GU/Gynae/Adrenal Flashcards
Features of RCC?
Heterogenous mass +/- cystic or necrotic components
Sometimes Ca2+ or Fat mass
Enhancing (>15HU)
Vascular invasion
RF - VHL, smoker, dialysis > 3yrs
Type
1. Clear cell (most common)
-Aggressive, VHL. Enhances equal to the cortex in corticomedullary phase
- T2 hyperintense
- Papillary
- Less vascular and not equal to cortex enhancement in CM phase.
- Strongly associated with dialysis patients
T2 DARK - Medullary
- Sickle cell trait. Young, very aggressive - Chromophobe - associated with Birt- hogg disease
Features of renal oncocytoma?
Benign solid
Can’t reliable differentiate from RCC
2nd most common benign lesion after AML (AML never Have Ca2+ )
Echogenic stellate central scar
Hypodense and non-enhancing on CT
PET - Hotter than surrounding parenchyma, RCC colder
Bilateral = Birt hogg Dube
Also **chromophobe RCC
Renal lymphoma?
Can mimic anything as multiple different appearances
Commonly
- Bilateral
- Enlarged kidney
- Low density cortical based solid masses/nodules
NB - restricts diffusion on MRI
NHL is commonest cause
Bialteral enlarged kidney DDX
- Amyloid - increased echogenicity
- nephrotic syndrome. either primary or secondary and Hodgkin lymphoma
- HIV - increased echogenicity The sinus fat, however, becomes oedematous and therefore hypoechoic.
Features of Multilocular cystic nephroma
More common in paeds setting
Large, multilocular, cystic renal mass, typically 10cm
Thick fibrous capsule
NO solid components
protrudes into the renal pelvis
Michael jackson lesion - likes 4-year-old boys and 40-year-old women.
Bosniak classification for cystic lesions?
1 = Simple cyst. No septations or calcifications. Walls smooth and thin. < HU 20 on PV phase
2 = Hyperdense <3cm. smooth, thin walls and septations. Thin calcifications
2F = Hyperdense > 3cm.EHANCING thin walls or septations. +/- Nodular Ca. <5% chance Cancer
6 monthly review and then yearly for 5 years*
3 =**Thick **(> 4 mm) wall or septation. Mural nodule enhancement. Caorse calcification. 50% chance Cancer
4 = Large cystic/necrotic area. solid enhancing structures > 15HU. 100% Cancer
Hyperdense cyst
- HU > 70 and homogenous its benign 99.9%
Which has liver fibrosis - ARPKD or ADPKD
ARPKD
Presents in infants
Perinatal : More severe renal disease with pulmonary hypoplasia
Juvenile: Less renal disease, more hepatic issues. Portal hypertension & fibrosis develop in 50%.
Severity of the Liver fibrosis is inverse to renal disease
US - Smoothly enlarged kidneys and diffusely echogneic with loss of CM differentiation
Multiple innumerable tiny cysts. kidneys are normal to small in volume?
Lithium nephropathy
Common features of ectopic pregnancy?
Usually, isthmus portion of the fallopian tube
US signs -
Tubal ring sign - echogenic ring around the ectopic (95%)
Complex adnexal cystic mass (95%)
Free fluid + empty uterus (+B-hcg) (70%)
Pseudogestational sac (20%)
Simple adnexal cyst (10%)
Which sequence is best to assess mucle involvement in bladder Cancer?
T2
Detrusor muscle returns low signal but the continuity of this layer will be disrupted if there is invasion.
T1
useful for evaluating lymph node involvement and any bony metastases
STIR
extent of extravesical extension into the perivesical fat
Post-contrast images are of limited use in bladder cancer imaging but can be used to differentiation of tumour (enhances earlier) from inflammatory post-biopsy changes
Features of adrenal myelolipoma?
Bening tumour contain bulk fat
CA2+ (1/4)
Big, if >4cm
Can bleed, cause retroperitoneal haemorrhage
Associated but do not cause endocrine disorders - Cushings, conns)
Nb -
Signal suppression with fat saturation (STIR) and persistent signal on out-of-phase imaging indicate MACROSCOPIC fat, rather than the intracellular lipid characteristic of adrenal adenomas.
Features of prostate Cancer?
