23205001

Section VI – Genitourinary Radiology

Figure 1
136. You are shown a sagittal T2-weighted image from an MR of the pelvis in a 38-year-old woman
with pelvic pain (Figure 1). What is the MOST likely diagnosis?

A. Leiomyoma
B. Adenomyosis
C. Endometrial cancer
D. Cervical cancer

1
Diagnostic In-Training Exam 2006

Question #136
Rationales:
A. Incorrect. 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 bor-
ders 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. Incorrect. For endometrial cancer, one would expect the high intensity endometrial stripe to be
thickened, as well as inhomogeneous.
D. Incorrect. 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.

2 American College of Radiology


Figure 2A
137. You are shown two ultrasound images of the scrotum in a 44-year-old man (Figures 2A and 2B).
What is the MOST LIKELY diagnosis?

A. Testicular torsion
B. Seminoma
C. Epididymo-orchitis
D. Lymphoma



Figure 2B

4

Question #137
Rationales:
A. Incorrect. 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 intratestic-
ular neoplasm.
C. Incorrect. While epididymo-orchitis can cause enlargement of the testicle as well as hypoechoic
areas within the testicle, it is not typically painless.
D. Incorrect. While lymphoma could present as a testicular mass, it is less common than germ cell
tumors such as seminoma.



Figure 3A

Figure 3B



Figure 3C
138. You are shown a pelvic ultrasound (Figure 3A) and T1-weighted (Figure 3B) and fat-saturated
T1-weighted (Figure 3C) MR images in a pregnant patient. What is the MOST likely diagnosis?

A. Ectopic pregnancy
B. Ovarian teratoma
C. Ovarian serous cystadenoma
D. Ovarian fibroma

7

Question #138
Rationales:
A. Incorrect. An ectopic pregnancy can present as a complex mass by ultrasound, although it typically
will not have the classic features of a teratoma described in the discussion for the correct answer in
“A”. More importantly, a heterotopic pregnancy (concurrent intra-uterine and ectopic pregnancy)
incidence is estimated at 1 out of 30,000 pregnancies. The finding of an intrauterine pregnancy
effectively excludes an ectopic pregnancy in a patient except for those with high risk factors (ovula-
tion induction, etc.)
B. Correct. The ovarian teratoma (dermoid) is the most common ovarian neoplasm and occur most
commonly during the reproductive years of a woman’s life.
The ultrasound exam demonstrates a complex right adnexal mass that has two features highly sug-
gestive of an ovarian teratoma. The first is the highly echogenic, non-shadowing nodule along the
caudal wall of the mass. This is most consistent with a Rokitansky protuberance in a teratoma. The
second is the hyperechoic lines and dots within the cystic portion of the mass that is caused by hair
within the teratoma.
The MRI confirms the diagnosis by showing high signal intensity fat within a portion of the mass
on T1 images that “saturates” or loses signal intensity on T1 images with fat suppression technique.
This is diagnostic of an ovarian teratoma containing fat.
C. Incorrect. Serous cystadenoma is the most common epithelial neoplasm of the ovary and can occur
in a young, pregnant female. However, the sonographic appearance is typically of an anechoic,
unilocular cyst or minimally complex cyst with a few internal septations. Additionally, there would
be no evidence for fat within the mass as is seen with the teratoma in this case.
D. Incorrect. The ovarian fibroma is an uncommon neoplasm of the ovary in the stromal tumor catego-
ry. It comprises only 4% of ovarian neoplasms. The sonographic appearance is typically of a solid,
hypoechoic or mixed echogenicity mass that may attenuate sound posteriorly much like a peduncu-
lated leiomyoma. Additionally, no fat would be present within this neoplasm.



Figure 4
139. You are shown a delayed contrast-enhanced CT image (Figure 4) in a 60-year-old with
hematuria. What is the MOST LIKELY diagnosis?

A. Schistosomiasis
B. Blood clots
C. Cystitis cystica
D. Transitional cell carcinoma


Question #139
Rationales:
A. Incorrect. Not a typical appearance. No calcifications.
B. Incorrect. Should not be adherent to the wall and enhancing.
C. Incorrect. Not cystic.
D. Correct. Often multifocal. Classically enhance. Rarely calcify.

