RD 2015 Formatted

Question 1

1. Ultrasound findings in renal transplant

a. High RI is specific for rejection
b. Reverse end diastolic flow suggestive of renal vein thrombosis
c. Lymphocele collects radiotracers
d. Lymphocele occcus in the first two days post transplant.
e. PSV 1m/s is consistent with renal artery stenosis

Answer 1

b. Reverse end diastolic flow suggestive of renal vein thrombosis

• *LJS - agree. But lymphoceles also collect tracer in lymphoscintigraphy
  https: //www.ajronline.org/doi/pdf/10.2214/ajr.178.2.1780405
• *LJS - further review - don’t collect renal tracer, which is what the question is asking. Lymphoceles generally collect tracer during lymphoscintigraphy i.e. administered to to lymphatic system directly. Agree with LW below
• LW: agree with LJS comment, but not on routine Nukes… so would need to check wording with regards to Nuke stem, if if general renal scintography then this is generally considered to be FALSE.

Question 2

2. 25 year old male, visitor to Sydney. Presents with dry cough and fever. Has been unwell for previous several months. CXR shows bilateral perihilar interstitial opacity and a 3 cm thin wall cyst in the right lower lobe. Most likely
   a. Staphylococcus
   b. Mycoplasma
   c. Pneumocystis
   d. TB

Answer 2

c. Pneumocystis

Question 3

3. Routine pre CABG CXR. You see an spiculated 2cm mass in the lung. What should you do as per RANZCR guidelines on Communication.
   a. Call the referer
   b. Leave a message with the cardiology clinic
   c. Send an email to cardiology clinic and cc referrer.

Answer 3

a. Call the referer

Question 4

4. Young girl with seizure, CT showed calcific right frontal mass. Cyst with calcified mural nodule. Remodeling of the skull. Most likely
   a. Ganglioglioma
   b. Oligodendroglioma
   c. Astrocytoma

Answer 4

a. Ganglioglioma 35% calcify, commonly cause seizures

Question 5

5. Regarding T99m thyroid scan, true option
   a. Low up take in initial phases of subacute thyroiditis
   b. Low background uptake in toxic adenoma
   c. Decreased up take about TSH induced hyperthyroidism
   d. Increased up take in factitious thyroiditis

Answer 5

*LW:
Sub acute thyroiditis, likely referring to Sub acute De Quervain granulomatous thyroiditis, which shows low uptake thyroid scans.

Functioning thryoid adenoma are hot on uptake scan with colder background parenchyma.

Previously:
a. Low up take in initial phases of subacute thyroiditis

Subacute thyroiditis- measle mumps coxackie- hypothyroidism- self limiting- U/S: hypo echoic, hypo vascular, small or large thyroid- Tc 99m : decreased uptake
but you can also have low background uptake in toxic adenoma?? ummm

Question 6

6. Regarding oncology imaging, PET is able to distinguish
   a. Hibernoma from high grade liposarcoma
   b. Residual disease from post-op change in immediate postop period
   c. Metastatic disease from inflammatory disease
   d. Benign and malignant phaeochromocytoma

Answer 6

d. Benign and malignant phaeochromocytoma chang et al cancer imaging 2016.

Question 7

7. During liver biopsy, the patient became unwell, blood pressure drop to 75/58mmHg, heart rate 58. You should
   a. Atropine
   b. IM adrenaline
   c. IV adrenaline

Answer 7

a. Atropine

also put their feet up (probably vas-vagal)

Question 8

8. Young woman, 8-10 weeks post LMP. Presents with lower abdominal pain. US shows left adnexal mass with focal increase vascularity. TRACE of free fluid. (no mention of bHCG or intrauterine sac)
   a. Unruptured ectopic
   b. Ruptured ectopic
   c. Corpus luteum

Answer 8

a. Unruptured ectopic
8-10 weeks post LMP so assume pregnant

*AJL - Above is probably the answer ‘they’ are looking for however could also be a ruptured corpus luteum. Both have a ‘ring of fire’ around them, free fluid and cause pain. Need more info to answer this question.

Question 9

9. 36 year old woman undergoing IVF. US showed right sided ovarian mass consists of multiple anechoic cysts. Normal left ovary. Most likely
   a. Ovarian hyperstimulation
   b. Tubo-ovarian abscess
   c. Polycystic ovarian disease
   .d. Normal ovarian stimulation.

