RD Genitourinary formatted Flashcards
1. Middle aged male followed up for an incidental 3cm echogenic mass identified on ultrasound, the lesion is well demarcated and shows homogeneous high T1, low T2. A. Simple cyst B. Renal cell carcinoma c. Haemorrhagic cyst d. Proteinaceous cyst e. Angiomyelolipoma
*LW: favoured answer of haemorrhagic cyst.
- DDx for High T1 renal lesion = angiomyelolipoma, haemorrhagic cyst, proteinaceous cyst.
- Promethius states DDx for Low T2 = papillary RCC, lipid poor AML and haemorrhagic cyst,
- A lipid poor AML could account for a high T1 and low T2 appearances, but would have a heterogenous US appearance, not echogenic, being lipid poor.
- Given haemorrhagic cyst would appear T1 and T2 bright with likely fluid debris levels, (follow up likely less than 72 hours), but can become T2 dark sub acutely.
- Favoured answer is thus haemorrhagic cyst.
- At MR imaging, papillary RCC frequently shows a pseudocapsule and frequently has low signal intensity on both T1- and T2-weighted images, whereas cRCC has higher signal intensity on T2-weighted images.
**LJS - favour haemorrhagic cyst.
Proteinaceous cyst can be high T1 but ?more likely remain high T2. Haemorrhagic cyst typically T1 high and T2 low (RP, Stat dx, Prometheus).
Prior notes:
b. Renal cell carcinoma ? T variable US appearance (50% hyperechoic, 40% isoechoic, 10% hypoechoic); variable MRI appearance but usually isointense on T1 & T2, but 40% are T1 hyperintense & most are T2 heterogenous. However papillary RCC is generally MR homogeneous, and is often high T1 & low T2I think this is a haemrrhagic cyst. 1. Middle aged male followed up for an incidental 3cm echogenic mass identified on ultrasound, the lesion is well demarcated and shows homogeneous high T1, low T2.
a. Simple cyst F anechoic, T1 low, T2 high
b. Renal cell carcinoma ? T variable US appearance (50% hyperechoic, 40% isoechoic, 10% hypoechoic); variable MRI appearance but usually isointense on T1 & T2, but 40% are T1 hyperintense & most are T2 heterogenous. However papillary RCC is generally MR homogeneous, and is often high T1 & low T2
c. Haemorrhagic cyst F on US contains internal echoes (acute) or thick walls with multiloculation (chronic); on MRI usually T1 hyperintense (subacute, < 72 hours) & T2 hyperintense (not as high as simple cyst) +/- fluid-debris level
d. Proteinaceous cyst ?T simulates haemorrhage (Statdx)
e. Angiomyolipoma F typically markedly echogenic on US; at MRI heterogenous with T1 hyperintense fat content, often T2 mod hyperintense; fat areas will decrease signal on fat sat or out of phase imaging; post Gd vascular portion will enhance, but fatty portion will not
AJR June 2009 On T2-weighted images, most papillary RCCs are hypointense and clear cell RCCs, hyperintense. The T2 hypointense appearance of papillary RCCs correlated with a predominant papillary architecture at pathology.
RG Nov 2006:Papillary RCCs typically appear hypovascular and homogeneous on imaging studies. Another important feature of papillary RCC is that bilateral and multifocal tumors are more common than in other subtypes of RCC (especially with hereditary syndromes) (11). Larger tumors show heterogeneity due to necrosis, hemorrhage, and calcification. Papillary RCC commonly demonstrates low signal intensity on T2-weighted MR images possibly due to the presence of by-products of hemorrhage and necrosis.
- Middle aged male followed up for an incidental 3cm echogenic mass identified on ultrasound, the lesion is well demarcated and shows homogeneous high T1, high T2.
a. Simple cyst
b. Renal cell carcinoma
c. Haemorrhagic cyst
d. Proteinaceous cyst
e. Angiomyelolipoma
*LW: favoured answer of proteinaceous cyst.
**LJS - agree
- DDx for High T1 renal lesion = angiomyelolipoma, haemorrhagic cyst, proteinaceous cyst.
- A lipid poor AML could account for a high T1 and low T2 appearances, but would have a heterogenous US appearance, not echogenic, being lipid poor.
- Given haemorrhagic cyst would appear T1 and T2 bright with likely fluid debris levels, (follow up likely less than 72 hours.
- Favoured answer is thus proteinacesous cyst.
- At MR imaging, papillary RCC frequently shows a pseudocapsule and frequently has low signal intensity on both T1- and T2-weighted images, whereas cRCC has higher signal intensity on T2-weighted images.
RCC tends to occur in 50-70yr olds: unsure if this is considered older than middle age tho.
c. Haemorrhagic cyst T? on US contains internal echoes (acute) or thick walls with multiloculated (chronic); on MRI usually T1 hyperintense (subacute, < 72 hours) & T2 hyperintense (not as high as simple cyst) +/- fluid-debris leveld. Proteinaceous cyst T? simulates haemorrhage (Statdx)I think it’s more D2. Middle aged male followed up for an incidental 3cm echogenic mass identified on ultrasound, the lesion is well demarcated and shows homogeneous high T1, high T2. a. Simple cyst F anechoic, T1 low, T2 high
b. Renal cell carcinoma F variable US appearance (50% hyperechoic, 40% isoechoic, 10% hypoechoic); variable MRI appearance but usually isointense on T1 & T2, but 40% are T1 hyperintense & most are T2 heterogenous
c. Haemorrhagic cyst T? on US contains internal echoes (acute) or thick walls with multiloculated (chronic); on MRI usually T1 hyperintense (subacute, < 72 hours) & T2 hyperintense (not as high as simple cyst) +/- fluid-debris level
d. Proteinaceous cyst T? simulates haemorrhage (Statdx)
e. Angiomyelolipoma T typically markedly echogenic on US; at MRI heterogenous with T1 hyperintense fat content, often T2 mod hyperintense; fat areas will decrease signal on fat sat or out of phase imaging; post Gd vascular portion will enhance, but fatty portion will not.
