FRCR 2A Genitourinary SBA

Findings: A large infiltrative mass is present in the right kidney with extension of mass into the renal pelvic fat, the right renal vein and IVC. There is also retroperitoneal lymphadenopathy and splenomegaly.

A. 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. 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. Up to 50% of sickle cell patients develop papillary necrosis.
D. Medullary type papillary necrosis shows only central erosion of the papilla.

"A. Correct. Ipsilateral seminal vesicle cysts, absent ipsilateral ureter, absent ipsilateral hemitrigone and absent ipsilateral vas deferens are all associated with renal agenesis.
B. They are usually lateral to the prostate.
C. They are typically unilateral.
D. They are usually due to congenital hypoplasia of the ejaculatory duct.

  

A. The risk of malignancy for a simple cyst smaller than 5.0cm diameter in a postmenopausal women is very low and these masses can be followed with repeat ultrasound exams every 3-6 months without operative intervention.
B. 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. See “A” above. The natural history of these masses is unknown and follow-up is required.

A. 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. The urinary bladder is the most common site of urinary tract involvement.
D. Contain basophilic staining inclusions known as Michaleis-Gutmann bodies.

"A. Testicular neoplasms most commonly present as a painless mass.
B. 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 suggested 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. Sonography is highly sensitve (95 to 100%) for the detection of testicular tumors.

A. Autosomal dominant polycystic disease usually presents with multiple bilateral simple renal cysts between ages 20-39 years. Autosomal recessive polycystic disease has a spectrum of presentation ages but is typically seen from the neonatal through childhood periods rather than adulthood.
B. This description is more typical of the appearance of the infantile form of ARPKD.
C. The kidneys are typically small and atrophic with multiple cysts in acquired cystic renal disease of dialysis as compared to markedly enlarged kidneys in ADPCD.
D. Correct. ADPCD typically has multiple hepatic cysts in over 50% of cases. Autosomal recessive polycystic disease is associated with hepatic fibrosis particularly in the juvenile onset form.

A. Transitional cell carcinoma is the most common urothelial malignancy followed by squamous cell carcinoma. Adenocarcinoma is distinctly rare.
B. Leukoplakia is associated with squamous cell carcinoma of the bladder, not transitional cell carcinoma. The urachus is a site where transitional epithelium can undergo metaplasia to glandular epithelium and result in adenocarcinoma.
C. The entire urothelium is at risk, but transitional cell carcinomas are more common in the bladder than in the upper tracts.
D. 8% of renal malignancies develop from the urothelium.

A. Correct. Adenomas are the most common adrenal mass and occur in 2-8% of the population.
B. Adenomas most often have non contrast density of less than 10 H.U.
C. Adenomas typically decrease in signal intensity on the out of phase portion of opposed phase imaging.
D. Adenomas typically washout 50% of their initial enhancement levels on a 10 minute delayed CT exam.

A. 70% of prostate cancers arise from the peripheral zone, the remainder from the transitional and central zones.
B. Prostate carcinomas in the peripheral zone are generally isointense to surrounding prostate tissue on T1-weighted images. T2-weighted images demonstrate prostate cancers as low signal intensity compared to the surrounding normal high signal intensity peripheral zone.
C. Correct. Prostate cancer in the peripheral zone (where the majority of prostate cancers arise) demonstrates increased enhancement compared to the normal peripheral zone tissue.
D. This metastatic pathway is characteristic of testicular neoplasms, not prostatic. Lymph node metastases from prostate carcinoma are generally first to the obturator, external and internal iliac chains.

A. Most bladder ruptures, two-thirds, are extraperitoneal, caused by trauma and pelvic fractures.
B. The uremia and elevated creatinine occur because of intraperitoneal ruptures, not extraperitoneal ruptures.
C. CT cystograms require active distention of the bladder with contrast. Passive filling of the bladder, such as seen in delayed images through the bladder after a normal contrast exam, may miss intraperitoneal ruptures which occur high in the dome, and thus may be higher than the level of the contrast-opacified urine seen during passive filling of the bladder. A CT cystogram, with active filling, overcomes this obstacle, by filling the entire bladder lumen with contrast. In addition, CT cystograms do not require post-void images.
D. Correct. Intraperitoneal bladder rupture generally require surgical closure. They do not close on their own. If uncorrected, they cause uremia and elevated creatinine as noted above.

A. Extraperitoneal bladder ruptures account for 80%-90% of major bladder injuries. Intraperitoneal ruptures account for 10%-20% of major bladder injuries.
B. Extraperitoneal bladder ruptures are almost always associated with pelvic fractures and are due to bladder laceration by the fracture fragments.
C. Correct. Intraperitoneal bladder rupture is typically treated with surgical repair of the tear and diverting vesicostomy.
D. Even delayed images of the bladder with CT and intravenous contrast are not adequate to exclude major bladder injury. This is because there is inadequate distension of the bladder. At least 300 ml of fluid is required to adequately distend the bladder and evaluate for extravasation.

A. It is the MOST common cause of hydronephrosis in children.
B. UPJ obstruction is being discovered increasingly in the prenatal period due to frequent use of obstetric ultrasound. When detected due to symptoms or signs, congenital ureteropelvic junction obstruction most often presents in infancy or childhood with an abdominal mass, flank or abdominal pain, failure to thrive, or nonspecific gastrointestinal complaints. Infection, hypertension, hematuria, and stone formation less commonly are the cause for the child to come to medical attention. In a significant number of cases, the disorder is clinically silent into adulthood, when hematuria, flank pain, fever, or rarely, hypertension, are the presenting clinical symptoms. Pain in adults is often episodic and in some cases may only present by high urine flow rates such as those produced by beer drinking.
C. Males are affected more than females by 2:1.
D. Correct. Crossing vessels are seen in only 15%-20% of cases but significantly reduce the success of pyeloplasty. Thus, many advocate the use of CT for preoperative planning.

A. Chronic glomerulonephritis is a cause of cortical nephrocalcinosis, not medullary nephrocalcinosis as is seen in this case.
B. 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. 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.

A. 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. Wilms’ tumor is a renal neoplasm that arises from the matanephric blastema and is usually diagnosed by age 5.
D. Mesoblastic nephroma is a benign renal neoplasm usually present at birth.

A. 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 ADPKD with lung cysts.
B. 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. 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. 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.

A. 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. 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. 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.

A. Power Doppler is more sensitive than color Doppler for detecting flow, especially in neonates and young boys. Power Doppler shows superiority in demonstrating intratesticular vessels. Power Doppler is limited somewhat by being more sensitive to patient motion than color Doppler.
B. Correct. Cases of intravaginal torsion are caused by a bell-clapper deformity of attachment of the mesentery to the testis. The abnormality is bilateral in nearly all cases.
C. Testicular torsion only accounts for 30% of cases of scrotal pain in boys age 12-18. Epididymoorchitis or torsion of an appendix testis/epididymis are much more common causes of scrotal pain.
D. In early torsion (when most critical to detect torsion to permit salvaging the testicle), testes may have normally preserved gray-scale appearance. Later gray-scale ultrasound may demonstrate decreased echogenicity of the testis, testicular swelling or reactive hydrocele. Early on, the sonographic diagnosis of testicular torsion relies on the demonstration of decreased or absent flow in the torsed testis on color or power Doppler.

