Viva cases and tips

I made this list while preparing for viva. The list is not exhaustive but common cases are listed. Practice making “set answers” for these common cases are present them out loud.

Some material is copied from journal articles and so this should only be used for personal use.

DDs

Diffuse dense bones
    1. Child
      1. Osteopetrosis – Erlenmeyer flask deformity, bone-in-bone, sandwich vertebrae, h/o anaemia, thrombocytopenia, supernumerary teeth
      2. Pyknodysostosis –  short stature, hypoplastic lateral ends ofclavicles, hypoplastic terminal phalanges, bulging cranium anddelayed closure of the anterior fontanelle, wormian bones.
    2. Adult
      1. Blastic mets – prostate and breast – look for breast shadow (absent in female and present in male! from hormone therapy for prostate cancer)
      2. Renal osteodystrophy – look for PD catheter, Permcath, HPT findings like subperiosteal resorption
      3. Fluorosis – ligament calcification, interosseous membrane ossification
      4. Myelofibrosis – extramedullary hemopoesis, splenomegaly
      5. Lymphoma – splenomegaly
      6. Mastocytosis – splenomegaly with small bowel wall thickening
  1. Erlenmeyer flask – Lead GNOME
    1. Dense metaphyseal band – lead poisoning
    2. Generalised osteopenia with pencil thin cortex + AVN + HSmegaly – Gaucher
    3. Niemann Pick
    4. Diffuse sclerosis – osteopetrosis
    5. Sclerosis of the diaphysis and lucency in the metaphysis – Metaphyseal dysplasia – Pyles
    6. Coarse trabeculae cobweb bone – thalassemia
  2. Sclerotic lesion with lucent center
    1. OO
    2. Osteoblastoma
    3. Brodie
  3. Coarse trabecular pattern
    1. Paget – bone expanded
    2. Thalassemia
    3. Hemangioma (in VB and skull)
    4. Osteoporosis
  4. Metastasis
    1. Lytic expansile – RCC, melanoma, thyroid
    2. Sclerotic – prostate, breast, TCC, stomach
  5. Epiphysis lesion:
    1. Chondroblastoma
    2. GCT
    3. EG
    4. Osteomyelitis
  6. Grossly expansile lytic lesions of the bone
    1. RCC, thyroid mets
    2. ABC
    3. Plasmacytoma
    4. Telangiectatic OS
  7. Widening of ribs:
    1. Chronic anemias
    2. FD
    3. Paget
  8. Lateral clavicle resorption:
    1. MM
    2. Post traumatic osteolysis
    3. Metastasis
    4. Hyperparathyroidism
    5. RA
  9. Lytic lesion in terminal phalange:
    1. Glomus tumour
    2. Epidermoid inclusion cyst
    3. Enchondroma
    4. Sarcoid
    5. Bronchogenic carcinoma metastases
  10. Bilateral symmetrical periosteal reaction
    1. Adults:
      1. HPOA
      2. Vascular insufficiency – always lower limb
      3. Thyroid acropachy – hand – thumb and index finger
      4. Pachydermoperiostitis
      5. DISH
    2. Children:
      1. Caffey disease – mandible, clavicle, long bone diaphysis
      2. Leukaemia
      3. NAI – with fractures
      4. Rickets – with splaying and fraying
  11. Madelung
    1. Dyschondrosteosis – mesomelic dwarfism
    2. Idiopathic
    3. Turner
    4. Diaphyseal aclasis
    5. Enchondromatosis – Olliers
  12. Fused carpals
    1. Apert
    2. JRA
    3. TB
  13. Short 4th MC
    1. Turner
    2. Sickle cell (dactylitis – infarction)
    3. Pseudo and pseudopseudohypoparathyroidism
  14. Miliary lung nodules:
    1. Metastasis: thyroid, melanoma, breast (rare but disease more common), lung (rare but disease more common)
    2. TB
    3. Sarcoid
    4. Wegner / RA (larger than miliary)
    5. High density:
      1. Alveolar microlithiasis – asymptomatic
      2. Silicosis, stannosis
      3. Healed varicella – no LN
      4. Healed histoplasmosis – calcified LN
      5. Hemosiderosis – in MS
      6. Metastasic calcinosis – HPT, milk alkali, sarcoid
  15. Bilateral apical fibrosis
    1. TB
    2. Sarcoid – hilar nodes, lung parenchymal changes
    3. AS – look for spine changes, AVN from steroids
    4. Pneumoconiosis (except asbestosis which affects lower lobes) egg shell nodes
    5. HP
    6. Radiation –
  16. Cavitating lung mass
    1. TB
    2. SCC
    3. Wegner
    4. Septic emboli
  17. Bilateral lower zone fibrosis
    1. IPF
    2. Asbestosis – look for pleural plaques
    3. Systemic sclerosis – look for dilated oesophagus, cutaneous calcinosis. Correlate with ANA
    4. Bleomycin/amiodarone – look for sclerotic bones (bleomycin) and a dense liver
    5. RA – look for clavicle erosion
  18. Egg shell calcification nodes:
    1. Sarcoid
    2. Silicosis
    3. CWP
    4. Histoplasmosis
    5. Treated lymphoma
  19. Chronic air space opacification (present over several radiographs):
    1. COP
    2. BAC
    3. Chronic eosinophilic pneumonia
    4. Lipoid pneumonia
  20. Hyperlucent lung:
    1. Foreign body
    2. Pneumothorax
    3. Pulmonary embolism
    4. Chest wall
    5. Swyer James
    6. Asthma
  21. Pericardial calcification –
    1. TB
    2. Post viral
    3. uremic pericarditis
  22. Calcified liver lesion –
    1. Granuloma
    2. Hydatid
    3. Metastasis – mucinous adenocarcinoma bowel, osteosarcoma, islet cell tumour
  23. Lesions crossing the corpus callous –
    1. GBM
    2. Lymphoma
    3. Demyelination
  24. Periarticular calcification –
    1. Myositis ossificans: peripheral to central calcification, trauma
    2. Synovial osteochondromatosis – evenly sized loose bodies with central lucency
    3. Tumoral calcinosis – black ethnicity, lobulated mass-like, fluid level on MRI
    4. Synovial sarcoma – soft tissue around the knee
    5. Soft tissue calcification near a long bone –
      1. Parosteal osteosarcoma
      2. Juxtacortical hematoma
  25. Ivory vertebra – Mets.. LP HIM
    1. Metastasis – patchy sclerosis
    2. Lymphoma – diffuse sclerosis, can be anterior VB scalloping from LN
    3. Paget – sclerosis is more in the periphery with expanded vertebra – picture frame
    4. Hemangioma – increased trabeculation and expansion but younger age than paget
    5. Infection – end plate destruction and multiple level involvement
    6. Mastocytosis
  26. Sandwich vertebra
    1. Renal osteodystrophy – blurred margin between end plate sclerosis and central lucency – rugger jersey
    2. Osteopetrosis – sharp – bone within bone
    3. Paget – picture frame
  27. Sequestrum:
    1. Osteomyelitis
    2. Lymphoma
    3. LCH
  28. Lucent metaphyseal bands:
    1. Rickets – with other signs
    2. Leukemia – with periosteal reaction due to subperiosteal leukemic infiltrate
    3. Neuroblastoma metastasis – asymmetrical, permeative
  29. Short 4th metacarpal:
    1. Post-traumatic.
    2. Postinfarction (e.g.from sickle cell disease).
    3. Turner’ssyndrome.
    4. Pseudohypoparathyroidism.
    5. Pseudopseudohypoparathyroidism.
  30. Acro-osteolysis
    1. Hyperparathyroidism – mid portion with calcification
    2. Scleroderma – distal tuft or base (erosion) with calcification
    3. Psoriatic – base
    4. Raynaud – can occur with scleroderma
    5. Pyknodysostosis
  31. Madelung deformity
    1. Turner – short 4th MC
    2. Dyschondrosteosis
    3. Diaphyseal aclasis
  32. Vertebra plana –
    1. EG – MC in children – spared posterior elements
    2. Osteoporosis – generalised osteopenia
    3. Infection (TB) – end plate destruction
    4. Neoplasm – metastasis, lymphoma, myeloma – preserved end plates
    5. Trauma
    6. Calve-Kummel disease – AVN – single level
    7. Scheurmann’s disease – multiple levels, irregular end plates
  33. Posterior element lytic lesion:
    1. ABC: young, expansile, blood level
    2. Metastasis – older, body extending to posterior element, solid component
    3. Osteoblastoma – surrounding deem
  34. Widened sutures in a child: >10mm at birth, 3mm at 2y and 2mm at 3y
    1. Raised ICT – hydrocephalus, ICSOL
    2. Leukemia
    3. NAI – trauma
    4. Rickets
  35. Wormian bones – PORK CHOPS
    1. Pyknodysostosis
    2. Osteogenesis imperfecta
    3. Rickets
    4. Kinky hair syndrome
    5. Cleidocranial dysplasia
    6. Hypothyroidism
  36. Terminal ileal thickening:
    1. Lymphoma
    2. TB
    3. IBD
  37. Linitis plastica
    1. Carcinoma stomach
    2. Breast metastasis
    3. Lymphoma
    4. Radiation
  38. Target lesion in the stomach:
    1. Carcinoma stomach
    2. Breast, lung and melanoma metastasis
    3. Leiomyoma
    4. Lymphoma
    5. Neurofibroma
  39. Interstitial lung shadows with preserved volume:
    1. LAM: uniform size, females, chylothorax, pneumothorax
    2. LCH: nodules, bizzarre shapes, spare base and middle lobe/lingula
    3. NF: skin nodules
    4. TS
  40. Multiple lytic lesions in a child:
    1. Polyostotic FD
    2. Multiple NOF – Jaffe-Campanacci syndrome
    3. NF – Fibroxanthomas (will be hypo intense on all sequences)
    4. LCH
    5. Multiple enchondromas
    6. Brown tumours – other findings of HPT
    7. Lymphoma / leukemia – aggressive appearance
  41. Low signal synovium on MRI:
    1. PVNS
    2. Amyloid
    3. Synovial hemangioma – will have flow voids
    4. Synovial sarcoma – will calcify
  42. Crazy paving lung:
    1. Alveolar proteinosis
    2. Sarcoidosis
    3. Pulmonary edema / ARDS
    4. Lipoid pneumonia
    5. PCP
    6. BAC
  43. Destructive rib lesions in a child:
    1. LCH
    2. Ewing
    3. Lymphoma
    4. Osteomyelitis
    5. Neuroblastoma metastasis
  44. Mesenteric mass:
    1. Carcinoid
    2. Metastasis
    3. Desmoid tumour – ass. with FAP
  45. Super scan:
    1. Mets
    2. Metabolic – HPT, renal osteodytrophy, osteomalacia
    3. Myeloproliferative – Lymphoma, Mastocytosis, Myelofibrosis

