VIQ - chest

Question 1

@#e 2) In acute respiratory distress syndrome what is the first change usually seen on the chest radiograph?

a. confluent consolidation

b. pleural effusions

c. increased heart size with globular shape

d. volume loss with atelectasis

e. patchy ill-defined opacities

Answer 1

e. patchy ill-defined opacities

Acute respiratory distress syndrome (ARDS) commences with interstitial edema, progressing to congestion and extensive alveolar, and interstitial edema and hemorrhage. The chest radiograph is often normal for the first 24 hours, before patchy opacities appear in both lungs. These progress to massive airspace consolidation over the following 2448 hours. True volume loss, atelectasis, cardiomegaly and effusions are not seen in ARDS.

Question 2

@# 41- Which of the following CT features indicates post-primary rather than primary pulmonary tuberculosis?

(a) Miliary nodules

(b) Bronchiectasis

(c) Cavitation

(d) Tree-in—bud opacification

(e) Lymphadenopathy

Answer 2

(a) Miliary nodules

The difference between primary and post—primary (reactivated) TB is in the degree Of previous exposure the patient has had to T B. Most features are seen in both to some degree with the exception of miliary nodules.

Question 3

@#e 12. A 22 year old is diagnosed with tuberculosis. Which of the following features will make a diagnosis of primary tuberculosis more likely?

a. Mediastinal enlargement

b. Septal thickening

c. Upper zone cavitation

d. Miliary nodules

e. Apical consolidation

Answer 3

a. Mediastinal enlargement

Mediastinal enlargement Mediastinal lymph node enlargement is a feature of primary TB. The others are seen with reactivation or fibrocavitary TB. Miliary TB can be seen in any phase with haematogenous dissemination but primary presentation is uncommon.

Question 4

@# 32. A 35 year old female presents with generalised malaise and cough, occasionally bringing up grape-skin-like material. Blood screen reveals eosinophilia. The patient has a history of travel to several countries worldwide. Which of the following plain film features is unlikely?

a. Homogenous ovoid opacity

b. Cyst with a fluid level

c. Bilateral opacities

d. Calcification.

e. Lower zone location

Answer 4

d. Calcification.

Calcification The case describes hydatid disease. Hydatid cyst of the lungs can present as solid ovoid solitary or occasionally multiple lesions on plain films. When the cyst communicates with a bronchial tree, an air fluid level is demonstrated. Several other signs are described. Whilst bilaterality is less likely (up to 20%), calcification is extremely rare (0.7%).

Question 5

@# 47. A 45-year-old woman had allogenic bone marrow transplant for treatment of leukaemia. Two weeks later she developed cough and shortness of breath. CT demonstrates bilateral ground-glass shadowing, thickened interstitial lines and bilateral pleural effusion. What is the most likely diagnosis?

(a) Bronchiolitis obliterans

(b) Drug toxicity

(c) Pulmonary oedema

(d) Diffuse alveolar haemorrhage

(e) Bronchiolitis obliterans organising pneumonia

Answer 5

47. (c) Pulmonary oedema

This is usually secondary to fluid overload and associated renal dysfunction.

Bronchiolitis obliterans and bronchiolitis obliterans organising pneumonia are late complications seen after 3 months.

Drug toxicity and alveolar haemorrhages may present with ground-glass shadowing but do not show pleural effusions or interstitial involvement.

Question 6

@# 73 In the assessment of a thoracic CT, which of the following features is least supportive of a diagnosis of nonspecific interstitial pneumonitis?

(a) Traction bronchiectasis

(b) Volume loss

(c) Ground glass opacifrcation

(d) Thin-walled cysts

(e) Reticular abnormality

Answer 6

(d) Thin-walled cysts

Thin-walled cysts are not a feature of NSIP but should raise the possibility of LIP. The remaining features are typical. Consolidation, honeycombing and nodules are variably reported in the literature as being present or absent.

Question 7

@#e 1. A 50 year old male presents with a history of occasional haemoptysis and exertional shortness of breath which has been getting progressively worse. Plain chest radiograph demonstrates bibasal reticular shadowing with volume loss. HRCT demonstrates bibasal fibrosis and traction bronchiectasis. Incidental note is made of a patulous oesophagus. Which of the following is the most likely cause?

a. Tuberculosis

b. SLE

c. Rheumatoid arthritis

d. Wegener’s granulomatosis

e. Scleroderma

Answer 7

1. e. Scleroderma

Whilst haemoptysis may be a presentation in tuberculosis and Wegener’s and bibasal fibrosis maybe seen in all of the above except tuberculosis (where apical fibrosis is the more likely feature), scleroderma is the only condition resulting in a patulous lower oesophageal sphincter, oesophageal shortening and stricture formation.

Question 8

@#e 34. A 26 year old female patient with an optic nerve tumour and café-au-lait spots presents with exertional breathlessness. Imaging of the chest is most likely to reveal which of the following?

a. Multiple small lower lobe cysts

b. Emphysema

c. Lower zone fibrosis

d. Thick-walled cavities in the upper zone

e. Asymmetrical upper zone fibrosis

Answer 8

34. c. Lower zone fibrosis

The case describes neurofibromatosis I, which is associated with lower zone fibrosis and thin-walled bullae, mainly in the upper zones.

Apart from the pulmonary changes, skeletal abnormalities involving the ribs and spine and mediastinal masses may also be seen

Question 9

@#e 49. A patient with a known collagen vascular disease has pulmonary fibrosis. HRCT reveals bilateral lower lobe bronchiectasis. Which collagen vascular disease is most likely?

a. Sjogren syndrome

b. Progressive systemic sclerosis

c. SLE

d. Rheumatoid arthritis

e. Dermatomyositis

Answer 9

49. a. Sjogren syndrome

Whilst pulmonary fibrosis is a feature of all the above conditions, bronchiectasis is most likely seen in Sjogren syndrome

Question 10

@# 3. A chest radiograph shows diffuse lung disease with fibrotic changes predominantly affecting the upper lobes. What is the most unlikely diagnosis?

(a) Sarcoidosis

(b) Cystic fibrosis

(c) Allergic bronchopulmonary aspergillosis

(d) Langerhans cell granulomatosis

(e) Scleroderma

Answer 10

3. (e) Scleroderma

Other conditions cause predominantly upper zone disease.

Question 11

@# 9. A 48-year-old female non-smoker presents to the Accident & Emergency Department with acute dyspnoea and chest pain. The chest radiograph shows bilateral basal airspace shadowing. Chest CT shows disuse basal consolidation and air-bronchograms within a background of ground-glass opacity. There is septal thickening and bilateral pleural effusions. The most likely diagnosis is?

(a) Desquamative interstitial pneumonitis

(b) Lymphocytic interstitial pneumonitis

(c) Acute interstitial pneumonia

(d) Usual interstitial pneumonitis

(e) Cryptogenic organising pneumonia

Answer 11

9. (c) Acute interstitial pneumonia

This clinically presents as adult respiratory distress syndrome and has high mortality. It has a fulminant course leading to respiratory failure and requiring mechanical ventilation with a mortality of > 50%. CT findings are non-specific but include bilateral, diffuse ground-glass opacity with consolidation and air bronchograms. Honeycombing and traction bronchiectasis may be seen in advanced cases after recovery.

Question 12

@# 5. Which of the following are correct about pulmonary sarcoidosis: (T/F)

(a) Normal CXR excludes the diagnosis.

(b) The large airways are involved in 4-5% of cases.

(c) Subcarinal lymph nodes are characteristically spared.

(d) Fibrosis occurs predominantly in the lower zones.

(e) Pleural effusion is common CXR.

Answer 12

Answers:

(a) Not correct.

(b) Correct

(c) Not correct

(d) Not correct

(e) Not correct

Explanation:

Between 5% to 15% of patients have a normal CXR when first examined.

Pleural effusion is a rare finding (2%).

All mediastinal lymphnodes can be affected in sarcoidosis.

On CT 50% of cases show enlarged subcarinal lymphnodes.

Middle and upper zone fibrosis is characteristic

Question 13

@# 39. The following finding is more in keeping with chronic eosinophilic pneumonia rather than Churg-Strauss:

A. Centrilobular nodules within areas of ground-glass change

B. Peripheral consolidation with tendency towards lobular distribution

C. Transient opacities, shifting over days

D. Homogenous peripheral airspace consolidation

E. Interlobular septal thickening

Answer 13

D. Homogenous peripheral airspace consolidation

Chronic eosinophilic pneumonia is characterised by the presence of homogenous peripheral airspace consolidation on CT, whereas the peripheral consolidation in Churg-Strauss has a tendency towards lobular distribution and is often associated with centrilobular nodules within the ground glass opacity.

Question 14

@# 10- A 46-year-old man presents to an A&E department with shortness of breath. The CXR shows a diffuse opacity in the RUL. On a previous film, taken 3 months ago, he had a similar appearance in the LUL which cleared on a CXR taken 10 days later; there was a similar episode a year prior to this with an opacity in the middle lobe, which subsequently cleared. Which of the following conditions is the least likely diagnosis?

