GU Flashcards
GU
A contrast CT scan shows an incidental renal cyst that is hyperdense with thick septationsand a mural nodule. What is the Bosniak classification?
A. Type 1
B. Type 2
C. Type 2F
D. Type 3
E. Type 4
D. Type 3
Type 3 cysts have thickened irregular/smooth walls or septa in which measurable enhancement is present. These need surgery in most cases, as neoplasm cannot be excluded. They include complicated haemorrhagic/infected cysts, multilocular cystic nephroma and cystic neoplasms.
Type 2F (F denotes follow-up) cysts may contain multiple hairline-thin septa. Perceived(not measurable) enhancement of a hairline smooth septum or wall can be identified, and there may be minimal thickening of the wall or septa, which may contain calcification that may be thick 25 and nodular. There are no enhancing soft-tissue components; totally intrarenal non-enhancing high-attenuation renal lesions (>3 cm) are also included in this category. These lesions are generally well marginated and are thought to be benign but need follow-up.
Type 1 is a benign simple water attenuation cyst with a hairline-thin wall that does not contain septa, calcifications, or solid components and does not enhance.
Type 2 is a benign cystic lesion that may contain a few hairline septa in which perceived(not measurable) enhancement might be appreciated; fine calcification or a short segment of slightly thickened calcification may be present in the wall or septa. Uniformly high-attenuation lesions (<3 cm) that are sharply marginated and do not enhance are included in this group. No intervention is needed.
Type 4 are clearly malignant cystic masses that can have all of the criteria of Type 3 but also contain distinct enhancing soft-tissue components independent of the wall or septa; these masses need to be removed.
GU
A 21-year-old woman with infertility undergoes US that shows a 2-cm right adnexal mass with posterior acoustic enhancement. Another multilocular cyst is seen in the left ovary. Further evaluation with MR shows multiple small lesions in both the ovaries and pouch of Douglas, which were hyperintense on fat-suppressed T1W images with shading sign onT2W images. What is the likely diagnosis?
A. Dermoid
B. Endometrioid carcinoma of the ovary
C. Endometriosis
D. PCOS (polycystic ovarian syndrome)
E. Pelvic inflammatory disease
C. Endometriosis
Endometriosis is a common multifocal gynaecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. The ovaries are among the most common sites (20%–40% of cases). It manifests either as superficial fibrotic implants or as chronic retention cysts with cyclic bleeding (endometriomas). Endometriomas are thick-walled cysts with a dark, dense content that represents degenerated blood products. The cysts may be solitary or multiple, and they are bilateral in 50% of cases. Endometriomas may include peripheral nodules (blood clots) or fluid–fluid levels; in the latter, the non-dependent portion represents the freshest bleeding. A multilocular-appearing endometrioma may consist of multiple contiguous cysts. Endometriomas are a marker of severity of deeply infiltrating endometriosis.
On MRI, cystic cavities can appear as simple fluid, with high signal intensity on T2-weighted and low signal intensity on T1-weighted images. They also may show high signal intensity on T1-weighted andT1-weighted fat-saturated images because of their haemorrhagic content. The shading sign, a common and unique feature of endometriomas, represents old blood products, which contain extremely high iron and protein concentrations. These haemorrhagic cysts typically show high signal intensity on T1-weighted images and low signal intensity on T2-weightedimages.
However, endometriomas also may show variable signal intensity on T2-weighted images.
GU
A 50-year-old builder is involved in a high-speed RTA. CT is performed according to trauma protocol, demonstrating extra-peritoneal rupture of the bladder. Which of the following best describes this?
A. Contrast pooling in the para colic gutters.
B. Contrast outlining small bowel loops.
C. Flame-shaped contrast seen in the peri-vesical fat.
D. CT cystogram is usually normal.
E. Intramural contrast on CT cystogram.
C. Flame-shaped contrast seen in the perivesical fat
Sandler described five types of bladder injuries with conventional cystography.
Type 1: Contusion: Bladder contusion is defined as an incomplete or partial tear of the bladder mucosa. Findings at conventional and CT cystography are normal.
Type 2: Intraperitoneal rupture: CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds and in the para-colic gutters.
Type 3: Interstitial injury: Interstitial bladder injury is rare. CT cystography may demonstrate intramural contrast material without extravasation.
Type 4: Extraperitoneal rupture: Extraperitoneal rupture is the most common type of bladder injury (80%–90% of cases) Extravasation is confined to the peri-vesical space in simple ruptures (Type 4a), whereas in complex ruptures, contrast extends beyond the peri-vesical space (Type 4b) and may dissect into thigh, perineum and properitoneal fat planes.
Type 5: Combined rupture: CT cystography usually demonstrates extravasation patterns that are typical for both types of injury.
GU
Which of the following characteristics is typical of prostate cancer?
