Fair Game Flashcards
Case 56
What do you do with CT contrast and Metformin to avoid contrast-induced nephropathy?
Hold Metformin for 48 hours
Check blood for signs of CIN
Restart if all is well
Case 56
What do you when there is CT contrast extravasation in the arm?
Elevate the arm Cold compress Call Surgeon - Lg vol high-osmolar contrast w necrosis - Neuromuscular dysfunction - Compartment Syndrome
Case 56
When does the severity of the soft tissue injury peak after contrast extravasation in an extremity?
48 hours
Case 56
How do you treat hives (urticaria) if Benadryl isn’t working?
Consider
- Cimetidine
- Epinephrine
Case 56
How do you treat a contrast reaction of hypotension with bradycardia?
Atropine
- Vasovagal reaction!
Case 56
How do you treat a contrast reaction of hypotension with tachycardia?
Trendelenburg position
IV fluids
Epinephrine
Case 56
How do you treat a contrast reaction of dyspnea?
Oxygen
Beta-agonist inhalants
Case 57
Name three causes of Medullary Nephrocalcinosis
Hyperparathyroidism
Renal Tubular Acidosis
Medullary sponge kidney
- typically unilateral
Case 57
Is renal function impaired with Medullary Nephrocalcinosis?
No (particularly if it is reversed) Unless - Severe, long-standing hypercalcemia and/or - Renal tubular acidosis
Case 57
What is the most common complication of Medullary Nephrocalcinosis?
Urolithiasis
Case 58
What GU tract anomalies are associated with ureteral duplication?
UPJ Obstruction
Hydronephrosis
Ureterocele
Ureterovesical reflux
Case 58
What is the Weigert-Meyer rule?
Upper pole ureter
- Inserts inferior and medial to the lower pole ureter
Upper pole moiety
- Obstructs
Lower pole moiety
- Refluxes
- Causes lower pole atrophy
Case 59
What is the conventional treatment for emphysematous pyelonephritis?
Radical nephrectomy
Drainage / Abx is Insufficient
Case 59
What type of patients are predisposed to emphysematous pyelonephritis?
What is the most common organism?
Diabetics
E. coli
Case 60
What mechanism causes a horseshoe kidney?
Arrest of cranial migration of the kidney by the IMA
Abnormal contact of the developing metanephric tissues
Case 60
What are common complications associated with horseshoe kidneys?
Nephrolithiasis
UPJ obstruction
Duplication anomalies
Recurrent infection
Higher susceptibility to renal injury from trauma
TCC (slight increase in incidence from urinary stasis)
Case 61
Dx of a solid, enhancing renal mass?
RCC
Oncocytoma
Lipid-poor angiomyolipoma
Metastasis
Case 61
What percentage of angiomyolipomas have no identifiable fat on CT or MRI?
What complication is AML associated with?
5%
Spontaneous Hemorrhage
Case 62
What percentage of angiomyolipomas are associated with tuberous sclerosis?
20%
Case 62
What size of an AML increases risk of bleeding?
What causes the tumor to bleed?
How do you deal with a nonhemorrhagic AML?
> 4cm
Small aneurysms develop in arteries supplying AML’s
Prophylactic excision, ablation, or embolization
Case 63
A patient with multiple AML’s likely has?
Tuberous sclerosis
Case 63
Three skin lesion associated with Tuberous Sclerosis?
Adenoma sebaceum (Adenofibroma)
Nevus depigmentosus
Cafe au lait spots
Case 63
What percentage of tuberous sclerosis patients have AML?
80%
Case 63
What are the 6 primary features of tuberous sclerosis?
(This to me is more of a neuroradiology question!)
Cortical tubers Giant cell astrocytoma Calcified subependymal nodules Retinal astrocytoma Facial angiofibromas Ungual fibromas
Case 64
What other renal masses besides angiomyolipoma can contain fat?
Angiomyolipoma Rarely - Lipoma - Liposarcoma - Wilms' tumor (dedifferentiated) - RCC that engulfs adjacent renal hilar fat
Case 65
Define a Bosniak I renal cyst and how do you manage it?
Simple cyst
- No follow-up
- Round
- Imperceptible wall
Case 65
Define a Bosniak II renal cyst and how do you manage it?
Minimally complex
- No follow-up
Case 65
Define a Bosniak IIF renal cyst and how do you manage it?
Minimally complex: 6 month follow-up >3cm >3 septa that are thicker or nodular Thick calcification Hyperdense but nonenhancing
Case 65
Define a Bosniak III renal cyst and how do you manage it?
Indeterminate
- 25-45% malignant
- Partial nephrectomy/RFA
- Multiple thick septations
- Coarse calcifications
- Hyperdense and enhancing
Case 65
Define a Bosniak IV renal cyst and how do you manage it?
Malignant
- Partial or total nephrectomy
- Solid and enhancing mass
- Cystic or necrotic components
Case 66
What renal tumor do patients with horseshoe kidneys more commonly have?
