Obstetrics & gynaecology and breast

Question 1

1. A 40 year old mother of three presents with menorrhagia and dysmenorrhoea. Transvaginal
   ultrasound shows an enlarged uterus with focal heterogeneous myometrial
   echotexture. The endometrium appears widened. T2-weighted MR imaging demonstrates
   focal widening of the junctional zone. There is a hypointense elongated myometrial
   mass with ill-defined margins. The mass contains foci of high signal on both
   T1- and T2-weighted imaging. The mass demonstrates contrast enhancement but to a
   lesser degree than the surrounding myometrium. What is the most likely diagnosis?
   a. Leiomyoma
   b. Endometrial carcinoma
   c. Adenomyosis
   d. Fibroma
   e. Haematoma

Answer 1

1. c. Adenomyosis
   Adenomyosis is a focal or diffuse benign invasion of myometrium by endometrium, which
   incites reactive myometrial hyperplasia. It is associated with endometriosis (20–40%). It
   typically presents in multiparous women in the late reproductive years. Symptoms include
   pelvic pain, menorrhagia and dysmenorrhea, although adenomyosis it may be an incidental
   finding.
   Adenomyosis may be diffuse or focal. Ultrasound appearances are variable but usually
   there is slight enlargement of the uterus with loss of homogeneity of the myometrium. There
   may be pseudo-widening of the endometrium due to increased myometrial echogenicity. MRI
   is more specific and demonstrates thickening of the junctional zone. When diffuse, a widened
   low-intensity junctional zone >12mm confirms the diagnosis whereas <8mm excludes the
   disease. For indeterminate sizes, further findings may aid the diagnosis, such as high-signalintensity
   linear striations extending out from the endometrium into the myometrium on
   T2 and high signal foci on T1 – representing ectopic endometrial tissue/haemorrhagic foci.
   When focal (adenomyoma), there is typically an oval/elongated mass with ill-defined
   margins residing within the myometrium which is in continuity with the junctional zone.
   Distinction from leiomyomas may be difficult but these tend to be round, sharply marginated
   masses occurring anywhere in the myometrium and they may contain calcifications.

Question 2

2. A 42 year old woman presents with post-coital bleeding. Transvaginal ultrasound shows
   the cervix to be enlarged, irregular and hypoechoic. MRI demonstrates a large cervical
   cancer with involvement of multiple pelvic lymph nodes. The left kidney is hydronephrotic.
   What is the most appropriate staging based on these findings?
   a. T1
   b. T2b
   c. T3a
   d. T3b
   e. T4

Answer 2

2. d. T3b
   Cervical neoplasms are staged according to the TNM/FIGO classification. Stage I tumours
   are confined to the uterus. In stage IIA, there is involvement of the upper two-thirds of the
   vagina. Stage IIB shows parametrial invasion without pelvic sidewall involvement. Stage IIIA
   demonstrates invasion into the lower third of the vagina, and IIIB includes pelvic sidewall
   invasion with or without hydronephrosis. Tumour invasion into the bladder and rectal
   mucosa or distant metastasis accounts for stage IV disease. Pelvic nodal metastases do not
   alter the FIGO stage but para-aortic or inguinal node metastases are classified as stage IVB.

Question 3

3. A 50 year old woman presents with pelvic pain and abdominal fullness. Ultrasound
   reveals ascites and a large hypoechoic ovarian mass with posterior acoustic enhancement.
   CT demonstrates a well-defined solid pelvic mass which shows poor contrast
   enhancement. There is also a right-sided pleural effusion. Follow-up imaging postsurgical
   resection shows no residual tumour and resolution of ascites. What is the most
   likely diagnosis?
   a. Serous cystadenocarcinoma
   b. Mucinous cystadenocarcinoma
   c. Ovarian fibroma
   d. Brenner tumour
   e. Massive ovarian oedema

Answer 3

3. c. Ovarian fibroma
   The condition described is Meigs syndrome. This occurs in about 1% of ovarian fibromas
   but is characterised by a large fibroma, ascites and a pleural effusion (typically right-sided).
   Ascites and effusion resolve after tumour resection.
   Fibromas are benign stromal tumours composed of fibrous tissue. On ultrasound they
   are typically solid hypoechoic lesions with posterior acoustic enhancement.

Question 4

4. A 34 year old man presents with a dull ache and a focal non-tender lesion in the
   right inguinal region. It is heterogeneous on ultrasound and CT. On MR, it has a heterogeneous signal intensity on T1- and T2-weighted imaging, which enhances
   post-gadolinium. Which of the following is the likely diagnosis?
   a. Haematoma
   b. Lipoma of the cord
   c. Neurofibroma
   d. Abscess
   e. Malignancy in an undescended testis

Answer 4

4. e. Malignancy in an undescended testis
   Lipoma of the cord will have a high signal on both T1-weighted and T2-weighted images.
   Neurofibroma will demonstrate a target sign on T2-weighted images and is of low attenuation
   on CT. Abscess will be clinically apparent, hypoechoic on ultrasound and have high
   signal on T2-weighted images. Haematomas are usually of higher attenuation on CT with
   varying appearances on MR, but do not demonstrate contrast enhancement.
   (Ref: Bhosale PR et al. The inguinal canal: anatomy and imaging features of common and
   uncommon masses

Question 5

5. A 65 year old man undergoes a penile MR for staging of penile cancer. Which of the
   following is true?
   a. Corpus spongiosum has a high signal on T1-weighted images
   b. On T2-weighted images, the periurethral tissue has high signal intensity relative
   to the corpus spongiosum
   c. Corpus spongiosum enhances more rapidly following gadolinium as compared to
   the corpora cavernosa
   d. MR can reliably differentiate between Buck’s fascia and tunica albuginea
   e. A pelvic coil is preferred for local staging of penile canc

Answer 5

5. c. Corpus spongiosum enhances more rapidly following gadolinium as compared
   to the corpora cavernosa
   Both corpus spongiosum and the corpora have a low signal on T1-weighted images and
   high signal on T2-weighted images. The periurethral tissue is low signal on T2-weighted
   images. MR cannot reliably differentiate between Buck’s fascia and tunica albuginea. They
   are depicted as a single, thick, low-signal rim. A surface coil is used for local disease staging.

Question 6

6. A 69 year old man undergoes an MR for staging of prostate cancer. Which of the
   following is true regarding MR imaging of the prostate gland?
   a. The zonal anatomy is best depicted on T1-weighted images
   b. The central zone has a higher signal than the peripheral zone on T2-weighted
   images
   c. The low signal intensity posterolateral to the capsule on T2-weighted imaging
   represents the seminal vesicles
   d. The proximal urethra is usually identified easily
   e. Post-contrast, the peripheral zone enhances more than the central zone

Answer 6

6. e. Post-contrast, the peripheral zone enhances more than the central zone
   The zonal anatomy is best depicted on T2-weighted images. The proximal urethra is not
   routinely identifiable, unless the patient is catheterised or has had previous TURP. Seminal
   vesicles are bright on T2-weighted images; the low-intensity structures indicate the neurovascular
   bundles. The peripheral zone has a higher signal on T2-weighted images and
   enhances more.

