RD Genitourinary formatted Flashcards

Question

3.Features of Xanthogranulomatous pyelonephritis? 1.Kidney is typically small. 2.20% of cases have a renal calculus. 3.Majority of cases are bilateral. 4.Associated with pseudomonas infection in 70%. 5.Diffuse involvement commoner than focal involvement.

Answer 1

5.Diffuse involvement commoner than focal involvement. - T focal in 10-17% 9.Features of Xanthogranulomatous pyelonephritis? (GC) 1.Kidney is typically small. - F enlarged 2.20% of cases have a renal calculus. - F staghorn in 75% 3.Majority of cases are bilateral. - F 4.Associated with pseudomonas infection in 70%. - F proteus, e.coli 5.Diffuse involvement commoner than focal involvement. - T focal in 10-17%

Answer 2

4.Papillary necrosis is seen. - T 10.Features of Renal TB? (GC) 1.Infundibulopapillary involvement is late. - F EARLIEST sign is moth-eaten calyx (necrotizing papillitis)= smudged papillae= irregular feathery appearance due to surface erosion. 2.CXR is frequently abnormal - F normal in >50% 3.Erosion of a papilla is a late feature. - F see (a) 4.Papillary necrosis is seen. - TRef. Dahnert pg 984, Renal TB (RG 2004) SCS: Cavities comminicating w collecting sustem - “ball on tee sign” Blunted dilated calyces.

Answer 3

3.< 10 PSA , bone involvement is unlikely. - T Confined disease (stage A or B) in 75% with PSA <4, and 53% if 4-10 11.Concerning Prostate carcinoma? (GC) 1.Hyper intense on T2 weighted images. - F T2 hypointense focus within the normally hyperintense peripheral zone. 2.Hyper echoic on US. - F most are hypo 3.< 10 PSA , bone involvement is unlikely. - T Confined disease (stage A or B) in 75% with PSA <4, and 53% if 4-10 4.Rectal US is good for capsular spread. - F – MRI for extracapsular extension (90% specific, 15% sensitive) – From ANZJ Surg 2007;77; 860-865 “The main role of TRUS in prostate cancer is for guiding biopsy. It has a positive predictive value (PPV) of 50–63% for the detection of ECE (BJU 2000). Moreover, overall detection is poor – up to 50% of nonpalpable tumours may not be visualized on grey-scale ultrasonography and only 17–57% of hypoechoic lesions in the peripheral zone are malignant”The reported accuracy of TRUS in the staging of PCa varies. Large multicentre study found an accuracy rate of only 62% However, a 1997 prospective multicentre study showed a continuously poor performance for TRUS, with its ability to detect ECE matching digital rectal examination (Ammersham)Ref. Dahnert pg 949

Answer 4

4.Scleroderma. ? (StatDx lists PAN, SLE as causes) 12.Which is not a cause of renal vein thrombosis ? (AB) 1.Membranous glomerulonephritis. 2.Gastroenteritis. 3.Dehydration in infants. 4.Scleroderma. ? (StatDx lists PAN, SLE as causes) 5.Amyloid. Renal vein thrombosis in infants most commonly due to dehydation/sepsis. In adults, most commonly due to nephrotic syndrome (which in turn is most commonly due to membranous glomerulonephritis). Amyloid is a recognised cause. Other important causes: RCC; trauma; post-transplantation; hypercoagulable states. Scleroderma affects the renal arterioles and causes cortical necrosis.Reference: Dahnert 6th ed.

Answer 5

3.Haemolytic uraemic syndrome. Medullary nephrocalcinosis occurs in medullary sponge kidney, hyperparathyroidism, renal tubular acidosis. In sickle cell anaemia, renal echogenicity can be normal (most common) or mildly increased (medulla only or medulla and cortex). HUS causes increased cortical echogenicity (from acute cortical necrosis).Reference: Dahnert 6th ed.; From the Archives of the AFIP: Sickle Cell Anaemia, Radiographics, 2001; Increased Renal Parenchymal Echogenicity: Causes in Pediatric Patients, Radiographics, 1990.

Answer 6

3.Low resistance flow on Doppler is normal. A high-frequency linear transducer is used (7.5-10 MHz; higher in young children). Low resistance flow is typical. Microlithiasis is arbitrarily defined as 5 or more tiny (1-2 mm) hyperechoic and typically non-shadowing foci per image. Reference: Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update, Radiographics, 2005

Answer 7

1.AP resection - T 2.Prostatomegaly - F – fish hook of distal ureters 3.Ureterocele - F 4.AAA – F *LW: FALSE - Promethius states this causes lateral displacement, as makes sense anatomically. 5.Left retrocaval ureter - F – retrocaval ureter is RIGHT sided – which can cause medial deviation of the proximal ureter. DDx (Dahnert) Medial deviation of DISTAL ureter: Hypertrophy of iliopsoas muscle Enlargement of iliac lymph nodes Aneurysmal dilatation of iliac vessels Bladder diverticulum at VUJ (Hutch) Following abdominoperineal surgery + retroperitoneal lymph node dissection Pelvic lipomatosis Renal cyst (parapelvic and lower pole) Medial deviation PROXIMAL ureter: Retrocaval ureter (right side only) Retroperitoneal fibrosis AAA (fibrosis if chronic leakage)(note: Primers puts prostatic enlargement as DDx for medial displacement- J-shaped—I am choosing to ignore this and consider fish hooking as separate to medial displacement)Added options ‘ d’ and ‘e’

Answer 8

1.AP resection - T 2.Prostatomegaly - F – fish hook of distal ureters 3.Ureterocele - F 4.AAA – FALSE 5.Left retrocaval ureter - F – retrocaval ureter is right sided – which can cause medial deviation of the proximal ureter. DDx (Dahnert)Medial deviation of DISTAL ureter: Hypertrophy of iliopsoas muscle 'Enlargement of iliac lymph nodes 'Aneurysmal dilatation of iliac vessels Bladder diverticulum at VUJ (Hutch) Following abdominoperineal surgery + retroperitoneal lymph node dissection Pelvic lipomatosis Renal cyst (parapelvic and lower pole) Medial deviation PROXIMAL ureter: Retrocaval ureter (right side only) Retroperitoneal fibrosis AAA (fibrosis if chronic leakage) (note: Primers puts prostatic enlargement as DDx for medial displacement- J-shaped—I am choosing to ignore this and consider fish hooking as separate to medial displacement) Added options ‘ d’ and ‘e’

Answer 9

2.Indinavir related calculi are radiolucent - T – (true for pure stones, however can be detected on CT if contain other substances – Ca++, uric acid) 18.Regarding HIV related renal problems (TW) 1.Nelfinavir related calculi cannot be seen on CT – F – unlike indinivar – nelfinavir stones have been reported to be seen on CT, pure indinivar stones not seen on all modalities. 2.Indinavir related calculi are radiolucent - T – (true for pure stones, however can be detected on CT if contain other substances – Ca++, uric acid) 3.Majority of HIV associated nephropathy kidneys have enlarged kidneys *LW: TRUE. Radiopedia - longitudinal renal size is increases, with increased parenchymal echogenicity, and decreased renal sinus fat. CT also shows enlarged kidneys. Diagnosis is biopsy proven. SCS: Dahnert also agrees “globally enlarged kidneys… increased cortical enchogenicity. 4.Only a minority of HIV-infected patients develop renal impairment during their illess. – F – most HIV infected patients develop RI. (Radiographics 2008) ** SCS: Dahnert: HIV Nephropathy 40%. FSGS, nephrotic syndrome. 5.Hypertensive nephropathy is the leading cause of renal failure in HIV patients – F – HIVAN is leading cause (40% of cases of HIV related renal disease). (Radiographics 2008)Indinovir (protease inhibitor for treatment of HIV-type 1) – precipitations of drug crystals in renal tubule.

Answer 10

19.Medial deviation of the ureter in the bony pelvis is seen T/F (TW) 1.In pelvic adenopathy - T 2.In prostatomegaly - F - fish hook of distal ureters 3.In herniation of the ureter through the sacro-sciatic foramen - F 4.In ureterocele - F 5.Following abdomino-peritoneal resection – T

Answer 11

5.Diabetes ?? F - occurs late - however more there is literature saying can actually occur early with DM too. AJR 2003 (The resistive Index in Renal Doppler Sonography: Where Do We Stand?)Doppler RI = ([PSV – EDV] / PSV) = 1-(EDV/PSV)Most consider RI 0.70 to be upper threshold of normal in adults (with exceptions: commonly >0.70 in 1st year of life, and can be >0.70 up to 4yo).Elevation of RI more likely with vascular / tubulointerstitial process, less likely with glomerular disease. Elevation of RI:Vascular:Acute vascular rejectionRenal vein thrombosisincreased intraparencyhmal pressure :ATN: elevated resistive index >0.75 (in 91% ) – where as pre-renal ARF cause has normal RI. RI greater than 0.07 was found to be a reliable discriminator between acute tubular necrosis and prerenal failure (AJR, Dahnert)Pyelonephritisperinephric / subcapsular fluid collectionrenal transplants (ATN / rejection)Cardiacsignificant systemic hypotensionmarkedly decreased heart rate (converse is true as well)Diabetes (?late finding) – combination of small vessel disease plus abnormal cardiac function in T2DM patients – generalized reduction in vascular compliance associated with arteriosclerosis in a range of vascular beds. in neonates + infants: normal findingHRS – develop renal dysfunction in pts with acute or chronic, severe liver disease - ?due to reduced renal vlood flow and vasoconstriction (due to local & systemic factors).Ureteric obstruction: > 0.7 - Obstructive cause initially thought to be mechanical cause (ie pressure increase) – but research suggests complex interactions between several regulatory pathways (RAS, kallikrein-kinin, PG-thromboxane) are responsible for intense, post obstructive renal vasoconstriction.

