Opening Round Flashcards
Case 1
Is there an increased risk of Renal Cell in ADPKD
No
Case 1
How does ADPKD tend to present clinically?
Hematuria
Hypertension
Renal Insufficiency
Case 1
Name two Complications of Autosomal Dominant Polycystic Kidney Disease
Renal failure
- Nearly all patients
Intracranial aneurysms
- 15% of patients
Case 2
Define the four classes of Renal Trauma
Class I
- Contusion or Capsular hematoma
Class II
- Major Laceration
Class III
- Multifocal laceration or renal vessel injury
Class IV
- UPJ disruption
Case 2
How do you manage renal injury based on class
Class I
- Conservative
Class II/III
- Depends on patient stability
Class IV
- Surgery
Case 3
What is the normal path of renal migration during development?
Ureteral bud
- Develops at the S1 level
- Migrates cranially to the L2 level
Case 3
What is the most common complication of a pelvic kidney?
UPJ Obstruction
Followed by
- Reflux
- Stone formation
Case 4
What single imaging feature is diagnostic of multilocular cystic nephroma?
Herniation in to the renal pelvis
- Very specific
- Not very sensitive
Case 3
What causes pelvic ectopia of a kidney?
Arrest of cranial migration of the ureteral bud as it tries to join the metanephric bud
Case 4
DDX of a renal mass with septations and thickened margins
- Renal cell carcinoma
- Multilocular cystic nephroma
- Complicated renal cyst
- Infection
- Hemorrhage
Case 5
Causes of unilateral papillary necrosis?
Pyelonephritis
Ureteral Obstruction
Tuberculosis
Renal Vein Thrombosis
Case 4 What Bosniak class cystic masses require surgery?
III and IV
Case 5
Name causes of Papillary Necrosis
POSTCARD
Pyelonephritis Obstruction Sickle Cell Disease TB Cirrhosis / Pancreatitis Analgesic Abuse Renal Vein Thrombosis Diabetes
Case 6
T/F
Hydronephrosis in the setting of pyeolonephritis may be nonobstructive
True
- Bacterial Endotoxin
- Smooth muscle paralysis
- Non-obstructive hydronephrosis
Case 6
What is the mechanism by which Pyelonephritis occurs
Infection ascending from the bladder via reflux
Case 5
Are filling defects in Papillary Necrosis in the renal calyx or the medulla
Medulla
Case 6
What else can look like pyeolonephritis?
Renal contusion
Case 6
What is the cause of decreased enhancement in pyelonephritis?
Papillary necrosis
Case 7
What is the likelihood that a calcified renal mass is a renal cell?
60%
–> All calcified renal masses should be further evaluated
Case 7
Is rim calcification a benign or malignant feature
80% Benign
- Cysts complicated by
- Infection
- Hemorrhage
20 % malignant!
(the q may be asked in reverse)
Case 8
What stage is an RCC with renal vein tumor thrombosis?
III
Case 8
How often do you see synchronous RCC lesions?
2%
Case 9
Is RCC more common in men or women?
Men
- x 2
- Age 50-70
Case 10
How often do you see synchronous TCC lesions?
40%
vs RCC
- 2%
Case 10
What percentage of TCC’s develop in the bladder
90%
Case 10
DDX of a non-calcified filling defect on a urogram
Radiolucent stone
TCC
Air bubble
Infectious debris
Case 11
T/F
Uric acid stones are radiolucent on CT.
False
- virtually all calculi are radiodense on CT
Case 10
Risk factors for urinary bladder cancer?
Smoking Benze exposure Analgesic abuse Balkan nephropathy Some oncologic chemoRx
Case 12
What modalities can help to differentiate hydronephrosis versus peripelvic cysts seen on Ultrasound
Postcontrast CT
Postconstrast MRI
IVP
Case 11
What is soft tissue rim sign?