(a) Chronic eosinophilic pneumonia

(b) Chug-Strauss syndrome

(c) Extrinsic allergic alveolitis

(d) Good pasture’s syndrome

(e) Loeffler’s syndrome

Answer 14

(a) Chronic eosinophilic pneumonia

Loeffler’s syndrome is also known as transient pulmonary eosinophilia Churg-Strauss syndrome (allergic angiitis granulomatosis) classically presents with fleeting pulmonary opacities.

Causes of pulmonary hemorrhage/vasculitis can also give this appearance (e.g. Wegener’s granulomatosis or Good pasture’s syndrome).

EAA can occur following exposure to the relevant trigger, which subsequently resolves on its removal.

Chronic eosinophilic pneumonia typically has a peripheral distribution (the ‘photographic negative’ of pulmonary edema) and appearances typically remain unchanged for weeks or months.

Question 15

@# 9 A 45 year old man is referred from chest clinic with a cough and intermittent breathlessness. A CT of his thorax demonstrates ill-defined centrilobular nodules and a mosaic attenuation pattern, exacerbated on expiratory phase imaging. What is the most likely diagnosis?

(a) Respiratory bronchilitis-interstitial lung disease

(b) Chronic pulmonary thrombo-embolism

(c) Sarcoidosis

(d) Extrinsic allergic alveolitis

(e) Lymphocytic interstitial pneumonitis

Answer 15

(d) Extrinsic allergic alveolitis

The clinical features are non-specific, but many patients with EAA (also known as hypersensitivity pneumonitis) have exacerbati,on of symptoms on exposure to the antigen, e.g. returning to the workplace.

EAA has acute, sub acute and chronic phases which may progress to widespread pulmonary fibrosis.

The mosaic attenuation with gas trapping described here is a characteristic finding.

Question 16

@#e 31. A young man presents with progressive productive cough and halitosis. He had severe pneumonia as a child. Plain chest radiograph demonstrates bronchial dilatation and bronchial wall thickening with some volume loss. Which of the following HRCT findings is the most sensitive finding for bronchiectasis?

a. Air trapping

b. Mucous-filled dilated bronchi

c. Bronchial wall thickening

d. Bronchi seen in the subpleural region

e. Lack of bronchial tapering

Answer 16

31. e. Lack of bronchial tapering

Whilst all the above can be seen in patients with bronchiectasis, a lack of progressive tapering of the bronchi is the most sensitive (80%).

Question 17

@# QUESTION 29 You are asked to review the CT scan of an elderly female patient who has evidence of left upper lobe collapse on a CXR. On CT, in which one of the following directions will the left upper lobe have collapsed?

A Anteriorly and laterally

B Anteriorly and medially

C Inferiorly and medially

D Posteriorly and medially

E Superiorly and medially

Answer 17

B Anteriorly and medially

Left upper lobe collapse results in volume loss in an anterior and medial direction, as opposed to superior and medial collapse of the right upper lobe collapse.

Question 18

@# 50 A 40-year-old schoolteacher presented with a non-productive cough, dyspnoea and low-grade pyrexia. She has never smoked. The CXR demonstrated several bilateral areas of patchy consolidation which were confirmed on HRCT and shown to be in a mainly sub-pleural distribution. In addition there is also patchy ground-glass change and small (<5 mm) centrilobular nodules). What is the most likely diagnosis?

a Bronchoalveolar cell carcinoma

b Histoplasmosis

C Sarcoidosis

d Cryptogenic organising pneumonia

e Multifocal streptococcal pneumonia

Answer 18

50 Answer D: Cryptogenic organising pneumonia

These imaging findings are classical of COP. Effusions and adenopathy are also present in up to one third of patients. Bronchoalveolar cell carcinoma is an important differential, but is most commonly solitary and centrilobular nodules are not a feature, and there is a strong smoking association.

Question 19

@# 40. A 60-year-old recently retired postman presents with chronic cough. The chest radiograph shows soft tissue opacity extending from the right hilum to the lateral chest wall, with loss of the right heart border. There is loss of right lung volume and the right costophrenic angle is seen. Bronchoscopy demonstrates a large endobronchial mass. What is the most likely bronchus involved?

(a) Right upper lobe bronchus

(b) Right middle lobe bronchus

(c) Right lower lobe bronchus

(d) Bronchus intermedius

(e) Right lower lobe apical segment bronchus

Answer 19

40. (d) Bronchus intermedius

The chest radiograph findings are suggestive of combined right middle lobe and right lower lobe collapse secondary to tumour obstructing the bronchus intermedius.

Question 20

@# 13 Which of the following drugs used in treating patients with haematological malignancy is not associated with pulmonary haemorrhage?

(a) Bleomycin

(b) Cytarabine

(c) Amphotericin B

(d) Rituximab

(e) Cyclophosphamide

Answer 20

(a) Bleomycin

Bleomycin may result in one of two conditions: an organising pneumonia with multiple foci of consolidation or tree-in-bud opacification, or diffuse alveolar damage which gives appearances akin to ARDS.

Question 21

@# 32 Plain radiographic signs seen more commonly in patients with acute pulmonary embolism include all but which of the following?

(a) Cardiomegaly

(b) Decreased vascularity

(c) Pulmonary oedema

(d) Pleural opacity

(e) Atelectasis

Answer 21

(c) Pulmonary oedema

Pulmonary oedema is seen in patients with PE rarely (4% vs 13% in patients without PE). Other signs include pleural effusion.

Question 22

@# 62 A 72 year old woman with a history of recent surgery presents with shortness of breath and pleuritic chest pain. On examination there is a slight swelling of the right leg compared to the left. The D-dimer level is raised. Which imaging investigation should be performed next?

(a) Chest X-ray

(b) CTPA

(c) Pulmonary angiogram

(d) Ultrasound bilateral lower leg veins

(e) V/Q scan

Answer 22

(a) Chest X-ray

The patient is at high risk for a PE. The CXR is less likely to be diagnostic, but may provide a differential diagnosis in some cases (e.g. spontaneous pneumothorax) and forms an important part of the diagnostic flow chart.

A normal CXR means a V/Q scan would be the next appropriate investigation, abnormal CXR requires CTPA.

The right leg swelling may be post-operative rather than due to a DVT, but regardless, it is important to diagnose a PE over a DVT as most clinicians recommend a longer treatment period for the former.

Pulmonary angiography is invasive and is now rarely used in the context of PE diagnosis.

Question 23

@# QUESTION 6 A 70-year-old man recently underwent a laparoscopic prostatectomy. He now presents to the Emergency Department complaining of shortness of breath, pleuritic chest pain and haemoptysis. D-dimer levels were measured and found to be significantly elevated. A CXR is performed as part of the initial set of investigations. Which one of the following is the most likely CXR finding?

A A normal chest radiograph

B Linear atelectasis

C Localised peripheral oligaemia

D Peripheral airspace opacification

E Pleural effusion

Answer 23

A normal chest radiograph

A normal chest radiograph is the most common finding in the setting of a suspected pulmonary embolus (PE).

Question 24

@# 75. A 24-year-old woman who is 28 weeks pregnant is admitted with suspected pulmonary embolism. As the on-call radiologist, her obstetrician contacts you seeking advice regarding further management. An admission CXR is normal. What investigation do you advise initially?

A. Venous ultrasound.

B. Low-dose CTPA.

C. Reduced dose lung scintigraphy.

D. MRA.

E. Catheter pulmonary angiography.

Answer 24

75. A. Venous ultrasound.

For pregnant patients, venous ultrasound is recommended before imaging tests with ionizing radiation are performed. Up to 29% of pregnant patients with PE will have a positive venous ultrasound, obviating the need for further imaging.

The majority of the PIOPED II investigators currently recommend V/Q scanning over CTPA in the evaluation of PE in pregnant patients. The foetal dose with V/Q is similar to that with CTPA, although the effective dose per breast is much greater with CTPA.

MRI requires further evaluation and gadolinium-based contrast agents have not been proven to be safe in pregnancy.

The role of catheter angiography is probably limited to those patients requiring mechanical thrombectomy.

It should be noted that even a combination of CXR, lung scintigraphy, CTPA, and pulmonary angiography exposes the foetus to approximately 1.5mGy of radiation, which is well below the accepted limit of 50 mGy for the induction of deterministic effects in the foetus. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.

Question 25

@# 33 A patient with a known malignancy presented with acute shortness of breath. The attending physician requested CT pulmonary angiogram to exclude a pulmonary embolus. A filling defect was seen in the left lower pulmonary artery with a wedge-shaped collapse distal to it. Which primary tumour is most frequently associated with pulmonary embolism? a Lung carcinoma b Hepatocellular carcinoma C Gastric carcinoma d Ovarian cystadenoma e Prostate carcinoma

Answer 25

33 Answer C: Gastric carcinoma Ovarian carcinoma and extra hepatic bile duct carcinomas also demonstrate a high rate of pulmonary emboli.

Question 26

@# 7. Which of the following has the greatest incidence of metastases to the lung? A. Choriocarcinoma B. Hypernephroma C. Ewing’s sarcoma D. Rhabdomyosarcoma E. Testicular seminoma

Answer 26

A. Choriocarcinoma In order of decreasing frequency, pulmonary metastases arise from choriocarcinoma, hypernephroma/Wilms’ tumor, Ewing’s/rhabdomyosarcoma and testicular tumors.

