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CTC GU Flashcards

1
Q

What should the echogenicity of the kidney be?

A

Equal to or slightly less than the liver and spleen.

If greater than lever = impaired renal function (medical renal disease).

Liver echogenicity greater than kidney = fatty liver.

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2
Q

Fetal lobulation vs scarring?

A

Lobulation - Renal surface indentations overlie the space between the pyramids

Scarring - Renal surface indentations overlie the medullary pyramids.

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3
Q

What is a Dromedary Hump?

A

Focal bulge on the left kidney.

Forms as a result of adaptation to the adjacent spleen.

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4
Q

Associations with unilateral agenesis

A

GU anomalies

Women - unicornate uterus.
Men - Absence of ipsilateral epididymis and vas deferens or ipsilateral seminal vesicle cyst.

Ipsilateral seminal vesicle cysts, absent ipsilateral ureter, absent ipsilateral hemitrigone and absent ipsilateral vas deferens.

Mayer-Rokitansky-Kuster-Hauser - Mullerican duct anomalies including absence or atresia of the uterus. Associated with unilateral renal agenesis.

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5
Q

What is Mayer-Rokitansky-Kuster-Hauser?

A

Mullerican duct anomalies including absence or atresia of the uterus. Associated with unilateral renal agenesis.

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6
Q

Associations with Horseshoe Kidney?

A 
Traumatic Injury
UPJ obstruction
Recurrent infection
Recurrent stones
Wilms Tumor (8x higher)
TCC (from infection)
Renal Carcinoid

Turner Syndrome is associated

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7
Q

What Syndrome is associated with Horseshoe Kidney?

A

Turners

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8
Q

What is pseudoenhancement?

A

Less than 10 HU increase in attenuation is w/in technical limits of the study and is not considered to represent enhancement.

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9
Q

What are the subtypes of RCC?

A

Clear Cell - MC subtype. Associated with VHL. Typically more aggressive than papillary, and will enhance equal to the cortex on corticomedullary phase.

Papillary - 2nd MC. Less aggressive than clear cell (more rare subtypes are very aggressive). Less vascular and will not enhance equal to the cortex on corticomedullary phase. Classic T2 dark differential (along with lipid poor AML, and hemorrhagic cyst).

Medullary - Sickle Cell. Highly aggressive and usually large and already metastasized at the time of diagnosis.

Chromophobe - Birt Hogg Dube

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10
Q

What is Clear Cell subtype of RCC?

A

MC subtype. Associated with VHL. Typically more aggressive than papillary, and will enhance equal to the cortex on corticomedullary phase.

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11
Q

What is Papillary subtype of RCC?

A

2nd MC. Less aggressive than clear cell (more rare subtypes are very aggressive). Less vascular and will not enhance equal to the cortex on corticomedullary phase. Classic T2 dark differential (along with lipid poor AML, and hemorrhagic cyst).

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12
Q

DDx of T2 dark renal cyst?

A

Papillary RCC
Lipid Poor AML
Hemorrhagic Cyst

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13
Q

What subtype of RCC is seen in Birt Hogg Dube?

A

Chromophobe

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14
Q

Subtype of RCC associated with VHL?

A

Clear Cell

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15
Q

Staging of RCC

A

1: Limited to kidney and <7 cm
2: Limited to kidney and >7 cm
3: Still inside Geroga’s Fascia
3A: Renal vein invaded
3B: IVC below diaphragm
3C: IVC above diaphragm
4: Beyond Gerota’s Fascia, Ipsilateral adrenal.

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16
Q

MC appearance of renal lymphoma?

A

Bilateral (usually bilateral) enlarged kidneys, with small, low attenuation cortically based solid nodules or masses. Solitary mass is seen in about 1/4 of cases.

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17
Q

MC visceral organ involved with lymphoma?

A

Kidney

Smooth and enlarged. Hypodense lesions are cortically based only, with little if any involvement of the medulla.

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18
Q

Syndrome associated with bilateral renal oncocytomas?

A

Birt Hogg Dube - also get chromophoge RCC

Solid mass with central scar - CT or MRI
US: “spoke wheel” vascular pattern
PET CT will be hotter than surround renal cortex

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19
Q

How to RCC and Oncocytoma look on PET?

A 
RCC = COLDER than surrounding renal parenchyma
Oncocytoma = HOTTER
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20
Q

What is a Multilocular Cystic Nephroma?

A

“Non-communicating, fluid-filled locules, surrounded by thick fibrous capsule.”

Absence of a solid component or necrosis.

“Protrudes into the renal pelvis.”

Bimodal occurance - 4 y/o boys and 40 y/o women.
Michael Jackson lesion - young boys and women

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21
Q

What is the Bosniak Classificaion?