T2 low (background is high) - highest grade of suspicion for transitional zone lesions
**Restricts on diffusion (focal high b-value and corresponding low ADC signal) - best for peripheral zone **
Enhances - early and washes out. Type 3 curve
Stage B - confined by capsule, abutment of capsule but not bulging
Stage C - Extension through the capsule, bulging or frank extension through it
PSA density > 0.1
TZ cancer vs BPH?
Transition zone cancers on T2WI:
-lenticular nodules NO capsule.
-infiltrative borders
-homogeneous decreased signal
-generally anterior location
BPH
-Nodules: Round/oval; usually with capsule
-Most nodules will be internally heterogeneous, containing both increased and decreased signal on T2
- Nb can restrict diffusion and enhance with washout
Differentiate prostatic Utricle cyst vs Mullerian duct cyst?
Both midline cysts. Hard to differentiate
müllerian duct cyst
-large size and extension above the prostate
- ‘teardrop’ shape
Prostatic utricle cyst
-Typically small and at the base of the prostate
- ‘Pear shaped’
- communicates with the prostatic urethra
- Associated with hypospadias
Features of seminal vesical cyst?
Unilateral, lateral (paramedian)
Congenital or acquired
If congenital associated with
- Renal agenesis
- Vas defs agenesis
- Ectopic ureteric insertion
- Polycystic kidney disease
Acquired
- Hx prior prostatic surgery
Nb Zinner syndrome
Infertility + ipsilateral SV cyst and renal agenesis
Avascular, Well defined, round encepasulated with concentric hypoechoic and hyperechoic rings in the testicle?
Epidermoid cyst
‘Onion skin’ sign
Variably sized network of dilated tubules near mediastinum testis with no flow on color Doppler?
Tubular Ectasia of Rete Testis
DDx
-Mixed germ cell tumors/teratomas will often have cystic areas
- Does not form network of tubules
-Surrounding parenchyma is abnormal
- Will have abnormal flow on colour Doppler
Difference between spermatocele and epidydmal cyst?
Spermatocele
-multiseptated; may contain diffuse internal low-level echoes due to spermatozoa
- can be big
Epidydimal cyst
- simple and smaller
What lymphatics do testicular cancer spread to intially?
Para-aortic/retroperitoneal nodes at renal hilum.
Nb if nodes in pelvis/external iliacs are inguinal this is considered ‘non regional’ = M1 disease
What are the main types of testcular cancers?
Germ cell tumours
- Seminoma
- Non-seminomatous germ cell
Seminomas:
-Typically no cystic areas or calcification (rarely microcalcifcation)
-Best prognosis. Radiosensitive - melts with radiation.
- Age at diagnosis 40s
- US homogenously hypoechoic rounded mass
- MRI Homogenously T2 dark
Nonseminomatous:
- Heterogenous - Variable cystic elements, macrocalcifications, necrosis/hemorrhage
-Nb most are MIXED GERM cell. not pure cell type
- Teratoma or Yolk sac - 10
- Choriocarcinoma - 20s and 30s (most aggressive) as its mets haematogenously.
- Embryonal cell - 30s
Multiple hypoechoic masses in both testes with increased Vascualrity?
Testicular lymphoma
which testicular tumours are associated with elevated HCG and AFP?
HCG
- Seminoma
- Choriocarcinoma
AFP
- Mixed germ cell
- Yolk sac
Testicular tumours by age?
10s = Yolk sac tumour or teratoma
20s + 30s = Choriocarcinoma
30s = Embryonal cell carcinoma
40s = Seminoma
Features of XGP?
Staghorn calculus
Enlarged, often nonfunctioning kidney (chronic presentation)
Multiple low-attenuation masses throughout kidney
‘Bears paw’
DDx
Pyonephrosis - Purulent material within collecting system; usually no staghorn calculus
Rounded or triangular calyceal filling defect and blunted/rounded calyces?
Papillary necrosis
-medullary (round or oval cavity, calyceal blunting)
-papillary (triangular cavity, ‘lobster claw’ appearance)
-sloughed papilla ‘signet ring’ appearance
-Contrast fills curvilinear cavities at papilla periphery = Claw sign
-Contrast fills central cavities surrounded by intact papilla = Ball-on-tee sign
Commonest cause is diabetes and 50% sickle cell patients develop
Causes of medullary versus cortical nephrocalcinosis?