A. Salpingitis isthmica nodosa involves the isthmic portion of the fallopian tube. Hysterosalpingogram will reveal small outpouchings of contrast outside the expected lumen of the tube. It is seen in 4% of infertility cases. It indicates scarring and is associated with an increased incidence of ectopic pregnancy.
B. Adhesions or clumping of a fallopian tube cause convolution of the tube but not the appearance of multiple serpentine structures in the expected location of the isthmic portion of the tube.
C. A hydrosalpinx is a dilated, fluid-filled fallopian tube. Usually the ampullary portion of the tube is dilated. The fallopian tube may or may not be obstructed.
D. Correct. Contrast intravasation into the uterine wall causes multiple serpentine venous structures to fill adjacent to the uterus. The contrast-filled veins often mimic the appearance of the fallopian tube. Often venous intravasation occurs when the fallopian tube is blocked, as in this case. Confirmation occurs after waiting 2-3 minutes, in which time the contrast dissipates from the veins. Contrast in a fallopian tube would not change in density in that time. Unfortunately, once venous intravasation occurs, further attempts to visualize the tube are futile since the intravasation usually occurs again with the next immediate injection.

"A. Although leiomyomas typically have low intensity on T2 weighted images, they would be expected to be round and well defined.
B. Correct. Adenomyosis results from the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent myometrial hyperplasia. It is frequently associated with symptoms of pelvic pain, hypermenorrhea, and uterine enlargement. The diffuse thickening of the low intensity junctional zone is typical of diffuse adenomyosis of the uterus (junctional zone thickness 12 mm is generally considered diagnostic), and other imaging findings include poor definitions of the borders of the junctional zone, or the presence of high-signal foci on T2- or T1-weighted images. This case demonstrates diffuse adenomyosis; focal adenomyosis may also be seen.
C. For endometrial cancer, one would expect the high intensity endometrial stripe to be thickened, as well as inhomogeneous.
D. For cervical cancer, one would expect an isointense mass in the area of the cervix, which may deform the endocervical canal or disrupt the low-signal-intensity fibrous stroma, and one may see tumor extension towards the vagina and/or parametrium. In this case, the endocervical canal and cervical region appears normal.

A. Correct. Septate uterus is the most common uterine anomaly and is associated with an internal septum and outer horizontal fundal contour. 

"A. This image demonstrates a rounded filling defect with dilation of the ureter distal to the filling defect (“goblet sign”). Acute filling defects do not result in dilation of the ureter distal to the filling defect.

A. Horseshoe kidney is a common congenital renal abnormality, but is not associated with Mullerian duct abnormalities.

"A. The lacunar space (Space of Smith) surrounds the tunica albuginea and is superficial to where the calcifications occur in Peyronie disease.

A. This has a heart shaped uterine fundus, with indentation on the outer contour of the uterus.

A. While dysmenorrhea can be seen in the setting of unicornuate uterus with a rudimentary horn, it is not life-threatening.

A. Reflux can result in pelvicaliectasis and concurrent pyelonephritis; however, an ipsilateral ureteral jet should be visualized as this uereter is not obstructed. Pyelonephritis can develop in the setting of an obstructed collecting system. A ureteral calculus would be a more common presentation of new onset flank pain in a young person.

"A. Although a complex cystic lesion of the testicle would be concerning for neoplasm, a simple cyst in the testicle is expected to be benign.

A. Correct.

D. Correct.

"B. Correct.

"D. Correct.

C. Correct.

C. Correct.

"B. Correct.

A. CT is normal in most patients although larger endometriomas may be seen.
B. Larger endometriomas usually have internal echoes from debris. Most patients with endometriosis have no abnormalities on US related to this entity.
C. 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. These small implants are usually not seen by any imaging modality. Laparoscopy is typically used for diagnosis.

A. Correct. Most cases involve dilatation of 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. 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 normal ureter above this level.
C. 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. In contrast to true ureteral obstruction, the calyces are typically sharp with no delay in excretion or other signs typical of acute obstruction.

A. High osmolar agents have greater incidence of CIN
B. 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. 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.

"A. This is the definition of Type III posterior urethral injury.
B. Extravasation of contrast below the urogenital diaphragm (UGD) into the perineum on urethrography indicates disruption of the UGD and signifies Type III injury.
C. This is the definition of Type II posterior urethral injury.
D. This is the definition of Type I posterior urethral injury.

 

"A. Testicular torsion typically presents as acute testicular pain with or without testicular enlargement. Testicular echogenicity is typically homogeneous, with normal testicular echogenicity initially, becoming hypoechoic with ongoing torsion and infarct.
B. Correct. The images show an intratesticular mass. Seminoma is the most common solid intratesticular neoplasm.
C. While epididymo-orchitis can cause enlargement of the testicle as well as hypoechoic areas within the testicle, it is not typically painless.
D. While lymphoma could present as a testicular mass, it is less common than germ cell tumors such as seminoma.

Findings: IVU demonstrates complete duplication of both the right and left collecting systems. There is dilatation of both lower pole-collecting systems, right more than left. The right lower pole calyces are blunted. The CT image demonstrates cortical thinning of the lower pole of the right kidney overlying a dilated calyx that shows a contrast-urine level confirming it is a dilated calyx. The combination of cortical scarring overlying a dilated calyx is typical of reflux nephropathy.

A. Intramural pseudodiverticuli are prominent submucosal esophageal glands associated with gastroesophageal reflux and Candida.
B. Correct. Salpingitis isthmica nodosa manifests as tiny diverticula arising from the fallopian tubes secondary to chronic inflammation. This is most easily seen during hysterosalpingography.

A. At stage II A the tumor has spread beyond the cervix but has no obvious parametrial involvement, is confined to the upper two thirds of the vagina and no invasion of the ureter or bladder.
B. Stage II B has obvious parametrial involvement but does not extend to the pelvic side wall.
C. Stage III A extends to the lower third of the vagina but not the pelvic sidewall and does not obstruct the ureters or invade adjacent organs.
D. Correct. Stage III B tumors extend to pelvic sidewall and/or causes hydronephrosis or non-functioning kidney.

Findings: Images demonstrate left cortical thinning, dilated collecting system, infiltration of the fat adjacent to the left kidney, and calcifications in the left renal collecting system.

A. In early acute pyelonephritis, the kidney may actually appear within normal limits on CT, particularly on noncontrast scanning, but in more advanced cases, after intravenous contrast may demonstrate striated nephrogram or focal wedge-like areas of abnormally decreased enhancement. Although the infiltration of fat seen around the kidney in this case could be seen with acute pyelonephritis, the obstructing stone, cortical thinning, and dilated, fluid-filled collecting system suggests a more chronically obstructed, infected system.
B. Correct. Xanthogranulomatous pyelonephritis is a chronic suppurative granulomatous infection in the setting of chronic obstruction. Common organisms are Proteus mirabilis and E Coli. Histologically there is diffuse infiltration by plasma cells and lipid-laden macrophages. Symptoms are generally of long duration, and the affected kidney is nonfunctioning. The kidney is diffusely enlarged, but maintains its reniform shape, with one or more relatively large calculi typically seen. The renal pelvis is typically poorly defined or normal in size, as in this case.
C. While acute obstruction could result in hydronephrosis and perinephric stranding, it would not account for the cortical thinning seen here, and with acute obstruction, one would expect to see dilatation of the renal pelvis.
D. Multilocular cystic nephroma is an uncommon renal neoplasm containing many cysts of varying sizes, surrounded by a thick fibrous capsule. Calcifications may rarely be seen, but are usually only in the cyst walls or intervening stroma. It would not account for the significant infiltration of the adjacent perinephric fat seen in this case.