A

1: Simple cyst - less than 15 HU, no enhancement
2: Hyperdense (<3 cm), thin calcifications, thin septations
2F: Hyperdense (>3 cm), minimally thickened calcs (5% chance of cancer)
3: Thick septations, mural nodule (50% chance of cancer)
4: Any enhancement (>15 HU)

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22
Q

What is a Hyperdense Cyst?

A

> 70 HU and homogeneous = benign (hemorrhagic or proteinacious cyst).

DDX of T2 dark cyst:
Hemorrhagic cyst
Lipid Poor AML
Papillary Subtype RCC

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23
Q

What do people with ADPKD get?

A

Berry aneurysms

No intrinsic risk of cancer, but do get cancer once they are on dialysis

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24
Q

What is ARPKD?

A

Get HTN and renal failure.

Liver involvement is different than the adult form. Instead of cysts they have abnormal bile ducts and fibrosis. Congenital hepatic fibrosis is ALWAYS present.

Ratio of liver and kidney disease is inversely related - worse liver the better the kidneys do. Better the liver, the worse the kidneys are.

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25
Q

What is VHL?

A

AD

Pancreas: Cysts, serous microcystic adenomas, neuroendocrine (islet cell) tumor
Adrenal: Pheochromocytoma (often multiple)
CNS: Hemangioblastoma of the cerebellum, brain stem, and spinal cord.

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26
Q

What is Tuberous Sclerosis?

A

AD - Hamartomas everywhere

Lung- LAM - thin walled cysts and chylothorax
Cardiac - Rhabdomyosarcoma (typically involving cardiac septum)
Brain - Giant Cell Astrocytoma, cortical and subcortical tubers, subependymal nodules
Renal- AMLs, RCCs (in younger patients)

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27
Q

What is Lithium Nephropathy?

A

Can lead to DI and renal insufficiency.
Kidneys are normal to small in volume with multiple (innumerable) tiny cysts, usually 2-5 mm in diameter. These “microcysts” are distinguishable from larger cysts associated with acquired cystic disease of uremia.

MRI with history of bipolar.

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28
Q

What is Multicystic Dysplastic Kidney?

A

Multiple tiny cysts forming in utero.

“No functioning renal tissue”
Contralteral renal tract abnormalities occur like 50% of the time.

Does NOT communicate
Will show no excretory function.

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29
Q

Difference between a Peripelvic vs Parapelvic Cyst

A

Peri: Originates from renal sinus, mimics hydro
Para: Originates from parenchyma, may compress the collecting system.

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30
Q

DDx of striated nephrogram

A 
Acute ureteral obstruction
Acute pyelonephritis
Medullary sponge kidney
Acute renal vein thrombosis
Radiation nephritis
Acutely following renal contusion
Hypotension (bilateral)
Infantile polycystic kidney (bilateral)
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31
Q

What is Emphysematous Pyelitis?

A

Less bad relative to emphysematous pyelonephritis.

Gas is localized to the collecting system. MC in women, diabetics, and people with urinary obstruction.

Gas outlining the ureters and dilated calices.

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32
Q

What is Xanthogranulomatous Pyelonephritis (XGP)?

A

Chronic destructive granulomatous process that is basically always seen with a staghorn stone acting as a nidus for recurrent infection.

Can have as associated psoas abscess with minimal perirenal infection.

“Bear Paw” appearance on CT. Kidney is not functional and sometimes nephrectomy is done to treat it.

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33
Q

What is the “Kerr Kink”?

A

Sign of renal TB with scarring leading to a sharp kink at the peri-ureteric junction.

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34
Q

What does HIV nephropathy look like?

A 
Normal sized (or big) kidneys that are echogenic on US. 
Loss of renal sinus fat appearance has also been described (it's edema in the fat)
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35
Q

What does disseminated PCP look like in the kidneys?

A

HIV patients

Punctate (primarily cortical) calcifications.

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36
Q

Types of renal stones?

A

Calcium Oxalate - MC
Struvite Stone - MC in women, and associated with UTI
Uric Acid- “unseen” on x-ray
Cystine - rare, associated with congenital disorders of metabolism
Indinavir - Stones in HIV which are ONLY not seen on CT.

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37
Q

Causes of Medullary Nephrocalcinosis?

A

Hyperechoic renal papilla/pyramids - may or may not shadow.

PTH
Lasix (as a child)
RTA - distal - type 1
Medullary sponge kidney - if asymmetric

RTA and PTH cause a more dense calcifkcation than medullary sponge kidney.

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38
Q

What is Medullary Sponge Kidney?

A

Congenital cause of medullary nephrocalcinosis - usually asymmetric.

Cystic dilation of the collecting tubules of the kidney - association with Ehlers Danlos.

Also associated with Carolis and Beckwith-Weidmann

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39
Q

Signs associated with Renal Infarcts?