See image
Remember that unilateral medullary nephrocalcinosis is likely secondary to medullary sponge kidney
bilateral in adults - hyperparathyroidism
bilateral in children - RTA
What conditions are associated with medullary sponge kidney? What is the underlying mechanism of sponge?
Ethler-Danlos
Carolis
Beckwith-weidman
medullary and papillary portions of the collecting ducts are dysplastic with cystic dilatation of the collecting tubules of the kidney
Delayed post contrast CT may demonstrate a paintbrush appearance to the renal medullary regions
Intravenous pyelogram
-ectatic distal collecting ducts - bouquet of flowers apperance
-Striated nephrogram
What are the doppler features of renal vein thrombosis ?
Reversed Diastolic flow
Renal vein thrombosis is more common than renal artery stenosis in weeks 1-4 post renal transplant
Renal transplant collections - Urinoma, haematoma, Lymphocele
Urinoma
- first 2 weeks post op.
- Anechoic, minimal thin/no septations, rapidly increasing in size
- Fluid collection containing extravasated/layering contrast material in the collection delayed/post excretory-phase CT/MR or contrast extravasation during cystogram.
- MAG 3
Haematoma
- Immediately post-op
- if large can cause a compressive hydro
US: Echogenicity varies with age and size of clot
NECT: Typically > 30 HU
MR: Variable signal depending on age of blood products but often heterogeneous
Lymphocele
- 1-2 months after transplant
-most common peritransplant fluid collection
-US - anechoic and may have septations
-Well-defined, cystic, extraperitoneal lesion along lymphatic pathways
Differentiate between Acute rejection and ATN in transplant kidney?
Both occur in first week or so with prominent pyramids on US, enlarging transplant and elevated RIs
MAG - 3
- ATN has normal perfusion
- Rejection doesn’t
Chronic rejection
- one year post transplant
- enlarged kidney with loss of CM differentiation
- elevated RI
Signs of renal artery stenosis in a transplant kidney?
Occurs most commonly 2-12 months postoperatively
PSV > 200/300cm/s in stenotic area
PSV ratio > 3 (iliac/RA)
Tardus Parvus @ the hilum of the main renal artery
Aliasing artefact at the anastomosis
RI = PSV - EDV/PSV
Classic arrangement of the duplex system?
complete duplication
ureter draining upper pole (UP) of kidney inserts in bladder inferior & medial to ureter draining lower pole (LP) of kidney
(Weigert-Meyer rule)
LP ureter inserts orthotopically in trigone - tends to have VUR
UP ureteral orifice is ectopic in location & often associated with ureterocele - tends to obstruct
Features of Intraperitoneal, extraperitoneal bladder ruputre?
Intraperitoneal rupture : 10-20%
-Opacified urine fills peritoneal spaces (pouch of Douglas, Morrison pouch)
-outlines bowel loops and intraperitoneal viscera
-Usually bladder dome rupture
-Needs Sx!!!
Extraperitoneal rupture : 80-90%
-Adjacent pelvic fractures sometimes with bone spicules pointing toward bladder
-bladder base
-Molar tooth sign
-Complex: Extravasation extends beyond extraperitoneal pelvic spaces [e.g., thigh, scrotum, penis, perineum, anterior abdominal wall, retroperitoneum
Types of Uteroceles ?
Ureterocele: Cystic dilatation of terminal ureter
Intravesical: Ureterocele is entirely in bladder
Ectopic: Insertion at bladder neck or in posterior urethra
~ 80% of ureteroceles (in pediatric population) are seen in association with duplicated collecting system
~ 60% of these pediatric ureteroceles have ectopic insertion
Adult ureteroceles are mostly intravesical and orthotopic with single ureter
Cobra head or spring onion appearance of distal ureter with surrounding radiolucent halo
Smooth, round, intravesical filling defect
Causes of pseudotumor in the kidney?
Persistent foetal lobultaiton
-Multiple indentations in renal outline, between renal pyramids or calyces; preserved cortical thickness
-Distinguished from scars of pyelonephritis, which are directly over calyces with thinned cortex
dromedary hump
-Only occurs in left kidney: “Splenic hump”
-Focal bulge in lateral border of midpole of left kidney with similar echogenicity as rest of kidney
Column of Bertin
Hypertrophic medial bands of cortical tissue that separate pyramids of renal medulla
Isoechoic, continuous with renal cortex, normal renal outline
Features of ovarian granulosa tumours and thecoma?