Breast

  1. When assessing microcalcifications in the breast, describe the site, distribution (widespread versus localized), shape, heterogeneity (are the calcifi cations of the same size and shape?) and density.
  2. These are bilateral mediolateral oblique and craniocaudal mammograms. After making a global inspection of both breasts, I would examine all the films under magnification, using workstation tools to assess for microcalcifications.
  3. Differentiate from inversion and retraction. Retraction will be slit like while inversion involves the entire nipple. Slow bilateral inversion is seen with many benign processes like duct ectasia and fat necrosis.
  4. In a patient with previous mastectomy:
    1. Lymphangitis carcinomatosis
    2. Diffuse sclerotic bones
    3. Lung metastasis
    4. Pleural effusion
    5. Axillary node clips
    6. Right hemidiaphragm elevation from liver met
    7. Radiation fibrosis

Cardiac

Set answer for MI viability:
  1. Decreased segmental wall motion and thinning of myocardium on cine images. There is abnormal systolic wall bulging suggesting akinesia.
  2. High signal (delayed or late hyperenhancement) in the myocardium on the delayedpost-contrast images.
  3. Subendocardial pattern of myocardial hyperenhancement.
  4. No reflow zone is seen as linear low signal within the subendocardium of delayedmyocardial hyperenhancement.
  5. Intra-cardiac low signal along the enhancing myocardium indicates thrombus. May beappreciated on cine images but it is better seen on first-pass perfusion and post-contrast delayed images. Mostly it appears as low signal due to hypovascularity.
  • A left ventricular aneurysm is defined as the part of the left ventricle that demonstrates both abnormaldiastolicandsystolicbulging. This is distinct from akinesia or dyskinesia, where there is onlysystolicbulging.
  • Look for calcification – pericardial, myocardial, coronary or valvular. Myocardial calcification with hypointense / non-enhancing LV thrombus can mimic pericardial calcification so always look outside the calcification for the pericardial fluid.
  • Sequences:
    • SE (black blood),
    • gradient ECHO:SSFP/FIESTA/FISP (white blood), CineMRI, perfusion, viability, flow quantification, motion tagging
  • Planes: SA, 2CH (vertical long), 3CH, 4CH (horizontal long)
  • How to review:
    • Structure (size, thickness)
    • Function (motility, volumes, EF, cardiac output)
    • Valves (morphology, flow)
    • Ischemia: T2 STIR, perfusion first pass and stress, viability (DHE
Base: Mitral valve to tip of papillary muscle – anterior, anteroseptal, anterolateral, inferior, inferoseptal, inferolateral
Mid wall: Tip of papillary muscle to insertion of papillary muscle – same 6 segments
Apical – 4 segments – anterior, septal, lateral, inferior
LV walls divided into 17 segments according to AHA consensus.21 Left, Segments at basal, mid ventricular, and apical levels and the apex (segment 17). Right, Bull’s eye image (polar map

Study of ischemia sequences

  • T2 weighted STIR:edema-weighted imaging. Hyper intensity could appear in acute infarct or myocarditis.
  • CINE b-SSFP: motility: Hypokinesia dyskinesia of ischemic areas
  • Perfusion: first pass of EGE (early Ga enhancement): ischemic areas no enhancement.

    Stress perfusion with adenosine and dobutamine: Induced ischemia.

  • Viability DHE (delayed enhancement) or LGE (late Ga enhancement) after 10-20 mins. Gadolinium in interstitial space in acute infarct because of edema and rupture of membrane and in chronic infarct due to scarring, showing the extension of the scar.

    Scarring less than 25% of the thickness of the wall (subendocardial), 25-50%, greater than 50% (transmural). This usually associates with thinning of the wall and is a prognosis factor that predicts functional recovery after revascularization.

CNS

  1. In CP angle masses, always look at the contrast images to comment on whether there is extension into the IAC. Look for multiple meningiomas and for contralateral IAC mass. In NF2 when you see bilateral acoustic neuromas, look for meningiomas elsewhere on the scan
  2. In any prepontine mass (nerve sheath tumor, meningioma), say that you want to rule out perineural spread of tumor and look for enhancement within the skull base foramina.
  3. ICSOL: This is an MRI brain of an adult / child. There is an intra-cranial space occupying lesion in (which) lobe. It appears to be intra / extra-axial because… The lesion is (explain signal characteristics) and shows / does not show calcification or haemorrhage or enhancement. The lesion is causing mass effect and I am looking for herniation syndromes, hydrocephalus and oedema. Based on the appearance and age of the patient, this is most likely a (diagnosis). I will inform the neurosurgeons urgently for decompression (if there is herniation). This patient will require imaging of the spine to look for metastasis. This patient will require admission and discussion in the next MDT.
  4. In a case of hemolytic anemias, apart from marrow expansion, look for complications of treatment (hemosiderosis in the liver and spleen), extramedullary hematopoesis which can cause epidural extensions and compress the spinal cord, osteomyelitis, AVN, gallstone. Say that you will do a T2* sequence to quantify cardiac iron load.
  5. In a case of meningitis, if you see a subdural empyema, do NOT say LP to confirm. It is contraindicated due to the risk of herniation. Look at the perimesencephalic cisterns for early sign of raised ICT.
  6. In any patient where history of HIV is provided, mention if the diagnosis is AIDS defining (Oesophageal candidiasis, CMV or herpes, PCNSL, PTB, Kaposi, PCP, Cerebral toxo, invasive Ca Cx)
  7. Look for sutural diastasis in all cranial trauma cases (very subtle finding). Mention the risk of CSF leak and meningitis in cribriform plate, naso-orbito-ethmoid and sigmoid plate fractures.
  8. Change in shape of the lens from biconvex to concave signifies subluxation
  9. Spondylodiscitis and epidural abscess: There is high signal fluid in the disc space on T2 and STIR.The disc has lost considerable height. There is enhancement of the disc with contrast. The adjacent vertebral body shows T2 high signal and T1 low signal, possibly from edema. This suggests an infective spondylodiscitis. There is displacement of the dura with a T2 high signal anterior epidural collection which enhances post contrast. This suggests an epidural abscess. There is sub ligamentous tracking of the collection beneath the anterior longitudinal ligament over several vertebral levels. The epidural collection is causing compression of the spinal cord at this level which shows high T2 signal suggesting myelopathy. Paraspinal collections which extend into the psoas muscle are also noted. Overall, the presence of sub ligamentous tracking and paravertabral collections are features favouring a tubercular spondylodiscitis but a pyogenic etiology is also possible. This patient will require CT guided aspiration of the collection and urgent neurosurgical referral for spinal decompression.
  10. MS: These are FLAIR and post-gadolinium MRI images which show oval shaped FLAIR hyper intensities in the periventricular white matter arranged perpendicular to the ventricular wall. There are also lesions in the callososeptal and callosomarginal interface and the juxtacortical region. Some of these lesions show incomplete ring enhancement. The optic nerves appear normal. The appearances are consistent with demyelination and I would like to review previous images or follow up this patient. I would also like to screen the spine. The presence of enhancing lesions suggests active demyelination and dissemination in time or the presence of lesions in juxtacortical, periventricular, infratentorial and spine (any 2) allow a diagnosis of MS. Or else, MS is a possibility but vasculitis and ischemia as differentials and follow up is needed to look for dissemination in time or space.
  11. Tuberous sclerosis: There are several areas of enlarged gyro with cortical-subcortical flair hyper intensity. These areas do not show any enhancement on post contrast images. If a GRE or SWI sequence is available, I will look for calcification within the lesions. There are nodular lesions along the ventricular wall which are low signal on T2. These lesions enhance on post contrast images. One lesion is noted in the region of the Foramen of Monroe and is causing obstruction and hydrocephalus. This might represent a giant cell astrocytoma and I would like to review prior images to look for interval increase in size. The combination of these findings suggest Tuberous Sclerosis and I would like to look for other associations. A CT of the abdomen shows numerous soft tissue enhancing nodules in the kidney with areas of fat density within suggesting AML. There is no evidence of complications by haemorrhage. There are numerous hypodense cysts in both the kidneys. TS can be associated with cardiac rhabdomyomas and I would like to screen the heart with Echocardiogram. Thoracic involvement with LAM can be screened with CXR. The cutaneous manifestations include Adenoma sebaeum and I will look for it. This patient will require Neurology referral for seizure control and also genetic and family screening. He will require neurosurgical referral for ventricular shunting / removal of the GCT. Aternatively, he will need annual MRI follow up to detect malignant transformation of the SEGA.
  12. Demyelination –
    1. optic nerve + cord +/-periventricular brain – NMO / Aquaporinopathy.
    2. Brain with MS pattern
    3. Brain with multifocal involvement of pons and basal ganglia with swollen cord – ADEM ask about previous viral illness.
  13. In cases of NF1, look for cutaneous neurofibromas on the MRI sections provided. Hamartomas vs astrocytoma: tell them you will compare with old scans to look for enlargement or enhancement with time.
  14. HSV encephalitis: also affects the posteromedial temporal lobe while MCA infarct spares this area (Supplied by PCA). Cytotoxic edema occurs in both so it will involve grey and white matter.
  15. To differentiate global cerebral anoxia from SAH – look at the basal cisterns
  16. In suspected SAH with normal CT, do LP after 12 hours of headache. Small SAH may be missed on CT. FLAIR high signal is also seen in meningitis.
  17. Subependymal calcified nodules on CT: CMV, Toxo, Tuberous sclerosis
  18. In a Chiari I malformation: There is a small posterior fossa with herniation of the cerebellar tonsils into the foramen magnum. A cystic lesion is noted in the upper cervical cord. This could represent a syrinx. Further scanning of the brain and spine is recommended to assess the accompanying features. However, no obvious brain changes in the visualized part to suggest Chiari II.
    Complete evaluation of the skull base for CV junction abnormalities – platybasia, occipital assimilation.
    Further evaluation by contrast enhanced MRI is recommended to assess the cystic cord lesion to confirm that it is only a syringomyelia. Chest X-ray is recommended to assess other features of Klippel-Feil syndrome: e.g. Sprengel’s deformity, omovertebral bone. An ultrasound abdomen to assess possible associated renal anomalies.
  19. When you see dissection in a young patient, say that you suspect an underlying condition like FMD and will screen for the presence of other vascular stenosis.
  20. When bilateral thalami show hypo density or T2 hyper, look for internal cerebral vein thrombosis
  21. Frequently misdiagnose – glomus jugulare – lytic lesion in the petrous bone, NCC – ring enhancing, calcified, cysts all of different stages, Neurosarcoid (when things don’t fit into one diagnosis, think TB or sarcoid), Apoplexy in a pituitary tumour (T1 bright or blood products in the pituitary region – not just cranio will be T1 bright).
  22. In a case of medulloblastoma, say that you will screen the spine for drop mets and also if there is a VP shunt, there is chance of peritoneal metastasis and also bone mets.
  23. In NF1: spine lesions extending through the neural foramina can be lateral thoracic meningocele, not necessarily neurofibromas. Look carefully for enlarged neural foramina in the C spine X-ray. Adrenal mass is a phechromocytoma. Renal size discrepancy is due to RAS.
    1. >6 cafe au lait spots evident during one year
    2. two or more neurofibromas or one plexiform neurofibroma
    3. optic nerve glioma
    4. distinctive osseous lesion
    5. sphenoid wing dysplasia
    6. two or more iris hamartomas (Lisch nodules)
    7. axillary or inguinal freckling
    8. primary relative with NF1 with above criteria
    9. pheochromocytoma
    10. malignant peripheral nerve sheath tumour (MPNST)- previously known as neurofibrosarcoma – overall risk of developing a MPNST is ~10% 7
    11. Wilms tumour
    12. rhabdomyosarcoma
    13. renal angiomyolipoma
    14. glioma
    15. juvenile pilocytic astrocytoma
    16. optic nerve glioma
    17. diffuse brainstem glioma
    18. spinal astrocytoma and spinal pilocytic astrocytoma

