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2007 ACR Diagnostic Radiology In-Training Exam Rationales

Section III Genitourinary Radiology 47. You are shown a CT image of the pelvis in a patient with vaginal carcinoma (Figure 1). What is the MOST LIKELY diagnosis for the bladder finding? A. Simple ureterocele B. Ectopic ureterocele C. Pseudoureterocele D. Fungus ball RATIONALES: A. Incorrect. The mass invades from the vagina through the posterior bladder. A simple ureterocele is a nonmalignant focal dilatation of the submucosal distal ureter. B. Incorrect. The mass invades from the vagina through the posterior bladder. An ectopic ureterocele is a nonmalignant focal dilatation of the submucosal distal Ectopic ureter. C. Correct. Looks like a ureterocele, but in this case is the result of a malignancy invading the bladder trigone. D. Incorrect. Mobile, often multiple, laminated, gas-containing filling defects within the bladder. REFERENCES: Dunnick et. Al. Textbook of Uroradiology 3rd ed. Lippincott, Williams & Wilkins,Philadelphia, PA. 2001.


48. You are shown two images from a contrast-enhanced CT scan of the abdomen (Figures 2A and 2B). What is the MOST LIKELY diagnosis? A. Angiomyolipoma B. Renal cell carcinoma C. Oncocytoma D. Multilocular cystic nephroma RATIONALES: A. Correct. The mass is nearly completely fat density when compared to subcutaneous fat. B. Incorrect. Although renal cell carcinoma more commonly extends into the IVC and can contain a small amount of fat, this mass has no significant soft tissue component. C. Incorrect. Oncocytomas are not predominantly fat density and can have a central scar. D. Incorrect. These masses are cystic and commonly extend into the renal pelvis and not the IVC. REFERENCES: Dunnick et. Al. Textbook of Uroradiology 3rd ed. Lippincott, Williams & Wilkins,Philadelphia, PA. 2001.


49. You are shown three images from a CT scan focusing on the right adrenal gland. The images include a non-contrast CT scan (Figure 3A), early enhanced phase (Figure 3B), and delayed enhanced phase (Figure 3C). What is the BEST diagnosis? A. Lipid rich adenoma B. Lipid poor adenoma C. Myelolipoma D. Indeterminate nodule RATIONALES: A. Incorrect. Diagnosis of a lipid rich adrenal adenoma is made on the non-

contrast CT with HU < 10. The HU in this case on the non-contrast phase is 27.

B. Incorrect. Lipid poor adenoma can be diagnosed if % washout is > 60%. In this case the calculated % washout is 53%. Additionally, the early enhanced phase image shows some heterogeneity of the lesion and washout calculations should be done only on homogeneous lesions.

C. Incorrect. Myelolipoma is diagnosed by identifying macroscopic fat within the mass

D. Correct. This nodule is indeterminant by CT washout criteria. A malignant neoplasm can’t be excluded and followup or biopsy would be indicated. Additionally, close inspection of the images shows there is heterogeneity in this mass rendering washout evaluation of questionable value. Approximately 3 years after this study, the patient was found to have a very large adrenocortical carcinoma.

References: Dunnick NR, Korobkin M. Imaging of Adrenal Incidentalomas: Current Status. AJR: 179. September 2002. 559-568.