Both oestrogen secreting and associated endometrial thickening - PMB/irregular bleeding
Granulosa tumours -
- Prepubescent girls
- Precocious puberty
-Large (mean: 10-12 cm), multilocular, solid and cystic mass with areas of hemorrhage.
-**‘sponge-like, ‘Swiss cheese’ **appearance.
-Thick septations
- differentiated from epithelial ovarian tumours (e.g. Mucinous cystadenomas) by their lack of a feature described as ‘intracystic papillary projections’
-associations with Ollier disease (multiple enchondromas) and
Maffucci syndrome (multiple enchondromas and haemangiomas/venous malformations).
Thecoma
- thickening - PMB/irregular bleeding
- ultrasound = **hypoechoic but solid ovarian masses (acoustic shadowing) **
- MRI = Low signal with both T1 and T2
Fibromas
- Nb ovarian fibromas are radiologically the same as Thecoma, don’t secrete oestrogen can be bilateral and strong association with Gorlin-Goltz syndrome
- Fibromas are commonest benign ovarian tumour to cause MEIGS - ascites, pleural effusion and ovarian lesion
Ovarian tumour, young women with virilization and hirsutism?
Sertoli-leydig cell tumour
Well-defined, enhancing, solid ovarian mass
Appearances of fibroids on MRI ?
Uterine fibroids/Leiomyomas
Intramural, subserosal, or submucosal
-low signal (compared to the myometrium) on T2 and T1 weighted sequences
Myxoid degeneration
-very complex ‘cystic type’ structure
-foci of **very high T2 signal **on backdrop of low T2
Hyaline degeneration
-most common form
-Calcification (typically described as popcorn calcification, sometimes visible on plain films
Cystic degeneration
- high T2 signal.
Red degeneration
**-related to pregnancy **or use of the oral contraceptive pill
-haemorrhagic necrosis and can present acutely as abdominal pain
- MRI characteristics vary depending on the degradation of blood within the fibroid. Peripheral high T1 signal is often described.
Malignant degeneration
Difference between barthloin, skene, gartner, nabothian
Skene duct cyst
- retention cysts of the paraurethral ducts
-inferior to the pubic symphysis but lateral to the external urethral meatus
Bartholin gland cyst
-posterolateral aspect of the inferior vagina
- When infected or inflamed a Bartholin gland cyst can present as a painful lump
- MRI high T1 as mucoid fluid content
Gartner duct cyst
-usually found incidentally on MRI scans but can cause dyspareunia
-superiorly in the anterolateral wall of the vagina
-imaging they appear straightforwardly cystic
-associated with renal agenesis or ectopia
Nabothian cyst
-Blockage of the mucinous glands on the cervix
- mall yellow bumps on colposcopy.
-cystic with high T2 signal and can show high T1 signal owing to their mucein content
- Asymptomatic and incidental
Nb Urethral diverticulum (also known as urethrocele) can cause Dysuria, dyspareunia and post-void dribbling.
Urinary stasis within the diverticulum predisposes patients to the formation of calculi, which can be seen as low signal on the T2 scan, and adenocarcinoma which will enhance with gadolinium
Posterior urethral valve ?
Dilated bladder + keyhole sign
Bladder “funnels” into dilated posterior urethra
Dilated posterior male urethra with distinct caliber change at level of valves.PUV lie just distal to prostatic urethra
Diagnosis is made on voiding cystourethrogram (VCUG), cystoscopy, or cystosonography
Perinatal: Anuria, pulmonary hypoplasia → pneumothorax
Infancy: Urinary tract infection, sepsis, urinary retention, poor urinary stream, failure to thrive
Features of endometrioma?
often ovarian in location they can be found in the peritoneal cavity
Cystic hemorrhagic ovarian mass with thick wall
No internal enhancement or Doppler flow
May contain fluid-fluid levels
Ultrasound -
-single cyst with posterior acoustic enhancement and homogeneous internal low-level echoes
MRI -
-vary depending on the blood content.
-High T1 signal suggests old blood products
— Differentiated from the fat of a potential teratoma by checking to see that the signal persists (or is not suppressed) on the fat saturated sequences.
- **T2 shading **
—-Make the distinction from haemorrhagic corpus luteal cysts since the fresh blood in those will not have degraded sufficient to cause the T2 darkening of endometriomas
DDx for endometrial thickening?