Question 7

7. A 23 year old female has a renal ultrasound scan for recurrent urinary tract infections.
   The only abnormality detected is a 3 cm hyperechoic mass in the upper pole of the left
   kidney. She subsequently undergoes CT which shows the lesion to have an average
   HU of –10. Which of the following is the most likely diagnosis?
   a. Renal cell carcinoma
   b. Transitional cell carcinoma
   c. Renal lymphoma
   d. Angiomyolipoma
   e. Renal abscess

Answer 7

7. d. Angiomyolipoma
   The finding of fat attenuation values within a renal lesion on CT is diagnostic of angiomyolipoma.
   This is a benign tumour that is typically hyperechoic on ultrasound and of high
   signal on T1-weighted MR due to fat. It does not enhance post-gadolinium, in contrast to
   renal cell carcinoma, which usually does enhance.

Question 8

8. An 84 year old diabetic female is investigated for recurrent E. coli urinary tract infections
   and microscopic haematuria. An intravenous urogram is performed, which shows
   numerous small filling defects in the ureter and small mural plaque-like defects within
   the bladder. Which one of the following is the most likely diagnosis?
   a. Malakoplakia
   b. Leukoplakia
   c. Emphysematous cystitis
   d. Emphysematous pyelonephritis
   e. Pyeloureteritis cystica

Answer 8

8. a. Malakoplakia
   Malakoplakia is the most likely diagnosis based on the history provided. This is a rare
   granulomatous infection affecting elderly females with a history of E. coli infections. It
   primarily affects the bladder, and affects the remainder of the renal tract with decreased
   incidence as one progresses proximally. Leukoplakia may have similar appearance, but is
   more common in males with bladder involvement, and is characterised by the passage of
   gritty soft-tissue flakes. Pyeloureteritis cystica typically produces multiple round filling
   defects rather than plaques.

Question 9

9. A 65 year old male has a renal ultrasound scan for right flank pain which demonstrates
   a 7 cm solid mass within the right kidney with a hypoechoic centre. Subsequent CT
   scan of the chest, abdomen and pelvis reveals the lesion to have a low-attenuation
   central scar. There is no renal vein invasion or evidence of malignancy elsewhere in the
   body. Which of the following is the most likely diagnosis?
   a. Lymphoma of the kidney
   b. Transitional cell carcinoma
   c. Collecting duct tumour
   d. Oncocytoma
   e. Nephroblastoma

Answer 9

9. d. Oncocytoma
   The features described are typical of renal oncocytoma. Oncocytoma is a tubular adenoma
   that is very rarely malignant. They are often asymptomatic even when large. The central
   scar is typical and is due to haemorrhage and infarction of the tumour having outgrown its vascular supply. Radiological differentiation from renal cell carcinoma can be very difficult
   and percutaneous needle biopsy is unreliable. Nephrectomy is therefore often indicated.

Question 10

10. A 62 year old woman presents with two small masses in her right breast. These are well
    circumscribed masses in the upper outer quadrant. They show no calcification, no
    desmoplastic reaction and are not spiculated. They are thought to represent metastases
    to the breast. The most likely primary in a woman of this age is:
    a. Ovarian carcinoma
    b. Renal carcinoma
    c. Lymphoma
    d. Melanoma
    e. Bronchial carcinoma

Answer 10

10. c. Lymphoma
    Metastases to the breast are infrequent and can be difficult to distinguish from primary
    breast cancer. The most common primary source is lymphoma, followed by melanoma and
    then rhabdomyosarcoma. Most patients who are diagnosed with breast metastases already
    have a diagnosis of a primary tumour, however, in 25% of cases breast metastases are the
    first manifestation of malignancy

Question 11

11. A 24 year old woman attends A&E with lower abdominal pain and vaginal bleeding.
    A pregnancy test is positive. She is haemodynamically stable and an ultrasound is
    requested to confirm the presumed diagnosis of an ectopic pregnancy. Which of the
    following is the most common location for an ectopic pregnancy?
    a. Cervix
    b. Ovary
    c. Abdominal cavity
    d. Ampullary portion of the fallopian tube
    e. Interstitial portion of the fallopian tube

Answer 11

11. d. Ampullary portion of the fallopian tube
    The most common site of implantation is the fallopian tube, which accounts for over 90%
    of ectopic pregnancies. Ovarian and abdominal sites account for only approximately 3%
    and 1%, respectively. Within the fallopian tube the most common site is the ampulla (73%)
    followed by the fimbrial and interstitial regions.

Question 12

12. A 26 year old pregnant woman attends for an obstetric ultrasound at 37 weeks. She is
    shown to have polyhydramnios. Which of the following would be a possible cause?
    a. Cystic adenoid malformation
    b. Ventricular septal defect
    c. Infantile polycystic kidney disease
    d. Posterior urethral valves
    e. Intrauterine growth retardation

Answer 12

12. a. Cystic adenoid malformation
    The remainder of the conditions listed above will cause oligohydramnios. Polyhydramnios
    is defined as amniotic fluid volume >1500–2000 cm3 at term. Most cases are due to
    maternal factors, with diabetes causing the majority of these. Oligohydramnios is defined
    as an amniotic fluid volume of <500 cm3 at term; the most common causes include demise
    of the fetus, drugs and renal anomalies

Question 13

13. A 28 year old woman presents with a dull ache in her pelvis. Ultrasound shows
    a 7 cm well-defined ovarian cyst. A distinct echogenic nodule which causes dense
    acoustic shadowing is seen projecting into the cyst’s lumen. What is the most likely
    diagnosis?
    a. Mature cystic teratoma
    b. Tubo-ovarian abscess
    c. Endometrioma
    d. Ovarian carcinoma
    e. Corpus luteum cyst

Answer 13

13. a. Mature cystic teratoma
    Mature cystic teratomas (dermoid cysts) account for approximately 15% of all ovarian
    tumours. They are benign germ cell tumours containing tissues from all three germ cell
    layers. They most commonly present in younger women of reproductive age (20–40 years)
    and may be bilateral in up to 25%. They are generally cystic masses that may contain a
    pathognomonic distinct hyperechoic mural nodule (dermoid plug/Rokitansky nodule)
    which projects into the cystic lumen and causes posterior acoustic shadowing. This nodule
    represents in-growth of solid tissue such as hair or teeth from the tumour wall

Question 14

14. A 23 year old woman undergoes investigation for dyspareunia. Pelvic ultrasound
    was unremarkable. MRI demonstrates a 1 cm thin-walled ovoid cystic lesion at the
    anterolateral aspect of the upper vagina. It is homogeneously hypointense on T1 and
    shows marked hyperintensity on T2. What is the most likely diagnosis?
    a. Bartholin cyst
    b. Nabothian cyst
    c. Cervical fibroid
    d. Gartner duct cyst
    e. Cervical polyp

Answer 14

14. d. Gartner duct cyst
    Gartner’s duct cysts are remnants of mesonephric ducts and have a reported incidence
    of 1–2%. They are ovoid, thin-walled cysts located at the anterolateral aspect of the upper
    vagina and generally measure less than 2 cm. They may contain proteinaceous material,
    making them slightly hyperintense on T1. They may be associated with Herlyn–Werner–
    Wunderlich syndrome (ipsilateral renal agenesis and ipsilateral blind vagina) and ectopic
    ureter inserting into the cyst.
    Bartholin cysts are located at the lateral introitus adjacent to the labia minora. Nabothian
    cysts are epithelial inclusion cysts which develop in the endocervical canal and are most commonly found in the perimenopausal period. Cervical fibroids and cervical polyps show
    mainly as solid lesions.