Answer 12

2.Hemihypertrophy is a known association - F Phaeo is the 10 % TUMOUR 10% are bilateral/multiple, 10% are extradrenal and 10% are malignant and 10% are familial and 10% have speckled calcification Hemihypertrophy is assoc with Wilms tumor. Phaeo associations: MEN II Neuroectodermal disorders - NF, VHL, TS Familial Phaeo I think this is meant to be Carney’s Triad = Gastric epithelioid leiomyosarcoma, functioning exra-adrenal paraganglioma, pulmonary chondromas) rather than Carney syndrome (Cardiac Myxoma, hyperpigmented skin lesions, breast fibroadenoma, psammomatous melanotic schwannoma, pituitary adenoma, large cell calcifying sertoli cell tumour, primary pigmented nodular adrenocortical hyperplasia)

Answer 13

3.HUS - F - Haemolytic Uraemic Syndrome: triad of thrombocytopaenia, microangiopathic haemolytic anaemia and acute oliguric renal failure leading to uraemia. HUS leads to acute cortical necrosis and cortical nephrocalcinosis [prerequisites US] 22.In the pediatric patient, which is the least likely cause of echogenic medulla? (CC) 1.RTA - T RTA renal parenchymal disease is often a pathophysiological type diagnosis with histology and renal function parameters including Renal tubular acidosis (RTA) which leads to chronic metabolic alkalosis as the distal nephrons are unable to resorb bicarbonate or secrete hydrogen (depending on the type I-IV). [GU pre requisites and Merck Manual] 2.Sickle cell -T Sickle Cell Disease – rare cause. Can cause cortical (eMed) and medullary nephrocalcinosis (Dahnert 6th pg 894). 3.HUS - F - Haemolytic Uraemic Syndrome: triad of thrombocytopaenia, microangiopathic haemolytic anaemia and acute oliguric renal failure leading to uraemia. HUS leads to acute cortical necrosis and cortical nephrocalcinosis [prerequisites US] 4.MSK - T Medullary Sponge Kidney = benign tubular ectasia. Leads onto medullary nephrocalcinosis in 40-80%. Recognised associations [Dahnert]:Parathyroid adenoma, Caroli’s Disease, Ehlers Danlos Syn 5.HPT - T All causes of hypercalcaemia can result in echogenic medulla.

Answer 14

4.scleroderma - F - SLE does

Answer 15

4.Inf mononucleosis F Inf mononucleosis –T. Usually associated with splenomegaly and Epstein Barr virus (EBV) = a tetrad of fever, pharyngitis, fatigue and lymphadenopathy. However, EBV genome is found is a minority of Burkitt Lymphoma which can enlarge the kidneys. I think this is too much of a stretch for this question hence True - not a cause of bilateral renal enlargement [Merck, and Dahnert] 24.Which of the following is not a cause of bilateral renal enlargement? (CC) 1.TS T TS : multiple cysts are found in cortex and medulla in 10 – 15% mimicking adult polycystic kidney disease 2.Leukemia T Leukaemia is a recognized cause of smooth bilateral renal enlargment from infiltrative replacement of renal interstitial tissue. 3.RTA T RTA is a functional deficit, which can later lead to chronic renal failure from nephrocalcinosis (chronic interstitial nephritis with cellular infiltration). 4.Inf mononucleosis FInf mononucleosis –T. Usually associated with splenomegaly and Epstein Barr virus (EBV) = a tetrad of fever, pharyngitis, fatigue and lymphadenopathy. However, EBV genome is found is a minority of Burkitt Lymphoma which can enlarge the kidneys. I think this is too much of a stretch for this question hence True - not a cause of bilateral renal enlargement [Merck, and Dahnert] 5.HUS T - normal to slightly inc in size

Answer 16

1.ectopic insertion gives bed wetting in boys F – boys always have ectopic insert above sphincter therefore no enuresis 25.Which of the following statements about duplex renal systems is incorrect? (CC) 1.ectopic insertion gives bed wetting in boys F – boys always have ectopic insert above sphincter therefore no enuresis 2.PUJ obstruction of lower system T – usually involves lower pole (LJS edit: combined PUJ + duplex collecting system is case report level rare) 3.Retention is a presenting symptom in both sexes T 4.Reflux lower system T 5.Epididymo orchitis is a presenting symptom T – in preadolescent malemales do not have infrasphincteric insertion, only females [Dahnert]PUJ obstruction from extrinsic vessels usually effects the lower pole (anterior in 25-39%, posterior in 5-10%) )selectively involving the lower system. Presenting symptoms of duplex systems: [Weiss, comprehensive urology]UTI – most common Loin pain but also central and epigastric that may be associated with vomitingNeonatal abdominal mass – most common cause of neonatal hydronephrosisHaematuriaHypertension VUR affects the lower moiety more commonly due to a shorter submucosal tunnel [Dahnert]Although rare, ectopic insertion can be in the seminal vesicles (because of relationship with mesonephros) and presents with epididymo-orchitis or UTI rather than urinary incontinence.

Answer 17

1.It is usually bilateral F - 10% bilateral 26.Regarding neonatal adrenal haemorrhage, which is false: (TW) 1.It is usually bilateral F - 10% bilateral 2.More common on the right T – R>L 7:3 3.More common with a breech presentation T – difficult labor / delivery / breech 4.Occurs in the first 7 days T – first week of life 5.Increased with respiratory distress T – assoc with hypoxia /neonatal stress Aetiol : Neonatal stressDifficult labour – forceps, breechHypoxia/asphyxia due to prematuritySepsisHaemorrhagic disorders eg.DICIncreased risk LGA, diabetic mums. (Dahnert 6th pg 918)

Answer 18

1.More common in central zone F – Periph zone 80%, TZ 15% CZ 5%. Multifocal in 40% (Dahnert 6th) 27.Prostate cancer, which is false: (TW) 1.More common in central zone F – Periph zone 80%, TZ 15% CZ 5%. Multifocal in 40% (Dahnert 6th) 2.Can be hyperechoic on ultrasound T – can be but nb. 61% hypoechoic, mixed 2%, hyperechoic 0nly 2% (Dahnert 6th). 3.Transrectal ultrasound poor for evaluating capsular invasion T – see below 4.Bone metastasis not common if asymptomatic and PSA <10 T - Disease confined to gland 53% pt with PSA 4-10mg/mL (Dahnert 6th) From ANZJ Surg 2007;77; 860-865 “The main role of TRUS in prostate cancer is for guiding biopsy. It has a positive predictive value (PPV) of 50–63% for the detection of ECE (BJU 2000). Moreover, overall detection is poor – up to 50% of nonpalpable tumours may not be visualized on grey-scale ultrasonography and only 17–57% of hypoechoic lesions in the peripheral zone are malignant”The reported accuracy of TRUS in the staging of PCa varies. Large multicentre study found an accuracy rate of only 62% However, a 1997 prospective multicentre study showed a continuously poor performance for TRUS, with its ability to detect ECE matching digital rectal examination (Ammersham)

Answer 19

2.Aortorenal ratio of 2.5 means >than 70% stenosis F - > 3.5 for >70% 28.Renovascular hypertension, which is false: (TW) 1.Systolic – diastolic / systolic equals index T 2.Aortorenal ratio of 2.5 means >than 70% stenosis F - > 3.5 for >70% 3.Hyperpulsatility means a more distant stenosis - T - before a stenosis will have high resistance wave form - ie little, no, or reversed diastolic flow with high arterial flow (trying to get through stenosis). At stenosis have turbulent flow, and distal to stenosis the arterial flow drops and have a low resistance wave form - ie tardus parvus. 4.0.12 sec acceleration time intrarenal arteries indicates proximal stenosis - T AT > 0.07s (indirect sign)

Answer 20

2.Recurs post dilation T - but PTA 90% success rate with very low restenosis rate (Dahnert) 29.Regarding fibromuscular dysplasia of the renal artery: (TW) 1.Most common at the ostium F – 1st 1/3 of the renal artery spared in 98% 2.Recurs post dilation T - but PTA 90% success rate with very low restenosis rate (Dahnert) 3.Osteal stenosis F – see (a) 4.More commonly in the elderly F – most common cause of renovascular hypertension in children and young adults (<30-40y).FMD – involves mid and distal renal artery 79%. (Dahnert 6th)

Answer 21

2.10% have cysts T – 8-10% males (RG 2002). 30.Testicular ultrasound: (TW) 1.Can tell teratoma from seminoma F – although age group, and some sonosgraphic appearances may help (see below), probably cannot differentiate confidently. “With rare exception, solid intratesticular masses should be considered malignant (Radiographics 2002)”. 2.10% have cysts T – 8-10% males (RG 2002). 3.TB only affects the epididymus F – -Seminoma – uniformly hypoechoic. Larger tumors more heterogeneous. Cystic component 10%. Avg age is approx 40yo. -teratoma – well-circumscribed complex masses. Cysts common feature. Heterogeneous. Echogenic foci. Children – 75% occur <5yo. -Benign testicular cysts – either in tunica albuginea or parenchyma. Tunica albuginea cysts – peripherally located and may be single or multiple. Intratesticular cysts usually near mediastinum testis. If any solid component need to treat as malignant (and DDx from cystic lesions – Teratoma). -Tuberculous epididymitis from ascending/descending route of infection. Tuberculous orchitis usually from direct extension from epididymal infection, rarely from hematogenous spread.