Answer 9

*AJL - I favour normal ovarian stimulation.
If it was hyperstimulation then they would need to say enlarged, free fluid etc. TOA doesn’t have this appearance (simple cysts). PCOS is bilateral AND the question say undergoing IVF rather than pre-IVF. It’s a bit of a weird question though, especially with only one ovary doing anything…

*LW: unsure of this….
If assume undergoing IVF, means recieving IVF ovulatory drugs, this would be a bilateral appearance, which doesn’t make sense if left ovary normal.
Ovarian hyperstimulation and PCOS are also bilateral processes.
Options are thus;
- Normal ovarian stimulation, in absence of full blown IVF drugs (unlikely the other ovary didn’t respond at all to drugs). Maybe in pre IVF work up this may be a possibility (i’m now stretching the imagination of the question)
- Tubo ovarian abscess: although it appears as a mass, multiple anechoic cysts is not classic…..

Previous answer:
d. Normal ovarian stimulation.

9. 36 year old woman undergoing IVF. US showed right sided ovarian mass consists of multiple anechoic cysts. Normal left ovary. Most likely
   a. Ovarian hyperstimulation bilateral, ascites, pleural effusion.
   b. Tubo-ovarian abscess assume if for IVF that have had the swabs/Rx for PID so unlikely.
   c. Polycystic ovarian disease. Bilateral.
   d. Normal ovarian stimulation.

Question 10

10. Young men with destructive sacral mass. Rings and arc calcification. Most likely
    a. Chondrosarcoma
    b. Chordoma
    c. GCT

Answer 10

a. Chondrosarcoma

Question 11

11. Presents with fever and pain. Heterogeneous mass in the retroperitoneum, ranges from -60HU to 60HU. Envelops the kidney and adrenal glands.
    a. Liposarcoma
    b. Ruptured xanthogranulomatous pyelonephritis
    c. Angiomyolipoma

Answer 11

a. Liposarcoma

Question 12

12. Beta decay, which is correct
    a. Too many electrons in the outer ring
    b. Too many protons
    c. Too many neutrons
    d. Emits xray
    e. Emits gamma ray

Answer 12

c. Too many neutrons beta minus
b. Too many protons beta plus note:

Alpha decay
- the process in which an alpha particle (containing two neutrons and two protons) is ejected from the nucleus.
- An alpha particle is identical to the nucleus of a helium atom.
RD226 -> Rn 222 + helium

Beta decay
- type of radio-active decay
- depends on how many protons and neutrons
If too many neutrons (beta minus decay)
- neutron -> protons + B - (electron)
If too many protons (beta positive decay)- protons -> neutrons + B+ (positron)

Question 13

13. Women with breast lesion, findings on combined imaging with mammography and US consistent with Category 4 SUSPICIOUS. Biopsy result comes back as ‘fibroglandular tissue’, no malignancy found. What is the most appropriate next step
    a. MDT discussion
    b. Re-biopsy
    c. Reassure patient
    d. Repeat mamm and US in 6 months

Answer 13

a. MDT discussion then rebiopsy probably

*AJL - agree with above. Though it’s tricky as the classic line is ‘needs repeat biopsy.’
In reality these go for discussion in MDT (or results are given in MDT) for radiology-pathology correlation and then go for surgical excision. I can’t find anything which specifically says rebiopsy before MDT discussion. (Let me know if you have found something else or think something else.)
Paper from 2016 lays it out: For Radiologically suspicious but pathologically benign lesions it says ‘The findings are discussed with referring physician and pathologist, a repeat biopsy in form of open surgical biopsy should be done.’

(https://www.alliedacademies.org/articles/concordant-versus-discordant-ultrasound-guided-breast-biopsy-results-how-they-effect-patient-management.pdf)

Question 14

14. What is not a paraneoplastic syndrome associated with RCC?
    a. Limbic encephalitis
    b. Feminization
    c. Neutrophilia
    d. Hypercalcemia
    e. Liver dysfunction
    f. Limbic encephalitis

Answer 14

c. Neutrophilia

Around 25% of RCC patients will develop a paraneoplastic syndrome
19-21:- hypercalcemia (20%)
- hypertension (20%)
- polycythemia: from erythropoietin secretion (~5%)
- Stauffer syndrome: hepatic dysfunction not related to metastases
- feminisation
- limbic encephalitis

Question 15

16. Diabetes insipidus, what is not a cause
    a. TB meningitis
    b. Trauma to skull
    c. Desmopressin toxicity
    d. Suprasellar tumor

Answer 15

c. Desmopressin toxicity

Desmoresspin = ADH - used in treating DI and nocturnal diuresis

Question 16

17. Herniation of the brain, most likely

a. Uncinate herniation can result in pontine haemorrhage
b. Uncinate haemorrhage can result in 4th CN compression
c. Something about cingulate gyrus in parasaggital herniation