Question 15

15. A 48 year old woman undergoes investigation for postmenopausal bleeding. Ultrasound
    shows a hyperechoic endometrial mass which contains several small
    cystic spaces. Power Doppler reveals a vessel at its base. On T2-weighted MR imaging
    the mass contains a central fibrous core with low signal intensity and small, welldelineated
    cysts showing marked high signal intensity. The central core enhances
    post-contrast administration. The junctional zone is intact. What is the most likely
    diagnosis?
    a. Endometrial hyperplasia
    b. Submucosal leiomyoma
    c. Submucosal fibroid
    d. Adenomyoma
    e. Endometrial polyp

Answer 15

15. e. Endometrial polyp
    Endometrial polyps are common benign tumours of the endometrial cavity. They are most
    common after the age of 40 years and are rare before menarche. Typical ultrasound
    appearance is of a hyperechoic endometrial mass which may or may not contain cystic
    spaces. A feeding vessel is often demonstrated from its base on power Doppler.
    (Submucosal fibroids are generally of reduced echogenicity).
    On MRI, a mass which contains a central fibrous core that enhances post-contrast and
    also contains well-demarcated T2-hyperintense cysts suggests endometrial polyp. An intact
    junctional zone and smooth tumour-myometrium interface also favour a polyp.

Question 16

16. A 36 year old man suffers pelvic fracture following a road traffic accident. On
    examination, blood is noted at the urethral meatus and the patient has urinary
    retention. Regarding urothelial injuries:
    a. Associated bladder injuries are seen in 50% of patients
    b. Anterior urethral injuries are commoner with pelvic fractures
    c. They are more commonly associated with pelvic fractures in females rather than
    males
    d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males
    e. Impotence is a rare complication of male urethral injury

Answer 16

16. d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males
    Urethral injuries are seen in up to 20% of male patients following pelvic fractures. They are
    much less common in women. The posterior urethra is the commonest site; impotence can
    develop in up to 40% of these patients.

Question 17

17. A 70 year old man undergoes an MR examination of the prostate to assess the stage of
    prostatic carcinoma. Which of the following is the least accurate?
    a. Obliteration of the rectoprostatic angle is suggestive of extracapsular spread
    b. Bladder and rectal involvement are best seen on coronal images
    c. Focal low signal in the seminal vesicles on T2-weighted imaging is a feature of
    invasion
    d. On T2-weighted images, prostate cancer usually demonstrates low signal intensity
    in contrast to the normal peripheral zone
    e. Prostatic volume measurements are bigger on CT than MR

Answer 17

17. b. Bladder and rectal involvement are best seen on coronal images
    Bladder and rectal involvement are best appreciated on axial and coronal images. MR is
    much more accurate for prostatic volume assessment and CT usually overestimates
    prostatic volume.

Question 18

18. A 28 year old woman suffers blunt injury to her abdomen following a road traffic
    accident. A polytrauma CT scan does not demonstrate any intra-abdominal injuries,
    but there are features indicating retroperitoneal injuries. Regarding these features,
    which of the following is true?
    a. Retroperitoneal air may indicate pulmonary injuries
    b. Haematomas in the posterior pararenal space do not extend into the pelvis
    c. The most common region demonstrating retroperitoneal haemorrhage following
    trauma is usually around the aorto-caval region in the midline
    d. Adrenal injuries are more common on the left
    e. Low-attenuation fluid (<–20 HU) in the retroperitoneum is always indicative of
    injury to the pelvi-calyceal system or the ureters

Answer 18

18. a. Retroperitoneal air may indicate pulmonary injuries
    Air in the retroperitoneum can follow pneumothorax. However, in the absence of pneumothorax,
    it is strongly indicative of duodenal/colonic injury. The posterior and anterior
    pararenal spaces communicate freely with the pelvic retroperitoneum, whilst the perinephric
    space is enclosed. The retroperitoneum is divided into three zones: I – midline retroperitoneum;
    II – lateral retroperitoneum; and III – pelvic retroperitoneum. Zone III is the
    commonest site for haematoma following blunt injury. Adrenal injuries are more common
    on the right. Low-attenuation fluid can be seen even in the absence of urine leak, usually
    indicating hypoperfusion shock syndrome.

Question 19

19. A 45 year old male is diagnosed with renal cell carcinoma and is being worked up for
    curative nephrectomy. Which one of the following imaging modalities would you
    advise as being the most accurate at ruling out malignant renal vein invasion?
    a. Doppler ultrasound
    b. B-mode ultrasound
    c. CT
    d. MRI
    e. PET-CT

Answer 19

19. d. MRI
    MRI is superior to the other imaging modalities listed at ruling out renal vein invasion. CT
    is still very accurate (reported as high as 96%), but MR has the advantage of being able to
    accurately differentiate benign from malignant thrombus. MR offers no advantage in
    detecting nodal disease, however, and patients being considered for curative surgery should undergo staging CT of the chest, abdomen and pelvis. PET does not have a specific role for
    detecting renal vein invasion.

Question 20

20. A 31 year old male is involved in a road traffic accident. The patient was catheterised
    immediately in A&E and the bladder was found to be empty. A trauma series CT is
    requested and a left-sided pelvic fracture is noted. A CT cystogram is therefore
    performed and bladder rupture is diagnosed. Which of the following signs would be
    an unexpected finding with this history?
    a. Contrast extravasation into the paracolic gutters
    b. Contrast extravasation into the perivesical fat
    c. Contrast extravasation into the anterior abdominal wall
    d. Flame-shaped contrast extravasation
    e. Contrast extravasation into the upper thigh

Answer 20

20. a. Contrast extravasation into the paracolic gutters
    Extraperitoneal rupture of the bladder is associated with pelvic fractures following trauma
    and cystography should be performed if this is suspected. The injury is usually at the base of
    the bladder, anterolaterally. Contrast is seen to extravasate with a streaky or flame-shaped
    appearance and collects in the space of Retzius, upper thighs, inguinal regions, perivesical
    fat and anterior abdominal wall. Contrast in the paracolic gutters suggests intraperitoneal
    rupture of the bladder. This is associated with a different method of injury, typically rupture
    at the bladder dome following blunt trauma with a distended bladder or secondary to
    iatrogenic injury such as cystoscopy

Question 21

21. A 71 year old male undergoes renal CT for characterisation of a cystic renal mass.
    Which one of the following five features would classify the lesion as a Bosniak III
    lesion?
    a. Lack of enhancement
    b. Septation
    c. Minimally irregular wall
    d. Curvilinear calcification
    e. Uniform wall thickening

Answer 21

21. e. Uniform wall thickening
    The Bosniak classification groups cystic renal lesions into one of four categories based
    on CT/MR appearances. The differentiation between groups II and III is important as
    group II are typically ‘follow-up lesions’ and group III are ‘surgical lesions’. Features of a
    Bosniak III lesion include irregular thickened septa, measurable enhancement, coarse
    irregular calcification, multiloculation, nodularity, uniform wall thickening and margin
    irregularity.

Question 22

22. A 29 year old woman with a history of three previous failed pregnancies attends the
    ultrasound department for a scan. She has had a positive pregnancy test. Which of the
    following is not necessarily indicative of a failed pregnancy?
    a. A crown rump length of 11mm with no heartbeat detectable on TA scan
    b. A crown rump length of 5mm with no heartbeat detectable on TV scan
    c. A gestation sac, mean sac diameter >20mm with no visible yolk sac
    d. A gestation sac, mean sac diameter >25mm with no visible embryo
    e. A flat M mode scan

Answer 22

22. b. A crown rump length of 5mm with no heartbeat detectable on TV scan
    In order to assess the presence or absence of a heartbeat accurately on TV scanning, the
    crown rump length needs to be >6 mm. On TA scanning the crown rump length needs to
    be >10 mm in order to accurately assess the absence of a heartbeat. The other options all
    represent signs of fetal demise. Usually two qualified ultrasound practitioners are required
    to assess a fetus if there is concern regarding embryonic demise.

