RD 2021 Chch and Auck combined Flashcards
Hysterosalpingogram:
A. Spillage in 1 tube and not the other definitely means tube is blocked
B. If lipiodol is used thyroid status should be checked
C. Good for differentiating bicornuate and septate uterus
D. Can be safely performed at any stage of menstrual cycle
CCF - I would favour B
1. http://www.thyroid.org/wp-content/uploads/publications/ctfp/volume8/issue6/ct_public_v86_7_8.pdf
2. https://pubmed.ncbi.nlm.nih.gov/18958768/
This study (1) shows that thyroid hormone levels can be
affected by the administration of Lipiodol. HSG during a fertility evaluation puts women at risk of developing mild hypothyroidism at a time when they are trying for a pregnancy. The paper suggests that
women getting lipiodol as part of HSG should have thyroid function monitored closely for at least 24 weeks after the procedure. Another paper suggested to check pre-procedure (2).
As WJI states below - widely accepted that HSG should be preformed during proliferation phase both for increased visualisation and reduced risk of pregnancy. Therefore can we infer that HSG is less safe post ovulation due to pregnancy risk making D less correct?
WJI B. Agree CCF.
Should be performed in proliferation phase as endometrium is thinnest and unlikely to be pregnant.
-can have tubal spasm or underfilling
-hyperthyroidism is a contraindication to lipiodol
-endometrial cavity of bicornuate and septate uteri look the same
Which is most typical location:
A. Myxopapillary ependymoma at filum terminale
B. Central neurocytoma temporal horn
C. Ganglioglioma frontal lobe
D. Paediatric haemangioblastoma parietal lobe
WJI A. Myxopapillary ependymoma at filum terminale
MM - agree
B body of LV
C temporal lobe
D posterior fossa
Golfers elbow:
A. Tear in deep aspect
B. Chronic micro tear and repetitive injury of pronator and flexors
C. Tear on medial aspect more common then lateral
D. Most common in college athletes
E. Only seen in golfers
WJI, MM B. Chronic micro tear and repetitive injury of pronator and flexors
Lateral epicondylitis (tennis elbow) is more common
Most common in 4th, 5th decades
In overhead throwers pain in the elbow is secondary to:
A. Acromial impingement of supraspinatus
B. Medial compression and lateral ligament strain
C. Valgus injury reported in baseball and javelin sport people
D. Cumulative stress
WJI C. Valgus injury reported in baseball and javelin sport people
Throwers get valgus stress injury with medial strain (medial epicondyle apophysitis/avulsion/ucl tear/medial epicondylitis) and lateral compression (osteochondral fracture). “Throwers elbow”, “little leaguer’s elbow”
Stenner lesion:
A. Migrates proximal to adductor pollicis
B. Migrates proximal to abductor pollicis
C. Requires MRI for diagnosis
WJI, MM A. Migrates proximal to adductor pollicis
UCL avulsion injury where the distal insertion is entrapped superficial to the adductor pollicis aponeurosis. This can be diagnosed on US.
Right retrocardiac mass in a 3yo on CXR; which is not a cause?
A. Left atrium normal variant
B. Ganglioneuroblastoma
C. Medulloblastoma met
D. Duplication cyst
E. Round pneumonia
WJI A. Left atrium normal variant
Medulloblastoma commonly shows zuckerguss or drop metastases. Pulmonary metastases are rare but possible.
Petroclival lesion, mildly T1 hyper intense, homogeneously T2 hyperintense, mild enhancement?
A. Cholesteatoma
B. Chlesterol granuloma
C. Myxoid chondrosarcoma
D. Fibrous dysplasia
E. Asymmetrical marrow
CCF . Would probably favour B. Myxoid Chondrosarcoma over FD.
Rationale.
- Rare for FD to only involve petroclival junction. – typically more diffuse and if so why would stem use “petroclival junction” in the question stem (buzz word for chondrosarc.