Answer 16

a. Uncinate herniation can result in pontine haemorrhage

Question 17

18. Regarding radial scar, most accurate
    a. Looks like normal parenchyma on DCE-MR unless there is associated malignancy
    b. Looks like normal parenchyma on US unless there is a associated malignancy
    c. Architectural distorion with central density
    d. Artchitectural distortion
    e. Focal assymetry

Answer 17

d. Artchitectural distortion

Question 18

20. Mammographic appearance of plasma cell mastitis
    a. Curvilinear calcification
    b. Dense linear calcification
    c. Amorphous calcification

Answer 18

b. Dense linear calcification

Question 19

21. The rate limiting factor in FSE imaging with T3 MRI scanner
    a. TR
    b. TE
    c. TI
    d. SAR

Answer 19

d. SAR I think

Specific absorption rate

Question 20

note improve MRI SNR by

Answer 20

note improve SNR by

• increased FOV
• increased voxel
• increase slice thickness
• increase magnetic field strength
• decrease matrix size

Question 21

22. Gastroschisis, most accurate
    a. Defect is small 2 – 4cm
    b. Liver herniates in 20 – 40%
    c. Associated with chromosomal abnormality

Answer 21

a. Defect is small 2 – 4cm

Question 22

23. 24 week scan shows hydrops, echogenic left intrathoracic mass. Stomach in the abdomen. Prominent vascular supply from below the diaphragm. Most likely
    a. Neuroblastoma
    b. Sequestration
    c. CPAM

Answer 22

b. Sequestration

Question 23

24. Middle age male with fever and reduced mentation. Previously well. MRI showed multiple small T2 hyperintense lesion in the thalami bilaterally, variable diffusion restriction. Basilar leptomeningeal enhancement. Most likely
    a. Neurocystocercosis
    b. Metastasis
    c. Lymphoma
    d. Astrocytoma
    e. Cryptococcus

Answer 23

e. Cryptococcus

Question 24

25. Old lady with left leg and arm weakness. MR showed enhancing intramedullary lesion in left side of C6 and central intramedullary lesion in T4. Most likely
    a. Mets
    b. Hemangioblastoma
    c. Transverse myelitis
    d. Astrocytoma

Answer 24

• LW:
  a. Mets: although rare, this is probably the best answer.
  b. Hemangioblastoma: FALSE: in the absence of VHL - vast majority are single lesions.
  c. Transverse myelitis: FALSE: younger age presentation, long segment lesions and usually span > 2/3 cord width.
  d. Astrocytoma: FALSE: usually present as young adult, long segments.

Question 25

26. Young man on anabolic steroid presents with jaundice. Echogenic liver parenchyma. No gall stones. Normal bile duct calibre. Which is the most likely a. Cholestasis b. Steatosis c. Steatohepatitis

Answer 25

* AJL favours c. Steatohepatitis a. Cholestasis

Question 26

27. Placental anomaly with highest association with placenta previa a. Velamentus cord insertion b. Biloabe placenta c. Succinturate placenta d. Circumvallate placenta e. planceta accrete spectrum

Answer 26

should be placenta accreta/increta spectrum

Question 27

28. 25 year old man with history of heavy alcohol use. Presents with pain on swallowing. Barium swallow shows nodular mucosal irregularity in distal oesophagus. Most likely a. Reflux oesophagitis b. Varices c. Caustic oesophagitis d. Barrett’s oesophagus

Answer 27

*LW: Would probably favour Reflux oesophagitis, given age, while varices within DDx given stem states heavy alcohol use....but hopeful for discriminating word of longitudinal filling defect. **LJS - agree with LW Previous answer d. Barrett’s oesophagus 28. 25 year old man with history of heavy alcohol use. Presents with pain on swallowing. Barium swallow shows nodular mucosal irregularity in distal oesophagus. Most likely a. Reflux oesophagitis potentially b. Varices too young for cirrhosis c. Caustic oesophagitis d. Barrett’s oesophagus

Question 28

29. Young girl presents with hypertension. Ostial renal artery stenosis. Most likely a. FMD b. Takayasu c. Polyarteritis nodosa d. Giant cell arteritis

Answer 28

*LW: Favoured answer is Takayasu. **LJS - agree, Takayasu can affect abdominal aorta and branch vessels, incl renal arteries. a. FMD: FALSE - mid - distal sting of peals sign. b. Takayasu: Possible c. Polyarteritis nodosa: renal micro aneurysms. d. Giant cell arteritis: FALSE, usually elderly, and ECA preference. Previous answer: a. FMD