A

Cortical Rim Sign - Absent immediately after insult, but seen 8 hours to days later. Have dual blood supply, which allows the cortex to stay perfused.

Flip flop enhancement - Where a region of hypodensity/poor enhancement on early phases becomes relatively hyperdense on delayed imaging.

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40
Q

Normal RI

A

<0.8

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41
Q

Urologic complications of renal transplant?

A

Urinoma - 2 weeks - anechoic fluid collection with no septations, rapidly increasing in size. MAG3.

Hematoma - Immediately post op. Usually resolves spontaneously. Large can produce hydro. Acute will be echogenic and will progressively become less echogenic (older will be anechoic and septated).

Lymphocele (1-2 months) - fluid collection medial to the transplant - between the graft and the bladder

Chronic rejection - 1 year post transplant. Kidney may enlarge, can lose corticomedullary differentiation. RIs will elevate (>0.7) which is nonspecific

Calculous Disease - Increased risk of stones.

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42
Q

Velocities for Renal Artery Stenosis?

A

PSV > 200-300 cm/s
PSV > 3.0 (external iliac A/RA)
Tardus Parvus: Measured at the main renal artery hilum (not at the arcuates)
Anastomotic jetting

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43
Q

Tardus vs Parvus?

A

Tardus: Slowed systolic upstroke

Parvus: Decreased systolic velocity

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44
Q

How will a renal AVF be shown?

A

Tissue vibration artifact - perivascular, mosaid color assignment due to tissue vibration)

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45
Q

Cancer in renal transplant patients

A

RCC - in the native kidney

PTLD - B-cell proliferation. MC in first year post transplant, often involves multiple organs. Decrease immunosuppression.

Cyclophosphamide - increase exposure is associated with increased risk of urothelial cancer.

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46
Q

High doses of Cyclophosphamide is associated with increased risk of what?

A

Urothelial Cancer

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47
Q

What is Congenital (primary) MEGAureter?

A

“Wastebasket” term for enlarged ureter which is intrinsic to the ureter (as opposed to distal obstruction).

Distal adynamic segment (analogous to achalasia, or colonic Hirschsprungs)
Reflux at the UPJ
Idiopathic

The distal adynamic type “obstructing primary megaureter” can have some hydro, but generally speaking an absence of dilation of the collecting system helps distinguish this from actual obstruction.
Most cases have dilation of the lower 1/3. Almost always unilateral (favoring the left side).

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48
Q

What is a Ureterocele?

A

Cystic dilation of the intravesicular ureter - 2/2 obstruction at the ureteral orifice.

IVP will show “cobra head” sign with contrast surrounded by a lucent rim, protruding from the contrast filled bladder.

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49
Q

What is a Pseudoureterocele?

A

Acquired dilation of the submucosal portion of the distal ureter. Loss of normal lucent line around the “cobra head” suggests a pseudouterocele.

Impacted stone, recently passed stone, or bladder malignancy.

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50
Q

MC congenital anomaly of the GU tract in neonates?

A

UPJ obstruction

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51
Q

Things to know about UPJ Obstruction?

A

MC congential anomaly of the GU tract
Associated with crossing vessels (early branching lower pole vessels compreses the ureter)
Associated with multicystic dysplastic kidney on the other side

Use a Whitaker Test - urodynamics study combined with antegrade pyelogram to differentiate between prominent extrarenal pelvis.

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52
Q

What is a Whitaker Test?

A

Urodynamics study combined with antegrade pyelogram to differentiate between prominent extrarenal pelvis and UPJ obstruction.

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53
Q

What can cause ureteral wall calcifications?

A

TB

Schistosomiasis

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54
Q

Difference between Uteritis Cystica and Ureteral Pseudodiverticulosis?

A

Ureteritis Cystica - Numerous tiny subepithelial fluid filled cysts w/in the wall of the ureter. Result of chronic inflammation (from stones, chronic and/or infection). Typically in DM and recurrent UTIs. May have increased risk of cancer.

Ureteral Pseudodiverticulosis - Also result of chronic inflammation (stones, infection). Instead of being cystic filling defects - multiple small outpouchings. Bilateral 75% and favor upper and middle third. Association with malignancy.

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55
Q

What is Malacoplakia?

A

Inflammatory condition that occurs in the setting of chronic UTIs (highly associated with E. coli). Often in female immunocompromised patients.

Plaque-like or nodular intramural lesions, where bugs are incompletely dgested. MC renal finding is obstruction 2/2 a lesion in the lower tract.

Michaelis-Gutmann Bodies.

Bladder is more commonly affected.

Malacoplakia is NOT premalignant and usualy gets better with abx.

56
Q

Difference between Leukoplakia and Malacoplakia

A 
Leukoplakia = premalignant
Malacoplakia = not premalignant
57
Q

What is Retroperitoneal Fibrosis?

