MCQ

Question 1

Cholestasis of pregnancy

Answer 1

.

Question 2

Breast MRI enhancment patterns

Answer 2

Rapid early enhancement with washout suspicious for malignancy
If intermediate early enhancement, may be type 1 (persistant, most benign but could still be malignant) type 3 (plateau - suspicious), or type 3 (washout - highly suspicious)

Peripheral enhancement first is suspicious for malignancy
Central more benign

Question 3

Benign breast ultrasound features

Answer 3

Marked hyperechogenicity
Thin echogenic pseudocapsule
Wider than tall / parallel
Circumscribed
Ellipsoid
Gentle lobulations

Question 4

Malignant breast ultrasound features

Answer 4

Spiculate - most specific
Taller than wide
Angular or microlobulated
Shadowing
Markedly hypoechoic
Calcs
Poorly defined margin

Question 5

Linguine sign

Answer 5

Hypoinense lines on MR

Intracapsular silicone implant rupture

Question 6

Tomosynthesis radiation dose

Answer 6

Single DBT images has dose similar to single FFDM image

Question 7

Atypical ductal hyperplasia on biopsy

Answer 7

Spectrum of change from normal, to flat epithelial atypia, to atypical ductal hyperplasia, to DCIS
If core biopsy shows ADH, treat with open biopsy - 18% are upstaged to DCIS or invasive carcinoma

Question 8

Cleopatra view

Answer 8

AKA axillary view

A supplementary exaggerated CC to see the axillary tail, performed if a lesion is only seen in the axilla on MLO

Question 9

Failed pregnancy

Answer 9

CRL >/= 7mm with no heartbeat
MSD >/= 25mm with no embryo
Absence of embryo with heartbeat:
2 weeks after GS without yolk sac
11 days after GS with yolk sac

Question 10

Cervical carcinoma

Answer 10

High T2 signal compared with background low signal Cervix
T2 to assess parametrial invasion to see if surgical candidate - if T2 hypointense cervical ring intact, parametrial infasion unlikely.
CT is primarily for assessing adenopathy (although MR can do similar?)
Most are squamous - HPV 16 and 18
Several adenocarcinoma types- clear cell, endometrioid, mucinous, serous
Also neuroendocrine (small) and adenosquamous) - small cell have a poor outcome
Adenos generally though to give higher rates of mets - thoracic and adrenal

Question 11

Ovarian cycle

Answer 11

Proliferative - becomes trilaminar
Secretory - uniformly hyperechogenic
Imaging best performed in early proliferative
Proliferative = follicular
Secretory = luteal

Question 12

Twin demise

Answer 12

Flatenned remnant known as fetus papyraceus
Surviving co-twin at risk of growth restriction, encephalomalacia and microcephaly
Twin embolisation syndrome a rare complication - multi-organ ischaemia, usually antecedent twin-twin transfusion syndrome

Question 13

Fitz-Hugh-Curtis syndrome

Answer 13

Perihepatitis from peritoneal spread of infection in PID

Question 14

Molar pregnancy

Answer 14

Complete, 90% diploid 46XX (less commonly XY) - single sperm or less likely two sperm
Partial, triploid 69XXY, normally from two separate sperm, one X and one Y (other triploid combos possible)
Complete - multiple intrauterine cystic space - bunch of grapes or snow storm
Partial - large cystic placenta and growth retarded fetus

Increased incidence in Asia

Question 15

Physiological gut herniation of fetus

Answer 15

Should not be seen after 12 weeks

Question 16

Ultrasound screening

Answer 16

Unacceptably high rates of biopsy of benign lesions

Question 17

How many Ca does screening miss

Answer 17

1 in 8 pre-menopausal, 1 in 10 post

Question 18

Clinical exam breast sensitivity

Answer 18

Detects 50% of cancers, including 5% of cancers not visible on mammography. May modestly improve early detection

Question 19

Mammogram timing

Answer 19

Early follicular phase, as breasts are less dense

Question 20

Fibroadenoma, epi

Answer 20

Commonest breast lesion in <40

Question 21

Stellate

Answer 21

93% are malignant.

Most invasive breast cancers are stellate (2:1 stellate:circular)

Question 22

Radial scar

Answer 22

Must have no skin thickening or retraction
Long spicules with intervening lucencies, different on different projections
AKA complex sclerosing lesion
Removed as can have associated carcinoma which is not distinguished on core biopsy
Black star - lucent centre (different from carcinoma)

Question 23

Single reader v double reader v CAD

Answer 23

Routine use of CAD significantly increases recall rates. No significant effect on positive predictive value for biopsy – can increase detection rate by 4.7%, sensitivity by 4%.
CADET II study showed cancer detection rates attained with single reading with CAD were equivalent to those attained with double reading.
Performed equally well at recalling patients with cancer in whom the predominant radiologic feature was either a mass or a microcalcification.
Double reading showed superior performance for parenchymal deformities and in women with denser background pattern – i.e. CAD poor at detecting architectural distortion.
Single reader with CAD was better than double reading for asymmetric densities, but the number of these is small and accounted for only 35 of cancers.

