RD Aug 2014: Formatted

Question 1

1. Young girl present with dyspnoea, clear CXR, positive D-dimer and S1T3Q3 on ECG. She has a VQ scan what are you likely to see?

a. Multiple small peripheral perfusion defects
b. Multiple large perfusion defects
c. Matched defects
d. Decreased ventilation with normal perfusion
e. Complete loss of unilateral perfusion.

Answer 1

b. Multiple large perfusion defects

Question 2

2. Old guy history of trauma to left hemidiaphragm. CT scan of the chest shows multiple left sided pleural nodules. Most likely diagnosis:
   a. Bronchogenic carcinoma
   b. Splenosis
   c. Mesothelioma

Answer 2

b. Splenosis

Question 3

3. Post lung biopsy a patient has a >50% volume pneumothroax and no midline shift. The patient is well. Next management?
   a. CXR in 4 hours
   b. CXR in 24 hours
   c. Oxygen
   d. Intercostal catheter immediately
   e. Intercostal catheter the next day

Answer 3

d. Intercostal catheter immediately

3. Post lung biopsy a patient has a >50% volume pneumothroax and no midline shift. The patient is well. Next management?
   a. CXR in 4 hours if less than 20%, then probably again the next day,
   b. CXR in 24 hours
   c. Oxygen and this
   d. Intercostal catheter immediately
   e. Intercostal catheter the next day
   The development of tension pneumothorax or collapse greater than 20% should be treated with chest drainage.

Question 4

4. Young guy with a tubular structure parallel the right heart border. Most likely?
   a. PAPVR
   b. Bronchogenic cyst
   c. Lung carcinoma

Answer 4

a. PAPVR

Question 5

5. Man with a cough has a 7mm solid, non-calcified and irregular nodule on NECT. Most appropriate next step?
   a. Biopsy
   b. 12 month follow-up
   c. If stable over 30 months there is a <2% risk of malignancy
   d. If it enhances >35 HU it has a 97% chance of malignancy

Answer 5

5. Man with a cough has a 7mm solid, non-calcified and irregular nodule on NECT. Most appropriate next step?
   a. Biopsy
   b. 12 month follow-up non smoker – 6-12 and 18-24. Smoker 3-6, 9-12, 24.
   c. If stable over 30 months there is a <2% risk of malignancy I think this is most correct.
   d. If it enhances >35 HU it has a 97% chance of malignancy actually > 15HU good sensitivity but not so good specificity. Doubling time usually less than 400 days if malignant (except GG nodules)

*AJL - the answer above does not reflect the most recent fleicshner guidelines (2017).
Solitary solid node
<6mm - low risk (nothing), high risk (optional F/U at 12 months)
6-8mm - low risk and high risk (6-12/12 and 18-24/12 (optional low risk))
>8mm - 3/12 CT, PET or biopsy.

Question 6

6. Colpocephaly is classically associated with:
   a. Holoprosencephaly
   b. Dandy Walker malformation
   c. Agenesis of the corpus callosum
   d. Chiari I
   e. Chiari II

Answer 6

c. Agenesis of the corpus callosum

Question 7

7. Typical appearance of a pilocytic astrocytoma?

a. Hyperdense mass in the cerebellar vermis
b. Hyperdense mass in the cerebellar hemisphere
c. Hypodense mass in the cerebellar vermis
d. Hypodense mass in the cerebellar hemisphere
e. Hypodense mass with an enhancing nodule in the cerebellar hemisphere.

Answer 7

e. Hypodense mass with an enhancing nodule in the cerebellar hemisphere.

Question 8

8. Middle aged patient with progressive lower limb weakness. MRI spine shows abnormal signal from C6-T7. Most likely diagnosis?
   a. Transverse myelitis
   b. Astrocytoma
   c. Ependymoma
   d. Metastasis

Answer 8

*AJL - Favours ependymoma

Difficult to distinguish between ependymoma, astrocytoma and TM on these details.
Astrocytoma spans an average of 4-7 segments (RP) and likely homogeneous signal abnormality.
Ependymoma is more likely in an adult and can have extensive oedema accounting for the long segment change but may be more heterogeneous signal abnormality.
TM is usually acute change.
I think given it’s progressive rather than acute and in an adult perhaps ependymoma is more likely (also favoured by a neuroradiologist).
I think the important thing is that we’ve all learnt something?

