Path 2020 Flashcards

Question

Which is most associated with associated with knee OA? a. CPPD b. Hydroxyapatite disease c. Ochronosis d. Gout

Answer 1

a. CPPD CPPD crystal deposition can be associated with osteoarthritis (OA) May be synchronous and unrelated to OA, or may be due to repetitive microtrauma

Answer 2

b. Caecal cancer typically presents with fatigue and weakness not occult rectal bleeding. Regarding colon cancer what is most correct a. Nodule architecture is the most important factor in assessing risk - F (assuming this is regarding colorectal adenomas) Adenomas can be classified as tubular, tubulovillous, or villous based on their architecture. These categories, however, have little clinical significance in isolation. b. Caecal cancer typically presents with fatigue and weakness not occult rectal bleeding. - T Cecal and other right-sided colon cancers are most often called to clinical attention by the appearance of fatigue and weakness due to iron deficiency anemia. Left-sided colorectal adenocarcinomas may produce occult bleeding, changes in bowel habits, or cramping and left lower quadrant discomfort. c. (the possible other correct answer)

Answer 3

a. Venous ischaemia has a gradual transition Regarding bowel ischaemia a. Venous ischaemia has a gradual transition - T b. Watershed area is at the hepatic flexure - F splenic flexure and descending colon > sigmoid

Answer 4

b. IMA occlusion (causes ischaemic colitis) _______ Ischaemic enteritis causes: Vascular occlusion: Embolic events (atrial fibrillation, endocarditis), thrombotic events (atherosclerosis), mechanical obstruction (strangulation, tumor). Closed-loop obstruction especially dangerous Hypercoagulable states: Oral contraceptives, protein C deficiency, factor V Leiden deficiency Inflammatory: Pancreatitis, peritonitis, vasculitis (Angiography may show microaneurysms and occluded vessels) Iatrogenic : Radiation and chemotherapy, therapeutic drugs (digitalis, dopamine, vasopressin), illicit drugs (heroin, cocaine, amphetamines) Hypoperfusion (more common in ischemic colitis): Low-flow states, hypotension, sepsis, heart failure

Answer 5

Intraluminal GI gas: Intramural pressure or mucosal injury → gas enters wall Bacterial gas production: Bacterial invasion → high tension → gas diffusion

Answer 6

c. 20% of chronic gout die from renal failure Regarding gout a. Primary gout is 30% associated with….. ? Gout can be divided into primary and secondary forms, both sharing the common feature of hyperuricemia. In the primary form (90% of cases), gout is the major manifestation of the disease and the cause is usually unknown. In secondary gout (10% of cases), uric acid is increased because of a known underlying disease that usually dominates the clinical picture. b. Not associated with hyperuricaemia - F see above c. 20% of chronic gout die from renal failure - T Renal manifestations sometimes appear in the form of renal colic associated with the passage of gravel and stones and may proceed to chronic gouty nephropathy. About 20% of those with chronic gout die of renal failure. Gouty nephropathy refers to the renal complications caused by MSU crystals or tophi in the renal medullary interstitium or tubules. Complications include uric acid nephrolithiasis and pyelonephritis, particularly when the urates induce urinary obstruction. d. Most people only have one episode - F Although some patients never have another attack, most experience a second acute episode within months to a few years. In the absence of appropriate therapy, the attacks recur at shorter intervals and frequently become polyarticular.

Answer 7

c. Arises from the metaphysis in the long bone ABC most likely a. Most commonly associated with another tumour - F 70% of aneurysmal bone cysts (ABCs) are primary b. Usually vertebral bodies - F (15%) c. Arises from the metaphysis in the long bone- T It most frequently develops in the metaphysis of long bones (70-90%) and the posterior elements of vertebral bodies (15%) d. More than 50% recurrence following curettage - F The treatment of aneurysmal bone cyst is surgical, usually curettage or, in certain situations, en bloc resection. The recurrence rate is low, and spontaneous regression may occur following incomplete removal. StatDx: Recurrence rate following curettage is variable in different series (20-50%)