GI

  1. Abdomen X-ray
    • Bowel – distribution of gas, dilation and wall thickening
    • Gas patterns – free peritoneal and retroperitoneal gas, pneumobilia and portal venous gas
    • Organs – enlarged, atrophic or calcification
    • Bone and joints
    • Review areas: lower chest, appendicolith, hernial orifices, renal stones
  2. Common Barium diagnoses: always consider the number of lesions in BMFT – single is malignant, multiple are benign
    • Cancer (polyps, apple core strictures)
    • Emergencies – volvulus and megacolon (barium not given – it will be a plain study). Gastric volvulus – GC superior to LC is organoaxial, Antrum superior to GEJ is mesenteroaxial.
    • IBD – always look for gall stones, sacroilitis and malignancy
    • Target lesions may be subtle and multiple
    • Hiatus hernia + reflux esophagitis + mid esophageal stricture = Barret
    • Aunt Minnies – candida, achalasia, linitis plastica, pneumatosis cystoides intestinalis
  3. SBO:  there are central dilated small bowel loops. The large bowel is not dilated and there are numerous air-fluid levels makingmechanical obstruction more likely than ileus. The jejunum measures >4 cm diameter and the ileum>3 cm diameter. If there is an erect X-ray the “string of beads”sign ifseen and an air–fluid level greater than 2.5 cm makesmechanical obstruction more likely rather than ileus. I will look for pneumoperitoneum. I will also look for pneumatosis andportal venousgasin cases of bowel ischemia. I will look for air in the biliary tree and for an ectopic radio-opaque gallstone in cases ofgallstone ileus. I will look at the hernial orifices. This patient requires urgent surgical intervention following a CT. Remember – barium should not be given in a large bowel obstruction as it can inspissate (limited barium enema can be done).
  4. Set answer for candida esophagitis –  The barium swallow shows a longitudinally arranged, shaggy serrated appearance of the middle and lower third of the oesophagus with innumerable small filling defects. Multiple tiny erosions and areas of ulceration are present. There is no evidence of obstruction or barium hold-up. No mass lesions identified. No stricture formation. Features are likely to represent candida oesophagitis, particularly given the history of HIV. This is an opportunistic infection of the oesophagus. I would like to examine the patient for evidence of oropharyngeal candidiasis, which is often manifested as white plaques in the mouth. As candida oesophagitis is an AIDS-defining illness in an HIV-positive patient, I would also like to discuss the case urgently with the referring clinician to ensure appropriate clinical management. Fungal cultures from the upper gastrointestinal tract can be obtained for definitive diagnosis.
  5. Set answer for achalasia –  There is a gas-filled structure in the posterior mediastinum that extends from the upper mediastinum to the level of the gastro-oesophageal junction. The features are of a dilated oesophagus. The barium examination confirms the presence of a dilated oesophagus, together with a ‘bird’s-beak’ lower oesophageal sphincter. Tertiary contractions are demonstrated in the distal oesophagus. The features are consistent with achalasia. The differential diagnoses include infiltrating carcinoma from the stomach and Chagas’ disease, both of which can sometimes be indistinguishable from achalasia on barium studies. Scleroderma is easily differentiated from achalasia, as the lower oesophageal junction is usually patulous in the former. However, presence of concurrent secondary lower oesophageal stricturing can sometimes cause confusion. The diagnosis will need to be confirmed with manometry. OGD, possibly with endoluminal ultrasound, can be helpful to exclude carcinoma. CT may also be useful in differentiating between carcinoma and achalasia. [always consider malignancy (irregularity – in a barium swallow; check the stomach for extension of gastric Ca to esophagus) and esophageal resection and colonic bypass (in a plain film) and candidiasis (diffuse irregularity with dilation due to aperistalsis). Look at the lung (aspiration in achalasia and fibrosis in scleroderma with dilated GEJ). If it is a chest X-ray, mention that the vertebral bodies and intervertebral disc space is normal which makes a paravertebral abscess less likely and esophageal dilation more likely].
  6. Carcinoid – look for complications like small bowel obstruction (adhesions or intussusception), ischemia (vein obstruction) and metastasis in the liver on a CT or octreotide scan. Pulmonary and Tricuspid Stenosis can occur causing RHF.
  7. Cirrhosis: The liver is small in size with volume redistribution with an enlarged caudate lobe. There is a nodular contour and heterogeneous parenchymal enhancement. There are areas of capsular retraction. This appears like cirrhosis and I will look for other complications.
    • Look for hepatic vein thrombosis as Budd Chiari can be a cause for cirrhosis
    • Look for the cause of cirrhosis – high density in hemochromatosis and look for complications (HCC, varices).
    • If you see a HCC with cirrhosis – don’t assume that the perihepatic fluid is ascitis, it could be a ruptured HCC.
    • DDs for cirrhosis included pseudo cirrhosis from treated breast metastasis, confluent hepatic fibrosis.
    • Say that you will check INR before doing a biopsy and otherwise offer transjugular biopsy
  8. In any case of inferior rib fracture with elevated hemidiaphragm and pleural effusion – rule out solid organ injury
  9. This is a DCBE which shows numerous outpouchings from the sigmoid and descending colon. There is an area of narrowing possibly due to stricture or spasm. Barium is tracking outside the lumen which suggests a sinus tract and into a extraluminal collection outside the bowel, possibly an abscess. I am looking for other complications like fistulae with the bladder – looking for air in the bladder. These features suggest a diverticulitis with fistula formation and abscess. A differential is colonic carcinoma, but the absence of mucosal ulceration, the presence of diverticula and absence of shouldering make it less likely. This patient will require a CT of the abdomen to diagnose the extra intestinal complications and possibly CT-guided aspiration of the abscess and antibiotic treatment. Follow up imaging and referral to surgery.
  10. Set answer for IBD: This is a single image from a DCBE. In my usual practise, I will review the entire series. There is mucosal irregularity involving the terminal ileum with multiple areas of aphthous ulceration (early) or multiple linear ulcers and inter communicating stellate ulcers (more advanced) or have a cobblestone appearance (deep ulceration) with intervening areas of normal mucosa. These lesions are more in the mesenteric border with pseudo-sacullation noted in the anti mesenteric border. There is separation of the bowel segments in the distal ileum region, probably from a combination of bowel wall thickening and fibrofatty mesenteric proliferation. There are several segments of narrowing of the distal ileum representing a skip strictures. There are multiple fistulous tracts from the terminal ileum to the right colon. I would also look for fistulous communications with the bladder. There is no air in the region of the bladder. There is sclerosis of the sacroiliac joints suggesting sacroilitis. I would also look for
    1. if there has been bowel resection and comment on whether there is stricture or leak at the anastomosis site.
    2. Complications of adenocarcinoma or lymphoma
    3. Fistula
    4. Abscess (on CT)
    5. AVN and sarcoilitis
    6. Gall stones
  11. In a case of retroperitoneal fibrosis say that you will take a drug history – beta blockers, methysergide
  12. In ischemic colitis, search for an embolic source especially left atrial appendage and left ventricle. Differentiate arterial (thin wall, reduced mesenteric vessels) from venous (thick wall, misty mesentery) and non-occlusive (non territorial)
  13. Review areas in a barium enema: look at bowel rotation, look at presacral width
    Key points

    Review areas for ‘normal-appearing barium enema’ in viva situation:

    • Skeletal abnormality. Check for bone metastases, sacroiliitis, hip abnormalities such as avascular necrosis.

    • Bowel distribution. Malrotation of the bowel, bowel displaced by organomegaly (e.g. splenomegaly, liver enlargement from metastases).

    • Serosal colonic pathology. The mucosa remains intact but extrinsic compression may cause stenosis or narrowing (e.g. serosal deposits from peritoneal malignancy, such as ovarian cancer).

    • Endometriosis. Usually appears as a submucosal mid-rectal lesion in the anterior wall with a serrated appearance, best seen on the lateral projection.

    • Abnormal calcification. Chronic pancreatitis, calcified gallstones, ovarian dermoid.

