The document discusses rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to nuclear radiology. It provides details and images from various nuclear medicine studies, including thyroid scintigraphy, bone scintigraphy, renal scintigraphy, CNS shunt study, pulmonary perfusion scan, PET imaging, and radioimmunotherapy. For each question, it discusses the correct answer and explains why the other answer options are incorrect based on the findings and characteristics of the studies.
A post-menopausal woman presented with an asymptomatic 3.0 cm simple ovarian cyst. Of the following statements, the one that is TRUE is that the cyst should be removed if the patient has an increased serum CA-125 level. A simple cyst under 5.0 cm in diameter in a post-menopausal woman has a very low risk of malignancy and can be followed with serial ultrasounds without surgery. The most common neoplasm found on surgical removal of these cysts is a serous cystadenoma, not a fibrothecoma.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to pediatric radiology. It provides the correct answer and an explanation for each question, referencing imaging findings and typical presentations of various pediatric conditions like congenital cystic adenomatoid malformation, hematometrocolpos, pulmonary sling, Hirschsprung's disease and more. Key anatomic and imaging features are discussed in the rationales to explain why each answer choice is right or wrong.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to cardiac radiology. Question 102 asks which statement about cardiomyopathies is true. The correct answer is that cyclosporine immunosuppressive therapy can cause left ventricular hypertrophy. Cyclosporine is used after cardiac transplantation and can result in left ventricular hypertrophy as a side effect.
The document provides rationales for questions on a diagnostic radiology exam. Question 29 asks about an image showing changes in the small bowel. The most likely diagnosis is graft versus host disease based on the classic "ribbon bowel" appearance seen in the image. Graft versus host disease produces a total absence of mucosal folds in the small bowel, typically seen in the ileum rather than jejunum as seen in the image. This appearance is distinct from other potential diagnoses that may also cause small bowel abnormalities.
Gallium-67 citrate scintigraphy is preferred over In-111 leukocyte scintigraphy for the detection of disk space infection. While both agents are sensitive for osteomyelitis, gallium-67 has been shown to be more sensitive for disc space infection compared to In-111 leukocyte imaging. This is due to potentially confusing normal bowel activity seen on gallium-67 scans that could obscure abdominal pathology. In-111 leukocyte imaging is generally preferred for evaluating other infectious/inflammatory conditions like abdominal abscesses and infected joint prostheses due to less potential for false positives from normal biodistribution.
The document discusses rationales for exam questions related to chest radiology. Question 202 discusses a CT scan showing a smooth, round upper lobe mass with eccentric calcifications and air-trapping. The most likely diagnosis is a carcinoid tumor. Question 203 shows chest radiographs of a man with cough, demonstrating a classic right upper lobe collapse with a "Reverse S of Golden" suggestive of a central mass. Question 204 involves a CT scan showing post-intubation tracheal narrowing below the thoracic inlet.
This document contains 5 clinical case scenarios involving interventional radiology procedures (questions 265-269). Each case is accompanied by an image and 4 possible answers. The correct answer is identified and a brief rationale is provided for each case. Question 270-279 continue testing knowledge of interventional radiology with additional multiple choice questions related to procedures, techniques, and disease processes.
The document provides rationales for questions on an interventional radiology exam. It includes descriptions of imaging findings and the correct answers for 7 multiple choice questions. For each question, it summarizes the key imaging findings and explains why the correct answer is right and the other options are wrong based on those findings and published references. The questions cover topics like cholangiocarcinoma, splenic artery occlusion, pneumothorax management, mesenteric ischemia, Eustachian valve, gonadal vein reflux, and popliteal artery entrapment syndrome.
A post-menopausal woman presented with an asymptomatic 3.0 cm simple ovarian cyst. Of the following statements, the one that is TRUE is that the cyst should be removed if the patient has an increased serum CA-125 level. A simple cyst under 5.0 cm in diameter in a post-menopausal woman has a very low risk of malignancy and can be followed with serial ultrasounds without surgery. The most common neoplasm found on surgical removal of these cysts is a serous cystadenoma, not a fibrothecoma.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to pediatric radiology. It provides the correct answer and an explanation for each question, referencing imaging findings and typical presentations of various pediatric conditions like congenital cystic adenomatoid malformation, hematometrocolpos, pulmonary sling, Hirschsprung's disease and more. Key anatomic and imaging features are discussed in the rationales to explain why each answer choice is right or wrong.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to cardiac radiology. Question 102 asks which statement about cardiomyopathies is true. The correct answer is that cyclosporine immunosuppressive therapy can cause left ventricular hypertrophy. Cyclosporine is used after cardiac transplantation and can result in left ventricular hypertrophy as a side effect.
The document provides rationales for questions on a diagnostic radiology exam. Question 29 asks about an image showing changes in the small bowel. The most likely diagnosis is graft versus host disease based on the classic "ribbon bowel" appearance seen in the image. Graft versus host disease produces a total absence of mucosal folds in the small bowel, typically seen in the ileum rather than jejunum as seen in the image. This appearance is distinct from other potential diagnoses that may also cause small bowel abnormalities.
Gallium-67 citrate scintigraphy is preferred over In-111 leukocyte scintigraphy for the detection of disk space infection. While both agents are sensitive for osteomyelitis, gallium-67 has been shown to be more sensitive for disc space infection compared to In-111 leukocyte imaging. This is due to potentially confusing normal bowel activity seen on gallium-67 scans that could obscure abdominal pathology. In-111 leukocyte imaging is generally preferred for evaluating other infectious/inflammatory conditions like abdominal abscesses and infected joint prostheses due to less potential for false positives from normal biodistribution.
The document discusses rationales for exam questions related to chest radiology. Question 202 discusses a CT scan showing a smooth, round upper lobe mass with eccentric calcifications and air-trapping. The most likely diagnosis is a carcinoid tumor. Question 203 shows chest radiographs of a man with cough, demonstrating a classic right upper lobe collapse with a "Reverse S of Golden" suggestive of a central mass. Question 204 involves a CT scan showing post-intubation tracheal narrowing below the thoracic inlet.
This document contains 5 clinical case scenarios involving interventional radiology procedures (questions 265-269). Each case is accompanied by an image and 4 possible answers. The correct answer is identified and a brief rationale is provided for each case. Question 270-279 continue testing knowledge of interventional radiology with additional multiple choice questions related to procedures, techniques, and disease processes.