TCC
- Related to renal stasis
No increase in RCC incidence
Case 66
Why should you always perform an angiogram in patients who have horseshoe kidney and RCC?
Surgical planning
Almost always have
- Aberrant arterial supply
- Anomalous Venous drainage
Case 66
What pathology occurs with increased incidence in the setting of horseshoe kidney?
Infections
Stones
UPJ Strictures
TCC
Case 67
What are causes of spontaneous perinephric hemorrhage
Neoplasm (60%) Complicated renal cyst Vasculitis Infarction Infection
Case 68
DDx on U/S of a solid, heterogenous, hyperechoic mass (4 lesions)?
Renal cell carcinoma
Oncyocytoma
AML
Metastasis
Case 68
What differentiates Stage III from Stage IV RCC?
Stage III
- Regional lymph nodes
- Venous extension
Stage IV
- Direct invasion of adjacent organs (besides adrenal)
- Distant metastasis
Case 69
What are four causes of renal vein thrombosis?
RCC
Hyper coagulable state
Dehydration
Glomerulonephritis
Case 69
What has a better prognosis in Stage III RCC, venous extension or regional lymph node involvement?
Venous extension
Case 69
Why is it important to determine if renal venous tumor thrombosis with IVC thrombus extends above the level of the hepatic veins?
If it extends above the hepatic veins
- Abdominal incision isn’t enough for resection
- Requires thoracoabdominal incision w/ cardiopulmonary bypass
Case 70
What three diseases are associated with renal cysts and solid renal masses?
Tuberous sclerosis
von Hippel-Lindau Disease
Long-term dialysis
Case 70
What are common manifestations of vHL Disease
Retinal angiomas Renal cysts RCC (clear cell variety) Pancreatic cysts and cystic tumors Cerebellar hemangioblastomas
Case 70
A patient with multiple renal cysts. What helps differentiate the cause between ADPKD v. vHL Disease
If they have pancreatic cysts, it’s most likely vHL.
Patients with ADPKD don’t get pancreatic cysts
Case 71
What tumors grow in the kidney in an infiltrative pattern?
Urothelial tumors (TCC or SCC)
Metastasis
Lymphoma
Infiltrative RCC
Case 71
What are common causes of bilateral or multiple renal solid masses?
Metastasis
Oncocytoma
Lymphoma
AML
Multifocal RCC
Case 72
What two renal lesions are common in patients with tuberous sclerosis?
AML
Renal cysts
Case 73
A solid renal mass with a central stellate scar (spoke-wheel on angiography) is diagnostic of an oncocytoma. T or F?
False
- Highly suggestive
- Not diagnostic
- May be RCC
This is a surgical lesion! Biopsy won’t help. Take it out!
Case 74
DDx of bilateral infiltrative renal lesions (tumors and nontumors)?
Metastasis
Lymphoma
Infarcts
Pyelonephritis
Case 75
What are four ways that lymphoma involving the kidneys presents?
Perirenal space spread from retroperitoneum
Multifocal infiltrative renal masses
Diffuse renal infiltration
Solid renal mass (mimics RCC)
Case 75
How can ureteral position help differentiate lymphoma from retroperitoneal fibrosis
Lymphoma
- Lateral ureteral displacement
RPF
- Medial ureteral displacement
Case 75
What type of lymphoma involves the kidneys?
Non-Hodgkins Lymphoma
Case 76
What helps differentiate a right perinephric abscess caused by a perforated duodenal ulcer from pyelonephritis?
Normal cortical enhancement is unusual in pyelonephritis
Case 77
When you see a rim of enhancement around a renal cortical infiltrative abnormality, what is the likely diagnosis?
Renal infarct
The rim is caused by flow from the renal capsular artery
Case 78
What causes a “faceless kidney,” which is defined as a sold mass proliferating the renal sinus and obliterating its fat?
Transitional cell carcinoma
Squamous cell carcinoma less commonly
Case 79
What is the mechanism of developing xanthogranulomatous pyelonephritis (XGP)?
Recurrent upper urinary tract infections
- E. coli or Proteus
Calculus formation
- Obstruction
Renal inflammation with lipid-laden histiocytes
Destruction and replacement of renal parenchyma
Case 79
What patients are most susceptible to XGP?
Middle-aged women
Diabetics
Case 80
What mechanism causes a urinoma?
Laceration of the ureter at the UPJ
Case 80
How is a urinoma treated non-surgically to allow the ureteral laceration to heal?
Percutaneous nephrostomy
Ureteral stent
Case 80
What is a Page kidney?
Renovascular hypertension
- Subcapsular fluid (or hematoma)
- > Compresses renal parenchyma
- > Underperfusion and ischemia
- > Triggers renal renin-angiotensin-aldosterone system
- -> HTN
Case 80
What is a Goldblatt kidney?
Renovascular hypertension
- Caused by renal artery stenosis or occlusion
Case 81
What are two ways that a subcapsular hematoma can be distinguished from a hematoma in the peritoneal space?