Question 23

23. A 62 year old woman with Paget’s disease of the nipple is also found to have a 2 cm
    spiculate mass in the subarealor region of her right breast suspicious for malignancy.
    The cancer most commonly associated with Paget’s disease of the nipple is:
    a. Invasive ductal carcinoma
    b. Invasive lobular carcinoma
    c. Tubular carcinoma
    d. Ductal carcinoma in situ
    e. Medullary carcinoma

Answer 23

23. d. Ductal carcinoma in situ
    The most commonly associated is ductal carcinoma in situ (60%). The next most common
    is invasive ductal carcinoma. Fifty per cent of cases of DCIS are over 5 cm at the time of
    diagnosis and this often involves the nipple and subareolar ducts.

Question 24

24. In a 72 year old man undergoing abdominal CT for ongoing lower abdominal pain,
    a 2 cm right-sided adrenal lesion is detected. He has no history of malignant disease.
    Which of the following parameters would be more in keeping with a malignant than
    a benign adrenal lesion?
    a. Size of 2.5 cm
    b. Hounsfield units of 8 on non-enhanced CT
    c. Washout of >60% when comparing non-enhanced CT with contrast-enhanced CT
    d. Loss of signal within the lesion on out-of-phase MRI imaging
    e. Maximum standardised uptake value >4 on FDG-PET

Answer 24

24. e. Maximum standardised uptake value >4 on FDG-PET
    This is suspicious for metastatic malignant disease with the most common primary sites
    being lung, colon, melanoma and lymphoma. An incidental adrenal lesion is detected on 1%
    of abdominal CT. Even in the presence of a known malignancy, 87% of incidental lesions
    less than 3 cm in size are benign. Other features suggestive of malignancy are large size,
    irregularity and inhomogeneity

Question 25

25. A 19 year old female presents with vague lower abdominal pain. Ultrasound shows a right 5 cm thin-walled unilocular ovarian cyst. Follow-up ultrasound six weeks later shows cyst regression. What is the most likely diagnosis? a. Corpus luteum cyst b. Endometrioma c. Serous cystadenoma d. Surface epithelial inclusion cyst e. Follicular cyst

Answer 25

25. e. Follicular cyst These are common ovarian masses that result from a failure of the mature Graafian follicle to rupture and release ova. Typically, they are smooth, thin-walled, unilocular anechoic cysts that show spontaneous regression within four to six weeks. They may undergo haemorrhagic change producing internal echogenic material. They are generally larger than 2.5 cm and may occasionally grow up to 10 cm.

Question 26

26. A 14 year old girl presents with acute onset of right lower abdominal pain. She reports that she has had similar symptoms previously. Ultrasound shows an ovoid-shaped enlarged right-sided ovary containing multiple enlarged follicles. The ovarian stroma is echogenic compared to adjacent myometrium. There is peripheral blood flow on power Doppler and free fluid within the pelvis. What is the most likely diagnosis? a. Ovarian hyperstimulation b. Ovarian torsion c. Polycystic ovary syndrome d. Theca lutein cysts e. Serous cystadenoma

Answer 26

26. b. Ovarian torsion Ovarian torsion usually presents in the first three decades of life and is predisposed in patients with co-existing ovarian pathology such as follicular cyst. There may be history of similar episodes indicating intermittent torsion and spontaneous detorsion. Torsion causes venous outflow obstruction and engorgement of the ovary. Eventually arterial supply is compromised and necrosis ensues. Diagnosis is suggested by unilateral enlargement of a round or oval-shaped ovary containing multiple enlarged peripheral cysts (caused by transudation of fluid into follicles). Free fluid is present in the majority of cases. Peripheral blood flow may be present but may be absent with infarction. Ovarian hyperstimulation can present with abdominal pain and may show an enlarged multicystic ovary associated with ascites. However, the condition usually arises from ovarian hormone stimulation in the setting of infertility. Polycystic ovary syndrome typically presents with menstrual disturbance, obesity and hyperandrogenism.

Question 27

27. A female patient undergoes investigation for dysmenorrhea. She is obese, hirsute and has elevated luteinising hormone levels. Which of the following ultrasonographic findings is consistent with a diagnosis of polycystic ovarian syndrome? a. Ovarian volume >10 ml when no follicles measuring over 5mm in diameter are present b. Ten or more follicles (3–12mm diameter) present in an ovary c. Ovarian volume >15 ml when no follicles measuring over 10mm in diameter are present d. Twelve or more follicles (3mm diameter) present in an ovary e. Ovarian volume >10 ml when no follicles measuring over 10mm in diameter are present

Answer 27

27. e. Ovarian volume >10 ml when no follicles measuring over 10mm in diameter are present Diagnosis of polycystic ovary syndrome should not be made on imaging findings alone; clinical and biochemical studies must be obtained. The diagnosis can be supported when one or more of the following ultrasonographic features are demonstrated:  Twelve or more follicles (3–12mm diameter) are present in an ovary (either peripheral or diffusely arranged).  Ovarian volume>10 ml when no follicles measuring over 10mmin diameter are present. If a follicle >10mm is present then the volume should be recalculated on a repeat scan when the ovary is quiescent to prevent overestimation of the ovarian volume.

Question 28

28. A 60 year old female presents with a large abdominal mass. CT demonstrates a large retroperitoneal fat-containing mass. Which of the following is true about the different fat-containing retroperitoneal masses? a. Predominantly low signal on T1-weighted and a high signal on T2-weighted images preclude a diagnosis of liposarcoma b. Calcification within a liposarcoma is usually associated with a better prognosis c. Lipomas are rare in the retroperitoneum d. An extremely FDG-avid retroperitoneal fat-containing tumour is almost certainly a liposarcoma e. Given time, most lipomas will dedifferentiate into liposarcomas

Answer 28

28. c. Lipomas are rare in the retroperitoneum Liposarcomas are the most common sarcomas in the retroperitoneum. Whilst welldifferentiated liposarcomas are the commonest, myxomatous and dedifferentiated liposarcomas can have varying appearances and so low T1-weighted signal does not preclude a diagnosis of liposarcoma. Lipomas, whilst exceedingly rare in the retroperitoneum, almost undergo malignant changes. Whilst liposarcomas can have minimal-to-increased FDG uptake, a very FDG-avid fat-containing retroperitoneal tumour is quite likely a hibernoma.

Question 29

29. A 40 year old female is found to have a suspected incidental left adrenal lesion on ultrasound. Which of the following CT or MR features is least likely in a phaeochromocytoma? a. High signal on T2-weighted images b. Avid enhancement post-gadolinium injection c. Mean lesion attenuation of more than 10HU d. Less than 40% washout on delayed CT scanning e. Calcification

Answer 29

29. e. Calcification Whilst phaeochromocytomas can have varied appearances on CT and MR, typically they are high on T2-weighted and low on T1-weighted images and enhance avidly post-contrast. They normally have an attenuation value of more than 10 HU, but calcification is seen in only about 10% of cases.