Previous answer…
a. Transverse myelitis

Acute transverse myelitis (ATM) is an inflammatory condition affecting both halves of the spinal cord and associated with rapidly progressive motor, sensory, and autonomic dysfunction.It is mostly imaged with MRI, which generally shows a long segment (3-4 segments or more) of T2 increased signal occupying greater than two-thirds of the cross-sectional area of the cord, with variable pattern of enhancement and no diffusion restriction.
Cause:acute infection (most commonly viral)post-infection (ADEM )post-vaccination autoimmune (SLE, MS)systemic malignancy
Treatment and prognosis
Treatment of secondary ATM depends on the underlying cause. No treatment currently exists for idiopathic cases.One-third of patients recover with little or no sequelae, one-third are left with a moderate degree of permanent disability, and one-third are left with severe disabilities 3.
DDX:
- MS
- NMO
- ADEM
- infarct

Question 9

9. Lucent jaw lesion around the root of a tooth but not centred on it. Ill defined and non-expansile. Most likely?
   a. Dentigerous cyst
   b. Ameloblastoma
   c. Odontoma
   d. Metastasis
   e. Radicular cyst

Answer 9

*LW:
Favouring radicular cyst
AJL agree. Ameloblastoma is usually more expansile and erodes roots.
**LJS - unsure. Mets have been chosen for this stem previously. Radicular cyst typically well circumscribed and centered on tooth. Age of pt would be useful for ?mets

Previous answer
Ameloblastoma?

Question 10

10. Facial bone fracture. Pyramidal in shape with base the teeth and apex the nasofrontal suture. Pterygoid plates and medial wall of the orbits involved.
    a. Tripod fracture
    b. Nasal ethmoidal fracture
    c. Lefort 1
    d. Lefort 2
    e. Lefort 3

Answer 10

d. Lefort 2

Question 11

11. Midline chin lesion shows HU of -50 and 10. What is the most likely diagnosis?
    a. Thyroglossal duct cyst
    b. Dermoid
    c. Epidermoid
    d. Laryngoccele

Answer 11

b. Dermoid

Question 12

12. A renal lesion is increased T1, decreased T2 and shows no contrast enhancement. Most likely:
    a. Angiomyolipoma
    b. Proteinaceous cyst
    c. Haemorrhagic cyst
    d. Renal cell carcinoma
    e. Oncocytoma

Answer 12

**LJS - Cyst containing proteinaceous fluid would be T1 high and T2 high
Haemorrhagic cyst with high T1 signal could have variable T2 depending on age of blood. Radiopedia says low T2 in haemorrhagic cyst –> hence favored answer is Haemorrhagic cyst

b. Proteinaceous cyst
Haemorrhagic cyst would be high T1 and T2

Differential for a low T2 renal lesion

• Fat poor AML
• Pap RCC
• Hemorrhagic cyst

Question 13

13. Watery diarrhoea, hypokalaemia and an enhancing lesion in the pancreas, most likely?
    a. Insulinoma
    b. Glucagonoma
    c. Gastrinoma
    d. VIPoma
    e. Somatostatinoma

Answer 13

d. VIPoma

Question 14

14. MRI spine shows a epidural mass that is iso signal to CSF on T1 and T2 and there are vertebral anomalies. Most likely?
    a. Epidermoid
    b. Dermoid
    c. Neurenteric cyst
    d. Arachnoid cyst

Answer 14

*LW:
Neuroenteric systs usually intra dural extramedullary in location, ventrally located, usually thoracic.
Associated with vertebral anomalies (Klippel feil, hemi vertebrae, spina bifida)
Variable signal intensity on T1 and T2.

Arachnoid cyst, can be intra or extra dural, and can be associated with spina bifida, although vertebral anomalies generally uncommmon, following CSF signal intensity on T1 and T2.

so…..
I think incomplete recall, and question stem was aiming towards neuroenteric cyst, given vertebral anomalies component, and axial location may have been incompletely recalled.

c. Neurenteric cyst

Question 15

15. 5cm anal mass with ipsilateral inguinal lymph nodes (number not provided). What is the stage?
    a. I
    b. II
    c. IIIA
    d. IIIB
    e. V

Answer 15

For this question the answer can only be 3a or 3c stage -> so answer is C (3a)

Can’t be 3b (T4NoMo)

Stage:

• 1 - T1No
• 2 - T2N0
• 3a T1-2N1M0
• 3b - T4N0M0
• 3c - T3N1M0 or T4N1M0
• 4 - met

Primary tumor (T)TX: primary tumor cannot be assessed
T0: no evidence of primary tumor
Tis: carcinoma in situ (Bowen disease, high-grade squamous intraepithelial lesion [HSIL], anal intraepithelial neoplasia II-III (AIN II-III)

T1: tumor 2 cm or less in greatest dimension
T2: tumor >2 cm but <5 cm in greatest dimension
T3: tumor >5 cm in greatest dimension
T4: tumor of any size invades adjacent organ(s), e.g. vagina, urethra, bladder (note that direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4)

Regional lymph nodes (N)
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in regional lymph nodes
N1a: metastases in inguinal, mesorectal, and/or internal iliac lymph nodes
N1b: metastases in external iliac lymph nodes
N1c: metastases in external iliac and in inguinal, mesorectal, and/or internal iliac lymph nodes

Distant metastasis (M)
Mx: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasisInvolvement of para-aortic or more distant lymph nodes is considered as M1.

Question 16

16. Young man kicked in the balls. Ultrasound shows diffuse abnormal reflectivity (did not specify high/low or vascularity) and an intact tunica albugenia. Most likely?
    a. Testis fracture
    b. Testis rupture
    c. Haematoma
    d. Torsion

Answer 16

c. Haematoma

16. Young man kicked in the balls. Ultrasound shows diffuse abnormal reflectivity (did not specify high/low or vascularity) and an intact tunica albugenia. Most likely?
    a. Testis fracture linear signal abnormality +/- disruption of the tunica.
    b. Testis rupture must have disrupted tunica albuginea.
    c. Haematoma
    d. Torsion is associated with trauma. Avascular.

Question 17

17. Middle age female has an AXR for follow-up of renal stones. It shows sclerosis of the iliac side of the lower aspect of the sacro-iliac joints. Most likely diagnosis?
    a. Rheumatoid arthritis
    b. Psoriatic arthritis
    c. Ankylosing spondylitits
    d. Osteitis condensans ilii

Answer 17

d. Osteitis condensans ilii
Triangular, bilateral, normal joint space. Lower iliac bones only.
Sacroiliac joint- upper 1/3 fibrocartilaginous- lower 2/3 synovial

Question 18

20. Pain in forefoot. Hypoechogenic structure in the subcutaneous fat overlying the 2nd, 3rd and 4th metatarsal heads. Most likely?
    a. Morton’s neuroma
    b. Intermetatarsal bursitis
    c. MTP synovitis
    d. Adventitial bursitis
    e. Stress fracture

Answer 18

d. Adventitial bursitis. Only option that can be subcutaneous

ADventitial bursitis- occurs are area of friction- formed from coalescing fluid pockets which becomes well cirucmscribed with time. - superficial

Question 19

21. 15 year old boy fell off skateboard. X-ray of the wrist is least likely to show?
    a. Soft tissue swelling over the dorsum of the wrist
    b. Scaphoid fracture
    c. Ulnar styloid fracture
    d. Distal radius fracture - ?may have been epiphyseal fracture
    e. Dorsal triquetrial fracture

Answer 19

dorsal triquetrum fracture - less common then scaphoid

Question 20

22. Vertebral end plates changes low T1 and high T2. Which could it not represent?
    a. Ankylosing spondylitis
    b. Modic type II changes
    c. Pyogenic discitis

Answer 20

b. Modic type II changes

Question 21

23. Meconium aspiration CXR features:
    a. Hyperinflation of the lung
    b. Bronchopulmonary dysplasia
    c. Consolidation

Answer 21

a. Hyperinflation of the lung

Question 22

24. Newborn immigrant child without any antenatal scanning is cyanosed and collapsed. He is resuscitated and CXR shows increased pulmonary vascularity. The most likely condition is:

a. Tetralogy of Fallot
b. Transposition of the great arteries
c. Tricuspid atresia
d. Ventricular septal defect
e. Consolidation

Answer 22

b. Transposition of the great arteries

Question 23

25. CXR of a young patient shows hyperlucent left lung. CT scan shows complete tracheal rings and absent right pulmonary artery. Most likely?
    a. Bronchial atresia
    b. Pulmonary venolobar syndrome
    c. Pulmonary agenesis
    d. Swyer-James McLeod syndrome
    e. Foreign body