Answer 8

a. Strep pneumonia is most common cause of acute Infective endocarditis, which is false? a. Strep pneumonia is most common cause of acute - F, Staph aureus b. Prosthetic vale sewing ring - T? Endocarditis of mechanical valves; often starts at sewing cuff or from thrombi near sewing ring; leads to paravalvular leak, ring abscess, extension of infection into adjacent tissue c. isolated organism in up to 60% - T? In about 10% of all cases of endocarditis, no organism can be isolated from the blood (“culture- negative” endocarditis); reasons include prior antibiotic therapy, difficulties in isolating the offending agent, or because deeply embedded organisms within the enlarging vegetation are not released into the blood. d. IVDU involves right valves. - T Approximately 90 percent of patients with right-sided IE are people who inject drugs (PWID); in contrast, PWID comprise approximately 20 percent of cases of left-sided IE

Answer 9

- BRCA2 Pancreatic ductal adenocarcinoma most likely: - Li Fraumeni - F - Not associated - BRCA2 -T - Increased, 5- 10% lifetime risk - MEN1 - F (pancreatic NETs) - VHL - F (serous cystadenomas and NETs) - FAP - F - Increased, unknown lifetime risk ____ Heritable syndromes associated with ↑ risk include Hereditary pancreatitis, hereditary breast and ovarian cancer syndrome, Peutz-Jeghers, ataxia telangiectasia, familial colon cancer, Gardner syndrome, and familial aggregation of pancreatic cancer

Answer 10

Unclear EDWH - MS is almost exclusive for CRHD as per robbins. Favour this to be the answer. ________ Chronic rheumatic fever disease most likely asso/complication - due to group A strep myocarditis during childhood - F immunologically mediated, multisystem inflammatory disease classically occurring a few weeks after an episode of group A streptococcal pharyngitis; occasionally, RF can follow streptococcal infections at other sites (skin). - mitral stenosis due to thickened chordae tendinae - T? (but not exclusively) The cardinal anatomic changes of the mitral valve in chronic RHD are leaflet thickening, commissural fusion and short ening, and thickening and fusion of the tendinous cords - acutely myocarditis and pericarditis often fatal - F Clinical features related to acute carditis include pericardial friction rubs, tachycardia, and arrhythmias. Myocarditis can cause cardiac dilation that may culminate in functional mitral valve insufficiency or even heart failure. Approximately 1% of affected individuals die of fulminant RF involvement of the heart. - subacute infective endocarditis ?expected is a complication of chronic RHD

Answer 11

- Kidney Rheumatoid subcutaneous nodules are the most common cutaneous lesions. They occur in approximately 25% of affected individuals, usually those with severe disease, and arise in regions of the skin that are subjected to pressure, including the ulnar aspect of the forearm, elbows, occiput, and lumbosacral area. Less commonly they form in the lungs, spleen, pericardium, myocardium, heart valves, aorta, and other viscera.

Answer 12

Unsure NEC least likely - Asso with enteral feeding - T In addition to prematurity, most cases are associated with enteral feeding, suggesting that some postnatal insult (such as introduction of bacteria) sets in motion the cascade culminating in tissue destruction. - Most common in caecum/terminal ileum - T Necrotizing enterocolitis typically involves the terminal ileum, cecum, and right colon, although any part of the small or large intestines may be involved. - Reversal relation to gestational age - T Necrotizing enterocolitis is most common in premature infants, with the incidence of the disease being inversely proportional to the gestational age. - Previous broad spectrum antibiotics - ? Can't find reliable info - coincide with onset of feeding - ? Can't find reliable info

Answer 13

endodermal sinus tumour (= yolk sac tumour)

Answer 14

- choriocarcinoma

Answer 15

- NMO most likely bilateral MS most likely - random distribution of plaques - F Plaques commonly occur adjacent to the lateral ventricles, and are also frequent in the optic nerves and chiasm, brainstem, ascending and descending fiber tracts, cerebellum, and spinal cord. Plaques can also extend into gray matter, since myelinated fibers are present there as well. - Axon degeneration and destruction in acute setting - F In active plaque, inflammation, lymphocytes/monocytes presenet. oligodendrocytes are depleted, axons are relatively preserved, . In inactive gliotic plaque, there is severe demyelination, and axons are reduced. - NMO most likely bilateral - T (bilateral optic neuritis)