Question 27

@# 49. Which of the following is most likely to present as a haemorrhagic rather than a calcified pulmonary metastases? A. Breast cancer B. Chondrosarcoma C. Testicular cancer D. Choriocarcinoma E. Mucinous adenocarcinoma of the colon

Answer 27

D. Choriocarcinoma Choriocarcinoma, renal carcinoma, and melanoma are causes of haemorrhagic pulmonary metastases.

Question 28

@# 5- A 24-year-old asymptomatic man has a CXR for insurance purposes. The report describes a solitary 2 cm nodule. A subsequent CT is arranged. Which of the following of the features favor a diagnosis of carcinoid over hamartoma? (a) Avid 18FDG-PET uptake (b) Calcification (c) Central location (d) Hounsfield value of —30 (e) Solitary lesion

Answer 28

(c) Central location Pulmonary carcinoids represent < 4% of all lung tumors and approximately 15% of all carcinoid tumors within the body. They can be typical (type 1; local tumor; 90%) or atypical (type 2; metastasizes to local LNs, rarely to liver), 80% are centrally located. They rarely cause carcinoid syndrome, often enhance strongly, 1/3 contain calcification, and they typically have no uptake at PET. Hamartomas are well circumscribed solitary nodules; 90% are peripheral. They are benign tumors composed of cartilage, connective tissue, muscle, fat, and bone. Fat attenuation at CT is described as pathognomonic, pompom' calcification is also diagnostic but is seen in only 20%

Question 29

@# 38- A 40-year-old Woman presents hemoptysis- CXR shows multiple cavitating lesions in both lungs- Needle biopsy confirms the lesions are metastatic. Which of the following is the least likely cause? (a) Squamous cell carcinoma of the larynx (b) Adenocarcinoma of the cervix (c) Transitional cell carcinoma of the bladder (d) Adenocarcinoma of the colon (e) Giant cell tumor of the distal femur

Answer 29

(e) Giant cell tumor of the distal femur The differential diagnosis for cavitating metastases also includes melanoma. Giant cell tumor metastases may calcify.

Question 30

@# 26 A 64 year old man undergoes nephrectomy for a right renal tumour. A year later he presents with haemoptysis. CT of the chest shows 3 lesions in the right hemithorax measuring 20 x 10 mm, 20 x 12 mm and 10 x 10 mm. Biopsy confirms these are metastases. After a course of chemotherapy, the lesions measure 18 x 8 mm, 17 x 10 mm and 10 x 8 mm. By RECIST criteria the status of the disease is? (a) Stable disease (b) Partial response (c) Good response (d) Excellent response (e) No response

Answer 30

(a) Stable disease Baseline is defined as the sum of the long diameters of the target lesions where up 2 target lesions per organ and 5 overall can be used. Partial response involves a decrease of 30% or more in the sum of the long diameters. Complete response implies the disappearance of all lesions. Disease progression involves an increase in the sum of the long diameters of 20%. Good response, no response and excellent response are not part of the RECIST criteria.

Question 31

@# 17. The staging chest CT of a 40 year old man with a known primary malignancy demonstrates cavitating pulmonary metastases. The least likely type of primary lesion would be: a. Squamous cell carcinoma b. Malignant melanoma c. Renal cell cancer d. Sarcomas e. Colonic carcinoma

Answer 31

17. c. Renal cell cancer

Question 32

@#e 38. A 68 year old miner develops an irregular opacity in the upper zone on plain chest radiograph. Which imaging feature would be more in favour of malignancy than progressive massive fibrosis (PMF)? a. Peripheral enhancement on contrast-enhanced MR b. Peripheral location on axial images c. Presence of calcification d. High signal on T2-weighted images e. Avid lesion on PET-CT

Answer 32

d. High signal on T2-weighted images PMF has a peripheral location which moves towards the hilum on follow-up imaging. Calcification and cavitation may also be seen. PMF lesions can be FDG-avid on PET-CT. However, high signal in a mass on T2-weighted images is strongly suspicious for malignancy.

Question 33

@# 59. A 60 year old man presents with progressive breathlessness. The plain chest radiograph reveals reticular shadowing in the right lower zone, but is otherwise unremarkable. HRCT demonstrates the presence of beaded thickening of the interlobular septae forming a polygonal reticular network in the right lower lobe with central dots within. There is also a small pleural effusion. Which of the following is the most likely cause? a. Sarcoidosis b. Bronchogenic carcinoma c. Heart failure d. Extrinsic allergic alveolitis e. Fibrosing alveolitis

Answer 33

59. b. Bronchogenic carcinoma The changes described indicate lymphangitis carcinomatosis. Whilst similar appearances are seen in sarcoidosis, the changes are usually in the upper lobe and pleural effusion is rare. In heart failure, the interlobar septal thickening is usually smooth and usually bilateral. In EAA, pleural effusion is rare and changes are more bronchocentric and bilateral. The polygonal structure is usually distorted in both EAA and cryptogenic fibrosis, where changes are again subpleural.

Question 34

@# QUESTION 32 A middle-aged man has recently had a CT abdomen performed for chronic lower left abdominal pain. Whilst mild sigmoid diverticular disease was present, it was also noted that there was significant para-aortic lymphadenopathy. Lymphoma was the suspected diagnosis and a chest CT was performed, prior to biopsy. "Which additional CT finding is most likely to suggest a diagnosis of non-Hodgkin’s lymphoma rather than Hodgkin's disease? A Isolated pulmonary consolidation B Paramediastinal interstitial fibrosis C Peripheral subpleural masses with a pleural effusion D Peripheral subpleural masses without a pleural effusion E Pulmonary consolidation with mediastinal lymphadenopathy

Answer 34

A Isolated pulmonary consolidation At presentation, Hodgkin's disease most commonly has lung parenchymal disease accompanied by intrathoracic adenopathy, whereas isolated lung involvement is not uncommon in non-Hodgkin's lymphoma. Pleural effusions (unilateral) are common in both types of lymphoma, as are peripheral subpleural masses. Consolidation with air bronchograms can also be seen in both diseases.

Question 35

@# 17. A 34-year-old woman presents with a 4-month history of gradually increasing dyspnoea and cough. A CXR and subsequent CT scan show multiple cavitating lung lesions. On the CT scan, some of these lesions are noted to have surrounding ground-glass attenuation. No other abnormality is seen. Which of the following diagnoses are the fi ndings most compatible with? A. Rheumatoid lung. B. Lung abscesses. C. Eosinophilic granuloma. D. Churg–Strauss syndrome. E. Melanoma metastases.

Answer 35

17. E. Melanoma metastases. The GGO surrounding a nodule is known as the ‘halo’ sign and represents perilesional haemorrhage. The differential diagnosis given rests on the presence of this feature and cavitation. Melanoma metastases can both cavitate and produce perilesional haemorrhage. The halo sign may also be seen in other conditions with perilesional haemorrhage or cellular infiltration and is usually best seen on HRCT. These diagnoses include bronchoalveolar carcinoma, haemorrhagic metastases, Wegener’s granulomatosis, and angio-invasive infections, such as invasive aspergillosis. Alternative correct answers would be Wegener’s granulomatosis, lymphoma, bronchoalveolar carcinoma, and squamous cell carcinoma as these can produce both cavitating nodules and the halo sign. Rheumatoid lung, eosinophilic granuloma, and lung abscesses are associated with cavitating nodules but not the halo sign. Churg–Strauss syndrome is not associated with the halo sign and cavitation is rare.

Question 36

@# 34. A 68-year-old patient has a CXR carried out due to a recurrent chest infection. The patient is a smoker. The CXR shows a solitary pulmonary nodule. A CT is carried out which demonstrates a 2.8-cm lesion in the right lower lobe as noted on CXR. This lesion is spiculated. There is a second lesion noted in the right lower lobe that is 1.2 cm in size and was not visible on the CXR. There is a 0.8-cm ipsilateral peribronchial lymph node identified. There are no evident metastases. A PET-CT is carried out which shows an SUV max of 8 in both pulmonary lesions. There is no uptake in the lymph node. No metastases are identified. A biopsy confirms non-small cell lung cancer. Based on the available imaging, what is the stage of this lesion? A. Stage 1A. B. Stage 1B. C. Stage 2A. D. Stage 2B. E. Stage 3A.

Answer 36

34. D. Stage 2B. The TNM definitions, on which the staging system is based, were recently updated in 2010. In this update, the nodal classifications were not changed, but the T staging was updated, as was M staging. Sub-classifications were added to T1, with lesions <2 cm being T1a and lesions between 2 and 3 cm being T1b. Lesions between 3 and 5 cm are T2a and between 5 and 7 cm are T2b. Lesions over 7 cm are T3, as are synchronous lesions within the primary lobe, as in this case. Multiple lesions within the primary lobe were formerly T4. In this question, the lymph node is not enlarged by size criteria and is not FDG avid on PET. While this may yet still be involved, on imaging findings alone, this lesion should be classed as N0. The absence of metastases is obviously M0. Thus this patient is T3 N0 M0, which corresponds to stage 2b. T2b N1 tumours are also in this stage. Stage 2a lesions are T2a N1 or T2b N0. Stage 3a lesions are T3 or less with N2 disease or T3 N1 lesions.

