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PBR 2 and 3 > Page 24 > Flashcards

Page 24 Flashcards

1
Q

APW and RPW values of Adrenal adenoma

A

15 min - APW >60%
- RPW >40%
10 min - APW >52%
- RPW >40%

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2
Q

Pollack + Brant: What adrenal tumors are called “10% tumors”?

A

PHEOCHROMOCYTOMA

10% extra-adrenal locations,
10% are bilateral,
10% are malignant,
10% familial,
10% incidental

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3
Q

Extra-adrenal sites for pheochromocytoma

A

organ of Zuckerkandl near aortic bifurcation and near the origin of the IMA, bladder, and para-aortic sympathetic chain

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3
Q

With what conditions is pheochromocytoma associated?

A

MEN II, vHL (type II), NF1, Carney

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4
Q

(Dunnick) How are pheochromocytomas that arise from parasympathetic tissue of the CNs or vagus called?

A

glomus tumors, chemodectomas, or carotid body tumors

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4
Q

(Dunnick) How are extra-adrenal pheochromocytomas or those that arise from sympathetic paraganglia called?

A

paragangliomas

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5
Q

(Dunnick) In what part of the adrenal gland is hematoma usually found?

A

medulla

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5
Q

(Dunnick) On which side is congenital UPJ obstruction more common?

A

left

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5
Q

Side more commonly affected in unilateral adrenal hemorrhage

A

right (this may be from acute rise in venous pressure, which is directly transmitted to the R adrenal gland because the R adrenal vein enters the IVC directly)

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6
Q

(Dunnick) Which direction of crossed ectopy is more common?

A

left to right

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6
Q

(Dunnick) Side of predilection of multicystic dysplastic kidney

A

left

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6
Q

Which diseases may cause diffuse adrenal calcification assoc with Addison disease?

A

TB and histoplasmosis

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7
Q

Adrenal tumors that calcify in children

A

neuroblastoma and ganglioneuroma

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7
Q

(Dunnick) Ureteral dilatation in pregnancy is more pronounced in which side?

A

right (because of slight differences in the angles at which the arteries and ureters cross)

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7
Q

(Dunnick) On which side is renal vein thrombosis more common?

A

left (left renal vein is longer than the right)

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7
Q

(Dunnick) More common side for ovarian vein thrombosis

A

right

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7
Q

(Dunnick) Ureteral involvement by Crohn disease usually occurs in which side?

A

right

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8
Q

Size of nodule that is suspicious for malignancy

A

> 4 cm (Dunnick >3 cm)

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8
Q

Adrenal tumors that calcify in adults

A

adrenal ca, pheochromocytoma, and ganglioneuroma

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8
Q

Adrenocortical ca syndromes

A

Beckwith-Wiedemann syndrome, Carney complex, FAP, Li-Fraumeni ca syndrome, MEN-1

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8
Q

Usually the most difficult adrenal tumors to detect because they tend to be the smallest

A

adenomas in Conn syndrome

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9
Q

Tumors that may rarely secrete ACTH

A

oat cell ca, bronchial adenoma, tumors of the ovary, pancreas, thymus, and thyroid

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9
Q

Small medullary lesions may be missed in this phase?

A

Corticomedullary - cortex enhances before medulla

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10
Q

MRI appearance of adenomas

A

relatively low signal on both T1 and T2 (to differentiate from mets, mets have high T2 signal)

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10
Q

What is the method of choice in the evaluation of hematuria?

A

CT urogram

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10
Q

What are the phases of CT urogram?

A

Corticomedullary (30-40s), nephrographic (120s), pyelogram / excretory (3-5 mins)

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11
Q

What is the innermost zone of the medulla, closest to the draining calyx?

A

papilla

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11
Q

What is this anatomic variant caused by the incomplete fusion of the upper and
lower poles of the kidney? What is its classic US appearance?

A

Junctional parenchymal defect - wedge-shaped echogenic defect between upper and middle thirds of kidney

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11
Q

What other anomalies should you look for in patients with unilateral renal agenesis?

A

Genital tract anomalies in females, ipsilateral adrenal agenesis (10%) or hypertrophic adrenal

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12
Q

What is the MC renal fusion anomaly?

A

Horseshoe kidney

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12
Q

(Dunnick) Which condition is commonly associated with horseshoe kidney?

A

UPJ obstruction

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12
Q

(Dunnick) What rare abnormality is marked by extensive fusion between the 2 renal masses?

A

lump or pancake kidney

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13
Q

What are the subtypes of RCC?