- Young man with flank trauma, presents with hematuria. Has CT that shows large vascular heterogenous mass containing fat. Hemodynamically stable. What to do next?
a. MRI
b. DSA
c. Family history
d. Urgent surgery
b. DSA T best answer – look for active bleed which could be embolised at time; expect a highly vascular mass lesion with sacculated pseudoaneurysms & absence of AV shunts (AV shunting more in keeping with RCC)
Young man with flank trauma, presents with hematuria. Has CT that shows large vascular heterogenous mass containing fat. Hemodynamically stable. What to do next?
a. MRI ?F not sure how this would help – maybe of brain to look for TS??
b. DSA T best answer – look for active bleed which could be embolised at time; expect a highly vascular mass lesion with sacculated pseudoaneurysms & absence of AV shunts (AV shunting more in keeping with RCC)
c. Family history
d. Urgent surgeryPatients presenting with spontaneous bleeding are treated with embolization initially. Large tumours > 4cm should have intervention, either surgery or embolisation.
cause of renal vein thrombosis, which is false.
a. dehydration in kids.
b. amyloid
c. scleroderma
d. nephritis
e. nephritic syndrome
*LW: this is likely a bad recall, as Nephritic syndrome does not cause renal vein thrombosis, but presume the original question was nephrotic syndrome.
Scleroderma does NOT cause renal vein thrombosis, is an arterial process.
Therefore likely correct answer in this setting is scleroderma.
**LJS agree - all do except scleroderma and nephritic syndrome
E = F – RVT is assoc/ w/ nephrotic syndrome, not nephritic syndrome A = T B = T C = ?T (can’t find a reference!) D= if pyelonephritis T E = F – RVT is assoc/ w/ nephrotic syndrome, not nephritic syndrome
Complication of post renal transplant. which is false?
a. reversal of flow indicates renal vein thrombosis
b. high RI in transplant renal artery is indicative of rejection
c. lymphoceles takes up something or
D. lymphoceles happens 3 or 4 days post op
D = lymphoceles seen typically 2-4 months post-op (StatDx). RG 2005 “They may develop at any time, from weeks to years after transplantation. However, they are usually an early complication, occurring within 1–2 months after transplantation.”
*LW:
Promethius states they lymphoceles are photopenic.
Nuk Medicine paper states “A lymphocele presents as a persistent photopenic area, although a mild degree of filling-in on delayed imaging has been observed”
Based on wording, would still agree 3-4 days post op is LEAST correct.
A – ? T this suggests RVT - although reversal of diastolic flow is non-specific (also seen in severe rejection & ATN), the combination of absent venous flow & reversed arterial diastolic flow is virtually diagnostic of RVT. Best diagnostic clue (StatDx) = “Echogenic material in renal vein with absence of flow on color Doppler US”
B = ? T – chronic rejection shows thin cortex & mild hydronephrosis – intrarenal RI may be normal or slightly raised with ↓ vascularity; acute rejection may have increased intrarenal RI, but not sensitive or specific. StatDx: rejection “not imaging diagnosis”.
C = no mention in StatDx of lymphocele taking up radiotracer; lymphoceles can extrinsically obstruct. RG 2005 “Radionuclide studies are helpful for excluding the presence of urine (urinoma)”.
D = lymphoceles seen typically 2-4 months post-op (StatDx). RG 2005 “They may develop at any time, from weeks to years after transplantation. However, they are usually an early complication, occurring within 1–2 months after transplantation.”Elevated RI (RI > 0.8 equivocal, RI > 0.9 more convincing) seen with severely increased vascular resistance in the kidney – from rejection or RVT.
regarding testicular U/S
a. microlithiasis a/w Kleinfelters
b. seminoma more cystic than embryonal
c. teratomas in kids less than 2 usually malignant
A = T = microlithiasis assoc/ w/ GCT, cryptorchidism, Klinefelter syndrome, Down syndrome, male pseudohermaphroditism
B = F = Seminomas are usually well-defined, hypoechoic, solid without calcification or tunica invasion; 1/3 of embryonal have cystic necrosis
C = F = In the child, differentiated mature teratomas usually follow a benign course. In the postpubertal male all teratomas are regarded as malignant, capable of metastatic behavior whether the elements are mature or immature (Robbins)
- Echogenic renal cystic structure on USS, high signal T1 and T2, no enhancement (VIC – shows enhancement), most correct:
a. Haemorrhagic cyst
b. Proteinaceous cyst
C. Simple cyst
d. AML
e. ?
a. Haemorrhagic cyst T (but non enhancing)
b. Proteinaceous cyst F at US has ‘few scattered internal echoes’ (Statdx)
c. Simple cyst F not echogenic
d. AML F not cystic
e. ?
- Renal mass, high T1, low T2, diffuse marked enhancement, most correct
a. Proteinaceous cyst
b. Haemorrhagic cyst
c. Simple cyst
d. Papillary RCC
e. Clear cell RCC
d. Papillary RCC ?T often T2 hypointense, show less enhancement (Hamm – Direct Diagnosis Urogenital imaging)
* LW: Promethius states papillary RCC included within T2 dark DDx (as well as lipid poor AML and haemorrhagic cyst), but also states are less vascular and not enhance equal to cortex on corticomedullary phase.
