GU Flashcards
DDx for medullary nephrocalcinosis
“HAM HOP”
H: hyperparathyroidism
A: (renal tubular) acidosis (type 1)
M: medullary sponge kidney, milk alkali syndrome
H: hypercalcemia/hypercalciuria, hypervitaminosis D
O: oxalosis
P: papillary necrosis
DDx for cortical nephrocalcinosis
"COAG" C: cortical necrosis O: oxalosis A: Alport syndrome G: (chronic) glomerulonephritis
What are the 4 histologic types of RCC?
- Clear cell (most common)
- Papillary
- Chromophobe
- Sarcomatoid
What are serum tumor markers for testicular neoplasms?
- Beta hCG- seminomas and choriocarcinomas
- Alpha fetoprotein- yolk sac tumors
What are the typical MR features of uterine leiomyomata?
- T1: Isointense to myometrium
- T2: loss of signal
- May be hyperintense on T1 and T2 if undergoing degen.
- Calcs may appear as areas of signal drop
How do you calculate absolute adrenal washout? What is considered an adenoma?
(PVP - Delayed) / (PVP - Unenhanced) x 100%
Absolute washout >60% = adenoma
How do you calculate relative adrenal washout? What is considered an adenoma?
(PVP - Delayed) / PVP x 100%
Relative enhancement washout >40% = adenoma
What is the timing for the enhanced and delayed phases for adrenal washout?
Radiology Assistant and Radiopaedia state, “1 min (PVP) for enhanced and 15 min for delayed”
A spoke wheel pattern of enhancement is characteristic of what renal tumor?
Oncocytoma; however, b/c it cannot be reliably distinguished from RCC and is much less common than RCC, oncocytoma should not be diagnosed prospectively.
What are the diagnostic criteria for Polycystic Ovarian Syndrome?
The revised Rotterdam consensus criteria devised in 2003 require 2 of 3 criteria for the dx:
1) oligo- or anovulation
2) hyperandrogenism (clinical or biochemical) and
3) polycystic ovaries: on imaging
- As well as the exclusion of other etiologies, such as congenital adrenal hyperplasia, Cushing syndrome and/or an androgen secreting tumour.
True or False: The frequency of malignant renal neoplasms in patients with adult PKD is the same as that in the general population.
True (Radcases)
What are imaging findings of PCOS?
- ≥ 12 follicles per ovary
- ≥ 10 mL ovarian volume
- Fulfillment of 1 criterion by 1 ovary is sufficient
- Usually bilateral, may be unilateral
- Peripheral follicles, “string of pearls”
- T2: Multiple small, subcapsular ↑ SI follicles, thick ↓ SI ovarian cortex, ↑ volume central ovarian stroma
- T1 C+: Rim enhancement of follicles
- Endometrial changes in 30-40%
- Endometrial thickening ± cystic change
- Cannot exclude atypia or endometrial carcinoma
What are indications for treatment of renal artery aneurysm?
- Size > 2 cm
- pregnancy
- expansion
- presence of other complications
What is the most common site for transitional cell carcinoma (TCC)?
Bladder, followed by the upper urinary tract
What is the rate of synchronous and metachronous TCC?
- 12% of upper urinary tract cases;
- 4% of bladder TCC will have synchronous or metachronous lesions
What is malakoplakia?
Flat areas of wall thickening, granulomatous inflammation, of the renal pelvis, ureter and bladder (most common site) are usually multiple and a/w UTI.
What is the mgmt of malakoplakia?
Although malakoplakia may be extremely aggressive, invading the perivesical space, and it can even cause bone destruction, non-surgical medical management is the mainstay of treatment, and as such biopsy for accurate diagnosis is essential.
What is the measurement cutoff for adenomyosis?
Thickening of the juntional zone of >12 mm is considered specific.
What is the typical appearance of multilocular cystic nephroma?
A cystic mass with multiple thin septa and herniation into the renal pelvis is characteristic.
What is the typical age distribution of multilocular cystic nephroma?
Bimodal: MLCN occurs most commonly in boys younger than 4 years of age or women older than 30 years.
What is the most common neoplastic lesion of the ovary?
dermoid cyst
What percentage of bladder ruptures are intraperitoneal?