Question 37

@# (GU) 67. A 48-year-old women presents with shortness of breath and undergoes an HRCT of the chest to assess interstitial changes seen on plain film. She has emigrated from Eastern Europe and knows that she had a gynaecological cancer that was treated there, but is unsure of her treatment. The HRCT reveals unilateral thickened interlobular septa, perilymphatic nodules, and ipsilateral hilar adenopathy. What is the most likely underlying diagnosis? A. Cervical carcinoma. B. Ovarian epithelial carcinoma. C. Endometrial carcinoma. D. Leiomyosarcoma of the uterus. E. Vaginal carcinoma.

Answer 37

67. A. Cervical carcinoma. This patient has developed lymphangitis carcinomatosis. In 50% of cases the septal thickening is focal or unilateral and this is useful in distinguishing lymphangitis from other causes of septal thickening, such as pulmonary oedema or sarcoidosis. Hilar adenopathy is present in 50% and pleural effusion in 30–50%. The interlobular septal thickening can be smooth (as in pulmonary oedema and alveolar proteinosis) or nodular (also found in sarcoidosis and silicosis). Lymphangitis carcinomatosis usually occurs secondary to the spread of (adeno-) carcinoma, most commonly bronchogenic, breast, and stomach. The mnemonic Certain Cancers Spread By Plugging The Lymphatics (Cervix Colon Stomach Breast Pancreas Thyroid Larynx) is useful. Lymphangitis carcinomatosis is occasionally associated with cervical carcinoma and certainly more so than with the other options presented.

Question 38

@# (Ped)46 A 12-year-old girl with known osteosarcoma of the proximal femur presents with acute shortness of breath. What is the most likely finding on CXR? a Bilateral hilar lymphadenopathy b Pneumothorax C Coarsened bronchovascular markings with reticular opacities d Bilateral lower lobe atelectasis e Multiple cavitating nodules

Answer 38

46 Answer B: Pneumothorax The rupture of subpleural metastatic nodules into the pleural space can cause spontaneous pneumothorax. Cavitating metastases classically occur in squamous cell carcinoma. Osteosarcoma lung metastases can calcify.

Question 39

@# 31 A 32-year-old man developed a low-grade fever and weight loss and was found to have Hodgkin's lymphoma with lymphadenopathy in both thorax and abdomen. Involvement of which extra-nodal site is associated with the worst prognosis? a Pleural effusion b Spleen c Thymus d Bone e Small intestine

Answer 39

31 Answer E: Small intestine.

Question 40

@# 36 A 55-year-old man presented with a persistent cough and wheeze. CT of his thorax showed a solitary 2-cm endobronchial polypoidal mass that enhanced vividly in the late arterial phase. There were no other positive findings and a PET scan showed no uptake in this lesion. From which artery is the blood supply to this lesion most likely to be derived? a Pulmonary artery b Bronchial artery c Adjacent intercostal artery d Internal mammary artery e Inferior thyroid artery

Answer 40

36 Answer B: Bronchial artery Pulmonary carcinoid is a slow-growing low-grade malignant vascular tumour supplied by the bronchial circulation.

Question 41

@# 43 An 18-year-old male was investigated for lethargy and haemoptysis. A chest radiograph revealed multiple lung nodules, which contained small irregular calcifications. Assuming these lesions to be metastases, what it the most likely underlying primary tumour? a Pancreas b Renal C Prostate d Testis e Lung

Answer 41

43 Answer D: Testis Other primary malignancies causing calcification within metastases include breast, colon (mucinous adenocarcinoma), osteosarcoma and ovarian.

Question 42

@# 43. A 62-year-old man with known primary malignancy presents with haemoptysis. Chest radiograph shows a cavitating lesion in the left mid zone. Which is the least likely diagnosis? (a) Carcinoma of the colon (b) Melanoma (c) Transitional cell carcinoma of the bladder (d) Carcinoma of the prostate (e) Squamous cell carcinoma of the lung

Answer 42

43. (d) Carcinoma of the prostate The rest of the tumours are all common causes of cavitating metastatic lesions.

Question 43

@# 42. Which of the following are correct concerning lymphoma: (T/F) (a) Lymph node calcification occurs. (b) Hodgkin’s disease is more common in the chest than non-Hodgkin’s disease. (c) Posterior mediastinal lymph nodes favour lymphoma rather than Sarcoidosis. (d) Intrapulmonary lymphoma can present with massive pneumonia – like lobar infiltrates. (e) Miliary nodules can be the presenting appearance on chest X-Ray.

Answer 43

Answers: (a) Correct (b) Correct (c) Not correct (d) Correct (e) Correct Explanation: In lymphoma anterior mediastinal lymph nodes are seen.

Question 44

@# (MSK) 5) A young patient suffers a fractured femur and acetabulum in a road traffic collision and undergoes intramedullary nailing and plateand- screw internal fixation of the acetabulum. He is well until 8 days postoperatively, when he develops acute shortness of breath and right-sided chest pain. A chest radiograph shows only a small right-sided pleural effusion. What is the most likely diagnosis? a. fat embolism b. bronchial pneumonia c. pulmonary embolism d. pneumothorax e. hyperventilation due to pain

Answer 44

c. pulmonary embolism Pulmonary embolism is a common complication following immobility and major surgery, particularly orthopaedic surgery of the pelvis. It typically occurs 7–10 days post-surgery. Chest radiograph findings can be normal but include small effusion, collapse or consolidation, elevation of the hemidiaphragm, a prominent pulmonary artery and hypertransradiance of the affected side (Westermark sign). Fat embolism is preceded by long bone injury in 90% of cases but usually occurs within 36 hours of the injury, and is much less common than pulmonary embolus from deep vein thrombosis even in the context of major trauma. Pneumonia and pneumothorax do of course occur in postoperative patients, but it would be reasonable to expect associated findings on the chest film. Hyperventilation should be a diagnosis of exclusion once other potentially serious causes have been excluded.

Question 45

@# 73) A 52-year-old man presents 1 year post-heart transplantation and has a routine follow-up chest radiograph. This shows multiple nodules of varying sizes, with enlarged hilar lymph nodes. What is the most likely diagnosis? a. graft-versus-host disease b. aspergillosis c. cytomegalovirus infection d. post-transplantation lymphoproliferative disorder e. Epstein–Barr virus infection

Answer 45

d. post-transplantation lymphoproliferative disorder Post-transplant lymphoproliferative disorder (PTLD) occurs after bone marrow or solid organ transplantation, usually within 2 years. The type of tumor varies. This can produce single or multiple lung nodules with or without hilar and mediastinal lymphadenopathy. The nodules may be diffuse, subpleural or peribronchial and may have a surrounding halo of ground-glass opacification. The findings in graft-versus-host disease are of bronchiolitis obliterans – hyperinflation, bronchial dilatation and wall thickening, reduced vascularity/mosaic perfusion, and air trapping. In the acute phase, it often presents as non-cardiogenic pulmonary edema. Aspergillosis presents with nodular opacities or consolidation, which may have a halo of ground-glass opacification, but occurs in the first 30 days. Cytomegalovirus infection usually occurs within the first 6 months after bone marrow transplantation, with a variety of appearances. Epstein–Barr virus is a causative factor in PTLD but is not in itself a cause of the pulmonary changes.

Question 46

@# 4 Regarding lung transplantation, which of the following conditions would not be suitable for a single lung transplant, and would necessitate a double-lung transplantation? (a) Bronchiectasis (b) Emphysema (c) Idiopathic pulmonary fibrosis (d) Primary pulmonary hypertension (e) Sarcoid

Answer 46

(a) Bronchiectasis Suppurative lung disease, such as cystic fibrosis and bronchiectasis, necessitates double lung transplant to prevent the spread of infection from native lung to the graft. The other conditions can be treated with single lung transplantation, although patients with PPH or emphysema may also be offered double lung transplantation.

Question 47

@#e 45. Eight days after lung transplantation for alpha-1 antitrypsin deficiency, a 45 year old man develops pyrexia, breathlessness and desaturation. HRCT reveals perihilar heterogenous opacities and ground glass changes with new pleural effusion and septal thickening. Which of the following is the most likely cause? a. Reperfusion oedema b. Acute rejection c. Anastomotic dehiscence d. Post-transplantation PCP infection e. Hyperacute rejection

Answer 47

45. b. Acute rejection Hyperacute rejection presents within hours of the transplantation. Reperfusion oedema usually presents within 24 hours of the transplantation, peaking by about day four. Posttransplant infections can be broadly divided into those occurring within the first month (gram-negative bacteria, fungi (candida, aspergillosis)) and those occurring after the first month (CMV, PCP). Anastomotic dehiscence is usually an early feature, but the presentation and features are not those described.

Question 48

@# 46. An 18-year-old man was brought to the Accident & Emergency Department. The patient was the driver of a car involved in a road traffic accident. What is the most common/expected abnormality on chest CT? (a) Pneumothorax (b) Flail chest (c) Clavicle fracture (d) Diaphragmatic injury (e) Oesophageal rupture

Answer 48

46. (a) Pneumothorax Pneumothorax, lung contusions and rib fractures are the most common expected abnormalities in blunt trauma to chest, seen in more than two-thirds of cases. Other abnormalities are far less common.