Question 30

30. A 38 year old man with a swollen right hemiscrotum has an ultrasound examination. Which of the following is true? a. The epididymis is hypoechoic compared to the normal testis b. Seminomas are most commonly hyperechoic compared to the normal testis c. The majority of extratesticular tumours are benign d. Lipomas are the commonest intratesticular benign tumours e. Epidermoid cysts are most commonly seen in the head of the epididymis

Answer 30

30. c. The majority of extratesticular tumours are benign The epididymis is iso- or hyperechoic compared to the testis. Seminomas are homogenous masses and hypoechoic to the testis. Epidermoid cysts are the commonest intratesticular benign neoplasm. Lipomas are the commonest benign tumours in the spermatic cord. (Ref: Kim et al. US MR imaging correlation in pathologic conditions of the scrotum.

Question 31

31. A 56 year old female presents with a three-month history of pyrexia, loin pain and weight loss. Urinalysis reveals pyuria and haematuria. Urinary culture reveals Proteus mirabilis. A renal CT demonstrates a globally enlarged kidney with extensive perirenal inflammation, an absent nephrogram and a staghorn calculus. Which one of the following diagnoses is most likely? a. Leukoplakia b. Emphysematous pyelonephritis c. Pyeloureteritis cystica d. Xanthogranulomatous pyelonephritis e. Page kidney

Answer 31

31. d. Xanthogranulomatous pyelonephritis The most likely diagnosis is xanthogranulomatous pyelonephritis. This is a chronic granulomatous infection in a chronically obstructed kidney, often secondary to a staghorn calculus. It often presents insidiously in middle-aged to elderly females. It is most commonly diffuse, but the focal form seen in 15% of cases may provide a diagnostic dilemma as it can be difficult to confidently distinguish from renal cell carcinoma.

Question 32

32. A 32 year old male presents with right flank pain and an intravenous urogram is requested with the provisional diagnosis of ureteric calculi. The renal outline is smooth and wavy, with a decreased overall size. The fornices are widened with club-shaped calyces. After further questioning he reveals a recent overuse of analgesia. Which one of the following diagnoses is most likely? a. Acute cortical necrosis b. Acute tubular necrosis c. Papillary necrosis d. Acute interstitial nephritis e. Haemorrhagic cystitis

Answer 32

32. c. Papillary necrosis Papillary necrosis occurs due to ischaemic damage to the medulla of the kidney, and does not primarily involve the cortex. There are many causes including diabetes, analgesic nephropathy, pyelonephritis, renal vein thrombosis and sickle cell disease. It may be localised or diffuse, bilateral or unilateral depending on the cause. Intravenous urogram appearances are varied and include clubbed calyces, calcification and sloughing of necrotic papilla and alteration in the renal contour.

Question 33

33. A 29 year old male has microscopic haematuria and symptoms suggesting left ureteric colic. An unenhanced CT abdomen and pelvis is requested. A 4mm calcific density is seen near the bladder in the left hemi-pelvis. Which one of the following signs may be useful to help differentiate between a phlebolith and ureteric calculi? a. Lobster claw sign b. Soft-tissue rim sign c. Signet ring sign d. Nubbin sign e. Drooping lily sign

Answer 33

33. b. Soft-tissue rim sign The soft-tissue rim sign is thickening of the ureteric wall around the calculus due to oedema. It has a reported specificity of up to 92% for renal calculi. Other signs that may favour a diagnosis of ureteric calculi include asymmetrical perinephric fat stranding, periureteral oedema, hydronephrosis and unilateral renal enlargement. The lobster claw and signet ring signs concern papillary necrosis on intravenous urogram. The nubbin and drooping lily signs both refer to ureteral duplication.

Question 34

34. An 18 year old woman who is 32 weeks pregnant is referred for an obstetric ultrasound for ongoing abdominal pain. She is shown to have a small placenta relative to gestational age. Which one of the following would be a possible cause? a. Molar pregnancy b. Maternal diabetes c. Umbilical vein obstruction d. Pre-eclampsia e. Maternal anaemia

Answer 34

34. d. Pre-eclampsia Pre-eclampsia, IUGR, chromosomal abnormality and intrauterine infection can all cause a decrease in placental size. Enlargement of the placenta is defined as a measurement of >5 cm when obtained at right angles to the long axis of the placenta. The causes of placentomegaly include maternal diabetes, chronic intrauterine infection (e.g. syphilis), maternal anaemia, thalassaemia and twin–twin transfusion syndrome. Fetal chromosomal abnormalities may cause either a large or small placenta.

Question 35

35. A 27 year old woman who is 32 weeks pregnant is admitted with acute abdominal pain. The surgical team have requested an abdominal MRI to further investigate her pain before considering laparotomy. You are asked to protocol the request card. Which one of the following statements is correct? a. The mother should be asked to lie prone for the scan b. MRI should be avoided in the third trimester of pregnancy c. Gadolinium diethylenetriaminepentaacetic acid (DTPA) chelate does not cross the placenta d. Gadolinium-based contrast material crosses the placental membrane and circulates through the amniotic fluid e. MRI would be the first imaging modality of choice

Answer 35

35. d. Gadolinium-based contrast material crosses the placental membrane and circulates through the amniotic fluid The use of MRI in the evaluation of abdominal pain in pregnant patients is increasing. The primary imaging modality of choice, however, remains ultrasound, and MRI is usually reserved for situations where the ultrasound findings are equivocal. The use of gadolinium is not usually necessary in the investigation of abdominal pain in the acute setting and there is little evidence as to its effect on the fetus.

Question 36

36. A middle-aged woman presenting to the medical team with headaches, palpitations, tachycardia and hypertension is suspected to have a phaeochromocytoma. You are asked advice on imaging modalities. Which one of the following statements is true regarding the imaging characteristics of a phaeochromocytoma? a. I-131 MIBG imaging is only 20% sensitive for phaeochromocytoma b. Poor contrast enhancement on CT c. Bilateral in 25% of cases d. Usually hypovascular on angiography e. No change in signal intensity between in-phase and out-of-phase T1-weighted MRI images

Answer 36

36. e. No change in signal intensity between in-phase and out-of-phase T1-weighted MRI images There is no change between the in-phase and out-of-phase imaging on MRI as there is very low fat content in phaeochromocytoma. MR is the method of choice for imaging and usually (60%) the phaeochromocytoma will be hyperintense to spleen on T2-weighted imaging. Angiography can localise the lesion in >90% of cases. Appearance on ultrasound can be variable with about 70% appearing as solid lesions whilst 15% are cystic. The ‘rule of tens’ applies to phaeochromocytoma, i.e. 10% are bilateral, 10% are extra-adrenal, 10% are malignant and 10% are familial.

Question 37

37. A 38 year old female undergoes investigation for weight loss and abdominal fullness. CT shows large bilateral adnexal masses, ascites and several small omental soft-tissue nodules. MRI demonstrates bilateral sharply marginated ovarian tumours with preservation of the ovarian contours. The tumours consist mainly of hypointense solid material interspersed with foci of high-signal cysts. On post-contrast T1-weighted imaging the solid components are hyperintense. What is the most likely diagnosis? a. Cystadenocarcinoma b. Dysgerminoma c. Krukenberg’s tumour d. Burkitt’s lymphoma e. Granulosa cell tumour

Answer 37

37. c. Krukenberg’s tumour Krukenburg’s tumours are metastatic tumours of the ovary. The colon and stomach are the most common primary tumour sites, but other sites, such as the breast, lung and pancreas, have also been reported. They display characteristic imaging features, including bilateral, sharply marginated oval tumours which preserve the contour of the ovary. Identification of hypointense solid components on T2-weighted imaging corresponding to areas of dense collagenous stroma is also considered characteristic.