A

Proliferation of aberrant fibro-inflammatory tissue which typically surrounds the aorta, IVC, iliac vessels, and frequently traps and obstructs the ureters.

Idiopathic 75% = Ormond Disease

Radiation, medications (methyldopa, ergotamine, methysergide), inflammatory causes (pancreatitis, pyelonephritis, inflammatory aneurysm), and malignancy (desmoplastic reaction, lymphoma).

58
Q

Trivia about Retroperitoneal Fibrosis

A

Mostly (80%) idiopathic - “Ormond Disease”
Associated with IgG4 disorders (autoimmune pancreatitis, reidels thyroid, inflammatory pseudotumor)
Classically shown with medial deviation of ureters
More common in men
Malignancy associated RP fibrosis occurs about 10% of the time (some people advocate using PET to find a primary).
The fibrosis will be Gallium avid, and PET hot in its early stages and cold in its late stages (mirroring its inflammatory stages). Metabolically active RP fibrosis will show increasaed FDG and Gallium uptake, regardless of a benign or malignant underlying cause.

59
Q

What is a Subepithelial Renal Pelvis Hematoma?

A

Patients on long term anticoagulation.

Thickened upper tract wall - mimic for TCC.

Show you pre and post contrast to show you that it’s hyper dense on the pre-contrast and does NOT enhance.

60
Q

Risk factors for TCC

A

“Goblet” or “champagne glass sign” on CT IVP

Smoking
Azo Dye
Cyclophosphamide
Aristolochic acid (Balkan Nephropathy)
Horseshoe Kidney
Stones
Ureteral Pseudodiverticulosis
Hereditary Non-polyposis colon cancer (type 2)
61
Q

Stats for TCC

A

Ureter is the least common location for TCC of the urinary tract
TCC of the renal pelvis is 2x-3x times more common than ureter
TCC of the bladder is 100x times more common than ureter
In the ureter 75% of the TCCs are in the bottom 1/3
If you have upper tract TCC there is a 40% chance of developing a bladder TCC.
If you have a bladder TCC there is a 4% chance of developing a Renal Pelvis or Ureteral TCC
Ureteral TCC is bilateral 5%.

62
Q

What is Balkan Nephropathy?

A

Degenerative nephropathy endemic to the Balkan states.

High rate of renal pelvis and upper ureter TCCs.

Thought to be secondary to eating aristololchic acid (AA) in seeds of the Aristolochia clematitis plant.

63
Q

Predisposing factor for SCC

A

Schistosomiasis

64
Q

Causes of medial deviation “waisting” of the ureters

A

Retroperitoneal fibrosis
Retrocaval uretera (right side)
Pelvic lipomatosis
Psoas Hypertrophy (distal ureter)

65
Q

Causes of lateral deviation of the ureters

A

Retroperitoneal adenopathy
Aortic aneurysm
Psoas Hypertrophy (proximal ureter)

66
Q

What is Prune Belly?

A

Eagle Barrett

Malformation triad which occurs in males. Baby gram with a kid shaped like a pear (big wide belly).

Deficiency of abdominal musculature
Hydroureteronephrosis
Cryptorchidism (bladder distention interferes with descent of testes)
67
Q

What are bladder diverticula?

A

More common in boys

“Hutch Diverticulum” - at the UVJ and is NOT associated with posterior urethral valves, or neurogenic bladder. Is associated with reflux (b/c the normal slanted insertion of the ureter is altered).

Bladder diverticulum (including the Hutch types) can be seen with Ehlers Danlos. Bladder diverticula can also be acquired secondary to chronic outlet obstruction (big prostate)

68
Q

What are Bladder ears?

A

“Transitory extraperitoneal herniation of the bladder”

Not a diverticulum. Transient lateral protrusion of the bladder into the inguinal canal

69
Q

What is a Cloacal Malformation?

A

GU and GI both drain into a common opening. Only happens in females.

70
Q

What is Bladder Rhabdomyosarcoma?

A

MC bladder cancer less than 10.

Often infiltrative and its hard to tell where they originate. Can met to the lungs, bones, and nodes.

Botyoid variant produces a polypoid mass, which looks like a bunch of grapes.

71
Q

What is the MC TCC bladder subtype?

A

Superficial Papillary

72
Q

Bladder cancer types and their associations?

A 
Typical = Transitional Cell
Schistosomiasis = Squamous
Urachus = Adenocarcinoma
Kids = Rhabdomyosarcoma
73
Q

Causes of Colovesiculal, Ileovesical, and Rectovesical Fistulas

A

Colovesicial = Diverticular Disease

Ileovesical = Crohns

Rectovesical = Neoplasm or trauma

74
Q

What is a “pine cone” sign bladder?