50. You are shown two CT images of the same patient, one of the chest and one of the mid-abdomen (Figures 4A and 4B). Which one of the following is the MOST LIKELY diagnosis? A. Autosomal dominant polycystic kidney disease (APCD) B. Acquired cystic renal disease C. Tuberous sclerosis D. von Hippel-Lindau disease RATIONALES: A. Incorrect. The kidneys are often enlarged in adult polycystic kidney disease, but the enlargement is due to innumerable renal cysts, not fatty tumors. The masses in this case contain macroscopic fat as evidenced by the HU number of -97 consistent with angiomyolipomas, not cysts. Additionally, there is no association of APCD with lung cysts. B. Incorrect. Acquired cystic renal disease is a condition affecting patients with renal failure. The kidneys are typically small, not enlarged, as in this case. Multiple cysts develop often complicated by hemorrhage and calcification. Additionally, there is increased risk for developing renal cell carcinomas that present as solid masses. C. Correct. The renal masses in this case have macroscopic fat consistent with angiomyolipomas. 80% of patients with tuberous sclerosis have renal angiomyolipomas and 1% of patients with tuberous sclerosis have lung cysts indistinguishable from those found in lymphangiomyomatosis. D. Incorrect. Renal cysts and renal cell carcinomas develop in patients with VHL, but there is no association with angiomyolipomas. Additionally, there is no association of VHL with lung cysts. References: Dunnick NR et al: Textbook of Uroradiology, 3rd Ed. Philadelphia. Lippincott, Williams & Wilkins. 109-111, 114, 116. 2001. Federle et al: Diagnostic Imaging. Amirsys. Salt Lake City. III:3:56. 2004 Webb WR et al: High Resolution CT of the Lung, 3rd Ed. . Philadelphia. Lippincott, Williams & Wilkins. 431-435. 2001


51. You are shown a KUB (Fig 5A) and noncontrast CT scan of the abdomen (Fig 5B) in a 55 year old woman. Which one of the following is the MOST LIKELY diagnosis? A. Chronic glomerulonephritis B. Acute cortical necrosis C. Hyperparathyroidism D. Milk-alkali syndrome RATIONALES: A. Incorrect. Chronic glomerulonephritis is a cause of cortical nephrocalcinosis, not medullary nephrocalcinosis as is seen in this case. B. Incorrect. Acute cortical necrosis is a cause of cortical nephrocalcinosis, not medullary nephrocalcinosis as is seen in this case. C. Correct. Hyperparathyroidism is the most common cause of medullary nephrocalcinosis. Other common causes include renal tubular acidosis type I (distal type), and medullary sponge kidney. D. Incorrect. Although milk-alkali syndrome is known to cause medullary nephrocalcinosis, it is much less common than hyperparathyroidism, renal tubular acidosis type I (distal type), and medullary sponge kidney. References: Dunnick NR et al: Textbook of Uroradiology, 3rd Ed. Philadelphia. Lippincott, Williams & Wilkins. 178-182, 2001. Federle et al: Diagnostic Imaging. Amirsys. Salt Lake City. III:3:52-54. 2004


52. You are shown images (Figures 6A and 6B) from a retrograde cystogram on a 48 year old man who presented after a motor vehicle accident. What is the MOST LIKELY diagnosis? A. Extraperitoneal bladder rupture B. Traumatic colovesical fistula C. Ureteral transection D. Intraperitoneal bladder rupture RATIONALES: A. Incorrect. The contrast is seen surrounding loops of bowel and outlining the peritoneal cavity. These findings would not be present with extraperitoneal bladder rupture. B. Incorrect. As noted in rationale A, the contrast is in the peritoneum (as well as in the bladder). Although it would be hard from these 2 projections to exclude contrast in the rectum, no appearance particularly suggestive of that is seen, and it would be distinctly unusual to have a colo-vesical fistula as a manifestation of trauma. A colo-vesical fistula may be seen in the setting of diverticulitis or sometimes in malignancy (often post-XRT), but a much more irregular contour to the contrast collections would be expected in such a case, due to inflammation or neoplasm. C. Incorrect. Interstitial bladder rupture is a rare injury, which is a result of incomplete perforation of the bladder wall. On cystography, a mural defect is seen in the bladder wall, without extravasation of contrast. D. Correct. The bladder lumen is shown with a foley catheter balloon and there is considerable contrast extravasation outlining the peritoneal cavity and adjacent bowel loops. References: Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 469-472.