Question 38

38. A five year old girl presents with atypical genital bleeding, breast development and pubic hair growth. T2-weighted MR imaging demonstrates a large solid mass with high signal intensity and an enlarged uterus with thick endometrium. Ascites is also present. Post-gadolinium T1-weighted imaging shows homogeneous tumour enhancement. What is the most likely diagnosis? a. Immature teratoma b. Sertoli–Leydig cell tumour c. Thecoma d. Sclerosing stromal tumour e. Granulosa cell tumour

Answer 38

38. e. Granulosa cell tumour Granulosa cell tumours are the most common ovarian tumours with oestrogenic manifestations that are classified as sex-cord-stromal tumours. They are subdivided into adult and juvenile types. The juvenile form affects prepubertal children and causes pseudoprecocity. In about a third of cases Sertoli–Leydig cell tumours cause virilisation. Thecomas are oestrogen-producing tumours but more than 80% occur in postmenopausal women. Immature teratomas are extremely rare but do occur in children. Elevated alpha-fetoprotein is found in up to 65% of cases. Sclerosing stromal tumours usually affect women younger than 30 years of age and a few cases have shown androgenic or oestrogenic manifestations They are also known as hypervascular tumours which show early peripheral enhancement with centripetal progression.

Question 39

39. A 23 year old female presents with acute lower abdominal pain. She has been sexually active since the age of 15 years. Ultrasound shows a well-defined, oval-shaped, relatively thin-walled, anechoic fluid-filled structure lying adjacent to the left lateral wall of the uterus. The mass appears septated although the septae do not fully cross the lumen. What is the most likely diagnosis? a. Hydrosalpinx b. Tubo-ovarian abscess c. Haemorrhagic ovarian cyst d. Endometrioma e. Thrombosed ovarian vein

Answer 39

39. a. Hydrosalpinx Hydrosalpinx describes a fallopian tube filled with fluid. The fluid is most often anechoic. When the fluid becomes infected, the term pyosalpinx is used and the fluid contents tend to be echogenic. Hydro/pyosalpinx appear as tortuous, well-defined, fluid-filled, oval-shaped structures which extend from the cornua to the ovaries. They are often mistaken for multicystic adnexal masses or septated ovarian cysts due to apparent internal septations. However, the septa, actually the folded wall of the fallopian tube, do not cross the lumen completely. Hydro/pyosalpinx occur most commonly as a result of acute salpingitis and pelvic inflammatory disease (history of early sexual activity/multiple sexual partners). They have also been reported following pelvic surgery. Tubo-ovarian abscesses tend to be multilocular, irregular, thick-walled, complex masses containing debris and internal septations. Internal fluid-fluid levels or gas may also be seen.

Question 40

40. A 2 cm adrenal lesion with an attenuation value of 20 HU is seen on a non-contrast CT of a patient with lung cancer. The following are all true except: a. A 60% washout on delayed post-contrast CT would be in keeping with an adenoma b. A signal intensity decrease of 40% or more on chemical shift imaging indicates malignancy c. PET-CT is interpreted as positive if the FDG uptake of the adrenal lesion is greater than that of the liver d. Functioning adrenal adenomas can be a cause for false positives on PET-CT e. PET-CT has somewhat higher and more consistent accuracy than dynamic CT or chemical shift MR imaging

Answer 40

40. b. A signal intensity decrease of 40% or more on chemical shift imaging indicates malignancy A signal intensity decrease of less than 20% is usually indicative of malignancy in an adrenal lesion.

Question 41

41. A 24 year old man is referred for an ultrasound examination following blunt trauma to the scrotum. Which of the following is not true? a. The left testis is more susceptible to blunt trauma b. Intratesticular haematomas need to be followed up until resolution c. Penetrating injuries are more likely to be bilateral compared to blunt injuries d. An ultrasound finding of an intact tunica albuginea allows the confident exclusion of a testicular rupture in the absence of a haematocoele e. An atrophic testis is more likely to dislocate

Answer 41

41. a. The left testis is more susceptible to blunt trauma The testis suffers blunt trauma against the thigh or the symphysis pubis and the right testis, being higher, is more susceptible. Intratesticular haematomas should be followed up to resolution to rule out an underlying neoplasm and also rule out any ensuing complications such as abscess formation which may necessitate orchidectomy.

Question 42

42. A 62 year old man presents with bilateral testicular enlargement. Ultrasound reveals bilateral smoothly enlarged testes with diffuse hypoechoic areas and normal epididymis. Which of the following is the most likely diagnosis? a. Lymphoma b. Metastasis from prostatic cancer c. Seminoma d. Tuberculosis e. Leydig cell tumour

Answer 42

42. a. Lymphoma This is the wrong age group for Leydig cell tumour (childhood) and seminoma (around 40 years). Lymphoma is the commonest tumour in this age group. It is more likely to have a diffuse hypoechoic appearance and be bilateral as compared to metastasis, which usually presents with multiple focal lesions. Tuberculosis of the testis is most often secondary to epididymitis.

Question 43

43. A 49 year old African male presents to the outpatient urology clinic with a five-month history of macroscopic haematuria. A plain KUB X-ray is requested, which reveals thin arcuate calcification outlining the bladder and the distal ureters. Which one of the following causes is most likely? a. Transitional cell carcinoma b. Squamous cell carcinoma c. Schistosomiasis d. E. coli cystitis e. Proteus cystitis

Answer 43

43. c. Schistosomiasis The differential for bladder calcification includes tuberculosis, post-radiotherapy cystitis, urachal carcinoma, TCC, and squamous cell carcinoma. However, schistosomiasis is the commonest cause, especially in the African population, where it is often endemic. The bladder is usually a normal size and shape, with thin curvilinear calcifications. Ureteric strictures, inflammatory pseudopolyps and vesicoureteric reflux are seen in addition to bladder and ureteric calcification.

Question 44

44. A 21 year old female undergoes a renal ultrasound scan following an abdominal X-ray that demonstrated multiple foci of calcification in both renal areas. The ultrasound reveals multiple medullary cysts bilaterally which are seen to communicate with the collecting system. The medullae of both kidneys are of increased echogenicity. Which of the following diagnoses is most likely? a. Megacalicosis b. Multicystic dysplastic kidney c. Autosomal dominant polycystic kidney disease d. Autosomal recessive polycystic kidney disease e. Medullary sponge kidney

Answer 44

44. e. Medullary sponge kidney The features are those of medullary sponge kidney. This is a non-inheritable condition that produces cystic dilatation of the collecting ducts and nephrocalcinosis; 75% of cases are bilateral and it is usually asymptomatic. It is associated with an increased incidence of infection and urolithiasis but is not thought to predispose to malignancy

Question 45

45. A 65 year old male undergoes renal CT following the finding of multiple hypoechoic masses in both kidneys on ultrasound. Multiple poorly defined masses of decreased attenuation are demonstrated, which encase the renal vessels. The vessels remain patent, however, and the renal contour is preserved. Which of the following is most likely to represent the underlying diagnosis? a. Renal cell carcinoma b. Transitional cell carcinoma c. Multiple myeloma d. Non-Hodgkin’s lymphoma e. Reninoma

Answer 45

45. d. Non-Hodgkin’s lymphoma The most likely diagnosis is non-Hodgkin’s lymphoma. Primary renal involvement is rare, but is often involved either by haematogenous spread or direct invasion. The kidneys represent one of the most common extra-nodal sites of disease in non-Hodgkin’s lymphoma, but are rarely involved in Hodgkin’s disease. Involvement is usually bilateral, with masses of decreased attenuation and mild homogenous enhancement with intravenous contrast on CT. Patency of the renal vessels despite encasement is highly suggestive, as is preservation of the normal renal contour.