Answer 16

Caudate nucleus

Answer 17

- Progresses slowly CJD least likely - Variant affects the basal ganglia - T Caudate and putamen > globus pallidus - Progresses slowly - F Long incubation period but rapidly progressive once clinical symptoms begin. The mean duration of illness for vCJD is longer than for sCJD, 14 versus 4-5 months - Several variants involving the inferior colliculus- ?? Can't find anything to rule this in or out. The Heidenhain variant presents as isolated visual symptoms such as impaired visual acuity, distortions of shapes and colours, and visual hallucinations. The Brownell-Oppenheimer variant presents as isolated cerebellar ataxia.

Answer 18

MRI may be the most sensitive test in the early stages of disease, showing abnormalities even before the onset of characteristic clinical findings such as myoclonus and periodic sharp wave complexes (PSWC) seen on EEG Early CJD is characterized by increased DWI signal in cortex, corpus striatum (caudate and anterior putamen), or both. The abnormal signal may be unilateral or bilateral; focal, multifocal, or diffuse; and asymmetrical or symmetrical. The corresponding apparent diffusion coefficient (ADC) values are decreased, suggesting restricted diffusion from spongiform encephalopathy.

Answer 19

- follicular adenoma and carcinoma cannot be differentiated from FNA Thyroid carcinoma most likely - papillary multifocal - F?, (more likely medullary) Papillary carcinomas may be solitary or multifocal. Sporadic medullary thyroid carcinomas present as a solitary nodule. In contrast, bilaterality and multicentricity are common in familial cases. -papillary most commonly cystic lymphadenopathy - T? 50% have lymph node involvement at presentation (vs 10% for follicular). Differentiated thyroid cancer (papillary & follicular): nodes heterogeneous: Solid, cystic, calcified, variable in size & enhancement - follicular commonly involves lymph nodes - F, papillary Because follicular carcinomas have little propensity for invading lymphatics, regional lymph nodes are rarely involved, but vascular (hematogenous) dissemination is common, with metastases to bone, lungs, liver, and elsewhere. Papillary: Metastases to adjacent cervical lymph nodes occur in up to half of cases. -anaplastic presents with bone metastases - F, follicular Anaplastic carcinomas usually present as a rapidly enlarging bulky neck mass. In most cases, the disease has already spread beyond the thyroid capsule into adjacent neck structures or has metastasized to the lungs at the time of presentation. Widely invasive follicular carcinoma often presents with systemic metastases. - follicular adenoma and carcinoma cannot be differentiated from FNA - T Careful evaluation of the integrity of the capsule is critical in distinguishing follicular adenomas from follicular carcinomas, which demonstrate capsular and/or vascular invasion. Because of the need for evaluating capsular integrity, the definitive diagnosis of adenomas can be made only after careful histologic examination of the resected specimen.

Answer 20

- Cholesterol granuloma Young male with headache. MRI high T1 and high T2 lesion temporal bone apex with bone expansion - Cholestatoma, F (low T1) - Cholesterol granuloma, T (low T2 haemosiderin rim possible) - Petrous apicitis, F (destruction without expansion, low T1) - Chondrosarcoma, F (low T1)

Answer 21

Periosteal (juxtacortical) chondroma? Surface lesion arising from metaphysis of tubular bone, producing chondroid matrix Location: Metaphyseal, arising on surface of bone. Proximal humerus and femur (70%) Radiographic findings: Small, scalloped radiolucent lesion on outer surface of the cortex, may have intralesional calcification; minimal periosteal reaction Age: 2nd-4th decades most frequent; may occur in children. Slightly younger age group than periosteal chondrosarcomas Statdx doesn't state nuc med findings specifically, but shows a case where the lesion is hot on bone scan.