- Renal mass, high T1, low T2, diffuse marked enhancement, most correct
a. Proteinaceous cyst F simulates haemorrhage (Statdx)
b. Haemorrhagic cyst F on US contains internal echoes (acute) or thick walls with multiloculation (chronic); on MRI usually T1 hyperintense (subacute, < 72 hours) & T2 hyperintense (not as high as simple cyst) +/- fluid-debris level
c. Simple cyst F anechoic, T1 low, T2 high
d. Papillary RCC ?T often T2 hypointense, show less enhancement (Hamm – Direct Diagnosis Urogenital imaging)
e. Clear cell RCC ?T often heterogenous (StatDx). Variable US appearance (50% hyperechoic, 40% isoechoic, 10% hypoechoic); variable MRI appearance but usually isointense on T1 & T2, but 40% are T1 hyperintense & most are T2 heterogenous. clear cell - high T1, high T2papillary - high t1, low t2RG
Rad-Path Papillary RCC May 2009At contrast material–enhanced computed tomography, pRCC enhances less than does cRCC in all phases of contrast-enhanced imaging. The difference in the degree of enhancement between pRCC and cRCC is due to differences in their intratumoral vascularity. In general, if a heterogeneous mass enhances to a degree similar to that manifested by the renal cortex, it is likely to be a cRCC. A mass that enhances to a lesser degree is likely to be a non–clear cell RCC (papillary or chromophobe RCC).AJR June 2009On T2-weighted images, most papillary RCCs are hypointense and clear cell RCCs, hyperintense. The T2 hypointense appearance of papillary RCCs correlated with a predominant papillary architecture at pathology.RG Nov 2006:Papillary RCCs typically appear hypovascular and homogeneous on imaging studies. Another important feature of papillary RCC is that bilateral and multifocal tumors are more common than in other subtypes of RCC (especially with hereditary syndromes) (11). Larger tumors show heterogeneity due to necrosis, hemorrhage, and calcification. Papillary RCC commonly demonstrates low signal intensity on T2-weighted MR images possibly due to the presence of by-products of hemorrhage and necrosis.
- Complications of renal transplantation
a. Increased RI in the transplant artery is specific for rejection
b. Lymphocoele accumulates tracer
c. Lymphocoeles occur within 4/7 of operation
d. Renal artery PSV of > 1m/s is diagnostic of stenosis
e. Reversal of diastolic flow in renal artery suggests RVT
e. Reversal of diastolic flow in renal artery suggests RVT T – this suggests RVT - although reversal of diastolic flow is non-specific (also seen in severe rejection & ATN), the combination of absent venous flow & reversed arterial diastolic flow is virtually diagnostic of RVT
3. Complications of renal transplantation
a. Increased RI in the transplant artery is specific for rejection Fi. AR: Resistivity index (RI) lacks sensitivity and specificity, RI 0.8-0.9 suspicious, abnormal > 0.9ii. CR: RI may be normal or slightly raised with reduced vascularity
b. Lymphocoele accumulates tracer F
*LW: agree: promethius states they are photopenic.
Nuke med paper states: “A lymphocele presents as a persistent photopenic area, although a mild degree of filling-in on delayed imaging has been observed”
(https://journals.sagepub.com/doi/pdf/10.1177/2010105815611813)
c. Lymphocoeles occur within 4/7 of operation F lymphoceles seen typically 2-4 months post-op (StatDx)
d. Renal artery PSV of > 1m/s is diagnostic of stenosis F 1 m/s = 100cm/s - High peak systolic velocity waveform (200-250 cm/s) on Doppler examination indicates arterial stenosise. Reversal of diastolic flow in renal artery suggests RVT T – this suggests RVT - although reversal of diastolic flow is non-specific (also seen in severe rejection & ATN), the combination of absent venous flow & reversed arterial diastolic flow is virtually diagnostic of RVT
- MAG3 study with Captopril
f. RAS
g. PUJ obstruction
h. VUR scan
i. Assess for renal function
j. RCC metastases
a. RAS T use ACE-I to evaluate renovascular HTN (Primer p940); can also use DTPA with captopril
4. MAG3 study with Captopril
a. RAS T use ACE-I to evaluate renovascular HTN (Primer p940); can also use DTPA with captopril
b. PUJ obstruction F use frusemide
c. VUR scan F usually use pertechnetate – alternatives are DTPA & sulphur colloid
d. Assess for renal functione. RCC metastases
- DMSA nuclear medicine renal scan is best for detecting (most correct):
a. PUJ obstruction
b. Scarring from reflux neprhopathy
c. Metastatic RCC
d. Renal hypertension
e. Renal function
b. Scarring from reflux nephropathy
5. DMSA nuclear medicine renal scan is best for detecting (most correct):
i) PUJ obstruction F MAG3 (or DTPA) with frusemide
ii) Scarring from reflux nephropathy T
iii) Metastatic RCC
iv) Renal hypertension F DTPA or MAG3 with captoprilv) Renal function F DTPA best for GFR (100% glomerular filtration)
- DTPA nuclear medicine renal scan is best for detecting (most correct):
a. PUJ obstruction
b. Scarring from reflux nephropathy
c. Metastatic RCC
d. Renal hypertension
e. Renal function
v) Renal function T DTPA is the agent of choice for quantification of GFR
- Regarding prostate cancer, which is most correct?
a. More often arises in central zone
b. More often hypoechoic than hyperechoic
c. PSA is independent of gland size
d. PSA normal in 50% of patients with prostate cancer
b. more often hypoechoic than hyperechoic T may be hypoechoic (60-70%), hyperechoic (1-5%), or isoechoic (30-40%) at TRUS [statdx]
- Regarding prostate cancer, which is most correct?
a. more often arises in central zone F peripheral zone
b. more often hypoechoic than hyperechoic T may be hypoechoic (60-70%), hyperechoic (1-5%), or isoechoic (30-40%) at TRUS [statdx]
c. PSA is independent of gland size F In men without prostate cancer, serum PSA reflects the amount of glandular epithelium, which in turn reflects prostate size. Thus as prostate size increases with increasing age, the PSA concentration also rises; it increases at a faster rate in elderly men. [UTD]. PSA will go up with BPH, but goes up much higher per gram of tissue with cancer. If PSA is > 60, there are bony mets, and staging starts with a bone scan. If PSA is < 20, it is very uncommon to have bony mets.
d. PSA normal in 50% of patients with prostate cancer F NPV of 85% for a PSA value ≤4.0 ng/Ml [UTD]
* *LJS Robbins: 20-40% pt with organ confined prostate carcinoma has PSA < 4 (normal)
70 yo. testicular lesion.
a. seminoma.
b. lymphoma
c. yolk sac tumour
ANS = B (lymphoma) = Most common testicular tumour in men > 60, multiple lesions; 50% of cases bilateral (StatDx & Primer p337)
hypo echoic on renal u/s
a. aml
b. fungal ball
c. renal calculi
d. lymphoma.