The document provides rationales for questions on an interventional radiology exam. It includes descriptions of imaging findings and the correct answers for 7 multiple choice questions. For each question, it summarizes the key imaging findings and explains why the correct answer is right and the other options are wrong based on those findings and published references. The questions cover topics like cholangiocarcinoma, splenic artery occlusion, pneumothorax management, mesenteric ischemia, Eustachian valve, gonadal vein reflux, and popliteal artery entrapment syndrome.
This document contains a multiple choice question and rationales from a pediatric radiology exam. The question shows MRI images of a 22-week fetus and asks for the most likely diagnosis. The rationales eliminate the other answer choices of posterior urethral valves, multicystic dysplastic kidneys, and bilateral ureteropelvic junction obstruction. The correct answer is Autosomal Recessive Polycystic Kidney Disease, as the images show enlarged, fluid-intensity kidneys without urine production, typical of this condition.
This document provides rationales for answers on a diagnostic radiology exam related to musculoskeletal radiology. The case presented involves radiographs and MRI images of various musculoskeletal injuries and conditions. The correct diagnosis for each case is provided along with explanations for why the other answer choices are incorrect. Key details that help distinguish between similar conditions are emphasized, such as findings that are more or less typical for a given diagnosis. A variety of musculoskeletal injuries, abnormalities, and diseases are discussed.
The document discusses several radiology cases involving the brain and spine. Question 291 presents CT scans of a woman with headaches and asks for the most likely diagnosis of a fat-containing extraconal orbital mass. Question 292 shows MR images of a woman with extremity weakness and asks for the most likely diagnosis of multiple brain and spine lesions. Question 293 presents MR images of a man with back pain and asks for the diagnosis of a posterior spinal mass seen on the images.
This document contains 3 figures and associated questions from a diagnostic radiology in-training examination. Figure 1 shows images from an F-18 FDG PET study in a man with abdominal pain. Figure 2 shows a posterior Tc-99m bone scintigram in a man with back pain. Figure 3 shows an anterior whole body Tc-99m bone scan in a woman with head and neck pain and a history of thyroid cancer. The questions assess the examinee's ability to interpret the images and select the most likely diagnosis.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to breast radiology. The rationales discuss the correct answers and explain why the other answer options are incorrect based on imaging findings and characteristics of different breast diseases. Invasive lobular carcinoma is identified as the most likely diagnosis for one case based on its appearance on mammography of being seen best on one view only or at least.
This document provides rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to ultrasound imaging. It discusses the correct answers and rationales for questions regarding various pathologies seen on ultrasound of the uterus, testes, kidneys, abdomen and fetal anatomy. Key details include identifying a cornual pregnancy based on its location, tubular ectasia of the rete testis in an older male, medullary nephrocalcinosis seen as echogenic renal pyramids, the left renal vein in the transverse abdominal image, and measuring fetal head circumference at the level of the thalami and cavum septi pellucidi.
This document provides rationales for questions on the 28th Annual In-Training Examination for Diagnostic Radiology Residents. It includes explanations for answers to 5 multiple choice questions related to pediatric radiology cases. The questions cover topics such as autosomal recessive polycystic kidney disease, everting ureterocele, necrotizing enterocolitis, non-accidental trauma, and vein of Galen aneurysm. The rationales discuss the findings in the images and explain why each answer choice is right or wrong based on those findings and typical presentations of the diseases.
The 48-hour whole body In-111 pentetreotide images showed multiple focal areas of increased tracer uptake in both lobes of the liver, consistent with neuroendocrine tumor hepatic metastases. There was also a large focal area of increased uptake in the epigastric region in the expected location of the pancreas body. The most likely diagnosis given these findings is islet cell carcinoma of the pancreas. Pheochromocytoma, carcinoid tumor, lymphoma, and colon adenocarcinoma are less likely given the imaging findings.
- Echogenic intracardiac focus is most commonly seen as a normal variant on prenatal ultrasound but should prompt careful examination for other abnormalities.
- While it represents a normal variant, echogenic intracardiac focus has been associated with trisomy 13 and 21 but not trisomy 18.
- The majority (90%) of echogenic intracardiac foci are located in the left ventricle, not the right ventricle as stated in one response option.
This document provides rationales for questions on the 2005 American College of Radiology Diagnostic In-Training Examination for interventional radiology residents. It includes the questions, images associated with some questions, findings for each image, and rationales for the correct answers. The questions cover topics such as locations of dialysis catheters, diagnoses for angiograms, standards for uterine artery embolization, and indications for percutaneous nephrostomy.
This document contains rationales for exam questions related to neuroradiology. Question 70 describes images showing increased T2 signal in the dorsal columns of the cervical spinal cord. The most likely diagnosis is subacute combined degeneration, which is caused by vitamin B12 deficiency and commonly presents with numbness in the hands. Question 71 concerns images of a child with seizures and developmental delay, showing features of holoprosencephaly. Question 72 discusses images of a man with seizures, showing a punctate calcification with ring enhancement, most consistent with cysticercosis given the patient's Hispanic ethnicity.
A 15-year-old female volleyball player presented with low back pain without trauma. Bone scan showed increased uptake in the left L5 lamina. SPECT localized this to the pars interarticularis. Radiographs were normal. This is most consistent with a stress fracture of the left L5 pars interarticularis, a common injury in young athletes.
This document appears to be a series of questions and answers from a diagnostic radiology in-training examination. The questions cover topics in genitourinary tract radiology and ask examinees to identify diagnoses, classifications, or characteristics based on provided radiographic images and clinical scenarios. Rationales are given for each answer that provide additional radiologic and clinical details.
A 23-year-old woman presented with hearing loss. CT showed a soft tissue mass in the left middle ear cavity eroding the scutum and demineralizing the ossicles. The most likely diagnosis is cholesteatoma, a common middle ear soft tissue mass.
A 68-year-old woman presented with left eye pain and proptosis. Angiography showed early filling of both cavernous sinuses and ophthalmic veins, indicating a carotid-cavernous fistula.