A

Neurogenic bladder

75
Q

Segments of male prostate

A

Penile, Bulbar, Membranous, and Prostatic.

76
Q

Types of urethral injuries

A

1: Stretched - periurethral hematoma would be present. Not well seen on RUB
2: Rupture ABOVE the UG diaphragm. Extraperitoneal contrast is present
3: Rupture BELOW the UG diaphragm. Extraperitoneal and perineal contrast is present
4: Injury involves the bladder extending to the urethra
5: Injury to anterior urethra.

77
Q

What is a straddle injury?

A

MC external cause of traumatic stricture.

Compression of the urethra against the inferior edge of the pubic symphysis.

Bulbous urethra is the site of injury - likely question.

78
Q

What is a Gonococcal Urethral Stricture?

A

Long irregular stricture (the straddle stricture was short).

Distal bulbous urethra.

79
Q

What are Condyloma Acuminata?

A

Multiple small filling defects seen on RUB should make you recommended b/c of possibility of retrograde seeding.

80
Q

What is a Urethrorectal Fistula?

A

May occur post radiation and is classically described with brachytherapy (occurs 1% of patients)

81
Q

What is a urethral diverticulum?

A

In a man, this is almost always the result of long term foley placement.

82
Q

Cause of cancer in the male urethra?

A

SCC

Exception is that prostatic urethra actually has transitional cell 90% of the time.

83
Q

Type of urethral diverticulum cancer?

A

ALWAYS adenocarcinoma

84
Q

Causes of of female urethral diverticulum?

A

Way more common in females. Usually result of repeated infection of the periurethral glands (“repeated UTIs).

Sagittal MRI.

Often coexists with stress urinary incontinence (60%) and urinary infection.

Buzzword: “Saddle-bag” configuration, which supposedly is how you tell it from the urethra. Stones can develop. Infection and irritation leads to risk of cancer - MC is adenocarcinoma.

85
Q

MC cancer in female urethral diverticulum?

A

Adenocarcinoma

86
Q

What do the Mullerian Ducts make?

A

Make the ovaries, uterus, and upper 2/3 of the vagina.

The urogenical sinus grows up to meet the mullerian ducts and makes the bottom 1/3 of the vagina.

Wolfian ducts are the boy parts and should regress completely in girls.

87
Q

What is Mullerian Agenesis?

A

Mayer-Rokitansky-Kuster-Hauser Syndrome

Vaginal atresia
Absent or rudimentary uterus (unicornuate or bicornuate)
Normal ovaries.

Kidneys have issues (agenesis, ectopia) in about half the cases.

88
Q

What is Unicornuate Uterus?

A

4 subtypes: +/- rudimentary horn, +/- endometrial tissue.

Endometrial tissue in a non-communicating horn is going to cause pelvic pain. Endometrial tissue in a rudimentary horn (communicating or not - increases the risk of miscarriage and uterine rupture).

40% have renal issues - usually renal agenesis - ipsilateral to the rudimentary horn.

89
Q

What is Uterine Didelphys?

A

Complete uterine duplication (two cervices).

If patient does not have vaginal obstruction, usually asymptomatic.

90
Q

What is Bicornus vs Septate Uterus?

A

Bicornus - (one cervix unicollis, two cervix bicollis) - Separation of the uterus by a deep myometrial cleft. Can have increased risk of fetal loss, but much less than septate.

Septate - Two endometrial canals separated by a fibrous (or muscular) septum. Fibrous vs muscular can be determined with MRI and distinction changes surgical management - different approaches. Increased risk of infertility. Can resect septum.

Need cross sectional imaging to tell difference. Tell by apex of the fundal contour:
Apex of fundal contour > 5mm above tubal Ostia = septate
Apex of fundal contour <5 mm above tubal Ostia = bicornuate

91
Q

What is an Arcuate Uterus?

A

Smooth concavity of the uterine fundus (instead of normal straight or convex). Normal variant.

Not associated with infertility or OB complications.

92
Q

What is a T-shaped uterus?

A

DES related anomaly.

Synthetic estrogen given to prevent miscarriage. Daughters of parent’s who took drug ended up with vaginal clear cell carcinoma and uterine anomalies - T-shaped uterus.

93
Q

What are the disorders of vertical fusion?

A

Canalization defects - upper 2/3 fails to fuse normally with the bottom 1/3 (sinovaginal bulb).

Cervical Dysgenesis.

Transverse Vaginal Septa - most common in the upper vagina.

94
Q

What is Salpingitis Isthmica Nodosa?

A

Nodular scarring of the fallopian tubes.

Usually involves the proximal 2/3 of the tube. Unknown etiology, but likely post inflammatory/infectious.

Strongly associated with infertility and ectopic pregnancy.

95
Q

What is Ashermans Syndrome?