Answer 22

1.Increased flow post spontaneous untorsion recognized - T – normal or increased flow may be seen with spontaneous detorsion (eMed 2008, Dahnert 6th pg975) 31.Testicular torsion: (TW) 1.Increased flow post spontaneous untorsion recognized - T – normal or increased flow may be seen with spontaneous detorsion (eMed 2008, Dahnert 6th pg975) 2.Epididymis and testes involved vs just testical inflammation vs torsion - ?not sure what this stem is 3.Normal grey-scale appearance of the testicles excludes torsion - F – can have normal appearance in first 6hrs. 4.Colour duplex imaging has sensitivity and specificity of ~60% - F – 86% sensitive, 100% specific, 97% accurate (Dahnert 6th)

Answer 23

1.Diabetes F Renal artery aneuyrsms – 2/3rd extrarenal, 1/3rd intrarenal -Extrarenal aneuyrsms: Atherosclerotic (most common), FMD, pregnancy, NF, Ehlers Danlos (CTD), Pseudoaneurysms: Trauma, Behcet, mycotic (staphy, strep, pneumococcus, salmonella) -Intrarenal Aneurysm: Congenital Arteritis: Incl PAN, wegeners, Tx rejection, drug abuse, SLE [HBsAG immune complex deposition -> immunologic injury -> necrotising angiitis] Degenerative- Atherosclerosis Tumour: incl RCC, AML Mesenchymal disease: NF Trauma Infection: Syphilis, TB (Dahnert 6th pg 894)

Answer 24

3.5% Cushings associated with adrenal carcinoma T 33.Regarding adrenals, which statement is true? (TW) 1.Calcification excludes malignancy F – Adrenocortical adenocaricinoma – calcified 30%, Phaeo Ca+ in 10% 2.Adrenal hyperplasia is less common in malignancy F 3.5% Cushings associated with adrenal carcinoma T 4.Conn’s verses Cushings can be differentiated on CT F Adrenal Ca+ (Chapman and Nak, Dahnert 6th)child: cystic disease (usually from haemorrhage), neuroblastoma, ganglioneuroma, Wolman’s disease. Adult: cystic disease, carcinoma, addison’s, ganglioneuroma, inflammatory, phaeo.Adrenocortical carcinoma – large size and calcification suggests malignancy (D 6th) Adrenocortical hyperplasia has 4x increase in incidence in patients with malignancy (D 6th)Cushings syndrome assoc with adrenocortical carcinoma 5-10% cases (10% in adults, 66% children) (D 6th)

Answer 25

5.Delayed scanning is always indicated in cases of suspected renal trauma – F – indicated if the initial CT shows a deep parenchymal laceration or a large perirenal fluid collection. 34.Renal trauma, which is false: (GC) 1.Large subcapsular haematomas may appear biconvex - T – small ones are Crescentic, large exert mass effect and appear biconvex 2.Pelvic kidney is at risk of trauma - T 3.A rim nephrogram may not be seen in the acute setting of traumatic renal infarction – T – indicates a devascularised kidney (grade 5), develops >8hr post occlusion of main RA by intimal flap, reflects preserved perfusion by capsular aa. 4.Grade 3 lacerations do not involve the collecting system - T – Grade 3: lacerations >1cm deep without extension into collecting system or urinary extravasation 5.Delayed scanning is always indicated in cases of suspected renal trauma – F – indicated if the initial CT shows a deep parenchymal laceration or a large perirenal fluid collection. (To check for urine leak from collecting system injury). Ref. Dahnert pg 981, CT Blunt Renal Trauma (RG 2001)

Answer 26

3.PUJ is bilateral in 70% F - bilateral in 10-40% 35.Fetal genitourinary anomalies, which is false: (GC) 1.Primary megaureter is due to an alteration at the VUJ T - 1° megaureter is due to an idiopathic congenital alteration at the VUJ (obstructed/aperistaltic, refluxing, or non-refluxing/unobstructive). 2° megaureter is due to bladder or urethral obstruction (eg. PUV). 2.Bilateral renal agenesis results in oligohydramnios T - Potter sequence: pulmonary hypoplasia, bowing of legs, loose skin, growth retardation. Other renal causes include PUV, ARPKD, MCDK 3.PUJ is bilateral in 70% F - bilateral in 10-40% 4.Hydrops due to a renal cause leads to a bad outcome T – high mortality 5.Urogenital sinus malformations occur only in phenotypic girls T – like cloacal malformation

Answer 27

4.Wolman's disease and adrenal atrophy = Primary familial xanthomatosis. AR inheritance, deficiency of lysosomal acid esterase. Bilateral punctate calcification throughout adrenals, but maintain their normal shape. Also hepatosplenomegaly, SB wall thickening, generalized osteoporosis. 36.There is a recognised association between all of the following EXCEPT: (GC) 1.Pelvicalyceal obstruction and Xanthogranulomatous pyelonephritis T - 75% have staghorn calculus. 2.Calcification in a non-peripheral renal mass and malignancy T - Calcification within a solid renal mass is indicative of malignancy, whereas in a cystic renal mass, calcification can be seen in the wall/septa of benign or malignant lesions.* 3.Medullary sponge kidney and Caroli's disease T - 80% of Caroli’s have medullary sponge kidney. 4.Wolman's disease and adrenal atrophy = Primary familial xanthomatosis. AR inheritance, deficiency of lysosomal acid esterase. Bilateral punctate calcification throughout adrenals, but maintain their normal shape. Also hepatosplenomegaly, SB wall thickening, generalized osteoporosis. 5.Schistosomiasis and bladder calcification T - S. haematobium. Bladder wall calcifn in up to 56% - begins at base and involves all wall layers. End stage shows reduced bladder capacity + post void residual. May also see bladder calculi, filling defects, distal ureteral calcifn or strictures.

Answer 28

2.Scleroderma F – SLE does. 37.Which is not a cause of renal vein thrombosis (GC) 1.Membranous glomerulonephritis T – Nephrotic syndrome is a hypercoagulable state – heavy proteinuria leads to decreased antithrombin III, relative excess of fibrinogen, and other changes in clotting factors. 2.Scleroderma F – SLE does. 3.gastroenteritis T – secondary to dehydration 4.Dehydration in infants T 5.Amyloid T - Accumulation of eosinophilic protein substances

Answer 29

4.Hypoparathyroidism F 38.Complications of renal transplantation include all except?: (GC) 1.Avascular necrosis T - Most commonly occurs in femoral head, bilateral in 60-80%. May be due to steroids, secondary to hyperparathyroidism, liver disease, dialysis (incr protein catabolism 2.Amyloid T – Cx of CRF 3.Sift tissue calcification around the joints T – from secondary hyperparathyroidism 4.Hypoparathyroidism F 5.An increased incidence of lymphoma T – Prevalence of NHL is 35x greater than in general population. Also increased risk of skin cancers and RCC

Answer 30

2.Prostatic carcinomas are more often hypoechoic than hyperechoic compared with adjacent prostate 39.Prostate carcinoma, which is true: (GC) 1.Prostatic carcinoma arises more often in the central zone than in the peripheral zone - F 80% in periph zone 2.Prostatic carcinomas are more often hypoechoic than hyperechoic compared with adjacent prostate 3.The serum PSA level, as a predictor of prostatic carcinoma, is independent of prostate size - F 4.About 50% of patients with prostatic carcinoma have a normal serum PSA level - F 19-30% 5.Haematospermia is due to prostatic carcinoma in about 75% of cases - F rare cause CME 02.38 Ref. Dahnert pg 949

Answer 31

2.CT is better than surgery for extravesical spread ?T – see below. Obviously Sx will not pick up a lung met. However is ?Sx better for local extension. 40.With regards to bladder cancer, which is true? (TW) 1.TCC hypervascular on angio ??? with fast dynamic contrast-enhanced imaging, bladder cancer enhances more avidly and earlier than other tissues in the normal bladder. But bladder Ca is heterogeneous – so may have variable enhancement? 2.CT is better than surgery for extravesical spread ?T – see below. Obviously Sx will not pick up a lung met. However is ?Sx better for local extension. 3.Internal iliac LN first involved F – various lymphatic drainage – superior bladder to ext iliac, inferior to int iliac, some around neck region to sacral or common iliac nodes. 4.CT is good for detecting seminal vesicle invasion by losing fat plane F – loss of fat plane may relate to inflammation / tumor involvement Bladder carcinoma Radiographics Article 2006. CT 52% accurate due to ‘overstaging’ “imaging is important for accurate staging … detection of pelvic side wall invasion or lymph adenopathy as clinical staging is inaccurate”“sensitivity and specificity for detecting perivesical spread with 92% and 98% respectively and accuracy of 96%”.

