path recall April 2016 - formatted

Question 1

1. Young woman with fever and neck mass isoechoic to muscle on ultrasound and anterior to the carotid sheath - Repeat question.

a) Lymphoma
b) Metastatic papillary thyroid
c)
d)
e)

Answer 1

a) Lymphoma

Question 2

2. man / woman mildly elevated ESR fusiform AAA and perianeurysmal soft tissue swelling (These were two separate questions, one middle aged man and the other 40 year old woman)

a) Saccular mycotic
b) Inflammatory
c) Pseudoaneurysm
d) Takayasu
e) PAN

Answer 2

b) Inflammatory – if male

d) Takayasu – if female

Question 3

3. Man involved in high speed accident undergoes CT which demonstrates 2mm, well defined outpouching from thoracic aorta anteroinferior wall immediately distal to left SC origin

a) Ductus diverticulum
b) Traumatic aortic injury
c) Dissection
d) Transection

Answer 3

b) Traumatic aortic injury could be ductus diverticulum?? um
Traumatic pseudoaneurysm:- inferior aortic isthmus- acute angle- no calc. Surrounding stranding
Ductus- anteromedial isthmus- obtuse angle- calcium : very helpful clue

Question 4

Location of aortic injury

Answer 4

Location aortic isthmus: 90%ascending aorta: 5%diaphragmatic hiatus: 5%

Aortic isthmus (90% of initial survivors); commonly along inferomedial aspect at level of left pulmonary artery
Aortic root (5-14% of initial survivors), Most die at scene of accident
Diaphragmatic hiatus (1-12%), May be associated with diaphragmatic injury

Question 5

4. Previous EVAR, sac increasing in size with evidence of contrast endoleak through porous graft materal

a) Type 1
b) Type 2
c) Type 3
d) Type 4
e) Type 5

Answer 5

d) Type 4

Question 6

5. Liver tumour between primary (primary is confluence of right and left hepatic duct, secondary is confluence of second order ducts) and secondary confluence - what type is it (Klatskin tumour question) – Bismuth Corlette classification.

Type 1
Type 2
Type 3a
Type 3b  
Type 4 Cholangio

Answer 6

*LW:
type I
limited to the common hepatic duct, below the level of the confluence of the right and left hepatic ducts

type II
involves the confluence of the right and left hepatic ducts

type IIIa
type II and extends to the bifurcation of the right hepatic duct

type IIIb
type II and extends to the bifurcation of the left hepatic duct

type IV
extending to the bifurcations of both right and left hepatic ducts
or
multifocal involvement

type V
stricture at the junction of common bile duct and cystic duct

Type 3a If right
Type 3b If left
Type 4 Cholangio If both

Question 7

6. Granulosa cell tumour question. Was either a 15 yo or a 30 yo woman with hyperestrogenism symptoms.

a) Granulosa cell tumour
b)
c)
d)
e)

Answer 7

a) Granulosa cell tumour

• IVM additional information;
• granulosa cell tumours can be seen in any age, but more commonly post menopausal (2/3)
• Usually oetrogen secreting, but occasioanlly produce androen

Question 8

7. Infertility in a 25 yr old obese female with ultrasound demonstrating bilateral ovarian lesions with homogeneous low grade internal echogencity. Most likely

a) Endometrioma
b) PCOS
c) Teratoma
d) Mucinous cyst adenoma
e) Serous cyst adenoma

Answer 8

a) Endometrioma

Question 9

8. Infertility for 18 months - most likely cause

a)	polycystic ovaries
b)
c)
d)
e)

Answer 9

polycystic ovaries

Question 10

9. Criteria for PCOS - false?

a) Follicle size <10mm
b) Androgen exess
c) Anovulation
d) Follicles >12
e)

Answer 10

d) Follicles >12 used to be true, now >20

**LJS - Criteria for polycystic ovarian morphology:
>20 follicles per ovary and/or enlarged ovary >10ml
Other supportive findings (but not required for diagnosis):
Echogenic stroma - very vascular
Follicles at periphery of ovary - string of pearls
Follicles of similar size (2-9mm)

Need 2 from 3 of (and exclusion of other cause e.g. CAH):
Polycystic ovarian morphology on USS
Ovulatory dysfunction - oligo or anovulation
Clinical and biochemical signs of hyperandrogenism

Wji: as lotte says 2-9m follicles is a feature but not a diagnostic criteria. So when this question was written a. was false. D. is now also false.

Question 11

10. 3 year old boy with outward bowing of the knees and mild beaking of the medial metaphysis

a) physiologic
b) Blount disease
c) AVN
d) NF1
e)

Answer 11

b) Blount disease

Classic findings:
Tibial shaft in varus position.
Wedge shaped epiphysis- under developed, sloping medially with adjacent irregular physis
Medial metaphyseal beaking/spur.

NF1 gets tibial pseudoarthrosis

Question 12

11. Women with menorrhagia and dysmenorrhoea, ultrasound demonstrates heterogenous myometrium and smooth serosa.

a) Endometriosis
b) Uterine fibroids – Would have irregular serosa (most are subserosal)
c) Endometriosis – Adenomyosis??
d)
e)

Answer 12

Adenomyosis??

Question 13

12. Smoker 40 yr old woman with multiple cystic masses in and around the parotid on ultrasound on US

a) Warthins tumour
b) Pleomorphic adenoma
c) Metastasis
d) Sarcoidosis
e) Benign lympoepithelial lesions

Answer 13

Benign lympoepithelial lesions – Esp if history of HIV

a) Warthins tumour Older and male.
b) Pleomorphic adenoma - not usually multiple, but are hypoechoic and may b=have posterior aoustic enhancment
c) Metastasis - possible, mets to intraparotid nodes and cervical LN to explain surrounding masses
d) Sarcoidosis – Solid enlargement
e) Benign lympoepithelial lesions – Esp if history of HIV

• ESG- favour mets if unilateral and includes truly extra-parotid lesions - BLELs and Sjogren shouldn’t be extra-parotid.
• WJI - disagree. BLEL characteristically has associated cervical adenopathy and adenoid hypertrophy secondary to HIV

Question 14

13. 3 weeks old with torticollis, US shows sternomastoid (whatever that is?) MASS which is moderately vascular on US

a) Rhabdomyosarcoma
b) FIbromatosis colli
c) Capillary haemoangioma

Answer 14

b) FIbromatosis colli Presents with enalrgement of muscle (there can be a mass, no pain).

a) Rhabdomyosarcoma If mass and il-defined margins
b) FIbromatosis colli Presents with enalrgement of muscle (no mass, no pain).
c) Capillary haemoangioma Possible?

Question 15

14. Painful 2nd MTP and 2nd inter tarsal. Compressive sc hypo echoic fat layer 2 3 4 MT heads

a) interstitial bursitis
b) inter metatarsal bursitis

Answer 15

interstitial bursitis (adventitial bursitis)

Question 16

15. Tarlov cyst - what is correct

a) Most often affects the 1st and 4th sacral levels
b) often has bone erosion remodelling anyway
c) If multiple then it’s likely syndromic

Answer 16

b) often has bone erosion remodelling anyway

a) Most often affects the 1st and 4th sacral levels 2,3
b) often has bone erosion remodelling anyway
c) If multiple then it’s likely syndromic

Question 17

16. Bx of ilium - how do you do it. Depends on what you are doing it for

a) most direct route
b) ant approach
c) post approach
d) FNA
e) core

Answer 17

) core ?? um

Question 18

17. Breast - 40yo woman asymptomatic. Well defined hypo echoic lesion taller than wide, most likely.

a) IDC
b) ILC
c) mucinous

Answer 18

a) IDC – Most common
17. Breast - 40yo woman asymptomatic. Well defined hypo echoic lesion taller than wide, most likely

a) IDC – Most common
b) ILC Not well defined
c) mucinous Well defined but micro lobulated, often mixed solid cystic. Pure type can be anechoic (usually acoustic enhancement) - older patient (75 yo +)

Question 19

18. PASH

a) incidental no treatment
b) palpable mass
c) d)e)