A

Intrauterine Adhesions - scarring 2/2 injury - prior D&C, surgery, pregnancy, or infection (classic GU TB).

HSG with either non-filling of the uterus, or multiple irregular linear filling defects (lacunar pattern) with inability to appropriately distend the endometrial.
MRI would show a bunch of T2 dark bands.
Infertility.

96
Q

What characteristic of fibroids on MRI makes them more likely to respond to IR treatment?

A

Higher T2 signal.

Usually T2 dark (or intermediate), T2 dark, and variable enhancement.

97
Q

What are the types of Fibroid Degeneration?

A

Hyaline - MC - Outgrows its blood supply - end up with accumulation of proteinaceous tissue. T2 dark, and do not enhance post Gd.

Red (Careous) - Occurs during pregnancy - venous thrombosis. Peripheral rim of T1 high signal. T2 is variable.

Myxoid - Uncommon type - T1 dark, T2 bright and minimal gradual enhancement.

Cystic - uncommon

98
Q

What is Adenomyosis?

A

Endometrial tissue that has migrated into the myometrium. MC in multiparous women of reproductive age - especially if had a history of uterine procedures.

Usually generalized, favoring large portions of the uterus - especially the posterior wall, but sparing the cervix. Marked enlargement of the uterus with preservation of the overall contour.

US: less specific with findings of a heterogeneous uterus (hyperechoic adenomyosis with hypoechoic muscular hypertrophy) or just enlargement of the posterior wall.
MRI: Thickening of the junctional zone of the uterus to more than 12 mm (normal <5 mm). Thickening can be focal or diffuse. Small high T2 signal regions corresponding to regions of cystic change.

99
Q

Risks for endometrial cancer?

A

Estrogen secreting tumors - Granulosa Cell tumors of the ovary.
Hereditary Non-Polyposis Colon Cancer (HNPCC) - have 30-50x increased risk.

Tamoxifen - causes subendometrial cysts and development of endometrial polyps.

100
Q

Cervical Cancer Staging

A

Once you have parametrial invasion (stage IIb) or involvement of the lower 1/3 of the vagina it’s gonna get chemo/radiation.

Stage IIA - Spread beyond the cervix, NO parametrial invasion - Surgery
Stage IIB - Parametrial involvement but does NOT extend to the pelvic side wall - Chemo/radiation
Stage IIIA - Involves the lower third of the vagina but NOT the pelvic sidewall and does NOT obstruct the ureters or invade adjacent organs - Chemo/radiation
Stage IIIB - Involves the pelvic sidewall or causes hydronephrosis - Chemo/Radiation

101
Q

What is the Parametrium?

A

Fibrous band that separates the supravaginal cervix from the bladder. Extends between the broad ligament.

Uterine artery runs inside the parametrium, hence the need for chemo - once invaded.

102
Q

What are the solid vaginal masses?

A

Leiomyoma - rare in vagina, but can occur - MC in anterior wall

SCC - MC cancer of the vagina - associated with HPV - just like the cervix

Clear Cell Adenocarcinoma - Women whose mothers took DES - synthetic estrogen thought to prevent miscarriage. Get T shaped uterus.

Vaginal Rhabdomyosarcoma - MC vaginal tumor in the vagina of children - anterior wall of the cervix - Can occur in the uterus, but typically invades it secondarily. Solid T2 bright enhancing mass in the vagina/lower uterus.

103
Q

What is a Vaginal Rhabdomyosarcoma?

A

MC vaginal tumor in the vagina of children.

Come from the anterior wall of the cervix. Can occur in the uterus, but typically invades it secondarily.

Solid T2 bright enhancing mass in the vagina/lower uterus.

104
Q

Trivia about mets to vagina?

A

Met to the vagina anterior wall upper 1/3 is “always” upper genital tract

Met to vagina posterior wall lower 1/3 is “always” from the GI tract.

105
Q

Difference between Gartner Duct Cysts, Bartholin Cysts, and Skene Gland Cysts

A

Gartner Ducts Cysts - Incomplete regression of the wolfian ducts. Anterior lateral wall of the upper vagina - at the level of the urethra - can cause mass effect on the urethra.

Bartholin Cysts - Obstruction of Bartholin glands (mucin secreting glands from the urogenital sinus). Found below the pubic symphysis.

Skene Gland Cysts - Periurethral glands - can cause recurrent UTIs and urethral obstruction.

106
Q

Surge in what hormone causes ovulation?

A

LH

107
Q

What is a Cumulus Oophorus?

A

Collection of cells in a mature dominant follicle that protrudes into the follicular cavity and signals imminent ovulation.

108
Q

What are Theca Lutein Cysts?

A

Functional cysts related to overstimulation from b-HCG. Large cysts (~2-3 cm) and the ovary has a typical multilocular cystic “spoke-wheel” appearance.