    • Lung bases and hernial orifices


  14. Carcinoma colon – look for synchronous lesions, look for other polyps (saddle shape and polyps with central ulcers are likely malignant).
  15. Liver trauma – arterial extravasation + venous pooling = active bleed. Arterial extravasation + venous washout = aneurysm. Bare area lacerations can cause retroperitoneal hemorrhage.
  16. Subtle signs of pancreatic head cancer:
    • Double duct sign
    • Effacement of the portal vein with collaterals
    • Tear drop superior mesenteric vein sign
    • Retroperitoneal lymph nodes in tail cancers
    • Peritoneal deposits with fat stranding
  17. In all cases of cyst in the pancreas – ask for a history of pancreatitis. If no history, call it a mucinous cyst adenoma or IPMN
  18. In any case of pancreatitis – look for aerobilia to suggest a recent ERCP, gall stone to suggest cholelithiasis pancreatitis and cirrhosis for alcoholic pancreatitis. Also look for calcification elsewhere – renal stones – to suggest hyperparathyroidism.
  19. In all cases of intestinal obstruction look
    1. At the hernial orifices – gas over the thigh
    2. For surgical clips to suggest adhesion
    3. Air in biliary tree to suggest gall stone ileus
    4. Bones for metastasis – malignant obstruction
    5. Free gas secondary to perforation
  20. In any bowel malignancy say that you will look for synchronous lesions
  21. In UC, patients with rectal sparing might be seen if they are on treatment with enemas
  22. Always say that you will look at source images in an MRCP and angiography
  23. In any case of Crohn’s:
    • Sacroilitis
    • AVN from steroids
    • Megacolon
    • Gall stones
    • Renal stones
    • Cholangiocarcinoma
  24. Toxic megacolon – always consider this in any case of dilated colon and be prepared to say “a barium enema is contraindicated” – loss of haustral markings, dilated, free gas
  25. In any case of NF1: look for subcutaneous nodules and for adrenal pheochromocytoma and renal asymmetry (RAS). DO NOT say biopsy to confirm a suspected pheochromocytoma – crisis; rather say MIBG scan and urine metanephrine.
  26. In a case of liver abscess, look for an aetiology – cecal thickening, diverticular disease, appendicitis. Look for complications – portal vein thrombosis, rupture
  27. In a DCBE, use a generic term like colitis when you see mucosal thickening and irregularity. Differentials can be given based on distribution and the findings.
  28. Nutcracker esophagus is not an imaging diagnosis – it is diagnosed on manometry when there is increased peristaltic tone. Diffuse oesophageal spasm is a radiological diagnosis with corkscrew appearance.
  29. Cyst in the peritoneum / mesentery:
    1. Lymphatic malformation / lymphangioma – most common, can have septations
    2. Enteric duplication cyst – much rarer, mimics LM but will have thicker wall
    3. Peritoneal inclusion cyst – in the pelvis of post op women
    4. Pseudomyxoma peritoneii
    5. Peritoneal carcinomatosis
    6. Non pancreatic pseudocyst – after trauma or hematoma – thick wall with enhancement and debris
  30. In a patient with low signal intensity of the liver:
    1. Is spleen also has low signal – it is from iron overload in Thalasseima – look for marrow replacement and extra medullary hematopoesis
    2. If spleen has normal signal – look at pancreas, heart and pituitary – they will have low signal if it is primary hemochromatosis.
  31. Urine tests:
    1. Pheochromocytoma – metanephrine and catecholamine
    2. Neuroblastoma – VMA
    3. Carcinoid – 5-HIAA

GU

  1. Testicular torsion – the testis is enlarged and has an abnormal orientation. The parenchyma shows a heterogeneous echo pattern. There is reduced colour flow on doppler. These findings suggest testicular torsion and I will refer urgently even if the testis is unsalvagable because infarction  can lead to gangrene and production of antibodies. Also, look for bell clapper in the other testis – horizontally oriented.
  2. Of all the causes of medullary nephrocalcinosis, only medullary sponge kidney can be differentiated from them on the excretory phase of IVU (paintbrush). Other causes can be made out in the skeleton (hyperparathyroidism – brown tumor, renal osteodystrophy) or association with cortical nephrocalcinosis (oxaluria), medical history (renal tubular acidosis)
  3. When you see a CT of a patient with diffuse renal disease (like ADPKD), always say that you will follow up the patient if contrast has been given or avoid using contrast if only plain has been done.
  4. Mention that you will screen patients with genetic diseases like ADPKD, TS, VHL and NF
  5. In IVU study the labels carefully to see what phase it is in – there can be delayed nephrogram, persistent nephrogram, non excretion, “release film”, “compression film”
  6. Always look at the pelvis in IVU (same with barium studies). Look for pubic bone diastasis suggesting bladder extrophy.
  7. In any confirmed malignancy, always say that you will do a staging CT
  8. In a patient with ADPKD, look for associations like liver cysts, aortic aneurysms, dissections, cerebral aneurysms
  9. In a patient with bladder calcification from schistosomiasis – look for discontinuity in the calcification to suggest SCC. They will also require frequent follow up to assess for SCC change which can occur 30 years later.
  10. In any male patient with a pelvic mass – look for an undescended testis
  11. When you see an adrenal lesion, say that you will look at the lung to look for a primary and also that you will look at the other adrenal.
  12. Renal calculi – look for features of HPT and horseshoe, BPH. Consider other calcification – TCC calcified, TB, retained catheter, renal artery aneurysm. Lymph node, pancreas, phlebolilth.
  13. Ovarian torsion: the left ovary is enlarged. There is central increased echogenicity / T2 hyperintensity and peripherally arranged cysts. Areas of fat density an calcification are noted in the lesion suggesting a teratoma. Colour doppler / contrast shows lack of enhancement / flow. The uterus is deviated to the right and there is free fluid in the pouch of Douglas. These findings are suggestive of ovarian torsion secondary to a teratoma. This patient requires urgent gynecology referral and laparotomy.
  14. When you see a uterine anomaly say that you will screen for renal anomaly and agencies

MSK

  1. In a bone X-ray:
    1. Density: increased or decreased – metabolic, dysplasia
    2. Focal lesions – lytic, sclerotic, fracture – infection, tumour
    3. Soft tissue, lungs, abdomen
  2. Atrophy of muscles + bones + osteoporosis = poliomyelitis
  3. Diagnosing the cause of AVN on X-ray: When given an X-ray with unilateral AVN, say that you will get an MRI to look for early AVN on the other side.
    Avascular necrosis of one or both of the femoral heads on a pelvic radiograph has a number of causes. This film is a common scenario in the viva part of the FRCR examination. It is worth thinking of the associated features that may help determine the underlying cause of AVN:

    ○ Ileostomy bag, thumb printing, sacroilitis. This indicates steroid use in ulcerative colitis prior to surgery .

    ○ Ankylosing spondylitis – SI joint sclerosis. Non-steroidal anti-infl ammatory drugs used in this condition can lead to AVN (note the right hip prosthesis) and also renal papillary necrosis. So look for it (in the form of calcified papillae) on abdominal radiographs .

    ○ Renal transplant clips in the iliac fossa or a calcified rejected renal transplant indicate current or previous treatment with steroids .

    ○ In sickle cell disease always look for H-shaped vertebrae in the lumbar spine on the film, gallstones, splenic calcification, altered bone trabeculae.

    ○ Splenomegaly – myelofibrosis and Gaucher’s disease. Both conditions lead to AVN of the femoral heads, and in the case of Gaucher’s disease the development of H-shaped vertebrae in addition.

    ○ Pancreatic calcification on an abdominal radiograph suggests chronic pancreatitis and a possible aetiology for AVN
    ○ An abdominal radiograph that demonstrates AVN of the femoral head, H-shaped vertebrae, a small spleen (high splenic fl exure) and gallstones or cholecystectomy is indicative of sickle cell disease.

  4. Always look at the sacrum first in a pelvis X-ray – easy to miss findings here – sacral agenesis, sacroilitis!
  5. Negative findings:

    1. In any case of Pagets (common exam case) always look for complications: fractures, osteosarcoma
    2. In any case of osteoarthritis look for secondary causes
    3. Look for soft tissue gas, sequestrum and skin ulcer in charcot’s joint (cellulitis rather than charcot) and look for digital vascular calcification (charcot rather than cellulitis)
  6. In any case with isolated posterior malleolus fracture ask for the leg X-ray
  7. In a patient with Lisfranc joint, ask for a history of trauma – if there is no trauma, suspect Charcot joint
  8. H-shaped vertebrae with renal papillary necrosis = sickle cell disease. Once sickle cell disease has been diagnosed, look for other signs – AVN, replaced joints, cholelithiasis, autosplenectomy (high splenic flexure), renal stones, cholecystectomy clips
  9. Always ask for a lateral view in a wrist trauma case if it is not provided in the first instance. Look for combination fractures in the wrist: radial styloid – scaphoid – proximal capitate – proximal hamate – ulna styloid with perilunate dislocation
  10. In any expansile bone lesion – look for: surgical clips in the abdomen (RCC), surgical clips in the neck (hyperparathyroidism / thyroid cancer), distal clavicle lysis (HPT), previous films (FD) and pathological fractures
  11. In any lesion where bone metastasis, myeloma or lymphoma is seen (multiple lytic or sclerotic lesions in elderly) or on bone scan, look for primary in the same image. Conversely, if you see a primary in the lung or any other organ, look for metastsis in the same film:
    Chest radiograph – look on the edge of the film for humeral metastases. In a patient with rib metastases, look for a mastectomy, or breast asymmetry in cases of breast carcinoma. Do not forget to look for surgical clips below the diaphragm that suggest nephrectomy for renal carcinoma or clips in the neck that suggest thyroidectomy (caution: a lytic lesion in the rib + surgical neck clips may represent parathyroidectomy and brown tumour).
  12. Hyperparathyroidism is a common case. Any hand or abdomen radiograph that looks normal is HPT. – search for all the findings (including brown tumors and chondrocalcinosis, acro-osteolysis, subarticular erosions, cortical tunneling,); search for the cause: renal osteodystrophy (search for an AV fistula in the wrist), adenoma. A single abdominal radiograph can show: renal stones, SI joint erosion, vascular calcification, nephrocalcinosis, calcific pancreatitis, brown tumour. A single chest radiograph can show clavicle erosion, rugger jersey spine, Hemodialysis catheter, superior rib notching and a lytic brown tumour. After diagnosing HPT, say that you will correlate with serum HPT levels and calcium and do an USG and sestamibi scan.
  13. Set answer for arthritis: These are radiographs of both the hands with the wrist joints of a skeletally mature individual. There is a predominantly mono/polyarticular symmetric / asymmetric joint disease of both hands. The main joints involved are the MCP and CMC with relative sparing of the DIP / DIP involved. The joint spaces are uniformly reduced. There is / is no periarticular osteopenia. Erosions are noted of the involved joints which are periarticular / intraarticular. There is / is no periostitis or new bone formation. There is associated soft tissue swelling. There is subluxation of involved joints. Mention any descriptors “gull wing in erosive OA”, pencil in cup in psoriasis, buttonhole / swan neck deformity in RA, sausage digit, acro-osteolysis / calcinosis cutis in scleroderma. This pattern represents an erosive arthritis and the symmetrical / asymmetrical pattern suggests a seropositive / seronegative arthropathy. I would like to review previous radiographs to look at progression and also other radiographs of the spine / SI joint / feet if available. I would inform the referring physician about the possible diagnosis and correlate with available history and suggest a rheumatology referral for further management.
  14. Set answer for AS: This is a frontal radiograph of the spine of a skeletally mature individual. There are vertically oriented flowing syndesmophytes in the visualised lumbar spine. The disc spaces are preserved. There is also a linear calcification in the central spinal column which possibly represents a calcified interspinous ligament. The visualised upper part of the SI joints show sclerosis of the iliac side of the joint with some erosion. A dedicated SI joint radiograph will be needed for further evaluation. I would also like to review lateral radiographs of the spine to look for ankylosis of the facet joints. In a young male, I would consider ankylosing spondylitis as my principal diagnosis. I would correlate with previous radiographs if available and also with HLA B27 status as AS is associated with it. Further referral to rheumatology for management.
  15. Set answer for skeletal dysplasia – This is a radiograph of the chest and abdomen of an infant. There is rhizomelic shortening of the humerus. The ribs are short and broad. The pelvic inlet has a champagne glass appearance and the iliac bones have  a tombstone appearance due to the vertically oriented acetabulum. The interpedicular distance reduces in the lumbar spine and the lateral radiograph shows posterior vertebral scalloping and anterior beaking. these appearances suggest an appearance of a skeletal dysplasia most likely achondroplasia. A screening radiograph of the cervical spine and skull may be useful as there is commonly a small foramen magnum with spine compression. If you can not make out the dysplasia – list the findings and say the constellation of findings suggest a skeletal dysplasia and a particular type doesnt come to mind and i will consult a senior colleague or paediatric radiologist and look up a text book after discussing with the clinicians.
  16. Rib and pelvis are common sites for chondrosarcoma and rare for enchondroma. Hand and feet are common for enchondroma and rare for chondrosarcoma. When you see an enchonroma, ask to compare with old films to look for change suggesting malignancy: get an MRI to assess malignant potential: endosteal scalloping, soft tissue. Always mention that a low grade chondrosarcoma is difficult to differentiate from an enchondroma and follow up is needed.
  17. Don’t miss Montaggia fractures in children. Always look at the radial head-capitellar line in an ulna # for dislocation. Classify by Bodo system (1 – anterior dislocation, 2 – posterior dislocation 3 – lateral dislocation, 4 – radius # and anterior dislocation). Always get an elbow and wrist X-ray dedicated for all forearm #
  18. Always search for the medial epicondyle epiphysis in an elbow injury – it can be avulsed into the elbow joint in hyperextension-valgus injury
  19. Always look at the lung in a shoulder X-ray: look for pneumothorax, rib and vertebral destruction, lung masses and mediastinal masses.
  20. Osteomyelitis can spread across the physis in infants – always look for extension into the joint
  21. Sacroilitis: look for sigmoid colon wall thickening (UC), check the lung for fibrosis and tuberosities for whiskering (AS), HD line or PD cath (hyperparathyroidism), unilateral (infection)
  22. In any case of SCFE, ask for a frog leg even if it is obvious on the AP because the contralateral side may have an early SCFE
  23. Atlanto-axial subluxation + erosion = RA; + posterior scalloping and anterior beaking = morquio; + bamboo spine = AS; in a child with soft tissue = abscess
  24. Look for osteopoikilosis, osteopathia striatica and AVM in any patient with melorheostosis
  25. In a case of thalassemia, look for complications of iron chelation: dense metaphyseal bands, chondrocalcinosis. Look for paraspinal masses: extra medullary hemopoesis, posterior rib expansion, hepatosplenomegaly and gall stones, cardiomegaly.
  26. In cases of osteomalacia – commonly due to renal failure – look for HD catheters, hyperparathyroidism (eroded lateral clavicle, brown tumour, soft tissue calcification).
  27. Chondroblastoma vs GCT: both are epiphyseal lesions. ABC is metaphysical and in younger. Sclerosis around chondroblastoma and in MRI, edema is seen around chondroblastoma.
    When confronted with a GCT: get an MRI to assess size, soft tissue extent – locally aggressive. 
  28. In any child bone X-ray which looks normal, look for widening of the physeal plate for Salter Harris type 1 fracture and for widened hip joint space for septic arthritis
  29. Ankylosing spondylitis is a definite case: SI joint erosions/slcerosis or spine changes – Romanus, Anderson
  30. In all skull X-rays and C-spine X-rays look for air-fluid level in the sphenoid sinus.
  31. The LATeral tibial plateau should be fLAT. The medial tibial plateau should be concave. If both are flat, suspect fracture of the lateral plateau.
  32. Absent lateral clavicle: multiple lung masses – mets, soft tissue calcification & clips in the neck – hyperparathyroidism, shoulder replacement/joint space narrowing – RA, osteosclerosis – pyknodysostosis, rib fractures – post traumatic osteolysis.
  33. Lytic mets: Thyroid, renal, colorectal, lung, bladder (neuroblastoma in kids)
  34. In unilateral diffuse periosteam thickening, consider vascular insufficiency. If bilateral, consider hypertrophic osteoarthropathy and pachydermoperiosteitis. Always take a chest X-ray to rule out lung malignancy/asbcess/pleural fibroma.
  35. Difference between dermatomyositis and polymyositis is basal pulmonary fibrosis (like scleroderma) in the former. Electromyography and serum CK levels are used to diagnose and assess disease activity. Dermatomyositis has a high association with lung and ovary and GI malignancy and CT is indicated.
  36. When you see Erlenmeyer flask deformity, assess:
    Craniometaphyseal dysplasias (Pyle disease) – sclerosis of cranial bones, small sinuses, scoliosis, platyspondyly – sclerotic diaphysis and lucent metaphysis
    Hemoglobinopathies – coarse trabeculae cobweb bone
    Thalassemia – diploic expansion, wide medulla with cortical thinning
    Sickle cell disease – often with AVN
    Osteopetrosis – sandwich vertebrae, diffuse increased density in both diaphysis and metaphysis
    Niemann-Pick disease – osteoporosis,
    Gaucher disease – often with AVN, moth eaten appearance of bones with diffuse osteopenia and pencil thin cortex and splenomegaly
    • Other
    Lead poisoning – dense metaphyseal bands
    Fibrous dysplasia
    Osteochondromatosis
    Enchondromatosis
    Fibromatosis
  37. When you see widening of the medial clear space on an ankle >5mm – image the upper fibula.
  38. Sclerotic lesion in the bone – healing FCD and NOF. Especially in the tibia or fibula.
  39. Differential for metastatic calcification: renal failure, hyperparathyroidism, sarcoidosis, milk-alkali syndrome
  40. In a wrist X-ray, look specifically for a triquetral fracture or a hamate fracture when there is a bone fragment in the dorsal aspect of the carpal bones on the lateral view. The hamate articulates with the 4th and 5th MC and is often associated with dislocations of the 4th or 5th CMC joint.
  41. If an osteochondroma is noted, look at the hip joint – if the femoral necks are short and broad, it is likely that it is part of a multiple hereditary exostosis syndrome – then look for other osteochondromas. Also comment on – epiphyseal closure, neurovascular bundle compression, bursal reaction, fracture, malignant transformation (>1.5cm).
  42. Lesions with sequesterum – osteomyelitis, eosinophilic granuloma, fibrosarcoma, and malignant fibrous histiocytoma are other causes of sequestra
  43. On a lateral radiograph of the spine – trace every vertebral body to its posterior element – if there is a discrepancy, it could be vertebra plana – mets, MM, EG, lymphoma, trauma, TB
  44. Long lesion in a long bone = FD – it can be expansile and lytic.
  45. Remember that vertebra plan means that the intervertebral disc space is preserved.
  46. When there is synovial osteochondromatosis, look for a secondary cause – OA, AVN or epiphyseal dysplasia (Meyer’s dysplasia in the hip)
  47. In children:
    • Monteggia # – ulnar # with radial head dislocation – posterior interosseous branch of radial nerve injury
    • Galeazzi  # – radial # with distal ulna Salter-Harris 1 injury
  48. Expansile rib lesions in an adult:
    • Myeloma or plasmacytoma.
    • Lytic metastases represent the commonest malignant rib lesions.  Always look below the diaphragm and in the neck region – the presence of surgical clips in the retroperitoneum or neck may suggest previous renal cell or thyroid carcin- oma respectively as the underlying primary malignant cause of the lytic bone lesion.
    • Chondrosarcoma is the commonest primary malignant bone tumour and is typically located near the costochondral junction.
    • Brown tumour of hyperparathyroidism – look for other signs of hyperparathyroidism, e.g. erosive osteolysis of distal clavicle, brown tumours in humerus.
    • Fibrous dysplasia – monostotic or polyostotic. Monostotic fibrous dysplasia is the commonest cause of an expansile rib lesion in children – typically a ‘ground-glass’ rib lesion. Look at previousfilms.
    • Paget’s disease.