Answer 32

2.Conn's adenomata are characteristically less than 3cm in diameter. T – aldosteronoma – 1.7cm avg size. 41.On CT of the adrenals: (TW) 1.The right gland characteristically occupies a more caudal position to the left. F – eMed, however I’ve found the occasional contradicting answer. 2.Conn's adenomata are characteristically less than 3cm in diameter. T – aldosteronoma – 1.7cm avg size. 3.Calcification within a mass indicates that it is benign. F – Adrenocortical carcinoma, phaeo, cysts can all calcify. 4.Fat within a mass indicates an angiomyolipoma. F – AML of adrenal is rare++. Myelolipoma can have fat (macroscopic), but can’t differentiate from well differentiated liposarcoma. Perc Bx for Dx. 5.Both glands are normal in a patient with Cushings disease F – Cushings disease – adrenal hyperplasia due to overproduction of ACTH. 70% of endogenous causes. (CD is in the ACTH dependent group of Cushings syndrome)

Answer 33

2.Benign adenomas are typically <3cm in diameter on CT. T - <5cm, avg size 2.0-2.5cm. 42.The following statements regarding adrenal imaging are true: (TW) 1.Benign adenomas are typically of high attenuation on CT F – UECT <10HU (96% specific), <0 (100% specific) 2.Benign adenomas are typically <3cm in diameter on CT. T - <5cm, avg size 2.0-2.5cm. 3.Cushing syndrome is most commonly caused by a solitary adrenocortical adenoma F - Cushing’s disease most common cause (68%). See below. 4.Phaeochromocytomas are typically <3cm in diameter FCauses of Cushings Syndrome divided into ACTH (corticotrophin) dependent or ACTH independent.ACTH dependent (has bilateral adrenocortical hyperplasia): Cushing’s disease 68%, Ectopic ACTH 12%. (Cushing’s disease = pituitary hypersecretion of ACTH)ACTH-independent CS – adrenal adenoma 10%, Adrenal carcinoma 8%. CME 03.60 (5) (ref. UpToDate)

Answer 34

4.On Doppler ultrasound,a renal artery to aorta peak systolic ratio of 2.5 in 50% F >3.5 for >60% (Dahnert 6th) 43.With regard to renovascular hypertension: (TW) 1.lt accounts for about 5% of all cases of hypertension T – 1-5% (Dahnert 6th, eMedicine) 2.Normal pre- and post-captopril scintigraphy excludes renovascular hypertension with a confidence of >90% T (see below) 3.Stent insertion is the treatment choice in atherosclerotic ostial renal artery stenosis with resistant hypertension T – Revascularization is usually indicated in pts with hemodynamically significant lesion whith resistant HTN, malignant HTN. Revascularisation procedure of choice perc angio with stent, esp if there is concomitant ostial or proximal renal artery disease. (UpToDate, ACC/AHA 2005 guidelines) 4.On Doppler ultrasound,a renal artery to aorta peak systolic ratio of 2.5 in 50% F >3.5 for >60% (Dahnert 6th) ACE inhibitor scintigrams should be interpreted as consistent with a low, intermediate, or high probability of renovascular disease. The most specific diagnostic criterion for RVH at scintigraphy is an ACE inhibitor–induced change on the scintigram….. A normal ACE inhibitor scintigram indicates a low probability (<10%) of RVH. (Radiographics 2000;20:1355)

Answer 35

5.There is an association with hemihypertrophy of the body F Bilateral in 10%. Marked T2 hyperintensity due to cystic areas. 10% occur in extra-adrenal sites and are called paragangliomas. Theses have a higher incidence of malignancy(20-40% vs 10%). 10% of phaeochromocytomas occur in familial syndromes. These include VHL, NF-1, MEN-2A, MEN-2B and Sturge-Weber. MEN-2B patients have multiple mucosal neuromas or ganglioneuromas at a variety of sites. Adrenocortical carcinoma, not phaeochromocytoma, is associated with congenital hemihypertrophy.Reference: Robbins 7th ed.; Dahnert 6th ed.

Answer 36

*RY 4 = true for lipid rich adenoma, the most common form of adenoma (60-90% of adenomas). Signal drop out on out of phase due to microscopic fat content. Cases on statdx/radiopaedia are all lower signal than spleen. Adrenal to spleen ratio mentioned on stat dx (<0.7 = adenoma) Example: https://radiopaedia.org/cases/adrenal-adenoma-chemical-shift-imaging-4?lang=gb. 1 = false. According to the ACR adrenal management paper. "Although there are some data to suggest that CS-MRI may be slightly more sensitive for the detection of intracellular lipid than unenhanced CT, high-density adenomas (>20-30 HU on unenhanced CT) may remain indeterminate on CS-MRI, and adrenal CT with washout has been shown to outperform CS-MRI". In patients with malignancy, do adrenal CT. if does not washout then consider follow up, biopsy, PET-CT or resection depending on clinical scenario. https://www.jacr.org/article/S1546-1440(17)30551-3/fulltext ADB- some mets such as HCC and RCC (clear cell subtype) may contain microscopic fat which will show similar chemical shift appearances to adenoma Prior answer: 1.Chemical shift MR is most accurate in differentiating adenoma from metastasis

Answer 37

1.Cortical rim nephrogram indicates renal devascularization - T Not certain about this one. “Imaging of Renal Trauma: A Comprehensive Review”, Radiographics, 2001: minor injuries (not involving collecting system acount for up to 85% of blunt renal trauma; haematuria is absent in 24% with thrombosis of the renal artery due to an intimal flap (a form of pedicle injury), and the cortical rim sign is associated with this injury (due to continued perfusion of outermost cortex by the capsular artery, which branches early from the renal artery and is often spared). “MDCT Findings of Renal Trauma”, AJR , 2006: Gross haematuria is the most reliable indicator of serious urologic injury, although the degree of haematuria does not correlate with the degree of renal injury. There are also Pubmed references to gross haematuria corresponding to higher AAST grades of inury. So, gross haematuria indicates severe injury, but its absence does not exclude severe injury. By this reckoning, the last stem is also correct. Classification: Superficial cortical laceration (75-85%)Subcapsular hematomalenticular-shaped area + flattening of subjacent parenchymaRenal contusionpoorly defined area of low attenuation Small cortical laceration without caliceal disruption Rx:observationComplete cortical laceration/fracture communicating with caliceal system (10%)extravasation of contrast materialseparation of renal poles (= fracture)Rx:clinical judgement requiredShattered kidney / injury to the renal vascular pedicle (5%)multiple separate renal fragments (= shattered kidney)lack of enhancement of part / all of kidney± "rim sign" (= enhancement of renal periphery through intact capsular / collateral vessels)extravasation of contrast materialRx:surgeryDDx:respiratory motion artifact (low-attenuation area surrounding kidney)

Answer 38

1.Effective renal plasma flow can be measured by Tc 99m DMSA F – cortical scarringDMSA is a cortical agent. Note that glomerular filtration (required for DTPA imaging) does not mature until about 1 month of age.Reference: Mettler, Essentials of Nuclear Medicine Imaging, 5th ed.CME 02.50

Answer 39

4.Spread across the midline with vascular encasement is a recognised appearance on ultrasound and CT T48.Which of the following statements regarding neuroblastoma in children is TRUE: (AB) 1.Almost all occur in the abdomen F – thorax 15%, neck 5%, other 10% 2.Peak age of incidence is 5 years F – peak age is 2 years 3.Neuroblastoma in infants has a worse prognosis than those occurring in later childhood F – better prognosis if < 1 year 4.Spread across the midline with vascular encasement is a recognised appearance on ultrasound and CT T 5.Bone scintigraphy with 99mTc-Pi1DP is more accurate than 1 131-MIBG for detection of skeletal mestastases F - we use MIBG here About 60% occur within the abdomen. Neuroblastoma has a perculiar Stage IV-S: age < 1 year; localised primary tumour; dissemination limited to skin, liver, bone marrow. Prognosis approaches almost 100%, often with spontaneous regression. MIBG and bone scans have similar sensitivities (about 70%), but bone scans are less specific. Bone scans have a role in detecting non-MIBG-avid metastases.Refereence: UpToDate

Answer 40

1.Testicular microlithiasis is associated with Klinefelter syndrome - T 49.The following statements regarding testicular ultrasound are true: (AB) 1.Testicular microlithiasis is associated with Klinefelter syndrome - T 2.Cysts are more typically seen in seminomas than yolk sac/ endodermal sinus tumours - F 3.Seminomas typically contain cystic elements on US - F – solid, homogeneous, hypoechoic 4.The majority of teratomas in childhood are malignant F – change of CME stem 5.Teratoma is the commonest tumour occurring in association with testicular microlithiasis - F - seminoma Answer: A is the unambiguously correct answer.Microlithiasis is associated with Klinefelter syndrome. Seminomas tend to be homogeneous at ultrasound, with cysts rare (though Dahnert reports cystic elements in 10%...). Testicular teratomas behave benignly in young children. As for the tumour most commonly associated with microlithiasis, I’m not so sure. Germ cell tumours as a class are, and seminoma is the most common germ cell tumour. Two case studies in Radiology with limited numbers examined this question with conflicting results re: seminoma.