- Neither options fit with provided T1 characteristics But T2 more in keeping with Chondrosarcoma.
FD Heterogenous low/intermediate T2 (but sometimes heterogenous high T2 regions). (Stat dx and Radiopediia).
Chondrosarcoma Homogenously high T2 hyperintense– classic feature and stated verbatim in stem, note can have punctate low T2 If Ca2+ (Radiopedia and stat Dx).
Myxoid type Chondrosarcomas can arise from skull base (although rare)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505352/
https://pubmed.ncbi.nlm.nih.gov/1545025/
** SCS agree w CCF.
Location and signal characteristics favour chondosarc. Myxoids are intermediate lesions with patchy C+
- Fibrous dysplasia is heterogeneously avid contrast enhancement. Intermediate to Low T1 (hence Fibrous)
Hyperdense cyst 3.8cm with thin enhancing septations, what is Bosniak grade?
WJI: 3
1: simple cyst
2. Few hairline septae or calcifications. May have perceived enhancement. OR non enhancing high attenuation cyst <3cm without enhancement
2F: multiple hairline septa or smooth walls or nodular calcifications or >3cm high attenuation without enhancement. This requires FU
3: enhancing walls or septae. This requires excision.
4: enhancing soft tissue components
Creutzfeldt-Jacob; false?
A. Cortical T2 hyperintensity
B. Basal ganglia and striatum T2 hyperintensity
C. Dentate nuclei T2 hyperintensity
D. Cerebellum atrophy
WJI C. Dentate nuclei T2 hyperintensity
Non enhancing DWI/FLAIR hyperintensity of cortex and basal ganglia/thalamus followed by rapidly progressive atrophy
Cystic and peri cystic lung disease get which cancers?
A. Adenocarcinoma
B. SCC
C. Small cell
D. Large cell
E. Carcinoma
WJI, MM: a. Adenocarcinoma
Nodular wall thickening of a cystic space is an invasive mutinous adenocarcinoma spectrum lesion
Adenocarcinoma; which is false?
A. Minimally invasive is <3cm
B. Atypical adenomatous hyperplasia is a small GG nodule
C. Lepidic predominant has necrosis/haemorrhage
D. Invasive mucinous has >5mm invasion
WJI
A. Minimally invasive is <3cm - true
B. Atypical adenomatous hyperplasia is a small GG nodule -true ( <5mm).
C. Lepidic predominant has necrosis/haemorrhage - false, microinvasive spread along normal alveolar tissue framework
D. Invasive mucinous has >5mm invasion - true (this feature distinguishes ‘invasive’ from ‘minimally invasive’, which is <5mm invasion)
**SCS: “lepidic” = a pathologic term referring to growth pattern along the lining the alveolar structures. Can be seen in AIS, MIC and invasive carcinoma.
-Necrosis is a histological feature of invasive ca.
Jaw pain, lucent mandibular lesion 37 and 38 roots, expansile and non-enhancing?
A. Giant radicular cyst
B. Follicular cyst
C. Odontogenic keratocyst
D. Ameloblastoma
** SCS: I favour OKC. Causes jaw pain vs periapical cysts are asymptomatic. Associated with TWO roots thus insinuating/spaying the roots. Classic location adjacent to 3rd molar. Expansile buzzword not associated w periapical cyst.
No mention of “non-vital tooth”/associated caries.
Radicular cysts generally <10mm. Only giant in case reports…. No mention of giant in radiopaedia or StatDx.
Does the non-enhancing imply “no solid component” to distinguish from Ameloblastoma?
WJI - favour C over possibly alse A
Bladder TCC best seen on?
A. T1FS
B. T2
C. T1
D. DWI
E. STIR
WJI: T2 is used for staging. Or DWI ?
SCS: Agree T2 gives good anatomical delineation. Note DWI good road map… TCC diffusion restricts. As with most pelvic MR use DWI to localise pathology/nodes and use other sequences to characterise.