Nuclear Medicine

  1. Squat or pelvic inlet view is used to see the sacrum (overlap of bladder over the sacrum is removed)
  2. Leuckocyte  scan  uptake in the bowel at one hour is always abnormal. At three hours, there can be physiological excretion. HMPAO-WBC scan can show normal renal activity but In-WBC will not show renal and bladder activity.
  3. Use the term increased tracer uptake and not “hot spot”. Use the term photopenic area and not “cold spot”
  4. Presenting case: This is a planar whole body / SPECT scan or spot view MDP bone / MIBG / octreotide of ___organ or MAG3 renogram in the anterior and posterior views with dynamic / static acquisition. In a renal scan, start with kidney size & position —> uniform and symmetrical tracer uptake in both kidneys —> tracer drainage into the collecting system & hydronephrosis —> any renal activity at 20 min (obstruction). Then comment on renogram curves and split renal function.
  5. Bone scan cases:  this is a planar whole body MDP bone scan in the anterior and posterior view showing (always say that you will correlate with radiographs for bone scan)
    1. Diffuse symmetrical increase in tracer uptake involving the axial and appendicular skeleton with a lack of renal and soft tissue tracer uptake. This is consistent with a malignant superscan and I would correlate with clinical data. If this was a female, I’d ask the referring physician to perform a breast exam and if this was a male, i’d correlate with the PSA and prostate exam.
    2. There is diffuse increase in tracer uptake which is also present in the distal appendicular skeleton and the calvarium which is consistent with a metabolic super scan. I would correlate with the serum parathormone levels and with radiographs of the hands.
    3. Multiple randomly distributed focal areas of increased tracer uptake of varying size and intensity in the vertebrae, ribs and skull which suggest disseminated skeletal metastasis. I would correlate with plain radiographic findings if they are available. If this is patient has a known malignancy, I would speak to the referring physician and convey the findings. If this is the first presentation of the patient, I would speak with the referring physician and organise a screening for a primary malignancy. If this is a follow up image for a known malignancy, I would review previous images as bone scans can show a flare up after chemotherapy in the first 6 months due to reactive bone healing.
    4. Symmetrical linear cortical uptake in the bones of the leg. I would correlate with available radiographs which might reveal periosteal reaction which would suggest HOA and then recommend a screening of the lungs with chest radiographs.
    5. Areas of increased tracer uptake in a linear fashion involving the posterior ribs, H shaped uptake in the sacrum and a focus of uptake in the humerus – consistent with trauma and insufficiency fracture
    6. Focal increase uptake in the proximal femur and hemipelvis with bone expansion. These are very suggestive of Paget disease. I would correlate with available radiographs.
    7. Lytic lesions on an X-ray with non-corresponding bone scan uptake = multiple myeloma with pathological fractures.
    8. Three-phase bone scintigraphy demonstrates mild hyper perfusion in the flow phase and hyperemia in the blood pool phase in the right hip, with focally increased activity in the femoral neck on the delayed  image. Pinhole and SPECT images show focally increased activity in the anterior right femoral neck. There is an area of increased tracer uptake surrounding the focal area of intense tracer uptake – the double density sign. I would correlate with radiographs for a sclerotic lesion in the right femoral neck suggesting a osteoid osteoma.
    9. Three phase MDP bone scan of the hands and wrists show increased tracer perfusion in the dynamic flow image and hyperemia in the static blood pool. Delayed image shows periarticular increased tracer activity. I would normally correlate with radiographic findings. This pattern of tracer uptake is non specific and differential diagnosis include the early stage of Reflex Sympathetic osteodystrophy if there was trauma. Radiographs will show osteopenia. Other differentials to consider are infection and trauma which may both show three-phase uptake. An infection can be diagnosed with appropriate history and blood cell counts and a WBC scintigraphy.
    10. Metastasis in ribs vs pathological fractures = linear uptake vs focal uptake
  6. Renal cases:
    1. MAG3 for PUJ obstruction: This is a MAG3 renogram study demonstrating the symmetrical size and perfusion of the kidneys. No obvious cortical defect is seen on the images displayed. There is rapid transit of tracer into the collecting systems bilaterally. The right kidney shows tracer retention within a dilated collecting system and a continuously rising renogram curve. There is little response to the diuretic administration at 15 minutes. The left kidney shows normal drainage. Split renal function is symmetrical. There is a rising curve on the right side with no response to diuretic administration. The appearances are those of a pelviureteric junction obstruction. An ultrasound examination would be useful to confirm and assess the degree of hydronephrosis. I would refer the patient to a urologist. Compared with the previous examination, the drainage of the right kidney is no longer obstructed and now shows a good response to diuretic administration, the renogram curve shows a fall after the diuretic administration; this did not occur on the earlier renogram. The patient is likely to have undergone a corrective procedure following the previous renogram.
    2. MAG3 for congenital megaureter: This is a MAG3 renogram study demonstrating the symmetrical size and perfusion of the kidneys. No obvious cortical defect is seen on the images displayed. There is rapid transit of tracer into the collecting systems bilaterally. The right kidney shows a dilated collecting system and ureter. On frusemide administration, there is normal response with reduction in the tracer activity at 20 minutes. The post micturition image shows that there is no reflux. Both kidneys have normal isotope uptake and excretion curves on the venogram.
    3. MAG3 with captopril for RAS: Pre-captopril baseline MAG3 renogram time-uptake curve shows normal uptake and excretion in both kidneys with excretion at 20 minutes. After captopril is administered, there is a right-ward shift of the curve in the right kidney with an ascending curve pattern with normal curve in the left kidney, suggesting worsening renal function and asymmetrically increased activity in the right kidney at 20 min.
    4. VCUG for reflux (be careful to differentiate between VCUG and Renogram!)  Technetium-99m pertechnetate voiding cystourethrography (VCUG) study. Serial static images of the renal tract with background subtracted count profiles have been obtained. The count profile over the bladder falls rapidly, demonstrating satisfactory emptying. There is increased activity over both renal pelves with micturition on the serial images. This is confirmed quantitatively by a rise in radioactivity with micturition demonstrated by the count profiles of the regions of interest in both kidneys. The appearances are in keeping with bilateral vesicoureteric reflux. I would like to review the previous ultrasound and DMSA images. Plain abdominal radiographic examination is required if there is a suspicion of urolithiasis. A referral to the paediatricians/urologists is required. Further investigation is guided by the clinical picture.
    5. DMSA: This is a DMSA study. The kidneys are symmetrical in size and position. There is a photopenic area in the interpolar region of the left renal cortex.Nofurther focal defect is present in the rest of the kidneys. There is no feature suggestive of hydronephrosis. The split renal function is symmetrical with the left kidney contributing49%and the right kidney51%to total renal function. The differential diagnosis for the appearance would include a focal renal scar, a cystic abnormality, or a focus of infection. I would reviewthe images from the previous admission, as this may be relevant, to identify a cause for this.
      1. There should be symmetric and simultaneous uptake in both kidneys at 1 min
      2. There should be ureter and pelvis uptake by 5 min.
      3. There should be drainage and bladder uptake by 10 min
      4. There should be no renal activity at 20 min
      5. Poor functioning kidney / RAS – delayed and reduced uptake in one kidney
      6. Retained activity = obstruction.
      7. Furosemide given at 10 min – should accentuate the drainage in the renogram curve
  7. Octreotide scan for Carcinoid tumour – no activity above diaphragm and on the posterior view, the spleen should show much higher uptake than the liver – used for carcinoid. If the liver shows more uptake, it is metastasis. Octreotide uptake also seen in islet cell tumours and neuroblastoma.
  8. VQ: This is a ventilation-perfusion study of the lungs in several projections. The ventilation scan shows normal inspiratory and equilibrium phase tracer uptake without retention in the  exp. There are segmental areas of V-Q mismatch in the right lung involving the upper and lower lobes. This is classic of a pulmonary embolism and this patient will require urgent evaluation for DVT and possibly a CTPA according to local protocol.
  9. MIBG scan for pheochromocytoma, carcinoid, neuroblastoma, paragangliomoas (extra-adrenal pheo) – the salivary glands will show normal uptake and the liver will show more uptake than the spleen. This is an MIBG scan which shows pathological increased tracer uptake in the left upper abdomen. I would correlate with available cross sectional imaging to confirm that there is a left adrenal mass which would make the area of increased uptake most likely a pheochromocytoma / neuroblastoma. There is / is no uptake in the liver suggesting that there is liver metastasis. There is / is no focal uptake in the bone suggesting osseous metastasis.
  10. Thyroid – pertechnate or I123 – This is a pertechnate scintigraphy study showing the thyroid gland in the normal location, normal in size and shape / diffuse enlargement of the gland. There is homogeneous / heterogeneous tracer uptake. Comment on the % RAIU.
    1. Grave disease: The anterior view shows both thyroid lobes to be plump with convex borders and evidence of a pyramidal lobe arising from the isthmus. The thyroid to background ratio is high. The percent radioactive iodine thyroid uptake was 63%
    2. Toxic MNG: The thyroid scan shows mul- tiple areas of increased uptake consistent with hot nodules in both lobes and suppression of the remaining normal functioning thyroid.
    3. Solitary toxic nodule: This is a pertechnetate thyroid scan. There is a focal hot nodule in the right lobe of the thyroid. The rest of the gland shows markedly reduced activity. The total thyroid uptake is at the upper limit of normal at 4%of the total injected activity, 20 minutes post injection. The findings are that of a toxic autonomous nodule.
    4. The I123 scan shows a round photopenic defect in the middle of the right lobe. normal tracer uptake is noted in the rest of the thyroid at 24hours. Differentials for a cold nodule include a colloid cyst, malignancy and non-functioning adenoma. I will correlate with US of the thyroid and FNAC of the nodule.
  11. Parathyroid MIBI scan – this is a dual phase scan of the thyroid and parathyroid. Early imaging at 20 minutes shows normal physiological uptake in both lobes of thyroid and salivary glands and myocardium with an area of increased tracer uptake in the inferior pole of the left lobe of thyroid. Delayed imaging at 2 hours shows retained tracer activity in the left lower pole region suggesting a parathyroid adenoma. I would confirm with US of the neck and serum PTH and calcium levels and refer this patient to endocrine services.
  12. This is a MIBI myocardial perfusion scan in the rest and stress phase in the short axis, anterior long axis and lateral long axis view. There is a reversible perfusion defect on stress imaging involving the apex and inferior LV wall which show normal perfusion on the rest images. These suggest stress induced ischemia without a myocardial infarction. OR. There is a fixed perfusion defect seen on the rest and stress images and CINE image shows mild hypokinesia in this region and wall thinning. This suggests myocardial infarction without stress induced ischemia.
  13. HIDA
    1. for biliary atresia – this is a serial DISIDA / HIDA scan of a baby which shows normal hepatic uptake. There is non visualisation of the gall bladder and no biliary excretion or intestinal tracer uptake. Significant hepatic tracer retention is noted at 24 hours which is highly suggestive of biliary atresia. Inspissated bile syndrome can also produce this pattern and USG can help to differentiate the two by demonstrating echogenic bile in the CBD. I will inform the pediatric surgeons about this finding and early surgery is recommended for best results. Diagnosis can be confirmed with intraoperative cholangiogram.
    2. For cholecystitis – Representative images from a hepatobiliary scan with reveals no significant radiotracer uptake within the expected region of the gallbladder during the first hour of imaging. There is normal tracer transit through thecommon bile duct into the small bowel with incidental note of enterogastric reflux. Slight increased hepatic parenchymal activity (“rim” sign) is seen along the gallbladder fossa. No gallbladder activity was noted despite subsequent morphine administration. These findings suggest cystic duct obstruction and the rim sign suggests inflammation in the GB fossa suggesting acute calculus cholecystitis. I would correlate with US and blood parameters and recommend urgent surgical evaluation
  14. RBC scintigram – red blood cell labeled Tc scan: The flow images shows an area of tracer accumulation in the left abdomen At 35 min this has a curvilinear configuration suggesting small bowel location. And by 50 min this activity has increased and has distributed throughout much of the small intestine. The study demonstrates that the bleeding source is in the small bowel, and thus serves to appropriately direct either angiography or surgery.
  15. Meckel scan – This is a dynamic pertechnate scan which shows a focal area of abnormal tracer uptake in the right lower quadrant which intensifies over time simultaneously with the normal gastric mucosa. There is no tracer washout with peristalsis suggests ectopic gastric mucosa within a meckel diverticulum. A GI duplication cyst with ectopic gastric mucosa is a differential and can be differentiated with a CT or US of the abdomen.