Answer 19

a) incidental no treatment - True, usually microscopic incidental. No malignant potential (statdx).
b) palpable mass - True, sometimes.
Differential diagnosis for breast cancer- due to fibroblast proliferation- circumscribed/partially circumscribed mass, or architectural distortion- may look like fibroadenoma

Wide spectrum ranging from incidental finding to palpable mass
Most commonly incidental microscopic finding
Seen in 23% of breast biopsies and 19% of (healthy) mastectomies

Question 20

19. Fleischner guideline 3mm smoker

a) 12 month, then no followup
b) c)d)e)

Answer 20

a) 12 month, then no followupf/u because of high risk
Fleischner Society Recommendations and this table do NOT apply to:
Patients who have a known cancer.
Immunosuppressed patients.
Lung cancer screening, which has separate criteria.
Intra-fissural, perifissural, and subpleural pulmonary nodules. Perifissural lung nodules are usually benign, unless suspicious nodule morphology is present (reference).
Spiculated margins.
Displacement of the pulmonary fissure.
Cancer history.In these cases, follow-up should be considered.
Diameter of lung nodule is the average of the short and long axes, rounded to the whole millimeter.
Lung Cancer Risk Factors:
Tobacco use.
Family history of lung cancer.
Upper pulmonary lobe location of nodule.
Presence of emphysema.
Pulmonary fibrosis.
Older Age.
Female gender.

Question 21

20. ovarian cyst complex 3.5 cm young woman

a) 6 week followup different cycle If complex means multiseptated
b) 4 week followup same cycle
c) no followup if simple, or haemorrhagic
d) gynae blah

Answer 21

a) 6 week followup different cycle If complex means multiseptated

Question 22

22. Left ventricle atrial mass 80 yo screen for dementia. Cystic with minimal peripheral enhancement. What is most likely.

a) met
b) CP Ca
c) CP cyst
d) e)

Answer 22

c) CP cyst

a) met Not sure
b) CP Ca No. Essentially only in children
c) CP cyst
d) e)

Choroid plexus cyst, as in choroid plexus xanthogranuloma

Question 23

23. Posterior fossa mass excision hx, falx density, jaw cystic lesion skin lesion

a) Basal cell naevus
b) c) d)

Answer 23

a) Basal cell naevus

aka Gorlin or Gorlin-Goltz
Multiple keratocystic odontogenic tumors, basal cell carcinoma, medulloblastoma, intracranial dural calcifications, bifid ribs (Statdx).
Robbins includes ovarian fibroma, cleft lip/palate, vertebral segmentation, bifid, fused, missing or splayed ribs.

Question 24

24. 40 yo headache vomiting. Cyst +nodule but cyst not enhancing

a) HGBL
b) met
c) Astrocytoma
d) e)

Answer 24

a) HGBL

a) HGBL
b) met possible, (most common posterior fossa mass in adults)
c) Astrocytoma Younger
d) e)

Presume question means cyst not enhancing, but nodule is.
Cyst wall does not enhance in HGBL, but does 50% of the time in astrocytoma.

Question 25

25. Hx rheumatic fever. Now unwell with meningism. Heart murmur. a) multiple ring enhancing lesion b) leptomeningeal enhancement

Answer 25

a) multiple ring enhancing lesion - septic emboli

Question 26

26. Diffuse axonal injury which is most correct? a. All are haemorrhagic b. Affects cortex c. Genu of corpus callosum usually affected d. Dark on T2 e. Affects dorsal midbrain dorsolateral midbrain and upper pons

Answer 26

e. Affects dorsal midbrain dorsolateral midbrain and upper pons 26. Diffuse axonal injury which is most correct? a. All are haemorrhagic 80% non-haemorrhagic (stat dx) b. Affects cortex grey-white matter junction c. Genu of corpus callosum usually affected 2/3rds splenium d. Dark on T2 - if haemorrhage e. Affects dorsal midbrain dorsolateral midbrain and upper pons

Question 27

27. Progressive SOB. Symmetric peribronchovasc nodules, small-mod effusions, nodes, multiple small nodules. a) Sarcoidosis b) HP effusions c) lymphangitis carcinomatosis d) UIP effusions e) NSIP (was it one of the options?? not sure)

Answer 27

c) lymphangitis carcinomatosis 27. Progressive SOB. Symmetric peribronchovasc nodules, small-mod effusions, nodes, multiple small nodules. a) Sarcoidosis - no effusion b) HP effusions - no effusion - (CCF - can have effusion in cellular type Statdx). c) lymphangitis carcinomatosis d) UIP effusions - no effusion e) NSIP (was it one of the options?? not sure) - no effusion

Question 28

28. Male progressive restrictive lung disease. Nonsmoker bibasal septal thickening sub pleural cysts bronchiectasis a) UIP b) NSIP c) RB ILD d) DIP e)

Answer 28

a) UIP

Question 29

30. Parathyroid gland a) best seen on T2 b) Doesn’t enhance well on MRI c) Ectopic seen above superior aspect thyroid d) e)

Answer 29

a) best seen on T2

Question 30

31. Periprosthetic hip replacement a year ago, sclerosis and lucency for 6 months? a) Loosening without infection b) Infection and loosing c) infection without loosening

Answer 30

b) Infection and loosing Could be either or both.better to use In-111 WBC scan

Question 31

32. Myeloma detection a) Better with X-ray screen than bone scan b) c)d)e)

Answer 31

a) Better with X-ray screen than bone scan Bone scans can be normal

Question 32

33. Papillary thyroid ca on bx. Next best thing a) MRI with contrast b) CT with contrast c) I131 d) Tc99m scan e)

Answer 32

b) CT with contrast

Question 33

34. Most correct regarding knee injury what is correct a) mostly lipohaemarthrosis detectable with a fracture b) segond can happen with osteoporosis c) subtle sclerosis medial femoral condyle may represent fracture d) e)

Answer 33

c) subtle sclerosis medial femoral condyle may represent fracture lipohaemarthrosis - a/w intra-articular fracture

Question 34

35. 15 year old generalised bone pain. Enlarged ribs, vertebral height loss cardiomegaly. a) Sickle cell b) MPS c) thalassaemia major d) Glycogen storage e) Fibrous dysplasia

Answer 34

again debate around sickle cell or thalassaemia majorthalassaemia has more expansion *RY - would probably favour thalassaemia because of the expansion. Statdx describes the marrow replacement of sickle cell as very subtle, usually not detectable on plain radiograph. Rib expansion is well documented for thalassaemia, compression fractures also known to occur. **SCS: Sickle cell and Thalassaemia get cardiomegaly from high cardiac output (LVH etc). **wji -dahnert only talks about widened ribs in thalassaemia and h shaped vertebrae in sickle cell. This is unhelpful. 35. 15 year old generalised bone pain. Enlarged ribs, vertebral height loss cardiomegaly. a) Sickle cell Probably most correct. Potentially but more infarcts, less expansion b) MPS c) thalassaemia major d) Glycogen storage – Adenomas of the liver e) Fibrous dysplasia – not generalised

Question 35

36. OCP use. Liver echo normal. No biliary tree dilatation. Jaundice a) steatohepatitis - ? To have jaundice b) cholestasis c) fatty liver d) e)

Answer 35

b) cholestasis ummm **LJS ?? fatty liver or steatohepatitis should have echogenic liver at least, if not enlarged.

Question 36

37. CT liver vascular lesion. MRI with hepatobiliary agent (forgot its name) - hyperintense scar on delayed. Hyper early iso progressively on delayed a) HCC b) FNH c) Adenoma d) e)

Answer 36

b) FNH * *LJS - FNH scar is only supposed to enhance on typical Gad agents (not hepatobiliary agents). Everything else fits with FNH though * ESG disagree, hepatobiliary contrast agent will do everything that extracellular agents do (including enhancement of FNH central scar on 5 min delays), and *in addition* allow evaluation of hepatobiliary phase with FNH being iso- to hyper-intense (except for the central scar, which has now become hypointense).