Answer 23

*LW:
Complete tracheal rings are a rare, isolated tracheal or tracheobronchial anomaly resulting from abnormal cartilage growth, forming a complete ring and often causing airway stenosis.
Associated with:
- aberrant left pulmonary artery (pulmonary artery sling) in 35-50%
- >75% have associated oesophageal, cardiac, skeletal, and/or genitourinary anomalies
- congenital heart disease in 25%
- trisomy 21

Pulmonary aplasia: has ipsilateral absence of pulmonary artery, with contralateral hyper inflation. No mention about complete tracheal rings.

c. Pulmonary agenesis because of the absent PA? Not sure though.

Question 24

26. Obese female who is infertile and has previous ectopic pregnancy. Pelvic ultrasound shows a multilocular cystic mass. What is the most likely cause of her infertility?
    a. Mucinous cystadenoma
    b. Serous cystadenoma
    c. Dermoid cyst
    d. Tuboovarian abscess
    e. Polycystic ovaries

Answer 24

e. Polycystic ovaries

*LW:
TOA could be also be included within this…
Stem same multilocular cystic mass (i.e. singular, PCOS usually bilateral), however obesity associated with PCOS.
Although there is stated ectopic risk with PCOS (but not in radiopedia or STATDx), ectopic more associated with PID - TOA….

So hopefully incomplete recall, as another discriminator between the two options of TOA and PCOS would be helpful…..but I would favour TOA

**LJS - agree with LW

Question 25

27. Haemorrhagic appearing 5.6cm ovarian cyst. Appropriate follow-up? a. Gynaecological review b. 4 week follow-up in the same stage of the cycle c. 6-12 week follow-up in a different stage of the cycle d. No follow-up

Answer 25

c. 6-12 week follow-up in a different stage of the cycle Depends on age of the patient. If pre menopausal 6-12 week follow-up. If peri-menopausal < 5cm, f/u, > 5cm MRI or surgery If post-menopausal, any haemorrhagic cyst needs f/u or surgery ORADS: Premenopausal >5 <10cm follow up 8-12 weeks (if persists gynae) Post menopausal gynae