20%
What is the typical MR appearance for uterine leiomyoma?
- isointense to myometrium on T1
- hypointense to myometrium on T2. A whorled pattern is characteristic.
- Hyperintensity on T1- or T2-WI may be seen in leiomyomata undergoing degeneration.
What are the 4 most common sources of adrenal metastases?
melanoma and cancers of the lung, breast, kidney
What are features of DES exposure to the uterus?
-T-shaped uterus, a wide lower uterine segment, small hypoplastic uterus, narrow fundal endometrial canal, irregular endometrial margins, and intraluminal uterine filling defects
DDx bilateral renal lesions
- RCC
- AML
- renal abscesses
- lymphoma
- metastases
- extramedullary hematopoiesis
- Erdheim Chester disease
DDx enhancing adnexal mass
- ovarian malignancy
- germ cell tumor
- sex cord stromal tumor
- pedunculated fibroid
- uterine sarcoma
- smooth muscle tumor of unknown malignant potential (STUMP) (rare)
What conditions are associated with pheochromocytoma?
- MEN II: both MEN IIa and MEN IIb (account for 3% of all pheochromocytoma)
- -almost never extra-adrenal
- -almost always bilateral
- von Hippel-Lindau disease
- von Recklinghausen disease (NF I)
- Sturge-Weber syndrome
- Carney triad: for extra-adrenal pheochromocytoma
- tuberous sclerosis
- familial pheochomocytoma
What biochemical markers are there for pheochromocytoma?
- 24-hour urine collection for creatinine, total catecholamines, vanillylmandelic acid, and metanephrines
- plasma free metanephrines
- serum chromogranin A (83% sensitive and 96% specific for identifying a pheochromocytoma. Chromogranin A levels are sometimes used to detect recurrent pheochromocytoma.)
What is the treatment of pheochromocytoma?
Definitive treatment is surgical, and if complete resection is achieved, without metastases, then surgery is curative, and hypertension usually resolves.
What nuclear medicine test can be used for detection of pheochromocytoma?
- I-123 MIBG (sensitivity 81%)
- Indium 111-DTPA Octreotide scan
What is Wunderlich syndrome?
Wunderlich syndrome is a rare condition, in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces. Most common causes are AML and RCC rupture.
- Characterized by the Lenk’s triad:
1) acute flank pain
2) flank mass
3) hypovolemic shock
What percentage of renal AML’s are associated with phakomatoses?
20%
Which phakomatoses are associated with AML’s?
- Tuberous sclerosis most common
- Also described in VHL and NF-1
What are theca lutein cysts?
Theca lutein cysts develop as a result of ovarian hyperstimulation by excessive B-hCG, either endogenous or exogenous.
- Bilaterally enlarged ovaries with multiple cysts of varying size
- Hypervascular central uterine mass if associated with molar pregnancy
- Ovaries are typically 6-12 cm in length but may be as large as 20 cm
- Individual cysts vary in size but usually measure several centimeters
- Preservation of underlying ovarian architecture
- Cysts are thin walled
- No nodules or solid component
- “Spoke-wheel” appearance of ovaries: Central stroma surrounded by peripheral cysts
What is the most common urachal remnant?
a) patent urachus
b) urachal diverticulum
c) urachal sinus
d) urachal cyst
a) Patent urachus is the most common type of urachal remnant and accounts for 50% of cases. Urachal cyst (30%), urachal sinus (15%), urachal diverticulum (5%)
Where are Gartner duct cysts located?
- Anterolateral wall of the proximal (superior) vagina and are typically located above the level of the inferiormost aspect of the pubic symphysis.
- Can be a/w developmental anomalies of the GU system; imaging of the kidneys should be considered when a symptomatic Gartner cyst is revealed on pelvic MR
Where are Bartholin gland cyst located?
Bartholin cysts located in posterolateral aspect of the distal (inferior) vagina. Can rarely develop malignancy, including SCC and adenoid cystic carcinoma
What are 4 types of ovarian neoplasm?
- ovarian epithelial neoplasms (60% of tumors, 85-90% of ovarian malignancies)
- germ cell neoplasms (15-30%)
- sex cord and stromal elements origin (5-10%)
- metastasis (5-15%)
What cancers can arise in endometriosis?