Question 37

38. Breast cancer risk. Woman is 30. Mum at 60 and cousin at 60s. How would you advise screening? a) 2 yearly screen starting at 45 b) Immediate MRI starting annually c) Investigate then annual mammogram for life d) annual ultrasound till 35 then annual mamm

Answer 37

a) 2 yearly screen starting at 45

Question 38

39. Breast implant - not sensitive on MRI a) Rupture b) free silicone c) capsular contraction d) Multifocal cancer e) IDC

Answer 38

not sure *RY - Probably capsular contraction (hardening, with rounding/deformation in later stages). Note the general disadvantage of breast MRI = low specificity for benign versus malignant abnormality. In terms of implants, MRI usually not needed for saline rupture because should be clinically apparent.

Question 39

40. Breast implant - if it ruptures we can tell which type it is on ultrasound… a) intracapsular rupture b) extracapsular rupture c) d)e)

Answer 39

b) extracapsular rupture – snowstorm easier

Question 40

41. Which is better US vs MRI a) intracapsular b) extra capsular c) capsule contour contraction

Answer 40

c) capsule contour contraction??

Question 41

42. Lesion femoral diaphysis cortex night pain a) Osteoid osteoma b) Ossifying fibroma

Answer 41

a) Osteoid osteoma

Question 42

43. Osteoblastoma a) confined to vertebral body b) smaller than 1.5cm at dx c) Resolves d) found in vertebra 1/3 e)

Answer 42

d) found in vertebra 1/3 (40% stat dx), mostly cervical

Question 43

44. Wrong option a) Chance fracture almost always has neurologic involvement - b) Tear drop fracture - ventral cord injury c) DISH can fracture disc d) remote vertebral injury in 2 different places 5% e)

Answer 43

a) Chance fracture almost always has neurologic involvement - 44. Wrong option a) Chance fracture almost always has neurologic involvement - b) Tear drop fracture - ventral cord injury true c) DISH can fracture disc true d) remote vertebral injury in 2 different places 5% e)

Question 44

45. About to do an intervention. on clopidogrel (antiplatelet) clexane (LMWH) and metformin a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel b) Stop clopidogrel for 12 hours clean 10 days c) Stop clopidogrel and Metformin d) Stop Clean and Metformin e)

Answer 44

a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel 45. About to do an intervention. on clopidogrel (antiplatelet) clexane (LMWH) and metformin only consider stopping metformin if renal inpairment a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel b) Stop clopidogrel for 12 hours clean 10 days c) Stop clopidogrel and Metformin d) Stop Clean and Metformine)

Question 45

46. Lung bx - SOB. Post biopsy haemoptysis with focal area of haemorrhage in the right lower lobe posterior segment. Whats the best position. a) Right side down b) Left side down c) supine d) prone e) sit up

Answer 45

a) Right side down Biopsy side down (although its posterior so could argue for supine)

Question 46

47. Indication for tube on PTX in 80yr old with traumatic pneumothorax a) air fluid level b) clear pleural line seen c) lung collapsed to hila d) ipsilateral mediastinal shift - contralateral implies tension e)

Answer 46

c) lung collapsed to hila Indicating >50%

Question 47

48. 30 yo woman. 4cm jejunum with loss of pattern followed by 5cm stricture, and fistula to the terminal ileum fistula. a) Crohn b) Coeliac c) Scleroderma d) SLE e) Was it UC????

Answer 47

a) Crohn

Question 48

49. 30 yr old with slowly growing neck mass, deep to parotid extending to the parapharyngeal space a) 1st branchial cleft b) 2nd branchial cleft cyst c) 3rd branchial cleft cyst d) Infected node e)

Answer 48

* *LJS edit - caution calling branchial cleft cyst in adult - think cystic nodal met, esp p16 +ve SCC, even in young adult non-smokers. If branchial cleft cyst, location deep to parotid would make me think 1st branchial cleft. 3rd and 4th are infrahyoid neck, 2nd is typically below angle of mandible. From options listed, I would choose 1st branchial cleft cyst** * LW --> Work type II, 1st BCC can occur within parotid or PPS space, so legit. Previous answer: b) 2nd branchial cleft cyst can extend between carotid arteries and abut pharyngeal wall. *LW Brachial cleft common feature summary: 1st branchial cleaft cyst: --> Cystic mass near pinna & EAC (Work type I) or extends from EAC to angle of mandible (Work type II) Location - Type I: Periauricular cyst or sinus tract: Anterior, inferior, or posterior to pinna & concha - Type II: Periparotid cyst or sinus tract: More intimately associated with parotid gland, medial or lateral to CNVII Superficial, parotid space, or parapharyngeal space (PPS). 2nd branchial cleft cyst: --> Cystic neck mass posterolateral to submandibular gland, lateral to carotid space, anterior to SCM Most are at or immediately caudal to angle of mandible Location - Type I: Deep to platysma muscle, anterior to SCM - Type II: Anterior to SCM, posterior to submandibular gland, lateral to carotid sheath (Most common) - Type III: Protrudes between ICA & ECA, may extend to lateral pharyngeal wall or superiorly to skull base - Type IV: Adjacent to lateral pharyngeal wall, probably remnant of 2nd pharyngeal pouch 2nd branchial apparatus fistula extends from anterior to SCM, through carotid artery bifurcation, & terminates in tonsillar fossa 3rd branchial cleft cyst: --> Unilocular, thin-walled cyst in upper posterior cervical space or lower anterior neck Location - Anywhere along course of 3rd branchial cleft or pouch - Upper neck: Posterior cervical space - Lower neck: Anterior border sternocleidomastoid muscle - Rarely in submandibular space, lateral to cephalad hypopharynx Classically, 3rd branchial fistula would exit base of pyriform sinus, course superior to superior laryngeal and hypoglossal nerves and inferior to glossopharyngeal nerve 4th Branchial cleft cyst: --> Sinus tract extending from apex of pyriform sinus to lower anterior neck after barium swallow Abscess in or adjacent to anterior left thyroid lobe Location - May occur anywhere from left pyriform sinus apex to thyroid lobe - Commonly against or within superior aspect of left thyroid lobe or attached to thyroid cartilage - Upper end may communicate with or be adherent to pyriform sinus

Question 49

50. Incidental pick up 2cm renal mass. On MRI T1 high T2 and post contrast enhancement a) Clear cell b) Papillary c) Haemorrhagicadenomyolipoma d) Proteinaceous cyst e) Simple cyst

Answer 49

a) Clear cell probably 50. Incidental pick up 2cm renal mass. On MRI T1 high T2 and post contrast enhancement a) Clear cell b) Papillary shouldn't be high T1 c) Haemorrhagic – if haemorrhagic adenomyolipoma d) Proteinaceous cyst wouldn't enhance e) Simple cyst

Question 50

51. Jejunal intussusception. Most likely a) Pancreatic divisum b) dorsal agenesis c) ectopic pancreas d) annular e) some other pancreas variant

Answer 50

c) ectopic pancreas

Question 51

52. Most common in small bowel in ileum causing intussusception a) Small bowel carcinoid b) Lymphoma c) Adenocarcinoma d) e)

Answer 51

* *LJS edit - from radiographics paper: SB intussusception most commonly has benign lead point (less often neoplasm). Of neoplastic causes, mets are most common. Maybe the unrecalled answers were benign lesion or mets? Of those listed, I would choose adenocarcinoma, as it is most common. (I have assumed stem was about adults)** * WJI -disagree with Lotte. Agree with prior answer: lymphoma. Adenocarcinoma most common small bowel tumour overall (30-50%, carcinoid 25-30%, lymphoma 15-20%) BUT adenocarcinoma favours duodenum then jejunum over ileum. Carcinoid and lymphoma favour ileum. "Small bowel lymphoma" listed on RP in malignant causes of intussusception with colon adenocarcinoma and mets. b) Lymphoma 52. Most common in small bowel in ileum causing intussusception a) Small bowel carcinoid second most common malignancy of small bowel b) Lymphoma c) Adenocarcinoma most common malignancy of SB https://pubs.rsna.org/doi/full/10.1148/rg.263055100