e. ureteric stent
D = Lymphoma = T hypoechoic relative to renal parenchyma
A = AML = F echogenic
B = Fungal ball = F filling defect within collecting system
C = Renal calculi = F echogenic/shadowing
D = Lymphoma = T hypoechoic relative to renal parenchyma
- LEAST CORRECT regarding US imaging of renal cell carcinoma
a. Approx 5% are isoechoic with renal parenchyma
b. Majority of RCC under 3cm in size are more echogenic than renal parenchyma
c. Demonstration of blood flow in substance of a complex cystic lesion is strong evidence of malignancy
d. DDx of RCC includes focal parenchymal hypertrophy
e. Approx 20% RCCs have detectable calcification
a. Approx 5% are isoechoic with renal parenchyma F hyper 48%, iso 42% and hypo 10% (statdx); often vascular; hypoechoic “pseudocapsule”
8. LEAST CORRECT regarding US imaging of renal cell carcinoma
a. Approx 5% are isoechoic with renal parenchyma F hyper 48%, iso 42% and hypo 10% (statdx); often vascular; hypoechoic “pseudocapsule”
b. Majority of RCC under 3cm in size are more echogenic than renal parenchyma T majority hyperechoic when smaller → a hyperechoic lesion at US needs CT evaluation to exclude RCC! (Zagoria, RANZCR ASM 2011)
c. Demonstration of blood flow in substance of a complex cystic lesion is strong evidence of malignancy T StatDx: Cyst vascularity greatly ↑ risk of malignancy
d. DDx of RCC includes focal parenchymal hypertrophy T column of Bertin
e. Approx 20% RCCs have detectable calcification T? up to 31% of RCCs contain calcium at CT (Zagoria p84); < 10% of RCC contain calcification (Statdx)Zagoria p84:• Up to 31% of RCCs contain calcium at CT• Peripheral calcification only: 80% are cysts• Central calcification & irregular: 87% are RCC’s• Mixed central & peripheral calcification: 50% are RCC’s, 50% are cysts.
- 30 year old male with lump on testes. On USS lump is well defined, 2cm, vascular and located in the epididymis. What is the most likely cause?
a. Thromboses varix
b. Adenomatoid tumour
c. Epididymal cyst
d. Rete appendix
e. Lymphoma
2.Adenomatoid tumour - T - Slow growing mesothelial neoplasm, in 2nd to 4th decade, solid mass, can be up to 5cm in size, typically within epididymis (Dahnert), particularly the epididymal tail (Zagoria); 30% of extratesticular tumours (Chapman); most common epididymal tumour (Zagoria)
- Regarding the features of seminoma, which of the following is the most correct?
a. Homogeneous on ultrasound
b. Early infiltration into tunica vaginalis
c. Bilateral
d. Insensitive to radiation
e. Common in children
- Homogeneous on ultrasound - T - tend to be homogeneously hypoechoic
- Regarding the features of seminoma, which of the following is the most correct? (JS)
- Homogeneous on ultrasound - T - tend to be homogeneously hypoechoic
- Early infiltration into tunica vaginalis - F - usually confined within the tunica albuginea
- Bilateral - F - bilateral in 1-3%, almost always asynchronous
- Insensitive to radiation - F - are radiosensitive versus NSGCT which are radioresistant 5.Common in children - F - average age is 40 years (Dahnert/Statdx)
- Which is false regarding horseshoe kidney?
a. It increases the risk of RCC
b. It often presents with UTI in children
c. DMSA scan is routinely normal
d. It is associated with obstruction
*LW:
Although StatDx states there is an increase in RCC, radiopedia, and literature review states no increase risk in RCC. Tumour incidence that is increased in horseshoe kidney includes: Wilms, TCC, and renal carcinoid. Donnelly 2nd Ed only mentions Wilms.
Commonly presents with UTI in children and is associated with obstruction.
Stat Dx doesn’t mention what specific study rather “Demonstrates fusion with functional parenchymal tissue
Can detect regional loss of function due to obstruction and inflammation”.
Quoted scarring in horseshoe kidneys is approx. 50%, and more than 50% have reflux, for which DMSA detects, thus it would appear that the DMSA scan would routinely be abnormal in horseshoe kidney.
Even more renal info….
–> Patients with hydronephrosis not due to VUR should be evaluated by a diuretic radionuclide scan with either (MAG-3 or technetium DTPA to differentiate hydronephrosis due to obstruction from nonobstructive urinary stasis
* thus appears both options A and C are false.
- DMSA scan is routinely normal F DMSA is used for investigation of horseshoe kidneys and can demonstrate amount of functional renal tissue
- Which is false regarding horseshoe kidney? (JS/SK)
- It increases the risk of RCC ? T Increased risk of malignancy – particularly Wilms (Primer) but with a small increased risk of adenocarcinoma (Donnelly). The incidence of renal cell cancer in the horseshoe kidney is no different from that of the normal kidney (eMedicine). StatDx says ↑ prevalence of RCC.
- It often presents with UTI in children T Associated with UTI in 30% (Primer)
- DMSA scan is routinely normal F DMSA is used for investigation of horseshoe kidneys and can demonstrate amount of functional renal tissueSK - ?? normal – StatDx – demonstrates fusion with functional parenchymal tissue. Can detect regional loss of function due to obstruction or inflammation. Considering the ↑ UTI, therefore would have possible cortical scarring at DMSA.
- It is associated with obstruction T Associated with PUJ obstruction in 30% (Primer)Emedicine:Certain cancers are more common in the horseshoe kidney.[1] This is thought to be due to teratogenic factors present at birth and the susceptibility of the diseased horseshoe kidney to certain cancers. Renal cell carcinoma is the most common renal cancer in horseshoe kidney, accounting for 45% of tumors.[2, 3] The incidence of renal cell cancer in the horseshoe kidney is no different from that of the normal kidney. Transitional cell cancer and sarcoma account for 20% and 7% of tumors, respectively. The relative risk of transitional cell carcinoma in the horseshoe kidney is increased 3- to 4-fold. This is thought to be due to chronic obstruction, stones, and/or infection in the affected kidneys. The incidence of both Wilms and carcinoid tumors is also higher in the horseshoe kidney. Examination of these tumors may provide an insight into the development and embryogenesis of the horseshoe kidney and the predilection of these two tumors to form in the horseshoe kidney.