A. These lesions may occasionally hemorrhage but are usually incidental masses with mixed amounts of soft tissue and macroscopic fat.
B. Correct. While other lesions such as renal cell carcinoma, oncocytoma, Wilm’s and metastasis have also been reported with areas of fat within these tumors, these cases are rare.
C. Angiomyolipomas have varying amounts of fat and soft tissue. Some have no fat visible by CT and a solid soft tissue renal mass in such a case is indistinguishable from renal cell carcinoma and should be treated as such.
D. Calcification in angiomyolipomas is unusual but may occur if there has been prior hemorrhage.

A. Correct. Approximately 80% of benign adrenal adenomas contain adequate intracellular lipid to give HU less than 10 on noncontrast CT. This is generally accepted as definitive evidence of benignity.
B. A small percentage of benign adenomas do not have adequate intracellular lipid to give attenuation values less than 10 on noncontrast CT. In these cases, intravenous contrast can be given and washout characteristics studied. Metastases tend to “hold” onto contrast longer than benign adrenal adenomas. Thus, adenomas have greater enhancement washout {[(E-D)/(E-U)]x100}, where E is enhanced attenuation value, D is delayed enhancement value, and U is the unenhanced attenuation value, and the accepted threshold value for a benign adrenal adenoma is greater than 60% washout. Washout less than 60% would be indeterminate and other lesions such as metastases would have to be considered. If unenhanced CT has not been performed, a relative enhancement washout can be calculated {[(E-D)/E]x100}, and greater than 40%-50% indicates benign adenoma.
C. Chemical shift MRI imaging uses the same physiological principles as noncontrast CT in evaluating an adrenal nodule. Intracytoplasmic lipid in a benign adenoma results in cancellation or loss of signal on out-of-phase images rather than no change or increase in signal intensity.
D. Attenuation values of 30-40 HU or less on delayed, contrast-enhanced CT images almost always indicate a benign adenoma. An attenuation value of greater than 50 HU would be in determinant.

A. Correct. Approximately 80% of benign adrenal adenomas contain adequate intracellular lipid to give HU less than 10 on noncontrast CT. This is generally accepted as definitive evidence of benignity.
B. A small percentage of benign adenomas do not have adequate intracellular lipid to give attenuation values less than 10 on noncontrast CT. In these cases, intravenous contrast can be given and washout characteristics studied. Metastases tend to “hold” onto contrast longer than benign adrenal adenomas. Thus, adenomas have greater enhancement washout {[(E-D)/(E-U)]x100}, where E is enhanced attenuation value, D is delayed enhancement value, and U is the unenhanced attenuation value, and the accepted threshold value for a benign adrenal adenoma is greater than 60% washout. Washout less than 60% would be indeterminate and other lesions such as metastases would have to be considered. If unenhanced CT has not been performed, a relative enhancement washout can be calculated {[(E-D)/E]x100}, and greater than 40%-50% indicates benign adenoma.
C. Chemical shift MRI imaging uses the same physiological principles as noncontrast CT in evaluating an adrenal nodule. Intracytoplasmic lipid in a benign adenoma results in cancellation or loss of signal on out-of-phase images rather than no change or increase in signal intensity.
D. Attenuation values of 30-40 HU or less on delayed, contrast-enhanced CT images almost always indicate a benign adenoma. An attenuation value of greater than 50 HU would be in determinant.

"A. Only approximately 5% of carcinomas occur in this region of the prostate.
B. 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.

"A. Bosniak I cysts are simple cysts and have no septations or calcifications. These require no further evaluation.
B. Bosniak II cysts have some atypical features, but are most likely benign. This group of cysts can have thin septations or calcifications but not complex septations or dense calcifications. Some lesions in this group are followed (subgroup IIF). Hyperdense, nonenhancing cysts are included in the Bosniak II category.
C. Correct. Bosniak III cysts can have dense calcifications, complex septations, and multiloculated cysts. This group cannot be distinguished from malignancy, and often these lesions require surgical exploration.
D. Bosniak IV cystic masses have features, which strongly suggest malignancy, such as an enhancing solid component or thick irregular walls. Lesions in this category are treated as presumed renal carcinomas.

  

Findings: Cystic changes near the mediastinum testes bilaterally.

Findings: Heterogeneous echotexture of the testicle, with no flow within the testicle on power Doppler.

A. This is not a typical appearance for schistosomiasis; in particular, no calcifications of the masses are seen.

Findings: Exophytic left renal mass containing a small amount of gross fat (density -52.5 HU).

A. The mass invades from the vagina through the posterior bladder. A simple ureterocele is a nonmalignant focal dilatation of the submucosal distal ureter.

A. Correct. The mass is nearly completely fat density when compared to subcutaneous fat.

Findings: A large infiltrative mass is present in the right kidney with extension of mass into the renal pelvic fat, the right renal vein and IVC. There is also retroperitoneal lymphadenopathy and splenomegaly.

Findings: Left adrenal mass containing gross fat and a small amount of coarse calcium.

A. This lesion is predominantly of soft tissue attenuation, however there are two small foci of gross fat. Although adrenal adenomas may have microscopic fat in them, they would not be expected to have macroscopic fat as in this case.

"

"

Multiple bilateral small outpouchings of the ureter involving the proximal two-thirds of the ureter. These are most often seen on intravenous urography, antegrade urography, or retrograde pyelography. Very infrequently, pseudodiverticulosis may be detected on multidetector CT.

 

There is no specific treatment indicated in asymptomatic patients. In the past, since there was an association between pseudodiverticulosis and urothelial carcinoma, more aggressive surveillance had been performed, but it is unclear if this is surveillance is useful.

 

A. The upper moiety ureter is longer, passed through the bladder wall, and inserts inferior and medial to the lower pole moiety ureter (which inserts normally on the bladder trigone).
B. The upper pole moiety tends to be subject to obstruction, due to stenosis at the ectopic ureteral insertion.
C. The lower pole moiety ureter inserts in a normal location on the trigone of the urinary bladder.
D. The upper pole moiety ureter inserts ectopically, and is associated with an ectopic ureterocele. The lower pole moiety is not.
E. The lower pole moiety is usually dominant, involving the lower pole and interpolar calyces, whereas the upper pole moiety tends to be smaller, and may only drain a few calyces.