Question 52

53. 15 year old kid who med oncology referral US shows caecal wall thickening. Apps not seen a) Typhilitis b) Appendicitis c) Colitis d) Diverticultis e)

Answer 52

a) Typhilitis

Question 53

54. Paraumbilical discharge, with mass in continuation with the bladder dome a) Adenocarcinoma b) SCC c) TCC d) e)

Answer 53

a) Adenocarcinoma | most common malignancy in urachal remnants

Question 54

55. Appendix inflammation on ultrasound. most correct a) can be up to 6mm b) surrounding fat less echogenic c) fluid collection d) vascular e) caecal thickening

Answer 54

c) fluid collection

Question 55

56. Placenta within 1cm to os on 20 week anatomy scan, 4cm cx. Most likely a) marginal b) bladder overly filled c) contraction d) abruption e) low lying placenta

Answer 55

*LW: Preferred option is bladder over filled. I think over filled bladder is most likely, as why else would they state cervical length of 4cm, which is slightly increased from normal (3cm), as over filled bladder can increase cervical length, and a over distended bladdr can mimic a low lying placenta, as it stretches the lower uterine segment. *RY - normal length at 20weeks is 4cm according to google, so low lying seems most correct. Boom. Mike drop. Get outta my house Logan. * *SCS: depends on if TV/TA. Re TA; MOH Obstetric USS guidelines say “TA assessment with a full bladder falsely elongates the cervical length”. In order to see anything TA, you need the bladder full - sonographic window. - also Obstetric guidelines; “Routine cervical length scanning at the time of the mid trimester ANATOMY scan is not currently recommended” they generally dont do TV scans at anatomy. - If TV scan -> LLP. - Im going with Disney prince… overfilled bladder on gameday. Previous answer e) low lying placenta

Question 56

57. PV bleed and pain. 3rd trimester. Retroplacental hypo echoic structure with septa a) abruption b) praevia c) d)

Answer 56

a) abruption

Question 57

58. Cord insertion not at placenta most likely cause a) velamentous cord b) succenturiate c) bilobed placenta d) e)

Answer 57

velamentous cord insertion 58. Cord insertion not at placenta most likely cause: a) velamentous cord insertion marginal more common b) succenturiate most commonly on main placenta, often marginal or velamentous c) bilobed placenta d) e)

Question 58

59. Not associated with abnormal pulmonary vasculature a) VSD b) PDA c) TOF d) AP window e) Coarctation

Answer 58

e) Coarctation 59. Not associated with abnormal pulmonary vasculature a) VSD b) PDA c) TOF - reduced vascularity (RV outflow obstruction) d) AP window ( seriously WTF) * *SCS: note this is an actual condition… L>R shunt, AKA aortopulmonary septal defect. Clinicians (non radiologists) call it AP window…abnormal communication between the proximal aorta and the pulmonary trunk e) Coarctation **LJS edit - infantile coarctation (preductal type) is ass/w PDA and hence RV hypertrophy and PA dilatation. Depends on whether age of patient given in stem**

Question 59

60. 10 week G1P0 abdo wall mass at junction of abdo wall and cord a) normal gut herniation b) gastroschisis c) omphaloceole

Answer 59

a) normal gut herniation **SCS physiological gut herniation should not persist after 12-13 weeks. starts 8 weeks See the gut at base of umbilical cord.

Question 60

61. Pregnant female, has a scan at 33 weeks (by LMP), had a scan at 7 weeks (dates baby at 35 wks), and then another scan at 20 weeks. Scan today shows baby measuring 32 weeks. Which is correct regarding which scan you should base the gestational age on and the current status of the fetus? a. Date baby by 7 wk scan, baby small for gestational age b. Date baby by LMP, baby normal for age c. Date baby by 20 week scan d. Date baby by LMP, ……

Answer 60

a. Date baby by 7 wk scan, baby small for gestational age

Question 61

62. 3T vs 1.5T, which is incorrect? a. Chemical shift artefact is increased at 3T b. Magnetic shift artefact is increased at 3T. c. The 300 gaus line is further from the bore of the magnet at 3T d. On a T1 FSE image at 3T, CSF will be darker than grey matter

Answer 61

b. Magnetic shift artefact is increased at 3T. Never heard of this 62. 3T vs 1.5T, which is incorrect? a. Chemical shift artefact is increased at 3T - true b. Magnetic shift artefact is increased at 3T. Never heard of this c. The 300 gaus line is further from/closer to (sorry can’t remember which one) to the bore of the magnet at 3T true if further from d. On a T1 FSE image at 3T, CSF will be darker than grey matter – true GAUSS LINE: The gauss (symbol: G or Gs) is a legacy CGS unit of magnetic flux density, which was superseded by the tesla. One gauss is defined as one maxwell per cm2 (Mx/cm2), which equates to 10-4 tesla, and is therefore a small unit. This is one of the reasons for its stubborn persistence in some scientific fields and its common occurrence in the literature.One area in which it continues to be widely applied is in MRI safety, whereby a 5 gauss line is demarcated around the magnet in the scanning room to show the region of risk to close by electronic devices that may be affected by the field, e.g. cardiac pacemakers.

Question 62

64. Which of these is correct? a. Samarium-153 treats bone metastases by beta emission. b. A 4 phase bone scan is flow, blood pool, 3 hr and 8hr c. MDP absorption is greatest in bone and blood at 30 mins

Answer 62

a. Samarium-153 treats bone metastases by beta emission. And gamma 64. Which of these is correct? a. Samarium-153 treats bone metastases by beta emission. And gamma b. A 4 phase bone scan is flow, blood pool, 3 hr and 8hr AND 24 hour c. MDP absorption is greatest in bone and blood at 30 mins (?)

Question 63

65. Primary thoracic TB a) upper lobe most common b) Adult s can have lymph node involvement only c) Paeds have more effusion than adult d) e) Kids often unilateral hilar and paratracheal nodes

Answer 63

*LW: Favor option E as correct, per radiopedia. Yes adults can have nodal involvement only, and seen 10-30% of time, so both correct, but I would favor E most correct b) Adult s can have lymph node involvement only 65. Primary thoracic TB a) upper lobe most common usually middle and lower lobes b) Adult s can have lymph node involvement only c) Paeds have more effusion than adult – Adults have more effusions. d) e) Kids often unilateral hilar and paratracheal nodes (usually on right), 90% of cases.

Question 64

66. Female patient on the OCP, presents with headache. CT scan shows infarcts in the thalamus and basal ganglia infarcts. Which vein is thrombosed? a. Inferior sagittal sinus b. Superior sagittal sinus c. Vein of Labbe d. Cavernous sinus

Answer 64

a. Inferior sagittal sinus (internal cerebral vein better answer if an option).

Question 65

67. Fibroadenolipoma – management? a. Routine 2yrly screening b. Mastectomy and axillary clearance c. Follow up mammogram in 12 months d. ?hookwire with surgical biopsy

Answer 65

a. Routine 2yrly screening

Question 66

68. Radial scar management a. Wide local excision with sentinel node biopsy b. Hookwire with open biopsy c. Mastectomy d.

Answer 66

b. Hookwire with open biopsy

Question 67

69. Hydroxy-apatite deposition disease, which is most correct? a. Chronic progressive process b. Supraspinatus and biceps tendon most commonly involved c. Subscapularis more common than supraspinatusd.

Answer 67

Supraspinatus most common, then infrapsinatus..umm

Question 68

70. Double bubble on AXR, contrast study demonstrates dilated proximal duodenum, thin trickle of contrast passing beyond the level of obstructing with a thin linear filling defect outlined by the contrast a. Duodenal web b. Duodenal atresia c. Annular pancreas

Answer 68

a. Duodenal web

Question 69

71. History of seizures, T2 hyperintensity in the medial temporal lobe, which is most likely? a. DNET b. Hippocampal sclerosis c. Oligodendroglioma d. Gemistocytic astrocytoma

Answer 69

a. DNET less common than mesial temporal sclerosis. b. Hippocampal sclerosis might be this one 71. History of seizures, T2 hyperintensity in the medial temporal lobe, which is most likely? a. DNET less common than mesial temporal sclerosis. b. Hippocampal sclerosis might be this one c. Oligodendroglioma 70% calcify, less common in temporal d. Gemistocytic astrocytoma

Question 70

Cystic lesion with an enhancing mural nodule in the brain, most likely? a. Astrocytoma b. Haemangioblastoma

Answer 70

a. Astrocytoma if young | b. Haemangioblastoma if adult and posterior fossa.

