Differentials Flashcards
Solid liver lesions
Benign epithelial
- FNH
- Adenoma
- Biliary Hamartoma
- Adrenal or pancreatic rest
- Regenerative nodule
- Nodular regenerative hyperplasia
Benign mesenchymal
- Haemangioma
- Lipoma
- Myelolipoma
- Angiomyolipoma
Malignant epithelial
- Mets
- HCC
- Cholangiocarcinoma
Malignant mesenchymal
- Liposarcoma
- Angiosarcoma
- Lymphoma
Cystic liver lesions
Infective
- Pyogenic abscess
- Amoebic cyst
- Hydatid cyst
Benign neoplastic
- Cystadenoma (MCN)
- Carolli disease
- Simple cyst
- Polycystic liver disease
Malignant
- Cystic met
- Cystic degeneration of HCC/cholangio
Traumatic
- Biloma
- Haematoma
Appearance on imaging: Haemangioma
USS: hyperechoic
CT: Discontinuous, nodular, peripheral enhancement on arterial
portal venous phase: progressive peripheral enhancement with more centripetal fill-in
delayed phase: further irregular fill-in and therefore iso- or hyper-attenuating to liver parenchyma
MRI: T1: hypointense relative to liver parenchyma
T2: hyperintense relative to liver parenchyma, but less than the intensity of CSF or of a hepatic cyst.
Contrast as for CT
Appearance on imaging: FNH
CT:late arterial phase - centrifugal filling (opposite to haemangioma and adenoma)
portal venous phase - sustained enhancement in the portal venous phase (as opposed to adenoma)
Central stellate scar
Appearance on imaging: Adenoma
CT: well-marginated and isoattenuating to the liver. On contrast administration, they demonstrate transient, relatively homogeneous enhancement, returning to near isodensity on portal venous and delayed phase images - faster contrast washout than FNH Centripetal filling (like haemangioma)
Tc99 Sulfur colloid: no uptake (unlike FNH)
MRI: variable. contrast as for CT
Appearance on imaging: HCC
CT: bright enhancement, rapid washout (as they are hypervascular and generally supplied by hepatic artery rather than portal vein)
MRI: T1 variable, T2 hyperintense. Contrast as for CT
Appearance on imaging: Cholangiocarcinoma
CT: minor peripheral rim enhancement with gradual centripetal filling
(cf HCC, which rapidly enhance and washout)
Neck lump
Ideally characterise by location
Benign and Malignant, or surgical sieve
Benign: V: carotid body tumour, aneurysm I: lymphadenitis, sialadenitis T: haematoma A: sarcoid, TB M: goitre I: N: lipoma, sebaceous cyst, dermoid cyst C: thyroglossal cyst, branchial cyst, cystic hygroma
Malignant: Lymphoma Metastasis Sarcoma Melanoma
Cervical Lymph Node
Infective vs Neoplastic vs other
Infective
- viral
- TB
- HIV
- filiariasis
- toxoplasma
- bacterial - skin/aerodigestive tract
Neoplastic
- lymphoma
- mets - SCC head and neck, melanoma, GIT, lung
Other
- Sarcoid
Non-thyroid neck mass by frequency
With non-thyroid neck masses in the adult:
85% are neoplastic
85% of those are malignant
85% of malignant masses are metastatic (mostly SCC)
85% of mets will be from primary above the clavicle (SCC)
Gynaecomastia
Physiological, Pathological or Drug-related
Physiological (high oestradiol to T ratio)
- Neonates
- Puberty
- Old age
Pathological
- Reduced oestrogen clearance = Liver disease
- Increased oestrogen production = testicular tumour, adrenal tumour, pituitary (prolactinoma), hepatoma
- Decreased testosterone production = Klinefelters, orchitis, cryptorchidism, hypopituitarism
Drugs
- Steroids
- Spironolactone
- Cimetidine
- Phenothiazines
- Tricyclics
- Cannabis
Nipple discharge
Lactational, Physiological, Pathological
Normal (lactation)
Physiological (galactorrhoea)
- Nonpathologic discharge unrelated to pregnancy or breast feeding – usually bilateral, never bloody
- Usually hyperprolactinaemia
Pathological
- Unilateral, persistent, spontaneous, bloody
- Papilloma - >50%
- Duct ectasia – 15-30%
- Cancer – 5-15%
- Infection
Colitis
Infective (C diff, shigella, salmonella, e.coli, giardia, CMV)
Ischaemic
Inflammatory (Crohn’s, UC, microscopic/collagenous)
Radiation-induced
Trauma
Diarrhoea
Colonic vs extracolonic
Colonic
- Infective (colitis)
- Ischaemic
- Inflammatory (IBD, microscopic colitis)
- Radiation
- Trauma
- Functional (fast transit, overflow)
Extracolonic
- Pancreatic insufficiency
- NET (VIPoma, Gastrinoma, Medullary thyroid ca, Carcinoid)
- Coeliac
- Hyperthyroidism
- Enteritis
- Lactose intolerance
- Short gut
Obstructive defaecation
Anatomical vs Functional
Anatomical
- Intussuception
- Rectocele
- Anal stenosis
Functional
- Pelvic floor dyssynergia
- Paradoxical anal contraction
Constipation
“I always want to exclude structural lesion as a cause, eg malignancy”
Impaired colonic function vs evacuatory dysfunction
Colonic anatomical
- Cancer
- Stricture
- Volvulus
Colonic function
- Slow transit
- Autonomic dysfunction (diabetes, parkinsons, MS)
- Drugs (opiates, antipsychotics)
- Spinal cord injury
- Hirschsprungs
Evacuatory anatomical
- Intussuception
- Stenosis
- Rectocoele
Evacuatory function
- Dyssynergia
-
Most common congenital neck mass?