Collar of ST around a ureteral stone on CT
Case 13
Two causes of immobile, off-midline stone in the bladder
Stone in - Bladder Diverticulum - Ureterocele Displacement of a stone by - Mass - Enlarged prostate
Case 13
Define a Ureterocele
Focal dilation of the distal end of the ureter
- Typically smooth regular wall
Case 13
Define a Pseudoureterocele
Dilation of the intramural ureter
- 2o to contiguous bladder dz
- Irregular thick, nodular wall
Case 13
What are the most common complications of an intravesical ureterocele?
- Obstruction
- Stones
- Milk of Ca+
- Recurrent UTIs
- Hydronephrosis
Case 14
What makes up most radiolucent urinary tract stones?
Uric acid
Case 14
DDx for filling defect in collecting system?
Radiolucent stone TCC Blood Clot Infectious debris Sloughed papillae Ari bubble
Case 15
Is UPJ obstruction functional or anatomic?
Functional
- Ureteral smooth muscle
- Deficiency
- Derangement
- > Failure of normal peristalsis
Case 15
What is congenital UPJ obstruction associated with?
Horseshoe kidney Contralateral multicystic dysplastic kidney Contralateral renal agenesis Ureteral duplication Vesicoureteral reflux
Case 15
How often is congenital UPJ obstruction bilateral?
How is it treated?
20%
Surgically
- Endopyelotomy
- Open Pyeloplasty
Case 16
When does the portal venous phase of contrast enhancement occur?
70-90 seconds
Case 16
When does the pyelographic phase of contrast enhancement occur?
120-180 seconds
Case 16
What are three most common primary renal tumors in adults?
Renal cell carcinoma
Transitional cell carcinoma
Squamous cell carcinoma
Case 17
Causes of hematuria
Stones UTI Malignancy Glomoerulonephritis Prostatic hypertrophy
Case 19
Is TCC more common in men or women?
Men
- 3 x
- 50-60 yo
Case 15
Most common cause of abdominal masses in neonates?
UPJ Obstruction
Case 18
Name four causes of bladder stones
Urinary stasis Foreign body Stones from kidneys 1o endemic stone dz - PESD
Case 19
What are two reasons to get a postvoid film on an IVP
Evaluate bladder
- Mucosa
- Function
Case 17
DDX of an adherent and irregular bladder mass
Bladder carcinoma Benign bladder tumor Fungal infection Cystitis Fibrosis Adherent blood products
Case 20
What is the most important feature of bladder cancer to determine therapy and prognosis?
Extension through the muscular bladder wall
Case 20
What stage is a bladder tumor that breaches the muscular layer of the bladder wall?
T3a
Case 20
What is the most common histologic subtype of bladder CA?
What histologic subtype is associated with urachal remnants?
TCC - 85%
AdenoCA
Case 21
What are two risk factors for emphysematous cystitis
Diabetes
Bladder outlet obstruction
Case 21
Is emphysematous cystitis an emergency?
How is it treated?
No, it’s not an emergency
Antibiotics
Bladder drainage (foley or suprapubic)
Treat the hyperglycemia in diabetics
Case 21
What common bacterial organisms cause emphysematous cystitis?
Most common
- E. coli
- Enterobacter
Followed by
- Clostredium perfringes
- Nocardia
- Candida
Case 22
What are the features of an intraperitoneal bladder rupture?
Cloud-like Collect in - Rectouterine - Rectovesical pouch Outline small bowel loops Extends to paracolic gutters
Case 20
DDx for multiple polypoid bladder masses
Multifocal bladder CA
Fungal infection
Focal proliferative cystitis
Case 23
How are extraperitoneal ruptures treated?
Foley Decompression
- Allows for spontaneous healing
Case 23
Which type of bladder rupture is considered a surgical emergency?
Intraperitoneal
Case 23
At least how much contrast is needed in the bladder to adequately evaluate for bladder rupture?
300 cc
Infused by low-pressure gravity infusion
Case 22
What are the features of an extraperitoneal bladder rupture?
Flame-shaped Collect in extra peritoneal spaces - Perivesical - Anterior prevesical (Retzius) - Retrorectal space
Case 24
T/F
Glands of Littre visualization is always a sign of pathology.