10


Figure 5
140. You are shown an image from a hysterosalpingogram on a 32-year-old woman (Figure 5).
What is the MOST LIKELY diagnosis?

A. Uterine hypoplasia
B. Unicornuate uterus
C. Fundal fibroid
D. Asherman’s syndrome


Question #140
Rationales:
A. Incorrect. No contrast has entered the endometrial cavity. Only the endocervix contains contrast.
Thus, you cannot comment on the size of the uterus.
B. Incorrect. No contrast has entered the endometrial cavity. Thus, there is no evidence that only one
uterine horn exists.
C. Incorrect. No contrast has entered the endometrial cavity. In addition, HSG doesn’t allow the specif-
ic diagnosis of filling defects which might be seen within the endometrial cavity. A differential
diagnosis must be given, including polyp, fibroid, synechia, and cancer.
D. Correct. Contrast fills only the endocervix, despite multiple attempts to fill the endometrial cavity.
These women usually report having very short and light menstrual days and give a history of a prior
D&C (common) or prior complications from pregnancy (uncommon).

12


Figure 6A

Figure 6B



Figure 6C
141. You are shown three images (Figures 6A through 6C) from a contrast-enhanced MR exam on
a man with renal cell carcinoma. Based on these images, what is the stage by Robson
classification?

A. Stage II
B. Stage IIIA
C. Stage IIIB
D. Stage IV

14

Question #141
Rationales:
A. Incorrect. Stage II extends beyond the renal capsule but not through Gerota’s fascia or into the renal
veins or local lymph nodes. Stage II includes involvement of the ipsilateral adrenal gland, which
this patient does have on the left.
B. Correct. Stage IIIA extends into the renal vein and may progress into the inferior vena cava.
C. Incorrect. Stage IIIB involves regional lymph nodes but no extension into the renal veins or IVC.
D. Incorrect. Stage IV includes distant metastases.


142. Which of the following is associated with testicular microlithiasis?

A. Testicular torsion
B. Epididymo-orchitis
C. Right-sided varicocele
D. Testicular neoplasm

Question #142
Rationales:
A. Incorrect. Microlithiasis is not typically seen in testicular torsion.
B. Incorrect. While the calcifications may be the result of prior infection, it does not have an increased
association with infection.
C. Incorrect. There is no increased incidence of varicocele with testicular microlithiasis..
D. Correct. While testicular microlithiasis is often incidental, there is an increased incidence of testic-
ular neoplasm, most of which are germ cell tumors.


Concerning renal medullary carcinoma, which one is TRUE?
143.

A. Usually peripheral in location
B. Commonly seen in diabetic females
C. Common in patients with sickle trait
D. Often very small at presentation

Question #143
Rationales:
A. Incorrect. They are usually central.
B. Incorrect. Commonly seen in African American patients with sickle trait; more commonly male.
There is no association with diabetes.
C. Correct. Renal medullary carcinoma typically is seen as an infiltrative mass in patients with sickle
trait.
D. Incorrect. They are usually large at presentation.

17

Concerning bladder rupture, which one is TRUE?
144.

A. There is equal incidence between intraperitoneal and extraperitoneal rupture.
B. Extraperitoneal bladder rupture causes elevated serum creatinine.
C. Delayed images after a contrast-enhanced CT scan are sufficient to exclude it.
D. Intraperitoneal bladder rupture requires surgical repair.

Question #144
Rationales:
A. Incorrect. Most bladder ruptures, two-thirds, are extraperitoneal, caused by trauma and pelvic frac-
tures.
B. Incorrect. The uremia and elevated creatinine occur because of INTRAPERITONEAL ruptures, not
extraperitoneal ruptures.
C. Incorrect. 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 fill-
ing, overcomes this obstacle, by filling the entire bladder lumen with contrast. In addition, CT cys-
tograms 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.


Concerning prostate carcinoma, which one of the following is CORRECT?
145.

A. 30% of prostate cancers arise from the peripheral zone of the prostate.
B. T1-weighted images provide the best contrast for detecting most prostate carcinomas.
C. Most prostate cancers demonstrate increased enhancement on immediate post-
gadoliniumfat-saturated T1 images.
D. Prostate cancer metastasizes early along the gonadal vein/lymphatic pathway to the periaortic
and pericaval region near the level of the kidneys.

