GU/Gynae/Adrenal Flashcards

Question

Causes of medullary versus cortical nephrocalcinosis?

Answer 1

See image Remember that unilateral medullary nephrocalcinosis is likely secondary to medullary sponge kidney bilateral in adults - hyperparathyroidism bilateral in children - RTA

Answer 2

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

Answer 3

Reversed Diastolic flow Renal vein thrombosis is more common than renal artery stenosis in weeks 1-4 post renal transplant

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

Presents in Neonates AR condition Lipoidosis **Large calcified adrenal glands **

Answer 8

**Phaeochromcytoma/Paragangliomas (ie. extraadrenal phaeochromcytoma) Neuroblastoma** **Carcinoid** ***Medullary ***thyroid cancer Good to do to find an extra adrenal phaeochromycytoma. if MIBG negative, Ocetrotide scan is useful

Answer 9

Premenopaual = < 5cm and simple apperance - NO follow up 5 - 7 cm - Repat US at different time of menstrual cycle ie 6 weeks, resolved or decreased in size? if not US every 6 to 12 months to ensure stability > 5cm + haemorrhageic features = MRI >7cm = MRI Postmenopausal <3cm discharge 3-5cm US at 6 months If haemorrhagic features = MRI

Answer 10

>50 years is more Likely to be a met than a primary Prostate Lung Kidney

Answer 11

Non-contrast - assess presence of CA2+ Corticomedullary phase - 25-40 secs - Characterise renal tumour - Papillary = less than cortex - Clear cell = similar to cortex - Evaluate renal arteries/ veins, tumour extension Nephogram - 70-180 secs - Renal parenchyma uniformly enhances. -*** most sensitive to detect RCC Excretory - - Evaluate TCC -'striated' nephogram - pyelonephritis

Answer 12

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

Answer 13

**Very high on T2/ light bulb (compared to liver)** low on T1- haemorrhage so can have high signal areas on T1 No drop out on out out of phase **Arterial enhancement** **I-123 MIBG - uptake, can also evaluate for metastatic disease ** Most solid, or mixed solid and cystic Remember it is a biochemical Dx. 10% Bilateral Ca2+ Extra-adrenal Malignant

Answer 14

Men 2A and 2B NF-1 VHL Carney triad

Answer 15

Congenital adrenal hyperplasia Precocious puberty

Answer 16

Astrocytoma Beckwith- Wiedamann hemihypertrophy

Answer 17

subserosal pedunculated fibroid maximum size threshold for embolisation is 13–15 cm. Above this, the post-embolisation volume may still result in bulk symptoms, and the necrosis from a large fibroid may result in a protracted post-embolisation syndrome T1 hyperintensity pre-MRI suggests fatty or haemorrhagic/red degeneration and is a negative predictor of success with a lower reduction in vascularity compared to fibroids with a low T1 signal. fibroids may undergo progressive liquefaction with increasing T2 signal.

Answer 18

oligo - IUGR Polyhydramnios - maternal DM - TOF - duodenal atresia - cystic adenomatoid lungs

Answer 19

*Combination of fat, fluid and calcification** being highly specific. *Mature teratomas are the most common ovarian neoplasm*(adults and kids) but are slow growing and usually benign. It will show the usual **signal drop-out on out of phase.** Calcification is low in signal on T2. May see on Xray!! Ovarian germ cell tumours include (AFP raised) -Teratomas, yolk sac tumours, choriocarcinomas and mixed germ cell tumours. -Embryonal carcinoma (beta HCG and AFP raised) and dysgerminomas too (beta HCG rasied). Quarter of all ovarian tumours and tend to affect young adults or children. Nb rarely teratomas can have malignant transformation = SCC

Answer 20

Actinomycosis

Answer 21

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

Answer 22

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

Answer 23

High signal in the prostate bed on axial T2

Answer 24

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

Answer 25

Prolonged washout pattern on CECT Absolute washout value of < 60% or relative washout value of < 40% after 15 minutes suggests metastasis or other "nonadenoma" Adenoma Absolute washout value of >60% or relative washout value of > 40% Out-of-phase T1WI GRE Lipid-rich adenoma: Marked signal dropout ....

Answer 26

Majority are endothelial cysts (lymphangiomas) Epithelial cysts exceedingly rare Simple or minimally complex with thin septations or thin septations/rim calcification, no enhancement

Answer 27

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

Answer 28

Benign Brenner tumor -Combination of calcifications demonstrated by US or CT and low signal intensity on T2WI MR Calcifications are present in ~ 50% of cases Malignant Brenner tumor -Indistinguishable from other malignant epithelial tumors

Answer 29

Sertoli-leydig cell tumour Well-defined, enhancing, solid ovarian mass

Answer 30

75-80% placenta accreta: Placenta attached to myometrium without muscular invasion 15% placenta increta: Chorionic villi (CV) invade myometrium 5% placenta percreta: CV penetrate serosa ± extend to involve adjacent bladder, rectum, parametrium

Answer 31

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

Answer 32

Pelvic infection History of pelvic radiation Connective tissue disease Asymptomatic fibroids Pregnancy Subserosal Pedunculated fibroids

Answer 33

Wilms tumours Omphalocele, macroglossia and gigantism

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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!!

Answer 40

**T2 the detrusor muscle returns low signal ** disrupted if there is invasion. MRI only if the patient is fit for intervention. T1 images are more useful for evaluating lymph node involvement and any bony metastases. Post-contrast images are of limited use in bladder cancer imaging. <10% are SCC. most TCC Bladder cancer normally spreads first to the internal and external iliac nodes. involvement of the inguinal nodes is considered non-regional disease

Answer 41

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

Answer 42

see picture

Answer 43

enlarged (>4cm in length) heterogenously echogenic periphery of the ovary, small fluid-filled follicles doppler ultrasound scan, twisting of the ovarian pedicle is a useful sign

Answer 44

Mucinous Ovarian Cystadenoma/Carcinoma Solid components increase suspicion for malignancy Lower ADC values of mural nodules Abnormal ascites

Answer 45

see picture

Answer 46

Majority Bladder 2nd = renal pelvis Ureter is least common site lower third is affected in around 75% of cases, followed by middle third. The **proximal third is affected in only around 3% of ureteric malignancies**.

Answer 47

see picture

Answer 48

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.

Answer 49

TB pyonephrosis (putty kidney) small shrunken kidney with dystrophic or amorphous calcification (autonephrectomy) irregular eroded calyx (moth-eaten appearance) cavities connected to the collecting system hydrocalicosis and infundibular strictures phantom and amputated calyces kink of renal pelvis renal stones. Strictures in the ureter result in sawtooth, corkscrew, beaded and pipestem ureter. Calcification is seen in the distal ureter whereas bladder wall calcification is rare. Bladder TB results in thick-walled small volume ‘thimble’ or shrunken bladder. Prostate TB causes radiating, streaky, low-signal areas on T2-weighted images (watermelon sign).