Pediatric

  1. Look at the ossification centers for approximate age. Head of humerus not seen = preterm
  2. Always look at the lines and tubes first  and comment on their position
  3. In any case of NAI: ask for the patient’s age: it usually is seen in <2y children.
  4. In any pediatric skeletal case, consider NAI and in case of NAI:
    1. Alert physicians to take a careful history
    2. Alert social services
    3. Follow local policy to protect the child
    4. Perform complete skeletal survey
    5. CT (acute) or MRI (non-acute) brain for head injury
  5. In case of osteogenesis imperfecta:
    1. Look for sclerotic metaphyseal lines secondary to pamidronate treatment
    2. exuberant callus formation
    3. gracile bones
  6. Rickets: DDs are RTA, metaphyseal chondrodysplasia and OI.
  7. Bowel obstuction in a neonate: use the term high and low bowel obstruction (difficult to differentiate large and small bowel). To differentiate ileal atresia, meconium ileus and hirshsprung, do Enema: microcolon confirms it is ileal atresia or meconium ileus (look for peritoneal calcification). Latter does not have fluid levels while former will have fluid levels. Large colon seen in Hirshsprung and meconium plug (CF) or small left colon (not CF). Imperforate anus can be ruled out clinically (look for gas in the bladder for fistula).
  8. Intussusception – The plain radiograph shows dilated small bowel loops. There is a meniscus of soft tissue mass in an air-filled colon in the right lower quadrant. There is no evidence of pneumoperitoneum. An US scan through the mass demonstrates concentric rings of alternating hyper- and hypoechoic layers (target/doughnut sign) and longitudinal scans show hypoechogenicity on either side of an echogenic mesentery (pseudo kidney). I would look for doppler evidence of vascularity within the bowel loops and also for free fluid. The presence of free fluid contraindicates radiological reduction and the absence of doppler signal makes reduction more likely to be unsuccessful. In a young child < 3 years, a lead point is usually not present and an air reduction can be attempted and the paediatric surgeons will be urgently informed to be on call in case it is unsuccessful. Since this child is older, a lead point must be suspected and a CT scan should precede treatment,
  9. Duodenal atresia – This is a radiographs of a neonate which shows a “Double-bubble” sign seen as gaseous distension or air–fluid levels within the stomach and duodenum. Paucity of gas within the remaining small and large bowels. These appearances suggest a duodenal obstruction. Causes include duodenal atresia, small bowel volvulus, annular pancreas or Ladd band. A UGI series can help to differentiate the various causes. The UGI series shows duodenal narrowing or stenosis. This suggests duodenal atresia. I will look for other associations in the VACTERL series – vertebral anomalies, anorectal malformation. An US should be arranged to look for genitourinary and cardiac anomalies. The findings will be communicated to the paediatric surgeons for urgent surgical correction.
  10. Hirschsprung – This is a plain radiograph of the abdomen of a neonate which shows signs of distal bowel obstruction. A barium enema study shows a small caliber rectum which is less than the caliber of the sigmoid colon. A transition zone is noted at the splenic flexure with a dilated proximal colon. These findings suggest Hirschsprung disease and confirmation can be by a rectal biopsy – full thickness or a suction biopsy.
  11. NEC: This is a plain abdominal radiograph of a neonate. I would first like to comment on the lines and tubes – NG, UV and UA catheter. There is dilation of the bowel loops (greater than coronal diameter of L1 VB). There are  bubbly areas and curvilinear areas of gas suggesting pneumatosis intestinalis. There is linear branching streaks of gas in the peripheral liver suggesting portal venous gas. In this particular supine radiograph there are features of pneumoperitoneum / no evidence of pneumoperitoneum but I would ideally obtain a cross table or lateral decubitus radiograph to confirm the same. I would like to review previous radiographs to look at the progression of the bowel dilation. These findings suggest NEC and the findings need to be urgently communicated to the paediatric surgeon since perforation is an indication for laparotomy. If there is no pneumoperitoneum, serial 6-12 hourly radiographs need to be done to monitor the progress as determined clinically. An alternative would be to follow up with US to detect free fluid, PV gas and bowel wall thickening.
  12. Meconium ileus – this is a single image from a water soluble contrast enema. There are dilated proximal bowel loops. The colon appears diffusely small. The contrast in the terminal ileum has a bubbly appearance from the presence of numerous filling defects suggesting meconium ileus. There is no evidence of calcification in the peritoneal cavity / there is calcification in the scrotum and peritoneal cavity suggesting meconium peritonitis. The bowel loops appear to be displaced, possibly from a meconium pseudocyst.
  13. CDH:  This chest radiographs of a neonate shows almost complete opacification of the left chest with marked mediastinal shift to the right. The NG tube and umbilical arterial line (arrowhead) are shifted to the right within the chest. The umbilical venous line (arrow) takes a very unusual course suggesting the liver is also displaced in the herniation. There are cystic lucencies in the upper left chest which represent gas-filled loops of bowel. This represents a congenital diaphragmatic hernia, most likely through the Foramen of Bochdalek. The patient requires urgent surgical referral for correction. AN upper GI series should not be done as this may further distend the bowel loops. A plain CT may be appropriate if it does not delay surgery as it will help with anatomical delineation of the herniating contents. The right lung most likely is hypo plastic and may not reexpand after surgery.
  14. Foreign body aspiration: There is hyper expansion of the right lung with flattening of the diaphragm and shift of the mediastinum to the left. If this child presents with choking or coughing or there is any suspicion of a foreign body aspiration clinically or historically, this child should proceed for bronchoscopy. If the history is not certain, an expiratory view can be arranged or a decubitus view with the right side down performed to look for air trapping. A lateral neck radiograph should also be done. If there is evidence of air trapping, a foreign body is likely and the child should proceed to bronchoscopy.
  15. Consider two pathologies in premature neonates: NEC and RDS. In any case of NEC look for intramural gas, pneumoperitoneum, portal venous gas.
  16. Loss of subarachnoid space in a neonatal cranial US means diffuse cerebral deem in HIE. Term, severe asphyxia – ventrolateral thalamus, putamen, perirolandic.
  17. I commonly miss thalassemia –
    1. Look out for coarse trabeculation in a pediatric skeleton.
    2. Look out for widening of the marrow space
    3. Extramedullary hematopoesis
    4. Erlenmeyer flask deformity
    5. Chrondrocalcinosis
    6. Dense metaphyseal bands from iron overload
    7. Hair-on-end, wide diploe, obliterated sinuses.
    8. Paraspinal mass
    9. Biconcave vertebrae
    10. Expanded ribs
    11. Pneumoperitoneum in an infant – either NEC or meconium peritonitis —> look for portal venous gas/pneumatosis or peritoneal calcification respectively
    12. In a case of RDS, if the pneumothorax is not obvious on AP, say that you will get a lateral (supine —> air will rise to the anterior area).
    13. In a case of a neuroblastoma – say that you will complete staging with MIBG
    14. In a case of PUV with VUR – comment on the kidney size (it can be scarred) and also on the thorax size (it can be small – Potter sequence)
    15. In a suspected foreign body aspiration where the X-ray looks normal: a standard PA and lateral CXR are an insufficient  evaluation.  A lateral neck film should be obtained to  examine the upper airway for evidence of swelling or  foreign body.  Decubitus films and/or expiratory films  should also be obtained to look for evidence of air  trapping.
    16. The thyme shadow (wide mediastinum) should normally be seen in any neonate – if it looks narrow – think of DiGeorge Syndrome.
    17. A gassless abdomen in a child is suspicious of an upper GI obstruction