Thyroglossal cyst
Most common salivary gland tumour
Parotid pleomorphic adenoma
Skin lesion
Benign and malignant
Benign:
- AK
- Seb K
- Dysplastic naevus
- Melanocytic naevus
- Keratoacanthoma
Malignant:
- BCC
- SCC
- Melanoma
- Merkel cell carcinoma
- Sebaceous carcinoma
Salivary gland tumours
Benign vs malignant - primary vs secondary
Benign
- Pleomorphic adenoma
- Warthin’s tumour
- Cystadenoma
- Oncocytoma
- Myoepithelioma
- Sialadenoma
Malignant primary
- Mucoepidermoid carcinoma
- Adenoid cystic carcinoma
- SCC
- Sebaceous carcinoma
- Carcinoma ex pleomorphic adenoma
- BCC
- Adenocarcinoma NOS
- Oncocytic carcinoma
- Clear cell carcinoma
Mets/secondary
- SCC
- Lymphoma
- Melanoma
Thyroiditis
Painless
- Hashimoto’s
- Grave’s
- Riedel’s/Fibrous
- Post-partum
- Lymphocytic
Painful
- DeQuervain’s/subacute
- Radiation-induced
- Traumatic/palpation
Goitre
Benign
- Diffuse non-toxic (iodine deficient)
- Multinodular
- Grave’s
- Hashimoto’s
- DeQuervain’s
- Riedel’s
- Infective thyroiditis
Malignant
- Thyroid ca
- Lymphoma
Alternative is toxic vs non-toxic
Hyperthyroidism
High iodine uptake (De Novo synthesis) (autoimmune, autonomous, tsh-mediated, hcg-mediated) - Grave's - Toxic Hashimotos - Toxic MNG - Toxic adenoma - TSH-secreting pituitary adenoma - TSH receptor mutation - Hyperemesis gravidarum - Trophoblastic disease
Low iodine uptake (gland destruction)
- Thyroiditis
- Struma Ovarii
- Functional thyroid ca mets
- Factitious toxicosis (ingestion)
Hypothyroidism
Primary vs Secondary
Iatrogenic
- Thyroidectomy
- Radioiodine
- External beam radiation
- Excess suppression
- Drugs - amiodarone
Inflammatory (Thyroiditis)
- Hashimoto’s
- DeQuervain’s
- Riedel’s
Secondary
- Hypopituitarism
- Iodine deficiency
- Sheehan syndrome
- Inactivating mutation of TSH or TSH-receptor
Retroperitoneal tumours
Benign vs malignant
Benign
- Lipoma
- Leiomyoma
- Paraganglioma
- Teratoma
- Hamartoma
- Peripheral nerve cell tumour
- Castleman disease
- Desmoid
Malignant
- Sarcoma
- Lymphoma
- Malignant paraganglioma
- Malignant peripheral nerve cell tumour
- GIST
- ACC
- RCC
- Malignancy of retroperitoneal organ - duo, panc
- Mets eg testicular cancer
Tissues:
- Fat
- Muscle
- Nerves
- Ganglia
- Lymphatics
Bleeding disorders
Congenital vs Acquired
Congenital
- vWF
- Haemophilia A
- Haemophilia B
Acquired
- Trauma-induced coagulopathy
- Vit K deficiency
- Iatrogenic (anticoags - warfarin, dabi etc)
- Liver disease
- DIC
- Massive transfusion
Solid pancreatic lesions
Benign vs malignant
Benign
- Solid pseudopapillary tumour
- PNET
- GIST
Malignant
- Ductal adenocarcinoma (85%)
- Acinar cell carcinoma
- Pancreatoblastoma
- Metastases (melanoma, RCC, lobular carcinoma)
- Malignant GIST
Cystic pancreatic lesions
Benign and malignant
Don’t forget non-neoplastic lesions eg pseudocyst
Benign
- MCN
- IPMN
- Serous cystadenoma
- Solid pseudopapillary lesion
- Cystic NET
- Pseudocyst
- Simple cyst
Malignant
- MCN with carcinoma
- IPMN with carcinoma
- Cystic ductal adenocarcinoma
- Cystic acinar cell carcinoma
- Serous cystadenocarcinoma
- Cystic malignant NET