Question 71

73. Idiopathic scoliosis, most correct? a. Female 10-18yrs, convex to right b. Female 10-18 yrs, convex to left c. Male 10-18 yrs, convex to right d. Male 10-18 yrs convex to left

Answer 71

a. Female 10-18yrs, convex to right S shaped curve most common * *SCS: Radiopaedia. - Adolescent and juvenile idiopathic scoliosis is more common in girls and tends to have a right thoracic curve (dextroscoliosis). - Infantile idiopathic scoliosis is more common in boys and they tend to have a left thoracic scoliosis (levoscoliosis).

Question 72

74. Gynae ultrasound, enlarged uterus with smooth contour, heterogeneous appearance, endometrial stripe 4mm, which is most likely? a. Endometrial carcinoma b. Adenomyosis c. Leiomyomas

Answer 72

b. Adenomyosis

Question 73

75. What is correct regarding contrast allergy a) non iodinated contrast reaction kills less than 1/80000 b) seafood allergy contraindicated c) premed 4 hours before if hydrocortisone. d) premed good for major rather than minor allergy

Answer 73

a) non iodinated contrast reaction kills less than 1/80000 75. What is correct regarding contrast allergy a) non iodinated contrast reaction kills less than 1/80000 wji-radiopaedia 1/170k b) seafood allergy contraindicated - incorrect c) premed 4 hours before if hydrocortisone. If prednisone have to give three doses 13, 7 and 1 hour before d) premed good for major rather than minor allergy - nope

Question 74

1. Most likely testicular tumour to cause haemorrhagic mets a. embryonal B. choriocarcinoma c. Leydig-sertoli cell d. seminoma

Answer 74

B. choriocarcinoma

Question 75

2. Most likely testicular tumour to follow an indolent cause ``` A. spermatocytic seminoma B. lymphoma C. leydig cell D. sertoli cell E. embryonal ```

Answer 75

A. spermatocytic seminoma Spermatocytic seminoma is a rare germ cell tumor distinct from classical seminoma, both clinically and pathologically. It affects older men, has not been associated with a history of cryptorchidism, and has no known counterpart in ovary or any other site. Pathologically, it is characterized by 3 distinct cell types, lack of cytoplasmic glycogen, and scant to absent lymphocytic infiltrate. Gain of chromosome 9 is the most consistent genetic abnormality. There have been few case reports of sarcomas arising in spermatocytic seminoma and only an occasional report of metastasis. It is important to differentiate this condition from its frequent mimics, such as classic seminoma and embryonal carcinoma, because patients with spermatocytic seminoma may not require further treatment after surgery. *wji sertoli and leydig close 2nd, 90%benign

Question 76

3. Which one is not an appropriate age range A. seminoma 30-40 B. spermatocytic seminoma >60 C. yolk sac tumour 5-15 D. ?embyonal cell 20-40

Answer 76

C. yolk sac tumour 5-15 <3 year, Schiller Duval bodies, raised AFP 3. Which one is not an appropriate age range A. seminoma 30-40 B. spermatocytic seminoma >60 C. yolk sac tumour 5-15 <3 year, Schiller Duval bodies, raised AFP D. ?embyonal cell 20-40 yolk sac tumour- aka endodermal sinus tumour - age < 2 - heterogenous solid mass with cystic component on ultrasound- schiller duval bodies- raised AFP- tx: orchitectomy

Question 77

4. Which is true regarding dissection A. 5-10% not associated with significant intimal tear B. haemorrhage occurs between in the media C. most occurring in young people are not associated with hypertension D. it is rare to see cystic medial degeneration in those without dissection

Answer 77

WJI - possibly which is false as I think all except D are true. Single best answer I would chose B. as this is true and A. is actually an IMH (although this is correct in multiple prior recalls). A. 5-10% not associated with significant intimal tear True (statDx), rupture of vasa vasorum 4. Which is true regarding dissection A. 5-10% not associated with significant intimal tear True (statDx), rupture of vasa vasorum B. haemorrhage occurs between in the media (how it was actually written) C. most occurring in young people are not associated with hypertension True as well. Most in young people due to other abnormalities (eg valve disease, marfans, Ehlers Danlos, crack cocaine, pregnancy, collagen vascular disease, syphilis) D. it is rare to see cystic medial degeneration in those without dissection Cystic medial necrosis (CMN) is a disorder of large arteries, in particular the aorta- accumulation of basophilic ground substance in the media with cyst-like lesions.- occur in certain connective tissue diseases such as Marfan syndrome, Ehlers-Danlos syndrome, and annuloaortic ectasia

Question 78

5. Most common location of carcinoid tumour ``` A. duodenum B. proximal ileum C. distal ileum D. proximal jejunem E. distal jejunem ```

Answer 78

C. distal ileum 45 percent midgut, 90% of these within 2 feet of ileocaecal valve

Question 79

6. Stone in cystic duct causing intrahepatic dust dilatation A. Mirrizzis syndrome-others

Answer 79

A. Mirrizzis syndrome Mirizzi syndrome refers to an uncommon phenomenon which results in extrinsic compression of an extrahepatic biliary duct from one or more calculi within the cystic duct or gallbladder. It is a functional hepatic syndrome but can often present with biliary duct dilatation and can mimic other hepatobiliary pathologies such as cholangiocarcinoma 2.

Question 80

7. Regarding mesothelioma A. spares visceral pleura B. is indistinguishable from adenocarcinoma macro and microscopically.-..can’t remember the rest

Answer 80

B. is indistinguishable from adenocarcinoma macro and microscopically. 7. Regarding mesothelioma A. spares visceral pleura Involves later/less than parietal B. is indistinguishable from adenocarcinoma macro and microscopically.-..can’t remember the rest

Question 81

8. Least associated with smoking ``` A. large cell B. small cell C. adeno D. squamous E. carcinoid ```

Answer 81

E. carcinoid And bronchoalveolar Small cell strongest smoking association Typical carcinoid the weakest association

Question 82

9. Risk factor for both squamous and adenocarcinoma of the oesophagus A. smoking B. alcohol C. hot beverages D. h. pylori

Answer 82

A. smoking | B. alcohol (also true)

Question 83

10. Squamous cell carcinoma of the oesophagus most correct A. associated with strictures in the lower third B. most commonly affects the middle third of the oesophagus C. others….

Answer 83

B. most commonly affects the middle third of the oesophagus 50 percent stat Dx, 30% lower third. Adeno more common in the lower third (Barrett's) 10. Squamous cell carcinoma of the oesophagus most correct A. associated with strictures in the lower third B. most commonly affects the middle third of the oesophagus 50 percent stat Dx, 30% lower third. Adeno more common in the lower third (Barrett's)

Question 84

11. Wegeners granulomatosis. Repeat question –what’s not involved A. Pulmonary arteries B. Renal arteries C. upper airways D. lower airways

Answer 84

B. Renal arteries The classic triad of organ involvement consists of: lungs: involved in 95% of cases upper respiratory tract / sinuses: 75-90% kidneys: 80%

Question 85

13. Best for flow cytometry A. chloroma (myeloid sarcoma) B. Ewings

Answer 85

A. chloroma (myeloid sarcoma)

Question 86

14. If you had cystic lesion in the jaw, calcs in falx and skin lesions then what is it

Answer 86

A. Gorlin syndrome (AKA basal cell naevus syndrome)

Question 87

17. B2 lesion of the breast A. ADH B. ALH C. Collagenous something D. DCIS? Not sure

Answer 87

C. Collagenous something - only benign lesion

Question 88

18. With Paget’s disease of the breast A. More than 50% of the time the nipple looks normal B. Can have DCIS 50% C. Can have invasive cancer 50%