Subcapsular hematoma deforms the renal shape
- No fat plane between the hematoma and the kidney
Case 81
Name 3 causes of a subcapsular hematoma
Trauma (blunt or biopsy)
Vasculitis
Vascular malformation
Case 82
What are known complications of renal biopsy?
Hemorrhage Abscess
Hematuria Sepsis
AV fistula Page Kidney
Case 82
What are 5 entities that are bright on T1 weighted MRI
Fat Methemoglobin
Melanin Gadolinium
Protein
Case 82
What are two risk factors for post-biopsy bleeding?
Coagulopathy
Severe hypertension
Case 83
Besides RCC, Dehydration, and Hypercoagulability, what are other less common causes of renal vein thrombosis?
Sickle cell disease
Vasculitis
Amyloidosis
Lupus
Case 83
What percentage of patients with renal vein thrombosis develop PE?
33%
Case 84
What % of patients on long-term dialysis develop RCC?
7%
RCC in these patients is typically less aggressive
Case 84
What is also common in long-term dialysis patients?
Multiple renal cysts
Case 85
T/F
Bilateral orthotopic uretereoceles are not associated with other urinary tract anomalies.
True
- Ectopic ureteroceles are however
Case 85
Ureteroceles >2 cm have a higher risk of what complications?
Urinary stasis
Obstruction
Stone formation
Infection
Case 85
What is the maximum thickness of the radiolucent halo around an orthotropic ureterocele?
Failed resorption of what structure is the proposed cause of this abnormality?
2 mm
Chwalla’s membrane
Case 86
What is a ureterocele-like abnormality with an irregular wall surrounding its bulbous portion or a thick halo (>2mm)
Pseudoureterocele
Case 86
What causes a Pseudoureterocele?
Ureteral stones
Edema from a recently passed ureteral stone
Manipulation of the UVJ
Bladder tumor blocking the ureteral orifice
Case 87
What is an amputed calyx on an IVP or CT urogram?
Abrupt cutoff of the infundibulum with minimal opacification of the calyces
Case 87
DDx of an amputed calyx on an IVP or CT urogram
TCC
TB
Case 88
What percentage of patients with calyceal TCC have synchronous tumors of the calyces?
Bladder?
25%
40%
Case 89
What is the single most important risk factor for TCC?
Smoking
Case 89
How does TCC typically present?
Hematuria (72%)
Dull pain (22%)
Renal colic due to obstruction
- Rare
Case 90
What is a Goblet sign?
Ureteral dilation below a radiolucent filling defect
Case 90
A “Goblet sign” is pathognomonic for what diagnosis?
Papillary TCC
Case 90
What causes the ureter to dilate with a TCC giving the appearance of a goblet?
Long-standing, slowly growing polypoid mass that is continuously being pushed down by peristalsis
Case 91
DDX of multiple ureteral filling defects on IVP
Uric acid stones Blood clots
Air bubbles Infectious debris (fungal)
Multifocal TCC (1/3 of patients) Sloughed papillae
Case 91
What percentage of TCC is Papillary?
67%
Case 92
Explain forniceal rupture related to a ureteral stone.
Spontaneous rupture of a calyceal fornix
Relief or “pop-off” valve reducing pressure
Contrast or urine extravasates into the perirenal space
Case 92
How does a fornix rupture present?
Is it an emergency?
Sudden relief of obstructive symptoms
It is a totally benign entity of no clinical significance
Case 93
T/F
Renal stones are the most common cause of transplant kidney hydronephrosis?
False
Stones only account for 2% of post-transplant hydro
Case 93
What are causes of transplant kidney hydronephrosis?
Anastomotic stricture
Blood clot
Ureteral edema
Pertransplant fluid collection (lymphoceles)
Case 93
How do you treat transplant kidney hydronephrosis?
Is the hydronephrosis symptomatic?
Percutaneous nephrostomy
Placement of a nephrovesical stent
No - painless in transplant kidney
Case 94
What is the likely cause of hematuria in a patient with hematuria and large filling defect in the kidney on IVP?
TCC
RCC
Vascular malformation
Case 94
What enzyme in urine leads to rapid change of pyelocalyceal blood clots?
Urokinase
Case 95
How do you best diagnose a traumatic ureteral injury?
CT Abdomen/Pelvis with IV only
Early and delayed images
Case 95
What are typical CT findings of ureteral injury?
Normal renal enhancement
Medial perirenal contrast extrav
Nonopacification ipsilateral distal ureter
Case 95
What is the best treatment for ureteral injury?
Percutaneous nephrostomy Nephroureteral stent placement Percutaneous urinoma drainage NOT surgery - They don't do as well
Case 96
DDX for distal ureteral stricture
Extrinsic compression ->Tumor Periureteral inflammation -> Appendicitis, IBD, Endometriosis Iatrogenic stricture Infection ->TB or Schistosomiasis Radiation
Case 96
How do you treat distal ureteral stricture?