- Vascular 2cm epididymal mass in 20 y.o. What is most likely?
e. Torted hydatid of Morgagni
f. Thrombosed varicocele
g. Adenomatoid tumour
h. Epidermoid
- Adenomatoid tumour - Slow growing mesothelial neoplasm, in 2nd to 4th decade, solid mass, can be up to 5cm in size, typically within epididymis (Dahnert), 30% of extratesticular tumours (Chapman); most common epididymal tumour (Zagoria)
- Vascular 2cm epididymal mass in 20 y.o. What is most likely? (JS)1.Torted hydatid of Morgagni = appendix testis, usually around 5mm, shouldn’t have flow if torted2.Thrombosed varicocele - Thrombosed varicocele shouldn’t have flow3.Adenomatoid tumour - Slow growing mesothelial neoplasm, in 2nd to 4th decade, solid mass, can be up to 5cm in size, typically within epididymis (Dahnert), 30% of extratesticular tumours (Chapman); most common epididymal tumour (Zagoria) 4.Epidermoid - Rare
- Which cystic renal mass is most likely to be malignant?
i. A soft tissue component
j. Thick, enhancing septa
k. HU >20
l. Rim calcification
1.A soft tissue component Bosniak 4 if there is enhancement (clearly malignant)
- Which cystic renal mass is most likely to be malignant? (JS)
- A soft tissue component Bosniak 4 if there is enhancement (clearly malignant)
- Thick, enhancing septa Bosniak 3 – surgical usually
- HU >20 Bosniak 2 - high density cyst considered benign if no enhancement post-contrast
- Rim calcification Bosniak 2 (low risk)
(Radiographics 2004 24:S101-115)
- Regarding seminoma, which of the following is true?
a. Radiosensitive
b. More aggressive than non seminomatous GCT
c. Heterogenously hyperechoic on USS
d. Stage II disease above diaphragm but no LN
- Radiosensitive Seminomas are radiosensitive versus NSGCT which are radioresistant (Robbins)
- Regarding seminoma, which of the following is true? (JS)
- Radiosensitive Seminomas are radiosensitive versus NSGCT which are radioresistant (Robbins)
- More aggressive than non seminomatous GCT NSGCT are more aggressive and have a poorer prognosis (Robbins)
- Heterogenously hyperechoic on USS Seminomas tend to be homogeneously hypoechoic (Primer)
- Stage II disease above diaphragm but no LN Stage II is distant spread, confined to retroperitoneal nodes below the diaphragm (Robbins)
Testicular staging:stage I: confined to testis, epididymis, spermatic cord, scrotumstage II: lymph nodes involved but no distant metastases and serum tumor markers are not very highstage III: distant metastases or moderately high serum tumor markers
1.Renovascular hypertension , which of the following are correct?
- Persistent dense nephrogram , delayed pyelogram with frusemide.
- Aorto:renal ratio of >2.5 means >70% stenosis.
- Fibromuscular dysplasia is cause in 50%.
- 15% of cause of hypertension.
- Persistent dense nephrogram , delayed pyelogram with frusemide. – T Pyelogram may be delayed if there is renal insufficiency
- Renovascular hypertension , which of the following are NOT incorrect? (GC/SK)
- Persistent dense nephrogram , delayed pyelogram with frusemide. – T Pyelogram may be delayed if there is renal insufficiency
- Aorto : renal ratio of >2.5 means >70% stenosis. - F >3.5 for >60% (Dahnert)
- Fibromuscular dysplasia is cause in 50%. - F 10-30%
- 15% of cause of hypertension. - F 1-5% of HTN (D)
2.Which is true in regards to renal trauma?
- Rim nephrogram on CT is seen in Vascular injury.
- Gross haematuria seen in all cases of severe trauma.
- Microscopic haematuria is an indication for CT.
- Lacerations communicate with pelvicalyceal system in majority.
1.Rim nephrogram on CT is seen in vascular injury. – T - devascularised kidney (grade 5), develops >8hrs post occlusion of main RA by intimal flap, reflects preserved perfusion by capsular a
a.Indications for CT:
Gross haematuria
Microhaematuria with shock
Microhaematuria with a positive DPL ( I assume a +ve FAST scan applies nowadays?)
3.Features of Xanthogranulomatous pyelonephritis?
- Kidney is typically small.
- 20% of cases have a renal calculus.
- Majority of cases are bilateral.
- Associated with pseudomonas infection in 70%.
- Diffuse involvement commoner than focal involvement.
- Diffuse involvement commoner than focal involvement. - T focal in 10-17%
- Features of Xanthogranulomatous pyelonephritis? (GC)
- Kidney is typically small. - F enlarged
- 20% of cases have a renal calculus. - F staghorn in 75%
- Majority of cases are bilateral. - F
- Associated with pseudomonas infection in 70%. - F proteus, e.coli
- Diffuse involvement commoner than focal involvement. - T focal in 10-17%
4.Features of Renal TB?
- Infundibulopapillary involvement is late.
- CXR is frequently abnormal
- Erosion of a papilla is a late feature.
- Papillary necrosis is seen.
- Papillary necrosis is seen. - T
- Features of Renal TB? (GC)
- Infundibulopapillary involvement is late. - F earliest sign is moth-eaten calyx (necrotizing papillitis)
- CXR is frequently abnormal - F normal in >50%
- Erosion of a papilla is a late feature. - F see (a)
- Papillary necrosis is seen. - TRef. Dahnert pg 984, Renal TB (RG 2004)
5.Concerning Prostate carcinoma?
- Hyperintense on T2 weighted images.
- Hyperechoic on US.
- < 10 PSA , bone involvement is unlikely.
- Rectal US is good for capsular spread.