A. Low on T1 High on T2
B. Low on T1 Low on T2
C. Isointense on T1 High on T2
D. High on T1 High on T2
E. Isointense on T1 Isointense on T2
B. Low on T1 Low on T2
On T1-weighted MRI, the normal prostate gland demonstrates homogeneous intermediate to low signal intensity. T1-weighted MRI has insufficient soft-tissue contrast resolution for visualising the intraprostatic anatomy or abnormality. The zonal anatomy of the prostate gland is best depicted on high-resolution T2-weighted images. Prostate has a homogenous low-signal background on T1-weighted images. On T2-weighted images, prostate cancer usually demonstrates low signal intensity in contrast to the high signal intensity of the normal peripheral zone. Low signal intensity in the peripheral zone, however, can also be seen in several benign conditions, such as haemorrhage, prostatitis, hyperplastic nodules, or post-treatment sequelae (e.g., as a result of irradiation or hormonal treatment).
GU
Which of the following is false?
A. Skene cyst – Lateral to external urethral meatus
B. Nabothian cyst – Lateral to the endocervical canal
C. Gartner’s dust cyst – Posterolateral aspect of the upper vagina
D. Bartholin’s cyst – Posterolateral aspect of the vagina
E. Urethral diverticulum – Posterolateral aspect of mid-urethra
C. Gartner’s duct cyst Posterolateral aspect of the upper vagina
Multiple paraurethral Skene’s glands are related to the female urethra. There are paraurethral ducts that drain into the distal urethral lumen. Nabothian cysts are retention cysts in the cervix related to chronic cervicitis. Gartner’s duct cysts are found at the anterolateral aspect of the proximal third of the vaginal wall. Bartholin’s gland cysts affect the posterolateral aspect of the lower vaginal wall. Urethral diverticulum occurs at the posterolateral aspect of the mid-urethra.
GU
A 55-year old man with several episodes of epididymo-orchitis in the past has an ultrasound of the scrotum. The radiologist performing the scan notices several hypoechoic structures within the mediastinum testis and incidental epididymal cysts. There was no Doppler flow. What is the most likely diagnosis?
A. Lymphoma of the testes
B. Cystic dysplasia of the testis
C. Seminoma
D. Abscess
E. Cystic transformation of rete testis
E. Cystic transformation of rete testis
Cystic transformation of rete testis is a benign condition, also known as tubular ectasia, resulting from partial or complete obliteration of the efferent ductules that causes ectasia and, eventually, cystic transformation. The location of the lesion in or adjacent to the mediastinum testis and the presence of epididymal cysts are characteristic. Cystic dysplasia of the rete testis is a rare benign testicular tumour that is found mainly in the paediatric population. Abscesses are usually secondary to epididymo-orchitis; however, they appear cystic with shaggy, irregular walls; intratesticular location; low-level internal echoes; and occasionally hypervascular margins. Teratomas are the most frequent to manifest as cystic masses; however, cystic tumours are rare and, when present, usually have an abnormal rind of parenchyma with increased echogenicity surrounding the cystic lesion.
GU
A 60-year-old heavy smoker presents with haematuria. US KUB shows a midline fluid-filled cavity with mixed echogenicity and calcification adjacent to the bladder wall. CT shows a focal low-attenuation enhancing mass along a cord-like structure extending from the bladder to the umbilicus. What is the most likely diagnosis?
A. Complex urachal cyst
B. Vescico urachal diverticulum
C. Urachal adenocarcinoma
D. Transitional cell carcinoma
E. Urachal rhabdomyosarcoma
C. Urachal adenocarcinoma
Urachal adenocarcinoma is characteristically located at the dome of the bladder in the midline or slightly off midline. Ninety percent of masses occur close to the bladder, with the remainder along the course of the urachus or at the umbilical end. A midline, infra-umbilical, soft-tissue mass with calcification is characteristic and is considered to be urachal adenocarcinoma until proved otherwise. Eighty percent of urachal cancers are adenocarcinoma. At CT, the tumour is mixed solid
and cystic in 84% of cases and solid in the remainder. CT is the most sensitive modality for calcification, which is present in 72% of cases and is more commonly peripheral than stippled. On T2-weighted MRI, focal areas of high signal intensity from mucin are highly suggestive of urachal adenocarcinoma. The solid portions of the tumour are isointense to soft tissue on T1-weighted images and enhance with intravenous contrast material.
GU
A woman presents with infertility and undergoes a hysterosalpingogram. This demonstrates a uterus with two converging horns. A wide angle is seen at the roof of the uterus.
Which uterine anomaly does the patient have?