Endometrioid tumor and clear cell tumor
What are theca lutein cysts?
-type of functional ovarian cysts. They are typically multiple and seen bilaterally.
-They are thought to originate due to excessive amounts of circulating gonadotrophins such as beta-hCG.
-Hyperplasia of the theca interna cells is the predominant characteristic on histology. The ovarian parenchyma is often markedly oedematous and frequently contains foci of luteinized stromal cells.
-Associations:
–>they have a very high association with gestational trophoblastic disease.
Other reported associations include: multifetal pregnancy, PCOS, diabetes mellitus, clomiphere intake, ovulation induction
DDx T2 dark ovarian/adnexal masses
- fibrothecoma
- ovarian fibroma
- brenner tumor
- possibly endometrioma
- broad ligament fibroid
What 3 ovarian tumors are associated with endometrial hyperplasia or endometrial carcinoma?
- Endometrioid ca
- granulosa cell tumor (secretes estrogen)
- occasionally thecoma or fibrothecoma
What are 4 types of post-traumatic bladder injury?
Type 1 is bladder contusion
Type 2 is intraperitoneal rupture (30%)
Type 3 is extraperitoneal rupture (60%)
Type 4 is combined (5-10%)
DDx submucosal bladder pathology
the “oma” differential
- lipoma (or fatty hypertrophy of the submucosa)
- leiomyoma
- neurofibroma
- paraganglioma
- hemangioma
- lymphoma
- metastases
What is cystitis cystica?
What is the risk of malignancy?
Cystitis cystica is the same condition as ureteritis cystica and closely related to cystitis glandularis. It is a relatively common chronic reactive inflammatory disorders that occur in the setting of chronic irritation of the bladder mucosa.
Unclear risk for malignancy; although an association with adenocarcinoma of the bladder has been described (radiopedia).
What are the 4 parts of the male urethra from anterior to posterior?
“PBMP”
Penile, bulbous, membranous, prostatic urethra
What renal tumor is classically seen in African-American patients with sickle cell trait?
Renal medullary carcinoma
What renal tumor is classically seen in young men and older women? (boys 4, women 40)
multilocular cystic nephroma
What is the most common location of solid endometrial implants in endometriosis?
uterosacral ligament
What is the most common form of renal lymphoma?
There are 3 basic patterns of renal involvement by lymphoma:
1) direct invasion by adjacent nodal disease,
2) focal masses that may be solitary or multiple (MOST COMMON), and
3) diffuse infiltration.
Gonadal vein thrombosis is more common on which side?
The right side. Theorized that reflux within the left gonadal vein may prevent thrombosis.
What is the most common cause of medullary nephrocalcinosis?
hyperparathyroidism
What are the top 3 most common types of ovarian cancer?
1) serous cystadenocarcinoma
2) endometrioid ovarian cancer
3) mucinous cystadenocarcinoma
What are causes of papillary necrosis?
"POST CARDS" Pyelonephritis Obstruction Sickle cell disease (Bilateral) TB Cirrhosis Analgesic abuse (Bilateral) Renal vein thrombosis Diabetes (Bilateral) Systemic vasculitis
If bilateral, that’s SAD
DDx for T2 hypointense adnexal mass
- Blood products
- Endometrioma
- Hemorrhagic cyst
- Hematosalpinx
- Cystic adenomyosis
- Smooth muscle
- uterine leiomyoma (bridging vessel sign)
- Fibrous tissue
- Fibroma
- Fibrothecoma
- Cystadenofibroma
- Mixed cellularity
- Brenner tumor
- Struma ovarii
- Krukenberg tumor
What are characteristics of a Bosniak type 2 cyst?
-Multiple hairline thin separations
Minimal thickening of septa or wall
-Thick or nodular calcification
-Includes hyper dense cysts that are not Bosniak 2 (exceed >3 cm; under
What is the management of a Bosniak 2 cyst?
- Initial 6 month follow-up
- Then 12 month follow-up
- Then annually for 5 years total
- F/u may vary depending on any changes, degree of complexity, patient age and other factors.
What are the different types of Mullerian (uterine) anomalies?