False
- Commonly seen in urethritis
- Can also be seen as normal variant
Case 24
In a RUG, what gives a slightly irregular contour along the dorsal aspect of the anterior male urethra?
Glands of Littre
Case 26
What are the two segments of the posterior male urethra?
Membranous
Prostatic
Case 26
What causes anterior urethral injury?
Straddle injury
- Bulbous urethera
Case 26
What causes posterior urethral injury?
MVA
- w/ pelvic fractures
- Esp anterior arch
Case 27
DDX for a spiral appearing fallopian tube
Salpingitis isthmica nodosa
Tuberculosis
Tubal adenomyosis
Case 27
What are the two complications associated with Salpingitis isthmica nodosa?
Infertility
Ectopic pregnancy
Case 27
What are contraindications to performing an HSG
Pregnancy
Active menstruation
PID
Recent D and C
Case 24
What is the duct that is seen arising posterolateral to the membranous urethra?
Cowper’s duct
- Imbedded in the urogenital diaphragm
Case 25
Iatrogenic strictures affect what part of the male urethra most commonly?
Membranous urethra
- penoscrotal junction
Case 28
What are the features of a Septate Uterus on ULTRASOUND?
Intercornual
- Distance less than 4 cm
- Angle less than 75 deg
Fundus
- Convex
- Flat
- Minimally concave
Case 29
Corpus luteum cysts are expected to resolve by when during pregnancy?
16 weeks
Case 29
Cysts of what size MUST be removed during pregnancy and at what point is it best to remove them?
What size cysts in pregnancy may be managed conservatively?
10cm (Controversy regarding cysts that are 5-10cm)
2nd trimester
5 cm
Case 30
What colonic wall thickness is considered abnormal and a sign of radiation colitis? When does it occur after radiation?
4 mm
Approx 2 yrs
Case 30
Is radiation colitis more common in cervical or endometrial cancer? Why?
Cervical
Higher radiation dose
Case 28
The mullerian or parasmesonephric ducts form what female structures?
Upper vagina
Uterus
Fallopian tubes
Case 25
What are causes of a urethral stricture?
Iatrogenic - most common cause in kids Infection Trauma Noninfectious urethritis - chemical irritation Neoplasm - long irregular strictures
Case 26
The membranous urethra is contained within what structure?
Urogenital diaphragm
Case 31
What complications occur with Dermoid cysts?
Torsion (most common) Infection Trauma Rupture w slow leak Malignant transformation (2% -> Squamous cell CA)
Case 31
T/F
Malignant transformation of dermoids most commonly occurs in postmenopausal women.
True
Case 32
Hydronephrosis indicates what T stage of cervical cancer?
T3a
Case 32
Is CT or MRI better for primary staging of cervical cancer?
MRI
- High spacial contrast
- Allows ID of dz beyond cervical stroma
- Best to evaluate for parametrial extension
- Must be used for any cervical mass > 1.5cm
CT
- Essential for advanced disease
- Best modality to look for distant mets
Case 32
In cervical CA, what stage allows for surgical cure?
T2A
- No parametrial invasion
Case 32
What T stages require brachytherapy?
Define each of those T stages?
T2B
- Parametrial invasion
T3
- Lower third of the vagina
T4
- Invasion of
- Rectum
- Bladder
- Vaginal fornices
Case 33
What is the most common appearance of ovarian cystadenocarcinoma?
Mixed fluid and soft tissue mass
Enhancing nodules
Thick septations
Usually seen w/ ascites
Case 33
What age group is affected by ovarian cancer
45-55 yo
- Perimenopausal
Case 33
In ovarian CA, why is hydronephrosis important to identify prior to CTX?
Because it must be treated with stents to allow for good renal function prior to chemotherapy
Case 27
What are the major differences between water-soluble and oil-soluble types of contrast media used for HSG?
Image detail
Peritoneal absorption
Case 32
What do you look for on MRI to determine if there is parametrial invasion?
What are the signal characteristics of cervical CA on T2?
Disruption
- Black ring of cervical stroma on T2
Cervical CA is bright on T2
Case 34
How often are Dermoid cysts bilateral?