Question 46

46. A routine screening mammogram of a 54 year old woman shows numerous scattered calcifications. Which of the following statements is true regarding breast calcifications? a. Parallel lines of calcification are usually venous in origin b. Malignant calcifications are usually >1mm in size c. Less than 5% of microcalcifications in asymptomatic patients are associated with cancers d. Dermal calcifications are usually central in location e. Popcorn calcification is seen in fibroadenoma

Answer 46

46. e. Popcorn calcification is seen in fibroadenoma Popcorn calcification is pathognomonic for fibroadenoma. The majority of biopsied clusters of calcifications represent a benign process (75–80%). Malignant calcifications are usually small (<0.5mm) and are usually irregular in size and density. They are, however, usually closely grouped. Benign calcifications tend to be numerous and scattered throughout the breast.

Question 47

47. An abdominal plain film of a four year old child taken for unexplained abdominal pain shows bilateral adrenal calcification as an incidental finding. Which of the following is the most common cause of adrenal calcification in children? a. Wolman’s disease b. Tuberculosis c. Adrenal haemorrhage d. Adrenal carcinoma e. Histoplasmosis

Answer 47

47. c. Adrenal haemorrhage All of the above cause adrenal calcification. The most common cause in both adults and children is adrenal haemorrhage. In adults this is most commonly unilateral and rightsided. In children adrenal haemorrhage is most common in newborn infants and is induced by episodes of birth trauma or hypoxia, but may also be related to non-accidental injury. Wolman’s disease is a rare disease causing enlarged calcified adrenal glands, hepatomegaly and splenomegaly.

Question 48

48. A 48 year old woman is referred to the breast clinic for investigation of a 1.5 cm lump in the right breast. Which of the following ultrasound features of a breast mass are more suggestive of a malignant than a benign pathology? a. Acoustic shadowing b. Anechoic contents c. Hyperechoic pseudocapsule d. Lack of internal blood flow on colour Doppler e. Hypervascular surrounding tissues

Answer 48

48. a. Acoustic shadowing Acoustic shadowing along with ill-defined margins, surrounding architectural distortion, heterogeneous internal echoes and a height measurement greater than width measurement (with the transducer parallel to the longitudinal axis) are all features more suggestive of a malignant rather than a benign pathology. A hypoechoic lesion containing echogenic debris along with lack of internal blood flow and hypervascularity of surrounding tissues are in keeping with a breast abscess.

Question 49

49. A 13 year old girl presents with lower abdominal pain. She says she has had it intermittently for over a year. She has not yet had a period. On ultrasound examination the uterus is displaced cranially by a large cystic mass in the region of the vagina. It contains a large quantity of echogenic fluid and a fluid-debris level is visible. The bladder is not visualised. What is the most likely diagnosis? a. Duplication cyst b. Rectovesical fistula c. Haematocolpos d. Hydrometra e. Cloacal malformation

Answer 49

49. c. Haematocolpos Haematocolpos is the accumulation of blood within the vagina and is typically caused by an imperforated hymen. This causes acute-on-chronic lower abdominal/pelvic pain as menstrual blood is prevented from normal discharge (apparent lack of menstruation). Ultrasound reveals an echogenic cystic mass with or without fluid-debris levels in the region of the vagina. The distended vagina often causes displacement of the uterus and compression of the bladder so that the latter may not be visualised. Cloacal malformation is a single perineal orifice for the bladder, vagina and rectum caused by early embryonic arrest. It manifests in the newborn period. Hydrometra is fluid within the uterus and may be due to cervical or vaginal dysgenesis. Rectal duplication cysts may reveal an echogenic cystic mass in childhood but they often present with constipation and faecal soiling.

Question 50

50. A female undergoes transvaginal ultrasound for postmenopausal bleeding. In which of the following situations can you virtually exclude the presence of endometrial cancer? a. An endometrial thickness of 5mm in a patient who has never undergone hormone replacement therapy (HRT) b. An endometrial thickness of 6mm in a patient using sequential combined HRT c. An endometrial thickness of 5mm in a patient using continuous combined HRT d. An endometrial thickness of 4mm in a patient using sequential combined HRT e. An endometrial thickness of 4mm in a patient who has not used any form of HRT for one year or more

Answer 50

50. d. An endometrial thickness of 4 mm in a patient using sequential combined HRT An endometrial thickness of 3mm can be used to exclude endometrial cancer in women who:  Have never used HRT, or  Have not used any form of HRT for more than one year, or  Are using continuous combined HRT. In the above conditions the post-test risk of a patient having endometrial cancer is 0.6–0.8% when the endometrial thickness is 3mm but 20–22% when the endometrial thickness is >3 mm. An endometrial thickness of 5mm can be used to exclude endometrial cancer in women using sequential combined HRT (or having used it within the past year). In this scenario the post-test risk of a patient having endometrial cancer is 0.1–0.2% when the endometrial thickness is 5mm but 2–5% when the endometrial thickness is >5 mm.

Question 51

51. A 25 year old woman presents with an eight-month history of intermittent lower abdominal pain. Ultrasound demonstrates a 4 cm complex mass related to her left ovary. On MRI the mass has predominantly high signal on T1- and T2-weighted imaging and T2- weighted fat-suppressed sequences. The most likely diagnosis is: a. Endometriosis b. Follicular cyst c. Cystadenocarcinoma d. Dermoid cyst e. Tubo-ovarian abscess

Answer 51

51. a. Endometriosis The ovaries are the most common site for endometriosis, accounting for greater than 80%. Other sites include the uterosacral ligaments, pouch of Douglas, uterine serosal surface, fallopian tubes and rectosigmoid. MRI is more specific than either CT or ultrasound in its detection. Typically, MR demonstrates a homogeneously hyperintense cyst due to the presence of methaemoglobin, which shortens T1. It is also hyperintense on fat-suppressed T2-weighted imaging, which virtually excludes a dermoid cyst. On T2-weighted imaging there may be faint or complete loss of signal. This phenomenon is referred to as ‘shading’ and results from the high protein and iron concentration from recurrent haemorrhage into the endometrioma.

Question 52

52. A 58 year old man presents with haematuria and suprapubic pain. Ultrasound reveals the presence of an area of bladder wall thickening and a mobile avascular mass within the urinary bladder. A degree of right hydronephrosis is also demonstrated. Which of the following is true regarding transitional cell carcinoma (TCC)? a. The ureter is the second commonest site of TCC after the urinary bladder b. TCC is the most common tumour of the urinary tract c. In the ureter, the lower ureter is the commonest site d. It is the commonest tumour arising in the urachus e. Previous schistosomiasis is a well-recognised risk factor

Answer 52

52. b. TCC is the most common tumour of the urinary tract TCC is the commonest cancer in the urinary tract. Whilst a predominant majority of them develop in the bladder, the renal pelvis is the second commonest site. In the ureter, the upper ureter is the commonest site. Adenocarcinoma is the commonest tumour in the urinary tract. Schistosomiasis is associated with squamous cell carcinoma.