MR of a 6-month-old boy with vomiting showed a large enhancing mass in the left lateral ventricle with flow voids. The most likely diagnosis is a choroid plexus
This document contains a radiology case study with 4 images (Figures 1-4) and accompanying questions. Figure 1 shows a lateral cervical spine x-ray. The diagnosis is ankylosing spondylitis based on diffuse bony ankylosis throughout the cervical spine. Figure 2 shows MRI images of the knee with a diagnosis of discoid meniscus due to excessive meniscal tissue. Figure 3 shows x-rays of the leg with a diagnosis of Brodie's abscess, seen as an elongated lytic lesion in the tibia. Figure 4 shows knee images of a 13-year-old boy with a diagnosis of chondroblastoma, seen as a well-defined lesion in the proximal tib
The document describes 3 radiology case studies involving the gastrointestinal system:
1) A case of scleroderma diagnosed based on an x-ray showing dilation of the small bowel with closely spaced folds.
2) A case of appendicitis diagnosed on CT showing an enlarged appendix with periappendiceal inflammation and an appendicolith.
3) A case of a gastric leiomyoma diagnosed on barium study and CT showing a rounded filling defect in the stomach with central ulceration arising from the gastric wall.
- The document discusses a chest radiograph and CT images of a 51-year-old man with shortness of breath. It shows bilateral perihilar opacities on chest radiograph and thin-walled cysts, ground glass opacities, and reticular opacities on CT.
- The most likely diagnosis is Pneumocystis carinii pneumonia. Findings are consistent with PCP including bilateral often perihilar reticular and ground glass opacification that may become confluent and cysts that are commonly multiple and have predilection for upper lobes.
- Other choices such as pulmonary alveolar proteinosis, cardiogenic pulmonary edema, idiopathic pulmonary fibrosis are
The CT images show a high-attenuation collection displacing the heart to the right, indicating hemopericardium or blood in the pericardial sac. Figure 3B further shows a brightly enhancing structure near a surgical clip on the distal posterior descending coronary artery, consistent with a pseudoaneurysm causing the hemorrhage. The findings are most consistent with hemopericardium developing several days after coronary bypass surgery.
The document discusses images from radiology exams of the pelvis and genitourinary system. Figure 1 shows a sagittal MRI of the pelvis showing diffuse thickening of the junctional zone, consistent with adenomyosis. Figures 2A and 2B show an intratesticular mass on ultrasound, indicating seminoma. Figures 3A-C show an ovarian teratoma on ultrasound and MRI of the pelvis in a pregnant patient. Figure 4 shows a bladder tumor on CT scan in a patient with hematuria. Figure 5 shows a hysterosalpingogram indicating Asherman's syndrome. Figures 6A-C show renal cell carcinoma extending into the renal vein, stage IIIA by
The document provides information on various radiological diagnostic methods and their applications. It discusses ultrasound, CT, MRI, x-rays, and other imaging techniques. Key points covered include how different methods are used to examine organs like the liver, kidneys, bones and joints. Common radiological signs of conditions like fractures, osteomyelitis, tumors, and abnormalities are also summarized. The document serves as a reference for choosing the appropriate imaging modality based on the clinical indication.
The document discusses breast radiology questions from an exam. Question 188 describes a case where a fibroadenoma was found on biopsy initially and a follow up mammogram 6 months later. The most likely diagnosis is a phyllodes tumor based on the description of phyllodes tumors typically appearing mammographically. Question 189 describes mammogram images and the most likely clinical presentation is peau d'orange skin in the left breast, indicative of inflammatory breast cancer. Question 190 involves calcifications on a mammogram and ductal carcinoma in situ is considered the most likely diagnosis.
This document contains a multiple choice question and rationales from a pediatric radiology exam. The question shows MRI images of a 22-week fetus and asks for the most likely diagnosis. The rationales eliminate the other answer choices of posterior urethral valves, multicystic dysplastic kidneys, and bilateral ureteropelvic junction obstruction. The correct answer is Autosomal Recessive Polycystic Kidney Disease, as the images show enlarged, fluid-intensity kidneys without urine production, typical of this condition.
This document provides rationales for answers on a diagnostic radiology exam related to musculoskeletal radiology. The case presented involves radiographs and MRI images of various musculoskeletal injuries and conditions. The correct diagnosis for each case is provided along with explanations for why the other answer choices are incorrect. Key details that help distinguish between similar conditions are emphasized, such as findings that are more or less typical for a given diagnosis. A variety of musculoskeletal injuries, abnormalities, and diseases are discussed.
The document discusses several radiology cases involving the brain and spine. Question 291 presents CT scans of a woman with headaches and asks for the most likely diagnosis of a fat-containing extraconal orbital mass. Question 292 shows MR images of a woman with extremity weakness and asks for the most likely diagnosis of multiple brain and spine lesions. Question 293 presents MR images of a man with back pain and asks for the diagnosis of a posterior spinal mass seen on the images.
This document contains 3 figures and associated questions from a diagnostic radiology in-training examination. Figure 1 shows images from an F-18 FDG PET study in a man with abdominal pain. Figure 2 shows a posterior Tc-99m bone scintigram in a man with back pain. Figure 3 shows an anterior whole body Tc-99m bone scan in a woman with head and neck pain and a history of thyroid cancer. The questions assess the examinee's ability to interpret the images and select the most likely diagnosis.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to breast radiology. The rationales discuss the correct answers and explain why the other answer options are incorrect based on imaging findings and characteristics of different breast diseases. Invasive lobular carcinoma is identified as the most likely diagnosis for one case based on its appearance on mammography of being seen best on one view only or at least.
This document provides rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to ultrasound imaging. It discusses the correct answers and rationales for questions regarding various pathologies seen on ultrasound of the uterus, testes, kidneys, abdomen and fetal anatomy. Key details include identifying a cornual pregnancy based on its location, tubular ectasia of the rete testis in an older male, medullary nephrocalcinosis seen as echogenic renal pyramids, the left renal vein in the transverse abdominal image, and measuring fetal head circumference at the level of the thalami and cavum septi pellucidi.
This document provides rationales for questions on the 28th Annual In-Training Examination for Diagnostic Radiology Residents. It includes explanations for answers to 5 multiple choice questions related to pediatric radiology cases. The questions cover topics such as autosomal recessive polycystic kidney disease, everting ureterocele, necrotizing enterocolitis, non-accidental trauma, and vein of Galen aneurysm. The rationales discuss the findings in the images and explain why each answer choice is right or wrong based on those findings and typical presentations of the diseases.