How often are mature cystic teratomas bilateral?
20%
(p50 CR)
10%
(p52 CR)
Case 34
How do you differentiate between a dermoid and a mature cystic teratoma?
Dermoid
- Skin and dermal appendages
Mature Cystic Teratoma
- All three primitive germ cell layers
- Includes a Rokatansky nodule (solid/calcified)
Case 34
What feature in an ovarian cyst is diagnostic of a dermoid?
Fat attenuation
Case 36
What is needed for primary staging of ovarian cancer?
Total abdominal hysterectomy Bilateral salphino-oophorectomy Omentectomy Peritoneal washings Wall samplings Lymph node sampling
Case 36
How is ovarian cancer spread?
Intraperitoneal dissemination via ascites
Case 36
Define the four stages of ovarian cancer?
Stage I
- Cancer confined to the ovaries
Stage II
- Spread into the true pelvis
Stage III
- Extrapelvic peritoneal implants or LN mets
StageIV
- Distant hematogenous metastasis (usually liver)
Case 36
What is the sensitivity of CT for ovarian peritoneal implants?
90%
Case 37
What size hemorrhagic cyst requires 6 week followup?
> 3cm
Case 37
DDx for a complex cystic ovarian/paraovarian mass
Hemorrhagic cyst
Tuboovarian abscess
Ectopic pregnancy
Ovarian tumor
Case 37
Classical clinical presentation of hemorrhagic cyst?
Pelvic or abdominal pain that may wake the patient from sleep
Case 38
T/F
Gas bubbles are common in TOA on CT.
False
Case 38
How does a TOA occur?
Cervical or vaginal infection
- Chlamydia
- Gonorrhea
Spreads into
- Endometrium
- Fallopian tubes
- Ovaries
Case 39
What do fibroids look like on MRI?
What do degenerated fibroids look like?
Fibroids
- Well-defined
- Homogenous
- Low T1/T2 relative to myometrium
Degenerating fibroids
- Heterogenous
- High T2 signal
- Irregular enhancement
- Difficult to differentiate vs Leiomyosarcoma
Case 40
What is the most common cause of postmenopausal bleeding and how is it defined?
Endometrial atrophy
- ES thickness less than 4 mm
Case 40
What endometrial thickness should prompt biopsy in a postmenopausal woman who is bleeding?
> 5 mm
Doesn’t matter if they are on hormones or not!
Case 40
What endometrial thickness should prompt biopsy in a postmenopausal woman who is NOT bleeding?
> 8 mm
Case 41
What feature makes a cervical cancer inoperable?
What stage would that be defined at?
Parametrial invasion
Stage IIb
Case 41
How is cervical cancer treated based on stage (Ib/IIa vs IIb and higher)?
Ib and IIa
- Radical hysterectomy
- XRT
IIb and higher
- XRT
- Chemotherapy
“2b or not 2b” is what determines if surgery is possible
Case 41
Is the incidence of cervical CA increasing or decreasing over the past 30 years?
Decreasing
Case 41
FIGO guidelines for clinical staging of cervical cancer
Bimanual pelvic exam CXR IVP Cystoscopy Imaging of lungs and skeleton
Case 42
DDX for bilateral adrenal masses
Adenomas Metastasis Hemorrhage Granulomatous adrenalitis Pheochormocytoma - 10% are bilateral
Case 42
What CT washout parameters define an adenoma?
50% washout at 10 minutes
60% washout at 15 minutes
Case 43
What are causes of adrenal hemorrhage?
Trauma Sepsis Coagulapthy Anticoagulation therapy Surgery
Case 43
How often is adrenal hemorrhage bilateral in Neonates and adults?
Neonates
- 10%
Adults
- 20%
Case 44
What is the most common cause of Adrenal pseudotumor?
Additional DDx?
Exophytic renal cyst
Splenule Splenic artery aneurysm Exophytic upper pole renal mass Pancreatic body or tail mass Gastric diverticulum
Case 44
When is it advised to treat a splenic artery aneurysm and how is it treated?