A. Uterine didelphys
B. Septate uterus
C. Arcuate uterus
D. Bicornuate uterus
E. Unicornuate uterus
D. Bicornuate uterus
While the presence of a divided rather than triangular uterine cavity at Hysterosalpingogram (HSG) may suggest the presence of an Mullerian duct anomaly (MDA), it is not possible to differentiate between subtypes. MRI and US provide greater anatomic detail; both of these imaging methods provide information on the external uterine contour, which is an important diagnostic feature of MDAs. Furthermore, both MRI and US may be used to assess for concomitant renal anomalies; renal anomalies occur at a higher rate among MDA patients. Unicornuate uterus appears as a small, oblong, off-midline structure on US and MRI. Uterus didelphys results from complete failure of Mullerian duct fusion. Each duct develops fully with duplication of the uterine horns, cervix and proximal vagina. A fundal cleft greater than 1 cm has been reported to be 100% sensitive and specific in differentiation of fusion anomalies (didelphys and bicornuate) from reabsorption anomalies (septate and arcuate). Bicornuate uterus involves duplication of the uterus with possible duplication of the cervix (bicornuate unicollis or bicornuate bicollis). HSG demonstrates opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes. Historically, an intercornual angle of greater than 105° was used for diagnosis of bicornuate uterus. Septate uterus is the most common form of MDA, accounting for approximately 55% of cases. Historically, an angle of less than 75° between the uterine horns has been reported to be suggestive of a septate rather than bicornuate uterus. However, considerable overlap occurs between septate and bicornuate uteri; as such, the angle measurement is not a reliable diagnostic feature. Arcuate uterus at HSG shows a single uterine cavity with a broad saddle-shaped indentation at the uterine fundus.
GU
A 40-year-old man who is a known hypothyroid patient, presents with weight loss and dull pain in the flank and back. He undergoes an abdominal CT. Regarding retroperitoneal fibrosis, all of the following is seen on imaging, except
A. Medial deviation of the ureters in the middle third, typically bilateral.
B. CT shows soft-tissue mass displacing the aorta anteriorly.
C. T2W MRI shows variable signal.
D. PET CT has high sensitivity.
E. Hydronephrosis is evident on CT urogram.
B. CT shows soft-tissue mass displacing the aorta anteriorly
Intravenous urography usually demonstrates the classic triad of medial deviation of the middle third of the ureters, tapering of the lumen of one or both ureters in the lower lumbar spine or upper sacral region, and proximal unilateral or bilateral hydroureteronephrosis with delayed excretion of contrast material. CT and MRI is the mainstay of non-invasive diagnosis of Retroperitoneal fibrosis (RPF). CT allows comprehensive evaluation of the morphology, location and extent of RPF and involvement of adjacent organs and vascular structures. Moreover, abdominal CT allows detection of diseases often associated with idiopathic RPF (e.g., autoimmune pancreatitis) or demonstrating an underlying cause in cases of secondary RPF (e.g., malignancy). CT shows a well-defined mass, usually anterior and lateral to the aorta, sparing the posterior aspect and not causing aortic displacement. Idiopathic RPF typically has low signal intensity on T1 weighted images. The signal intensity on T2 weighted images is variable and reflects the degree of associated active inflammation (hypercellularity and oedema). After administration of contrast material, early soft-tissue enhancement mirrors the degree of inflammatory activity observed at T2-weighted imaging. The sensitivity of 18F-FDG PET is very high, which allows detection and quantification of the metabolic activity of retroperitoneal lesions. Although sensitivity is high, specificity is low and aortic wall in the elderly can show FDG uptake.
GU
The causes of medullary nephrocalcinosis include all, except
A. Hyperparathyroidism
B. Renal tubular acidosis
C. Medullary sponge kidney
D. Hypervitaminosis D
E. Alport’s syndrome
E. Alport’s syndrome
Causes of medullary nephrocalcinosis include hyperparathyroidism, sarcoidosis, myelomatosis, primary or secondary hyperoxaluria (Crohn’s disease), hyperthyroidism, osteoporosis, idiopathic hypercalciuria, renal tubular acidosis, medullary sponge kidney and drug-induced (hypervitaminosis D, milk-alkali syndrome).
Alport’s syndrome is an autosomal dominant condition also called chronic hereditary nephritis, associated with ocular abnormalities, deafness, small kidneys, cortical calcification and progressive renal failure without hypertension.
GU
Of the normal uterus signal on MR, which is correct?
Endometrium – Myometrium – Junctional zone
A. High on T2 – Intermediate on T2 – High on T2
B. High on T2 – Intermediate on T2 – Low on T2
C. Isointense on T1 – Isointense on T1 – High on T1
D. Isointense on T1 – High on T1 – Low on T1
E. Low on T1 – Low on T2 – High on T2
B. High on T2 Intermediate on T2 Low on T2
On T1-weighted images, normal pelvic musculature and viscera demonstrate homogenous low-to-intermediate signal intensity. Zonal architecture is best demonstrated on T2-weighted MRI.