Answer 88

C. Can have invasive cancer 50%

Question 89

19. Most likely syndrome causing cancer in the right colon, caecum A. Cowden B. Peutz-Jeger C. Lynch Syndrome

Answer 89

C. Lynch Syndrome

Question 90

21. Breast ca lobulated appearance A. medullary B. Mucinous C. Radial scar

Answer 90

mucinous

Question 91

22. Regarding TB , most correct A. Pleural effusion Child > Adult B. Ghon focus is a peripheral area of caseous necrosis and an involved lymph node C. can have single organ involvement in kidney / meninges and this does not imply active pulmonary involvement D. Most likely happens in the upper lobe if primary

Answer 91

C. can have single organ involvement in kidney / meninges and this does not imply active pulmonary involvement 22. Regarding TB , most correct A. Pleural effusion Child > Adult nope. B. Ghon focus is a peripheral area of caseous necrosis and an involved lymph node ghon complex C. can have single organ involvement in kidney / meninges and this does not imply active pulmonary involvement D. Most likely happens in the upper lobe if primary secondary

Question 92

23. What is NOT sarcoid A. non caseating granulomatous B. basal meninigitis. C. chronic glomerulonephritis D. choroid retinitis - iritis

Answer 92

C. chronic glomerulonephritis **LJS - agree, though sarcoid can also be ass/w proliferative GN

Question 93

24. What is NOT Ankylosing Spondylitis A. Aortitis B. iritis C. Shoulder/hip/etc D. MTP involvement

Answer 93

D. MTP involvement ``` SD: Associations anterior uveitis (25-40%) psoriasis inflammatory bowel disease: ulcerative colitis/Crohn disease osteopenia cardiovascular disease apical/upper lobe predominant interstitial lung disease with small cystic spaces (in ~1% of patients) 4 aortic valve disease / aortitis secondary amyloidosis (rare) cauda equina syndrome (rare) ```

Question 94

25. CADASIL, least likely A. NOTCH 3 gene, B, arteriopathy distribution C. large and haemorrhagic infarcts D. anterior temporal and deep white matter

Answer 94

*LW: C - large haemorrgic infarcts - usually lacunar and micro bleeds A. NOTCH 3 gene: TRUE B, arteriopathy distribution: True, arteriopathy without atherosclerosis or amyloid, affecting basal ganglia, ant temporal lobe, deep white matter. C. infarcts - large and haemorrhagic - FLASE: lacunar infarcts and microhaemorrhages: D. anterior temporal and deep white matter: TRUE B, arteriopathy distribution - leptomeningeal C. infarcts - large and haemorrhagic microhaemorrhages

Question 95

26. Something about ADEM –what is NOT a feature? A. Following bacterial infection B. Is monophasic C. Can involve cord and cerebral hemispheres

Answer 95

A. Following bacterial infection - rare

Question 96

27. Conn syndrome - most characteristic A. hyperkalaemia. B. hyponatraemia C. Adrenal cortical adenoma.

Answer 96

C. Adrenal cortical adenoma. Stat dx 80%, Radiopaedia 30% 27. Conn syndrome - most characteristic: A. hyperkalaemia. Increased aldosterone – reabsorption of Na and Excretion of K. B. hyponatraemia C. Adrenal cortical adenoma. Stat dx 80%, Radiopaedia 30% Conn's- adrenal cortical adenoma 70%- Adrenal hyperplasia 30%- carcinoma

Question 97

28: Hashimoto disease, most correct A. transient hyperthyroidism then hypothyroidism B. small increased risk of ca – follicular lymphoma. C...

Answer 97

A. transient hyperthyroidism then hypothyroidism 28: Hashimoto disease, most correct A. transient hyperthyroidism then hypothyroidism B. small increased risk of ca – follicular lymphoma. Marginal zone b-cell lymphoma, possible papillary thyroid carcinoma C...

Question 98

29: Pituitary adenoma – what is NOT a feature A. MEN 2 B. Micro more likely to be hormone secreting C.

Answer 98

A. MEN 2

Question 99

30. Least likely in twin pregnancy A. Monozygotic with various combination? B. fused DCDA INDICATES monozygotic C. Risk of losing one of the two fetuses 1/8 D. DCDA means monozygotic

Answer 99

*LW: DCDA doesn't mean mono zygotic, monozygotic can occur in approx 20% of DCDA twins. probably C. Risk of losing one of the two fetuses 1/8 more like 1/5 DCDA - more common in dizygotic- but can occur in monozygotic Monozygotic twins can have any placentation type, depending on when zygote splits (single egg fertilised by single sperm) Dizygotic always DCDA (two egoos fertilsed by two spermies) WJI - b and d are both false. Fused appearing placenta and dcda can both be mono or dizygotic

Question 100

31. BRCA 1 gene not likely A. prostate ca B. ovarian C. pancreatic D. choriocarcinoma

Answer 100

D. choriocarcinoma ``` SD: BRCA1 mutation breast cancer: ~65% second primary breast cancer: ~30% at 5 years male breast cancer: 1-2% ovarian cancer: ~32.5% prostate cancer: <30% pancreatic cancer: ~2% colorectal cancer: 5x increased risk if <50 years 4 ```

Question 101

32. Infection testes first but not epididymis ``` A. gonorrhoae B. TB C. Chlamydia D. E coli E. Syphilis ```

Answer 101

E. Syphilis - in robbins p974 Syphilis Saj: In a child - MUMPs can cause isolated orchitis Crack the core -pg 114 vol 1

Question 102

33. HSV A. Haemorrhagic necrosis B. HSV 1 more common in neonates C. HSV 2 more is most common cause viral meningitis in adults

Answer 102

A. Haemorrhagic necrosis

Question 103

34. 3 months post partum. Has gradually increasing headache and blurry vision? Most likely A. Lymphocytic hypophysitis B. Empty sella C. Pituirary adenoma E. Was it cranio?

Answer 103

A. Lymphocytic hypophysitis Beware question that is immediate post-partum – Sheehan/apoplexy. Lymphocytic hypophysitis is seen most frequently in women, with a F:M of ~ 9:1, and often in the postpartum period or the third trimester of pregnancy.

Question 104

35. 3rd trimester bleeding, cord not attached to the placenta(was this RD?) A. Succenturiate B. Accessory C. praevia

Answer 104

C. praevia **LJS - I think answer was something else, likely velamentous cord insertion - could look unattached? Could also mean succinturiate lobe - no cord attached to the accessory lobe**

Question 105

37. Which is not a cause of moderate to massive splenomegaly? a. Schistosomiasis b. Sickle cell anaemia c. Thalassemia major d. Myelodysplasia e. Burkitts lymphoma endemic and non-endemic

Answer 105

*LW: Favor Burkitts. * *LJS - agree https: //pubmed.ncbi.nlm.nih.gov/29460043/ a. Schistosomiasis: true (although cant find size breakdown) b. Sickle cell anaemia: intially true c. Thalassemia major: TRUE d. Myelodysplasia: TRUE e. Burkitts lymphoma endemic and non-endemic: I favor this to be the correct answer: per the following from UpToDate: - -> Endemic (African) form presents as a jaw or facial bone tumor (picture 1) in 50 to 60 percent of cases. Primary involvement of the abdomen is less common. The primary tumor can spread to other extranodal sites, including mesentery, ovary, testis, kidney, breast, and meninges. Primary involvement of lymph nodes, mediastinum, and spleen are uncommon. - -> non-endemic (sporadic) form usually has an abdominal presentation, most often with massive disease and ascites, involving the distal ileum, stomach (picture 2), cecum and/or mesentery, kidney, testis, ovary, breast, bone marrow, or central nervous system (CNS). Presenting symptoms can include those related to bowel obstruction or gastrointestinal bleeding, often mimicking acute appendicitis or intussusception. Approximately 25 percent of cases will have involvement of the jaw or facial bones. Lymphadenopathy, if present, is generally localized. Previous answers: b. Sickle cell anaemia may have Splenomegaly initially then infarcts. e. Burkitts lymphoma endemic and non-endemic EJB thinks this one - Schistosomiasis causes splenomegaly with siderotic nodules and portal HTN - Burkitts listed as affecting solid abdominal organs in statdx but splenomegaly not specifically mentioned. Radiopedia mentions only kidneys/bowel