Multifetal pregnancy
Gestational trophoblastic disease (moles)
Ovarian Hyperstimulation Syndrome + ascites and pleural effusions - maybe pericardial.

109
Q

What is an Endometrioma?

A

Young women during reproductive years - chronic pelvic pain associated with menstruation. Infertility, dysmenorrhea, and dyspareunia.

Rounded mass with homogeneous low level internal echoes and increased through transmission. Fluid-fluid levels and internal septations can also be seen.

the more unusual or varied the echogenicity and the more ovoid or irregular the shape, the more likely an endometrioma than hemorrhagic cyst. Will not change on follow-up, compared to a hemorrhagic cyst.

Can get small echogenic foci adhering to the walls - make dx more likely. Want to differentiate this from a true wall nodule.

Complications - bowel obstruction, infertility, etc - due to fibrotic reaction associated with implant.

110
Q

Do endometriomas ever become cancer?

A

Can become clear cell carcinoma - malignancy is very rare in endometriomas smaller than 6 cm. Usually have to be bigger than 9 cm. Usually over than 45.

Older than 45
Bigger than 6-9 cm.

111
Q

Do Dermoids ever become cancer?

A

Can transform into SCC.

Size - >10 cm
Age - older than 50.

112
Q

Findings of adnexal lesions that make you think cancer?

A

Unilateral (or bilateral) comlex cystic adnesal masses with thick (>3 mm) septations, and papillary projections (nodule with blood flow).
Solid Adnexal masses with variable necrosis

Multiple thin or thick septations
Nodule with flow
Solid nodules without flow - MR to make sure not dermoid plug, if not, call surgeon.

113
Q

What is a Serous Ovarian Cystadenoma/carcinoma?

A

MC type of ovarian malignancy. Favor women of childbearing age, with malignant ones tending to occur in older women.

Unilocular with few septations. Frequently bilateral (especially when malignant).
Papillary projections are a common finding, which suggests malignancy.
If you see ascites = mets.

114
Q

What is Mucinous Ovarian Cystadenocarcinoma?

A

Often large. Typically multiloculated (although septa are often thin).
Papillary projections are less common. Can see low level echoes (from mucin).

Can get pseudomyxoma peritonei with scalloping along solid organs.
Smoking is known risk factor (especially for mucinous types).

115
Q

What is Endometrioid Ovarian Cancer?

A

2nd MC ovarian cancer - serous is #1, mucinous #3. Bilateral 15% of the time.

Associated with endometrial cancer (ovarian mass + endometrial thickening).
Endometriomas can turn into endometroid cancer.

116
Q

What is a Fibroma/Fibrothecoma?

A

Benign ovarian tumor - middle aged women.

Fibrothecoma/thecoma spectrum has similar histology. Very similar to fibroid.

US: hypoechoic and solid. MRI: T1 and T2 dark with band of T2 dark signal around the tumor on all planes. Calcs are rare.

117
Q

What is Meigs Syndrome?

A

Ascites, pleural effusion, and a benign ovarian tumor (MC fibroma).

118
Q

What is Fibromatosis?

A

Tumor-like enlargement of the ovaries due to ovarian fibrosis - girls around 25.

Associated with omental fibrosis, and sclerosing peritonitis. Dark T1 and T2 signal - “black garland sign”

119
Q

What is a Brenner Tumor?

A

Epithelial tumor of the ovary seen in women in their 50s to 70s. Fibrous and T2 dark. Calcs are common.

120
Q

What is a Paraovarian Cyst?

A

Congenital remnant that arises from the Wolffian Duct.

Round or oval, simple in appearance, and do NOT distort the adjacent ovary. Can indent the ovary and mimic an exophytic mass, but moves separately.

121
Q

What is Ovarian Thrombophlebitis?

A

Post partum women.
Acute pelvic pain and fever. 80% on the right.

Tubular structure with an enhancing wall and low-attenuation thrombus in the expected location of the ovarian vein.

Can get PE.

122
Q

What is a Peritoneal Inclusion Cyst?

A

Inflammatory cysts of the peritoneal cavity when adhesions envelop an ovary. Normal secretions from an active ovary confined by adhesions resulting in an expanding pelvic mass.

Prior pelvic surgery now with pain or History of PID or endometriosis.
US or MRI with complex fluid collection occupying pelvic recesses and containing the ovary.
Not uncommon to have septations, loculations and particulate matter w/in the contained fluid.

Key features:
Lack of walls - passive shape.
Entrapment of ovary. Either in the collection or at the periphery.

123
Q

What is a Hydatidiform Mole?

