VIQ - Female Imaging Flashcards

1
Q

@#e2 6. Regarding yolk sac tumours of ovary:

A. Are the most common malignant germ cell tumour of the ovary

B. Account for 5% of all ovarian malignancy

C. Carry a poorer prognosis than any other ovarian germ cell tumour

D. Haemorrhagic change is very rare

E. Are slow growing tumours

A

C. Carry a poorer prognosis than any other ovarian germ cell tumour

Yolk sac tumours are well-enhanced tumours consisting of mixed solid and cystic tissue with some area of haemorrhage.

A ‘bright dot’ sign is recognised; a well-enhanced dilated vessel on the post-contrast image.

Yolk sac tumours have a poor prognosis.

They account for 1% of ovarian malignancies.

They are the second most common malignant germ cell tumour after dysgerminomas.

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2
Q

@# 44. Regarding clear cell tumour of the ovary:

A. Are rarely invasive

B. Represents > 20% of ovarian carcinomas

C. Most patients present at stage 2 disease

D. Frequently occurs as a unilocular cyst with mural nodule

E. Has a poorer survival rate compared with other ovarian cancers

A

D. Frequently occurs as a unilocular cyst with mural nodule

50% of patients have a 5-year survival rate; it presents in stage I in 75% of cases and accounts for up to 10% of all ovarian cancers.

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3
Q

@#e2 13) A postmenopausal patient has a hysterectomy and bilateral salpingo-oophorectomy for bilateral ovarian masses. Histological examination confirms bilateral ovarian tumours and reveals concomitant endometrial adenocarcinoma. What is the most likely histological diagnosis of the ovarian lesions?

a. benign serous cystadenoma

b. benign mucinous cystadenoma

c. malignant serous cystadenocarcinoma

d. malignant mucinous cystadenocarcinoma

e. endometrioid tumour

A

e. endometrioid tumour

Benign serous cystadenoma is bilateral in 20% of cases, benign mucinous cystadenoma in 5%, malignant serous cystadenocarcinoma in 50% and malignant mucinous cystadenocarcinoma in 25%. However, not only are endometrioid ovarian tumours frequently bilateral (30–50%) but they are also often (30%) found with concomitant endometrial adenocarcinoma.

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4
Q

@#e2 47) A postmenopausal patient is investigated for ascites. Cytology from the ascites reveals cells in keeping with an epithelial ovarian malignancy. Which of the following is the most appropriate staging investigation?

a. CT of the abdomen and pelvis with oral and intravenous contrast

b. CT of the chest, abdomen and pelvis with oral and intravenous contrast

c. MRI of the pelvis

d. 18FDG PET

e. PET/CT

A

a. CT of the abdomen and pelvis with oral and intravenous contrast

Plain chest radiograph may be added to this as a routine, but chest CT would be requested only with an additional reason to do so. MRI of the ovaries can be helpful in characterizing ovarian masses where ultrasound scan and CA-125 are equivocal. There may be a role for PET/CT in defining disease extent, but cystic tumour deposits, particularly when they may be on or close to bowel or associated with ascites, present a challenge for this technique.

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5
Q

@#e2 60) MRI is performed for locoregional staging of vaginal cancer. Which of the following descriptions is the most likely appearance on a T2W sequence, given a small primary tumour confined to the vagina?

a. central high signal within the vagina; focal homogeneous, low-signal mass not breaching the surrounding ring of intermediate-signal vaginal wall

b. central high signal within the vagina; focal homogeneous, high-signal mass not breaching the surrounding low-signal vaginal wall

c. central high signal within the vagina; focal homogeneous, intermediate-signal mass breaching the surrounding low-signal vaginal wall

d. central high signal within the vagina; focal homogeneous, intermediate-signal mass not breaching the surrounding low-signal vaginal wall

e. central intermediate signal; focal homogeneous, high-signal mass contained by low-signal vaginal wall

A

d. central high signal within the vagina; focal homogeneous, intermediate-signal mass not breaching the surrounding low-signal vaginal wall

The vaginal epithelial layer and mucus are bright on T2W images. This is normally surrounded by low-signal (fibromuscular) vaginal wall. Tumours are typically intermediate signal on T2W images. If gadolinium is used, cancers often have early phase enhancement. Large tumours may have central necrosis.