Question #145
Rationales:
A. Incorrect. 70% of prostate cancers arise from the peripheral zone, the remainder from the transition-
al and central zones.
B. Incorrect. 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. Incorrect. 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.

19

Concerning gonadal vein thrombosis, which one is TRUE?
146.

A. Most common on the right side in post partum women
B. Best study for diagnosis is excretory urography
C. Usually treated surgically
D. Commonly seen in diabetic males

Question #146
Rationales:
A. Correct. TRUE. Gonadal vein thrombosis is in the differential for cause of fever in post partum
woman.
B. Incorrect. FALSE. CT or MR are most sensitive in detection of gonadal vein thrombosis. The diag-
nosis may also be made with US. IVU would not be expected to be helpful in this diagnosis.
C. Incorrect. FALSE. Patients are usually treated with anticoagulation and antibiotics.
D. Incorrect. FALSE. There is no association with diabetes; gonadal vein thrombosis is most com-
monly seen in post partum women (answer A).


Concerning pseudodiverticula of the ureter, which one is TRUE?
147.

A. They represent ulcerations within a transitional cell carcinoma lesion.
B. They represent the site of premalignant lesions, similar to carcinoma in situ.
C. 40% of patients have co-existing transitional cell carcinoma.
D. They warrant semi-annual investigation.

Question #147
Rationales:
A. Incorrect. They represent intramural outpouchings from the ureter. They indicate an increased risk
of transitional cell carcinoma, either in the ipsilateral ureter or in the bladder.
B. Incorrect. They are benign, but indicate mural inflammation, thought to predispose the patient to
developing malignancy.
C. Incorrect. Up to 25% of patients with pseudodiverticula have TCC in the ipsilateral ureter or blad-
der.
D. Correct. Patients require immediate work-up. If, however, they do not have transitional cell carci-
noma, they need semi-annual follow-up to exclude the interval development of tumor.

21

148. Concerning cervical carcinoma, what stage is a lesion that is confined to the upper two thirds of
the vagina on clinical exam and that shows right hydroureter to the level of a poorly defined cer-
vical soft tissue mass on CT exam?

A. Stage II A
B. Stage II B
C. Stage III A
D. Stage III B

Question #148
Rationales:
A. Incorrect. 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 blad-
der.
B. Incorrect. Stage II B has obvious parametrial involvement but does not extend to the pelvic side
wall.
C. Incorrect. 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-func-
tioning kidney.


Concerning renal lymphoma, which one is TRUE?
149.

A. Multiple or solitary focal nodular masses are the most common form.
B. It demonstrates uniform, hyperintense enhancement after IV gadolinium.
C. Direct extension to and involvement of the psoas muscle is more characteristic of primary renal
cell carcinoma than of renal lymphoma.
D. Tumor thrombus commonly occurs in renal lymphoma.

Question #149
Rationales:
A. Correct. There are 3 basic patterns of renal involvement by lymphoma: 1) direct invasion by adja-
cent nodal disease, 2) focal masses that may be solitary or multiple (most common), and 3) diffuse
infiltration.
B. Incorrect. Renal lymphoma typically enhances minimally to a mildly heterogenous pattern.
C. Incorrect. Renal lymphoma can commonly extend to and involve the adjacent psoas muscle. This
feature is rare in primary renal carcinoma.
D. Incorrect. Renal lymphoma rarely causes tumor thrombus. This is a common feature of renal carci-
noma.

23

Which one would result in a pelvic CT image that is abnormally noisy?
150.

A. Higher-than-normal tube voltage (kVp)
B. Thicker-than-normal slice thickness
C. Smoothing reconstruction algorithm
D. Lower-than-normal tube current

Question #150
Rationales:
A. Incorrect. Higher kVp yields lower image noise.
B. Incorrect. Increasing slice thickness decreases image noise.
C. Incorrect. Normally smoothing algorithms decreases image noise.
D. Correct. Lower tube current means fewer x-ray photons, therefore increased image noise.


Concerning adrenal cortical carcinoma, which one is TRUE?
151.

A. It is the most common cause of an adrenal mass.
B. It most often displays areas of macroscopic fat.
C. It usually presents with <10 H.U. on non contrast CT.
D. It usually presents as a large heterogeneous soft tissue mass.