A

Complete: Involves the entire placenta - no fetus. Karyotype is diploid. Fertilization of an egg that has lost its chromosomes (46,XX).
First Trimester: Uterus filled with echogenic, solid, highly vascular mass, often described as “snowstorm” in appearance.
Second Trimester: Vesicles enlarge into individual cysts (2-30 mm) and produce “bunch of grapes” appearance.

Partial Mole: Involves only a portion of the placenta. Have fetal parts - triploid karyotype. Fertilization of an ovum by two sperm (69XXY).
Placenta will be enlarged and have areas of multiple, diffuse anechoic lesions. May see fetal parts.

124
Q

What is an Invasive Mole?

A

Invasion of molar tissue into the myometrium. See it after instrumentation of hydatidiform mole. Echogenic tissue in the myometrium. MRI is better at demonstrating muscle invasion: focal myometrial masses, dilated vessels, and areas of hemorrhage and necrosis.

125
Q

What is Choriocarcinoma?

A

Very aggressive malignancy that forms only trophoblasts (no villous structure). Spread locally into myometrium and parametrium then spread hematogeously to any site in the body. Very vascular and bleeds.

B-hcg levels rise in the 8-10 weeks following evacuation of molar pregnancy.

US: High echogenic solid mass

Treat with MTX.

126
Q

What are the zones of the prostate?

A

Peripheral
Transitional
Central

Transitional and Central make up the central “gland” - dark on T2 - BPH.

127
Q

Staging of prostate cancer?

A

Stage B:
Confined by capsule
Abutment of the capsule w/o bulging.

Stage C:
Extension through capsule
Bulging of the capsule or frank extension through it.

128
Q

Where does BPH happen?

A

Transitional Zone - median lobe hypertrophies and sticks up into the bladder.

“J shaped” or “Fishhook” shaped ureter

Cancer is rare in transitional zone.

129
Q

What is a Prostatic Utricle Cysts/Mullerian Duct Cyst?

A

Focal dilation of the prostatic urethra. Midline structure near the bladder of a man.

Looks similar to a mullerian duct cyst (anatomical variant of the caudal ends of the mullerian ducts - equivalent of the vagina/cervix).

Hypospadius is the MC associated condition.
Prune Belly Syndrome, Downs, unilateral renal agenesis, and imperforate anus are also associated
If large, can become infected.

130
Q

What is a Seminal Vesicle Cyst?

A

Unilateral, lateral cyst (lateral to prostate).

Congenital: Associated with renal agenesis; Associated with vas deferens agenesis; Associated with ectopic ureter insertion.

Acquired: Obstruction often from prostatic hypertrophy or chronic infection/scarring; Classic history is prior surgery.

131
Q

What are the non-seminomatous germ cell tumors?

A

Not a seminoma

Mixed germ cell tumors, teratomas, yolk sac tumors, and choriocarcinoma.

Young age relative to seminoma. More heterogeneous and have larger calcifications.

132
Q

What is Testicular Lymphoma?

A

Can hide in testes b/c of the blood testes barrier.
Immunosuppressed patients are at increased risk for developing extranodal/testicular lymphoma.
Almost all are non-Hodgkin B-cell subtypes.
Normal homogeneous echogenic testicular tissue is replaced focally or diffusely with hypoechoic vascular lymphomatous tissue.

Buzzword = multiple hypoechoic masses of testicle.

133
Q

Testicular Trivia

A

Seminoma is MC and has the best prognosis - melts with radiation
Multiple hypoechoic masses = lymphoma
Homogeneous and microcalcifications = seminoma
Cystic elements and macrocalcifications = mixed germ cell tumor/teratoma
Most testicular tumors met via lymphatics (choriocarcinoma mets via the blood and bleeds)
Gynecomastia can be seen with Sertolic Leydig Tumors
Sertoli Cell Tumors are also seen with Peutz Jeghers

Elevated hCG = Seminoma and Choriocarcinoma
Elevated AFP = Mixed Germ Cell and Yolk Sac

134
Q

What testicular tumors have elevated hCG vs AFP?

A

Elevated hCG = Seminoma and Choriocarcinoma

Elevated AFP = Mixed Germ Cell and Yolk Sac

135
Q

Causes of Obstructive vs Non-obstructive male infertility

A

Obstructive: Congential bilateral absence of the vas deferens (seen in CF), ejaculatory duct obstruction, prostatic cysts. Associated renal anomalies (Zinner Syndrome)

Non-obstructive: Varicocele, cryptorchidism, anabolic steroid use, ED.

136
Q

What is Zinner Syndrome?

A

Triad of Wolffian duct anomalies comprising of unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction

137
Q

Syndromes associated with male infertility

A 
Pituitary adenoma making prolactin
Kallmans Syndrome (can't smell + infertile)
Klinefelters Syndrome (tall + gynecomastia + infertile)
Zinner Syndrome (renal agenesis + ipsilateral seminal vesicle cyst).

Body (5 decks)

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