phase imaging or have HU less than 10?
20%
| - Lipid-poor
209
Case 149
| What are three etiologies of adrenal hemorrhage in neonates v. adults?
Neonates:
- Birth trauma
- Anoxia
- Dehydration
Adults:
- Anticoagulation
- Trauma
- Surgery
210
Case 149
| What is the DDX for an adrenal mass in a neonate
Adrenal hemorrhage
| Neuroblastoma
211
Case 150
| What are the three types of adrenal cysts?
True cysts
- Endothelial (lymphangioma)
- Epithelial
Pseudocysts
- Develops from prior adrenal hematoma
Infectious cysts
- Echinococcal
212
Case 151
| What is Waterhouse-Friderichsen Syndrome?
Adrenal hemorrhage associated with fulminant meningococcemia resulting in acute adrenocortical insufficiency
213
Case 152
| What is the most common type of true Adrenal cyst
Endothelial cyst
| - Lymphangioma > Hemangioma
214
Case 152
| Is calcification a common feature of adrenal cysts?
Yes
| - up to 54%
215
Case 152
| What is the most common cause of adrenal pseudocyst?
Adrenal hemorrhage
216
Case 153
What are the two histologic contents of an adrenal myelolipoma?
Malignant potential?
Hematopoietic tissue
Mature adipose tissue
No malignant potential
217
Case 153
| What two ways do myelolipomas present
Incidental
Pain
- 2o to hemorrhage
218
Case 154
| How can you differentiate that an adrenal mass represents an adenoma v. pheochromocytoma v. metastasis
```
Adenoma
- CT or MRI
Pheochromocytoma
- I-131 MIBG scan
- Urine VMA level
Metastasis
- PET/CT
```
219
Case 116
Define septate uterus.
How is it treated?
Divided by Fibrous septum
- Convex, flat or minimally indented fundus
- Intercornual distance
219
Case 151
| Which adrenal is more prone to traumatic hemorrhage?
Right
| - Due to compression by the adjacent liver
220
Case 155
| Where do pheochromocytomas typically recur postop?
Surgical bed
Ipsilateral retroperitoneum
- local metastasis
221
Case 155
| What 3 clinical tests are used for Pheochromocytoma?
Serum plasma catecholamine levels
24-hour urine vanillylmandelic acid (VMA)
Metanephrine levels
222
Case 156
| DDX of adrenal calcifications
```
Granulomatous disease
- TB
- Histoplasmosis
Prior hemorrhage
Treated metastasis
```
223
Case 156
What is the adrenal morphology in Addison's disease?
Symptoms?
Small adrenals
Calcifications
```
Asthenia
Hypotension
Anorexia
Weight loss
Pain, N/V/D
Hyperpigmentation
```
224
Case 156
| What are the causes of Addison's disease?
```
Autoimmune
Adrenal destruction
- Hemorrhage
- Infection
Metastasis
- Very rare
```
225
Case 157
| What syndrome is associated with Insulin-dependent diabetes, autoimmune thyroiditis, and Addison's disease?
Schmidt's syndrome
| - Polyglandular Synd Type II
226
Case 157
| DDx for adrenal enlargement.
```
Granulomatous adrenalitis
Adrenal hemorrhage
Mets
Lymphoma
Sarcoidosis
Amyloidosis
```
227
Case 158
| Where does renal artery stenosis typically occur?
Ostium
| Proximal 2cm
228
Case 159
| What are the two most commonly affected arteries in Fibromuscular dysplasia (FMD)?
Renal arteries
- 70%
Carotid arteries
- 30%
229
Case 159
| What is the best treatment for FMD?
Balloon angioplasty
- 90% effective
No need for stents
230
Case 160
| Why should renal arterial aneurysms be treated no matter their size?
Increased risk
- Rupture
- Renal embolization
231
Case 161
| What do renal transplant surgeons need to know by imaging prior to taking a donor kidney?
Number of renal arteries (they prefer one)
Size and location of renal arteries
Number, size and location of renal veins
Size and location of the kidneys
Presence of congenital or acquired renal disease
232
Case 161
| What is the preferred donor kidney for transplant?