Question 106

signs of fetal demise on ultrasound

Answer 106

Ultrasound: - absent fetal heart beat - absent fetal movements - occasional findings: - overlapping of skull bones (Spalding sign) - gross distortion of fetal anatomy (maceration) - soft tissue oedema: skin >5 mm - echogenic amniotic fluid (fetal demise fragments)- uncommon findings - thrombus in fetal heart - gas shadow in fetal heart (Robert sign)​

Question 107

38. Which is the least likely complication after acute myocardial infarction? a. Acute mitral regurgitation b. Acute aortic regurgitation c. Fibrinous pericarditis d. Pericardial tamponade e. Left ventricular mural thrombus

Answer 107

b. Acute aortic regurgitation

Question 108

39. Which is most correct? a. Subacute bacterial endocarditis causes valvular destruction b. Subacute bacterial endocarditis is complicated by emboli and aneurysms c. Acute bacterial endocarditis….

Answer 108

*LW: maybe un recalled answer: But A is technically correct, according to Robbins, but I would doubt it was the most correct option. a. Subacute bacterial endocarditis causes valvular destruction: less valvular destruction than acute. Granulaiton tissue at bases. Pathoma states does not destroy valve. b. Subacute bacterial endocarditis is complicated by emboli and aneurysms: known complication of acute bacterial endocarditis. c. Acute bacterial endocarditis: - friable bulky destructive vegetations - Aortic and mitral most common - Tricuspid in IVDU - probably b a is right too 39. Which is most correct? a. Subacute bacterial endocarditis causes valvular destruction but less so than acute b. Subacute bacterial endocarditis is complicated by emboli and aneurysms probably this one c. Acute bacterial endocarditis….

Question 109

41. Which breast disease is most commonly associated with diabetes? a. Fibroadenoma b. PASH

Answer 109

Neither SCS: Diabetic mastopathy?

Question 110

Which is most correct? a. Pancreatic adenocarcinoma in the head of the pancreas is associated with normal parenchymal volume of the body and tail of the pancreas

Answer 110

usually atrophy

Question 111

44. Which is not an indication for TIPS procedure? a. Hepatorenal syndrome b. Hepatopulmonary syndrome c. Intractable ascites d. Bleeding gastric varices e. Fulminant liver failure

Answer 111

e. Fulminant liver failure Good radiopaedia article. Along with right heart failure, sepsis, portal vein thrombosis. **SCS: Hepatopulmonary syndrome is also a bit dubious. There are some papers reporting success but typical treatment is liver tx…. Fulminant liver failure is a (relative) contraindication. HPS is not listed in the above radiopaedia article.

Question 112

45. Which doesn’t involve the corpus callosum? a. Lymphoma b. Glioblastoma multiforme c. Multiple sclerosis d. Marchiafava-bignamie. Can’t remember other option

Answer 112

– all the above do hahahahaha

Question 113

46. Which is the most diagnostic feature of a GBM on histology? a. Number of mitoses b. Necrosis and vascular endothelial proliferation c. Peripheral expansion beyond (?gross) tumour margins d. Peri-lesional oedema extent

Answer 113

b. Necrosis and vascular endothelial proliferation

Question 114

47. Which of the following does sarcoid not cause? | a. Glomerulonephritis

Answer 114

a. Glomerulonephritis **SCS: sarcoid can cause interstitial nephritis.

Question 115

48. Which of the following is not a feature of Wegeners? a. Upper respiratory tract necrotizing granulomas b. Lower respiratory tract necrotizing granulomas c. Glomerulonephritis d. Pulmonary arterial vasculitis e. Renal arterial vasculitis

Answer 115

e. Renal arterial vasculitis

Question 116

49. Hypocalcaemia is most likely in which of the following? a. Parathyroid adenoma b. Parathyroid carcinoma c. Primary hyperparathyroidism d. Secondary hyperparathyroidism e. Tertiary hyperparathyroidism

Answer 116

d. Secondary hyperparathyroidism Hypocalcaemia is the cause of increased PTH in this condition -primary hyperparathyroidism parathyroid adenoma (~80%) multiple parathyroid adenomas (4%) parathyroid hyperplasia (10-15%) 2,5 parathyroid carcinoma (1-5%) -secondary hyperparathyroidism caused by chronic hypocalcemia with renal osteodystrophy being the most common cause (others include malnutrition, vitamin D deficiency) results in parathyroid hyperplasia -tertiary hyperparathyroidism autonomous parathyroid adenoma caused by the chronic overstimulation of hyperplastic glands in renal insufficiency

Question 117

50. HPV causes which of the following? a. Vocal cord polyps b. Laryngoepiglottitis c. Juvenile papillomatosis

Answer 117

**LJS - Vocal cord nodules/polyps - occur on true cords in singers/smokers due to chronic irritation, NOT HPV related. 9th Ed Rob p739 HPV lesions include: - Laryngeal papilloma/"squamous papilloma". Benign neoplasm on true VC. Due to low risk HPV subtypes - Juvenile laryngeal papillomatosis - multiple papillomas, due to HPV (can be acquired at birth) "Juvenile papillomatosis" is also the breast, not related to HPV preferred option is C. juvenile papillomatosis.

Question 118

52. Which feature is most likely to be seen in ulcerative colitis rather than Crohn’s disease? a. Colonic pseudopolyps b. Cholelithiasis

Answer 118

a. Colonic pseudopolyps An inflammatory pseudopolyp is an island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue (denuded ulcerative mucosa). It is seen in long-standing ulcerative colitis.

Question 119

Which is most correct regarding colonic fistulas to the urogenital tract? a. Colo-vesical fistulae are more common in women b. The most common cause is diverticulitis c. Something about colo-vaginal fistula (?colovaginal fistula the connection can always be seen on CT)

Answer 119

b. The most common cause is diverticulitis **SCS: Radiopaedia [colovesical fistula article]: Diverticulitis (60%). Colon cancer (~20%), Crohn Dis ( 10%). Other RTx, appendicitis, trauma.

Question 120

58. CADASIL, which is least correct? a. Infarcts are large and haemorrhagic b. Something about predilection for frontal and temporal lobes? c. Something about white matter involvement

Answer 120

* LW: a. Infarcts are large and haemorrhagic: usually lacunar infarcts, with adjacent white matter changes. Can be haemorrhagic but less common. *SCS: CADASIL = cerebral autosomal dominant arteriopathy with Subcortical infarcts. Distribution: anterior temporal pole, external capsule, paramedian frontal lobe (highly sens/spec). [StatDx]. NOTCH 3.

Question 121

59. Which of the following causes and irregular uterine contour? a. Leiomyomas b. Adenomyosis c. Endometrial d. adenocarcinoma

Answer 121

a. Leiomyomas most common Adenomyosis can also on HSG....

Question 122

60. Risk factors for SCC and adenocarcinoma of oesophagus, which one do they have in common? a. Tobacco b. Alcoho c. Hot drinks

Answer 122

a. Tobacco b. Alcoho (and also this) *LW: UTD (which our exam is not) states the following regarding Adenocaricnoma of the oesphagus: --> A meta-analysis of 20 case-control and four cohort studies including a total of 5500 cases concluded that there was no association between alcohol drinking and esophageal AC risk, even at higher levels of consumption. So if correct recall, I would prefer smoking. *AJL - Robbins says smoking and alcohol. If this was a correct recall, the most correct answer would be alcohol. Smoking can involve more than just tobacco technically....

Question 123

65. BRCA-1 mutation is least likely to be associated with? a. Pancreatic cancer b. Male breast cancer although less common than BRCA 2 c. Prostate cancer d. Endometrial cancer

Answer 123

d. Endometrial cancer

Question 124

66. Regarding mesothelioma, which is most correct? a. Can appear histologically (?and morphologically) identical to adenocarcinoma b. Does not involve the visceral pleura c. Association with smoking d. Time lag is between 5-15 years e. Despite being more common in asbestos exposure, Incidence still remains low in asbestos exposure (<0.01% ??)