A. Septate uterus is the most common anomaly, and accounts for almost 50%.
B. The criteria for diagnosing septate uterus (as opposed to bicornuate) in a uterus with two horns is that the outer contour of the uterus is convex, flat or minimally indented (no more than 1 cm).
C. Urinary tract anomalies are seen is 20-50% of patients with uterine anomalies.  
D. A bicornuate uterus does not usually require treatment, as there is a much lower pregnancy complication rate than seen with septate uterus

A. Mural thickening, thick septations, papillary projections and solid components are all features suggestive of malignancy, not benignity.
B. Papillary projections and solid components are features suggestive of malignancy, not benignity.
C. Solid components are features suggestive of malignancy, not benignity.
D. Hemorrhage in a cystic mass is good evidence that the lesion is benign.

A. The presence of even a small amount of macroscopic fat is diagnostic of myelolipoma.
B. A typical myelolipoma is mostly composed of macroscopic fat.

A. PET-CT can be useful in characterizing adrenal lesions in cases where MRI and/or CT are equivocal as adenomas typically show no significant FDG uptake.
B. Delayed imaging should be performed at 15 minutes when assessing washout of an adrenal nodule.
C. Low attenuation within an adrenal nodule correlates with the presence of intracytoplasmic lipid, which is found in the majority of adrenal adenomas but not metastatic lesions. Therefore this measurement is a highly accurate predictor of benignity when less than 10 HU.
D. T2 signal is not useful in this scenario due to the significant overlap in T2 signal between these two lesions. Chemical shift imaging, with loss of signal on out of phase images due to the presence of lipid, is virtually diagnostic of an adenoma.

A. Ovarian vein thrombosis is right-sided 80-90% of the time, possibly due to retrograde flow into the left ovarian vein preventing stasis.
B. Ovarian vein thrombosis is most commonly seen in post-partum patients. Less common associations are gynecological malignancies, pelvic inflammatory disease and pelvic trauma.
C. If left untreated, potential complications include propagation into the renal veins and IVC and pulmonary embolism.
D. The left ovarian vein typically inserts into the left renal vein while the right renal vein inserts directly into the IVC.

A. Ureteritis cystica is secondary to chronic inflammation and is not associated with increased risk of transitional cell carcinoma.
B. Most renal transitional cell carcinomas occur in the extra-renal pelvis.
C. Two percent of patients with bladder TCC also have synchronous upper tract tumors at presentation, and 6% will develop metachronous upper tract disease
D. 85% of upper tract transitional cell carcinomas are low-stage, superficial, papillary neoplasms. They are usually small at diagnosis and grow slowly.

"A. T2 hyperintensity is a characteristic feature of pheochromocytoma
B. 10% of pheochromocytomas are extra-adrenal.
C. 16% of pheochromocytomas demonstrated absolute percentage washout of 60% and relative percentage washout of 40% (similar to an adrenal adenoma). However, pheochromocytomas tend to have absolute levels of contrast enhancement higher than would be expected for adrenal adenomas.
D. Hypertensive crisis secondary to administration of intravenous contrast media in a patient with pheochromocytoma has been described with ionic contrast agents. This does not appear to be the case with non-ionic contrast media.

Terminology
Tumor arising from chromaffin cells of adrenal medulla or extraadrenal ectopic tissue
Paraganglioma or ganglioneuroma (extraadrenal)

Imaging
Adrenal medulla (90%)
Extraadrenal (10%)
Along sympathetic chain: Anywhere from neck to urinary bladder
Subdiaphragmatic (98%); thorax (1-2%)
Organ of Zuckerkandl and near urinary bladder are relatively common sites
Also called tumor with ""rule of 10s"" or 10% tumor
10% extraadrenal: Paragangliomas
10% bilateral, malignant, extraabdominal
10% familial, pediatric, silent
10% have autosomal dominant transmission
Usually > 3 cm in sporadic (nonsyndromic) cases
Helical NE + CECT
Hypertensive crisis is rare or nonexistent with IV administration of nonionic contrast material
Heterogeneous enhancement (necrosis or bleeding)
± areas of curvilinear or mural calcification
MR: Markedly hyperintense on T2WI (characteristic)
Heterogeneous signal intensity (in 33% of cases)
Due to hemorrhage and necrosis with fluid levels
MIBG: For ectopic, recurrent, and metastatic tumors

"A. Bosniak I would be a simple cyst.
B. While likely benign, given the slightly thick calcification, this lesion would probably most appropriately receive follow-up.
C. Slightly coarse calcification more appropriately places it into a follow-up category.
D. This category would apply to a cystic lesion with more concerning imaging features, such as thick irregular enhancing septations.

  

"A. Endometriomas have high T1 signal due to the presence of blood products, however they lose signal on T2 weighted sequences. This is secondary to repeated intracystic hemorrhage giving rise to highly viscous blood products and proteinaceous material with resultant decrease in water content.
B. Fibromas can have low T2 signal, proportional to their fibrous content, however they do not have high T1 signal.
C. The high signal seen in teratomas is usually due to fat, and as such, most mature cystic teratomas will lose signal on fat suppression sequences.
D. These cysts rarely lose signal on T2 weighted sequences, as they usually are short lived and not prone to repeated hemorrhage and increased viscosity of contents.

A. Adrenocortical carcinomas are typically large, heterogeneously dense masses. Although they can have areas of necrosis, a thin, uniform rim of enhancement as in this case would be unusual. Calcifications, present in 33% of adrenocortical carcinomas, are typically microcalcifications, not the dense rim calcifications seen in this case
B. The coronal CT clearly demonstrates this mass is separate from the right kidney.
C. Adrenal pseudocysts are uncommon lesions. The majority have rim-like or nodular calcifications. No central enhancing components. Causes include trauma and hemorrhage into vascular neoplasms or primary adrenal neoplasms.
D. Adrenal myelolipomas are uncommon benign neoplasms that have macroscopic fat. Typically, between 50-90% of any given lesion is composed of fat. The lesion in this case has no macroscopic fat on CT or MRI.

A. Transitional cell carcinoma is a cause of an intramural filling defect as it arises from the wall of the collecting system. The filling defects in this case are completely surrounded by contrast, indicating that they are intraluminal, with no attachment to the urothelium.
B. Renal calculi are a common cause of intraluminal collecting system filling defects, however almost all renal calculi are radiodense, rather than soft tissue density, on CT.
C. There are multiple small filling defects within the renal calyces surrounded by contrast and there is blunting and deformity of the involved calyces. Findings are compatible with sloughed papilla.
D. Lymphoma can infiltrate the perinephric space and renal hilum however intrinsic involvement of the collecting system is not a part of the disease spectrum.

A. An interstitial injury to the urinary bladder is characterized by a contained tear in the bladder wall. No contrast leaks outside of the confines of the bladder. In this case there is contrast both in the extra-peritoneal space and the intra-peritoneal space.
B. Intra-peritoneal bladder rupture is diagnosed by identifying high density contrast instilled into the urinary bladder leaking into the intra-peritoneal spaces including around bowel loops and in the paracolic gutters. This patient does have intra-peritoneal bladder rupture with contrast in the paracolic gutters, but there is also contrast in the prevesicle space of Retzius, an extraperitoneal space.
C. Extra-peritoneal bladder rupture is diagnosed by identifying high density contrast instilled into the urinary bladder leaking into extra-peritoneal spaces such as the space of Retzius. This patient does have extra-peritoneal bladder rupture with contrast in the space of Retzius, but there is also contrast in the paracolic gutters, an intra-peritoneal space.
D. There is contrast leaking from the urinary bladder into both intra-peritoneal (paracolic gutters) and extra-peritoneal spaces (space of Retzius).