Question #151
Rationales:
A. Incorrect. Adrenal adenoma and metastatic disease are much more common than primary adrenal
cortical carcinoma.
B. Incorrect. While fat can rarely be seen in these tumors, macroscopic fat in an adrenal lesion is
almost always in a myelolipoma.
C. Incorrect. Adrenal adenomas are more likely to present with the above characteristics.
D. Correct. Most adrenal cortical carcinomas are > 6 cm and often have central necrosis. Calcification
is seen in approximately 30% of these lesions.

25

Concerning post-transplantation lymphoproliferative disorder, which one is TRUE?
152.

A. Epstein Barr virus infection is associated with the disorder.
B. T1- and T2-weighted MR images reveal hyperintense areas of soft tissue centrally within
the kidney.
C. It affects 12% of patients with solid organ transplants.
D. Radiation may be necessary if chemotherapy fails to involute the tumor.

Question #152
Rationales:
A. Correct. Despite advances in antiviral therapy, Epstein-Barr virus-induced posttransplant lympho-
proliferative disease (EBV-PTLD) continues to be a major complication after solid organ transplan-
tation.
B. Incorrect. MR imaging reveals hypointense tissue on both T1- and T2-weighted images. The tissue
shows little enhancement with gadolinium.
C. Incorrect. It affects 2% of patients with solid organ transplants.
D. Incorrect. First line of therapy is reduction in the level of immunosuppression. If that fails,
chemotherapy is warranted.


Which one of the following findings on IVU is MOST sensitive in detecting mild, acute ureteral
153.
obstruction?

A. Delayed, increasingly dense nephrogram
B. Demonstration of medullary rays in the nephrogram
C. Delayed opacification of the calyces and collecting system
D. Blunting of the calyceal fornices

Question #153
Rationales:
A. Incorrect. The classic “obstructive nephrogram” is often absent in mild, acute obstruction.
B. Incorrect. Medullary rays or faint striations may be seen in acute obstruction of moderate severity,
but may be absent in cases of mild obstruction.
C. Incorrect. Delayed opacification of the collecting system is a consequence of more severe obstruc-
tion and secondary oliguria.
D. Correct. Calyceal blunting is an excellent sign of mild obstruction. Visualizing sharp fornices virtu-
ally excludes mild obstruction.

27

Concerning adrenal adenomas, which one is TRUE?
154.

A. They are a more common cause of adrenal mass than is metastatic disease.
B. They typically have non-IV contrast density of more than 20 Hounsfield units.
C. They typically show no decrease in signal intensity on opposed phase MR imaging.
D. They typically retain 90% of their immediate contrast value on 10-minute delayed CT exam.

Question #154
Rationales:
A. Correct. Adenomas are the most common adrenal mass and occur in 2 - 8 % of the population.
B. Incorrect. Adenomas most often have non contrast density of less than 10 H.U.
C. Incorrect. Adenomas typically decrease in signal intensity on the out of phase portion of opposed
phase imaging.
D. Incorrect. Adenomas typically washout 50% of their initial enhancement levels on a 10 minute
delayed CT exam.


Concerning urothelial malignancy, which one is TRUE?
155.

A. Adenocarcinoma is the second most common urothelial malignancy.
B. Leukoplakia is associated with transitional cell carcinoma of the bladder at the urachal remant.
C. Transitional cell carcinoma of the upper collecting system is less common than within the
bladder.
D. 50% of primary renal malignancies develop from the urothelium.

Question #155
Rationales:
A. Incorrect. Transitional cell carcinoma is the most common urothelial malignancy followed by squa-
mous cell carcinoma. Adenocarcinoma is distinctly rare.
B. Incorrect. 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 glan-
dular epithelium and result in adenocarcinoma.
C. Correct. The entire urothelium is at risk, but transitional cell carcinomas are more common in the
bladder than in the upper tracts.
D. Incorrect. 8% of renal malignancies develop from the urothelium.

29

Concerning renal cystic disease, which one is TRUE?
156.

A. Autosomal recessive polycystic disease typically presents as multiple bilateral cysts in adult-
hood.
B. Autosomal dominant polycystic disease typically presents as enlarged hyperechoic kidneys in
the neonatal period.
C. Acquired cystic renal disease in chronic renal failure patients on dialysis is indistinguishable
from autosomal dominant polycystic disease.
D. Autosomal dominant polycystic disease has a higher incidence of associated hepatic cysts than
does autosomal recessive polycystic disease.