Prostate cancer <50% of 1 lobe, what is T stage?
WJI: T2a
T1 non palpable
T2 palpable; t2a-<50% 1 lobe, t2b>50% 1 lobe, t2c: bilateral
T3a-extraprostatic, t3b-seminal vesicles
T4-invades any other structures
Atrial myxoma; which is least likely?
A. Associated with carney syndrome
B. Characteristically T2 hypointense
C. Commonly pedunculated
D. Heterogeneous enhancement
E. Often attached to atrium
WJI
A and b are both wrong. Should be T2 hyperintense and it is associated with Carney Complex (myxoma and blue naevus). Carney syndrome is paraganglioma and gastrointestinal stromal sarcoma. Carney triad is paraganglioma, GIST and pulmonary chondroma
Well defined breast mass 56yo woman, most likely? (Auckland recall: well circumscribed on mammogram and solid on US)
A. Phylloides tumour
B. Mucinous
C. High grade IDC
D. DCIS
E. Fibroadenoma
**SCS: I favour HG IDC.
-Stat Dx: Circumscribed margins more common in High grade IDC. -Radiopaedia “circumscribed lesions more common in grade 3 [(high grade)] IDC”
In this age group always think canker.
A bit old for phyllodes. No hx of rapid expansion.
Mucinous is in older group (StatDX mean age 71)
This sort of question has come up on several prior recall sets. I suspect it’s trying trick people into relaxing and calling it benign.
Regarding phylloides?
A. Indistinguishable on mammogram and US from fibroadenoma
B. Most common in post-menopausal women
WJI: A. Indistinguishable on mammogram and US from fibroadenoma
Median age 45-49, mean 39.
Solid breast mass; which feature most likely suggests benign lesion?
A. Foci of T1 hyperintensity
B. T2 hyperintensity
C. Non-mass like enhancement
D. Non-enhancing septations
WJI
Either A or D. Probably A as lesions containing fat are benign and other causes of T1 hyperintensity (melanin, blood, proteinaceous fluid) would be unusual. Non-enhancing septations are a feature of fibroadenoma but lesion must also be well circumscribed with type 1 curve to diagnose FA.
T2 hyperintense lesions are typically benign except mucinous type carcinoma.
(Auckland recall a. As “high T1” and d. As “enhancing septations”. This would support A. As correct.
Most suggestive of high grade DCIS with comedonecrosis?
A. Non mass like enhancement on MRI
B. Dilated calcified ducts on US
C. Mass
D. Lucent centre calcifications
WJI
A. Non mass like enhancement on MRI
Calcified ducts also suggestive but could be papilloma or ducts ectasia/plasma cell mastitis
** SCS:
Stat Dx: MRI extremely sensitive for HG DCIS cf mammo. “Non-mass, clumped linear enhancement”. 98% sensitive.
USS: echogenic intraductal Ca++ visible + Mass in 43% of HG DCIS. But could be other things as above.
Immune drug of some description (IC something) not associated with?
A. Bronchiolitis
B. NSIP
C. UIP
D. COP
E. Acute interstitial pneumonia
WJI:
Immune checkpoint inhibitor therapy related pneumonitis can have following patterns:
-OP, NSIP, HSP, AIP, bronchiolitis, radiation recall pneumonitis; so maybe the answer is C. UIP
Or maybe it’s a trick because an OP pattern with a known cause wouldn’t be cryptogenic.
**SCS agree-> COP is idiopathic, probably a trick question
Posterolateral corner injury is not associated with injury to:
A. ACL
B. PCL
C. Popliteus
D. Actuate complex
E. Semitendinosus tendon
WJI:
E. Semitendinosus tendon
PLC injuries are strongly associated with cruciate injuries. C. and D. are PLC structures.
*SCS:
Biceps Femoris and LCL form conjoint tendon and are the marjor PLC structures.