- < 10 PSA , bone involvement is unlikely. - T Confined disease (stage A or B) in 75% with PSA <4, and 53% if 4-10
- Concerning Prostate carcinoma? (GC)
- Hyper intense on T2 weighted images. - F T2 hypointense focus within the normally hyperintense peripheral zone.
- Hyper echoic on US. - F most are hypo
- < 10 PSA , bone involvement is unlikely. - T Confined disease (stage A or B) in 75% with PSA <4, and 53% if 4-10
- Rectal US is good for capsular spread. - F – MRI for extracapsular extension (90% specific, 15% sensitive) – From ANZJ Surg 2007;77; 860-865 “The main role of TRUS in prostate cancer is for guiding biopsy. It has a positive predictive value (PPV) of 50–63% for the detection of ECE (BJU 2000). Moreover, overall detection is poor – up to 50% of nonpalpable tumours may not be visualized on grey-scale ultrasonography and only 17–57% of hypoechoic lesions in the peripheral zone are malignant”The reported accuracy of TRUS in the staging of PCa varies. Large multicentre study found an accuracy rate of only 62% However, a 1997 prospective multicentre study showed a continuously poor performance for TRUS, with its ability to detect ECE matching digital rectal examination (Ammersham)Ref. Dahnert pg 949
- Which is not a cause of renal vein thrombosis?
- Membranous glomerulonephritis.
- Gastroenteritis.
- Dehydration in infants.
- Scleroderma.
- Amyloid.
- Scleroderma. ? (StatDx lists PAN, SLE as causes)
- Which is not a cause of renal vein thrombosis ? (AB)
- Membranous glomerulonephritis.
- Gastroenteritis.
- Dehydration in infants.
- Scleroderma. ? (StatDx lists PAN, SLE as causes)
- Amyloid.
Renal vein thrombosis in infants most commonly due to dehydation/sepsis. In adults, most commonly due to nephrotic syndrome (which in turn is most commonly due to membranous glomerulonephritis). Amyloid is a recognised cause. Other important causes: RCC; trauma; post-transplantation; hypercoagulable states. Scleroderma affects the renal arterioles and causes cortical necrosis.Reference: Dahnert 6th ed.
- Least likely cause of increased renal medullary echogenicity?
- Medullary sponge kidney
- Hyperparathyroidism.
- Haemolytic uraemic syndrome.
- Sickle cell .
- RTA.
3.Haemolytic uraemic syndrome.
Medullary nephrocalcinosis occurs in medullary sponge kidney, hyperparathyroidism, renal tubular acidosis.
In sickle cell anaemia, renal echogenicity can be normal (most common) or mildly increased (medulla only or medulla and cortex).
HUS causes increased cortical echogenicity (from acute cortical necrosis).Reference: Dahnert 6th ed.; From the Archives of the AFIP: Sickle Cell Anaemia, Radiographics, 2001; Increased Renal Parenchymal Echogenicity: Causes in Pediatric Patients, Radiographics, 1990.
- Testicular imaging?
- Use 6MHZ probe.
- 3 calcific foci /field diagnostic of microlithiasis.
- Low resistance flow on Doppler is normal.
- Testicular cysts are always pathological
3.Low resistance flow on Doppler is normal.
A high-frequency linear transducer is used (7.5-10 MHz; higher in young children).
Low resistance flow is typical.
Microlithiasis is arbitrarily defined as 5 or more tiny (1-2 mm) hyperechoic and typically non-shadowing foci per image.
Reference: Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update, Radiographics, 2005
- Medial deviation of ureters T/F
- AP resection
- Prostatomegaly
- Ureterocele
- AAA
- Left retrocaval ureter
- AP resection - T
- Prostatomegaly - F – fish hook of distal ureters
- Ureterocele - F
- AAA – F *LW: FALSE - Promethius states this causes lateral displacement, as makes sense anatomically.
- Left retrocaval ureter - F – retrocaval ureter is RIGHT sided – which can cause medial deviation of the proximal ureter.
DDx (Dahnert)
Medial deviation of DISTAL ureter: Hypertrophy of iliopsoas muscle Enlargement of iliac lymph nodes Aneurysmal dilatation of iliac vessels Bladder diverticulum at VUJ (Hutch) Following abdominoperineal surgery + retroperitoneal lymph node dissection Pelvic lipomatosis Renal cyst (parapelvic and lower pole)
Medial deviation PROXIMAL ureter:
Retrocaval ureter (right side only)
Retroperitoneal fibrosis
AAA (fibrosis if chronic leakage)(note: Primers puts prostatic enlargement as DDx for medial displacement- J-shaped—I am choosing to ignore this and consider fish hooking as separate to medial displacement)Added options ‘ d’ and ‘e’
- Medial deviation of ureters T/F
- AP resection
- Prostatomegaly
- Ureterocele
- AAA
- Left retrocaval ureter
- AP resection - T
- Prostatomegaly - F – fish hook of distal ureters
- Ureterocele - F
- AAA – FALSE
- Left retrocaval ureter - F – retrocaval ureter is right sided – which can cause medial deviation of the proximal ureter.
DDx (Dahnert)Medial deviation of DISTAL ureter: Hypertrophy of iliopsoas muscle 'Enlargement of iliac lymph nodes 'Aneurysmal dilatation of iliac vessels Bladder diverticulum at VUJ (Hutch) Following abdominoperineal surgery + retroperitoneal lymph node dissection Pelvic lipomatosis Renal cyst (parapelvic and lower pole)
Medial deviation PROXIMAL ureter: Retrocaval ureter (right side only) Retroperitoneal fibrosis AAA (fibrosis if chronic leakage) (note: Primers puts prostatic enlargement as DDx for medial displacement- J-shaped—I am choosing to ignore this and consider fish hooking as separate to medial displacement)
Added options ‘ d’ and ‘e’
12.Regarding HIV related renal problems
- Nelfinavir related calculi cannot be seen on CT
- Indinavir related calculi are radiolucent
- Majority of HIV associated nephropathy kidneys have enlarged kidneys
- Only a minority of HIV-infected patients develop renal impairment during their illness.