Question 29

30. Intra-abdominal manifestation in AIDS, most correct a. Giant ulcers are associated with herpes oesophagitis b. Colon is the most common site of infection. c. Crytosporidium (not sure if its this or Crytococcus) infection results in ulceration in large bowel. d. Small bowel mass is more likely to be Kaposi sarcoma than lymphoma

Answer 29

b. Colon is the most common site of infection. Seems likely 30. Intra-abdominal manifestation in AIDS, most correct a. Giant ulcers are associated with herpes oesophagitis - no, small punched out ulcers b. Colon is the most common site of infection. Seems likely c. Crytosporidium (not sure if its this or Crytococcus) infection results in ulceration in large bowel. Minimal histological change according to Robbins. d. Small bowel mass is more likely to be Kaposi sarcoma than lymphoma - not sure

Question 30

31. 1 day old neonate with bilous vomiting. Barium study showed DJ flexure left of midline, at level of pylorus. Very slow passage of contrast. Most likely a. Ileal atresia b. Malrotation c. Hirschsrpungs d. Anal atresia e. Meconium ileus

Answer 30

a. Ileal atresia

Question 31

32. Echogenic bowel association a. T13 b. CF c. T18

Answer 31

``` b. CF echogenic bowel - CF - trisomy 21 - infection (CMV) ```

Question 32

33. T99m is good for imaging because a. t1/2 of 8 hours b. Decay product not radioactive c. Photons goes through patient’s body d. Emitted photon between 50eV and 500eV. e. Emits gamma and beta

Answer 32

c. Photons goes through patient’s body *AJL: While I agree with the above for this question, additional points below... Half life = 6 hrs Photon (gamma ray) is 140keV These two features are usually the ones that make it good for imaging (just in case this is a bad recall or the question gets re-worded)

Question 33

34. Phaeochromocytoma imaging a. MRI specific for extra-adrenal phaeo b. No signal loss on out-of-phase imaging c. PET can distinguish benign from malignant d. In111 pertechnetate is more sensitive than I 131 MIBG

Answer 33

* LW: C - PET can distinguish benign from malignant. 34. Phaeochromocytoma imaging a. MRI specific for extra-adrenal phaeo - true (*AJL very sensitive but not super specific) b. No signal loss on out-of-phase imaging: False: Pheo May demonstrate signal loss on opposed-phase chemical shift imaging due to presence of intracellular fat Can be confused with adrenal adenoma (STATDx) c. PET can distinguish benign from malignant: Probably true: FDG uptake is found in greater percentage of malignant than benign PHs https: //pubs.rsna.org/doi/10.1148/rg.275065729 * AJL - Statdx says Metastatic spread is only reliable criterion for diagnosis of malignant Phaeo. Dotatate PET has the highest detection rate of metastatic lesions therefore this is probably the most correct. d. In111 pertechnetate is more sensitive than I 131 MIBG: FALSE - MIBG best * *LJS - Indium-111 pentetreotide (not pertechnetate) can be used for pheo but not first line. Is more sensitive for malignant pheo than MIBG but other way around for benign https: //pubs.rsna.org/doi/10.1148/rg.275065729

Question 34

35. Regarding pathophysiology of NSF a. Chelated gadolinium leaked into tissue causing inflammation and fibroblast proliferation b. Free gadolinium leaked into tissue causing inflammation and fibroblast proliferation c. Chelating agents leaked into tissue causing inflammation and fibroblast proliferation

Answer 34

b. Free gadolinium leaked into tissue causing inflammation and fibroblast proliferation

Question 35

36. Woman with dysphagia. Posterior impression at C6. Most likely a. Cricopharyngeus achalasia b. Zenkers c. Achalasia

Answer 35

a. Cricopharyngeus achalasia

Question 36

37. Young man with painless neck lump. CT showed cystic lesion immediately deep to parotid gland with an extension into parapharyngeal space. Most likely a. 1st branchial cyst b. 2nd c. 3rd

Answer 36

It is 2nd! - i can only find articles on 2nd going into the parapharyngeal space (GL)2nd can extend medially to pharyngeal mucosal space

Question 37

38. Young women with night sweat. Single neck mass at level of thyroid, adjacent to carotid sheath structures. Density same as muscle on postcontrast CT. a. Metastatic melanoma b. Stage I Hodgkins c. Carotid body tumor d. Metastatic papillary thyroid carcinoma e. Metastatic follicular thyroid carcinoma

Answer 37

b. Stage I Hodgkins

Question 38