A

Conventional clear cell, multilocular clear cell, papillary, chromophobe, renal medullary

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13
Q

What is the MC solid renal mass in adult?

A

RCC

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13
Q

What is the MC type of RCC?

A

Conventional clear cell - 80%

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14
Q

(Dunnick) WHO classification of RCC and their sites of origin

A
  1. conventional / clear cell - PCT
  2. papillary - PCT
  3. chromophobe - collecting duct
  4. collecting duct ca - medullary collecting duct
  5. renal oncocytoma - collecting duct
  6. unclassified
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14
Q

Fat density in a solid tumor without calcification is diagnostic of what lesion?

A

AML

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15
Q

(Dunnick) What type of RCC is oncocytoma difficult to distinguish from?

A

Chromophobe

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16
Q

What type of RCC has the best prognosis?

A

Chromophobe

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17
Q

How can you differentiate clear cell from papillary or chromophobe RCC?

A
  • clear cell - avid heterogeneous enhancement
  • papillary, chromophobe - less enhancement, more peripheral/homogeneous
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17
Q

What are features to look for in evaluating for RCC?

A

Extension beyond Gerota’s fascia, involvement of renal vein or IVC, distant mets

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17
Q

What are predisposing conditions for RCC?

A

VHL, hereditary papillary RCC, acquired cystic disease from long-term HD, smoking, renal transplant, HIV

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17
Q

-peripheral pattern of enhancement?

A

chromophobe, collecting duct as well as papillary

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18
Q

What is the method of choice for tumor evaluation and staging?

A

CT with contrast

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18
Q

-conventional

A

hypervascular and heterogeneous

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19
Q

(Dunnick) CT enhancement pattern of RCCs:

A
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19
Q

-papillary

A

low level of enhancement and homogeneous (may be confused with complicated renal cyst)

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19
Q

How can you differentiate bland thrombus from tumor thrombus?

A

Bland thrombus - filling defect expanding vein/IVC with contrast; tumor thrombus - enhancing mass within vein/IVC

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19
Q

How can you differentiate AML from RCC?

A

AML-fat without calci, necrosis rare; RCC-fat with calci, necrosis more common, usually more heterogeneous

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20
Q

How do RCCs appear on US?

A

Heterogeneously hypoechoic or mildly hyperechoic, hemorrhage/necrosis appears cystic

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20
Q

(Dunnick) Distinguish the MRI appearance of conventional from papillary RCC

A

on T2, hypo si papillary, hyper si conventional

20
Q

How do most RCCs appear on MRI?

A

Heterogeneous on T2, high T1 may represent tumoral hemorrhage; clear cell - iso/slightly hypo T1, hypervascular with avid enhancement; papillary - hypo T1/T2, low-level homogeneous enhancement

20
Q

Distribution and location of AML in patients with tuberous sclerosis?

A

multicentric and bilateral

20
Q

To include RCC as a consideration in a lesion with macroscopic fat, what should be a concomitant finding?

A

calcification

20
Q

What is the most reliable finding of AML on MRI?

A

Decrease in signal in fat-sat images

20
Q

(Dunnick) Rare occurences but renal masses which may demonstrate macroscopic fat

A

Wilms tumor, oncocytoma, mets, RCC

20
Q

What well-encapsulated benign renal neoplasm is indistinguishable from RCC by all
imaging methods and must be surgically removed to confirm diagnosis?

A

Oncocytoma

21
Q

What is the appearance of the central scar of an oncocytoma?

A

low on T1 and T2

21
Q

What are the patterns of renal involvement of lymphoma?

A

Diffuse disease (enlarged kidney), multiple bilateral solid renal masses, solitary bulky tumor, perirenal tumor, tumor invasion from retroperitoneum into renal sinus

21
Q

What feature of a large oncocytoma is suggestive of its diagnosis?

A

Central stellate scar

22
Q

What are common primary tumors to metastasize to the kidneys?

A

Lung, breast, colon, melanoma

23
Q

How can you differentiate oncocytoma and RCC on T1?

A

oncocytoma - hypointense, RCC - intermediate signal to high signal

23
Q

Wilms tumor associations

A

sporadic aniridia, hemihypertrophy, Drash syndrome, Beckwith-Wiedemann syndrome

24
Q

What are the endocrine manifestations of renal adenoca?

A

HTN (renin), erythrocytosis (erythropoietin), hypercalcemia (PTH), galactorrhea (prolactin), gynecomastia (gonadotropin), Cushing syndrome (ACTH) - kaya tinawag na internist’s tumor

25
Q

How will bulky adenopathy displace the proximal ureters?