The 48-hour whole body In-111 pentetreotide images showed multiple focal areas of increased tracer uptake in both lobes of the liver, consistent with neuroendocrine tumor hepatic metastases. There was also a large focal area of increased uptake in the epigastric region in the expected location of the pancreas body. The most likely diagnosis given these findings is islet cell carcinoma of the pancreas. Pheochromocytoma, carcinoid tumor, lymphoma, and colon adenocarcinoma are less likely given the imaging findings.
- Echogenic intracardiac focus is most commonly seen as a normal variant on prenatal ultrasound but should prompt careful examination for other abnormalities.
- While it represents a normal variant, echogenic intracardiac focus has been associated with trisomy 13 and 21 but not trisomy 18.
- The majority (90%) of echogenic intracardiac foci are located in the left ventricle, not the right ventricle as stated in one response option.
This document provides rationales for questions on the 2005 American College of Radiology Diagnostic In-Training Examination for interventional radiology residents. It includes the questions, images associated with some questions, findings for each image, and rationales for the correct answers. The questions cover topics such as locations of dialysis catheters, diagnoses for angiograms, standards for uterine artery embolization, and indications for percutaneous nephrostomy.
This document contains rationales for exam questions related to neuroradiology. Question 70 describes images showing increased T2 signal in the dorsal columns of the cervical spinal cord. The most likely diagnosis is subacute combined degeneration, which is caused by vitamin B12 deficiency and commonly presents with numbness in the hands. Question 71 concerns images of a child with seizures and developmental delay, showing features of holoprosencephaly. Question 72 discusses images of a man with seizures, showing a punctate calcification with ring enhancement, most consistent with cysticercosis given the patient's Hispanic ethnicity.
A 15-year-old female volleyball player presented with low back pain without trauma. Bone scan showed increased uptake in the left L5 lamina. SPECT localized this to the pars interarticularis. Radiographs were normal. This is most consistent with a stress fracture of the left L5 pars interarticularis, a common injury in young athletes.
This document appears to be a series of questions and answers from a diagnostic radiology in-training examination. The questions cover topics in genitourinary tract radiology and ask examinees to identify diagnoses, classifications, or characteristics based on provided radiographic images and clinical scenarios. Rationales are given for each answer that provide additional radiologic and clinical details.
A 23-year-old woman presented with hearing loss. CT showed a soft tissue mass in the left middle ear cavity eroding the scutum and demineralizing the ossicles. The most likely diagnosis is cholesteatoma, a common middle ear soft tissue mass.
A 68-year-old woman presented with left eye pain and proptosis. Angiography showed early filling of both cavernous sinuses and ophthalmic veins, indicating a carotid-cavernous fistula.
MR of a 6-month-old boy with vomiting showed a large enhancing mass in the left lateral ventricle with flow voids. The most likely diagnosis is a choroid plexus
This document contains a radiology case study with 4 images (Figures 1-4) and accompanying questions. Figure 1 shows a lateral cervical spine x-ray. The diagnosis is ankylosing spondylitis based on diffuse bony ankylosis throughout the cervical spine. Figure 2 shows MRI images of the knee with a diagnosis of discoid meniscus due to excessive meniscal tissue. Figure 3 shows x-rays of the leg with a diagnosis of Brodie's abscess, seen as an elongated lytic lesion in the tibia. Figure 4 shows knee images of a 13-year-old boy with a diagnosis of chondroblastoma, seen as a well-defined lesion in the proximal tib
The document describes 3 radiology case studies involving the gastrointestinal system:
1) A case of scleroderma diagnosed based on an x-ray showing dilation of the small bowel with closely spaced folds.
2) A case of appendicitis diagnosed on CT showing an enlarged appendix with periappendiceal inflammation and an appendicolith.
3) A case of a gastric leiomyoma diagnosed on barium study and CT showing a rounded filling defect in the stomach with central ulceration arising from the gastric wall.
- The document discusses a chest radiograph and CT images of a 51-year-old man with shortness of breath. It shows bilateral perihilar opacities on chest radiograph and thin-walled cysts, ground glass opacities, and reticular opacities on CT.
- The most likely diagnosis is Pneumocystis carinii pneumonia. Findings are consistent with PCP including bilateral often perihilar reticular and ground glass opacification that may become confluent and cysts that are commonly multiple and have predilection for upper lobes.
- Other choices such as pulmonary alveolar proteinosis, cardiogenic pulmonary edema, idiopathic pulmonary fibrosis are
The CT images show a high-attenuation collection displacing the heart to the right, indicating hemopericardium or blood in the pericardial sac. Figure 3B further shows a brightly enhancing structure near a surgical clip on the distal posterior descending coronary artery, consistent with a pseudoaneurysm causing the hemorrhage. The findings are most consistent with hemopericardium developing several days after coronary bypass surgery.
The document discusses images from radiology exams of the pelvis and genitourinary system. Figure 1 shows a sagittal MRI of the pelvis showing diffuse thickening of the junctional zone, consistent with adenomyosis. Figures 2A and 2B show an intratesticular mass on ultrasound, indicating seminoma. Figures 3A-C show an ovarian teratoma on ultrasound and MRI of the pelvis in a pregnant patient. Figure 4 shows a bladder tumor on CT scan in a patient with hematuria. Figure 5 shows a hysterosalpingogram indicating Asherman's syndrome. Figures 6A-C show renal cell carcinoma extending into the renal vein, stage IIIA by
The document provides information on various radiological diagnostic methods and their applications. It discusses ultrasound, CT, MRI, x-rays, and other imaging techniques. Key points covered include how different methods are used to examine organs like the liver, kidneys, bones and joints. Common radiological signs of conditions like fractures, osteomyelitis, tumors, and abnormalities are also summarized. The document serves as a reference for choosing the appropriate imaging modality based on the clinical indication.
The document discusses breast radiology questions from an exam. Question 188 describes a case where a fibroadenoma was found on biopsy initially and a follow up mammogram 6 months later. The most likely diagnosis is a phyllodes tumor based on the description of phyllodes tumors typically appearing mammographically. Question 189 describes mammogram images and the most likely clinical presentation is peau d'orange skin in the left breast, indicative of inflammatory breast cancer. Question 190 involves calcifications on a mammogram and ductal carcinoma in situ is considered the most likely diagnosis.