53. Concerning hysterosalpingography, which of the following is TRUE? A. It is optimally performed in the latter half of the menstrual cycle. B. Acute pelvic inflammatory disease is a contraindication. C. A “T-shaped” hypoplastic uterus indicates prior pelvic inflammatory disease. D. Hysterosalpingography is sensitive for detecting adhesions. RATIONALES: A. Incorrect. HSGs are performed on days 7-10 of menstrual cycle, after menstrual bleeding complete. B. Correct. Contraindications for HSG include acute PID, active bleeding, preganancy, and hypersensitivity to contrast. C. Incorrect. “T-shaped” hypoplastic uterus is seen with in utero DES exposure, and has an association with clear-cell adenocarcinoma of the vagina. D. Incorrect. Hysterosalpingography is insensitive for diagnosing pelvic adhesions, but if extensive adhesions are present, abnormalities may be seen, such as failure of contrast spillage from the fimbriated end of the tube may, or if contrast spills, loculations of contrast. References: Dunnick et. Al. Textbook of Uroradiology 3rd ed. Lippincott, Williams & Wilkins,Philadelphia, PA. 2001.


54. Concerning testicular neoplasms, which of the following is TRUE? A. Most testicular tumors present as painful masses. B. Isolated testicular microlithiasis usually progresses to testicular cancer. C. Seminoma is the most common type of testicular cancer in adults. D. Sonography is able to detect only about 60% of testicular tumors. RATIONALES: A. Incorrect. Testicular neoplasms most commonly present as a painless mass. B. Incorrect. Although about 10% of patients with microlithiasis have a testicular germ cell tumor detected sonographically at the time of their initial ultrasound examination, and there have been case reports of patients who initially present with isolated microlithiasis (i.e., testicular microlithiasis with no tumor), longitudinal data on groups of patients with isolated testicular microlithiasis have suggest that the risk, if real, is quite low. C. Correct. Seminoma is the most common adult testicular tumors, accounting for 40-50% of adult neoplasms. D. Incorrect. Sonography is highly sensitve (95 to 100 %) for the detection of testicular tumors. References: Middleton, Kurtz, Hertzberg. Ultrasound: The Requisites, 2nd edition. St. Louis, MO; Mosby, 2004.


55. Concerning malacoplakia, which of the following is TRUE? A. It is a premalignant condition. B. It is associated with patients who are immunocompromised. C. The renal pelvis is the most common site of urinary tract involvement. D. It contains eosinophilic staining inclusions known as Howell-Jolly bodies. RATIONALES: A. Incorrect. It is not a premalignant condition. B. Correct. Malacoplakia is an uncommon inflammatory condition of the ureter associated with chronic urinary tract infection. It is more common among immunocompromised patients. C. Incorrect. The urinary bladder is the most common site of urinary tract involvement. D. Incorrect. Contain basophilic staining inclusions known as Michaleis-Gutmann bodies. REFERENCES: Dunnick et. Al. Textbook of Uroradiology 3rd ed. Lippincott, Williams & Wilkins,Philadelphia, PA. 2001.


56. Renal medullary carcinoma: A. is classically seen in young men and older women. B. is associated with African American patients with sickle cell trait. C. arises from metanephric blastema by 5 years of age. D. is a benign renal neoplasm usually present at birth. RATIONALES: A. Incorrect. Multilocular cystic nephroma is the renal neoplasm that is classically seen in young male patients and older females. B. Correct. Medullary carcinoma is the renal neoplasm that is classically seen in young black patients with sickle cell trait. C. Incorrect. Wilms’ tumor is a renal neoplasm that arises from the matanephric blastema and is usually diagnosed by age 5. D. Incorrect. Mesoblastic nephroma is a benign renal neoplasm usually present at birth. REFERENCES: Dunnick et. Al. Textbook of Uroradiology 3rd ed. Lippincott, Williams & Wilkins,Philadelphia, PA. 2001. 57. Concerning acquired cystic renal disease, which of the following is TRUE? A. The kidneys are usually enlarged with multiple cysts. B. Ultrasound is the best imaging tool in evaluating these patients. C. The risk of developing renal cell carcinoma is negligible. D. The renal cysts tend to regress after successful renal transplantation. RATIONALES: A. False: This disease is found in patients with chronic renal failure on dialysis, thus the kidneys are generally small. Multiple small cysts are characteristic. B. False: Because the kidneys and cysts are small, and the renal cell carcinomas that develop also tend to be small, contrast enhanced CT or MRI are the imaging modalities of choice C. False: 7% of patients with acquired cystic renal disease develop renal cell carcinoma. D. True: The cysts do tend to regress. However, the affect of renal transplantation on developing renal cell carcinoma isn’t known. References: Dunnick NR et al: Textbook of Uroradiology, 3rd Ed. Philadelphia. Lippincott, Williams & Wilkins. 116. 2001. Federle et al: Diagnostic Imaging. Amirsys. Salt Lake City. III:3:56. 2004