Question 53

53. A 60 year old patient with a history of previous urinary tract interventions presents with right hydronephrosis and deranged renal function. Imaging suggests a mid-ureteric stenosis. An MR urogram is planned. Which of the following is true? a. A static-fluid MR urography is performed using gadolinium-enhanced T1-weighted imaging b. Excretory MR urogram is preferred in patients with severe renal impairment c. T1-weighted imaging is useful in differentiating between clot and calculi d. Renal sinus cyst can be differentiated from dilated intrarenal collecting system on T1-weighted imaging e. Smaller filling defects are better seen on the MIP images rather than the source data

Answer 53

53. c. T1-weighted imaging is useful in differentiating between clot and calculi A static-fluid MR urogram is a heavily T2-weighted technique similar to MRCP. Excretory urogram is a post-gadolinium injection T1-weighted technique. A static-fluid MR urogram is preferred in patients with renal failure. Renal sinus cysts cannot often be differentiated from dilated intrarenal collecting systems on T1-weighted and T2-weighted images. They are better appreciated on the excretory urogram. Source data should be reviewed to ensure that small filling defects are not missed.

Question 54

54. A 47 year old with an obstructed urinary system is advised to have a percutaneous nephrostomy. Which of the following is appropriate? a. Persistent post-procedural haematuria usually needs a nephrectomy b. If appropriate, the preferred site of puncture on the renal surface is just anterior to the convex lateral margin c. A lower pole calyx is preferred when ureteral intervention is planned d. There is a 10% chance of developing haematuria post-procedure e. In an obstructed infected system, further imaging and manipulation are usually delayed after establishing drainage

Answer 54

54. e. In an obstructed infected system, further imaging and manipulation are usually delayed after establishing drainage The most common reasons for persistent haematuria are traumatic arteriovenous fistula, pseudoaneurysm or vascular injury, all of which are usually managed endovascularly. Brodel’s avascular plane is just posterior to the convex lateral margin. Whilst an easily accessible lower pole calyx is usually the target for a simple nephrostomy drainage, for ureteral interventions, a posterior calyx in the mid or upper polar region may be better. Almost all patients develop haematuria, but 1–3% may need transfusion or further intervention.

Question 55

55. A 43 year old female has a renal ultrasound which shows a left-sided renal ‘mass’. The ‘mass’ is continuous with the renal cortex and has the same echogenicity as the cortex. It is situated at the border of the upper and mid poles of the left kidney and is seen to extend between the renal pyramids. Which one of the following are these features most likely to represent? a. Renal scarring b. Hypertrophied column of Bertin c. Dromedary hump d. Persistent fetal lobulation e. Duplex kidney

Answer 55

55. b. Hypertrophied column of Bertin Many lesions may be mistaken for a renal cell carcinoma on imaging, and it is important to be able to differentiate such ‘pseudotumours’ from genuine carcinomas. The features described in the question are consistent with a prominent column of Bertin. This is normal renal tissue located between the pyramids and extending into the renal sinus. The key features include continuity with the cortex, identical echogenicity to normal cortex and the lack of mass effect or renal outline deformity. A dromedary hump is a focal bulge on the lateral border of the left kidney caused by its relationship with the adjacent spleen. Persistent fetal lobulation can be identified by indentations of the renal surface that overlie the space between the pyramids, whereas renal scarring lies directly over the medullary pyramids.

Question 56

56. A 31 year old female is admitted to hospital with placental abruption. Her renal function deteriorates significantly and therefore a renal ultrasound is requested. Kidneys with bilateral increased echogenicity and thin tramline calcification of the cortices are seen. Which of the following underlying conditions is most likely? a. Acute cortical necrosis b. Papillary necrosis c. Barter syndrome d. Drug-related nephrotoxicity e. Renal infarction

Answer 56

56. a. Acute cortical necrosis The features described are typical of cortical nephrocalcinosis. Causes of cortical nephrocalcinosis include acute cortical necrosis, chronic glomerulonephritis, sickle cell disease, Alport syndrome and congenital oxalosis. Acute cortical necrosis is a rare cause of acute renal failure, and is most commonly due to complications of pregnancy such as placental abruption, infected abortion and severe eclampsia.

Question 57

57. A 37 year old male undergoes an intravenous urogram and the right ureter is deviated medially in the lumbar region. Which one of the following could explain this finding? a. Psoas muscle hypertrophy b. Para-aortic lymphadenopathy c. Retrocaval ureter d. Urinoma e. Abdominal aortic aneurysm

Answer 57

57. c. Retrocaval ureter Medial deviation of the ureter is seen with retrocaval ureter on the right side and with retroperitoneal fibrosis. The other conditions listed all cause medial deviation of the ureter in the lumbar region. Retrocaval ureter is a rare entity which is caused by abnormal embryogenesis of the IVC. There may be symptoms of right ureteral obstruction and recurrent urinary tract infections

Question 58

58. The current NHS Breast Screening Programme was set up in 1988 as a result of the Forest Report. Which one of the following statements regarding the current screening programme is correct? a. Screening is only available to women aged 50–70 years b. Women are invited to attend at two-yearly intervals c. It detects 15 cancers per 1000 women screened d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS) e. Breast cancer screening has not been shown to reduce mortality from breast cancer

Answer 58

58. d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS) In the 2007–2008 review statistics, eight cancers were detected per 1000 women screened. Women between the ages of 50 and 70 years are invited to attend the Breast Cancer Screening Programme at three-yearly intervals. However, women over the age of 70 are encouraged to make their own appointments to attend. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35% reduction in mortality from breast cancer among screened women aged 50–69 years. This means that out of every 500 women screened, one life will be saved.

Question 59

59. A 72 year old woman with breast cancer has the following combination of clinical and radiologic findings: a tumour measuring 3.5 cm in the right breast but with no chest wall/skin involvement; ipsilateral axillary and supraclavicular lymph node involvement with the nodes fixed to underlying structures; no internal mammary node involvement; no bone, lung or liver metastases present. Which one of the following is the correct TNM staging of her disease? a. T2N2M0 b. T2N2M1 c. T3N1M1 d. T3N2M0 e. T4N2M1

Answer 59

59. b. T2N2M1 The correct TNM staging is T2N2M1. The presence of involved ipsilateral supraclavicular nodes makes the staging M1 even in the absence of other distant metastases. T2 tumours encompass those which are more than 2 cm but less than 5 cm in diameter. N2 disease signifies involved axillary nodes which are fixed either to one another or to underlying structures. N3 disease signifies internal mammary involvement

Question 60

60. On breast MRI, which of the following features of a breast mass is more suggestive of a malignant lesion than a benign lesion? a. Low-signal internal septations b. Lobulated mass which shows no enhancement c. Rim-like enhancement of the mass d. A focal area of hypointense T2 signal adjacent to the mass e. Stippled enhancement

Answer 60

60. c. Rim-like enhancement of the mass Rim-like enhancement is a relatively rare finding, but has a high correlation with malignancy (positive predictive value 84%). A focal area of hyperintense signal on T2 near a lesion is highly suggestive of malignancy. Whilst the other characteristics may be present in a malignant lesion, all are more suggestive of benign pathology. Irregular spiculated margins of a mass have a high positive predictive value for malignancy. Other features suggestive of malignancy are heterogenous internal septations and enhancing internal septa.