39. Patient with nasopharyngeal carcinoma. Left facial pain and numbness. Most likely a. Perineural spread in trigeminal n. b. Perineural spread in facial n. c. Obstruction of Eustachian tube, otitis media and referred pain.

Answer 38

a. Perineural spread in trigeminal n.

Question 39

40. Old man with obstructive nasal symptoms. CT showed mass centred at cribiform plate. Extends superiorly into anterior cranial fossa, inferiorly into nasal cavity. Enhances post contrast. Most likely a. Ethesioneuroblastoma b. Lymphoma c. SCC

Answer 39

a. Ethesioneuroblastoma

Question 40

41. Which of the following lymphoma is not usually treated with curative intent? a. Follicular lymphoma b. Burkitt’s lymphoma c. ALL

Answer 40

a. Follicular lymphoma

Question 41

42. Old man with left knee pain. No other joint pain. Clinical exams shows reduced range of motion and warm knee. Xray shows soft tissue swelling, symmetrical joint space loss and erosions. Most likely a. CPPD b. Infection c. Seronegative arthropathy d. Gout e. OA

Answer 41

Previous answer: a. CPPD **LJS - disagree. CPPD looks like OA but in joints atypical for OA. Agree with LW below - infection needs considered first. Especially since no other joint pain (*LW: confusingly radiopiedia states classic presentation of acute CPPD arthritis, commonly involves the knee with pain, swelling, erythema and warmth - i.e same as above case, however, patellofemoral mcuh more common than medial or lateral compartments, and although not required for Dx, would assume stem would include chondrocalcinosis in stem, if wanted CPPD) . Can have erosions (1/8 of cases show erosions). ? infection - can cause joint space narrowing due to cartilage destruction and marginal erosions. *LW - I think infection requires exclusion in first instance in this stem.

Question 42

43. SCC of the lung, what is true a. More peripheral than central b. More common in women c. Commonly calcified d. anyone remembered the true option..??

Answer 42

d. anyone remembered the true option..??

Question 43

44. Pneumococcal meningitis in a child. Subsequently develop profound senosineural hearing loss. Nodular calcifcation in the labyrinth a. Labyrinthitis ossificans

Answer 43

a. Labyrinthitis ossificans

Question 44

45. Regarding pneumocystis pneumonia, | a. Can be positive on T99m lung scan before CXR.

Answer 44

yes

Question 45

47. Old guy with chronic shortness of breath. Used to work in tunnel construction. Presents with small lung nodules a. Silicosis

Answer 45

yes

Question 46

48. Old guy with painful retroareolar painful lump. Mamm shows retroareolar lucent mass with thin capsule. Hyperechoic on US. a. Lipoma b. Hamartoma c. Gynecomastia d. Pseudogynecomastia

Answer 46

a. Lipoma

Question 47

51. Bladder tumor staging, which is the best for depth of invasion a. T1 fat sat b. T1 without fat sat c. T2 d. Post contrast

Answer 47

c. T2 MRI is superior to other modalities in locally staging the tumour and is in some instances able to distinguish T1 from T2 tumours on T2 weighted images.

Question 48

52. NAI, what is true a. Nuc Med scan is good for metaphyseal fractures b. Spiral long bone fractures are suspicious c. Buckle handle metaphyseal fractures are due to twisting injury d. Posterior rib fractures are more common than anterior. e. Scaphoid fracture is characteristic

Answer 48

d. Posterior rib fractures are more common than anterior. 52. NAI, what is true a. Nuc Med scan is good for metaphyseal fractures -good sensitivity b. Spiral long bone fractures are suspicious - if non-ambulant c. Buckle handle metaphyseal fractures are due to twisting injury - can be d. Posterior rib fractures are more common than anterior. e. Scaphoid fracture is characteristic

Question 49

53. Regarding renal scintigraphy, what is most accurate a. DTPA 100% renal filtration b. MAG3 is used for renal infarcts c. MAG3 is used to calculate GFR d. Consist of blood pool, parenchymal and excretion phase

Answer 49

a. DTPA 100% renal filtration

Question 50

54. Regarding infection in Charcot joint, most accurate a. sinus to skin b. joint effusion c. enhancement

Answer 50

a. sinus to skin

Question 51

55. Whats a marker for benign entity on breast US a. Taller than wide b. Hypoechogenicity c. Hyperechogeniticy d. Heterogeneity e. Posterior shadowing.

Answer 51

c. Hyperechogeniticy

Question 52

56. Young man with head injury months ago. Whats the best sequence to detect DAI？ a. Spoiled 3D gradient echo. b. Gradient echo c. DWI d. T2 e. FLAIR

Answer 52

b. Gradient echo unless SWI is an option