The North Slope Borough School District 2009-2014 Strategic Plan outlines their mission, vision, values, and strategic priorities over a 5 year period. Their mission is to ensure students excel in core subjects and understand Iñupiat culture, and that every student receives a diploma to pursue higher education or a career. Their vision is for all parents and communities to be involved in children's education so students understand their culture and responsibilities. Their strategic priorities are academic achievement, integrating Iñupiat culture, engaging families and communities, developing staff, and effective organizational management.
Ancient boxing had fewer rules than modern boxing, with fights continuing until one boxer was knocked out or conceded defeat, and hitting a downed opponent was allowed. There were no weight classes and opponents were chosen randomly. Chariot racing events included races for 2-horse and 4-horse chariots, as well as races for carts drawn by mule teams. Pankration was a combination of boxing and wrestling allowing punches and attacks now banned in modern sports. The pentathlon included five events: discus, javelin, long jump, running, and wrestling.
The document discusses constellations and their use for navigation, timekeeping, and storytelling throughout history. It notes that the International Astronomical Union standardized 88 constellations in 1922, some based on Greek mythology and others reflecting other cultures. While the standardization made constellations better reference points, it reduced their sizes. The document advocates restoring the original, larger constellations and interpreting the night sky as it was understood before the 1930s boundaries were established.
El documento presenta una revisión de conceptos fundamentales de física como tiro parabólico, movimiento circular, velocidad angular, periodo, frecuencia y aceleración para sistemas bidimensionales. También cubre conceptos tridimensionales como condiciones de equilibrio, momento de fuerzas, centro de masa y centro de gravedad.
Welcome To Jackson Systems, Zone Control Made SimpleThomas Jackson
This is a short introduction to Jackson Systems. We manufacturer and distribute controls for the HVAC industry. We specialize in forced air zone control, thermostats and commercial controls.
Challenges of AJAX Development for Smartphone PlatformsMaxMotovilov
The document discusses the challenges of developing AJAX applications for smartphone platforms. It outlines core challenges like small screen sizes, different input methods, and limitations of JavaScript, CSS, and DOM APIs on mobile browsers. It also provides a case study of Kannuu's search client and discusses platform-specific issues encountered on Symbian, iPhone, Android, Windows Mobile, and BlackBerry. Prospects and workarounds for different platforms are presented.
Norfolk and Portsmouth, Virginia are highlighted as an up-and-coming metropolitan area located on the coast with a thriving port. The cities offer amenities such as beaches, museums, and a revitalized downtown. Recent economic development initiatives have encouraged growth of businesses, including those owned by minorities. The region has experienced increasing tourism and airport traffic, highlighting its status as a transportation hub on the East Coast.
Ginger provided excellent guidance and ensured clients were fully informed throughout the home buying process. She helped long distance clients make their house hunting trip productive by helping them find the perfect house. Clients say Ginger is a great realtor who covered all details and points about houses so they never had to worry, and that she worked hard to find homes matching their criteria while making the experience pleasurable.
The document discusses blending digital learning in teacher education programs. It begins with definitions of blended learning as a combination of face-to-face and online instruction. It then discusses how K-12 classrooms are increasingly using mobile devices, laptops, and tablets, and how teacher education programs should keep up with these trends. Specifically, it references the Horizon Report and National Speak Up Survey on technology use in K-12. It promotes 21st century skills like collaboration, communication, and critical thinking when integrating technology into teacher education.
Visual content such as images, videos, and infographics gets significantly more engagement across social media and online articles than text-only content. Posts and articles with visuals see up to 150% more clicks, likes, comments, and views compared to those without visuals. Providing journalists with visual content to accompany press releases can increase coverage by up to 77% by giving them compelling materials to share with their audience.
"5 Things in 5min" Series No.2 - Ms. CMO, 5 Reasons Why You Need CloudArun Cavale Cavale
No.2 in the "5 Things in 5 Minutes" Series. This presents 5 reasons why Chief Marketing Officers (CMOs) need to adopt Cloud. And stay relevant in a profession that is rapidly changing.
Fuengirola Ayer y Hoy es un documento que describe cómo ha cambiado la ciudad de Fuengirola a través del tiempo, desde sus orígenes como pequeño pueblo pesquero hasta convertirse en un importante destino turístico en la actualidad, atraído por sus playas y clima cálido.
The document discusses the cloud and its three levels: infrastructure as a service, platform as a service, and software as a service. While not entirely new, the cloud is powered by massive interconnectivity and new devices. It notes that cloud infrastructure relies on open standards, specifications, and APIs, but that client access can be limited by device types and connections. The cloud allows for elastic computing, online storage, collaboration and subscription-based apps and revenue models. However, challenges revolve around data privacy, accessibility, security and ownership across global jurisdictions. It welcomes international standards but notes they could stifle innovation.
The document discusses excretory urography, which involves administering intravenous contrast and taking timed radiographic images of the urinary system. It describes the indications for excretory urography such as suspected urinary tract pathology or repeated infections. It outlines the procedure, potential findings on images including abnormalities of the kidneys, ureters and bladder, and complications to watch for like contrast reactions. Key phases of kidney imaging and abnormalities that can be identified are also summarized.
Urinary tract infections can lead to pyelonephritis, an inflammation of the kidney that is diagnosed using clinical symptoms and laboratory tests. Imaging findings on ultrasound, CT, MRI, and nuclear medicine scans include wedge-shaped regions of reduced enhancement and perfusion in the kidney following infection originating in the bladder. While most cases are treated with antibiotics, imaging may be used to identify complications or guide management of high-risk patients.
The document discusses several radiology cases involving the genitourinary system. Case 1 involves color and Doppler ultrasound images of a transplant patient with elevated creatinine, showing an arteriovenous fistula is most likely. Case 2 shows a contrast-enhanced CT of a motor vehicle accident patient with bilateral non-enhancing kidneys, indicating bilateral renal arterial injury. Case 3 involves a contrast-enhanced CT pelvis image of a prostate cancer patient showing a bulbous contrast-filled structure at the uretero-vesical junction, consistent with a simple ureterocele.