Thorax

  1. Always look at the side marker on a chest X-ray for Kartageners
  2. Interstitial markings (Kerley lines on the CXR) – look at the heart (cardiomegaly/pericardial effusion – pulmonary edema), breast shadow and axillary region (breast cancer) and mediastinal lymph nodes (sarcoid)
  3. Bilateral basal pneumonia with rib fractures – aspiration in an alcoholic
  4. In any case of air-space opacification, look for causes other than pneumonia (rib erosions – BAC, fractures – contusion, cavitation, bilateral hilar nodes – sarcoid). Say that you will repeat the X-ray after 4-6 weeks of antibiotics.
  5. Cannon ball mets – know the primaries (breast, sarcoma (can calcify), colon and RCC). Non malignant lesions – SCC, fungal,  Wegners (both will cavitate).
  6. Calcified lesions within the lung – silicosis, mucinous metastasis.
  7. Anterior mediastinal mass: confirm location (hilum overlay and descending aorta seen posteriorly), look for fat and calcification on CXR. If a lesion is going above the clavicle and its lateral border is sharply defined then it lies in the posterior mediastinum.
  8. In a case of sarcoid:
    1. Ways in which it can present:
      • Bilateral hilar nodes + egg shell calcification
      • Peribronchovascular nodules which may become confluent
      • Interlobular septal thickening
      • Upper lobe fibrosis + traction bronchiectasis
    2. Confirm with serum ACE and calcium
    3. Mention the radiographic staging
    4. If pacemaker is present: it can be due to heart block from sarcoid
  9. Bilateral upper lobe fibrosis – common viva case – sarcoid, TB, ankylosing spondylitis, chronic hypersensitvity pneumonitis, silicosis.
  10. CYSTIC FIBROSIS IS A VERY COMMON VIVA FILM: BRONCHIECTASIS + PORT. Look for pneumothorax complication of obstruction), mucus plugs, pulmonary hypertension, lymph nodes and visceral manifestations (distal intestinal obstruction syndrome), hepatic steatosis, pancreatic atrophy, osteoporosis (steroid use).
  11. Mediastinal mass is a definite case – DDs
    1. Anterior: 4Ts superiorly, inferiorly: pericardial cyst, morgagni hernia and sternal tumours
    2. Middle: bronchogenic cyst, bronchial carcinoma, LN, ascending aortic aneurysm
    3. Posterior: vertebral mass, abscess, nerve sheath tumours, extramedullary hematopoesis, esophageal mass and achalasia, aortic aneurysm, neurogenic tumours which calcify – gangliocytoma, neurobalstoma
  12. Always ask for old films in a lung mass: doubling time <20 or >400 days is benign. Also, know to stage a lung cancer on CT.
  13. Whenever you see rib fractures on a CT – look for flail component (# at two sites in consecutive ribs)
  14. Metastatic miliary nodules : +thyroid clips +mastectomy +pneumonectomy +humerus osteosarcoma
  15. Mediastinal mass set answer: There is a mass-like opacity in the upper zone. The lateral margins are well defined and the medial margin merges with the mediastinum with obtuse angles. It has lobulated margins. No differential densities / there is calcification within. The aortic arch and hilum is well seen through the lesion / it is silhouetting the aortic arch and the descending aorta is not seen separately / there is posterior rib splaying / the paravertebral stripe is displaced laterally / it extends below the diaphragm or above the clavicle into the neck. These features suggest a posterior / anterior mediastinal mass. Differentials for an anterior mediastinal mass include a lymphoma / thymic origin lesion / teratoma and thyroid enlargement. A CT with contrast needs to be done to further characterise the lesion and possibly obtain a CT guided biopsy. Differentials for a posterior mediastinal mass include paravertebral abscess (look at the IVD space and the lungs for TB), neurogenic tumour for which a CT thorax and MRI spine will better delineate anatomy and tissue characterisation, extra medullary hematopoesis (look at the ribs for marrow expansion), lymphoma, developmental neruoenteric cyst (look for spina bifida)
  16. Military nodules set answer: There are multiple small well-defined nodules that are around 1–2 mm in diameter, spread evenly throughout both lungs with no zonal predominance. No calcification and no pleural effusion. The heart and mediastinal contours are within normal limits. No bony abnormality. The two main differential diagnoses in this case would be infection (such as miliary tuberculosis, fungal and viral pneumonia) or metastatic disease. Less common differential diagnoses would include pneumoconiosis (such as silicosis and coal worker’s pneumoconiosis) or atypical sarcoidosis. I would want to look at previous chest radiographs to look for evidence of prior TB or lung nodules and speak to the clinician to obtain a full history as well as to discuss further management. Further investigations may include bronchoscopy with acid- and alcohol-fast bacilli (AAFB)/ cultures and CT chest/abdomen/pelvis to look for multiorgan involvement.
  17. UIP set answer:  This is a frontal chest radiograph of an adult. The chest radiograph demonstrates low lung volumes and a subpleural reticular pattern involving the entire lung with a basal predominance. The heart and mediastinal contours are within normal limits. The findings are consistent with pulmonary fibrosis due to the histological pattern of usual interstitial pneumonitis (UIP). I would like to arrange a high-resolution CT of the chest for further characterization of the disease.
    HRCT images demonstrate a symmetrical, predominantly subpleural pattern of reticulation with intralobular septal thickening, traction bronchiectasis and bronchiolectasis as well as severe subpleural honeycombing. Small amounts of ground glass in areas of architectural distortion. The findings are present in all lung zones, increasing in severity in a caudal direction. There is relative sparing of the central lung. The CT findings are in keeping with the histological diagnosis of UIP.
    The histological pattern of UIP can be due to idiopathic pulmonary fibrosis (IPF), connective tissue disease (in particular rheumatoid arthritis), asbestosis or drug reaction (busulfan and bleomycin). Idiopathic pulmonary fibrosis is essentially a diagnosis of exclusion. Look for:

    • Pleural plaques, – asbestos exposure,
    • Inflammatory joint disease of the shoulder and clavicle – RA.
    • Syndesmophytes / ligament calcification in the spine – AS
    • Lymph nodes – sarcoid
    • Egg shell nodes – silicosis
    • Dense liver / ventricular aneurysm – amiodarone therapy
    • Dilated esophagus – scleroderma
    • Pleura-Pericardial effusion – SLE would discuss the case with the clinician, as further clinical history would be invaluable. The patient will need to be referred to the chest physicians. Pulmonary function tests, which typically show a restrictive pattern with limited diffusion, should be ordered.
  18. Cystic fibrosis: A port-a-cath is noted with the tip in an appropriate location in the SVC. Posteroanterior radiograph of the chest shows pulmonary hyperaeration with diffuse peribronchial thickening, dilated bronchi and cystic spaces. These are compatible with bronchiectasis. The distribution is predominantly perihelar and in the upper lobes. This patient is probably on long term antibiotics. Differential will include cystic fibrosis. I will look at prior radiographs to look at the progression and also any infection which has resolved as there is no evidence of active infection in the X-ray. Other DD for upper lobe bronchiectasis are post infection (TB)_
  19. Cystic lung disease set answer: Numerous thin walled cysts involving both lungs including the apices and CP angles. Intervening lung is normal / there are bizzarely shaped nodules in the lung with sparing of the CP angles and the apices. Lung volumes are normal and not reduced. Associated with small pleural effusion / pneumothorax. There are no skin neurofibromas or skeletal abnormalities. Features are suggestive of Lymphangioleiomyomatosis and as this is associated with TS, I will screen for other associations like AML of the kidney and rhabdomyoma of the heart. Confirmation is with a lung biopsy after discussion with the respiratory physicians. Treatment is with sirolimus. Features are suggestive of Langerhan cell histiocytosis, especially if this is a smoker. I would suggest chest physician referral for further management.
  20. Wenger set answer: There are numerous discrete focal nodular lesions, approximately 2-4 cm with no zonal predilection. Some of them show cavitation, with variable wall thickness, and air-fluid levels. There is surrounding GGO and consolidation suggesting hemorrhagic changes. There is tracheal wall thickening and subsequent narrowing. I would like to compare with previous radiographs and also with PNS radiographs. If there is rapid progrssion of the lesions, differentials include septic embolism, TB or fungal lesions. Inflammatory lesions like Wegner, RA and sarcoid can also present ike this. In an older patient, metastasis must be considered (if cavitating, from SCC). Confirmation can be with lung biopsy, ANCA level and sputum analysis for infection. CT of the sinus shows mucosal thickening. There is bone destruction and nasal septum perforation.
  21. Cavitating lung nodules:
    • +shoulder arthropathy/clavicle resorption – RA,
    • +PNS/nasal septum perforation/tracheal thickening/GGO representing hemorrhage – Wegners
    • +humerus sarcoma – mets
    • + calcified LN – sarcoid, TB (post primary TB usually does not have nodes)
  22. Follow up of lung nodule > 8m – CT at 3, 9, 24 months +/- PET and biopsy. If smoker, even nodule < 4mm needs 12 month CT
  23. If you see consolidation on CT / X-ray, mention that the differentials will depend on the presentation of the patient. Infection (pneumonia) being a primary concern if the patient has productive cough and fever. The patient will require antibiotics and follow up X-rays to look for resolution. Alternatively, if previous X-rays are there I will review them and if there is no change, non-infective differentials like BAC, sarcoid must be considered. Finally, say that you would view in mediastinal window to look for fat attenuation within the consolation to look for lipoid aspiration pneumonia if it is lower lobe consolidation.
  24. On a CT thorax, if you see a fat containing anterior mediastinal mass, always scroll to the bottom and check if it is a Morgagni hernia (look for continuity of the omental vessels)
  25. Causes of lymphangitis carcinomatosis – lung, breast, stomach, colon. Kerley: Sarcoid, edema, lymphoma, lymphangitis
  26. When you see a pneumothorax – if it is tension – say that you will go assess the patient immediately and if dyspneic you will treat it immediately by placing a needle and inform emergency services for intercostal drain placement. Look for a cause – cavitating mass, cyst with air-fluid level, bulla, rib fracture
  27. In any patient with features of TB, even if it is scarring, say that you will follow up for 6 months or review old films of 6 months as at least 6 months of stability of findings are needed to rule out reactivation.
  28. In any weird looking chest X-ray, think of a post-lung-transplant status.
  29. When you see a thymic mass on CT or X-ray, check for pleural and pericardial deposits.
  30. When you talk about LCH or LAM, mention that the lung volumes are normal.
  31. When you see a right lower zone opacity merging with diaphragm, think of morgagni hernia
  32. Things I commonly miss: Parenchymal sarcoid presenting with nodular-reticular opacities, lymphangitis carcinomatosis with mastectomy, ABPA, right side aortic arch,  rib notching in coarctation, sclerotic mets after mastectomy, mycetoma (air crescent), look at the trachea in a CT thorax when everything looks normal.
  33. Checklist:
  • Trachea (deviation) – bronchi (cut off)
  • Hilum (enlarged or shifted)
  • Mediastinum – paratracheal, aortic knuckle (right sided, enlarged, coarctation)
  • Paraspinal mass
  • Lungs
  • Pleura
  • Diaphragm
  • Soft tissue – thyroid mass
  • standard review areas
    • Apices – mass or pneumothorax
    • Bones (ribs lytic or sclerotic, notching. shoulder AVN, lytic mass. Clavicle – look for absent clavicle, erosion. Vertebra – scoliosis, H shaped, pedicle destruction) and breast (asymmetry)
    • Cardia – retrocardiac area
    • Diaphragm – below the diaphragm – lung mass and pneumoperitoneum, spleen calcification, gas in spenic flexure (asplenia)
    • Edge of the film
    • right descending pulmonary artery (like a little finger)

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