Answer 22

4/5 options correct - this was probably a "least likely" question Hashimoto thyroiditis most likely - Hodgkin lymphoma - F 60-80x risk of thyroid NHL, most primary thyroid NHL have history of CLT. Rapid enlargement of thyroid in patient with history of CLT: NHL until proven otherwise Also at increased risk for the development of extranodal marginal zone (MALT) B-cell lymphomas within the thyroid gland - Chronic lymphocytic thyroiditis - T synonymous - Can have hyperthyroidism - T In the usual case, hypothyroidism develops gradually. In some patients, however, it may be preceded by transient thyrotoxicosis caused by disruption of thyroid follicles, leading to release of thyroid hormones (“hashitoxicosis”). - Commonly hypothyroidism - T Hashimoto thyroiditis most often comes to clinical attention as painless enlargement of the thyroid, usually associated with some degree of hypothyroidism, in a middle-aged woman. - Has anti TG ab - T Hashimoto thyroiditis is caused by a breakdown in self-tolerance to thyroid autoantigens. This is exemplified by the presence of circulating autoantibodies against thyroglobulin and thyroid peroxidase in the vast majority of Hashimoto patients.

Answer 23

All options are false, "Raised AFP" is the *least false* and therefore least correct answer WILD - ?poor recall? Robbins says AFP not associated with fibrolamellar. ___ Fibrolamellar HCC least likely - Raised AFP - F? Usually α-fetoprotein levels are normal. In 10% of cases, mild increase in levels (< 200 ng/μL) (StatDx) Only 7 to 11 percent of patients have an elevated serum AFP level (UpToDate) - associated with cirrhosis - F Slow-growing tumor that usually arises in normal (noncirrhotic) liver - associated with hep b - F (garden variety HCC) The most important underlying factors in hepatocarcinogenesis are viral infections (HBV, HCV) and toxic injuries (aflatoxin, alcohol). Thus where HBV and HCV are endemic, there is a very high incidence of HCC. There are no identified risk factors for FLC (UpToDate) - male more common than female - F In contrast to conventional HCC, FLC does not have a male predominance (UpToDate) No gender predominance (StatDx) Constituting less than 5% of HCCs. 85% occur under the age of 35 years and without gender predilection or identifiable predisposing conditions. (Robbins)

Answer 24

celiac disease Clinical profile: Young patient with history of steatorrhea, abdominal distension, and diarrhea CT enterography: Evidence of reversed fold pattern, multifocal intussusception Barium follow through: Dilatation of small bowel (jejunum): > 3 cm

Answer 25

-TB _______ 60 yo sore throat . complex cystic lesion in left pleura with extension in the intercostal space. Associated left lower lobe consolidation. -TB -T? Acid-fast bacillus Contiguous spread from infected lung or pleura Can cause empyema necessitans Robbins: Laryngeal tuberculosis may develop by spread through lymphatic channels or from expectorated infectious material. The mucosal lining may be studded with minute granulomatous lesions that may only be apparent microscopically. -actinomycosis - F? Can cause empyema necessitans, but can't explain sore throat -cryptoccocus - F Usually immunosuppressed -mets - F? Metastatic head + neck SCC could explain sore throat but wouldn't expect consolidation

Answer 26

-total gastrectomy with stricture (at oesophagojejunal anastomosis) in the other options, barium would pass through stomach before small bowel.

Answer 27

-duodenum and proximal jejunum

Answer 28

-spleen Primary haemochromatosis: Does not affect Kupffer cells or reticuloendothelial cells of bone marrow/spleen until late in disease. Only after hepatocytes are saturated. Secondary haemochromatosis: Initially, iron deposition in RES of liver and spleen, sparing parenchymal cells. After saturation of RES, iron accumulates in parenchymal cells of liver, pancreas, myocardium (*P*rimary = *P*ancreas, *S*econdary = *S*pleen)

Answer 29

? adenomyosis/adenomyoma can involve the cervix Wab- pid. ?cervicitis

Answer 30

- diastolic dysfunction HOCM most likely - left ventricular dilatation - F The essential feature of HCM is massive myocardial hypertrophy, usually without ventricular dilation - diastolic dysfunction - T The central abnormality in HCM is reduced stroke volume due to impaired diastolic filling. In 25%, “systolic anterior motion” of the anterior MV leaflet causes functional left ventricular outflow tract obstruction during mid-systole = H*O*CM. - fatty infiltration of ventricular wall- F occurs in arrhythmogenic RV cardiomyopathy, healed myocardial infarction - HTN - F not a feature of HCM - Asymmetry of the free wall - F (assuming this means asymmetrical hypertrophy of the free wall) The classic pattern involves disproportionate thickening of the ventricular septum relative to the left ventricle free wall (with a ratio of septum to free wall greater than 3 : 1), termed asymmetric septal hypertrophy.