(FULL) CME Glass (of milk) Half Full copy.pdfgdbnqj7b9v
Dr. Firhan Bin Hassan presented a case of a 33-year-old woman with progressive dyspnea and pleural effusions. Investigation of her pleural fluid found high triglyceride levels consistent with a diagnosis of chylothorax. Further testing found the woman to be positive for ANA and have elevated IgG, supporting an underlying connective tissue disease as the cause of her chylothorax. Management involved treating the underlying condition medically while draining the pleural effusions. The case highlights the importance of a thorough diagnostic workup to identify the etiology of chylothorax to guide appropriate management.
Relief of urinary urgency, hesitancy, and male pelvic pain with pulsed radiof...Jason Attaman
This document summarizes a case report of a 86-year-old man who underwent pulsed radiofrequency ablation (RFA) of the pudendal nerve to treat urinary urgency, hesitancy, and pelvic pain. The patient had a 30-year history of urinary symptoms and had tried various medications and procedures without success. After undergoing pulsed RFA of the pudendal nerve, the patient reported marked improvement in his pelvic pain and a significant reduction in his urinary symptoms. The summary concludes that pudendal nerve block with pulsed RFA may be an effective treatment for pelvic pain and urinary symptoms.
A 67-year-old woman presented with breathing difficulties and difficulty swallowing for 6 months. Examinations revealed an enlarged thyroid gland extending from her neck into her chest cavity, displacing her blood vessels and compressing her windpipe. Scans showed a large goiter measuring 8 by 6 by 10 cm in her neck and chest. She underwent a total thyroidectomy, which removed her entire thyroid gland. Her symptoms resolved after the surgery.
This case report describes a rare case of dual thyroid ectopia in a 5-year-old girl. Initial neck ultrasound found ectopic thyroid tissue in the neck but no normal thyroid gland. Thyroid scintigraphy then revealed two foci of functioning thyroid tissue - one corresponding to the neck swelling and another at the base of the tongue. Repeat neck ultrasound confirmed these dual ectopic foci. This case emphasizes that thyroid scintigraphy should be used to evaluate for ectopic thyroid tissue if the normal thyroid gland cannot be visualized by ultrasound in cases of suspected thyroid dysgenesis or absence. Combining ultrasound and scintigraphy provides the most accurate information for management of these complex thyroid abnormalities.
The document discusses spinal involvement in crystal-related diseases, focusing on gout. Spine involvement in gout is uncommon but can occur in cases of severe tophaceous gout. Symptoms may be asymptomatic initially or include acute or chronic back pain and nerve compression. Diagnosis is made through identification of urate crystals via aspiration or biopsy of spinal lesions. Imaging such as CT, MRI can show erosions, tophi, and lesions affecting various spinal structures including intervertebral discs, facet joints, and ligaments. Spinal cord or cauda equina compression may occur due to large tophi. While back pain is present in about half of cases, spinal involvement in gout is often missed likely due to
This document discusses a case of a 46-year-old male who presented with abdominal pain after a laparoscopic cholecystectomy and was found to have a bile leak. An ERCP revealed a leak from the cystic duct stump that was treated with stent placement. Bile duct injuries are a risk of cholecystectomy and can be classified in various ways. Diagnosis involves imaging studies and treatment aims to redirect bile flow away from leak sites.
Presentation1, radiological imaging of undescended testis.Abdellah Nazeer
This document discusses radiological imaging techniques for undescended testes (cryptorchidism). Ultrasound has moderate sensitivity and specificity for locating undescended testes, but MRI is the best imaging method, with sensitivity around 90% and specificity of 100%. MRI can identify locations of undescended testes that may be intra-abdominal, inguinal, or ectopic. The document presents several case examples demonstrating appearances of undescended testes on different imaging techniques.
Call prep: emergency nuclear medicine proceduresHerbert Klein
Guidelines for radiology and nuclear medicine procedures taking call on nights and weekends: gastrointestinal bleeding, hepatobiliary and lung scans. It is interactive, e.g. using Keynote presentation software. PowerPoint
The 9-year-old cat presented with a progressive hind limb mass, weight loss, pyrexia, heart murmur, and harsh lung sounds. Diagnostic testing revealed abnormalities consistent with disseminated mycobacterial infection involving the lungs, liver, kidneys, and bones. Acid-fast bacilli were identified on cytology of an aspirated kidney lesion, and subsequent PCR and culture confirmed Mycobacterium bovis infection. The cat responded well to antimicrobial therapy but later developed oral squamous cell carcinoma requiring euthanasia.
This patient presented with a one year history of recurrent right upper abdominal pain. Imaging showed gallstones. The diagnosis was chronic cholecystitis. The patient would undergo a laparoscopic cholecystectomy. Key decisions included whether to explore the common bile duct based on preoperative imaging and intraoperative findings. Proper placement of mops was important to safely expose Calot's triangle during the procedure.
The document describes an ultrasound examination of a 25-year-old female with a palpable right adnexal mass. Longitudinal and transverse endovaginal images show a 4 cm predominantly cystic mass with a heterogeneous echotexture arising from the right ovary. This is most consistent with a dermoid cyst, as dermoids can appear cystic with an echogenic mural nodule or "dermoid plug".
1. The document provides a pictorial review of abdominal radiograph findings to aid in interpretation.
2. Key findings discussed include patterns of bowel gas, which can indicate ileus, small bowel obstruction, or large bowel obstruction like sigmoid volvulus.
3. Other findings summarized are abdominal organ delineation, pathologic gas, calcifications, implanted devices, and foreign bodies. The review serves as a guide for systematic analysis of abdominal radiographs in the emergency department.
Inflammatory Bowel Disease Case Study The patien.docxcarliotwaycave
Inflammatory Bowel Disease
Case Study
The patient is an 11-year-old girl who has been complaining of intermittent right lower
quadrant pain and diarrhea for the past year. She is small for her age. Her physical
examination indicates some mild right lower quadrant tenderness and fullness.
Studies Results
Hemoglobin (Hgb), 8.6 g/dL (normal: >12 g/dL)
Hematocrit (Hct), 28% (normal: 31%-43%)
Vitamin B12 level, 68 pg/mL (normal: 100-700 pg/mL)
Meckel scan, No evidence of Meckel diverticulum
D-Xylose absorption, 60 min: 8 mg/dL (normal: >15-20 mg/dL)
120 min: 6 mg/dL (normal: >20 mg/dL)
Lactose tolerance, No change in glucose level (normal: >20 mg/dL rise in
glucose)
Small bowel series, Constriction of multiple segments of the small intestine
Diagnostic Analysis
The child's small bowel series is compatible with Crohn disease of the small intestine.