T1 tumours do not breach the low-T2-signal vaginal wall,

whereas T2 tumours do and extend into the paracolpal fat.

T3 tumours reach the pelvic side wall

while T4 tumours extend beyond the true pelvis or involve bladder or rectal mucosa

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6
Q

@# 63) On transvaginal ultrasound scan, an ovary measures 5 X 3 X 2 cm. Regarding the volume of this ovary, which of the following statements is most accurate?

a. it is large for pre- and postmenopausal ovaries

b. it is normal for pre- and postmenopausal ovaries

c. it is normal for a premenopausal ovary but large for a postmenopausal ovary

d. it is normal for a postmenopausal ovary but large for a premenopausal ovary

e. not enough information is given to assess the volume

A

c. it is normal for a premenopausal ovary but large for a postmenopausal ovary

Normal ovarian volume is less than 18 cm3 before the menopause and less than 8 cm3 after.

The volume can be estimated by multiplying the three diameters and dividing by two.

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7
Q

@# 70) A 17-year-old female with primary amenorrhoea is found on clinical examination to have a hypoplastic upper/middle vagina. MRI shows an absent uterus but normal tubes and ovaries. Which of the following is the most likely diagnosis?

a. uterus didelphys

b. unicornuate uterus

c. Mayer–Rokitansky–Kuster–Hauser syndrome

d. uterine agenesis

e. septate uterus

A

c. Mayer–Rokitansky–Kuster–Hauser syndrome

The uterus, fallopian tubes and upper vagina arise from the paired paramesonephric (mullerian) ducts. The caudal parts fuse and ultimately form the uterus and upper vagina with resorption of the midline septum. The cranial parts remain unfused and form the fallopian tubes. Congenital uterine abnormalities arise with failure of development or fusion of this duct, or failure of midline resorption following fusion. Mayer–Rokitansky–Ku¨ster–Hauser syndrome describes uterine agenesis accompanied by hypoplastic proximal/middle third of the vagina but normal tubes and ovaries. Forty per cent of patients with the syndrome have pelvic kidneys and other urinary tract anomalies are also associated. They have a normal genotype.

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8
Q

@#e 36 A 30 year old woman with a previous history of pelvic inflammatory disease is undergoing investigations for infertility. With regards to assessment of tubal patency, which of the following statements is correct?

(a) Gadolinium enhanced MRI is the investigation of choice

(b) Normal fallopian tubes are visible on pelvic US

(c) Hysterosalpingography should be performed in the first half of the menstrual cycle

(d) Hysterosalpingo contrast sonography is as good as laparoscopy and dye instillation

(e) Iodine based contrast is used for hysterosalpingo contrast sonography

A

(c) Hysterosalpingography should be performed in the first half of the menstrual cycle

Laparoscopy and blue dye instillation (with spillage of dye into the peritoneal cavity indicating patency) is the gold standard, but requires a general anaesthetic. MRI and standard pelvic US do not clearly demonstrate the fallopian tubes. HSG provides an accurate indication of tubal patency but employs ionizing radiation. It should therefore be performed in the first half of the menstrual cycle to avoid irradiating a patient with possible early pregnancy. Hysterosalpingo-ContrastSonography uses microbubbles to demonstrate the fallopian tubes and has the advantage of not using ionizing radiation or requiring anaesthesia but is less accurate than the other methods.

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9
Q

@#e QUESTION 45
A transvaginal ultrasound is performed on a 36-year-old woman with dysfunctional uterine bleeding. This demonstrates an enlarged globular uterus with a heterogeneous appearance of the myometrium. The myometrium contains diffuse echogenic nodules, subendometrial echogenic linear striations and 2- to 6-mm subendometrial cysts. Colour Doppler demonstrates a speckled pattern of increased vascularity within the heterogeneous area of myometrium. What is the most likely diagnosis?