A. Adenomyosis is characterized by thickening of the junctional zone of the uterus. This process can be diffuse, as in this case, or focal. Some studies have proposed cut-off values for junctional zone thickness, ranging from 5-12 mm.
B. Adenomyosis is diffuse, ill-defined and usually elliptical in shape while uterine fibroids are focal, usually well-circumscribed masses which exert mass effect on the endometrial sripe.
C. The endometrial stripe is normal in this patient
D. Leiomyosarcomas often present with massive uterine enlargement and large areas of necrosis. Although, it has been suggested that an irregular margin of a leiomyoma should raise suspicion for a leiomyosarcoma, the specificity of this finding is unknown, and there may be significant overlap in the imaging findings of a benign degenerating fibroid and a leiomysarcoma

"A. Classic appearance of a urethral diverticulum is a cystic mass surrounding the female urethra in the low pelvis. Urethral diverticula are thought to develop from rupture of an infected periurethral gland into the urethral lumen. Calculi can form in these diverticula due to urine stasis. Symptoms typically include urinary incontinence (dribbling) and repeated infections. There is increased risk of developing urethral carcinoma.  
B. An urachal diverticulum is located at the dome of the urinary bladder, not at the level of the bladder base or urethra.
C. Gartner duct cyst is an embryologic remnant of the mesonephric duct and is typically located in the anterolateral vagina above the symphysis pubis. This low pelvis, midline cyst would be an atypical location for a Gartner duct cyst.
D. Nabothian cysts are found in the cervix, not the lower pelvis.

"B. Renal angiomyolipoma with spontaneous hemorrhage.

A. The kidney is reduced in size in chronic pyelonephritis.
B. Kidney is reduced in size in reflux nephropathy.
C. Acute renal vein thrombosis gives rise to diffuse edema of the kidney, resulting in a unilaterally enlarged kidney.
D. Kidney is reduced in size in renal artery stenosis.

A. While a corpus luteum cyst is the most common ovarian mass seen in pregnancy, it is not a neoplasm. The corpus luteum is a normal physiologic cyst that secretes progesterone to support the early pregnancy. It usually appears as a simple or sometimes complex cyst in the ovary, usually less then 5cm in size but can be larger.
B. Ovarian tumors of low malignant potential can be seen in women of reproductive age and although they have histological features of malignancy, they are less aggressive then the usual ovarian carcinoma and have a better prognosis. However they are not the most common ovarian tumor seen in pregnant women.
C. Endometriomas are caused by focal deposits of functional endometrial tissue on the adnexae. These appear as cystic adnexal masses filled with low level echoes and are often multiloculated. Although endometriosis is associated with an increased incidence of infertility, endometriomas are occasionally seen in pregnancy, however, C is False, because endometriomas are not true neoplasms.
D. Ovarian cystic teratoma is the most common ovarian neoplasm found in women of reproductive age including pregnant women. In fact, about 10% of cystic teratomas are diagnosed during pregnancy.

A. Approximately 90% of cases of congenital adrenal hyperplasia are secondary to a defect in the 21-hydroxylase enzyme.
B. Because of the blockage in the synthesis of cortisol due to the enzymatic deficiency, cortisol in these patients is diminished, with elevation of ACTH and adrenal hyperplasia.
C. Congenital adrenal hyperplasia is inherited as an autosomal recessive trait.
D. In the more severe forms of the enzyme deficiency, there is diminished production of aldosterone in addition to cortisol. Affected female infants present with masculinization of the external genitalia; however, in male infants initial presentation can be with a salt-wasting crisis, as they are not identified earlier by abnormal genitalia, as is the case in affected female infants.

Cortisol is an adrenal steroid hormone that is required for normal endocrine function. Production begins in the second month of fetal life. Poor cortisol production is a hallmark of most forms of CAH. Inefficient cortisol production results in rising levels of ACTH, which in turn induces overgrowth (hyperplasia) and overactivity of the steroid-producing cells of the adrenal cortex. The defects causing adrenal hyperplasia are congenital (i.e., present at birth).

Cortisol deficiency in CAH is usually partial, and not the most serious problem for an affected person. Synthesis of cortisol shares steps with synthesis of mineralocorticoids such as aldosterone, androgens such as testosterone, and estrogens such as estradiol. The resulting excessive or deficient production of these three classes of hormones produce the most important problems for people with CAH. Specific enzyme inefficiencies are associated with characteristic patterns of over- or underproduction of mineralocorticoids or sex steroids.

A. The upper pole ureter inserts ectopically, inferior and medial to the lower pole ureter as per the Weigert-Meyer rule, and may be associated with a ureterocele. The upper pole ureter may insert beyond the bladder, into the urethra above the sphincter in the male and into the urethra or the vagina in the female.

A. The prostatic utricle is a normal anatomic variant that can occasionally be seen on VCUG, typically a few mm in length. At times the utricle can be quite large, reaching the base of the bladder. When large, it may result in infection and voiding frequency.
B. The prostatic utricle is a normal anatomic variant representing the remnant of the fused caudal ends of the mullerian ducts and thus is the male homologue of the female vagina and uterine cervix.
C. The utricle is located in the prostatic urethra between the ejaculatory ducts in the verumontanum. It extends back and upward within the medial lobe of the prostate.
D. Bladder diverticula are associated with Ehler Danlos syndrome. The prostatic utricle may be seen with prune belly syndrome, Down syndrome or patients with imperforate anus.

b>Findings: The CT scan demonstrates an enlarged ovoid mass located behind the bladder in the area of the right adnexa; the mass shows a peripheral cyst. The sonogram shows this to be a solid mass, with enlarged peripheral follicles, lying dorsal to a normal, small prepubertal uterus. These CT and sonographic findings are characteristic of ovarian torsion.

A. Correct. The test case shows characteristic CT and sonographic findings of ovarian torsion, with an enlarged, edematous ovary and dilated peripheral follicles.
B. Although patients with hydrometrocolpos can present with abdominal pain, hydrometrocolpos typically presents at puberty, with enlargement of a fluid-filled uterine and vaginal canals, due to accumulation of menstrual products. In the test case, the uterus is prepubertal and normal, and instead there is enlargement of the edematous ovary.
C. Ovarian dermoids are not uniformly solid, but rather are largely cystic, and contain fat, calcifications, and other material, such as hair, which lead to areas of inhomogeneous echogenicity. These lesions do not present as enlarged ovaries with peripheral follicles, as illustrated in the test case.
D. Appendicitis does not present as a solid, homogeneous ovoid mass with peripheral cysts. In appendicitis, there is an enlarged tubular structure with surrounding edema, which is not present in this case.
E. Rectal duplication is a cystic, retrorectal mass anterior to the sacrum, which presents with signs of obstruction to the gastrointestinal and urinary tracts.