Stent placement
Balloon dilation
Surgical resection
Case 97
What is a retrocaval ureter?
Abnormal course of the ureter posterior to the IVC
- Caused from anomalous development of IVC
Case 97
What defines medial displacement of the ureter?
The ureter courses medial to the L3 or L4 pedicle
Case 97
DDX for medial displacement of the ureter
Retroperitoneal fibrosis
Retroperitoneal mass
Prior surgery
Retrocaval ureter
Case 98
Where do most bladder tumors occur?
Posterolateral wall near the trigone
Case 98
What are the most common bladder tumors
TCC: 90%
SCC: 5%
Adenocarcinoma: 2%
Case 98
What predispose a patient to bladder squamous cell CA?
Schistosomiasis
Neurogenic bladder
Chronic Foley catheterization
Case 98
What is the most important prognostic factor for bladder cancer
Depth of bladder wall invasion (T2 or T3)
Treated with bladder cystectomy, not transurethral resection
Case 99
What causes bladder diverticula to develop?
Chronic bladder outlet obstruction
Case 99
What are common complications of bladder diverticula?
Chronic ureteral obstruction
Stones
Infection
Tumor
Case 100
What is an Indiana Pouch?
A urinary diversion
- Conduit of cecum and distal terminal ileum
- Prevents reflux and provides urinary continence
- No need for osmtomy bag with good capacity (0.5-1 L)
- Allows self-catheterization every 3-6 hours
Case 100
What is the best CT technique for evaluating a urinary diversion?
Oral only or IV only
- Allows separation of GI and GU tracts
Case 101
What is a Koch Pouch?
Continent cutaneous urinary diversion
Uses Terminal ileum
Case 101:
What early complications occur with Koch Pouch?
Anastamotic leak
Dehydration
Sepsis
Case 101:
What major late complications occur with Koch Pouch?
Struvite pouch stones
Afferent nipple stenosis
Reflux
Case 102
What is The Parfait Sign on MRI?
3 layers seen in the bladder on postcontrast MRI
Top layer: Urine (long T1)
Middle layer: Mixture or urine and Gd (short T2)
Bottom layer: Gadolinium
Case 103
What is the most common cause of vesicovaginal (VV) fistula in the US?
World wide?
XRT
Obstetric trauma
Case 103
What CT technique should be used to detect VV fistula?
IV contrast only
Delayed images with 3-5mm thin sections
Case 104
What are causes of a “pear-shaped” bladder?
Hematoma Urinoma
Lipomatosis IVC Obstruction
Lymphadenopathy Lymphocysts
Case 105
Who typically gets pelvic lipomatosis…Sex and race?
African American Men
- Men 94%
- African American 2/3
Many are obese
Case 105
What is the diagnosis if you see a pear-shaped bladder with multiple lobulated filling defects?
Pelvic Lipomatosis with Cystitis Glandularis
Case 106
What are the major causes of hemorrhagic cystitis?
Chemical urotoxins (Cyclophosphamide)
Radiation
Immune-mediated injury (related to viruses)
Case 106
What cancers is radiation cystitis most commonly related to
Prostate
Cervical
Case 107
Does cyclophosphamide treatment increases risk for cancer?
Yes
Case 107
How do you treat cyclophosphamide cystitis?
Forced diuresis
Bladder irrigation
Mesna
Case 108
What is the classic symptom with bladder herniation through the inguinal canal?
Two-stage voiding
Case 108
An indirect inguinal hernia lies lateral to what artery?
Deep inferior epigastric artery
Case 108
What are complications of a bladder hernia?
Hydronephrosis Strangulation Stone formation VU Reflux Inadvertent perforation in surgery
Case 109
DDX for mural bladder calcification
Schistosomiasis - ascends to the bladder from the prostate
TB cystitis - descends to the bladder from the kidney
Radiation cystitis
Intravesical chemotherapy
Neoplasm - SCC from chronic Schistosomiasis
Case 109
What is an imaging sign of malignant transformation in the bladder in a patient with mural calcification
Disruption of the calcification
Case 110
What is an artificial urinary sphincter used for
Stress incontinence
Post-prostatectomy sphincter weakness
Kids with incontinence related to spinal dysraphism
Case 111
Who typically have Congenital urethral diverticula? M or F?
Who typically have Acquired urethral diverticula? M or F?
Boys - 98%
Women
Case 111
What symptoms are seen with urethral diverticula?
Dyspareunia
Postvoid dribbling
UTI’s
Case 111
Urethral diverticula in women involve what segment?
The middle 1/3 dorsolaterally
More common in African-American women
Case 112
How do urethral diverticula occur in females?
Skene’s glands posteriorly in the inferior urethra obstruct leading to more proximal diverticula (in the middle 1/3)
Case 112
What is the most common tumor that develops in a urethral diverticulum?
Adenocarcinoma
Case 113
What are the 4 parts of the male urethra?