- Hypertensive nephropathy is the leading cause of renal failure in HIV patients
- Indinavir related calculi are radiolucent - T – (true for pure stones, however can be detected on CT if contain other substances – Ca++, uric acid)
- Regarding HIV related renal problems (TW)
- Nelfinavir related calculi cannot be seen on CT – F – unlike indinivar – nelfinavir stones have been reported to be seen on CT, pure indinivar stones not seen on all modalities.
- Indinavir related calculi are radiolucent - T – (true for pure stones, however can be detected on CT if contain other substances – Ca++, uric acid)
- Majority of HIV associated nephropathy kidneys have enlarged kidneys – F – majority have normal-sized kidneys (Radiographics 2008)
* LW: TRUE as Radiopedia disagrees with above - longitudinal renal size is increases, with increased parenchymal echogenicity, and decreased renal sinus fat. CT also shows enlarged kidneys. Diagnosis is biopsy proven. - Only a minority of HIV-infected patients develop renal impairment during their illess. – F – most HIV infected patients develop RI. (Radiographics 2008)
- Hypertensive nephropathy is the leading cause of renal failure in HIV patients – F – HIVAN is leading cause (40% of cases of HIV related renal disease). (Radiographics 2008)Indinovir (protease inhibitor for treatment of HIV-type 1) – precipitations of drug crystals in renal tubule.
- Medial deviation of ureters in the bony pelvis is seen T/F
- In pelvic adenopathy
- In prostatomegaly
- In herniation of urether through sacro-sciatic foramen
- In ureterocele
- Following abdomino-peritoneal resection
19.Medial deviation of the ureter in the bony pelvis is seen T/F (TW)
- In pelvic adenopathy - T
- In prostatomegaly - F - fish hook of distal ureters
- In herniation of the ureter through the sacro-sciatic foramen - F
- In ureterocele - F
- Following abdomino-peritoneal resection – T
- What is not a cause of increased RI
- acute pyelonephritis
- ATN
- Ureteric obstruction
- Hepatorenal syndrome
- Diabetes
5.Diabetes ?? F - occurs late - however more there is literature saying can actually occur early with DM too.
AJR 2003 (The resistive Index in Renal Doppler Sonography: Where Do We Stand?)Doppler RI = ([PSV – EDV] / PSV) = 1-(EDV/PSV)Most consider RI 0.70 to be upper threshold of normal in adults (with exceptions: commonly >0.70 in 1st year of life, and can be >0.70 up to 4yo).Elevation of RI more likely with vascular / tubulointerstitial process, less likely with glomerular disease. Elevation of RI:Vascular:Acute vascular rejectionRenal vein thrombosisincreased intraparencyhmal pressure :ATN: elevated resistive index >0.75 (in 91% ) – where as pre-renal ARF cause has normal RI. RI greater than 0.07 was found to be a reliable discriminator between acute tubular necrosis and prerenal failure (AJR, Dahnert)Pyelonephritisperinephric / subcapsular fluid collectionrenal transplants (ATN / rejection)Cardiacsignificant systemic hypotensionmarkedly decreased heart rate (converse is true as well)Diabetes (?late finding) – combination of small vessel disease plus abnormal cardiac function in T2DM patients – generalized reduction in vascular compliance associated with arteriosclerosis in a range of vascular beds. in neonates + infants: normal findingHRS – develop renal dysfunction in pts with acute or chronic, severe liver disease - ?due to reduced renal vlood flow and vasoconstriction (due to local & systemic factors).Ureteric obstruction: > 0.7 - Obstructive cause initially thought to be mechanical cause (ie pressure increase) – but research suggests complex interactions between several regulatory pathways (RAS, kallikrein-kinin, PG-thromboxane) are responsible for intense, post obstructive renal vasoconstriction.
15.Which of the following statements about Phaeochromocytoma is false?
- 10% are bilateral/multiple, 10% are extradrenal and 10% are malignant
- Hemihypertrophy is a known association
- contains central heterogenous areas of decreased signal intensity in 35% on T2WI
- I-131 MIBG is used to treat metastases
- does not contain fat
2.Hemihypertrophy is a known association - F Phaeo is the 10 % TUMOUR 10% are bilateral/multiple, 10% are extradrenal and 10% are malignant and 10% are familial and 10% have speckled calcification
Hemihypertrophy is assoc with Wilms tumor.
Phaeo associations:
MEN II
Neuroectodermal disorders - NF, VHL, TS Familial Phaeo
I think this is meant to be Carney’s Triad = Gastric epithelioid leiomyosarcoma, functioning exra-adrenal paraganglioma, pulmonary chondromas) rather than Carney syndrome (Cardiac Myxoma, hyperpigmented skin lesions, breast fibroadenoma, psammomatous melanotic schwannoma, pituitary adenoma, large cell calcifying sertoli cell tumour, primary pigmented nodular adrenocortical hyperplasia)
- In the pediatric patient, which is the least likely cause of echogenic medulla?
- RTA
- Sickle cell
- HUS
- MSK
- HPT
- HUS - F - Haemolytic Uraemic Syndrome: triad of thrombocytopaenia, microangiopathic haemolytic anaemia and acute oliguric renal failure leading to uraemia. HUS leads to acute cortical necrosis and cortical nephrocalcinosis [prerequisites US]
- In the pediatric patient, which is the least likely cause of echogenic medulla? (CC)
- RTA - T RTA renal parenchymal disease is often a pathophysiological type diagnosis with histology and renal function parameters including Renal tubular acidosis (RTA) which leads to chronic metabolic alkalosis as the distal nephrons are unable to resorb bicarbonate or secrete hydrogen (depending on the type I-IV). [GU pre requisites and Merck Manual]
- Sickle cell -T Sickle Cell Disease – rare cause. Can cause cortical (eMed) and medullary nephrocalcinosis (Dahnert 6th pg 894).
