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ACR Inservice Recall

ACR Inservice Recall


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  • 1. 2007 ACR Diagnostic Radiology In-Training Exam Rationales Section X Chest Radiology 202. You are shown two axial images from a CT scan of the chest of a 48-year- old woman with an abnormal chest radiograph (Figures 1A and 1B). Which one of the following is the MOST LIKELY diagnosis? A. Hamartoma B. Carcinoid Tumor C. Adenocarcinoma D. Granuloma Findings: Smooth bordered, round upper lobe mass with eccentric calcifications, air-trapping and mucocoeles (best seen on lung windows). RATIONALES: A. Incorrect. Though the lesion is round, and well-circumscribed, this lesion does not contain fat, which would be diagnostic for hamartoma. The calcifications are chunkier than the classic popcorn calcifications of pulmonary hamartoma. Usually, hamartomas have no effect on adjacent airways. The net result is that hamartoma is possible but not the most likely. B. Correct. The affiliation with the airway, round nature and chunky eccentric calcifications are very typical for pulmonary carcinoid tumors. In fact, 40% of carcinoids may be calcified on CT. Another feature of carcinoid tumors is their effect on the airway (seen in up to 50% of cases). In this case, the effect is air- trapping. C. Incorrect. These lesions may be anywhere in the lung but tend to be peripheral. They may present with areas of ground glass and somewhat spiculated borders. Smaller lesions may be smooth bordered and round. Calcifications may be eccentric in adenocarcinomas. Usually adenocarcinomas do not result in air-trapping. D. Incorrect. Granulomas tend to be smaller than 2 cm and are usually calcified. When calcified, they are entirely calcified, centrally calcified or lamellated. Airway effects from granulomas are rare. Though this lesion could be a granuloma, its CT appearance is not suggestive of one. References: Chong S, Lee KS, Chung MJ, Han J, Kwon OJ, Kim TS. Neuroendocrine tumors of the lung: clinical, pathologic, and imaging findings. Radiographics. 2006;26:41- 57 Jeung MY, Gasser B, Gangi A, Charneau D, Ducroq X, Kessler R, Quoix E, Roy C. Bronchial carcinoid tumors of the thorax: spectrum of radiologic findings. Radiographics. 2002;22:351-65.
  • 2. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 203. You are shown two chest radiographs of a 49-year-old man with cough (Figures 2A and 2B). Which one of the following is the MOST LIKELY diagnosis? A. Mucus plug B. Central mass C. Pneumonia D. Loculated pleural effusion Findings: Right upper lobe collapse from a central mass (Reverse S of Golden). RATIONALES: A. Incorrect. B. Correct. This radiograph represents the classic findings of right upper lobe collapse with increased opacity and volume loss. The central mass results in a convex inferior border which simulates a backwards “S” when viewed adjacent to the upper portion of collapse. This “Reverse S of Golden” should trigger the reader to think of a mass when it is present, usually bronchogenic carcinoma. C. Incorrect. D. Incorrect. References: Woodring JH, Reed JC. Types and mechanisms of pulmonary atelectasis. J Thorac Imag 1996;11:92-108. Woodring JH, Reed JC. Radiographic manifestations of lobar atelectasis. J Thorac Imag 1996;109-144.