Semitendinosis is other side- > pes anseriunus.
Bone marrow oedema: medial femoral condyle and tibia
Knee; which is false?
A. Discoid meniscus most likely medial
B. Radial vertical tears are associated with insufficiency fractures
C. Degenerative meniscal tears are usually vertical longitudinal
WJI:
A. Discoid meniscus most likely medial
* Usually affects the lateral meniscus
**SCS: other random trivia from StatDx:
Parameniscal cysts; assoc w meniscus tears, most commonly posterior horn medial meniscus. Always arises along peripheral border of the meniscus.
Menisculocapsular separation: posterior horn medial meniscus. Look for vertical hyper-intensity along the periphery of post meniscus (best seen Sagittal). Assoc. MCL superficial fibre injury.
Acute mesenteric ischaemia; which is least likely?
A. Bowel wall thickening
B. Intense mucosal hyperenhancement with submucosal oedema
C. High attenuation on NECT
D. Hypoenhancement of bowel wall
E. Pneumatosis
F. Pneumoperitoneum
WJI
B. Intense mucosal hyperenhancement with submucosal oedema
This is a feature of shocked bowel
Submucosal haemorrhage can give c.
Most specific sign in bowel wall trauma?
A. Intense mucosal hyperenhancement with submucosal oedema
B. Bowel wall thickening
C. Mesenteric oedema
D. IVC collapse
E. Intraperitoneal and retroperitoneal free fluid
WJI
B. Bowel wall thickening
Spina bifida on US?
A. 20% no overlying membrane
B. Extent most accurately visualised on sagittal
C. Normal posterior fossa excludes closed spina bifida
D. Lipomyelomeningocoele is a closed defect
E. More commonly sacrococcygeal than lumbosacral
WJI: c. And E. Are false.
A. 20% no overlying membrane - 90% open, of this 20% myelocoele/myeloschisis so this is probably correct.
B. Extent most accurately visualised on sagittal - true
C. Normal posterior fossa excludes closed spina bifida - false, it essentially excludes an open spinal dysraphism
D. Lipomyelomeningocoele is a closed defect - true
E. More commonly sacrococcygeal than lumbosacral - false: lumbar>sacral>thoracic>cervical
Open Spinal Dysraphism
- Myelomeningocele (98%)
- Myelocele
Closed spinal Dysraphism
- With subcutaneous mass
- Lipoma, Lipomyleomenigocele, Lipomyelocele
Lesion next to the epididymis in a 5yo with acute scrotal pain?
A. Torted appendix testis
B. Rhabdomyosarcoma
C. Chronic torsion
D. Adenomatoid
WJI:
A. Torted appendix testis - most common cause of acute scrotal pain in children
Physiological periostitis, which is true?
A. Lateral aspect of tibia more common than medial
B. Unilateral involvement is a described feature
C. Commonly age <1 month
D. Should be >3mm thick
E. Most commonly metaphyseal
WJI
D.
A, C and E are false. B and D probably false. Perhaps incomplete recall and either C or D have >/< back to front?
The usual appearance on radiograph is single-layered, thin periosteal reaction (commonly but not exclusively <2 mm) involving one aspect of the long bones.
DDx Caffeys; (infantile cortical hyperostosis) which tends to favour the flat bones. Prostaglandin use for ductal patency.
Max pressure for air reduction of intussusception?
A. 80mmhg
B. 100
C. 120
D. 140
WJI C. 120mmHg
Not a contraindication for ablation of a renal lesion?
A. Renal vein invasion
B. Hilar location
C. 32mm size
D. Uncorrectsble coagulopathy
E. Active sepsis
WJI C. 32mm size
Antenatal US brain findings at 20/40; true?
A. Fornices may be mistaken for CSP
B. CSP not seen until 24/40
C. Cingulate gyrus readily seen
D. Cisterns Magna measured as accurately on coronal plane as standard views
WJI A. Fornices may be mistaken for CSP (Stat Dx)
Radial scar most commonly presents as?