A Adenomyosis

B Endometrial polyposis

C Gestational trophoblastic.disease (GTD)

D Stage 1A endometrial cancer

E Uterine fibroid

A

A Adenomyosis

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10
Q

@#e A 60-year-old nulliparous woman presents with postmenopausal bleeding. On transvaginal ultrasound, her endometrium is 8 mm thick and the endomyometrial junction appeared indistinct. The radiologist suspects invasive endometrial cancer and refers her for an MRI examination. What are the likely findings on MRI?

A On unenhanced Tlw images the endometrial cancer appears of high signal intensity compared to the surrounding myometrium.

B On contrast-enhanced Tlw images, endometrial cancer shows avid enhancement compared with surrounding myometrium.

C On T2w images the normally high signal junctional zone is disrupted.

D Tlw fat-saturated sequences are best used to assess the junctional zone.

E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images

A

E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images

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11
Q

@#e QUESTION 73
A 64-year-old woman presents with bloating and vague pelvic pain and is referred for a pelvic ultrasound. On transabdominal ultrasound, she is found to have a large right adnexal mass. Which one of the following sonographic findings would indicate that this mass is more likely to be malignant than benign?

A Doppler waveform with a high resistive index (> 0.8)

B Homogeneously hypoechoic mass with posterior acoustic enhancement

C Multiple septations that are approximately 1 mm thick

D Papillary projections

E Size > 4 cm

A

D Papillary projections

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12
Q

@#e QUESTION 74
A 31-year-old woman has a hysterosalpingogram (HSG) as part of a series of investigations for primary infertility. The HSG shows a single vagina, single cervix but two separate uterine cavities leading to separate uterine horns. What is the most likely diagnosis?

A Arcuate uterus

B Bicornuate uterus

C Didelphus uterus

D Septate uterus

E Bicornis bicollis

A

B Bicornuate uterus

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13
Q

@#e2 28. Which of the following are correct regarding ovarian cancer: (T/F)

(a) It is the commonest gynaecological malignancy.

(b) It is associated with colorectal cancer.

(c) CA-125 is specific for ovarian cancer.

(d) CT only has a pre-operative staging accuracy of 50%.

(e) Doppler ultrasound may help with differentiating benign from malignant disease.

A

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Endometrial cancer is the most common gynaecological malignancy. CA-125 is not specific for ovarian cancer, it is increased in benign conditions like fibroids, endometriosis and inflammatory pelvic disease. CT only has a pre-operative staging accuracy of 70% - 90%.

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14
Q

@#e2 45 During a routine antenatal ultrasound performed at 11 weeks gestation, the nuchal skin thickness is measured at 5 mm. Which of the following is not part of the differential?

(a) Normal variation

(b) Noonan’s syndrome

(c) Zellwegger syndrome

(d) Klippel-Feil syndrome

(e) Fragile X syndrome

A

(e) Fragile X syndrome

The nuchal skin thickness should measure up to 3 mm at 9-13 weeks, up to 5 mm at 14-19 weeks and up to 6mm at 19-24 weeks. Although rare (<1%) normal variation is observed. Other causes of nuchal skin thickening include Turners and Downs syndromes.

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15
Q

@#e2 21 A 31 year old is pregnant with her first child. At 16 weeks’ gestation the corrected alphafetoprotein level is noted to be raised. What is a possible cause for this?

a Wrong dates - a normal pregnancy that is less advanced that originally dated

b Greater than average birth weight

C Ectopic pregnancy

d Trisomy 21

e Neural tube defect

A

21 Answer E: Neural tube defect

An elevated alpha-fetoprotein level is associated with foetal anomalies in 61 %, of which 51 % are neural tube defects. Other causes include a normal pregnancy that is more advanced, twin pregnancy, missed abortion, renal anomalies and anterior abdominal wall defects.