Answer 31

-primary TB Typically, the inhaled bacilli implant in the distal airspaces of the lower part of the upper lobe or the upper part of the lower lobe, usually close to the pleura. As sensitization develops, a 1- to 1.5-cm area of gray-white inflammation with consolidation emerges, known as the Ghon focus In most cases, the center of this focus undergoes caseous necrosis. Tubercle bacilli, either free or within phagocytes, drain to the regional nodes, which also often caseate. This combination of parenchymal lung lesion and nodal involvement is referred to as the Ghon complex.

Answer 32

-mediastinal invasion Mesothelioma -mediastinal invasion - T Malignant mesothelioma is a diffuse lesion arising either from the visceral or parietal pleura, that spreads widely in the pleural space and is usually associated with extensive pleural effusion and direct invasion of thoracic structures. -commonly asso with pulmonary asbestosis - F Concurrent pulmonary asbestosis (fibrosis) is present in only 20% of individuals with pleural mesothelioma. -commonly asso with mets at diagnosis - F Not common - but can't back this up -increased asso with smoking - F There is a long latent period of 25 to 45 years for the development of asbestos-related mesothelioma, and there seems to be no increased risk of mesothelioma in asbestos workers who smoke. - 5 -10 year post exposure - F see above

Answer 33

Confusing question 20 week pregnancy with normal fetus. Likely association if T21 - Aberrant right subclavian artery ARSA is present in 35% of patients with Down syndrome - Single umbilical artery Isolated in 2/3 of cases. Aneuploid in 10% (trisomy 18 and 13, not 21) *SD: from RP trisomy 21 (12.8% had an SUA), trisomy 18 (50% had an SUA), trisomy 13 (25% had an SUA) - Cardiac echogenic focus most often isolated finding in low-risk patient 15-30% of T21 fetuses have ECF - Hypoplastic nasal bone nasal bone hypoplasia has emerged as one of the strongest morphological markers of trisomy 21 to date 0.5-1.2% of normal fetuses have been found to have a hypoplastic nasal bone on a routine 2nd trimester scan, compared to 43-62% of fetuses with Down syndrome - choroid plexus cyst not associated with T21 hallmark for T18

Answer 34

- Indeterminate scan follow up scan recommended pregnancy scan with fluid in endometrial cavity. NO adnexal mass - 22mm gestational sac means failed pregnancy - F Failed pregnancy: mean sac diameter (MSD) of ≥25 mm and no embryo on a transvaginal scan - Normal pregnancy progress with normal antenatal care - F - Ectopic pregnancy - F - Indeterminate scan follow up scan recommended - T

Answer 35

-complete mole with fetal parts common Gestational trophoblastic disease least likely -complete mole with fetal parts common - F In complete moles the embryo dies very early in development and therefore is usually not identified. - partial mole not associated with choriocarcinoma - T Partial moles have an increased risk of persistent molar disease, but are not associated with choriocarcinoma. - ovarian choriocarcinoma is more aggressive than gestational choriocarcinoma - T Nongestational choriocarcinomas that arise outside of the uterus are much more resistant to therapy.