Answer 41

1.Intratesticular lesions are most often malignant. TTorsion can occasionally cause changes in the epididymis, causing a similar appearance on grey-scale. Orchitis occurs in 20-40% with acute epididymitis. Flow in the inflamed testis is usually increased (low RI) unless swelling within the rigid tunica albuingea compromises flow (high RI). Most intratesticular masses are malignant, particularly palpable solid or complex cystic lesions. Most paratesticular masses are benign.Reference: Dahnert, 6th ed.; eMedicine

Answer 42

5.AP resection T -AP resection is a recognised cause of medial deviation of the distal ureter. An ovarian mass would cause lateral displacement. In ureteric duplication, the upper moiety-associated ureterocoele can cause lateral displacement of the lower moiety ureter.

Answer 43

1.Escherichia coli infection and malacoplakia TE. coli infection is well recognised as a cause of malacoplakia. Renal tubular acidosis type 1 causes calcium phosphate (radiopaque) calculi. Only isolated case reports of TB/TCC and medullary sponge/RCC on Pubmed.

Answer 44

4.Wolman's disease and adrenal atrophy - FBilateral extensive calcification in enlarged normally-configured adrenals is diagnostic of Wolman disease.

Answer 45

1.There is an increased risk of malignancy F – low risk of malignancy. Life time risk estimates 1:2000 – 1:3000 based on available evidence. Risk of dying from an associated Wilm’s tumour is about 1:20,000 [Weiss, Comprehensive Urology] **SCS: gee this question is a bit stiff, given there is an increased risk of malignancy albeit small… 54.With regards to multicystic dysplastic kidney which of the following is FALSE (CC) 1.There is an increased risk of malignancy F – low risk of malignancy. Life time risk estimates 1:2000 – 1:3000 based on available evidence. Risk of dying from an associated Wilm’s tumour is about 1:20,000 [Weiss, Comprehensive Urology] 2.There is an increased incidence of pelvi-ureteric junction obstruction in the contralateral kidney T – PUJ obstruction in about 7 – 27% [Dahnert] 3.The ureter is atretic T - Dahnet suggests that ureteric obstruction/atresia is the underlying cause. Weiss says this may be a consequence of the genetics but I doubt the examiners read Weiss and then again everything is a spectrum - so True. Prerequisites uses this term an ultrasound sign. 4.In the hydronephrotic form, a dominant cyst is seen in the pelvis T – the dominant cyst is present in the hydronephrotic form. Paediatric Prerequisites. 5.In the pelvoinfundibular form, the cysts do not communicate T –Pelvoinfundibular subtype of MCDK is the more common. Dahnert quotes 93% accuracy in using non communicating cysts as a diagnostic sign for MCDK.

Answer 46

*WJI unsure about debate below about various literature from the olden days. 2 is most false. Thin calcs Bosniak 2 - 0% risk, thick/nodular calcs - 2F -5% *AJL - I would favour '5.Cysts develop in up to 50% of patients on long-term dialysis' to be the most incorrect. Cysts develop in around 90% of people on long term dialysis. Answer below is getting a bit complicated. ADB-->RP Acquired cystic kidney disease (ACKD) "Its incidence increases with the amount of time a patient is azotemic and has been estimated at 44% after three years of dialysis and 90% after ten years of dialysis 5. It is equally common with haemodialysis as with peritoneal dialysis".....though as above, option 2 seems dodgier than Manchester St. Previous answer: 2.The risk of malignancy in a cyst with calcification is about 50% - F Type III Bosniak lesion has a 50% chance of being malignant. If the cyst has suspicious calcification with enhancement then this stem is true according to 2002 Bosniak as this makes a renal cyst type III. Hartman goes on to quote Bosniak that qualitative assessment rather than quantitative assessment has not been and probably never will be quantifiable; as some observers will classify IIF as III due to what is perceived to be obscured wall enhancement rather than calcification per se. The stem doesn’t clarify what type of calcification pattern, and note that Dahnert & Hartman put irregular calcification as type III Bosniak which could makes this stem true if the description is “irregular calcification’. 55.Which of the following statements regarding renal cystic disease is FALSE: (CC)1.Calcification has been reported in 1-3% of renal cysts - T – quote from Radiographics 2004 Hartman Refresher Course Practical Guide to the Cystic Renal Mass, which quoted original article dated 1982. 2.The risk of malignancy in a cyst with calcification is about 50% - F Type III Bosniak lesion has a 50% chance of being malignant. If the cyst has suspicious calcification with enhancement then this stem is true according to 2002 Bosniak as this makes a renal cyst type III. Hartman goes on to quote Bosniak that qualitative assessment rather than quantitative assessment has not been and probably never will be quantifiable; as some observers will classify IIF as III due to what is perceived to be obscured wall enhancement rather than calcification per se. The stem doesn’t clarify what type of calcification pattern, and note that Dahnert & Hartman put irregular calcification as type III Bosniak which could makes this stem true if the description is “irregular calcification’. 3.Hyperdense cysts on CT are a feature of autosomal dominant polycystic kidney disease,- T – cyst haemorrhage in 66% [ Dahnert] 4.If septations in a cyst are smooth and less than 1 mm thick they are of no clinical significance - T - they are non surgical lesions [Radiographics 2004 Hartman Refresher Course Practical Guide to the Cystic Renal Mass]. 5.Cysts develop in up to 50% of patients on long-term dialysis - T After 3 yrs 10- 20 % develop renal cysts After 5 – 10 yrs 90% develop cysts. 7% develop solid renal neoplasm’s – adenoma, adenocarcinoma, oncocytoma [GU Requisites]CME 02.31 (16)

Answer 47

2.A rim nephrogram is seen in acute renal artery occlusion - T – due to collateral flow from capsular, peripelvic and peri ureteric vessels. Also seen in Renal VV Thrombosis, Acute tubular necrosis, Severe chronic urinary obstruction 56.Which of the following statements is TRUE: (CC) 1.An increasing dense nephrogram is a feature of acute glomerulonephritisT – [Dahnert] due to diminished plasma clearance of contrast material **SCS: types of nephrograms explained Dahnert Pg 890. Increasingly dense nephrogram: intially faint, increasingly dense over hours to days. Diminished plasma filtration, leakage of C+ into interstices, increaed tubular transit time Vascular: diminished renal perfusion Intra renal: GN Collecting system: intratubular obstruction: urate, bence jones protein (MM), Tamm-Horsfall protein, renal calculus. 2.A rim nephrogram is seen in acute renal artery occlusion - T – due to collateral flow from capsular, peripelvic and peri ureteric vessels. Also seen in Renal VV Thrombosis, Acute tubular necrosis, Severe chronic urinary obstruction 3.Renal papillary necrosis is unilateral in about 50% of cases - F - However, I can’t find a recent incidence on bilateral/unilateral papillary necrosis. eMedicine is all I could find and from an old study (1952), “In general, renal papillary necrosis is more common in women than in men. Mandel organized the first comprehensive review to focus attention on renal papillary necrosis. In his series, which examined 160 cases of renal papillary necrosis from the world literature, 96 patients (60%) had diabetes mellitus, 48 patients (30%) had urinary tract obstruction, and 15 patients (9.4%) had both. In the group with diabetes, women outnumbered men, and in the group of patients without diabetes, men outnumbered women, further reflecting the frequency and significance of urinary tract obstructions in elderly men with renal papillary necrosis. An autopsy report from 1957 by Simon and associates documented the presence of acute or chronic pyelonephritis in 95%.”. Assuming most urinary tract obstruction is unilateral, an incidence of about 30% or less would expected to be unilateral. 4.Hypertension due to renal cell carcinoma does not respond to nephrectomy – F Hypertension from Renin secreting RCC often normalizes with nephrectomy [Weiss, comprehensive urology, which quotes Sufrin seminars in urology 1989]5.Cortical calcification due to cortical necrosis is classically punctuate - T – [Dahnert] “tramline/punctate calcifications along margins of viable and necrotic tissue as early as 1 -2 months.”