A. Architectural distortion
B. Calcifications
C. Non-mass enhancement
D. Well circumscribed mass
WJI A. Architectural distortion
Acute unilateral ophthalmoplegia in all directions with proptosis, which is most likely imaging finding?
A. Non-opacified cavernous sinus
B. Central pons infarct
C. Medulla infarct
D. Ophthalmic artery occlusion
E. Occipital infarct
WJI A. Non-opacified cavernous sinus
SCS: note caroticocavernous fistula can also do this (ie cause CN 3, 4 6 palsy and proptosis))
Eye presentable oedema, painful, asymmetric bilateral involvement, periscleral involvement infiltration mass involving intracranial fat?
A. Sarcoid
B. Pseudotumour
C. Panophthalmitis
D. Thyroid eye disease
WJI B. Pseudotumour
SCS: Agree. Note Sarcoidosis looks similar. Often can’t tell on just orbital imaging alone. CXR next best test?
ADB:annoyingly usually unilateral, RPD–>Patients typically present with rapid-onset, usually unilateral (~90% of cases), painful proptosis and diplopia.
IgG4 related arteriopathy, least likely involved?
A. Thoracic aorta
B. Infrarenal aorta
C. Iliac artery
D. Suprarenal artery
E. Popliteal artery
WJI E. Popliteal artery
Causes aortitis and large to medium vessel vasculitis. Peripheral arterial involvement is rare.
Renal artery stenosis and occluded infra-aortic vessels in 20yo man?
A. Buerger
B. Takayasu
C. PAN
D. GCA
E. FMD
F. Kawasaki
CCF - Favour B -Takayasu
– Takayasu average onset 15-30 years old. Can effect the renal arteries causing renovascular HTN (esp. type IV). Chronic inflammatory and obliterative changes in the aorta and its branches. There are often reduced or absent peripheral pulses, giving rise to its alternative name of “pulseless disease” (Radiopeida).
- FMD prob doesn’t account for occur for infra-aortic vessels (rare anything other than carotid and renal, although RP does say can involve the iliac but occlusion not really primary a sequelae of FMD).
SCS: agree CCF. This is very similar to a recall from a previous year.
30yo female with irregular carotid artery stenosis and HTN?
A. PAN
B. FMD
C. Other vasculitis
FMD
Non perfusing upper pole of kidney in a trauma case, no extravasation or free fluid?
A. Segmental arterial avulsion
B. Renal venous thrombosis
C. Renal venous dissection
D. Renal artery dissection
WJI: D. Renal artery dissection
Best guess. I think avulsion would likely have bleeding or free fluid. Renal vein thrombosis and arterial dissection are both described in trauma.
Young adult male. Cystic floor of mouth (Auckland recall “sublingual”) lesion; low T1, high T2 with intrinsic nodular foci of intracystic T1 low/T2 low?
A. Epidermoid
B. Dermoid
C. Lymphatic malformation
D. Ranula
E. Warthins cyst
F. Pleiomorphic adenoma
E. 2nd branchial cleft cyst
WJI
As written I would choose b. As dermoids can calcify but should also show fat lobules (hypodense and T1/T2 hyperintense)
Epidermoid, lymphatic malformation, ranula and BCC do not often calcify.
If it said T1 high foci answer would be B.
If it said venolymphatic malformation foci could be phleboliths.
Auckland also recalled pleomorphic adenoma as an option. As this is benign it is less common in the minor glands but appears T1 dark/T2 bright with calcifications so is another plausible answer.
** SCS agree. As written I favour Dermoid. I acknowledge lack of T1 HYPERintense foci to indicate fat (a defining feature for dermoid) makes this hard to go with BUT stat dx states that if there is complex signal then the lesion most likely represents dermoid (if deciding dermoid vs epidermiod- which should only contain fluid)