Answer 36

-dysgerminoma Meigs syndrome is defined as the presence of ascites and pleural effusion in association with a benign, usually solid ovarian tumour. In the vast majority (80-90%) of cases, the primary tumour is an ovarian fibroma. Other primary tumours include: ovarian fibrothecoma ovarian thecoma granulosa cell tumours of the ovary Brenner tumour: rare

Answer 37

- can’t have 1.5 Tesla if cochlear implant MRI safety most likely -can’t have 1.5 Tesla if multiple ferromagnetic body piercing which are not removable - F If the patient is unable or unwilling to remove their non-ferrous/non-magnetic dermal piercings prior to scanning then scanning may proceed provided patients are advised to report any unusual sensations or heating in the implant area that occur during MR scanning. - can’t have 1.5 Tesla if cochlear implant-T Torque experienced by CI in 1.5T MR is sufficient to cause implant movement Most CI patients should not undergo MR -can’t have 1.5 tesla MRI if body shrapnel even though not close to vital organs - F Conducting 1.5T MRI examinations is safe in patients with retained metal fragments from combat and terrorist attacks not in the vicinity of vital organs. However, caution is advised. - can have 1.5 tesla MRI if insulin pump with tubing attached to patient - F (question states "can have") Very strong magnetic fields, such as those associated with MRI, can magnetize the portion of the pump’s motor that regulates insulin delivery and thus damage the device

Answer 38

- UAC at aortic arch UAC Ideal high line: Descending thoracic aorta (T6-T10) Acceptable low line: Distal abdominal aorta (L3-L4) T5 or above: Risk to aortic arch branches T12-L1: Risk to abdominal aortic branches UVC tip optimal location: IVC-RA junction PICC tip considered central if in: Superior vena cava (SVC); inferior vena cava (IVC) above renal veins, Brachiocephalic veins (controversial). Central tip position allows for effective infusion with appropriate hemodilution given greater blood flow Given the size of a neonate, accurate positioning of the tube may be challenging. The tip of this tube should be in the trachea approximately midway between the interclavicular line and the carina

Answer 39

- Egfr with non smokers Lung cancer - Passive smoking increase 5 times risk of cancer - F Passive smoking (proximity to cigarette smokers) increases the risk for lung cancer development to approximately twice that of non- smokers. - Egfr with non smokers - T The WHO estimates that 25% of lung cancer worldwide occurs in never smokers. This percentage is probably closer to 10% to 15% in Western countries. These cancers occur more commonly in women and most are adenocarcinomas. Cancers in nonsmokers are more likely to have EGFR mutations. - Asbestos exposure 5x increase risk with smoking - F Asbestos workers who do not smoke have a five-fold greater risk of developing lung cancer than do nonsmoking control subjects, and those who smoke have a 55-fold greater risk. - 20 pack year smoker 50% get cancer - F Since lung cancer develops in only 11% of heavy smokers, there are other factors that predispose individuals to this deadly disease.

Answer 40

Leptomeningeal enhancement (pachymeningeal)

Answer 41

Unclear - possibly increased pH least likely? hypercalcemia is a cause of pancreatitis hyperglycaemia and hypocalcaemia are caused by pancreatitis No hard link to hypokalaemia or alkalosis Metabolic acidosis can occur in acute pancreatitis for multiple reasons that include lactic acidosis resulting from shock, renal failure, or late in the course of disease because of loss of bicarbonate-rich pancreatic secretions due to pancreatic duct disruption

Answer 42

Not choledocholithiasis. _____ Robbins: Patients with hereditary pancreatitis have a 40% lifetime risk of developing pancreatic cancer; whether this increased cancer risk extends to other forms of chronic pancreatitis is unclear. Also Robbins: Chronic pancreatitis and diabetes mellitus are both risk factors for, and complications of, pancreatic cancer. In an individual patient it can be difficult to sort out whether chronic pancreatitis is the cause of pancreatic cancer or an effect of the disease, since small pancreatic cancers may block the pancreatic duct and produce chronic pancreatitis. A similar argument applies to the association of diabetes mellitus with pancreatic cancer, in that diabetes may develop as a consequence of pancreatic cancer and new-onset diabetes mellitus in an older patient may be the first sign that the patient has pancreatic cancer. StatDx: Risk factors: Cigarette smoking, alcohol, obesity, diabetes mellitus, chronic pancreatitis, high-fat diet