Intestinal absorption is diminished, as indicated by the abnormal D-xylose and lactose
tolerance tests. Absorption is so bad that she cannot absorb vitamin B12. As a result, she has
vitamin B12 deficiency anemia. She was placed on an aggressive immunosuppressive
regimen, and her condition improved significantly. Unfortunately, 2 years later she
experienced unremitting obstructive symptoms and required surgery. One year after surgery,
her gastrointestinal function was normal, and her anemia had resolved. Her growth status
matched her age group. Her absorption tests were normal, as were her B12 levels. Her
immunosuppressive drugs were discontinued, and she is doing well.
Critical Thinking Questions
1. Why was this patient placed on immunosuppressive therapy?
2. Why was the Meckel scan ordered for this patient?
3. What are the clinical differences and treatment options for Ulcerative Colitis and Crohn’s
Disease? (always on boards)
4. What is prognosis for patients with IBD and what are the follow up recommendations for
managing disease?
Urinary Obstruction
Case Studies
The 57-year-old patient noted urinary hesitancy and a decrease in the force of his urinary
stream for several months. Both had progressively become worse. His physical examination
was essentially negative except for an enlarged prostate, which was bulky and soft.
Studies Results
Routine laboratory studies Within normal limits (WNL)
Intravenous pyelogram (IVP) Mild indentation of the interior aspect of the bladder,
indicating an enlarged prostate
Uroflowmetry with total voided
flow of 225 mL
8 mL/sec (normal: >12 mL/sec)
Cystometry Resting bladder pressure: 35 cm H2O (normal: <40 cm H2O)
Peak bladder pressure: 50 cm H2O (normal: 40-90 cm H2O)
Electromyography of the pelvic
sphincter muscle
Normal resting bladder with a positive tonus limb
Cystoscopy Benign prostatic hypertrophy (BPH)
Prostatic acid phosphatase
(PAP)
0.5 units/L (normal: 0.11-0.60 units/L)
Prostate specific antigen (PSA) 1.0 ng/mL (normal: <4 ng/mL)
P ...
Benign Metastasizing Leiomyoma: A Case Reportsuppubs1pubs1
Metastasizing benign leiomyoma is an extrauterine smooth muscle tumour. Leiomyoma in spine is extremely rare. We report a case of a 47-year-old female with benign leiomyoma metastasizing to the spine. To our knowledge no case of benign leiomyoma metastasizing to the spine has been reported before. Magnetic Resonance Imaging (MRI) revealed C6, C7 vertebral involvement, T2, T4, T7, T8, T11, L2, L3, L4, L5 moderate spinal canal stenosis and cord impingement and cord compression at T12 level. She also presented with growth over her right elbow and psoas muscle.
MIDGUT VOLVULUS AND MALROTATION : AN UNUSUAL CAUSE OF INTESTINAL OBSTRUCTION ...WCER 2021
This document presents a case report of a 20-year-old male who presented with abdominal pain and vomiting due to midgut volvulus and malrotation, an unusual cause of intestinal obstruction in adults. Imaging including abdominal radiographs and CT showed dilated bowel loops and abnormal vascular relationships indicative of malrotation. The patient underwent surgery which confirmed malrotation of the bowel with Ladd's bands causing midgut volvulus. Malrotation results from abnormal rotation of the bowel during fetal development and typically presents in infants, but can occasionally cause obstruction in adults.
“Little Old Ladies Hernia”: A Case Report and Review of Literature_Crimson Pu...CrimsonPublishersAICS
“Little Old Ladies Hernia”: A Case Report and Review
of Literature by Sonali Sethi*, Satyajit Godhi, Pankaj Kumar and Amit Javed in Advancements in Case Studies
A 33-year-old woman presented with recurrent abdominal pain and jaundice. Imaging revealed a duodenal intussusception caused by a duodenal duplication cyst. Magnetic resonance imaging clearly depicted the cyst as the lead point for the intussusception and showed biliary dilatation. At surgery, a 4 cm cyst was removed from the duodenum. Histopathology confirmed it was a duodenal duplication cyst, a rare congenital anomaly usually diagnosed in childhood that can remain asymptomatic into adulthood.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam. The rationales provide explanations for the correct answers to multiple choice questions related to diagnostic radiology topics including test sensitivity and predictive values, medical ethics, and radiation safety. Specifically, one rationale discusses how the positive predictive value of a diagnostic test increases as the prevalence of a disease increases in a population. Another rationale examines the ethical requirement for physicians to be honest with patients about medical errors or complications. A third rationale identifies radon exposure as contributing the most to background radiation levels in the US.
The document discusses randomized controlled trials and which statements about them are true. It states that option C, "Randomization reduces the risk of an imbalance in factors which could influence the clinical course of the patients," is true. Randomization helps balance both known and unknown prognostic factors between treatment groups in a randomized controlled trial.
The document discusses gastrointestinal radiology and contains questions and answers about various gastrointestinal conditions and imaging findings. Question 226 asks which finding on helical CT with dynamic bolus contrast enhancement is the best prognostic indicator of acute pancreatitis. The correct answer is the presence of pancreatic necrosis.
This document contains a series of chest radiograph and CT images along with questions about cardiac findings.
Image 1 shows calcification of the aortic valve on a lateral chest x-ray, consistent with aortic stenosis.
Image 2 shows calcifications in the wall of the left atrium on a non-contrast CT, related to prior endocarditis from rheumatic heart disease.
Image 3 demonstrates enlargement of the central pulmonary arteries and diminished peripheral vasculature on chest x-ray, characteristic of pulmonary hypertension due to emphysema (cor pulmonale).
Image 4 shows a defect in the superolateral aspect of the atrial septum on CT, consistent with a sinus
The document is the rationales section from an in-training examination for diagnostic radiology residents sponsored by the American College of Radiology. It contains multiple choice questions in physics related to topics like radiation dose, CT, MRI, fluoroscopy, and radiography. For each question, the correct answer is identified and supported by a short explanation citing relevant references.