Question 49

@# 2. With regards to imaging of primary extranodal lymphomas, in which of the following sites does extranodal Hodgkin’s disease most commonly occur? A. Spleen B. Thymus C. Thyroid D. Small bowel E. Lung

Answer 49

B. Thymus When the main bulk of disease at an extranodal site, a lymphoma should be classified as the extranodal type, as these have distinctive pathological, radiological and clinical features from nodal lymphomas. The thymus is the only extranodal site where Hodgkin’s lymphoma commonly occurs, and almost all cases are of the nodular sclerosing subtype.

Question 50

@# 11. Which is the most common primary tumor to metastasize to the pleura? A. Breast B. Lymphoma C. Lung D. Ovary E. Stomach

Answer 50

C. Lung In order of decreasing frequency, metastases to the pleura arisefrom lung, breast, lymphoma, ovary and stomach cancers.

Question 51

@# 29. Plain radiographs of a previously well 60-year-old man with lower limb pain show lamellar periosteal reaction in the diametaphyseal regions. Bone scintigraphy demonstrates symmetrical increased uptake along the cortical margins in the diametaphyseal regions. What is the most likely underlying thoracic cause? A. Pulmonary haemangioma B. Pleural fibroma C. TB D. Blastomycosis E. Malignant mesothelioma

Answer 51

B. Pleural fibroma Hypertrophic osteoarthropathy is commonly associated with primary bronchogenic carcinoma, typically non-small-cell lung cancer (NSCLC). HOA is also seen in patients with pulmonary metastases from extrathoracic malignancies such as breast carcinoma, nasopharyngeal tumours, renal cell carcinoma, melanoma and osteosarcoma. Benign associations include pleural fibroma and bronchiectasis.

Question 52

@# 17) A 65-year-old man presents with painful wrists and ankles. There is no digital clubbing. A chest radiograph shows a well-defined pleural mass, forming an obtuse angle with the chest wall. CT confirms an ovoid, plurally based, enhancing mass with no bone destruction, effusion or volume loss. Radiographs of the wrists and ankles show symmetrical periosteal reaction. What is the most likely diagnosis? a. hypertrophic osteoarthropathy with bronchogenic carcinoma b. hypertrophic osteoarthropathy with malignant mesothelioma c. hypertrophic osteoarthropathy with pleural fibroma d. rheumatoid arthritis e. tuberculosis

Answer 52

c. hypertrophic osteoarthropathy with pleural fibroma The periosteal reaction is typical of hypertrophic osteoarthropathy (HOA), which has many causes, both intra- and extra thoracic. It is associated with bronchogenic carcinoma and malignant mesothelioma, but features of the described lesion are not typical of either of these, and are more in keeping with pleural fibroma. These are associated with HOA in 20–35% of cases and rarely with clubbing. They may arise in pleura adjacent to the chest wall or in a fissure, and can vary in size from 2 cm to 30cm in diameter. Tuberculosis is a rare cause of HOA. Rheumatoid arthritis is associated with bilateral periosteal reactions, but not HOA.

Question 53

@# 19 An adolescent male patient presents with dyspnoea, cough, and complains of feeling increasingly tired. The subsequent CXR shows a mass located within the anterior mediastinum. Which of the following is the most likely diagnosis? (a) Bochdalek hernia (b) Bronchopulmonary foregut malformation (c) Extramedullary haemopoeisis (d) Germ cell tumour (e) Neuroblastoma

Answer 53

(d) Germ cell tumour The other options are either exclusively or typically found within the posterior mediastinum. The anterior mediastinum is the third most common site of primary germ cell tumour, after gonadal and sacrococcygeal location.

Question 54

@#e 23. A 25 year old man has a routine chest radiograph prior to a work permit application. It demonstrates a well-defined, rounded mediastinal mass. Which of the following features on CT would make a diagnosis of bronchogenic cyst less likely? a. Soft-tissue density b. Thick wall c. Precarinal location d. Communication with tracheal lumen e. Unilocularity

Answer 54

23. b. Thick wall Bronchogenic cyst is the most common intrathoracic foregut duplication cyst. It could have all the above features, but in a mediastinal location, the cyst walls are usually thin. Thick-walled cysts are more likely to be oesophageal.

Question 55

@# (Ped) 18 A previously well seven-year-old boy has a chest radiograph for a possible chest infection. The lungs are clear but the film is reported as showing a posterior mediastinal mass with an air-fluid level and hemivertebrae of T3 and T4. What is the most likely diagnosis? a Intramural oesophageal tumour b Morgagni diaphragmatic hernia c Oesophageal duplication cyst d Cystic hygroma e Bronchogenic cyst

Answer 55

18 Answer C: Oesophageal duplication cyst Oesophageal duplication cysts account for 10-20% of all duplication cysts in the gastrointestinal tract. They are associated with vertebral anomalies, oesophageal atresia and small bowel duplication. They are most commonly found in the distal oesophagus where they are frequently asymptomatic.

Question 56

@# 43 A 74-year-old man presented with dyspnoea and chest pain. A chest radiograph showed pleural thickening encasing the right hemithorax and a right pleural effusion. There are no pleural plaques and the visible lung is normal. What is the most likely diagnosis? a Metastatic thymoma b Malignant mesothelioma C Tuberculosis d Metastatic colonic carcinoma e Pleural fibroma

Answer 56

43 Answer B: Malignant mesothelioma It is associated with pleural plaques in only about 50% of cases. Pleural effusions are common and can often be large enough to obscure the underlying tumour. A useful differentiator from other causes of pleural effusion is the lack of shift of midline structures as the mediastinum is fixed by the disease process.

Question 57

@# 14) A 3-day-old boy presents with respiratory distress without cyanosis. Clinically, there is reduced air entry in the right hemithorax with dull percussion note. A chest radiograph shows an opaque right hemithorax with mediastinal shift to the left. Ultrasound scan shows a large effusion, which aspiration demonstrates to be milky. What is the most likely cause? a. idiopathic b. birth trauma c. lymphangioleiomyomatosis d. thoracic duct atresia e. lymphangiectasia

Answer 57

a. idiopathic Chylothoraces in neonates are usually right sided, and in most cases no obvious cause is found. Treatment is conservative with special formula and intermittent aspiration. All of the listed conditions are causes of chylothorax, but lymphangioleiomyomatosis presents in adult females and not in the neonatal period.

Question 58

@# 74) A neonate is delivered following an uncomplicated pregnancy and presents with respiratory distress but no cyanosis. No resuscitation or ventilation is required. A chest radiograph shows a pneumothorax, which is treated by aspiration. What investigation should be considered? a. cranial ultrasound scan b. renal ultrasound scan c. abdominal radiograph d. barium swallow e. ascending urethrogram

Answer 58

b. renal ultrasound scan Spontaneous pneumothorax may occur in babies where there are renal anomalies, and routine ultrasound scan is recommended. This is often associated with maternal oligohydramnios, but this may not necessarily be present.

Question 59

@# 41. A seven year old girl with repeated chest infections and chronic cough presents with another episode of acute exacerbation. She is known to have raised sodium and chloride in her sweat. Which of the following features is least likely on an HRCT of her chest? a. Cylindrical bronchiectasis b. Centrilobular emphysema c. Segmental/subsegmental atelectasis d. Branching intrabronchial soft tissue e. Hilar lymphadenopathy

Answer 59

41. b. Centrilobular emphysema All the features described are of cystic fibrosis except centrilobular emphysema. They usually develop paraseptal emphysema.

Question 60

@# (Chest) 56. An 18-year-old woman with Poland syndrome is being assessed by plasticsurgery for reconstruction. As part of her pre-operative work-up a CT chest is requested. What is the classic finding in this disorder? A. Absence of the sternal head of pectoralis major. B. Hypoplastic clavicles. C. Anterior protrusion of the ribs. D. Bilateral breast aplasia. E. Anterior protrusion of the sternum.

Answer 60

56. A. Absence of the sternal head of pectoralis major. Poland syndrome is an uncommon congenital unilateral chest wall deformity characterized by partial or total absence of the greater pectoral muscle and ipsilateral syndactyly. Associated anomalies include ipsilateral breast aplasia and atrophy of the second to fifth ribs. Hypoplastic clavicles are a feature of cleidocranial dysostosis. Anterior protrusion of the ribs gives rise to pectus excavatum, whereas anterior protrusion of the sternum is seen in pectus carinatum.

Question 61

@# 8 An infant is born at 41 weeks following a traumatic delivery with passage of meconium. He quickly develops respiratory distress with grunting, tachypnoea and nasal flaring. A CXR is performed. What is the most likely appearance of the CXR? a Widespread ground-glass opacities b `White out' of the lung C Widespread patchy consolidation and air trapping d Focal consolidation with air bronchograms e Small volume lungs with bilateral pleural effusions

Answer 61

8 Answer C: Widespread patchy consolidation and air trapping Meconium aspiration is the most common cause of neonatal respiratory distress in full-term or postterm infants. Severe hypoxaemia induces a gasping reflex with resulting inhalation of meconium, which causes medium and small airway obstruction and chemical pneumonitis.