Answer 43

- Hutchinson Wilms tumour syndrome least likely - Hutchinson Hutchinson syndrome is a seldom-used term to denote a syndromic presentation of children with skeletal metastases from neuroblastoma. Widespread bone metastasis → bone pain, limping, pathologic fractures - Perlman Also called renal hamartomas, nephroblastomatosis, and fetal gigantism (catchy name) - Beckwith Wiedemann Increased risk of embryonal tumors, including Wilms tumor, hepatoblastoma, neuroblastoma, rhabdomyosarcoma, adrenocortical carcinoma - Denys drash Wilms tumour, male pseudohermaphroditism, progressive glomerulonephritis - WAGR Wilms tumor, aniridia, genitourinary anomalies, mental retardation

Answer 44

- BPH periurethral and transitional Prostate cancer most likely - Gleason system 5 morphological type on cytology - F (histology not cytology) Prostate cancer is graded using the Gleason system, which stratifies prostate cancer into five grades on the basis of glandular patterns of differentiation. A primary grade is assigned to the dominant pattern and a secondary grade to the second most frequent pattern. The two numeric grades are then added to obtain a combined Gleason grade or score. (max 10, min 2) - BPH periurethral and transitional - T BPH most commonly affects the inner periurethral zone of the prostate, producing nodules that compress the prostatic urethra.

Answer 45

-mesenchymal hamartoma Benign hepatic tumor, patients usually < 2 years of age Large multicystic or mixed solid-cystic mass Most likely hepatic neoplasms in young children Largely cystic in neonate/infant → mesenchymal hamartoma Solid, hypovascular in infant/toddler → hepatoblastoma Solid, heterogeneous, hypervascular in newborn → congenital haemangioma

Answer 46

- Hep B All risk factors for cholangiocarcinomas cause chronic inflammation and cholestasis, which presumably promote occurrence of somatic mutations or epigenetic alterations in cholangiocytes. The risk factors include infestation by liver flukes (particularly Opisthorchis and Clonorchis species), chronic inflammatory disease of the large bile ducts, such as primary sclerosing cholangitis, hepatolithiasis, and fibropolycystic liver disease. It should be noted that patients with hepatitis B and C, and non alcoholic fatty liver disease, not only have a higher risk of developing HCC, but also of cholangiocarcinoma *wji- depending on wording Ibd could be the better option. In western world psc is commonest cause and this is strongly associated with UC

Answer 47

- VHL *SD: MEN2 - almost always bilateral UpToDate: 10 to 20 percent in VHL syndrome, frequently bilateral 50 percent in MEN2 3 percent with NF1

Answer 48

Unclear Urothelial cancer most common - Papillary most commonly in bladder - T Radiopaedia: TCC bladder: superficial: 70-80% (of these, most are papillary - 70%) - Papillary most high grade - F generally low grade - Renal pelvic papillary most common - T Radiopaedia: account for >85% tumours ADB- Possibly testing that TCC more common in the bladder hence this option would be wrong - Sessile most common in ureter - F Radiopaedia: papillary account for 60% tumours

Answer 49

GCT ____ GCT: 80% in 3rd-5th decades of life F:M = 2.5:1 in spine 4% of all GCTs occur in sacrum Lytic, expansile lesion of vertebral body or sacrum Narrow zone of transition, margin not sclerotic Chordoma: Destructive Peak incidence 5th-6th decades (rare in children) M:F = 2:1 Most likely causes of solitary sacral mass in adult patient are GCT, chordoma, and plasmacytoma

Answer 50

Uric acid (tumour lysis)

Answer 51

- Leptomeningeal dissemination Diffuse Midline glioma in child most common location - Hypothalamus - F Pons (most common) and brainstem, thalamus, spinal cord - Basal ganglia - F as above - Necrosis and haemorrhage - T/F Necrosis, hemorrhage variable considered WHO grade IV tumours regardless of histological features - Avidly enhancing - F usually minimal (can enhance post radiotherapy) - Basilar invasion - F basilar artery displaced anteriorly against the clivus and potentially engulfed - Leptomeningeal dissemination - T Extensive spread is relatively frequent, both craniocaudally to involve the cerebral hemispheres and spinal cord, as well as leptomeningeal spread