What separates the anterior and posterior portions of the male urethra?
Anterior - Penile - Bulbous Posterior - Membranous - Prostatic
Urogenital diaphragm divides anterior from posterior
Case 113
How is a urethral injury typically treated
Suprapubic catheter for 3-6 months
Case 113
Describe the most common urethral injury?
What is it’s most common cause?
Type III
- Disrupted membranous and bulbous urethra
- Disrupted urogenital diaphragm and extravasation
MVC with pelvic fractures
Case 114
What are three causes of a urethral diverticulum?
Infection
Trauma
Prolonged catheterization
Case 115
DDX of an irregular urethra with stricture and filling defects
Carcinoma
- Predominantly SCC
Benign Conditions
- Papillary urethritis
- Nephrogenic adenoma
- Condylomata acuminata
- Amyloidosis
- Sarcoidosis
- Balanitis xerotica obliterans
Case 115
What has a better prognosis, anterior v. posterior urethra carcinoma?
Anterior
Case 115
Most commonly cited risk factor for SCC of the urethra?
Chronic urethral stricture of any cause
Case 116
Define septate uterus
How is it treated?
Divided by fibrous septum
- Convex, flat, or minimally indented
- Intercornual distance less than 4 cm
Treatment
- Hysteroscopic metroplasty
Case 116
Define bicornuate uterus.
How is it treated?
Divided by myometrial tissue
- Deeply concave fundus
- Horns are divergent
- Intercornual distance > 4cm
Treatment
- Abdominal metroplasty
Case 117
What is typically associated with Polycystic Ovary Disease?
Infertility
Hirsutism
Obesity
Oligomenorrhea
Case 117
How is POD diagnosed with LH/FSH?
LH/FSH ratio >2
Case 117
What are classic U/S findings in POD?
Are these imaging finding pathogmonic?
Enlarged hyperechoic ovaries
Multiple small peripheral follicles
- String of pearls
No
Case 118
What are imaging findings of Ovarian Hyperstimulation?
Ovaries
- Enlarged
- Multiple large follicles
Associated Findings
- Ascites
- Pleural effusions
- Pericardial effusion
Case 118
Who’s at risk for Ovarian Hyperstimulation Syndrome?
Thin Young High Gonadotropins High Estradiol levels PCOD patients
Case 118
What are complications of Ovarian Hyperstimulation?
Ovarian torsion Rupture - Hemorrhagic Cyst DVT PE
Case 119
What is suspected when you see a snowstorm appearance in the uterus?
What type of ovarian cysts are seen with this entity?
Complete hydatidiform mole
Theca Lutein Cysts
- Multilocular cysts
- Expand the ovary
- 2o to overstimulation (hCG)
Case 119
How do patients with molar pregnancy present?
Rapid uterine enlargement
Hyperemesis
Vaginal bleeding
Markedly elevated hCG levels
Case 120
DDx for postpartum patients with fever and lower abdominal pain?
Ovarian Vein Thrombosis Appendicitis Pyelonephritis Endometritis TOA Acute Cholecystitis
Case 120
What are the two most common causes of ovarian vein thrombosis?
Endometritis
Oncologic surgery
Case 120
What is the most likely side of ovarian vein thrombosis?
Right
Case 121
Describe a Cesarean section scar on MRI
Focal disruption in the junctional zone along the ventral uterine corpus
Junctional zone is inner third of myometrium
Case 122
What causes an ovarian mass with multiple thick septations, solid peripheral nodules, and ascites?
Ovarian Carcinoma
Case 122
CA-125 is elevated in what 5 entities?
Ovarian neoplasm - Elevated in 80% of pts Uterine leiomyoma Endometriosis PID Early pregnancy
Case 122
What are imaging features of ovarian cancer?
Increased ovarian size (>7.5cm) Solid component of the mass Mural nodules Internal papillary projections Thickened septations
Case 122
What are the four types of ovarian neoplasms
Epithelial
Germ cell
Sex cord-stromal
Metastasis
Case 123
Where do ovarian cancer peritoneal implants typically go?
Pouch of Douglas
Ileocecal region
Right paracolic gutter
Case 123
What is Pseudomyxoma peritonei?
Large amounts of gelatinous material
-> Peritoneal cavity
Transformation of peritoneal mesothelium
- to a mucin-secreting epithelium
- after perforation of a mucinous
- cystadenoma or cystadenocarcinoma
Case 124
What is Krukenberg Metastasis?
Mets to the ovary from GI adenoCA
- Stomach
- Colon
Case 124
How do you differentiate Krukenberg Metastasis to the ovary from primary ovarian neoplasm
Krukenberg Mets:
- Solid
- Bilateral
- Present late
Primary Mets
- Cystic >10 cm
- Unilateral
- Present early
Case 125
What is the DDX of a homogenous hypoechoic mass in the adnexa?
Ovarian fibroma
Pedunculate uterine leiomyoma
Case 125
What is Meig’s Syndrome?