A. Diethylstilbestrol was given to pregnant patients in the 1950's and 60's to prevent miscarriage. In addition to the characteristic T-shaped uterine cavity seen on HSG and MRI, these patients can have generalized uterine hypoplasia, short strictures of the uterine corpus, vaginal and cervical carcinomas (esp. clear cell adenocarcinoma), and increased spontaneous abortion and premature birth.
B. This is not associated with in utero DES exposure.
C. This is not associated with in utero DES exposure.
D. DES exposure in utero is not associated with urinary tract abnormalities.

A. Ileus is the most common post operative complication, affecting 18-23% of patients.
B. Urinary obstruction is a late complication, not an early complication.
C. Correct.
D. Stricture occurs on the left more than the right because of the angulation of the ureter.
E. Tumor recurrence occurs locally in 3-16% of cases.

A. Correct.
B. For either radiographic or radionuclide cystography, it is important to do a voiding study, to increase sensitivity for detection of vesicoureteral reflux.
C. Focal calyceal blunting or calyceal clubbing, with adjacent parenchymal thinning is the characteristic appearance of reflux nephropathy, or chronic atrophic pyelonephritis.
D. 26-51% of siblings will have VUR.

"A. 60% of patients have urinary incontinence.
B. Most diverticula are the result of repeated infection of the periurethral glands. This results in abscess formation and rupture into the urethra, thereby creating the diverticulum. 30-50% of patients have a history of recurrent urinary tract infections.
C. Urethral diverticula frequently have a characteristic ""saddle-bag"" shape, which can help identify it as originating from the urethra on imaging studies.
D. Voiding cystourethrography is not the most sensitive test for diverticula. MRI and voiding CT urethrography have much better sensitivity.

A. Although the effectiveness of hemodialysis in preventing NSF is unknown, aggressive dialysis is recommended to clear gadolinium from the bloodstream. Current recommendations are for 2 dialysis sessions within 24 hours of gadolinium administration.
B. Lowering dose most likely has a protective effect against NSF as studies have shown that renal failure patients receiving a double dose of gadolinium are much more at risk than in patients receiving a single dose.
C. Peritoneal dialysis (PD) is ineffective at clearing gadolinium (5 ml/min) versus hemodialysis (64 ml/min.) Gadolinium administration in patients on PD should be avoided.
D. Most patients with NSF have had some form of endothelial or vascular injury (such as surgery, thromboembolic event, vascular rejection, malignant hypertension), and up to 90% of patients have undergone some form of surgery (e.g. transplantation, fistula repair, other reconstructive vascular procedures), in addition to compromised renal function and exposure to gadolinium-based contrast agents.
E. NSF is a progressive, often severely debilitating disease that has been shown to involve visceral organs as well as the skin.

A. Only about 65% of pheochromocytomas have high signal on T2 weighted images.
B. Pheochromocytomas are associated with multiple syndromes, including MEN II and III, neurofibromatosis, von Hippel Lindau disease, Carney triad and Sturge Weber syndrome.
C. The only reliable indicator of malignancy in a pheochromocytoma is the presence of metastases. Tumor characteristics such as mitotic rate, capsular invasion and size are not accurate predictors of malignancy.
D. Pheochromocytomas have a variable appearance on imaging studies and can demonstrate hemorrhagic, cystic or fatty change, necrosis and calcification.

A. Papillary renal cell carcinomas typically appear as hypovascular, often minimally enhancing lesions.
B. Renal medullary carcinoma is an aggressive neoplasm which arises almost exclusively in patients with sickle cell trait.
C. According to the Robson system, renal cell carcinoma with both venous involvement and nodal metastases is staged as 3C disease.
D. While up to 33% of oncocytomas have a characteristic central stellate scar, this is not a pathognomonic feature and these benign solid tumors are indistinguishable from renal cell carcinoma on imaging studies.

A. The effect of radiation at this stage is “all-or-nothing.” If the conceptus survives, it is thought to develop fully, with no radiation damage.
B. Risk of prenatal death decreases during this stage, but risk of major organ malformations and growth retardation increase.
C. All risks decrease during this phase, except for cancer risk which is approximately the same throughout gestation.
D. Risk of prenatal death is highest in preimplantation phase and decreases after that.

A. High T1 signal is indicative of hemorrhage, fluid with high protein content, or fat. It is not diagnostic of a teratoma. Drop in signal on fat saturation images is needed to confirm fat within the lesion, and would then be diagnostic of a teratoma.
B. Low T2 signal can be seen in an endometrioma secondary to blood products. However, low signal can also be seen in fibrous lesions such as fibroma. Thecomas and Brenner tumors can also have low signal on T2 images.
C. Most extra-ovarian masses are benign. This is a key imaging feature to determine on any pelvic imaging exam.
D. The opposite is true. Mucinous ovarian neoplasms are typically larger and more complex than serous neoplasms. A serous cystadenoma can present as a unilocular, simple cyst.

A. This is a correct statement.
B. In males, the ectopic ureter insertion is always above the sphincter, and they are continent. A common clinical presentation for males is chronic or recurrent epididymitis due to ectopic insertion into the ipsilateral vas deferens or seminal vesicle.
C. In females, the ectopic ureteral insertion is usually outside of sphincter control and they are incontinent.
D. Most (> 2/3) of cases of extravesical ectopic ureteral insertions are associated with COMPLETE duplication.

A. Stage B disease is tumor confined by the capsule. Stage C disease is extension of neoplasm through the capsule.
B. Tumor transgression is suspected when the capsule is bulging or tumor extends through the capsule. Abutment of tumor to the capsule without bulging is more consistent with Stage B disease.
C. 80-90% of prostate cancers occur in the peripheral zone of the prostate gland.
D. Prostate cancers typically are hypointense relative to the normally hyperintense peripheral zone tissue on T2 weighted images.

A & T1: Clinically localized (tumor not palpable on digital rectal exam)
A1 & T1a: Focal tumor or low grade
A2 & T1b: Diffuse tumor or high grade

B & T2: Clinically localized (tumor palpable)
B1 T2a: Tumor involves <= 1/2 lobe

Findings: Fluid filled tubular structure anterior to the uterus on the left, with adjacent inflammatory change.

A. A urachal diverticulum would be midline and anterior to the bladder.
B. The above findings are most consistent with pyosalpinx.
C. Although the low level echoes within the structure could certainly be seen with an endometrioma, the tubular configuration and degree of surrounding inflammation would be unusual.
D. The abnormality is tubular and clearly involving a tube. An ectopic pregnancy would typically cause more rounded or amorphous lesions with surrounding fluid.

Findings: There are regions of heterogeneous echotexture within the testis, compatible with hematomas. There is a small crescentic fluid collection, compatible with blood, visible at the margin of the testis. There is a loss of continuity of the capsule. Findings are consistent with capsular disruption/testicular fracture, which is an indication for emergent surgery. Approximately 90% of ruptured testes can be salvaged if surgery is performed within 72 hours of testicular injury, whereas later surgery is associated with a salvage rate of only 55%.