Answer 52

AICA ____ hemifacial spasm usually caused by vascular loop compressing facial nerve at its root exit zone within cerebellopontine angle (CPA) cistern Offending vessels: AICA (50%), PICA (30%), VA (15%), vein (5%)

Answer 53

-labyrinthine ossificans ___ Young kid with previous meningitis with SNHL -labyrinthine ossificans - T Most common: Bilateral sensorineural hearing loss (SNHL) in child weeks to months after acute meningitis episode -fenestral spongiosis - F a subtype of otosclerosis/otospongiosis (the other being cochlear) -otoclerosis - F Young adult presents with unexplained bilateral progressive conductive (FOto) or mixed (FOto + COto) hearing loss

Answer 54

- Distal metacarpals UpToDate: CNO may affect any bone, but the metaphysis of the long bones of the lower extremities is the most common site, followed by the pelvis, vertebra, clavicle, long bones of the upper extremity, and mandible. StatDx: Location: Metaphyseal sites of distal femur, proximal and distal tibia, distal fibula, clavicle most common - Often crosses into adjacent epiphysis - Spine, pelvis, epiphyseal equivalents in thorax - Upper extremity rarely involved; exception is clavicle (involved in 30%) - Clavicular involvement fairly unique for CRMO

Answer 55

- T21 Craniosynostosis least likely - Crouzon - T - Thalassemia - T, secondary - Rickets - T, secondary - T21 - F? Included in the long list below. The only one not listed on radiopaedia. Not mentioned on UpToDate StatDx: Secondary Craniosynostosis Brain growth arrest (myriad causes) → premature sutural fusion (especially metopic or universal craniosynostosis) Reported causes include Intrauterine skull compression, teratogens, hematologic (sickle cell disease, thalassemia), metabolic bone disease (rickets, hypercalcemia, hyperthyroidism, hypervitaminosis D, ↓ PO4-vit D-resistant rickets), bone dysplasia (hypophosphatasia, achondroplasia, metaphyseal dysplasia), trisomy 21, mucopolysaccharidosis/mucolipidoses, microcephaly (brain atrophy, dysgenesis), brain malformations (holoprosencephaly, microcephaly, cephaloceles), post-CSF shunting procedures

Answer 56

?Craniopharyngioma vs lymphocytic hypophysis UpToDate: - In another cohort of 147 children followed from 2000 to 2013 in a single North American center, the most common single diagnosis was craniopharyngioma (25.2 percent) - Among infiltrative disorders, LCH >> lymphocytic hypophysitis

Answer 57

- Pneumatocele 24 yo treated with abx for a week. CXR now shows thin wall cysts with air fluid levels most likely: - Pneumatocele - T usually transient cystic airspace within the lung, usually due to pneumonia or trauma - Cavitating pneumonia - F surrounded by mass, nodule, or consolidation, creating wall thickness >2-4 mm - Tumour - F cavitating - thick-walled - Bronchogenic abscess - F subtypes of pulmonary abscess: - bronchogenic (aspiration, inhalation) - haematogenous - Pulmonary abscess - F Abscesses vary in size and are generally rounded in shape. They may contain only fluid or have a gas-fluid level. The wall of the abscess is typically thick and the luminal surface irregular.

Answer 58

-Haemosiderin rim _________ Cavernoma most likely -Has AV shunting - F DSA - usually normal, but can show slow intralesional flow without arteriovenous shunting -Normal or gliotic brain tissue ? Benign vascular hamartoma with intralesional hemorrhages, no neural tissue. Has a pseudocapsule of gliotic, hemosiderin-stained brain -Haemosiderin rim - T hypointense hemosiderin rim on T2 MR -Associated with venous haemangioma - F associated with developmental venous anomaly

Answer 59

-hyperextension varus hyperextension injury - direct force to anterior tibia with foot planted - contusion pattern: "kissing contusions" of anterior tibial plateau and anterior femoral condyle varus (force vector from medial to lateral) = medial contusions and lateral avulsions https://pubs.rsna.org/doi/pdf/10.1148/radiographics.20.suppl_1.g00oc21s121