Question 24

Digital mammography

Answer 24

40% more sensitive with no change in recall rate

Question 25

MRI indications

Answer 25

``` Lump with normal mammogram and USS Young with BRCA (annual from 30) Dense breast and LCIS Staging multicentric multifocal disease Positive node with negative uss and mammo Post surgical review of lumpectomy ```

Question 26

Maternal AFP

Answer 26

Elevated in 80% of cases with open spina bifida Normal in most fetuses with closed spina bifida Also elevated in omphalocele, multiple fetuses And liver tumours and germ cell tumours (esp. yolk sac tumour) Elevated in placental chorioangioma (the most common placental tumour) Reduced in Trisomies and Turners

Question 27

Spina bifida

Answer 27

Associated with trisomy 18, 13 Limb anomalies - DDH, talipes, rockerbottom feet Neurenteric cysts Lemon skull, banana cerebellum/Chiari

Question 28

Pregnancy screening

Answer 28

1st trimester: Nuchal translucency, PAPP-A, HCG 1:300 or less is increased risk - offer diagnostic testing <3mm is normal nuchal translucency 11.3-13.6 weeks, manigified, neutral neck, midline, fluid behind neck (CRL 45-84mm) 2nd trimester: AFP, HCG, oestriol and inhibin A In Downs, HCG up and PAPP-A down. AFP would also be down. Inhibin A higher, oestriol lower

Question 29

Ovarian tumour markers

Answer 29

CA125 AFP - teratomas and yolk sac tumours (esp) bHCG - small number of dysgerminomas (AFP positive in mothers with fetuses with neural cord defects)

Question 30

Endodermal sinus tumour

Answer 30

Is a synonym for yolk sac tumour

Question 31

Ovarian cystadenoma

Answer 31

Serous unilocular Serous more commonly bilateral (15% v 5%) (65% of malignant serous bilateral, 15% benign - 60% are benign, 25% malignant) Serous more common Mucinous multiloculated thin septations, and more commonly calcify (mural), and tend to be larger. 80% of mucinous are benign Serous have papillary projections, psammoma bodies Serous associated with BRCA1 Serous 60% benign, 25% malignant, rest boderline Mucinous 80% benign 10% malignant, rest boderline Mucinous associated with KRAS mutation

Question 32

CMV

Answer 32

Necrotising inflammation 90% asymptomatic (in utero infection) Prominent cytomegalic cells with intranuclear and intracytoplasmic inclusions Tendendy to localise in ependymal and subependymal regions of brain.

Question 33

Duodenal atresia

Answer 33

30% have Downs | Present in 3-5% of Downs

Question 34

Meckel Gruber syndrome

Answer 34

Triad Renal cystic dysplasia Occipital encephalocele / holoprosencephaly Post axial polydactyl (post axial is ulnar side) AR AKA pseudotrisomy 13

Question 35

Cleft palate

Answer 35

``` Approximately 1:1000 Amniocentesis as high rate of chromosomal abnormality 1-4 classification 1 lip 2 palate 3 bilateral lip 4 lip and palate 50% 4, 25% 1 and 25% 2 ```

Question 36

Hydrops

Answer 36

``` Immune - rhesus Non-immune - heart failure, infection, Parvovirus is the most common infection to cause hydrops TORCH Aneuploidy Turners - lymphatic failure ``` Any cause of failure - shunts from tumours, vascular malformations, Fetal anaemia - beta thalassamia not til 6-9 months. Homozygous alpha may be commonest cause of fetal hydrops in some parts of world Errors of metabolism CPAM could cause caval compression

Question 37

CPAM

Answer 37

Can cause caval compression and hydrops (33-80%), (although another source said 10%, and false when asked if most cases have an effusion) polyhydramnios from oesophageal compression (25-75%)

Question 38

Single umbilical artery

Answer 38

``` IUGR Velamentous cord Trisomy (if other abnormalities) Renal agenesis same side Sirenomelia / mermaid syndrome ```

Question 39

Ovarian sex-cord stromal

Answer 39

Granulosa (5% bilateral - most common oestrogenic tumour of ovary, 50% post-menopause, 45% pre) Thecoma The above two produce oestrogen, cause precocious puberty or endometrial hyperplasia / carcinoma Sertoli-Leydig - rare, virilisation (testosterone) Fibroma - most common one to cause Meigs (90% of M if fibroma. 40% of F causes Meigs)