Answer 48

5.On IVP, downward displacement of the lower pole calyces from obstruction of the non-orthotopic ureter is known as the drooping lily sign T 57.In complete duplication of the urinary collecting system which of the following statements is TRUE (CC) 1.Incomplete duplication is associated with pelvi-ureteric obstruction of the upper pole moiety F – PUJ occurs at lower pole [Dahnert 6th ed p987-8] 2.An associated ectopic ureterocele most often affects the lower pole moiety, F – ureterocele = upper pole [Dahnert] 3.The ectopic system may cause wetting in boys F – no, is above sphincter in boy [Dahnert] 4.At intravenous urography, an associated ureterocele is best visualised when the bladder is distended F – early filling shot [MCH protocol] 5.On IVP, downward displacement of the lower pole calyces from obstruction of the non-orthotopic ureter is known as the drooping lily sign T

Answer 49

4.The combination of absent venous flow and reversal of arterial waveform is characteristic of renal vein thrombosis - TT - Four direct criteria are used for proximal stenosis or occlusion of a renal artery: An increase in the peak systolic velocity in the renal artery > 150 cm/s for angles < 60 degree or >180 cm/s for angles > 70 degrees (in the literature, the threshold for significant RAS is 100 – 200 cm/s). A renal to aortic ratio of peak systolic velocity more than 3.5, Turbulent flow and/or flow reversal in the post stenotic area, Visualization of the renal artery without detectable Doppler signal, a finding that indicates occlusion. Absent venous flow and u-shaped/plateau-like reversal of diastolic arterial flow (renal vein thrombosis). 58.The following statements are true regarding complications after renal transplantation (CC) 1.Lymphocoeles accumulate radiotracer - F – photopaenic defect from displacement/impression on the renal transplant/urinary bladder [Dahnert 6th ed p 964] 2.Lymphocoeles appear in the first 4 days following transplantation – F [Dahnert 6th ed p 964] Lymhocoeles form within 4 – 8 weeks after transplantation. 3.Renal artery Doppler velocity greater than 1m/sec indicates renal artery stenosis – F - >180-200cm/sec depending on what you read. 2:1 ratio of peak stenotic and post stenotic, dampened signal post 4.The combination of absent venous flow and reversal of arterial waveform is characteristic of renal vein thrombosis - TT - Four direct criteria are used for proximal stenosis or occlusion of a renal artery: An increase in the peak systolic velocity in the renal artery > 150 cm/s for angles < 60 degree or >180 cm/s for angles > 70 degrees (in the literature, the threshold for significant RAS is 100 – 200 cm/s). A renal to aortic ratio of peak systolic velocity more than 3.5, Turbulent flow and/or flow reversal in the post stenotic area, Visualization of the renal artery without detectable Doppler signal, a finding that indicates occlusion. Absent venous flow and u-shaped/plateau-like reversal of diastolic arterial flow (renal vein thrombosis). 5.Normal ultrasound examination excludes rejection. - F – F in acute rejection ultrasound has a 30 – 50 % negative predictive value only, signs are [Dahnert]: Increase in renal volume from oedema, including decreased renal sinus fat, increased cortical thickness, Conspicuous pyramids and reduced cortical echogenicity, Thickening of the pelvoinfundibular wall, Diminished echogenicity of fat

Answer 50

3.Is associated with non functioning kidney in 75% - T – non functioning enlarged kidney is typical (80% have absent nephrograms) [Dahnert] although variable rim enhancement surrounding the central inflammatory process is common [Radiographics 2008, Craig] 59.The following are features of xanthogranulomatous pyelonephritis: (CC) 1.The kidney is typically small - F – Kidney is globally enlarged (smooth contour uncommon) [Dahnert]. Granulomatous inflammatory process (replaced by foamy macrophages) from chronic obstruction tetrad of :Non functioning enlarged kidney,Central calculus with contracted renal pelvis,Expansion of the calyces,Perinephric fatty stranding 2.Focal involvement is more common than diffuse involvement - F – F - Diffuse involvement more common(83 – 90%) [Dahnert] 3.Is associated with non functioning kidney in 75% - T – non functioning enlarged kidney is typical (80% have absent nephrograms) [Dahnert] although variable rim enhancement surrounding the central inflammatory process is common [Radiographics 2008, Craig] 4.The majority of cases are bilateral – F –F – most causes are unilateral. Only reference I could find to bilateral XGP isfrom eMedicine quoting Perez, J Urol, 1993. It states that bilateral XGP is usually fatal and that bilateral form can be treated with bilateral partial nephrectomy. 5.Calculi are present in 10%F – Calculi are absent in 10%, present ~80%.

Answer 51

4.Indinovir calculi are readily identified as radio-opaque on CT - Uric acid, xanthine, Matrix (mucoprotein/mucopolysaccharide), Indinavir (antiviral) drug precipitates in renal tubules, are non opaque. 60.Of the following statements which is FALSE (erics notes) (CC) 1.Central calcification within a renal mass is highly suggestive of malignancy - T – 15 – 20 % have calcification that is central and amorphous. In cystic type RCC can be curvilinear in nature. [Dahnert ,Warren and Mcfarlane BJU 2004] 2.Milk of calcium pattern of stone formation occurs proximal to a pelviureteric junction obstruction - T – T – Milk of Calcium can be seen in renal cyst, caliceal diverticulum and obstructed hydrocalyx {Dahnert 6th ed.] 3.Cystine stones are opaque on CT - T – cystine stones are mildly opaque [Dahnert ] 4.Indinovir calculi are readily identified as radio-opaque on CT - Uric acid, xanthine, Matrix (mucoprotein/mucopolysaccharide), Indinavir (antiviral) drug precipitates in renal tubules, are non opaque. 5.Cortical nephrocalcinosis is associated with chronic rejection of a transplant kidney – T – rejected renal transplant is a cause [Dahnert 6th ed.]Cortical nephrocalcinosis:Acute cortical necrosisChronic GNAlport syndrome = hereditary nephritis and deafnessCongenital oxalosisChronic paraneoplastic hypercalcaemiaToxic : ethylene glycol, methoxyfluraneSCARejected renal transplant

Answer 52

all false 61.In doppler examination of the kidney the following are true statements T/F 1.A high resistive index indicates a non-obstructive cause of acute renal failure F – RI does inc in acute obstruction but is often (N) in chronic obstruction. RI is raised in a large percentage of kidneys with acute, high grade obstruction 2.Renal to aortic peak systolic velocity ratio greater than 1.5 = renal artery stenosis F - Four direct criteria are used for proximal stenosis or occlusion of a renal artery:,An increase in the peak systolic velocity in the renal artery > 150 cm/s for angles < 60 degree or >180 cm/s for angles > 70 degrees (in the literature, the threshold for significant RAS is 100 – 200 cm/s), A renal to aortic ratio of peak systolic velocity more than 3.5, Turbulent flow and/or flow reversal in the post stenotic area,Visualization of the renal artery without detectable Doppler signal, a finding that indicates occlusion. 3.Increase in the resistive index in the interlobar arteries = renal artery stenosis F – loss of early systolic peak in interlobar arteries, so reduced RI. 4.The RI measurement is independent of heart rate F - RI depend on heart rate. Corrected RI = observed RI – 0.0026(80 – observed heart rate) [ Mostbeck, Radiology 1990] 5.The RI is dependent on the angle of insonation F - angle of insonation effects absolute velocity measurements, RI and SD ratios cancel these errors out [ McGahan, diagnostic ultrasound ] 6.Mag 3 …. (incomplete)

Answer 53

3.The average size at presentation is less than 3cm. T Dahnert: average size 2.0-2.5cm. 62.The following statements regarding imaging of the adrenals adenomas are true (CC, TW) 1.The presence of calcification in an adrenal mass effectively excludes carcinoma F – Malignant Calcification can be found in [Dahnert]:Neuroblastoma, Phaechromocytoma, Adrenal carcinoma, Metastases 2.They are hyperintense to liver on T2 weighted MR scans F (AJR 1986: most of the adrenal adenomas displayed low T2 signal with adrenal/liver ratio of 1.2. Phaeo adrenal / liver ratio was >3.4). T - [Dahnert] iso/hypointense on T1 to spleen. If hypertense to liver suspect carcinoma . Phaeos are hyperintense to spleen on T2. But T2WI cannot be relied upon to determine adenoma from non adenoma when compared with the liver [baker, AJR 1989] 3.The average size at presentation is less than 3cm. T Dahnert: average size 2.0-2.5cm. 4.In patients with known lung cancer, an adrenal lesion is likely to be metastatic F *AJL disagrees. Lung mets to adrenal commonly therefore that is the first thing to exclude. ** SCS: Although in practise i agree w Al…Dahnert specifically mentions EVEN if known Lung Ca, adenoma is still MORE likely. “ In a patient with lung carcinoma a solitary small adrenal mass is more likely to be adenoma than metastasis!” Pg 919. 5.Low signal on out of phase MR implies malignancy F Adenoma has fat and water signals which cancel out by > 20% on opposed phase sequences [Dahnert 6th ed. P919]Added word ‘adenomas’ to question. Added option ‘d’ and ‘e’.