58. Concerning a 3.0 cm simple ovarian cyst in an asymptomatic, post-menopausal woman, which of the following is TRUE? A. It has a moderate to high risk of being malignant and should be removed. B. Fibrothecoma is the most common neoplasm associated with this finding. C. The cyst should be removed if the patient has an increased serum CA-125 level. D. It requires no further follow-up treatment. RATIONALES: A. Incorrect. The risk of malignancy for a simple cyst smaller than 5.0cm diameter in a post-menopausal women is very low and these masses can be followed with repeat ultrasound exams every 3-6 months without operative intervention. B. Incorrect. The most common neoplasm in those cases that had surgical removal is serous cystadenoma. C. Correct. The CA-125 is a tumor marker that if elevated in a post-menopausal woman with an ovarian cyst indicates that removal is required. D. Incorrect. See “A” above. The natural history of these masses is unknown and follow-up is required. References: Castillo G, et al. Natural History of Sonographically Detected Simple Unilocular Adnexal Cysts in Asymptomatic Postemenopausal Women. Gynecol Oncol. 2004 Mar;92(3):965-969 Bailey CL et al. The malignant potential of small cystic ovarian tumors in women over 50 years of age. Gynecol Oncol. 1998 Apr;69(1):3-7


59. Concerning a septate uterus, which of the following is TRUE? A. It is less common than bicornuate uterus. B. Open surgical correction is recommended for patients with recurrent pregnancy loss. C. The uterine fundus will have a flat or convex contour. D. It is associated with the best reproductive outcomes among patients with congenital uterine anomalies. RATIONALES: A. Incorrect. Septate uterus comprises about 55% of mullerian duct anomalies, the most common type. Bicornuate constitutes about 10% of mullerian duct anomalies. B. Incorrect. Hysteroscopic resection can typically be done for patients with septate uterus and recurrent pregnancy loss. C. Correct. The fundal contour is the basic anatomic feature that distinguishes septate uterus from bicornuate uterus. Septate uterus will have a flat, convex, or minimally concave (< 1cm depth) fundal contour. D. Incorrect. Septate uterus has the poorest reproductive outcomes of the congenital uterine anomalies. There is a reported spontaneous abortion rate in the literature of nearly 65% for patients with septate uterus. References: Troiano RN, McCarthy SM. Mullerian Duct Anomalies: Imaging and Clinical Issues. Radiology 2004; 233:19-34.


60. Regarding endometrioid ovarian cancer, which of the following is TRUE? A. It is the most common form of ovarian cancer. B. Twenty-five percent of the women have concomitant endometrial cancer. C. Fewer than 5% are bilateral. D. It is much less likely to cause elevated CA-125 compared to serous tumors. RATIONALES: A. Incorrect. It is actually the second most common form of ovarian cancer. Serous cystadenocarcinoma is the most common form. Mucinous cystadenocarcinoma is the third most common form of ovarian cancer. B. Correct. Thus, if you see endometrial thickening and an ovarian mass, consider endometrioid ovarian cancer. The endometrial cancer is thought to be a primary tumor rather than a metastatic focus. C. Incorrect. 15% are bilateral. D. Incorrect. It is just as likely to cause elevated CA-125. References: Kawamoto et al. Radiographics 1999. 19 (Supplement 1): S85-S102.