  • 3. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 204. You are shown three axial images from a CT scan of the chest of a 65 year old woman (Figures 3 A-C). What is the MOST LIKELY diagnosis? A. Relapsing polychondritis B. Tracheomalacia C. Post-intubation stricture D. Saber-sheath trachea RATIONALES: A. Incorrect. Relapsing polychondritis is a rare autoimmune syndrome characterized by recurrent episodes of cartilaginous inflammation. This leads to destruction of the cartilaginous rings of the trachea resulting in thickening of the trachea. The posterior membrane is spared as it doesn’t contain cartilage. This helps distinguish from other causes, such as in this case of post-intubation stricture. B. Incorrect. C. Correct. Post-intubation stricture results when the high pressure of an endotracheal tube balloon results in tracheal mucosal necrosis. This eventually leads to scarring and stenosis, which typically occurs just below the thoracic inlet portion of the trachea. D. Incorrect. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 4. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 205. You are shown two axial images from a CT scan of the Chest of an 80-year old-man (Figure 4A and 4B). Which of the following drugs is MOST LIKELY responsible for the radiographic finding? A. Bleomycin B. Penicillamine C. Amiodarone D. Nitrofurantoin Findings: CT scan of the Chest shows high attenuation reticular opacities in both lower lobes of the lung and high attenuation of the liver. RATIONALES: A. Incorrect. B. Incorrect. C. Correct. Amiodarone is a triiodinated compound used in the treatment of cardiac arrhythmias. Pulmonary toxicity occurs in 5-10 % of the patients. The risk is increased if the daily maintenance dose is greater than 400 mg and if the patient is elderly. Combination of high attenuation abnormalities in the lung and liver on CT scan are characteristics radiographic features of amiodarone toxicity. D. Incorrect. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001 Webb, WR, Muller, NL, Naidich DP. High Resolution CT of the lung. Lippincott- Raven Publishers, Philadelphia, PA 1996
  • 5. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 206. You are shown two axial images from a CT scan of the Chest of an 80-year- old woman (Figures 5A and 5B). What is the MOST LIKELY diagnosis? A. Bronchogenic carcinoma B. Lipoid pneumonia C. Cryptogenic organizing pneumonia D. Streptococcus pneumonia RATIONALES: A. Incorrect B. Correct. Lipoid pneumonia is caused by aspiration of mineral oil. The disease occurs in elderly individuals who frequently use oil for constipation. The radiographic features include air space consolidation with spiculation or linear opacities. These changes are the result of interlobular septal thickening caused by infiltration of lipid laden macrophages and chronic inflammation. The presence of fat in the consolidation strongly favors this diagnosis. These features are present in the test case. C. Incorrect D. Incorrect References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 6. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 207. You are shown a single axial image from a CT scan of the chest of a 30- year-old woman (Figure 6). Which type of nodule is demonstrated? A. Centrilobular B. Tree-in-bud C. Miliary D. Perilymphatic RATIONALES: A. Correct. Centrilobular nodules or opacities occur in the center of the secondary lobule. They reflect bronchiolar or peribronchiolar abnormalities in the centrilobular distribution. They are typically seen 5 to 10 mm from the pleural surface. Since the lobules are evenly spaced, the nodules tend to appear evenly spaced. The differential diagnosis includes endobronchial spread of infection / tumor, hypersensitivity pneumonitis, pulmonary histiocytosis and vasculitis. B. Incorrect C. Incorrect D. Incorrect References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 7. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 208. Regarding pulmonary mycetoma, which one of the following is TRUE? A. Patients are usually immunocomprised. B. Cavity results from severe central cystic bronchiectasis. C. They are most often seen in the upper lobes. D. Hemoptysis results from angioinvasion by the fungal elements. RATIONALES: A. Incorrect. Actually, patients with mycetomas are usually immunocompetent. These fungal elements colonize a cavity from other diseases (emphysema, sarcoid, tuberculosis, etc). B. Incorrect. Central bronchiectasis is associated with aspergillus but with allergic bronchopulmonary aspergillosis (ABPA) not with mycetomas. The cavities are usually from an underlying chronic lung disease. C. Corrrect. Aspergillomas are usually seen in the upper lobes probably related to the common sites of the large cavities in the most commonly associated conditions (sarcoid, tuberculosis, emphysema). D. Incorrect. The hemoptysis results from the fragile bronchial circulation which feeds the cavity wall. These bronchials may need to be embolized and in certain situations, may precipitate lobectomy. References: Franquet T, Muller NL, Gimenez A, Guembe P, de La Torre J, Bague S. Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radiographics. 2001;21:825-37. Hennebicque AS, Nunes H, Brillet PY, Moulahi H, Valeyre D, Brauner MW. CT findings in severe thoracic sarcoidosis. Eur Radiol. 2005;15:23-30. Epub 2004 Sep 24.