Answer 54

4.Phaeochromocytomas are typically < 2cm in size at presentation F – average 5 cms and range from 3 – 12 cms [Dahnert 6th ed]6 3.Regarding CT of the adrenals, the following statements which is FALSE: (CC) 1.Aldosteronomas are typically hypodense T – referring to adrenal adenoma which are typically hypodense (<10HU on non-con) 2.In Cushing's syndrome due to hyperplasia, the adrenals are enlarged but usually normal in configuration T – [Dahnert], p925 6th ed.] Note the insertion of the phrase “due to hyperplasia” which makes this stem true, without which the stem could be false as adrenal adenomas can cause hypercortisolism and adrenals can be normal in up to 50% of patients with Cushing’s disease ( overproduction of pituititary ACTH). [Primer 4th ed] 3.Phaeochromocytomas are bilateral in approximately 10% of cases T- [Dahnert p 944 6th ed.] – the 10 % tumour 4.Phaeochromocytomas are typically < 2cm in size at presentation F – average 5 cms and range from 3 – 12 cms [Dahnert 6th ed] 5.Adrenal carcinoma is found in about 5% of patients with Cushing's Syndrome T – in Adults about 5- 10 %, in children about 66% [Dahnert 6th ed. P 925]

Answer 55

1.A cystic teratoma is likely to be malignant where as a solid teratoma is likely to be benign. F - A cystic teratoma is likely to benign where as a solid teratoma is likely to be malignant. [Robbins] 64.Retoperitoneal Teratomas, which of the following is false? (CC) 1.A cystic teratoma is likely to be malignant where as a solid teratoma is likely to be benign. F - A cystic teratoma is likely to benign where as a solid teratoma is likely to be malignant. [Robbins] 2.Benign teratomas are bilateral in 10 – 15% T - Benign teratomas are bilateral in 10 – 15%. [Robbins] 3.immature malignant teratomas are chiefly found in prepubertal femalesT - immature malignant teratomas are chiefly found in prepubertal females [Robbins] 4.Monodermal teratomas can present with hyperthyroidism T – Monodermal or specialized teratomas include strumii ovarii, ovarian carcinoid can present with paraneoplastic symptoms from secreting thyroid hormone and serotonin [Robbins] 5.pseudohermaphratism is associated with dysgerminomas T - Dysgerminomas occur in gonadal dysgenesis syndromes including pseudohermaphratism is Initial question read “retroperitoneal teratomas”… that was it, no options. So wrote question

Answer 56

LW: Preferred answer that is incorrect is 3: Surgery and taking Vitamin C are treatments. **SCS: Disagree. Radiopaedia says medical options primary tx , which includes antibiotics, ascorbic acid (Vit C) and anticholingergic agents. Surgery is mentioned under treatment options at Statdx in rarely locally aggressive cases. Dermnet also mentions Vit C as treatment for skin involvement… I favour the option stating Gram POSITIVE organisms (E coli, most common, gram NEGATIVE.) (Dahnert, StatDx, Radiopaedia). TLDR: the rest of the options are true Rant over. Malakoplakia is an inflammatory condition due to gram negative bacteria, vast majority is E.Coli, (hence uncommon to be due to gram positive organisms). Involves a defect in the phagolysosome mechanism of digestion resulting in Michaelis Gutmann bodies which contain Ca++ due to bacterial digestion. These lesions can cause obstruction of the lower urinary tract. Mainstay of treatment is ABx targeting E.Coli and that have a high concentration within the macrophages. Cannot find Vitamin C mentioned as main stay treatment. Surgery can often be required. Thus why Vitamin C option is incorrect. Patients commonly have a systemic disease / immune suppressed. * As radiologists, who dont actually treat patients, I think it is beyond the scope of this exam to know rare / uncommon treatment options*. ** stop being a lil bish. Prior notes: 2.Uncommon inflammatory response to gram positive organisms F – E. coli in 94% [Dahnert] **SCS agree. 65.Malakoplakia and E Coli which of the following statements is incorrect? (CC)1.The most frequent renal finding is obstruction secondary to a lesion in the lower tract T - Because malacoplakia most commonly manifests as a mucosal mass involving the bladder or ureter, the most frequent renal finding is obstruction secondary to a lesion in the lower tract [Radiographics 2008 Pyelonephritis:Rad-path review]2.Uncommon inflammatory response to gram positive organisms F – E. coli in 94% [Dahnert] 3.Surgery and taking vitamin C are treatments 4.Calcium deposition in Intracellular inclusion bodies is a characteristic of renal malakaplakia T – Calcum deposition in Michaelis – Gutmann bodies are a characteristic histological finding of renal malakoplakia from phagocytosied bacterial elements. [Radiographics 2008 Pyelonephritis:Rad-path review]+ Dahnert. 5.Gallium scintigraphy can detect clinically silent lesionsT - Gallium scintigraphy can detect clinically silent lesions [Weiss] 6.Nearly 50% of patients have serious systemic disease or are immunosuppressed T - Nearly 50% of patients have serious systemic disease or are immunosuppressed. Associated mortality in 15%, worse prognosis if upper tracts involved. [Weiss]uncommon chronic inflammatory response to Gram-negative infectionOrganism:E. coli (in 94%);diabetes mellitus predisposesHisto:submucosal histiocytic granulomas containing large foamy mononuclear cells (Hansemann macrophages) withintracytoplasmic basophilic PAS-positive inclusion bodies (Michaelis-Gutmann bodies) consisting of incompletelydestroyed E. coli bacterium surrounded by lipoprotein membranesPeak age:5th-7th decade; M:F = 1:4hematuriaraised yellow lesion <3 cm in diameterLocation:bladder > lower 2/3 of ureter > upper ureter > renal pelvis; multifocal in 75%; bilateral in 50%multiple dome-shaped smooth mural filling defectsscalloped appearance if lesions confluentgeneralized pelviureteral dilatation (if obstructive)displacement of pelvicaliceal system + distorted central sinus complexmultifocal parenchymal masses may cause diminished / absent nephrogramDDx:pyeloureteritis cystica

Answer 57

1.Has a high signal on T2 weighted images F – low signal in the normally high signal peripheral zone **SCS: high DWI signal, smudgy low T2. 66.Prostate Cancer 1.Has a high signal on T2 weighted images F – low signal in the normally high signal peripheral zone 2.On MR spectroscopy has an increase in the choline peak and decrease in citrate peak. (Choline rises/citrate declines with increasing malignancy)- cancer: inc choline, dec citrate **SCS: CrackCore: choline ass/w cell membrane turnover, more turnover more choline, hence elevated in HG tumour Citrate is something specific to prostste ca- reduced in Prostate cancer (Radiopaedia) Creatinine is decreased (increased Cho: Cr ratio). There as a decent radiopaedia article on protate ca MRS… 3.Arises in the peripheral zone T – 70% PZ > TZ > CZ 4.Is hyper echoic on ultrasound T -*AJL (30% of the time) hypoechoic 70% of the time.

Answer 58

*LW: 1.Anterior displacement of the descending duodenum: TRUE 2.Loss of the properitoneal fat strip: TRUE 3.Non obliteration of the right psoas shadow: FALSE, as you loose the psoas shadow, i.e. it is obliterated. 4.The inferior angle of the liver is obscure: TRUE 5.A scoliosis concave to the left: TRUE 1.Anterior displacement of the descending duodenum - T 2.Loss of the properitoneal fat strip - T Plain abdominal film findings loss of renal outline, loss of psoas shadow, scoliosis convex to the side of infection, and immobilization of the kidney on respiration on urographic studies. Gas is seen in fewer than 20% of patients, the majority of whom are diabetic (see section on emphysematous pyelonephritis). Chest radiographs may show pleural fluid, lower-lobe air space disease, or elevation of the hemidiaphragm on the affected side The most common site for collection of pus is behind the kidney in the posterior or dorsal perinephric space Diabetes mellitus is present in 30% of patients. Pyuria is present and urine cultures are positive in 60% of patients.