T2 signal reflects the water content, which is highest in the endometrium, intermediate in the myometrium and least in the junctional zone.
GU
A 25-year-old man undergoing abdominal CT shows the presence of bridging renal tissue across the midline at the level of the lower poles, consistent with a horseshoe kidney.
All the following are recognized associations, except
A. Bicornuate uterus
B. Cardiac anomaly
C. Undescended testis
D. Tracheo-oesophageal fistula
E. Anorectal malformation
D. Tracheo-oesophageal fistula
Horseshoe kidney is the most common fusion anomaly of the kidneys. There is recognised association with cardiovascular, skeletal, CNS, genitourinary anomalies (undescended testes, bicornuate uterus, duplication of ureter, hypospadias, etc.), anorectal malformations, trisomy 18 and Turner syndrome. Vesico ureteric reflux, hydronephrosis secondary’ to PUJ obstruction and increased frequency of complications like renal stones and infection are recognised.
GU
A 17-year-old girl is brought to the emergency department with sudden onset abdominal pain. She is known to have a cardiac tumour. On examination, she is hypotensive, peritonitic, and undergoes an urgent CT abdomen and pelvis. This shows bilateral large renal masses; the largest on the right measures 12 cm with multiple low-attenuation areas of -20 HU with large tortuous vessels and contrast extravasation into the retroperitoneum. These features arc associated with
A. Von Hippel-Lindau
B. Neurofibromatosis type 1
C. Sturge-Weber syndrome
D. Tuberous sclerosis
E. Amyloidosis
D. Tuberous sclerosis
Tuberous sclerosis (TS) is an autosomal, dominant, inherited neurocutaneous syndrome characterised by a variety of hamartomatous lesions in various organs. Classically, TS demonstrates
a triad of clinical features (Vogt triad): mental retardation, epilepsy and adenoma sebaceum. Recently advocated criteria for diagnosis of TS consist of both major and minor diagnostic features.
Major features include facial angiofibromas, hypomelanotic macules, cortical tubers and subependymal nodules (frequent); retinal hamartoma, LAM (lymphangioleiomyomatosis), renal AML (angiomyolipoma), and cardiac rhabdomyomas (common); and shagreen patches, ungual fibroma and subependymal giant cell tumours (uncommon). Minor features include dental enamel pits and hamartomatous rectal polyps (frequent); bone cysts, renal cysts, gingival fibromas and cerebral white matter radial migration lines (common); and confetti skin lesions and retinal achromatic patches (uncommon). Definite diagnosis requires two major or one major and two minor criteria.
GU
The following are signs of a normal gestational sac, except
A. Intradecidual sign.
B. Cardiac activity seen with a CRL (crown-rump length) of 6 mm.
C. Double decidual sign.
D. Mean sac diameter increases by 1 mm/day.
E. Embryo seen with a mean sac diameter of 10 mm.
E. Embryo seen with a mean sac diameter of 10 mm.
The gestational sac is first identifiable on transvaginal ultrasound at 4.5 weeks. It appears as a round 2-3 mm fluid collection. It is located in the central echogenic part of the endometrium (decidua). In some cases, it is surrounded by two echogenic rings corresponding to the two layers of decidua, described as the double decidual sac sign of intrauterine pregnancy. Sometimes the gestational sac is eccentrically located on one side of a thin white line corresponding to the collapsed uterine cavity, called the intradecidual sign.
The yolk sac is the first structure visualised on TVS (trans vaginal scan) within the sac at 5.5 weeks. Yolk sac is evident when sac diameter is 10 mm. Heartbeat is evident when crown-rump length (CRL) is 5 mm. On TVS, an embryo is seen when the mean sac diameter is 18 mm. Mean sac diameter increases by approximately 1 mm per day. Lack of foetal pole in a gestational sac with diameter more than 20 mm is suggestive of an anembryonic or nonviable pregnancy.
GU
A 56-year-old man undergoing CT urogram displays an incidental lesion in his right adrenal gland. He is asymptomatic apart from pain in the left loin, which is currently being investigated. All these features suggest that adrenal carcinoma is more likely than
a benign adenoma, except
A. Size more than 5 cm
B. Delayed washout
C. HU value of <37 on delayed contrast enhanced CT
D. Involvement of right kidney
E. Peripheral nodular enhancement
C. HU value of more than 37 on delayed contrast enhanced CT
Features suggestive of adrenal carcinoma on imaging include large size (>5 cm); invasion of other organs like liver, kidney, IVC, or diaphragm; calcification; central heterogeneous area of low density (tumour necrosis); peripheral nodular enhancement on contrast-enhanced images; and delayed washout. A HU of more than 37 on contrast-enhanced CT at 5-15 minutes after contrast injection is diagnostic of a benign adrenal lesion.