Question 62

@# 4 A premature infant, born at 27 weeks, was ventilated for the first 14 days and subsequently on CPAP for a further 21 days. A CXR is performed at three months of age. What is the likely appearance? a `White out' of the lungs b Patchy bilateral ground-glass opacities with air bronchograms c Hyperinflation with coarse linear densities and focal areas of emphysema d Reduced lung volumes with bilateral reticulonodular opacities e Normal volume lungs with no focal abnormality

Answer 62

4 Answer C: Hyperinflation with course linear densities and focal areas of emphysema The infant described has bronchopulmonary dysplasia, which is caused by oxygen toxicity and barotrauma in infants on assisted ventilation at >21 % oxygen for >28 days. Appearances change with time:

Question 63

@# 59 A neonate has a CXR for respiratory distress following a precipitous normal vaginal delivery at term. This shows mild cardiomegaly and mild hyperexpansion but no focal lung abnormality. Which of the following is the most likely underlying diagnosis? a Respiratory distress syndrome b Transient tachypnoea of the newborn C Meconium aspiration d Group B Streptococcal pneumonia e Pulmonary haemorrhage

Answer 63

59 Answer B: Transient tachypnoea of the newborn Cardiomegaly in neonates has multiple causes including hypoglycaemia, congenital heart disease, asphyxia and infants of diabetic mothers.

Question 64

@# 58 A CT chest is performed on a six year old. An incidental soft-tissue mass is seen in the middle mediastinum. Which of the following is it most likely to represent? a Neurogenic tumour b Great vessel aneurysm c Thymoma d Lateral meningocele e Teratoma

Answer 64

58 Answer B: Great vessel aneurysm Mediastinal lesions by location: * anywhere in the mediastinum - lymphoma/leukaemia, adenopathy, mediastinitis, haematoma * anterior mediastinum - teratoma, thyroid, thymoma * middle mediastinum - bronchopulmonary foregut malformations, hiatal hernia/other gastric or oesophageal abnormality, cardiac/pericardiac tumours and cysts, great vessels aneurysms/anomalies * posterior mediastinum - neurogenic tumours, neurenteric cysts, lateral meningoceles, spinal tumours/ osteomyelitis/ discitis, descending aortic or azygous anomaly/aneurysm, extramedullary haematopoiesis.

Question 65

@# 62 A two year old with pneumonia is not improving with antibiotics. CXR shows hyperinflation and patchy infiltrates. What is the likely diagnosis? a Chlarydia b Streptococcus pneuroniae c Pneurnocystis carinii d RSV e Adenovirus

Answer 65

62 Answer D: RSV The commonest organisms causing pneumonia at different ages: * Premature infants - (1) Group B Streptococcus, (2) E. coli, (3) Listeria, (4) CMV * Infants - (1) RSV, (2) Chlarnydia, (3) Streptococcus pneumoniae, (4) Haernophilus influenzae type B * School age - (1) Mycoplasma, (2) Influenza A, (3) Streptococcus pneurnoniae.

Question 66

@# 24) The bronchial tree receives blood from one right and two left bronchial arteries. From which vessel does the single right artery usually arise? a. aorta b. joint origin with left bronchial arteries c. second posterior right intercostal artery d. third posterior right intercostal artery e. fourth posterior right intercostal artery

Answer 66

d. third posterior right intercostal artery The bronchial tree derives its arterial supply via bronchial arteries. The two left-sided vessels arise direct from the aorta. The solitary right artery usually arises from the right third posterior intercostal artery. These vessels supply the bronchi from the carina to the respiratory bronchioles.

Question 67

@# 88) In anatomy of the aortic arch, after the normal configuration of vessels (brachiocephalic, left common carotid and left subclavian arteries), what is the next most common configuration seen? a. left vertebral artery arising from the arch between left common carotid and subclavian arteries b. common origin of the brachiocephalic artery and left common carotid artery c. right subclavian arising distal to the left subclavian artery d. common origin of left common carotid and left subclavian arteries e. double arch with common carotid and subclavian arteries arising from each side

Answer 67

b. common origin of the brachiocephalic artery and left common carotid artery The so-called normal aortic arch anatomy is seen in only 65% of people. The next most common configuration is where the left common carotid artery arises with the brachiocephalic artery in a common origin, seen in 13%, followed by the left common carotid arising from the brachiocephalic artery (bovine origin), seen in 9%. The left vertebral artery arising direct from the arch is seen in 2.5%, and the aberrant right subclavian artery (option c) occurs in 0.5%.

Question 68

@# 20- With regards to the anatomy seen on a normal plain chest radiograph, which of the following is incorrect? (a) The anterior junctional line is formed by the apposition of the visceral and parietal pleura of the anteromedial aspect of the lungs, separated by mediastinal fat (b) The anterior junctional line extends more cranially than the posterior junctional line (c) The right paratracheal stripe measures up to 4 mm (d) The left paratracheal stripe is seen less commonly than the right paratracheal stripe (e) The left paraspinal line is seen more commonly than the right paraspinal line

Answer 68

(b) The anterior junctional line extends more cranially than the posterior junctional line The posterior junctional line is formed by the junction between the lungs posterior to the esophagus and anterior to the 3rd — 5th thoracic vertebrae. It appears as a straight or mildly leftward convex line seen projected over the trachea. Unlike the anterior junctional line, it can extend above the clavicles.

Question 69

@# 64 A 70-kg patient with no relevant comorbidities underwent an abdominal percutaneous drain insertion. At the start of the procedure 10 mL of 1 % lidocame hydrochloride was infiltrated subcutaneously. The patient developed further pain as dilators and a stiff guidewire were inserted. How much more 1 % lidocaine can safely be administered? a None b 5mL c 10 mL d 20 mL e 40 mL

Answer 69

64 Answer C: 10 mL Lidocaine hydrochloride (xylocaine, lignocaine) is routinely used for local anaesthesia. 1 % means 1 g in 100 mL, that is 10 mg/mL. In a typical adult a maximum dose of 3 mg/kg is appropriate. (In solutions containing adrenaline, the maximum dose is higher: 7 mg/kg.)

Question 70

@#1 6. A 35 year old man undergoes autologous bone marrow transplantation following successful treatment of lymphoma. Two weeks later he develops scattered bilateral progressive breathlessness and dry cough. HRCT demonstrates several areas of bilateral ground glass changes with associated reticular changes, but no effusions. What is the most likely explanation? a. Angioinvasive aspergillosis b. Lymphoid interstitial pneumonia c. CMV pneumonia d. Drug toxicity e. Pulmonary oedema

Answer 70

d. Drug toxicity Drug toxicity Post transplant pulmonary complications may develop in up to 40–60% of patients. In the first two weeks or so after transplantation, neutropaenia is the underlying cause for most of these. Angioinvasive aspergillosis presents in the first two to three weeks, usually as multiple ground glass nodules with or without cavitation and peribronchiolar consolidation. Lymphoid interstitial pneumonia (LIP) is a late-phase complication usually seen more than three months after transplantation and may be an indication of chronic graft-versus-host response. CMV pneumonia may manifest at any time in the first 100 days after transplantation. Multiple nodules with associated ground glass changes or consolidation are usually seen, but reticular change is not a feature. Pulmonary oedema is also seen in the neutropaenic phase in the first two to three weeks. Whilst ground glass changes and interstitial lines are seen in pulmonary oedema, associated pleural effusion is common. Drug toxicity due to a variety of chemotherapeutic agents is seen in the neutropaenic phase as a combination of ground glass and reticular changes…

Question 71

@#1 45 A patient who was known to have HIV presented with shortness of breath and underwent further investigations. Their CD4 count was 208 cells per cu mm. What AIDS-defining illness would be most likely with this CD4 count? a Lymphoma b Histoplasmosis C Kaposi's sarcoma d Pneurnocystis carinii pneumonia e Pulmonary CMV

Answer 71

45 Answer C: Kaposi's sarcoma Lymphoma, histoplasmosis, Pneurnocystis and CMV are all usually seen when the CD4 count is below 200.

Question 72

@#1 40 In a 74-year-old female with chronic obstructive pulmonary disease (COPD), which of the following descriptions on HRCT would increase the possibility of a Mycobacterium avium intracellulare (MAI) versus Mycobacterium tuberculosis? a Pulmonary consolidation b Irregular pleural thickening C Diffuse bronchiectasis and centrilobular nodulation d Lesions affecting predominantly the apical segments of the lower lobes e Apical cavitation

Answer 72

40 Answer C: Diffuse bronchiectasis and centrilobular nodulation In the majority of cases the two organisms produce virtually indistinguishable radiological features. The history of COPD in an elderly woman should raise the possibility of MAI, and in this subset of patients diffuse bronchiectasis and centrilobular nodules are suggestive of the diagnosis. In favour of tuberculosis is the greater incidence of interlobular septal thickening. Often failure of response to antituberculous therapy leads to the consideration of MAI.

Question 73

@#1 52 A 62-year-old patient with ongoing dyspnoea underwent CT of the chest. Among other findings it demonstrated two ill-defined foci of consolidation within the posterior and apical segments of the right upper lobe. In addition, within the remainder of the right lung, and to a lesser extent the left lung, there was a more diffuse abnormality characterised by small (<4 mm) centrilobular, well-defined nodules within 1 cm of the pleural surface. These nodules were connected by linear, branching opacities. What is the most likely cause for these findings? a Obliterative bronchiolitis b Primary pulmonary lymphoma C Respiratory syncytial virus infection d Reactivation tuberculosis e Renal cell carcinoma metastases

Answer 73

52 Answer D: Reactivation tuberculosis The description of interconnected subpleural nodules is that of `tree-in-bud'. This represents bronchiolar luminal impaction with mucus, pus or fluid. The causes are myriad (in fact all the options are potential causes). Infection is the commonest cause, and tuberculosis (via endobronchial spread) is the commonest infection accounting for this appearance.