A

laterally (because proximal ureters lie lateral to the para-aortic nodes)

25
Q

What are the US criteria for simple cyst? 4

A

Round/oval anechoic mass, increased through transmission, sharply defined far wall, thin or imperceptible cyst wall

25
Q

How will bulky adenopathy displace the distal ureters?

A

medially (external iliac nodes are lateral to the distal ureters)

26
Q

..CT criteria? 4

A

Sharp margination with renal parenchyma, no perceptible wall, homogeneous attenuation near water (-10 to +10HU), no enhancement

26
Q

What is the MC renal mass?

A

Simple cyst

27
Q

..MR criteria? 4

A

Homogeneous, sharply defined round/oval mass, homo low T1, homo low T2 (similar to urine), no enhancement

28
Q

What characteristics disqualify a cyst form being simple?

A

internal debris, echogenic clot, fluid-debris levels, thick septations/wall, internal vascularity, thick/coarse calci

28
Q

What Bosniak classification requires surgical management?

A

Bosniak III-IV

28
Q

What are the differential diagnoses for a complicated cystic mass?

A

hemorrhage/infection, cystic tumor, abscess, obstructed upper pole duplicatio, calyceal diverticulum, lymphoma, aneurysm, pseudoaneurysm

29
Q

What Bosniak category includes cysts with thick or nodular calcification in the wall or septa?

A

IIF

29
Q

(Dunnick) What Bosniak category are exophytic hyperdense cysts? (Si brant, nakaspecifiy na <3 cm iyong size)

A

II

29
Q

What Bosniak classification is likely benign but requires follow-up to confirm benignancy? And at what intervals?

A

Bosniak IIF (“F” for follow-up). Follow-up at 3, 6, 12 months (Dunnick: 6 mos and repeated at 1-yr intervals)

30
Q

(Dunnick) What Bosniak category are intrarenal or large (>3 cm) hyperdense cysts?

A

IIF

30
Q

What renal lesions are classified under Bosniak III?

A

Multilocular cystic nephroma, multilocular clear cell RCC, complex benign hemorrhagic or chronically infected cysts

30
Q

Pyelonephritis with liquefactive necrosis results in this renal pathology?

A

Renal abscess

31
Q

Why is the size of a renal abscess an important determinant for treatment?

A

Small (<2cm) - antibiotics; Large (>2cm) - requires drainage

32
Q

What benign renal lesion is indistinguishable from multicystic RCC and requires surgical excision to confirm diagnosis?

A

Multilocular cystic nephroma - benign but Bosniak III-IV, varisized non-communicating cysts, +septations of varying thickness, +thick capsule

32
Q

What pancreatic cysts are seen in vHL disease?

A

serous cystadenomas

33
Q

Single most important criterion for distinguishing benign cystic renal masses from vascular solid lesions

A

enhancement

33
Q

What refers to dysplastic dilatation of the collecting tubules in the papilla?

A

medullary sponge kidney

33
Q

In which renal pole are milk of calcium cysts more common?

A

upper

33
Q

Entities associated with congenital hepatic fibrosis

A

infantile/AR polycystic kidney disease, adult polycystic disease, multicystic dysplastic kidneys, choledochal cyst, and Caroli disease

34
Q

What renal lesion has a characteristic feature of herniating into the renal pelvis?

A

multilocular cystic nephroma

34
Q

Which of the phakomatoses are associated with renal cysts?

A

tuberous sclerosis and vHL disease

34
Q

Cysts arising in the renal sinus?

A

peripelvic cyst (typically small, multiple, and often bilateral)

34
Q

Cortical cysts projecting into the renal sinus?

A

parapelvic cyst (usually large but solitary)

34
Q

What condition should you consider in the presence of multiple cysts in both renal sinus and parenchyma?

A

renal lymphangiomatosis

35
Q

Classification of congenital renal AVMs

A

cirsoid - multiple small AV communications; aneurysmal - solitary communication
(In Brant, sabi na other term ng congenital AVM iyong cirsoid)

35
Q

Findings are same with XGP but instead of hydronephrosis, there is marked proliferation of renal sinus fat?

A

replacement lipomatosis

35
Q

What is the hallmark of reflux nephropathy of childhood and chronic pyelonephritis?

A

focal cortical scar that overlies a blunted calyx

35
Q

What are the hallmarks of renal TB?

A

papillary necrosis, parenchymal destruction, and cavity formation

35
Q

(Dunnick) Hallmark of renal TB

A

multiple irregular infundibular stenoses/strictures with subsequent hydrocalycosis

35
Q

In which pole do parenchymal scars in chronic pyelonephritis more commonly occur?