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16
Q

@# 5) A 78-year-old man presents with a palpable, non-tender, left breast lump. Mammography demonstrates a well-defined, high-density, lobulated mass in the retroareolar region. Ultrasound appearances are of a hypoechoic mass with an eccentric position relative to the nipple. The ipsilateral axilla appears unremarkable. What is the most likely diagnosis?

a. invasive ductal carcinoma

b. lipoma

c. breast abscess

d. gynaecomastia

e. lymphoma

A

a. invasive ductal carcinoma

Most symptomatic male breast lesions are benign, with gynaecomastia representing the commonest benign entity.

Characteristic mammographic features are of a central, retroareolar, flame-shaped density.

Male breast cancers are usually invasive ductal carcinomas, which typically appear as a discrete, high-density, well-defined mass with lobulated or spiculated margins at mammography.

Microcalcification is seen less commonly than in females, but secondary signs, such as nipple retraction and skin thickening, occur earlier than in females due to smaller breast size.

Ultrasound scan is particularly helpful in assessing the relationship of the mass to the nipple. An eccentric position is highly suspicious for breast CA.

Axillary lymphadenopathy is seen in approximately 50% of patients.

17
Q

@# 30 A 45 year old previously well woman presents with a breast lump. US shows a round lesion of mixed attenuation. Biopsy determines that the lesion is a metastasis and has significant areas of haemorrhage within it. The other breast is normal. What is the most likely primary tumour?

(a) Malignant melanoma

(b) Ovarian carcinoma

(c) Lung carcinoma

(d) Kaposi sarcoma

(e) Renal oncocytoma

A

(a) Malignant melanoma

Haemorrhagic metastases to breast include melanoma, renal cell carcinoma, choriocarcinoma and Kaposi sarcoma.

Overall, the commonest non-mammary source of non-haemorrhagic metastases is lymphoma.

18
Q

@#e 44 A 48 year old female patient presents to the breast clinic with a painless breast lump. Clinical examination reveals a firm 2 cm mass in the right upper outer quadrant. Mammography shows a round, well defined soft tissue opacity in the corresponding location. Which of the following features on US suggest a malignant rather than benign cause?

(a) It is taller than it is wide

(b) It is markedly hyperechoic

(c) It has a thin echogenic capsule

(d) It has 3 lobulations

(e) It does not cast an acoustic shadow

A

(a) It is taller than it is wide

Malignant features on US include spiculation, being taller than wide, angular margins, accoustic shadowing, being markedly hypoechoic, and having microlobula’tions. Benign features include being hyperechoic, having 2-3 lobulations, being ellipsoid in shape and having a thin echogenic capsule. To characterise a lesion as being US benign, it must have no malignant features. If specific benign features are not found then lesion is indeterminate.

19
Q

@#e2 42 A 72 year old man is referred to breast clinic with a unilateral painless breast lump. He has no significant past medical history and is not on any medication. Which of the following statements is true?

(a) Unilateral swelling makes gynaecomastia unlikely

(b) Gynaecomastia is a risk factor for breast cancer

(c) Male breast cancer presents as earlier stage disease than female breast cancer

(d) Male breast cancer is usually oestrogen receptor positive

(e) Microcalcification in male breast cancer is common

A

(d) Male breast cancer is usually oestrogen receptor positive

Male breast cancer represents 0.5% of all breast cancers. Gynaecomastia for which there is a wide differential (including physiological, endocrine, neoplastic and drug related causes) may be unilateral and asymmetrical. Male breast cancer presents at a later stage than female breast cancer and at an older age. It is usually ER positive and unlike in female breast cancer, microcalcification is relatively uncommon.