Ovarian fibroma
Ascites
Hydrothorax
Case 125
What are the MRI characteristics of Ovarian Fibroma?
Well-circumscribed mass Low T1 Low T2 unless - edema - degeneration
Case 125
T/F
Most Ovarian Fibromas are surgically removed.
Ovarian Fibromas secrete steroids.
True
- Rare malignant potential
False
Case 126
What is the most common cause of ovarian torsion?
Benign cystic teratoma
Kids may get torsion without an underlying mass
Case 126
What are the classic imaging findings of ovarian torsion?
Enlarged ovary Complex, cystic or solid mass Dilated fallopian tube with a thick wall - see Case 129 image Intraperitoneal fluid Absent flow in the ovary Twisted vascular pedicle
Case 126
T/F
Doppler flow in the ovary excludes torsion.
False
Ovaries have dual blood supply
Doppler is therefore of limited use in torsion
Case 127
What should you consider in a patient with a mass presenting with severe, cyclical pelvic pain?
Endometriosis
Case 128
In US evaluation of an ovarian mass, what are the most important features for distinguishing between a benign and malignant ovarian mass?
Solid Elements
- Presence
- Echogenicity
Case 128
What is the Pulsatility index on sonography?
(Peak systolic velocity - End diastolic velocity) /
Mean velocity
Case 128
What is the Resistive index on sonography?
(Peak systolic velocity - End diastolic velocity) /
Peak systolic velocity
Case 128
What features suggest that an ovarian mass as malignant?
Solid component
Flow in a septation or the solid component
Free fluid in a postmenopausal woman
Thick septation (>3mm)
Case 129
What is the most likely cause of rapid or massive ovarian enlargement or edema?
Ovarian torsion
- Partial or intermittent
Case 129
What is the vascular supply of the ovaries?
Ovarian artery
- Branch of the aorta
Uterine artery
- Branch of the anterior trunk of the internal iliac artery
Case 130
What is ovarian pexy and what is its indication?
Ovaries are attached to superior pelvic sidewall
Removes the ovaries from radiation field in cervical CA
Case 131
U/S showing enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas is likely?
Gestational Trophoblastic Disease
- Molar pregnancy
- Partial Mole
- Choriocarcinoma
Case 131
DDX of an enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas
Gestational Trophoblastic Disease
Degenerated uterine leiomyoma
Endometrial proliferative disease
Degeneration of the placenta
Case 132
What are four causes of a thickened endometrium in postmenopausal women?
Endometrial hyperplasia Polyps Carcinoma Drugs - Tamoxifen - Estrogen replacement
Case 132
What is the most common type of endometrial cancer?
Adenocarcinoma (70%)
Case 132
What stage is endometrial cancer that invades the cervix
Stage IIB
Case 133
What is the best way to assess endometrial cancer?
Transvaginal Ultrasound
Case 133
What are risk factors for endometrial cancer?
Obesity Diabetes Nulliparity Unopposed Estrogen Tamoxifen therapy History of Breast or colon CA
Case 134
What is an adnexal mass that is T1 bright, T2 dark with no fat suppression on MRI?
Endometrioma
- Chocolate cyst
Case 134
What extrapelvic organs can have endometriosis?
Lungs
- Catamenial ptx
CNS
Case 134
T/F
Endometriomas increase likelihood for torsion
False
- adhesions
Case 134
T/F
MRI is the best modality to diagnose endometriosis
False
- Laparoscopy
- > best for diagnosis and staging
Case 135
What is the continuum of PID?
Cervicitis Endometritis Salpingitis Pelvic peritonitis Tuboovarian abscess - 1% of all PID patients get TOA's
Case 136
Uterine didelphys is a result of what?
What do you see?
Complete failure of fusion of the mullerian ducts
Two hemiuteri, with separate cervices and vagina
Case 136
What can cause dilation of one of the uterine horns?
- Transverse vaginal septum
- Cervical stenosis
Case 136
Uterine didelphys and Septate uterus are associated with what renal anomaly?
Unilateral renal agenesis
Case 137
What is the most important feature to distinguish bicornuate from a septate uterus?
External uterine fundal contour
Septate: Flat or convex
Bicornuate: Concave
Case 138
How often does ovarian vein thrombosis occur in surgical oncology patients?
80%
Case 138
What does ovarian vein thrombosis look like on MRI?
T1 dark
T2 bright
Case 139
Define adenomyosis
Aberrant ectopic endometrium within the myometrium
Case 139
What are the imaging characteristics of Adenomyosis?
Junctional zone > 12mm
Ectopic endometrial glands
- T2 hyperintense foci
Case 140
During what phase of the menstrual cycle is the endometrium thickest?
What should it measure?
Secretory phase
8-12mm
Case 140
T/F
The longer a person takes Tamoxifen and the higher the dose, the greater the risk for endometrial hyperplasia or cancer.
In women treated with Tamoxifen, endometrial hyperplasia is the most common endometrial abnormality resulting in abnormal endometrial thickening.