  • 8. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 209. Which of the following structures is a core or centrilobular component of the secondary pulmonary lobule? A. Pulmonary vein B. Septum C. Bronchiole D. Lymphatic RATIONALES: A. Incorrect. The pulmonary vein is located in the peripheral portion of the secondary lobule within the interlobular septum. B. Incorrect. The interlobular septum is a band of fibrous tissue, which surrounds the periphery of the secondary lobule. C. Correct. The bronchiole forms the center of the lobule with its accompanying pulmonary artery. D. Incorrect. The lymphatic vessel is also located with the vein in the interlobular septum. References: Heitzman ER, Maharian B, Berger I, et al. The secondary pulmonary lobule: A practical concept for interpretation of radiographs. Radiology 1969; 93:508-513 Webb WR, Stein MG, Finkbeiner WE, et al: Normal and diseased isolated lungs: High resolution CT. Radiology 1988; 166:81-87 Bergin C, Roqgli V, Coblentz C, et al. The secondary pulmonary lobule: Normal and abnormal CT appearances. AJR 1988; 151;21-25
  • 9. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 210. Concerning the solitary pulmonary nodule, which CT appearance is MOST predictive of a primary lung carcinoma? A. Laminated calcification B. Solid density C. Pure ground glass attenuation D. Mixed solid and ground glass opacity RATIONALES: A. Incorrect. Laminated calcification in a nodule less than or equal to 2 cm in diameter is an indication of a healed granulomatous infection, i.e. histoplasmosis or tuberculosis. B. Incorrect. C. Incorrect. D. Correct. In a CT screening study for lung cancer, Henschke et al found among 233 nodules a malignancy rate of 7% for solid nodules, 18% for pure ground glass and 63% for part solid, part ground glass. References: Sigelman SS, Khouri NF, Lee FP, et al. Solitary pulmonary nodules, CT assessment. Radiology 1986; 160:307-312 Hensche CI, Yankelwitz DF, Mirtheva R, et al. CT screening for lung cancer: Frequency and significance of part solid and nonsolid nodules. AJR 2002; 178:1053-1057.
  • 10. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 211. Eggshell calcification in hilar or mediastinal nodes occurs in which of the following diseases? A. Tuberculosis B. Metastatic mucinous adenocarcinoma C. Histoplasmosis D. Sarcoidosis RATIONALES: A. Incorrect. Calcification in lymph nodes in granulomatous infections tends to be diffuse with complete calcification of the node. B. Incorrect. Calcification in mucinous adenocarcinoma is usually psammonatous, i.e. punctate or flake like and distributed throughout the node. C. Incorrect. Calcification in lymph nodes in granulomatous infections tends to be diffuse with complete calcification of the node. D. Correct. Calcification in lymph nodes in sarcoidosis is a late manifestation and occurs in less than 5% of patients. The pattern is frequently of the eggshell (peripheral) type but this is less commonly seen than in patients with sarcoidosis. References: Gawne-Cain ML, Hansell DM. The pattern and distribution of calcified medistinal lymph nodes in sarcoidosis and tuberculosis: A CT study. Clin Radiol 1996; 51:263-267 Meller BH, Rosado-de-Christensen ML, McAdams HP, et al. Thoracic sarcoidosis: Radiologic pathologic correlation. Radiographics 1995; 15:421-437 Brown K, Mund DF, Aberle DR, et al. Intrathoracic calcification: Radiographic features and differential diagnoses. Radiographics 1994; 14:1247-1261
  • 11. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 212. Which one of the following is MOST LIKELY to cause obliteration of a portion of the descending aortic interface? A. Pericardial cyst B. Bronchogenic cyst C. Lymphoma D. Neurogenic tumor RATIONALES: A. Incorrect. B. Incorrect. C. Incorrect. D. Correct. The descending aortic interface is formed by the juxtaposition of the aerated lung and the opacity of the left lateral margin of the descending thoracic aorta. The interface is visible from the top of the aortic arch to the level of the diaphragm inferiorly. Since the descending thoracic aorta is a posterior structure, abnormalities that obliterate the descending aortic interface are within the posterior mediastinum. Of the choices provided, only neurogenic tumors occur in the posterior mediastinum. Thus, they are most likely to obliterate the descending aortic interface. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 12. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 213. Which of the following statements about localized fibrous tumors of the pleura is TRUE? A. They are associated with asbestos exposure. B. They are associated with hypertrophic pulmonary osteoarthropathy. C. They account for the majority of pleural tumors. D. Most of these tumors arise from parietal pleura. RATIONALES: A. Incorrect. B. Correct. Localized fibrous tumor of the pleura are relatively rare tumors of the pleura. About 80% of them arise from the visceral pleura. They affect male and female patients equally. They are not associated with smoking, asbestos exposure or other environmental pollutants. About half of the patients are asymptomatic when the tumor is discovered incidentally. They occasionally reach very large size and produce symptoms of cough, dyspnea and chest pain. Paraneoplastic syndromes such as hypoglycemia and hypertrophic osteoarthropathy are present in 4-5 % of the cases. C. Incorrect. D. Incorect. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001 Mcloud, TC. Thoracic Radiology: The Requisites. Mosby, Inc., St. Louis, MO 1998
  • 13. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 214. Concerning radiation pneumonitis, which of the following is TRUE? A. It usually occurs 6 months after completion of radiation therapy. B. Chemotherapeutic agents potentiate the effects of radiation. C. The acute phase of injury manifests as traction bronchiectasis. D. Preexisting lung disease has no effect on the development of radiation pneumonitis. RATIONALES: A. Incorrect B. Correct. Radiation pneumonitis is a complication of radiation therapy. Multiple factors determine the development and appearance of pneumonitis. They include, the volume of lung involved, the type of radiation used, the time period over which radiation therapy was given, whether chemotherapy was given at the same time, and whether there was preexisting lung disease to name a few. Radiation pneumonitis is divided into early and late manifestations. The early or acute pneumonitis occurs within 1 to 3 months following treatment and radiographically appears as homogeneous or patchy ground glass opacities. The changes evolve over the next 6 to 12 months and usually become stable within 2 years. They appear radiographically as dense consolidation, traction bronchiectasis and volume loss. C. Incorrect D. Incorrect References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 14. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 215. Which one of the following diseases is MOST LIKELY to be a cause of pulmonary artery aneurysm or pseudoaneurysm? A. Pulmonary infection B. Mediastinal fibrosis C. Metastasis D. Goodpasture’s syndrome RATIONALES: A. Correct. Pulmonary artery aneurysms are rare. They may occur secondary to infection (Septic emboli, Tuberculosis etc.), catheter-related complications, pulmonary hypertension or vasculitidies. The most common cause is probably catheter-related complications. Rasmussen aneurysm is a mycotic aneurysm that occurs in relation to tuberculus infection. B. Incorrect C. Incorrect D. Incorrect References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 15. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 216. Concerning pulmonary mycobacterium avium-intracellulare complex infection, which one of the following is TRUE? A. Cavitary lesions occur in patients with chronic obstructive pulmonary disease. B. Centrilobular nodules occur in immunocompromised patients. C. Mediastinal adenopathy occurs in elderly woman without underlying lung disease. D. RML and lingular bronchiectasis occurs in patients with hypersensitivity pneumonitis. RATIONALES: A. Correct. Mycobacterium avium-intracellulare complex infection have four distinct manifestations which occur in different sets of population depending on their underlying clinical status. The classic infection occurs in elderly men with underlying chronic obstructive pulmonary disease or pulmonary fibrosis. Radiographically, nodules and or cavitations are seen in the upper lobes. B. Incorrect. Mycobacterium avium-intracellulare complex infection in immunocompromised patients appear as mediastinal or hilar adenopathy. C. Incorrect. Mycobacterium avium-intracellulare complex infection in elderly patients appear as RML and Lingular bronchiectasis with scattered tree-in-bud opacities D. Incorrect. Hypersensitivity pneumonitis secondary to Mycobacterium avium- intracellulare exposure manifests as centrilobular ground glass opacities. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 16. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 217. Concerning lung cancer staging, which one of the following is MOST indicative of unresectability? A. Size of the tumor B. Pleural effusion C. Scalene node D. Ipsilateral hilar adenopathy RATIONALES: A. Incorrect. B. Incorrect. C. Correct. Lung cancer staging is based on the TNM classification. Based on this classification, stage III B and above is considered unresectable disease. Stage III B constitutes N3 and/or T4 disease. N3 disease involves contralateral hilar or mediastinal nodes or scalene or supraclavicular nodes. While T4 disease involves invasion of tumor into mediastinum, heart, great vessels, trachea, esophagus or chest wall as well malignant pleural or pericardial effusion. D. Incorrect. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 17. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 218. Concerning Morgagni hernia, which one of the following is the MOST common location for its occurrence? A. Left cardiophrenic B. Right cardiophrenic C. Left paraspinal D. Right paraspinal RATIONALES: A. Incorrect. B. Correct. Morgagni hernia represents a congenital diaphragmatic defect. They occur in the right cardiophrenic angle. The hernia sac usually contains intraabdominal fat and may contain air filled loops of bowel. C. Incorrect. D. Incorrect. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 18. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 219. Which one of the following radiographic signs represents chronic deep vein thrombosis at CT venography? A. Central low attenuation B. Perivenous soft tissue edema C. Venous dilitation D. Central calcification RATIONALES: A. Incorrect. B. Incorrect C. Incorrect. D. Correct. The findings of chronic deep vein thrombosis on CT venography include calcification of thrombi within veins as well as that of venous walls, shrunken veins and presence of collateral vessels. Central low attenuation within veins, perivenous soft tissue edema and venous dilatation are signs of acute deep vein thrombosis. References: Katz DS, Loud PA, Bruce D, Gittleman AM, Mueller R, Klippenstein DL, Grossman ZD. Combined CT venography and pulmonary angiography: A comprehensive review. Radiographics 2002; 22:S3-S24
  • 19. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 220. Which one of the following is true regarding the ACR recommendation for chest radiographs in patients requiring mechanical ventilation? A. Daily B. Twice a day C. Every other day D. Once a week RATIONALES: A. Correct. The ACR recommends daily portable chest radiographs in patients who are on mechanical ventilation and in those who have acute cardiac or pulmonary disease. Radiographs are also recommended following placement of support and monitoring devices. B. Incorrect. C. Incorrect. D. Incorrect References: American College of Radiology Standards for bedside radiographs. (www.acr.org).
  • 20. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 221. A computed radiography image with a 10-bit pixel depth will have how many possible shades of gray? A. 256 B. 1024 C. 4094 D. 8192 RATIONALES: A. Incorrect. B. Correct. Pixel depth is computed as 210 = 1024 C. Incorrect D. Incorrect 222. A patient undergoes a chest CT in a trauma center and later found to be pregnant. The radiation exposure to fetus is mainly from: A. primary x-ray radiation. B. internal scatter radiation. C. external scatter radiation. D. leakage radiation. RATIONALES: A. Incorrect B. Correct. C. Incorrect. External scatter radiation drops drastically from the edge of scan field, i.e., chest. The exposure is minimal from external scatter. D. Incorrect.
  • 21. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 223. Concerning idiopathic pulmonary fibrosis, which of the following is TRUE regarding the distribution of disease? A. Upper and central B. Upper and peripheral C. Lower and central D. Lower and peripheral RATIONALES: A. Incorrect B. Incorrect C. Incorrect D. Correct. Idiopathic pulmonary fibrosis affects patients between 50 and 70 years old. It is characterized by the development of relentlessly progressive fibrosis and is associated with 2-3 year median length of survival from the time of diagnosis. Radiographic findings include reticular opacities at the lung bases in peripheral distribution. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001
  • 22. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 224. Concerning cysts noted in the lung on High Resolution CT scan of the chest, which one of the following is TRUE? A. They are spherical and uniform in Langerhans cell histiocytosis. B. They lack a well defined wall in early centrilobular emphysema. C. They are spherical and in the upper lobes in panlobular emphysema. D. They are irregular and in the upper lobes in lymphangioleiomyomatosis. RATIONALES: A. Incorrect. In Langerhans cell histiocytosis. The cysts are often irregular and seen in the upper lobes. B. Correct. In early centrilobular emphysema the cystic areas within the lung have an imperceptible wall. In later stages, the entire secondary lobule, except the lobular wall is destroyed and can appear as multiple adjacent polygonal cysts. C. Incorrect. The disease is in the lower lobes. D. Incorrect. The cysts are smooth and round and they are evenly distributed throughout the lungs. References: Muller, N.L., Fraser, R.S., Colman, N.C., and Pare’, P.D. Radiologic Diagnosis of Diseases of the Chest. W.B. Saunders, Co., Philadelphia, PA 2001