61. Adenocarcinoma of the prostate gland most commonly occurs in what location? A. Central zone B. Transitional zone C. Peripheral zone D. Fibromuscular stroma RATIONALES: A. Incorrect. Only approximately 5% of carcinomas occur in this region of the prostate. B. Incorrect. This area accounts for about 5% of the prostate volume and is located in the periurethral tissue. This zone accounts for approximately 10% of prostate cancers. This area is prone to benign prostatic hyperplasia. C. Correct. This area accounts for about 70% of the volume of the prostate gland and approximately 85% of prostate cancer is located in this zone. D. This is the nonglandular portion of the prostate gland and is located anteriorly. It does not typically present with pathology. References: 1. Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 4, 394-408 2. Zagoria RJ, Tung GA, Genitourinary Radiology, The Requisites. First edition. St. Louis, MO: Mosby, 1997, pp 303-326


62. What is the average energy of a 100 kVp x-ray beam? A. 10 KeV B. 25 KeV C. 40 KeV D. 77.7 KeV RATIONALES: A. Incorrect. B. Incorrect. C. Correct. The average energy of a polychromatic x-ray beam is usually one-

third to one-half of the maximum kVp depending on the beam filter. Hence the average energy for 100 kVp x-rays would be between 33 – 50 keV and therefore 40 keV is correct.

D. Incorrect. References: The Essential Physics of Medical Imaging, 2nd edition. J.T. Bushberg, J.A. Seibert, E.M. Leidholdt, and J.M. Boone, Lippincott Williams & Wilkins (2002). 63. Concerning iodinated contrast induced nephropathy (CIN) in patients with pre-existing renal insufficiency, which one is TRUE? A. High-osmolar agents have equal risk for inducing CIN as low-osmolar agents. B. Diabetic patients have equal risk for CIN compared to non diabetics. C. IV hydration decreases the incidence of CIN. D. Previous allergic reactions to iodinated contrast agents increase the risk for CIN. RATIONALES: A. Incorrect. High osmolar agents have greater incidence of CIN B. Incorrect. Diabetic patients have increased risk of CIN especially if they already have baseline renal insufficiency C. Correct. IV hydration with ½ normal saline 12 hours before and after contrast

administration decreases the incidence of CIN in patients with chronic renal insufficiency.


D. Incorrect. Allergic reactions are a separate contrast reaction type and are not considered a risk factor for CIN. Pre-existing renal insufficiency, diabetes mellitus (especially with pre-existing renal insufficiency), dehydration, cardiovascular disease with CHF and myeloma are among the risk factors with increased incidence of CIN. References: Manual on Contrast Media, version 5.0, American College of Radiology, 2004 64. What is the principle reason that iodine contrast media causes an increase in the blood’s ability to attenuate x-rays? A. Higher atomic number of Iodine increases photoelectric interactions. B. Higher atomic number of Iodine increases the Compton interactions. C. Increasing the blood density increases the photoelectric interactions. D. Increasing the blood density increasing the Compton interactions. RATIONALES: A. Correct. Since the probability of photoelectric absorption is proportional to (Z)^3, the high atomic number of iodine greatly increases the stopping of the x-rays by photoelectric interactions B. Incorrect. The probability of Compton scattering is independent of the atomic number. C. Incorrect. There is little change in the blood’s density. D. Incorrect. There is little change in the blood’s density. References: The Essential Physics of Medical Imaging, 2nd edition. J.T. Bushberg, J.A. Seiabert, E.M. Leidholdt, and J.M. Boone, Lippincott Williams & Wilkins (2002), Chap 3, p42. Physics of Radiology, 2nd edition. Anthony Brinton Wolbarst, Medical Physics Publishing, Madison WI (2005), Chap 3, p32.