Left
| - Longer renal vein for anastamosis
233
Case 162
| What is the incidence of an AV fistula post biopsy and what is the typical course?
Incidence
- 9%
Spontaneously Thrombose
- 70-95%
234
Case 163
| What are 3 indications for renal artery embolization
Prior to nephrectomy to treat RCC
Prior to renal tumor ablation in nonsurgical patients
Posttraumatic bleeding
235
Case 164
| What % of patients with HTN have renal artery stenosis?
1%
236
Case 164
| What is the restenosis rate after treating RAS?
Up to 25%
237
Case 165
| What is the success rate of uterine fibroid embolization?
Up to 90%
238
Case 165
| What complications are associated with UFE's
Minor: 5%
- Pain
- Nausea
- Groin hematoma
- Amenorrhea
Major 0.5%
- Infection
- DVT
- PE
239
Case 166
| What are the indications for a percutaneous nephrostomy?
```
Relief of obstructive symptoms
Access for nephrolithotomy
Urothelial biopsy or ablation
- Urothelial tumor
Whitaker test
```
240
Case 170
| Retroperitoneal Liposarcoma can be differentiated by lipoma by?
Soft tissue components
- but not 100%
- Liposarcs can be purely lipomatous
241
Case 170
T/F
Poorly differentiated liposarcomas may not contain any detectable fat
True
242
Case 171
| What is Zinner Syndrome?
Coexistence of Ipsilateral
- Seminal Vesicle cyst
AND
- Renal dysgenesis or agenesis
243
Case 171
| DDX of lateral paraprostatic cysts
Seminal vesicle cyst
Bladder diverticula
- make sure to trace it to source
244
Case 171
| What renal anomalies are associated with unilateral seminal vesicle cyst?
```
Renal Agenesis
Renal Ectopia
APCKD
Duplicated system
Ectopic Ureteral Insertion
```
245
Case 172
| What organism is associated with prostatic abscesses?
E. coli
- Prostatitis
- Hematogenous spread
246
Case 173
| DDX for focal area of T2 hypointense signal in the peripheral zone of the prostate gland.
Adenocarcinoma
Hyperplasia
Prostatitis
Hemorrhage after biopsy
247
Case 173
T/F
Contrast is useful in assessing the prostate in MRI that uses an endorectal surface coil.
Some peripheral zone cancers have high signal intensity on T2W images.
False
- In most cases it adds no benefit
True
- Mucinous
- Signet-ring AdenoCA
248
Case 174
| What cancers cause osteoblastic bone metastasis?
```
Prostate
Breast
Bladder
Lymphoma
Lung
Carcinoid
```
249
Case 175
| What is the filling defect in the urethra posterior to the membranous urethra?
Verumontanum
251
Case 175
| How does Chron's disease typically affect the GU tract?
Direct extension of granulomatous enterocolitis
252
Case 176
| DDX of scrotal U/S showing branching tubular anechoic structures with garlic walls in the mediastinum testis.
Tubular Ectasia of the Rete Testis
- No differential
- Associated with epididymal cysts
- No f/u imaging necessary
253
Case 177
| DDX of testicular calcified testicular mass
```
Nonseminomatous germ cell tumor
Epidermoid cyst
Resolved infection
Hematoma
Infarction
```
254
Case 178
| What organisms typically cause Fournier's Gangrene?
Polymicrobial necrotizing fasciitis
- Gram-negative rods
- Streptococcal
- Staphylococcal
- Anaerobic strep
255
Case 178
| Where does Fournier's Gangrene start in women?
Vulva
| Bartholin's gland
256
Case 179
| Testicular U/S shows a linear hypoechoic band extending across the testicular parenchyma. What is the Dx?
Testicular fracture
- The tunica albuginea is maintained
Testicular rupture
- The tunica is disrupted
- Testicular contents are extruded
257
Case 180
| What arterial doppler findings are seen with erectile dysfunction after Papaverine injection?
Peak diastolic velocity > 3cm/sec
258
Case 180
| What are two main causes of vasculogenic erectile dysfunction?
Arterial inflow disease
| Venous incompetence