Tamoxifen
-Endometrial polyps, subendometrial cysts too
HRT
- Not sign of benignity however, and tissue sampling must still be sought.
- Subendometrial cysts would be unusual.
Adenomyosis
Endometrial cancer
Features of adenomyosis ?
Adenomyosis
-Adenomyosis and endometrial cancer can be hard to distinguish
-Adenomyosis affects the myometrium whereas endometrial cancer arises from the endometrium.
-ectopic presence of endometrial tissue within the myometrium
-diffusely or be limited to a focal area
-absence of mass effect on the endometrial lining
***** MRI classic = widening of the transitional zone (aka junctional zone; the inner layer of myometrium) to greater than 12mm.
-small areas of high T1 and T2 signal are seen representing areas of haemorrhage and cystic change respectively
US -
Uterine enlargement with poor definition of endomyometrial interface
Myometrial heterogeneity and hypoechogenicity
Subendometrial, myometrial, 1- to 5-mm cysts
HSG there will be small diverticuli
DDx
- Leiomyoma -
- Ultrasound: Well-defined mass in submucosal, subserosal, or mural location
- JZ in normal thickness
Features of endometrial cancer?
Endometrial cancer
-Anything that increases unopposed estrogen exposure causes an increased risk
- post-menopausal age group and thus presents with post-menopausal bleeding
-**endometrial thickness of >5mm in a postmenopausal lady **would be suspicious.
(<5mm 100% negative predictive value)
- Cellular diagnosis can be obtained at hysteroscopy
- MRI is used for staging -T2 weighted sequences
—-loss of the bright endometrial signal and breach of this black junctional zone denotes myometrial invasion
—– T1 weighted images the layers are all isointense to one another
—-Contrast is required for endometrial cancer staging in order to accurately assess the depth of myometrial invasion. Cancer enhances to a lesser degree than the strongly enhancing myometrium - pelvic and para-aortic lymph node groups ~(inguinal is none regional)
-cervical invasion which denotes stage II. Fertility sparing management (if required) is no longer a viable option
contrast also useful for staging ovarian tumours. However rectal and cervical tumours contrast is not useful!!
Gestational Trophoblastic Disease
Partial hydatidiform mole (normal ovum is fertilised by two sperm):
-Thickened placenta with cystic change and peripheral vascularity, may be associated with fetal parts
Complete hydatidiform mole (genetic material derives solely from the father):
-Enlarged placenta with multiple cysts = Snowstorm or bunch of grapes appearance
-No embryo
- No increased vascularity/relatively hypo vascular
- Ovarian theca lutein cysts present in 25-55% of cases - 2° to ovarian hyperstimulation, ↑ β-hCG hormone
Malignant GTD
Invasive mole
-Enlarged, heterogeneous cystic intrauterine mass with ↑ vascularity extending into myometrium
-Rarely metastasizes
Choriocarcinoma
-Enlarged, heterogeneous uterus with complex solid and cystic mass with ↑ vascularity
-May invade myometrium and have extrauterine extension
-Lungs: Most common site of metastasis
IOTA rules (International Ovarian Tumour Analysis)?
see picture
Difference between serous and mucinous epithelial ovarian tumours?
see chart
Multiloculated lareg cystic mass in the adnexa in peri- and early postmenopausal women. US - diffuse low level echoes and Stain glass apperance.
Mucinous Ovarian Cystadenoma/Carcinoma
Solid components increase suspicion for malignancy
Lower ADC values of mural nodules
Abnormal ascites
How to measure relative and absolute adrenal washout?
See chart
Features of cervical cancer
see picture
Staging patterns for prostate cancer based on risk
see picture
Mullerian duct abnormalities
Whe mention prominent fundal cleft (>1cm) it is between two things- *Didelphys or bicornuate. *
Didelphys uterine cavities do not merge/communicate.
Renal agenesis, ectopia and fusion present in 33% of patients
Aplastic/absent uterus + normal fallopian tubes and ovaries = MRKH syndrome
Two cervices also known as owl eyes on MRI = either didelphys or bicollis bicornuate (difficult to tell them apart)
Domed fundus (<1cm cleft) = reabsorption anomaly (Septate or arcuate)
Recurrent midterm miscarriages can be due to septate uterus and can be surgically resected to improve fertility.