- HUS - F - Haemolytic Uraemic Syndrome: triad of thrombocytopaenia, microangiopathic haemolytic anaemia and acute oliguric renal failure leading to uraemia. HUS leads to acute cortical necrosis and cortical nephrocalcinosis [prerequisites US]
- MSK - T Medullary Sponge Kidney = benign tubular ectasia. Leads onto medullary nephrocalcinosis in 40-80%. Recognised associations [Dahnert]:Parathyroid adenoma, Caroli’s Disease, Ehlers Danlos Syn
- HPT - T All causes of hypercalcaemia can result in echogenic medulla.
- Regarding renal vein thrombosis, which of the following is not a risk factor? (CC)
- dehydration
- membranous GN
- amyloid
- scleroderma
- nephrotic syndrome
4.scleroderma - F - SLE does
- Which of the following is not a cause of bilateral renal enlargement?
- TS
- Leukemia
- RTA
- Inf mononucleosis
- HUS
4.Inf mononucleosis F
Inf mononucleosis –T. Usually associated with splenomegaly and Epstein Barr virus (EBV) = a tetrad of fever, pharyngitis, fatigue and lymphadenopathy. However, EBV genome is found is a minority of Burkitt Lymphoma which can enlarge the kidneys. I think this is too much of a stretch for this question hence True - not a cause of bilateral renal enlargement [Merck, and Dahnert]
- Which of the following is not a cause of bilateral renal enlargement? (CC)
- TS T TS : multiple cysts are found in cortex and medulla in 10 – 15% mimicking adult polycystic kidney disease
- Leukemia T Leukaemia is a recognized cause of smooth bilateral renal enlargment from infiltrative replacement of renal interstitial tissue.
- RTA T RTA is a functional deficit, which can later lead to chronic renal failure from nephrocalcinosis (chronic interstitial nephritis with cellular infiltration).
- Inf mononucleosis FInf mononucleosis –T. Usually associated with splenomegaly and Epstein Barr virus (EBV) = a tetrad of fever, pharyngitis, fatigue and lymphadenopathy. However, EBV genome is found is a minority of Burkitt Lymphoma which can enlarge the kidneys. I think this is too much of a stretch for this question hence True - not a cause of bilateral renal enlargement [Merck, and Dahnert]
- HUS T - normal to slightly inc in size
19.Which of the following statements about duplex renal systems is incorrect?
- ectopic insertion gives bed wetting in boys
- PUJ obstruction of lower system
- Retention is a presenting symptom in both sexes
- Reflux lower system
- Epididymo orchitis is a presenting symptom
- ectopic insertion gives bed wetting in boys F – boys always have ectopic insert above sphincter therefore no enuresis
- Which of the following statements about duplex renal systems is incorrect? (CC)
- ectopic insertion gives bed wetting in boys F – boys always have ectopic insert above sphincter therefore no enuresis
- PUJ obstruction of lower system T – usually involves lower pole (LJS edit: combined PUJ + duplex collecting system is case report level rare)
- Retention is a presenting symptom in both sexes T
- Reflux lower system T
- Epididymo orchitis is a presenting symptom T – in preadolescent malemales do not have infrasphincteric insertion, only females [Dahnert]PUJ obstruction from extrinsic vessels usually effects the lower pole (anterior in 25-39%, posterior in 5-10%) )selectively involving the lower system. Presenting symptoms of duplex systems: [Weiss, comprehensive urology]UTI – most common Loin pain but also central and epigastric that may be associated with vomitingNeonatal abdominal mass – most common cause of neonatal hydronephrosisHaematuriaHypertension VUR affects the lower moiety more commonly due to a shorter submucosal tunnel [Dahnert]Although rare, ectopic insertion can be in the seminal vesicles (because of relationship with mesonephros) and presents with epididymo-orchitis or UTI rather than urinary incontinence.
- Regarding neonatal adrenal haemorrhage, which is false:
- It is usually bilateral
- More common on the right
- More common with a breech presentation
- Occurs in the first 7 days
- ?Increased with respiratory distress
- It is usually bilateral F - 10% bilateral
- Regarding neonatal adrenal haemorrhage, which is false: (TW)
- It is usually bilateral F - 10% bilateral
- More common on the right T – R>L 7:3
- More common with a breech presentation T – difficult labor / delivery / breech
- Occurs in the first 7 days T – first week of life
- Increased with respiratory distress T – assoc with hypoxia /neonatal stress
Aetiol : Neonatal stressDifficult labour – forceps, breechHypoxia/asphyxia due to prematuritySepsisHaemorrhagic disorders eg.DICIncreased risk LGA, diabetic mums. (Dahnert 6th pg 918)
21.Prostate cancer, which is false:
- More common in central zone
- Can be hyperechoic on ultrasound
- Transrectal ultrasound poor for evaluating capsular invasion
- Bone metastasis not common if asymptomatic and PSA <10
- More common in central zone F – Periph zone 80%, TZ 15% CZ 5%. Multifocal in 40% (Dahnert 6th)
- Prostate cancer, which is false: (TW)
- More common in central zone F – Periph zone 80%, TZ 15% CZ 5%. Multifocal in 40% (Dahnert 6th)
- Can be hyperechoic on ultrasound T – can be but nb. 61% hypoechoic, mixed 2%, hyperechoic 0nly 2% (Dahnert 6th).
- Transrectal ultrasound poor for evaluating capsular invasion T – see below
- Bone metastasis not common if asymptomatic and PSA <10 T - Disease confined to gland 53% pt with PSA 4-10mg/mL (Dahnert 6th)
From ANZJ Surg 2007;77; 860-865 “The main role of TRUS in prostate cancer is for guiding biopsy. It has a positive predictive value (PPV) of 50–63% for the detection of ECE (BJU 2000). Moreover, overall detection is poor – up to 50% of nonpalpable tumours may not be visualized on grey-scale ultrasonography and only 17–57% of hypoechoic lesions in the peripheral zone are malignant”The reported accuracy of TRUS in the staging of PCa varies. Large multicentre study found an accuracy rate of only 62% However, a 1997 prospective multicentre study showed a continuously poor performance for TRUS, with its ability to detect ECE matching digital rectal examination (Ammersham)