Question 40

Physiologic bowel herniation

Answer 40

Should not be seen after 12-13 weeks

Question 41

Polycystic ovary syndrome

Answer 41

``` Clinical and biochemical diagnosis Peripheral cysts - 12 or more follicles in each ovary (Rotterdam - new study says 25) "String of pearls" 2-9mm Volume of ovary > 10mL ``` ``` 2 out of 3 of Oligomenorrhoea Clinical and biochemical hyperandrogenism Polycystic ovaries on ultrasound AND Exclusion of other causes ``` Can cause endometrial hyperplasia / cancer / polyps 20% of reproductive age women

Question 42

Ovarian hyperstimulation syndrome

Answer 42

Bilateral ovaries > 5mL Numerous large follicular cysts, with increased blood flow Echogenic stromal tissue Ascites and effusions

Question 43

Ectopic pregnancy

Answer 43

2% of all pregnancies

Question 44

Clinodactyly

Answer 44

Angulation at interphalangeal joint, typically 5th finger Associated with aneuploidy - Down (60%), 18, Klinefelter, Turner (In Downs often also have hypoplasia of middle phalanx of 5th)

Question 45

Uterine malformations, outcomes

Answer 45

Bicornuate similar to general population | Didelphus and septate have increased miscarriage rates- 30% and 60%

Question 46

Twin peak sign / lambda sign

Answer 46

Sign of dichorionicity - placental tissue on separating membrane

Question 47

Tuberculous salpingitis

Answer 47

Thickwalled, cystic masses | Painful, afebrile

Question 48

Molar pregnancy

Answer 48

Complete mole haploid - 2 sperm empty egg or duplicated single sperm Partial mole - two sperm in an egg with chromosomes - triploid Bilateral theca lutein cysts from high HCG - upto 50%, more common in complete Invasiv mole 5-10% Choriocarcinoma 1-5%

Question 49

Echogenic bowel

Answer 49

``` Soft marker of T21 CF Intra-amniotic haemorrhage with swallowed blood products CMV IUGR Fetal hypoxia Hydrops ```

Question 50

Placental praevia

Answer 50

Low lying <2cm Marginal covers part of cervix but not os Partial - partially covers os Complete

Question 51

Omphalocele

Answer 51

Associated with trisomies - 18 most common, also 13 and 21. And Turners, Klinefelters Beckwith Weidemann Bladder exstrophy and cloacal exstrophy Raised maternal AFP (along with neural cord defects more commonly, and tumours)

Question 52

Toxoplasmosis

Answer 52

Calc in thalamus, basal ganglia, choroid plexus. If just periventricular think CMV or TS Microcephaly and mental retardation Or macrocephaly from aqueduct stenosis Head size may return to normal

Question 53

Fetal heart rate

Answer 53

100bpm 5-6 weeks | 140-160 at 8 weeks

Question 54

Monozygotic twins

Answer 54

MCDA 60%, DCDA 30%, MCMA 10%

Question 55

Number of yolk sacs

Answer 55

Is equal to the number of amnions

Question 56

Fused placentas, twins

Answer 56

Dichorionic can fuse, giving appearance of monochorionicitiy

Question 57

DCDA twins

Answer 57

2/3 dizygotic, 1/3 monozygotic

Question 58

FIGO cervical cancer staging

Answer 58

.

Question 59

Cervical MR appearance

Answer 59

T1 uniform intermediate High T2 mucosa Low T2 fibrous inner zone Intermediate T2 outerzone continuous with myometrium

Question 60

Fetal enteric duplication cyst

Answer 60

80% cystic, 20% tubular - more likely to communicate with GI tract Located in the mesentery 30% will have associated abnormalities - GI for hindgut and spine for foregut

Question 61

Urinary tract

Answer 61

In the fetus, ureteric dilatation more significant than renal pelvis dilatation, which may be normal

Question 62

Fetal pleural effusion

Answer 62

``` Most commonly chylo Associated with Aneuploidy Hydrops (and pulmonary masses e.g CPAM, sequestration, cardiac disease) May get secondary polyhydramnios ``` 10% resolve spontaneously May require thoracocentesis or thoracoamniotic shunting if large or recurrent Karyotyping advised -6% abnormal

Question 63

Normal placenta

Answer 63

>2cm thick | Thinned in diabetes, HTN. Puts fetus at risk of growth restriction

Question 64

Abruption

Answer 64

Clinical diagnosis. Ultrasound may be negative. Marginal most common Separation of chorionic plate and placenta (pre-placental collection) Raised placental edge in 50%

Question 65

Pseudoomphalocele

Answer 65

Deformation of abdomen from transducer pressure, and oblique scan angle. More common in oligohydramnios Also physiological gut herniation at early gestation

Question 66

Twins

Answer 66

``` 80% Didi, monodi 30%, mm 1% 5x risk of preterm delivery MCMA 54% perinatal mortality Didi 10% md 20% ```

Question 67

TTTS

Answer 67

10-20% of monochorionic pregnancies | More common if diamniotic

Question 68

Maternal diabetes

Answer 68

Associated with: Heart - VSD, truncus transposition Lung - RDS, TTN GI - situs, meconium plug CNS - lots - neural tube, holoprosencephaly, caudal regression, sirenomelia Renal - agenesis, hydronephrosis, ureteric duplication Skeletal - polydactyly, syndactyly Other - poly, macrosomia, IUGR, single UA

Question 69

Fetal intracranial calc

Answer 69

Toxoplasmosis and CMV - toxo random, CMV periventricular Tumours Sturge Weber and TS

Question 70

Mega cisterna magna

Answer 70

>10mm antenatally | Trisomy 18, CMV, infarction

Question 71

2,59,uterine cancer staging (endometrial), ovarian, others?

Answer 71

.

Question 72

Chorioangioma

Answer 72

.