True
- Especially > 5 years
False
- Endometrial polyps
Case 141
What pelvic tumors can invade the bladder?
Cervical
Prostate
Urethra
Rectum
Case 142
T/F
Patients with endometrial leiomyoma are more likely to get endometrial carcinoma.
True
Case 142
T/F
Benign Leiomyomas can metastasize to the lungs.
True
Case 143
DDX of a pregnant patient with pelvic pain
Subchorionic hematoma Degenerating fibroid Adenomyosis Focal myometrial contractions Solid adnexal mass
Case 143
What complications are associated with fibroids in pregnancy?
Pain Bleeding Spontaneous abortion Placental abruption Fetal malposition Mechanical obstruction of the uterus
Case 144
What symptoms do patients with pelvic congestion syndrome present with?
Pelvic fullness Pain - better in AM - worst at the end of the day Dyspareunia
Case 144
How is pelvic congestion syndrome treated?
Hormones Laparoscopic ligation Embolization - Ovarian vein - Internal iliac veins
Case 144
Does embolization of pelvic congestion reduce fertility?
No
- No effect on menstruation or fertility
Case 145
DDX of an adrenal mass
Adenoma - most common - even in cancer pts Metastasis Hyperfunctioning Adrenal neoplasm - Pheochromocytoma - Cushing's syndrome - Aldosteronoma
Case 146
What causes an adrenal adenoma to drop off in signal on chemical shift MRI?
Phase cancellation
- caused by the presence of both fat and water protons within the same voxel.
Case 147
For adrenal adenoma on dynamic CT
What absolute washout is diagnostic?
How is it calculated?
Absolute washout of 60%
(HU at dynamic CT - HU at 15 minute delayed) /
(HU at dynamic CT - HU at noncontrast CT) x 100
Case 147
For adrenal adenoma on dynamic CT
What relative washout is diagnostic?
How is it calculated?
Relative washout of 40%
(HU at dynamic CT - HU at 15 minute delayed) /
HU at dynamic CT x 100
Case 148
T/F
The spleen should be used as the control in evaluating an adrenal adenoma on in and out of phase imaging.
True
Don’t use the liver!
Case 148
What % of adenomas do not demonstrate signal drop-off on out-of-phase imaging or have HU less than 10?
20%
- Lipid-poor
Case 149
What are three etiologies of adrenal hemorrhage in neonates v. adults?
Neonates:
- Birth trauma
- Anoxia
- Dehydration
Adults:
- Anticoagulation
- Trauma
- Surgery
Case 149
What is the DDX for an adrenal mass in a neonate
Adrenal hemorrhage
Neuroblastoma
Case 150
What are the three types of adrenal cysts?
True cysts
- Endothelial (lymphangioma)
- Epithelial
Pseudocysts
- Develops from prior adrenal hematoma
Infectious cysts
- Echinococcal
Case 151
What is Waterhouse-Friderichsen Syndrome?
Adrenal hemorrhage associated with fulminant meningococcemia resulting in acute adrenocortical insufficiency
Case 152
What is the most common type of true Adrenal cyst
Endothelial cyst
- Lymphangioma > Hemangioma
Case 152
Is calcification a common feature of adrenal cysts?
Yes
- up to 54%
Case 152
What is the most common cause of adrenal pseudocyst?
Adrenal hemorrhage
Case 153
What are the two histologic contents of an adrenal myelolipoma?
Malignant potential?
Hematopoietic tissue
Mature adipose tissue
No malignant potential
Case 153
What two ways do myelolipomas present
Incidental
Pain
- 2o to hemorrhage
Case 154
How can you differentiate that an adrenal mass represents an adenoma v. pheochromocytoma v. metastasis
Adenoma - CT or MRI Pheochromocytoma - I-131 MIBG scan - Urine VMA level Metastasis - PET/CT
Case 116
Define septate uterus.
How is it treated?
Divided by Fibrous septum
- Convex, flat or minimally indented fundus
- Intercornual distance
Case 151
Which adrenal is more prone to traumatic hemorrhage?
Right
- Due to compression by the adjacent liver
Case 155
Where do pheochromocytomas typically recur postop?
Surgical bed
Ipsilateral retroperitoneum
- local metastasis
Case 155
What 3 clinical tests are used for Pheochromocytoma?
Serum plasma catecholamine levels
24-hour urine vanillylmandelic acid (VMA)
Metanephrine levels
Case 156
DDX of adrenal calcifications
Granulomatous disease - TB - Histoplasmosis Prior hemorrhage Treated metastasis
Case 156
What is the adrenal morphology in Addison’s disease?
Symptoms?
Small adrenals
Calcifications
Asthenia Hypotension Anorexia Weight loss Pain, N/V/D Hyperpigmentation
Case 156
What are the causes of Addison’s disease?
Autoimmune Adrenal destruction - Hemorrhage - Infection Metastasis - Very rare
Case 157
What syndrome is associated with Insulin-dependent diabetes, autoimmune thyroiditis, and Addison’s disease?