Question 74

@#1 59 A 32-year-old flight attendant presented with shortness of breath, fever, cough and haemoptysis. There were bilateral crepitations on auscultation and several blue/red raised skin lesions were noted. His CD4 lymphocyte count is 120 (normal >500). HRCT of the chest demonstrated patches of numerous, ill-defined nodules in a perihilar distribution and septal thickening. There was moderate hilar lymphadenopathy but no pleural effusion. What is the most likely diagnosis? a Streptococcus pneumonia b Pneumocystis carinii pneumonia C Kaposi's sarcoma d Mycobacterium avium-intracellulare infection e AIDS-related lymphoma of B-cell origin

Answer 74

59 Answer C: Kaposi's sarcoma Kaposi's sarcoma tends to affect patients whose CD4 count has fallen below 200. Pneurnocystis carinii pneumonia is the commonest cause of opportunistic pulmonary infection in HIV, but the presence of characteristic skin lesions confirms the diagnosis in this instance. Imaging features of Pneurnocystis carinii pneumonia include bilateral groundglass infiltrates, interstitial infiltrates and pneumatoceles. Adenopathy and effusions are rarely seen.

Question 75

@#1 45 A 45-year-old man presented to the Emergency Department with severe dyspnoea, pleuritic chest pain, malaise and diarrhoea. Blood tests showed hyponatraemia and a chest radiograph showed a moderate-sized pleural effusion, unilateral pulmonary infiltrates and prominent lymphadenopathy. In view of a recent local outbreak of Legionnaires' disease at a local conference centre this diagnosis was considered. What finding in the work-up would make a different diagnosis more likely? a Prominent lymphadenopathy b A moderate pleural effusion C Unilateral pulmonary infiltrates d Hyponatraemia e Pleuritic chest pain

Answer 75

45 Answer A: Prominent lymphadenopathy Lymphadenopathy is a rare finding.

Question 76

@#1 36 A 38-year-old female of West African decent presented with a fever, malaise and large joint arthralgia. She was also noted to have erythema nodosum. Her calcium levels were elevated and her chest radiograph showed bilateral nodular pulmonary hila. What is the most likely diagnosis? a Familial Mediterranean fever b Malaria c Acute sarcoidosis d Severe acute respiratory syndrome (SARS) e Lymphomatoid granulomatosis

Answer 76

36 Answer C: Acute sarcoidosis Features of acute sarcoidosis (Lofgren syndrome) include fever, malaise, bilateral hilar lymphadenopathy, erythema nodosum, arthralgia and occasionally parotitis and uveitis. The Kveim-Siltzbach test is rarely used and involves intracutaneous injection of a suspension of human sarcoid spleen. ACE levels are more commonly used, which are elevated in 70% of sarcoid patients and are an indicator of the granuloma burden on the body

Question 77

@#1 1. A 70-year-old male presents to his GP with cough. The chest radiograph shows bilateral egg shell calcifications in the hilar regions. Which of the following is the least likely diagnosis? (a) Silicosis (b) Asbestosis (c) Coal workers pneumoconiosis (d) Sarcoidosis (e) Histoplasmosis

Answer 77

1. (b) Asbestosis All the other given options are known to cause egg shell calcification of the hilar lymph nodes.

Question 78

@#1 32. Which of the following features is most strongly associated with active alveolitis on HRCT in a 40-year-old woman with a diagnosis of systemic sclerosis? A. Ground glass opacification without traction bronchiectasis in the middle lobe B. Basal ground glass opacification C. Lower lobar consolidation D. Interlobular septal thickening E. Pleural effusion

Answer 78

A. Ground glass opacification without traction bronchiectasis in the middle lobe The presence of ground glass opacification (without evidence of traction bronchiectasis) in the middle lobe and lingula is strongly associated with active alveolitis. Basal ground glass shadowing is a non-specific finding and a poor predictor of alveolitis.

Question 79

@#1 46. Which of the following is most likely to show peripheral reverse bats wings infiltrates on a chest radiograph? A. Eosinophilic pneumonia B. Pulmonary oedema C. Proeteinosis D. Lymphoma E. Goodpasture’s syndrome

Answer 79

A. Eosinophilic pneumonia Eosinophilic pneumonia, resolving pulmonary oedema, desquamative interstitial pneumonia and sarcoidosis are causes of reverse bats wings peripheral infiltrates. Causes of perihilar bats wings infiltrates include pulmonary oedema, proeteinosis, sarcoidosis, lymphoma, Goodpasture’s syndrome and alveolar cell carcinoma.

Question 80

@#1 39 A 74 year old man presents with progressive dyspnoea. CXR shows bilateral, lower zone, peripheral subpleural reticulation. Which of the following is least likely? (a) Amiodarone toxicity (b) Usual interstitial pneumonitis (c) Asbestosis (d) Rheumatoid arthritis (e) Chronic extrinsic allergic alveolitis

Answer 80

(e) Chronic extrinsic allergic alveolitis The acute and subacute forms of EAA can cause lower zone reticular change but the chronic form typically has an upper lobe distribution. Other drugs that can cause lower zone reticulation include bleomycin, methotrexate and nitrofurantoin. Asbestosis refers specifically to interstitial fibrosis in the context of asbestos exposure rather than the benign pleural asbestos related diseases. UIP is the commonest histological type of pattern found in idiopathic pulmonary fibrosis.

Question 81

@#1 69 A 70-year-old man with chronic obstructive airways disease underwent a CT scan and a tracheal diverticulum was identified. What is the most likely site of this abnormality? a just below the larynx on the left anterolateral wall b In the distal trachea on the anterior wall c just above the carina on the posterior wall d At the level of the thoracic inlet on the right posterolateral wall e At a variable level on the anterior wall

Answer 81

69 Answer D: At the level of the thoracic inlet on the right posterolateral wall Usually they occur between the cartilaginous and muscular portion of the wall and tend to be asymptomatic.

Question 82

@#1 70 A 45-year-old woman with pleuritic chest pain, shortness of breath and profound hypoxia was suspected of having had a pulmonary embolus and a CT pulmonary angiogram was performed. Opacification of the pulmonary vasculature is good with a measured density of 212 HU. What window settings would be optimal when evaluating the pulmonary artery for thrombus? a Window width 350 HU, window level 40 HU b Window width 1500 HU, window level -500 HU C Window width 700 HU, window level 100 HU d Window width 1500HU, window level 500HU e Window width 100 HU, window level 500HU

Answer 82

70 Answer C: Window width 700 HU, window level 100 HU

Question 83

@#1 17 A 25 year old woman has a CXR for insurance purposes. There is a 2 cm well-circumscribed lesion in the periphery of the RLL. The subsequent CT demonstrates fat and calcification within the lesion; no other lesions are identified. What two further conditions, if present, would make the diagnosis part of Carney's triad? (a) Atrial myxoma and extra-adrenal paraganglioma (b) Atrial myxoma and pituitary adenoma (c) Breast fibroadenoma and pituitary adenoma (d) Gastric leiomyosarcoma and breast fibroadenoma (e) Gastric leiomyosarcoma and extra-adrenal paraganglioma

Answer 83

(e) Gastric leiomyosarcoma and extra-adrenal paraganglioma Pulmonary hamartomas, gastric leiomyosarcomas (GISTs) and functioning extra-adrenal paragangliomas make up this rare triad. Almost all patients are female (80%) aged 10-30 years. Pituitary adenomas, cardiac myxomas, along with myxoid fibroadenomas of the breast and testicular tumours are associated with the autosomal dominant Carney complex.

Question 84

@#1 34 A 50 year old woman with a history of scleroderma and a 30 pack per year smoking history presents with a cough. CXR shows a 1.2 cm peripheral nodule in the right lower lobe. CT confirms the nodule is solitary and is of mixed attenuation with a ground glass appearance. There is no mediastinal lymphadenopathy. Repeat interval CT at 6 weeks, after treatment with antibiotics, shows the lesion has remained stable in size but there is some evidence of cavitation. 18FDGPET is performed and found to be negative. The likeliest diagnosis is? (a) Bronchoalveolar carcinoma (b) Squamous cell carcinoma (c) Atypical infection (d) Carcinoid (e) Adenocarcinoma

Answer 84

(a) Bronchoalveolar carcinoma BAC is a slow growing peripheral tumour associated with chronic lung disease and ground glass appearance on HRCT. It can cavitate and is PET negative in 55%.

Question 85

@#1 60 A 57 year old man with biopsy proven lung cancer attends for a PET-CT study. This demonstrates a 4 cm tumour in the left lower lobe, not abutting the pleural surface. There are enlarged, PET positive nodes in the left hilar, sub-carinal and cervical nodes. How would you stage this tumour? (a) T3 N3 MO (b) T2 N2 MO (c) T2 N3 MO (d) T2 N2 M1 (e) T2 N3 M1

Answer 85

(d) T2 N2 M1 T2 lesions are those greater than 3 cm not invading the parietal pleura and more than 2 cm away from the carina. N1 nodes are hilar, N2 nodes include ipsilateral mediastinum and sub-carinal, N3 nodes are supraclavicular and contralateral mediastinum. Nodes outside these regions are considered to be M1.