Question 26

``` 28. Echogenic bowel. ?not associated- can't remember the wording. A. Cystic fibrosis B. Infection C. T16 D. T21 ```

Answer 26

C. T16 if question is which is false

Question 27

29. 20 week scan shows mass next to umbilical cord. The cord inserts onto the mass. Diagnosis? a. Gastroschisis b. Physiological bowel herniation c. Omphalocele d. Pseudoomphalocele

Answer 27

c. Omphalocele

Question 28

30. A scan shows vasa previa. Your boss asks you what is the most common cause of vasa previa? a. Circumvallate placenta b. Low lying placenta c. Succenturiate lobe d. Velamentous cord insertion

Answer 28

d. Velamentous cord insertion

Question 29

31. Bicornuate uterus and single absent kidney. This is a malformation of? a. Wollfian duct b. Mullerian duct c. Mesonephric ridge

Answer 29

b. Mullerian duct

Question 30

32. Which is most likely to be a benign breast mass on USS? a. Hypoechoic rounded mass with a lip that extends into a dilated duct b. Hypoechoic something... c. Hypoechoic something or rather... d. Hyperechoic mass

Answer 30

d. Hyperechoic mass ie fat

Question 31

33. Mammo shows a mass that has long spicules (>4cm) and has a lucent centre. Most likely? a. Radial scar b. Ductal carcinoma c. Lobular carcinoma d. DCIS e. LCIS

Answer 31

a. Radial scar

Question 32

34. What is the appearance of metastatic carcinoid in the breast? a. Calcified b. Lobulated c. Microlobulated d. Spiculated e. Well defined?

Answer 32

e. Well defined | https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC2993447/

Question 33

35. Delay between injecting and scanning and length of scanning for a MAG-3 study. a. Inject and scan immediately for 30 minutes b. Inject and scan immediately for 60 minutes c. Inject and scan 4 hours later for 30 minutes d. Inject and scan 4 hours later for 60 minutes e. Inject 24 hours beforehand and scan for 30 minutes Delays from injection might not be exact but you get the idea.

Answer 33

a. Inject and scan immediately for 30 minutes 60s flow study and then 5min for 25min

Question 34

36. Delay between injecting and scanning and length of scanning for a pertechnetate study. a. Inject and scan immediately for 30 minutes b. Inject and scan immediately for 60 minutes c. Inject and scan 4 hours later for 30 minutes d. Inject and scan 4 hours later for 60 minutes e. Inject 24 hours beforehand and scan for 30 minutes Delays from injection might not be exact but you get the idea.

Answer 34

a. Inject and scan immediately for 30 minutes **LJS - I wonder if the correct answer was inject and scan after 30 mins, rather than immediately for 30 mins *RY i.e. Meckels scan. Quick google of patient info describes injection and immediate imaging for 30mins. Aim to see focal uptake at same time as stomach, which intensifies over time, non-peristaltic.

Question 35

37. 5 year old has PET scan. What shows physiological uptake? a. Thymus b. Pancreas c. Adrenal gland d. Bone marrow

Answer 35

a. Thymus noted. Bone marrow also seen but less intense than liver

Question 36

38. Differences between I-123 and I-131. Repeat question. a. I-131 is cheaper b. Radiation burden is the same

Answer 36

a. I-131 is cheaper http://am2015.aace.com/presentations/Friday/F21/NuclearMedicineImagingOfThyroidCancer.pdfThese results show improved quality of imaging with 50 MBq (1.5 mCi) I-123 compared with 111 MBq (3 mCi) I-131 for whole-body scanning in patients with differentiated thyroid cancer undergoing thyroid remnant ablation. I-123 imaging may prove to be the preferred procedure in such settings in patients with differentiated thyroid cancer.

Question 37

39. Repeat question of VQ scan. Which is true? (no option for thyroid) a. 90% of VQ mismatches will clear within 12 months b. Total unilateral perfusion defect is more commonly caused by a bronchogenic carcinoma than a PE.

Answer 37

b. Total unilateral perfusion defect is more commonly caused by a bronchogenic carcinoma than a PE.

Question 38

40. Bone scan question, which is true? a. MDP and something b. M 7 1/2 and something c. 4 phase scan is flow, blood pool, 3 hour and 8 hour.

Answer 38

MDP disphosphonate, taken up by osteoblasts Probably 4 Detects extra cellular fluid expansion, bone scans is looking at bone turnover. Image every 5 seconds for 60 seconds (flow), 5mins (pool), and 2-4 hours (delayed). Late delayed is 24 hours.

Question 39

41. What is the mass number of Tc-99m? a. 43 b. 56 c. 99 d. 235

Answer 39

c. 99 | Atomic number is 43

Question 40

42. Tc-98 and Tc-99m which number is the same? a. Protons b. Neutrons c. Atomic number d. Atomic mass

Answer 40

a. Protons | c. Atomic number same as number of protons

Question 41

43. Which is the correct test? Can’t quite remember the options but it was repeat a. I-123 MIBG is used for diagnosis of adrenocortical carcinoma b. Oncoscint is used to diagnose ovarian caner c. I-131 for medullary thyroid cancer d . ...

Answer 41

b. Oncoscint is used to diagnose ovarian caner Indium-111 OncoScint is a radiopharmaceutical used in SPECT imaging. It is a labelled monoclonal antibody that is directed against TAG-72 (tumour associated antigen) in - colorectal- ovarian

Question 42

44. PET can differentiate between? a. Uterine carcinoma and normal physiological premenstrual uterus b. Tumour recurrence and post surgical change 3 years later c. Hibernoma and something

Answer 42

b. Tumour recurrence and post surgical change 3 years later 44. PET can differentiate between? a. Uterine carcinoma and normal physiological premenstrual uterus can be difficult if small. MRI preferred for primary staging b. Tumour recurrence and post surgical change 3 years later c. Hibernoma and something tumour of brown fat (therefore PET avid) Hibernoma- brownt fat lipoma- more dense then normal lipoma but less dense then muscle

Question 43

``` 47. Radiation dose of a bone scan compared to a CXR A. 5 B. 50 C. 200 D. 1000 E. 2000 ```

Answer 43

C. 200 (0.02 – 5 ish) i.e 250 CXR equivalent

Question 44

``` 48. Risk of a solid fatal cancer after 10 mSv exposure? A. 1:100 B. 1:1,000 C. 1:10,000 D. 1:100,000 ```

Answer 44

B. 1:1,000