A. While a focal region of testicular injury may not be distinguishable from a focal neoplasm on ultrasound alone, this appearance of multiple heterogeneous regions and capsular trauma favors testicular fracture, particularly in the clinical setting of trauma.
B. The combination of loss of definition of the normal well-defined margin of the testicular capsule is a reliable sign of tunica disruption and testicular rupture. Findings of a heterogeneous echotexture within the testis, testicular contour abnormality, and disruption of the tunica albuginea are considered very sensitive and specific for the diagnosis of testicular rupture.
C. Scrotal trauma may result in testicular torsion, usually due to underlying bell-clapper deformity, with sonographic appearance similar to that of non-trauma-related testicular torsion. In testicular torsion without testicular rupture, one would not expect the heterogeneity and interruption in the tunica seen here.
D. There is capsular disruption, as seen by discontinuity of tunica.

Findings: Filling defect is seen in the proximal right ureter, in a non-dependent location.

A. A ureteral calculus would typically be more dense, and would typically be dependent.
B. Findings are most consistent with a small focus of transitional cell cancer in the proximal ureter.
C. Would typically be dependent.
D. Would typically be dependent.

Findings: Multiple hypoechoic masses of the testicle, which demonstrate arterial flow within them, consistent with solid masses within the testis.

A. Possible, although less common than lymphoma involving the testicle.
B. Not typically this relatively well defined and multifocal, with background normal testicular parenchyma.
C. Most common etiology for multiple hypoechoic masses of the testicle in patient of this age. Lymphoma accounts for about 25% of testicular tumors in patients older than 50 years of age. May appear as one or more focal hypoechoic regions or as a diffusely enlarged hypoechoic testis.
D. May appear similar to lymphoma, but less common.

Findings: The post-contrast CT demonstrates a striated enhancement pattern of the parenchyma of the renal transplant in the right pelvis, with wedge-like areas of decreased perfusion. There is a low density lesion which does not fill in with contrast in the upper pole, and mild infiltration of the fat adjacent to the kidney.

A. The finding of wedge-like/striated areas of hypoperfusion of the kidney, with mild infiltration of the adjacent fat, is characteristic of pyelonephritis. The non-enhancing lesion of the upper pole is consistent with a renal abscess.
B. This upper pole low density lesion does not fill with contrast as would be expected in an urinoma, and the abnormal enhancement pattern is characteristic of pyelonephritis.
C. Post transplant lymphoproliferative disease tends to occur approximately 12 months post transplant, and would not be associated with this striated abnormal enhancement of the kidney seen here.
D. The entire transplant is abnormal. Also, infarction with liquifaction would be atypical, especially in the presence of a striated nephrogram.

Findings: There is a right ovarian mass which is hyperintense on both T1 and T2 weighted sequences, however loses signal on frequency-selective fat saturated sequences. This is compatible with a fat containing lesion. A mature cystic teratoma is by far the most common fat containing ovarian tumor.

A. Hemorrhagic masses would be expected to be bright on T1-weighted sequences, but would not lose signal on fat-saturated sequences.
B. Endometriomas are usually bright on T1-weighted sequences, however frequently are lower in signal on T2-weighted images and will not lose signal with fat saturation.
C. Hydrosalpinx appears as a folded tube-shaped structure adjacent to but not within the ovary. It is bright on T2 weighted sequences and can have varying signal on T1-weighted sequences depending on its contents.
D. Mature teratomas contain fat, which will follow the signal of visceral fat on all imaging sequences, including fat-saturated sequences.

Findings: There is a cystic mass in the midline of the prostate gland which demonstrates uniform T2 signal and no enhancement. Out of the choices given, the most likely etiology of a cyst in this location is a Mullerian duct cyst.

A. Of the given choices, this is the most likely cause of a cystic lesion in the midline of the prostate gland. Utricular cysts also occur in the midline but are usually smaller and do not extend above the base of the prostate.
B. Cystic prostate carcinoma is rare and would not appear as a simple cyst. Heterogenous signal, irregular shape and solid nodules would be expected in a cystic prostate cancer.
C. Seminal vesicle cysts are located some distance from the midline.
D. A prostatic abscess can result in a cystic lesion at any location in the prostate, however peripheral enhancement would be expected in the case of an abscess.

Findings: The isthmus of the left fallopian tube is irregular with small, periluminal diverticular collections of contrast, most compatible with salpingitis isthmica nodosa.

A. There are multiple diverticular outpouchings involving an irregular isthmus of the left fallopian tube, compatible with this diagnosis.
B. Endometriosis can be the cause of tubal abnormalities detected on hysterosalpingogram, such as obstruction and hydrosalpinx, however the constellation of findings in this study would not be typical for endometriosis.
C. Tuberculsosis can give rise to isthmic diverticula identical to those seen with SIN, however contraction of the ampulla and adnexal calcifications are frequent associated findings with tuberculosis and are not present in the test patient.
D. There is contrast spillage into the peritoneal cavity.

Findings: There is hyperdense thickening of the collecting systems bilaterally compatible with suburothelial hemorrhage.

A. The presence of hyperdense thickening of the urothelium makes this diagnosis unlikely.
B. There is diffuse high attenuation thickening of the urothelium bilaterally, indicative of suburothelial hemorrhage.
C. While lymphoma can infiltrate into the collecting system, it would not be expected to be hyperdense on noncontrast CT.
D. For the same reasons explained in choices A and C, this choice would be unlikely.

D. Urethral strictures form as a complication of this entity typically when recurrent or peristent gonococcal urethritis is present. The bulbar urethra is the most common site for these probably due to the higher number of periurethral glands in this area. Serial strictures are common and can be short or several centimeters long.

Findings: Dense, bilateral medullary nephrocalcinosis

A. Acute cortical necrosis can cause cortical nephrocalcinosis, not medullary nephrocalcinosis.
B. Hyperparathyroidism with associated hypercalciuria is one of the common causes of medullary nephrocalcinosis. Other common etiologies include other causes of hypercalciuria/hypercalcemia states, medullary sponge kidney and renal tubular acidosis type I. Hyperparathyroidism and renal tubular acidosis type I tend to cause denser nephrocalcinoisis than medullary sponge kidney.
C. Chronic glomerulonephritis is a cause of cortical nephrocalcinosis, not medullary nephrocalcinosis.
D. Xanthogranulomatous pyelonephritis (XGP) is characterized by staghorn calculi located in the renal pelvis and infundibula, not calcifications in the renal medulla. Additionally, the calyces are typically dilated and filled with low density debris in Xanthogranulomatous pyelonephritis.

A. Most cases occur in renal insufficiency patients who have received a gadolinium based  contrast agent.

A. Clear cell renal cell carcinoma constitutes 65% of cases of renal cortical neoplasms.

Pathology of RCC:

"D. Surface epithelial neoplasms of the ovary, the most common type of ovarian malignancy, typically present as cystic, multilocular masses with solid components. They typically are large at presentation and often are already in advanced stages of disease.

CA-125 is useful for gauging progress of treatment of known disease but is not an accurate screening test.

"B. This area surrounds the proximal prostatic urethra and is the common site of BPH. Only 10% of prostate cancers occur in this zone.

The peripheral zone is where you see adenocarcinoma.