Answer 124

a. Can appear histologically (?and morphologically) identical to adenocarcinoma arises from either the visceral or the parietal pleura. The lifetime risk of developing mesothelioma in heavily exposed individuals is as high as 7% to 10%. 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. (SCS: note asbestos increases risk of primary lung cancer as well as mesothelioma. Is synergistic w smoking) Microscopically, malignant mesotheliomas may be epithelioid (60%), sarcomatoid (20%), or mixed (20%). This is in keeping with the fact that mesothelial cells have the potential to develop as epithelium-like cells or mesenchymal stromal cells. The epithelioid type of mesothelioma consists of cuboidal, columnar, or flattened cells forming tubular or papillary structures resembling adenocarcinoma (Fig. 15-52A). Immuno­ histochemical stains are very helpful in differentiating it from pulmonary adenocarcinoma. SCS: radiopaedia says hard to distinguish from METASTATIC adenocarcinoma. ‘The cytological and histological diagnosis can be difficult, with mesothelial hyperplasia and metastatic adenocarcinoma appearing similar’

Question 125

68. Which cystic kidney disease is most commonly associated with RCC? a. Acquired cystic renal disease b. Autosomal recessive polycystic kidney c. Autosomal dominant polycystic kidney

Answer 125

a. Acquired cystic renal disease a. k.a. dialysis associated. Patients with end-stage renal disease who have undergone prolonged dialysis sometimes show numerous cortical and medullary renal cysts. The cysts measure 0.1 to 4 cm in diameter, contain clear fluid, are lined by either hyper­ plastic or flattened tubular epithelium, and often contain calcium oxalate crystals. They probably form as a result of obstruction of tubules by interstitial fibrosis or by oxalate crystals. Most are asymptomatic, but sometimes the cysts bleed, causing hematuria. There is a 12- to 18-fold increased risk of renal cell carcinoma, which develops in 7% of dia- lyzed patients observed for 10 years.

Question 126

70. Which syndrome commonly causes caecal/ascending colon carcinoma? a. Gardners syndrome b. Cowdens syndrome c. Lynch syndrome d. Peutz-Jeghers

Answer 126

c. Lynch syndrome a. Gardners syndrome no predilection b. Cowdens syndrome doesn’t increase risk of GI malignancy. **LJS - get multiple hamartomas of skin, GIT** Breast cancer 30% ,lhermitte duclos ,5% follicular thyroid cancer ,multiple hamartomas including small and large bowel c. Lynch syndrome 70% r sided d. Peutz-Jeghers no predilection, hamartomas, often small bowel. **LJS - incr risk multiple malignancies including colonic adenocarcinoma, though polyps themselves not premalignant

Question 127

71. Stomach and small bowel adenomas are associated with what? a. Peutz-Jeghers b. Familial adenomatous polyposis

Answer 127

b. Familial adenomatous polyposis Pj are hamartomatous not adenomatous

Question 128

72. Which is most correct? | a. 50% of Familial adenomatous polyp patients have carcinoma of the colon by age 30 and 100% by 50

Answer 128

yes

Question 129

73. Which radiologically guided biopsy will be sent for flow cytometry? a. Thymic carcinoma b. Chloroma c. ? neuroendocrine tumour

Answer 129

b. Chloroma (myeloid sarcoma)

Question 130

74. Which one of these needs a core biopsy rather than an FNA? a. Lymphoma in a lymph node b. A secondary deposit in a lymph node c. Thyroid carcinoma d. Lung carcinoma

Answer 130

a. Lymphoma in a lymph node

Question 131

75. ABC – most correct? a. Is metaphyseal in > 50% b. Is associated with giant cell tumour in ? %15

Answer 131

a. Is metaphyseal in > 50% *AJL (addtional info) ABCs are secondary in 1/3 of cases. GCTs coexist with ABC 14% of the time (on GCT page of RP) *wji agree a. Most correct 70-90% -but statdx says 1/3 abc secondary and 20-40% secondary is in gct so this is pretty much true also.

Question 132

76. Pagets disease of the nipple a. 50% have DCIS in the underlying breast b. 50% have macroscopic changes in the nipple c. 50% …… have idc

Answer 132

c. 50% …… have idc

Question 133

78. Coeliac disease least accurate? a. Proximal small bowel affected more than distal small bowel b. Causes steatorrhoea c. Causes villous atrophy with something or other

Answer 133

all true

Question 134

79. Varices, which is least correct? a. Linear filling defects parallel to the long axis of the oesophagus b. Round sessile filling defect in the oesophagus c. Can be caused by SVC obstruction d. Can be caused by cirrhosis

Answer 134

b. Round sessile filling defect in the oesophagus

Question 135

80. Which is most correct of prion diseases? a. Present with rapidly progressive dementia and motor abnormalities b. Prions contain mostly protein with a small amount of DNA and RNA c. ? something about haemorrhage d. In the early stage predominantly affects white matter e. In the early stage predominantly affects basal ganglia and cortex f. ? something about temporal lobes

Answer 135

a. Present with rapidly progressive dementia and motor abnormalities e. In the early stage predominantly affects basal ganglia and cortex CJD is thought to be mediated via prions, a type of protein, which manifests in sheep as the disease scrapie, and in cows as bovine spongiform encephalopathy. Prions are considered infectious in the sense that they can alter the structure of neighbouring proteins. CJD leads to spongiform degeneration of the brain, which is thought to be caused by the conversion of normal prion protein to proteinaceous infectious particles that accumulate in and around neurons and lead to cell death.

Question 136

81. Carcinoid, which is least correct? a. Neuroendocrine rests in a scar are unremarkable (??) b. Atypical and typical carcinoid can’t be differentiated on histology c. Carcinoid arises from metaplastic bronchial epithelial cells d. All are malignant

Answer 136

*LW: Both B and C are incorrect. **LJS - agree a. Neuroendocrine rests in a scar are unremarkable (??): TRUE **LJS - agree Tumourlets - small hyperplastic nests of neuroendocrine cells in scars/chronic inflammation - no clinical significance Continuum of pulmonary NET: Benign tumourlets - typical carcinoid - atypical carcinoid - large cell neuroendocrine tumour - small cell carcinoma b. Atypical and typical carcinoid can’t be differentiated on histology: FALSE, they can be. * *LJS - Limited ability to differentiate on FNA but not on histology. Previous recalls have said FNA c. Carcinoid arises from metaplastic bronchial epithelial cells: False arise from Kulchistsky cells / neuroendocrine cells that line bronchial mucosa. d. All are malignant: I think true

Question 137

82. Which structure is worst affected by Huntingtons disease? a. Caudate nucleus b. Hippocampus and ….

Answer 137

a. Caudate nucleus

Question 138

83. Thyroid a. In hyperthyroidism nuclear med scan should be the first investigation b. In hyperthyroidism ultrasound should be the first investigation

Answer 138

a. In hyperthyroidism nuclear med scan should be the first investigation

Question 139

84. Anti-smooth muscle antibodies are mostly likely positive in which condition? a. ? psoriasis b. ? Primary sclerosing cholangitis c. ? primary biliary cirrhosis

Answer 139

*LW: UpToDate: states anti smooth muscle antibodies are seen in PSC, (along with auto immune hepatitis) in up to 75% of patients, while pANCA seen in upto 80% of patients with PSC. So....Based on options provided, I would chose PSC. * *LJS - agree LW https: //onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2012.05223.x Psoriasis - ?dunno PSC - pANCA PBC - AMA Previous answer: c. ? primary biliary cirrhosis

Question 140

85. Which is the most correct finding to distinguish an exostosis from chondrosarcoma a. Thickness of the cartilage cap b. Pointing away from the joint c. Medulla continuous with the medullary cavity of the origin bone

Answer 140

a. Thickness of the cartilage cap