Men vs Women?
If it is >2cm
- Stenting
- Embolization
- Resection
Women
- 90% found in women pregnant more than once
Case 44
Pseudolesions of the adrenal gland occur more frequently on which side?
Left
Case 45
DDX of an adrenal mass that contains fat
Adenoma Myelolipoma Exophytic renal AML Retroperitoneal - Lipoma - Liposarcoma
Case 45
An adrenal myelolipoma must be resected. True or False
False
- Growth not an indication
- Must be symptomatic
Case 46
What are two entities that give false POSITIVE adrenal FDG-uptake in a patient with lung cancer and an adrenal mass?
Pheochromocytoma
Adenoma
Case 46
What are two entities that give false NEGATIVE adrenal FDG-uptake in a patient with lung cancer and an adrenal mass?
Neuroendocrine tumor mets
BAC mets
Case 47
What causes an adrenal adenoma to drop in signal on out-of-phase MRI in chemical shift imaging
Intracellular lipid
Case 48
What is the treatment for a renal abscess
Antibiotics AND
Percutaneous drainage
Case 49
What is a CT sign that there is impending AAA rupture on CT?
Intraluminal high density crescent
Case 49
What is the likelihood that a >5cm aneurysm will rupture
40%
Case 50
How does retropertinoeal fibrosis spread?
Encasement from the aorta to the IVC and ureters
Case 50
How is RPF treated?
Ureteral stents temporarily
Surgical dissection or ureters for definitive treatment
Case 51
In what zone of the Prostate gland does BPH occur?
Transitional zone
Case 51
In what zone of the Prostate gland does cancer occur?
Nodules of benign prostate hyperplasia arise from which zone?
Peripheral zone - 85%
- 10% Transitional
- 5% Central
Transitional zone
Case 51
What is the first structure that is affected when Prostate carcinoma transgresses the capsule?
The neurovascular bundle
Case 52
DDX on US of a hypoechoic nodule in the peripheral zone
Prostate carcinoma Atypical hyperplasia BPH nodule Focal prostatitis Cyst
Case 52
On transrectal prostate US, what percentage of prostate carcinomas are hypoechoic?
70%
Case 31
Most common malignancy associated with dermoid cyst?
Squamous Cell Carcinoma
Case 53
What are sentinal nodes for right and left testicular cancer
Right
- Paracaval
- Inferior to the right renal artery
Left
- Renal perihilar
- Inferior to the left renal vein
Case 48
What are the two mechanisms that cause a renal abscess?
Pyelonephritis
Hematogenous spread
Case 53
How is Testicular cancer spread?
First
- Retroperitoneal lymph nodes
- Via lymphatics
Then
- Hematogenously
- Lungs
- Liver
- Bone
- BrainCase 53
Increased Alfa-fetoprotein and Human chorionic gonadotropin is seen in which types of testicular cancer
AFP
- Yolk sac
- Embryonal
- Teratoma
HCG
- Seminoma
- Embryonal
- Choriocarcinoma
Case 31
Imaging findings suggesting malignant transformation of dermoid cyst?
Rapid growth
Infiltration of adjacent tissues
Extensive adhesions
Peritoneal Implants
Case 34
What is a Rotanski nodule?
- Mural nodule in an ovarian Dermoid
- Contains most of the solid teratomatous elements
Case 54
Where is a scrotal pearl located?
Benign or premalignant?
Extratesticular
- Between the membranes of the tunica vaginalis
Benign
Case 54
What are causes of a scrotal pearl?
Inflammation Torsion - Appendix testis - Epididymis Almost always assoc w/ hydroceles
Case 55
What are causes of testicular calcifications
Testicular cancer
Resolved infection
Old hematoma
Prior infarct
Case 55
What is recommended followup for testicular microlithiasis?
Controversial
Now considered benign
- Assoc w GCT based on a single study
- Some will do q 1 yr US to age 40
Case 55
What is associated with testicular microlithiasis
Cryptorchidism
Testicular atrophy
Infertility