65. Concerning endometriosis, which one is TRUE? A. CT is abnormal in most patients. B. Endometriomas are typically anechoic on ultrasound. C. It most commonly affects postmenopausal women. D. It usually presents with multiple very small deposits. RATIONALES: A. Incorrect. CT is normal in most patients although larger endometriomas may be seen. B. Incorrect. Larger endometriomas usually have internal echoes from debris. Most patients with endometriosis have no abnormalities on US related to this entity. C. Incorrect. Women 30 -40 years old are most commonly affected. The growth of endometriosis appears to be estrogen sensitive and grow under cyclical hormonal influence. D. Correct. These small implants are usually not seen by any imaging modality. Laparoscopy is typically used for diagnosis. References: Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 505-506 66. Concerning primary megaureter, which one is TRUE? A. The lower one third of the ureter is most commonly dilated. B. There is mechanical obstruction in the lower ureter. C. Both ureters are involved in 75% of cases. D. There is blunting of the calyces, which differentiates it from typical obstruction. RATIONALES: A. Correct. Most cases involve dilatation only the lower third of the ureter although the lowest portion of the ureter adjacent to the ureterovesicle junction is normal in caliber. Severe cases can involve the entire ureter but are less common. B. Incorrect. There is functional obstruction of the juxtavesical ureter due to inadequate musculature which fails to transmit normal peristalsis and is less distensible than normal ureter. This portion of the ureter is relatively normal with


no associated filling defect or stenosis. There is prominent dilatation of the normal ureter above this level. C. Incorrect. It is unilateral in 75% of cases. Left side is more commonly affected than right and it is more common in men than women. D. Incorrect. In contrast to true ureteral obstruction, the calyces are typically sharp with no delay in excretion or other signs typical of acute obstruction. References: 1. Zagoria RJ, Tung GA, Genitourinary Radiology, The Requisites. First edition. St. Louis, MO: Mosby, 1997, pp 177-178 2. Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 25, 326-327 67. Concerning urinary bladder diverticula, which one is TRUE? A. Most bladder diverticula are congenital. B. A Hutch diverticulum is associated with contralateral vesicoureteral reflux. C. Lateral deviation of the distal ureter is more common than medial deviation. D. A diverticulum at the anterosuperior bladder is most often a urachal diverticulum. RATIONALES: A. Incorrect. Most are acquired and related to bladder outlet obstruction. B. Incorrect. Ipsilateral reflux is associated with a Hutch diverticulum. C. Incorrect. Medial deviation of the distal ureter adjacent to a diverticulum is more common than lateral deviation. D. Correct. A urachal diverticulum arises anterosuperiorly whereas typical bladder diverticula arise from the lateral walls or adjacent to ureteral orifices. References: 1. Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 362, 375. 2. Zagoria RJ, Tung GA, Genitourinary Radiology, The Requisites. First edition. St. Louis, MO: Mosby, 1997, pp211-12, 233.


68. Concerning seminal vesicle cysts, which one is TRUE? A. They are associated with ipsilateral renal agenesis. B. They are usually midline in location. C. They are usually bilateral. D. They are usually caused by prostate carcinoma. RATIONALES: A. Correct. Ipsilateral seminal vesicle cysts, absent ipsilateral ureter, absent ipsilateral hemitrigone and absent ipsilateral vas deferens are all associated with renal agenesis. B. Incorrect. They are usually lateral to the prostate. C. Incorrect. They are typically unilateral. D. Incorrect. They are usually due to congenital hypoplasia of the ejaculatory duct. References: 1. Zagoria RJ, Tung GA, Genitourinary Radiology, The Requisites. First edition. St. Louis, MO: Mosby, 1997, pp 53-4, 327 69. Concerning papillary necrosis, which one is TRUE? A. Common etiologies are analgesics, diabetes mellitus and sickle cell anemia. B. Conventional radiographs usually show characteristic calcification. C. Approximately 90% of sickle cell disease patients develop papillary necrosis. D. Medullary type papillary necrosis is associated with absence of the entire papilla. RATIONALES: A. Correct. The common etiologies of papillary necrosis have been immortalized by the mnemonic NSAID: Non-steroidal anti-inflammatory drugs, Sickle cell anemia, Analgesic nephropathy, Infection (such as tuberculosis) and Diabetes mellitus. B. Incorrect. Radiographs are usually normal. They can also show irregular calcifications 2-6 mm in size if part or all of the papilla is necrotic and may show a ring of calcification in a sloughed but retained papilla. C. Incorrect. Up to 50% of sickle cell patients develop papillary necrosis. D. Incorrect. Medullary type papillary necrosis shows only central erosion of the papilla.


References: Dunnick, Sandler, Newhouse, Amis, Textbook of Uroradiology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 299-302

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