Schmidt’s syndrome
- Polyglandular Synd Type II
Case 157
DDx for adrenal enlargement.
Granulomatous adrenalitis Adrenal hemorrhage Mets Lymphoma Sarcoidosis Amyloidosis
Case 158
Where does renal artery stenosis typically occur?
Ostium
Proximal 2cm
Case 159
What are the two most commonly affected arteries in Fibromuscular dysplasia (FMD)?
Renal arteries
- 70%
Carotid arteries
- 30%
Case 159
What is the best treatment for FMD?
Balloon angioplasty
- 90% effective
No need for stents
Case 160
Why should renal arterial aneurysms be treated no matter their size?
Increased risk
- Rupture
- Renal embolization
Case 161
What do renal transplant surgeons need to know by imaging prior to taking a donor kidney?
Number of renal arteries (they prefer one)
Size and location of renal arteries
Number, size and location of renal veins
Size and location of the kidneys
Presence of congenital or acquired renal disease
Case 161
What is the preferred donor kidney for transplant?
Left
- Longer renal vein for anastamosis
Case 162
What is the incidence of an AV fistula post biopsy and what is the typical course?
Incidence
- 9%
Spontaneously Thrombose
- 70-95%
Case 163
What are 3 indications for renal artery embolization
Prior to nephrectomy to treat RCC
Prior to renal tumor ablation in nonsurgical patients
Posttraumatic bleeding
Case 164
What % of patients with HTN have renal artery stenosis?
1%
Case 164
What is the restenosis rate after treating RAS?
Up to 25%
Case 165
What is the success rate of uterine fibroid embolization?
Up to 90%
Case 165
What complications are associated with UFE’s
Minor: 5%
- Pain
- Nausea
- Groin hematoma
- Amenorrhea
Major 0.5%
- Infection
- DVT
- PE
Case 166
What are the indications for a percutaneous nephrostomy?
Relief of obstructive symptoms Access for nephrolithotomy Urothelial biopsy or ablation - Urothelial tumor Whitaker test
Case 170
Retroperitoneal Liposarcoma can be differentiated by lipoma by?
Soft tissue components
- but not 100%
- Liposarcs can be purely lipomatous
Case 170
T/F
Poorly differentiated liposarcomas may not contain any detectable fat
True
Case 171
What is Zinner Syndrome?
Coexistence of Ipsilateral
- Seminal Vesicle cyst
AND
- Renal dysgenesis or agenesis
Case 171
DDX of lateral paraprostatic cysts
Seminal vesicle cyst
Bladder diverticula
- make sure to trace it to source
Case 171
What renal anomalies are associated with unilateral seminal vesicle cyst?
Renal Agenesis Renal Ectopia APCKD Duplicated system Ectopic Ureteral Insertion
Case 172
What organism is associated with prostatic abscesses?
E. coli
- Prostatitis
- Hematogenous spread
Case 173
DDX for focal area of T2 hypointense signal in the peripheral zone of the prostate gland.
Adenocarcinoma
Hyperplasia
Prostatitis
Hemorrhage after biopsy
Case 173
T/F
Contrast is useful in assessing the prostate in MRI that uses an endorectal surface coil.
Some peripheral zone cancers have high signal intensity on T2W images.
False
- In most cases it adds no benefit
True
- Mucinous
- Signet-ring AdenoCA
Case 174
What cancers cause osteoblastic bone metastasis?
Prostate Breast Bladder Lymphoma Lung Carcinoid
Case 175
What is the filling defect in the urethra posterior to the membranous urethra?
Verumontanum
Case 175
How does Chron’s disease typically affect the GU tract?
Direct extension of granulomatous enterocolitis
Case 176
DDX of scrotal U/S showing branching tubular anechoic structures with garlic walls in the mediastinum testis.
Tubular Ectasia of the Rete Testis
- No differential
- Associated with epididymal cysts
- No f/u imaging necessary
Case 177
DDX of testicular calcified testicular mass
Nonseminomatous germ cell tumor Epidermoid cyst Resolved infection Hematoma Infarction
Case 178
What organisms typically cause Fournier’s Gangrene?
Polymicrobial necrotizing fasciitis
- Gram-negative rods
- Streptococcal
- Staphylococcal
- Anaerobic strep
Case 178
Where does Fournier’s Gangrene start in women?
Vulva
Bartholin’s gland
Case 179
Testicular U/S shows a linear hypoechoic band extending across the testicular parenchyma. What is the Dx?
Testicular fracture
- The tunica albuginea is maintained
Testicular rupture
- The tunica is disrupted
- Testicular contents are extruded
Case 180
What arterial doppler findings are seen with erectile dysfunction after Papaverine injection?
Peak diastolic velocity > 3cm/sec
Case 180
What are two main causes of vasculogenic erectile dysfunction?
Arterial inflow disease
Venous incompetence