A

upper pole

35
Q

(Dunnick) Stones radiolucent on plain radiographs

A

uric acid, xanthine, matrix, pure struvite, protease inhibitor such as indinavir (Note: sa brant, radiopaque si struvite)

36
Q

Triad of findings in xanthogranulomatous pyelonephritis?

A

staghorn calculus, absent/diminished excretion of contrast, poorly defined renal mass

36
Q

The only calculi that are not high attenuation on noncontrast CT

A

indinavir (antiretroviral for HIV patients)

37
Q

Causes of medullary nephrocalcinosis

A

hyperpara, medullary sponge kidney, RTA, milk-alkali syndrome, hypervit D, hypercalcemia/hypercalciuria

38
Q

Causes of hypercalciuria

A

Increased absorption - hypervitaminosis D, milk-alkali syndrome, sarcoidosis, berylium poisoning, idiopathic hypercalciuria
Increased mobilization from bone - hyperpara, immobilization, bone mets, multiple myeloma, hyperthyroidism, Cushing syndrome
Decreased tubular reabsorption - RTA, Fanconi syndrome, Wilson disease, amphotericin B

38
Q

Diseases processes that cause secondary RTA (impairing H+ excretion by the distal tubule)

A

Fanconi syndrome, Wilson disease, amphotericin B toxicity

38
Q

Medullary nephrocalcinosis is usually bilateral. Which condition is an exception?

A

medullary sponge kidney (may be unilateral or segmental)

38
Q

Major causes of medullary nephrocalcinosis

A

RTA type I (distal), hypercalcemic states, medullary sponge kidney

38
Q

Earliest sign of acute ureteral obstruction

A

effacement of the paracalyceal fat

39
Q

Rule of 7’s

A

70% of stones <7 mm will pass spontaneously

39
Q

What drug predisposes xanthine stone formation?

A

allopurinol

39
Q

Hallmark of a circumcaval ureter

A

severe medial deviation

39
Q

Least dense stones

A

uric acid (150-500)

39
Q

In complete ureteral duplication, UPJ obstruction is a complication of which pole?

A

lower (due to reflux?)

39
Q

Most dense stones

A

CaOx stones (800-1000HU)

39
Q

Secondary signs of ureteral stone on CT

A

perrinephric stranding/fluid, periureteral edema, enlarged kidney, hydoureter/hydronephrosis

40
Q

Course of ureter and gonadal vein

A

level of renal hilum - ureter is medial to gonadal vein
pelvis - they cross so that ureter is lateral to the vein
gonadal vein is somewhat more anterior than ureter

40
Q

Where does the ureter draining the upper pole insert in relation to the normally placed ureter?

A

infero-medial

40
Q

Diameter of dilated ureter

A

> 3 mm

40
Q

IVC anomaly in retrocaval/circumcaval ureter?

A

persistence of the right subcardinal vein anterior to the ureter instead of the right supracardinal vein posterior to the ureter

40
Q

Which anomaly is virtually associated with all ectopic ureteroceles?

A

complete duplication

41
Q

Measurement of thickened wall of the renal collecting system?

A

> 2 mm

41
Q

VUR grading

A

I - ureter / distal ureter
II - collecting system without dilation
III - collecting system with mild dilation - mild blunting of the calyces
IV - collecting system with moderate diilation - marked hydroureter and greater degree of dilatation/blunting of the calcyces
V - collecting system with severe dilation - marked tortuosity and dilatation of the ureter

42
Q

What appearance represents a slightly dilated segment of the middle 1/3 of the ureter superior to the crossing iliac vessels?

A

ureteral spindle

43
Q

Ureteral course

A

-L1-L2 interspace - leaves the kidney through the hilus
-proximal ureter lies lateral, anterior, and then medial to the psoas muscle as it descends
-L4 to L5 - leaves Gerota fascia and crosses anterior to the common iliac artery
-true pelvis / level of iliac spine - gentle posterolateral course
-runs anteromedially to enter UB

44
Q

What should be the primary diagnosis when strictures are seen at multiple levels throughtout the intrarenal collecting system and ureter?

A

TB

45
Q

l system or ureter In what location is leukoplakia premalignant?

A

UB (not premalignant in the ureter)

46
Q

Possible etiologies of papillary necrosis

A

Acronym: NSAID
N-SAIDs
S-ickle cell
A-nalgesic nephropathy
I-nfection (especially TB) D-M

PBR 2 and 3 (41 decks)

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