Graphic displays zonal prostate anatomy at 3 different levels. The central zone (orange (white curved)) surrounds the ejaculatory ducts (black arrow) and encloses the periurethral glands and transitional zone (blue (black curved)), which can be grossly enlarged in BPH. The peripheral zone (green (white open)) forms an outer crescent of glandular tissue and is the most common site for developing carcinoma. Note the urethra (black open).

C. Unicornuate uterus is associated with renal anomalies in up to 40% of cases. It has the strongest association with renal anomalies of all the mullerian duct anomalies.

C. Undescended testicles are seen in up to 20% of premature males.

Most commonly found in the inguinal canal.

B. Correct.

More common in men by 3:1.

"C. This is the classic presentation of a hypoplastic kidney.

Hypoplastic kidney: < 1/2 size of contralateral kidney
Calyces and parenchyma are normal in proportion
Architecture should be normal, not scarred or dysplastic
Just smaller version of opposite kidney

Dysplasia: Congenitally malformed parenchyma
Chronic scarring and fibrosis also sometimes called ""dysplasia""

C. With Type 3 urethral injury, there is extravasation into the perineum.

Type 3 urethral injury involves urethral rupture at or below the UG diaphragm, resulting in extravasation into the perineum (and possible pelvis).

D. Diabetes is the most common cause of papillary necrosis in adults

C. Using a different contrast agent has been advocated as possibly effective in preventing a repeat reaction. This is in addition to a premedication regimen with steroids.

B. The upper pole obstructs and inserts posterolaterally. May have pseudoureterocele from stone.

D. True.

D. This is the most likely answer as it is the most common neoplasm of the bladder, accounting  for about 90% of bladder malignancies.

A. This is the correct answer as it is the only choice that would classically produce medullary nephrocalcinosis. This patient had hyperparathyroidism resulting in her hypercalcemia. The calcification in the lower right pelvis was a partially obstructing distal right ureteral calculus.

D. This is the correct answer since the filling defects are irregular and linear and not in a midline or other characteristic pattern for intrauterine anomalies. Likewise, the filling defects are not smooth or extrinsic as would be more typical for leiomyomata. This patient had undergone dilatation and curretage 9 months prior to this exam.

A. Greater than 80% of unilocular cysts identified in premenopausal women are benign, functional cysts that resolve on follow-up ultrasound exams in 6-8 weeks.

B. The nephrogram in acute renal failure can occasionally be striated in appearance.

D. This is the best explanation for this infiltrating penile mass with an enlarged enhancing inguinal lymph node.

C. The air density is consistent with the diagnosis.

A. The faulty attachment, or bell-clapper deformity, is an anatomic anomaly in which the tunica vaginalis completely surrounds the testis, causing the testis to be attached only to the spermatic cord and otherwise be freely suspended in the scrotal sac like a clapper in a bell. This predisposes to testicular torsion, and is usually present bilaterally, necessitating orchiopexy of the contralateral testicle as well at the time of surgery for the torsed testicle.
B. The viability of the testis depends on the duration of torsion as well as the number of twists of the spermatic cord. Infarction can occur as early as 4 hours after the appeararce of symptoms. However, if the degree of torsion is low (180 to 360 degress), the testes may remain viable for more than 24 hours. Typically, urologists try to operate within 6 hours of onset of symptoms.
C. Correct. Testicular ischemia in torsion may be seen as absence of flow or asymmetrically decreased flow on color Doppler.
D. In torsion, the affected testis will maintain a normal gray scale US appearance, until the point of infarction, at which time the testis will become hypoechoic and may be inhomogeneous.

A. Rather, women with dilated fallopian tubes are at increased risk for peritonitis.
B. If you see tubal abnormalities, women require an immediate dose of 200 mg followed by 100 mg of doxycycline BID for 5 days.
C. Women also need doxycycline in additon to the amoxicillin, since the amoxicillin is only a one time dose. Women need the doxycycline for 5 days.
D. Correct. The quoted risk is 1.4%.

A. Intravenous urography is normal in 80% of cases of uncomplicated acute pyelonephritis.
B. Correct. In acute pyelonephritis, noncontrast scans are typically normal or show only renal enlargement. Following contrast administration, striated or wedged areas of decreased contrast enhancement are often seen. Perinephric stranding may also be demonstrated on CT.

A. Incorrect. Ultrasound exam is usually negative. MRI is more sensitive (up to 70%).
B. Incorrect. An ovary is involved in approximately 60% of cases and there is often bilateral involvment.
C. Correct. The fibrotic reaction resulting from endometriosis can lead to complications such as infertility and bowel obstruction.
D. Incorrect. Endometrial implants tend to be small, 3-5 mm, which accounts for much of the difficulty in imaging this disease.

A. Usually presents in the perinatal/prenatal age group.
B. Usually results in enlarged kidneys but with innumerable tiny cysts.
C. Associated with oligohydramnios.
D. Correct. The hyperechogenicity is believed due to the extensive specular echoes from the numerous tiny 1-8 mm cysts/ectatic tubules as well as the compressed cortical tissue.

A. Incorrect. Multilocular cystic nephroma is a benign neoplasm.
B. Incorrect. Definative diagnosis is difficult preoperatively. This lesion is difficult to separate from cystic renal cell carcinoma.
C. Correct. While this is a classic feature of this lesion, it is not pathognomonic.
D. Incorrect. Usually innumerable thick septations with enhancement.

A. Correct.
B. Incorrect. Only a small percentage present with bilateral small kidneys.
C. Incorrect. Usually bilateral but may be asymmetric depending on the etiology.
D. Incorrect. These two very uncommonly coexist.

A. Correct. Renal agenesis is most often associated with unicornuate uterus.
B. Incorrect. Unilateral adrenal agenesis occurs in approximately 10%.
C. Approximately 75% are male.
D. Associated with ipsilateral seminal vesicle cyst.

A. This is the definition of a class IV anomaly commonly known as a bicornuate uterus.
B. This is the definition of a class V anomaly known as a septate uterus.
C. Correct. This is the definition of a class III anomaly known as uterus didelphys.
D. This is classically a class VI anomaly known as an arcuate uterus.

A. This is the definition of a class IV anomaly commonly known as a bicornuate uterus.
B. This is the definition of a class V anomaly known as a septate uterus.
C. Correct. This is the definition of a class III anomaly known as uterus didelphys.
D. This is classically a class VI anomaly known as an arcuate uterus.

A. Correct. Acute tubular necrosis can appear during or immediately after surgery.
B. Acute rejection becomes apparent 1-4 weeks after surgery.
C. Incorrect. Accelerated acute rejection becomes apparent in the first post operative week.

A. Conn's syndrome is the result of excess aldosterone production.
B. Correct. The most common etiology is a benign adenoma. 70% of cases are due to an adenoma.
C. Incorrect. 30% of cases of hyperaldosteronism are due to adrenal hyperplasia.
D. The most common etiology for primary hyperaldosteronism is a benign adenoma (70% of cases are due to an adenoma). Adrenocortical carcinoma causes aldosteronism in less than 1% of patients, and when it does, there is usually also hypercortisolism.