Question #156
Rationales:
A. Incorrect. 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. Incorrect. This description is more typical of the appearance of the infantile form of ARPKD.
C. Incorrect. 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.


Concerning renal angiomyolipomas, which one finding is MOST diagnostic?
157.

A. Fluid/fluid levels
B. Fat
C. Homogeneous soft tissue
D. Large irregular calcification

Question #157
Rationales:
A. Incorrect. 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. Incorrect. 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 carcino-
ma and should be treated as such.
D. Incorrect. Calcification in angiomyolipomas is unusual but may occur if there has been prior hem-
orrhage.

31

158. What characterizes Type II posterior urethral injury?

A. The membranous urethra is disrupted with extension of injury into the proximal bulbous urethra
and/or disruption of the urogenital diaphragm (UGD).
B. On urethrography, contrast material extravasates into the perineum.
C. Disruption of the urethra above the urogenital diaphragm.
D. The posterior urethra is stretched but intact.

Question #158
Rationales:
A. Incorrect. This is the definition of Type III posterior urethral injury.
B. Incorrect. Extravasation of contrast below the urogenital diaphragm (UGD) into the perineum on
urethrography indicates disruption of the UGD and signifies Type III injury.
C. Correct. This is the definition of Type II posterior urethral injury.
D. Incorrect. This is the definition of Type I posterior urethral injury.


Which one of the following conditions is MOST closely associated with female pelvic
159.
inflammatory disease (PID)?

A. Intramural pseudodiverticulosis
B. Salpingitis isthmica nodosa
C. Adenomyosis
D. Leukoplakia

Question #159
Rationales:
A. Incorrect. 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. They is most easily seen during hysterosalpingography.
C. Incorrect. Adenomyosis is the presence of endometrial glands and supporting tissue in the
myometrium. Increased incidence due to childbirth, Cesarean section, trauma, and tubal ligation.
D. Incorrect. Leukoplakia is an inflammatory condition of the ureter or bladder, associated with chron-
ic urinary tract infection and not PID per se.

33

160. A lateral abdominal radiograph is taken of a pregnant woman with a transmission path length of
30 cm. If the entrance dose is 10 mGy (1 rad), and the half-value layer thickness for the x-ray
beam is 3 cm of tissue, what is the approximate dose to the center of the uterus from the primary
radiation?

A. 0.3 mGy
B. 1 mGy
C. 2 mGy
D. 5 mGy

Question #160
Rationales:
A. Correct. The middle of the uterus would be midline in the patient, at a depth of 15cm. Since the
HVL equals 3 cm of tissue, the radiation must pass through 5 HVL’s of tissue to reach the uterus.
The primary radiation will then be reduced by (1/2)^5 or 1/32nd of the incident intensity.
B. Incorrect. See correct answer
C. Incorrect. See correct answer
D. Incorrect. See correct answer


Concerning epididymo-orchitis, which one is TRUE?
161.

A. Physical exam shows increasing testicular pain when the scrotum is raised above the level of the
symphysis pubis.
B. Hypervascularity in the epididymis and adjacent testicle supports the diagnosis.
C. Testicular involvement is seen in 80% of cases of epididymitis.
D. Treatment requires antibiotic therapy for 10 days to 2 weeks.

Question #161
Rationales:
A. Incorrect. Raising the scrotum above the level of the symphysis pubis DECREASES the scrotal
pain. This maneuver, known as the Prehn sign, helps to differentiate between epididymo-orchitis
and testicular torsion.
B. Correct. Hypervascularity of the epididymis and adjacent testicle are typically seen in epididymo-
orchitis. Studies have shown that males with epididymo-orchitis have resistive indices below 0.5 in
50% of cases. A peak systolic velocity higher than 15 cm/sec yields sensitivity for epididymo-orchi-
tis of 90-93%.
C. Incorrect. Orchitis is seen in 20-40% of cases of epididymo-orchitis.
D. Incorrect. The testicle is a sanctuary zone. Thus, antibiotic therapy is recommended for 4-6 weeks
to exclude recurrence of infection.

35

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