20
Q

@#e2 10. A 62 year old woman presents with two small masses in her right breast. These are well circumscribed masses in the upper outer quadrant. They show no calcification, no desmoplastic reaction and are not spiculated. They are thought to represent metastases to the breast. The most likely primary in a woman of this age is:

a. Ovarian carcinoma

b. Renal carcinoma

c. Lymphoma

d. Melanoma

e. Bronchial carcinoma

A
  1. c. Lymphoma

Metastases to the breast are infrequent and can be difficult to distinguish from primary breast cancer. The most common primary source is lymphoma, followed by melanoma and then rhabdomyosarcoma.

Most patients who are diagnosed with breast metastases already have a diagnosis of a primary tumour, however, in 25% of cases breast metastases are the first manifestation of malignancy.

21
Q

@#e2 23. A 62 year old woman with Paget’s disease of the nipple is also found to have a 2 cm spiculate mass in the subarealor region of her right breast suspicious for malignancy. The cancer most commonly associated with Paget’s disease of the nipple is:

a. Invasive ductal carcinoma

b. Invasive lobular carcinoma

c. Tubular carcinoma

d. Ductal carcinoma in situ

e. Medullary carcinoma

A
  1. d. Ductal carcinoma in situ

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

22
Q

@#e QUESTION 46
A 52-year-old postmenopausal woman presents for her first screening mammogram. Within the right upper outer quadrant, there is a 2-cm well-defined, oval mass that has dense ‘popcorn’ calcification within it and is surrounded by a thin radiolucent rim. On ultrasound, the mass is well defined and hyperechoic with areas of acoustic shadowing due to contained calcification. What is the most likely diagnosis?

A Fat necrosis

B Fibroadenoma

C Hamartoma

D Oil cyst

E Papilloma

A

B Fibroadenoma

Fibroadenomas may become calcified, particularly after menopause. Classically the calcifications have a coarse ‘popcorn’ appearance; however, they may also appear small and punctate. An oil cyst typically demonstrates eggshell calcification and is the result of fat necrosis.

23
Q

@#e2 QUESTION 49
A 56-year-old woman is found to have a screen-detected breast cancer on her second screening mammogram. Two breast radiologists both agree that there is no evidence of malignancy on the previous mammograms, even in retrospect. Which one of the following statement best describes this interval cancer?

A An interval cancer has a better prognosis, when compared with other screen detected cancers.

B This is known as a Type 1 interval cancer.

C This is known as a Type 2a interval cancer.

D This is known as a Type 2b interval cancer.

E This is known as a Type 3 interval cancer.

A

B This is known as a Type 1 interval cancer.

24
Q

@#e2 QUESTION 61
A 53-year-old woman is invited to attend a mobile breast screening unit for routine screening mammograms. Which one of the following statements is correct regarding the standard mammographic projections (the mediolateral oblique (MLO) and craniocaudal (CC) views)?

A A well-positioned CC view usually contains all the breast tissue.

B A well-positioned MLO view rarely shows the nipple in profile because of the oblique compression.

C On a well-positioned MLO the nipple should be at the lower border of the pectoralis minor.

D The MLO view is taken with the radiograph beam directed from superomedial to inferolateral.

E The pectoralis major muscle is demonstrated at the posterior border of a CC view in approximately 70% of individuals

A

D The MLO view is taken with the radiograph beam directed from superomedial to inferolateral.

25
Q

@#e QUESTION 79
A 28-year-old woman has a strong family history of breast cancer and is referred for an MRI examination of the breasts. Regarding MRI of the breast, which one of the following statements is correct?

A Breast MRI should be performed during the middle of the menstrual cycle to improve sensitivity.

B Malignant lesions tend to show poor enhancement following intravenous contrast, compared with surrounding breast tissue.

C MRI has a high sensitivity and specificity for the detection of invasive breast cancer.

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

E The patient is imaged in a supine position with the breasts placed in adedicated breast coil to improve signal to noise ratio.

A

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

Malignant breast lesions enhance postcontrast; however, normal hormonally active breast tissue can also enhance, particularly during the middle of the menstrual cycle (6th—17th days). In younger patients it may be helpful to repeat the scan earlier or later in the menstrual cycle to improve specificity