Answer 59

3.An epidermoid of the testis has a characteristic onion skin appearance T 4.95% of intra testicular masses are malignant T – 90-95% of testicular tumours are malignant 68.Regarding Testicular Ultrasound 1.An intra testicular varicocoele is always associated with an extra testicular varicocoele F – can occur in association with extratesticular varicocele, but their independent existence is more common 2.An intra testicular spermatocoele can be differentiated from a testicular cyst F 3.An epidermoid of the testis has a characteristic onion skin appearance T 4.95% of intra testicular masses are malignant T – 90-95% of testicular tumours are malignant 5.The majority of lesions detected with scrotal ultrasound are intra testicular compared to extra testicular FEpidermoid cyst rare but benign lesion, accounts for 1-2% of all testicular lesions; higher incidence (R) testes; on US bulls eye/target or onion ring appearance (unique onion ring appearance)

Answer 60

*AJL: I think there are multiple correct answers; abdominal musculature deficiency, VUR, cryptorchidism. **LJS edit: no posterior urethral stricture - posterior urethra is dilated but without mechanical obstruction (stat dx)*** *LW: agrees with above. Favoured answer is cryptochordism. 3.Ureteric obstruction F – non obstructed, dilated ureters. Ureters are dilated and tortuous and have a lack of muscle Typically a male with thin or lax abdominal wall and a long, dilated prostate urethra from prostate hyperplasia. Some have utricle diverticulum from the urethra, tortuous and dilated uteters all have cryptoorchidism

Answer 61

*AJL - I would favour AP resection being most correct. Previous answer: 1.Pelvic lymphadenopathy 5.AP resection

Answer 62

2.Is associated with non functioning kidney in 75% T 4.Diabetes mellitis is the most common systemic association T

Answer 63

1.Infection T 3.Diabetes T **SCS: Radiopaedia. - Typically, this condition is seen in diabetics with recurrent urinary tract infections -E. coli most frequently involved organism -Histologically there are numerous small submucosal epithelial-lined cysts representing cystic degeneration of metaplastic epithelium or submucosal Brunn cell nests -Radiology: multiple small 2-5 mm smooth-walled rounded lucent filling defects projecting into the lumen, usually of the ureter. Rarely they can be up to 2-3 cm in size 2,4. Shown on Fluoro/CT IVU. - Location: They are most common in the proximal 1/3 of ureter, but can be seen anywhere along the urinary tract: bladder (cystitis cystica) or renal pelvis (pyelitis cystica). Ddx: multifocal stones, ca (TCC), blood clots, Tb ureteritis (but get Ca++).

Answer 64

73.Wilms Tumour is associated with 1.Beckwith Weideman syndrome T 2.Aniridia T 3.Cerebral gigantism T – Sotos syndrome, 2-3% risk Wilms. 4.Vesico ureteric reflux ?F 5.Hypertrophic pyloric stenosis F Wilms Tumor associated with: WAGR (Aniridia, GU abnormalities, Mental retardation, Wilms); Perlman (AR overgrowth syndrome, fetal gigantism, visceromegaly, unusual face, bilateral renal hamartomas, nephroblastomatosis, wilms)

Answer 65

2.Adrenal masses are more likely to be malignant than extra adrenal masses - F --> Extra adrenal pheo's more commonly malignant 74.Phaeochromocytoma 1.30% are malignant in children - T 30% are extraadrenal in children and those are more likely to be malignant 2.Adrenal masses are more likely to be malignant than extra adrenal masses - F 3.Are associated with mucosal neuromas T (MEN 2B). 4.Are hyperintense on T2 weighted images T 10 % phaeochromocytomas occur in children, and kids have increased rate of : bilateral, malignant, multifocal, extraadrenal.

Answer 66

3.Small hypo dense kidneys – F hyperdense (LW: normal sized kidneys also). 75.Regarding Hyperoxaluria 1.Usually presents at 3-5 yrs – T (hyperoxaluria is a rare autosomal recessive inherited enzyme deficiency. Primary (hereditary) is more common. Secondary (acquired) is rare (enteric: disturbance of bile-acid metabolism after jejunoileal bypass, ileal resection, and blind loop syndrome)) 2.Associated with osteomalacia – T deposits in bone. 3.Small hypo dense kidneys – F hyperdense and normal size.

Answer 67

4.If epididymis/spermatic cord involved most likely lymphoma F – I think that this is probably true. This may actually be the answer. Of tumours it is true but in general a lesion involving testes and epididymus is more likely inflammatory (Tanya) **SCS: this is true. Dahnert pg 978. Epi and spermatic cord commonly involved. All are true.

Answer 68

78.Regarding Renal artery stenosis: 1.Peak velocity of 100cm/sec = normal T – peak systolic >150cm/sec; ratio of peak renal > peak aortic 3.5 2.In renal artery stenosis the Aortic PSV is less than the renal artery PSV Y (Aorta is normally 100-150cm/sec. So there would be increased renal artery/aorta PSV ratio > 3) 3.There is increased RI in subcapsular haematoma T 4.Increased RI excludes obstruction F

Answer 69

4.MAG 3 excreted by glomerular filtration F – Tubular 79.Regarding Nuclear renal imaging: 1.DMSA is for scarring T – DMSA: proximal and distal tubular uptake 2.DTPA is for split renal function T – DTPA: nearly 100% filtered GFR 3.MAG 3 accumulates tracer in ATN T – MAG3: 99% secreted 4.MAG 3 excreted by glomerular filtration F – Tubular

Answer 70

80.Regarding Renal transplant: 1.Lymphocele accumulates tracer - F – occurs in 10%, occurs week to months after transplantation, no creatinine. *LW: Nuk Med Paper states: " A lymphocele presents as a persistent photopenic area, although a mild degree of filling-in on delayed imaging has been observed". 2.Urinoma accumulates tracer - T – does have creatinine.

Answer 71

2.Nasopharynx – T – nasal mucosa 5.The kidney – T Blood pool - T. Gallium at 24h: reticulendothelial system, liver, spleen, bone marrow, bowel wall, renal cortex, nasal mucosa, blood pool. Gallium at 72h: equallydistributed among soft tissues. Kidney activity no longer detectable.

Answer 72

2.Most intratesticular masses are malignant - T 3.Seminoma occurs in older males than teratoma – T – teratoma = 5yo in 75%. 83.Regarding ultrasound of the testes. 1.The epididymis shows decreased echogenicity compared with the testis – F – isoechoic, hetereogeneous. 2.Most intratesticular masses are malignant - T 3.Seminoma occurs in older males than teratoma – T – teratoma = 5yo in 75%. Seminoma mean age is 40.5y 4. 90% of epididymitis is associated with orchitis – F – 20-40%

Answer 73

1.Doppler ultrasound can reliably distinguish ATN from rejection. F 84.Renal transplant ultrasound - which is False: 1.Doppler ultrasound can reliably distinguish ATN from rejection. F 2.Dilatation of the collecting system without obstruction is common in a normal transplant. T 3.An increase in renal size may be the first sign of rejection. T – increased renal volume from oedema 4.Vascular complications occur in 15%. ?T 10% (but radiographics says 1-2%)

Answer 74

1.Produce a better nephrogram than ionic contrast media. FIonic > nonionic with: widespread vasodilatation / fluid overload / direct effects on myocardium / antiplatelet and anticoagulant effects / stimulation of vasopressin (renal).

Answer 75

3.Infantile polycystic kidney disease shows multiple small cysts on ultrasound. - F – usually large echogenic centrally with sonolucent rim compressed cortex (cysts = small < 2mm produce increased echoes). Occasionally see macroscopic cysts <1cm (like MSK – in older children – juvenile) 86.Renal imaging. 1.Leukaemia produces bright enlarged kidneys - T 2.Lymphoma produces multifocal areas of low attenuation. - T - Metastatic or invasion of kidney àdiffuse kidney enlargement, multiple bilateral masses, solitary mass or sinus invasion 3.Infantile polycystic kidney disease shows multiple small cysts on ultrasound. - F – usually large echogenic centrally with sonolucent rim compressed cortex (cysts = small < 2mm produce increased echoes). Occasionally see macroscopic cysts <1cm (like MSK – in older children – juvenile)

Answer 76

HAHAHA THEY ARE ALL TRUE!!!

Answer 77

90.Calcification occurs in more than 10% of. 1.Wilm's tumours.?T 10-15% 2.Neuroblastoma. T 3.Ependymoma. T 4.Endodermal sinus tumours. F 5.Rhabdomyosarcoma. F

Answer 78

91.Vesico-ureteric reflux has the following associations. 1.Sibs with VUR. T 2.Nocturnal enuresis. F 3.Ipsilateral PUJ. F **LJS - true, 30-50% PUJ have contralateral renal abn e.g. VUR 4.Diverticula. T – hutch diverticulum, ureterocele, bladder outlet obstruction, voiding dysfunction 5.Duplex collecting system. T

Answer 79

LW: 1. Approx. 70% of cases of endogenous Cushings syndrome caused by bilateral adrenal hyperplasia. Favoured answer: adrenal hyperplasia accounts for 75-80% of Cushing syndrome cases, i.e. Cushings disease with production of ACTH causing bilateral adrenal hyperplasia. (StatDx). **LJS - most common cause of endogenous Cushings is pituitary microadenoma secreting ACTH (70%). Robbins 9th ed p. 1123 2. No mention of fat on imaging appearances, however difficult to ascertain what abundant infers, as if there is moderate increase in adrenal size with hyperplasia, there may be relatively reduced peri nephric fat volume. COnversely, common cause of Cushing's is exogenous steroids which causes adrenal hypoplasia, and hence likely relative increase in surrounding fat..... (I should check this tho). 5. False: Theoretical risk of induction of hyperadrenergic symptoms with iodinated contrast administration discounted by retrospective series where nonionic material utilized

Answer 80

4.Glomerular filtration T – 99% filtered

Answer 81

3.Full calyceal system - T *AJL - agree with above. This is because it is plumbed into the top of the bladder therefore calyces fill up (according to Rex)

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