“HUD B SAD”
- Hypoplasia/Agenesis
- Unicornuate
- Didelphys: Separate divergent uterine horns with large fundal cleft (as distinct from a septate uterus)
- Bicornuate (May help confirm anatomy by showing a deep (>1 cm) fundal cleft in the outer uterine contour and an intercornual distance of >4 cm)
- Septate (most common): the external uterine fundal contour may be convex, flat, or mildly (
What are the MR characteristics of peritoneal inclusion cysts?
- Generally T1-hypo, T2-hyperintense
- SI of fluid varies depending on fluid composition
- Hemorrhagic or proteinaceous fluid may be higher on T1-WI
- Septations of varying thickness, usually thin
- Tend to loculate and conform to surrounding structures, rather than displace them.
How is postpartum ovarian vein thrombosis treated?
With both broad-spectrum antibiotics and heparin
DDx renal mass with macroscopic fat
- AML
- RCC with osseous metaplasia or engulfing sinus fat
- liposarcoma at the renal capsule
- teratoma rarely
How do you diagnose renal artery stenosis on US?
- Elevated PSV (>200 cm/sec) in and just distal to the stenosis
- Ratio renal/aortic velocity > 3.5
DDx focal thickening of the endometrium
- endometrial polyp
- submucosal fibroid (shadowing pattern)
- blood clot
- RPOC in the correct setting (may show flow, but not always)
Normal endometrial thickness in premenopausal vs postmenopausal women?
- Abnormal if > 5 mm in POST-menopausal women with bleeding or > 8 mm if on HRT
- ASYMPTOMATIC POST-menopausal women: endometrium >11 mm, increased vascularity, inhomogeneity of endometrium, particulate fluid, should be referred to a gynaecologist
- No upper threshold in premenopausal women (secretory phase normal 7-16 mm)
DDx diffuse endometrial thickening
- Hematometrocolpos
- Endometritis
- Tamoxifen therapy (irregular with cystic changes)
- Endometrial hyperplasia
- Endometrial carcinoma
DDx extra-ovarian lesions
- Fibroid (pedunculated or broad ligament)
- Hydrosalpinx, pyosalpinx, hematosalpinx
- Peritoneal inclusion cyst (fluid colection with geometric margins)
- Para-ovarian cyst
- Non-gyne lesion
Cowper’s glands drain into which part of the urethra?
Bulbar urethra
Glands of Littre drain into which part of the urethra?
Urethral or periurethral glands (aka glands of Littre) empty into the Penile urethra
DDx T2 hypointense renal lesion
- AML (look for fat on T1 in/out and T1 +/- FS)
- papillary RCC
- lymphoma can be T1 and T2 hypointense to cortex
- Juxtaglomerular Cell Tumor (Reninoma)
- solitary fibrous tumor of the renal capsule (rare)
Risk factors for bladder squamous cell carcinoma
- chronic infection
- indwelling catheters
- neurogenic bladder
- schistosomiasis
What other adrenal lesion might show washout on an adrenal washout study?
- Pheochromocytoma (use 120 HU on enhanced phase as a cutoff to exclude adrenal adenoma)
- Should have a different clinical presentation. They also may have a higher absolute attenuation on the contrast phase (arterial or portal venous) and any adrenal lesion >120 HU with washout should not be diagnosed as an adenoma.
Formula for resistive index
RI = (PSV - EDV) / PSV
RI 0.7 or 0.8 is considered the upper limits of normal
DDx bladder wall calcification
- schistosomiasis (most common)
- post radiation
- interstitial cystitis
- TB
- TCC
- drug reaction (cyclophosphamide “cytoxan”)
- many others
DDx pear-shaped bladder
- pelvic lipomatosis
- hematoma
- iliopsoas hypertrophy
- normal variant
- lymphoma
- retroperitoneal fibrosis
Risk of malignant degeneration of an ovarian dermoid (teratoma)
Risk of torsion?
1-2% (squamous cell carcinoma)
17% risk of torsion
-(Statdx)
Which congenital uterine anomaly is most associated with renal anomalies?
“Renal anomalies are more commonly associated with unicornuate uterus than with the other müllerian duct anomalies and are reported in up to 40% of cases. “
AJR 2007
Which congenital uterine anomaly has the highest success rate for pregnancy (apart from arcuate)?
Uterus didelphys