Question 86

@#1 4. In an investigation for lung malignancy, all of the following may produce a false positive result on a PET-CT except: a. Pulmonary hamartoma b. Intralobar sequestration c. Tuberculosis d. Pneumonia e. Scarring

Answer 86

b. Intralobar sequestration Active tuberculosis, consolidation, atypical pulmonary hamartomas and scars may cause false positive results. Uncomplicated sequestration will not demonstrate FDG uptake.

Question 87

@#1 26 A patient is awaiting investigation and treatment of a superficial neck mass, suspicious for non- Hodgkin's lymphoma. Their chest radiograph shows bilateral hilar lymphadenopathy. When is the best time to perform PET CT in view of gaining a histological diagnosis and commencing treatment? a Wait 1 week after neck dissection b Wait 4 weeks after neck dissection C Wait 4-6/52 after start of chemotherapy d Within 1 week of commencing chemotherapy e Wait 4-6 weeks after starting radiotherapy

Answer 87

26 Answer C: Wait 4-6/52 after start of chemotherapy Performing PET imaging after a procedure will produce inaccurate results as traumatised tissues have an increased metabolism and will mask any adjacent uptake due to pathology. Imaging should ideally wait six weeks post surgery, one week post biopsy, six weeks post chemotherapy and six months post radiation to avoid false positive uptake. However, some tumours such as GIST can show reduced metabolic activity and hence reduced uptake as soon as 24 hours following commencement of chemotherapy where conventional imaging will appear no different for weeks.

Question 88

@#1 43 A 50-year-old man was admitted feeling unwell and multiple ill-defined nodules of varying sizes within both lungs were visible on his chest radiograph. These were suspected to be lung metastases. What is the most likely primary tumour? a Testicular teratoma b Renal cell carcinoma c Thyroid carcinoma d Melanoma e Pancreatic carcinoma

Answer 88

43 Answer B: Renal cell carcinoma All these tumours except pancreatic carcinoma often metastasise to the chest but renal cell carcinoma is both the most common and the most likely to present with lung metastases already present.

Question 89

@#1 (Ped) 40 A 10-year-old child is diagnosed with non-Hodgkin's lymphoma (NHL). He is found to have two single extranodal tumours on opposite sides of the diaphragm. What stage of disease does he have? aI b II C III d IV eV

Answer 89

40 Answer C: III The St Jude classification is used to stage NHL. There are four stages: I Single extranodal tumour/single anatomic area II (a) Single extranodal tumour + regional nodes (b) Two or more nodal areas on same side of diaphragm (c) Two extranodal tumours +/nodes on same side of diaphragm (d) Primary gastrointestinal tumour +/nodes III (a) Two extranodal tumours on opposite sides of diaphragm (b) Two or more nodal areas on both sides of diaphragm (c) Primary intrathoracic tumours (d) Extensive primary intra-abdominal disease (e) Paraspinal/epidural tumour IV Any of above + CNS/bone marrow involvement

Question 90

@#1 37 A 78-year-old female patient had a chest radiograph that showed multiple pulmonary nodules of varying sizes in both lungs, without zonal predilection which were thought to be metastases. What is the most likely site of an underlying primary tumour? a Breast b Colon c Bone d Pancreas e Ovary

Answer 90

37 Answer A: Breast

Question 91

@#1 48. The following statements regarding lymphangitis carcinomatosis are correct: (T/F) (a) Chest X-Ray appearances are of multiple reticulonodular opacities. (b) It is associated with gastric cancer. (c) Kerley A and B lines are seen. (d) Radiological changes usually precede symptom onset. (e) Hilar adenopathy is seen in 80-90%

Answer 91

Answers: (a) Correct (b) Correct (c) Correct (d) Not correct (e) Not correct Explanation: Lymphangitis carcinomatosis presents with shortness of breath before radiological changes. Hilar adenopathy is seen in 20% - 50%.

Question 92

@#1 32 A 3 year old presents with a persistent cough that has not responded to antibiotics. CXR demonstrates a triangular shaped-mass medially at the left lung base. CT is arranged for further investigation. What feature favours a diagnosis of intra- over extrapulmonary sequestration? (a) Air seen within lesion (b) Communication with the bronchial tree (c) Multiple associated anomalies (d) Systemic venous drainage (e) Systemic arterial supply

Answer 92

(a) Air seen within lesion Intralobar type is within the lung, sharing its pleura; it may be of airless, or air-containing, cystic type, and presents late in childhood / adulthood with recurrent infections or haemoptysis. Arterial supply is systemic, drainage is to the pulmonary vein in 95% and there is a low association with other anomalies. Extrapulmonary sequestration presents in neonates, is located outside the lung with its own pleura, has a systemic arterial supply, and drainage is to the systemic circulation. In 65% there are associated anomalies and it is 'always' airless (unless there is a communication with the GI tract).

Question 93

@#1 QUESTION 12 A 4-year-old child presents with upper back pain. General examination reveals hepatomegaly and blood tests demonstrate an iron deficiency anaemia. The child's chest radiograph demonstrates an abnormal mediastinal contour and subsequent CT confirms an 8-cm posterior mediastinal mass which contains calcification. The lungs are clear. Which one of the following is most likely the diagnosis? A Extramedullary haemopoiesis B Lymphoma C Neuroblastoma D Neurofibroma E Teratoma

Answer 93

C Neuroblastoma If a paediatric posterior mediastinal mass contains calcification, it is most likely to be a sympathetic chain tumour.

Question 94

@#1 30. A male neonate born at 26 weeks gestation is currently being treated in your neonatal ICU. The patient’s mother received corticosteroids prior to delivery and prophylactic surfactant administration as per your department’s standard practice. The CXR was clear for the first 7 days. Despite this the child developed streaky perihilar granular opacities and respiratory difficulties. Further surfactant administration has been carried out, but the CXR carried out today (day 28 postpartum) shows small streaky linear densities along with cystic bubbly lucencies, which have been becoming increasingly prominent over the last 7 days and are distributed in an irregular pattern bilaterally. What is the most likely explanation for this appearance? A. Surfactant deficiency. B. Meconium aspiration. C. BPD. D. Beta haemolytic streptococcal pneumonia. E. PIE.

Answer 94

30. C. BPD. Whilst surfactant deficiency is undoubtedly a feature of this case, the evolution of the clinical scenario indicates that a further condition is evolving to explain the findings and clinical condition. In this case the two likeliest conditions are BPD and PIE, both most commonly associated with immature lungs and both of which give bubbly lucencies on radiography. PIE is a feature of air leak phenomena which occur in stiff lungs and is due to either high airway pressure or alveolar overdistention causing passage of gas into the interstitial spaces. It is associated with other airleak phenomena such as pneumopericardium. BPD was originally described to occur in four stages, but the advent of refined ventilation, surfactant, and prophylactic administration of corticosteroids, have changed the typical progression. A complete discussion of these diseases is found in the article referenced below. BPD tends to develop more gradually than PIE (as described in the clinical vignette) and tends to occur later than PIE.

Question 95

@#1 50. A CT chest has been requested for a neonate in the neonatal ICU. This infant was born at 27 weeks gestation and developed right-sided PIE during the first week of life. The neonatologists practiced selective left bronchial intubation and no further air leak sequelae occurred. Also present on the CXR is a hyperlucent lesion in the right lower lobe. This is not clearly seen on the initial radiographs due to the generalized haziness present due to the surfactant deficiency. This lesion is not increasing in size and is not causing any significant respiratory embarrassment, but requires further assessment to define treatment. On CT a focal lesion is present confined to the right lower lobe, which consists of multiple cystic structures with central linear densities. This area demonstrates mild expansion. What is the diagnosis? A. Congenital cystic adenomatoid malformation. B. Persistent PIE. C. Congenital diaphragmatic hernia. D. Congenital lobar emphysema. E. Bronchogenic cyst.

Answer 95

50. B. Persistent PIE. Although alluded to in the clinical scenario, this should not be assumed to be the most likely diagnosis in the absence of the CT findings, as this is an extremely uncommon condition. The CT findings provide the diagnosis due to the linear densities within the cystic cavities representing the bronchopulmonary bundle surrounded by air within the interstitial space. This appearance is seen in over 80% of cases. The abnormality is often confined to a single lobe, but can be more widespread. Current optimal management is debated. Lesions increasing in size are thought to be best treated with surgical resection, with stable lesions often resolving over time with conservative management.

Question 96

@#1 53 A 15-year-old boy is found to have metastatic deposits in his lungs. Osteogenic sarcoma has been excluded. What is the most likely primary tumour? a Rhabdomyosarcoma b Wilms' tumour C Ewing's sarcoma d Medulloblastoma e Retinoblastoma

Answer 96

53 Answer C: Ewing's sarcoma The four paediatric tumours that tend to metastasise to the lungs are: * rhabdomyosarcoma primarily affects children ages 1-5 and 15-19 * osteogenic sarcoma primarily affects children under age 15 * Wilms' tumour primarily affects females under five years of age with a high incidence in African Americans.?