The document appears to be excerpts from an examination for diagnostic radiology residents, including four multiple choice questions and associated images regarding musculoskeletal diagnoses. Question #202 asks about a lateral tibial lesion in a child and provides images. The most likely diagnosis is osteofibrous dysplasia, characterized by a lobulated lucency in the anterior cortex associated with anterior bowing of the tibia.
This document contains information about the 28th Annual In-Training Examination for Diagnostic Radiology Residents, including sample test questions and rationales. The test is sponsored by the Commission on Education and Committee on Residency Training in Diagnostic Radiology of the American College of Radiology. Sample multiple choice questions are provided about various neuroradiology topics, such as diagnoses for different brain and spine imaging findings. Rationales are given for each answer choice.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
1. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
Section XI Nuclear Radiology
225. You are shown an anterior image of the neck from a Tc-99m pertechnetate
thyroid scintigram obtained in a 27-year-old woman presenting with elevated
serum T4 and T3 levels, a serum TSH<0.1 mIU/L and 24 hour I-131 thyroid
uptake of 50% (Figure 1). The MOST LIKELY diagnosis is:
A. Graves’ Disease
B. Toxic nodular goiter
C. Hashimoto’s thyroiditis
D. Factitious hyperthyroidism
Findings: Thyromegaly with diffusely prominent uptake throughout the thyroid
gland, without focal nodules is demonstrated.
RATIONALES:
A. Correct. This is a classic diagnostic picture of elevated T4/ T3, suppressed
TSH, elevated I-131 thyroid uptake and a homogeneous gland distribution
(typically, scan is normal.)
B. Incorrect. While the clinical presentation given is consistent with TNG, the
thyroid scan appearance is not. TNG is associated with an irregularly irregular
thyroid tracer distribution, with one or more focal hyperfunctioning nodules and
areas of suppressed normal thyroid tissue. In addition, an I-131 thyroid uptake of
50% is much higher than typically seen in TNG, where the uptake may be only
mildly elevated or even within normal limits.
C. Incorrect. Like Graves ’ disease, this is a chronic autoimmune thyroid disease,
which may present with painless, diffuse gland enlargement, elevated T4/T3
levels and a suppressed TSH, especially early in the course of the disorder.
However, in such cases, the iodine uptake is typically suppressed, with an
associated organification defect. Graves’ disease and Hashimoto’s thyroiditis
may also co-exist in the same patient. Late in the course of Hashimoto’s
disease, it more often produces hypothyroidism, and may present with a
multinodular goiter.
D. Incorrect. Also known as iatrogenic hypothyroidism or thyrotoxicosis factitia,
and most commonly seen in health care workers with ready access to
medications, exogenous thyroid hormone (T4, T3,dessicated thyroid) will
produce an elevated serum T4 level, associated with a suppressed TSH level
and either a normal scan or more commonly, poor visualization or non-
visualization of the gland. An elevated thyroid uptake value is incompatible with
this diagnosis.
2. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
226. You are shown flow, immediate and delayed static spot images (Figure 2A)
and delayed whole body images (Figure 2B) from a three-phase Tc-99m MDP
(methylene diphosphonate) bone scan in a previously healthy 11 year-old boy,
presenting with worsening knee pain and fever. Which of the following
diagnoses is MOST consistent with the imaging findings?
A. Tibial stress fracture
B. Reflex sympathetic dystrophy
C. Metastatic neuroblastoma
D. Osteomyelitis
FINDINGS: There is moderate focal hyperemia to the proximal left tibia. The
delayed static images demonstrate diffusely increased bone uptake in this
region, with a lesser degree of increased cortical uptake noted in the proximal
and mid left tibial shaft. Additional sites of asymmetrically increased uptake are
noted in the region of the right shoulder and left hip joints.
RATIONALES:
A. Incorrect. The extent of the lesion is greater than typically seen with a stress
fracture. In addition, there is also abnormal uptake at the right shoulder and left
hip, indicating a multifocal process.
B. Incorrect. Again, this is a multifocal process, and the distribution of the
abnormality is not typical of reflex sympathetic dystrophy (RSD), which classically
produces a “glove and stocking” peripheral distribution.
C. Incorrect. Neuroblastoma can certainly metastasize to bone, and would
typically involve the region of the physes (as in this case). However,
osteomyelitis is a more likely diagnosis in an 11-year-old child.
D. Correct. Although not specific, the findings in this case are consistent with
multifocal osteomyelitis, which is the most likely diagnosis of the options listed.
REFERENCES:
Taylor A, Datz. Clinical Practice of Nuclear Medicine. Churchill Livingstone.
1991.
Zeissman HA, O’Malley JP, Thrall JH: Nuclear Medicine-The Requisites. 3rd ed.
Mosby. 2006.
3. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
227. You are shown serial images (Figure 3A and 3B) from a Tc-99m diethylene-
triamine-pentaacetic acid (DTPA) radionuclide CNS shunt study. Which one of
the following statements is CORRECT?
A. This is a normal study.
B. There is high-grade obstruction of the efferent limb of the shunt.
C. There is abnormal loculation of activity in the peritoneal cavity.
D. There is scintigraphic evidence of diffuse peritonitis.
FINDINGS: The immediate static image demonstrates activity within the V-P shunt
reservoir and early passage of activity into the efferent limb of the shunt, progressing
inferiorly along the right lateral neck and upper chest. Subsequent images demonstrate
visualization of activity in the distal portion of the shunt catheter, overlying the right
lower quadrant of the abdomen at 10-20 minutes post-injection. Further delayed
images demonstrate progressive accumulation of activity within the peritoneal cavity in
the right lower quadrant from 30-60 minutes. A final image of the abdomen at 120
minutes demonstrates free intraperitoneal dispersion of the tracer.
RATIONALES
A. Correct. This study demonstrates normal progression of the tracer throughout the
shunt catheter, with normal drainage into the peritoneal cavity, without evidence of
loculation.
B. Incorrect. There is normal transit of tracer through the shunt, without evidence of
obstruction, which would appear either as non-entry of the dose into the efferent limb,
an abrupt stoppage of the tracer within the shunt catheter or failure of free intaperitoneal
dispersion of tracer.
C. Incorrect. Intraperitoneal loculation might be suspected on the images obtained at
30-60 minutes, but the further 120 minute delayed image clearly demonstrates free
intraperitoneal dispersion, without evidence of loculation.
D. Incorrect. The finding of diffuse peritoneal activity on the 120 minute image is a
normal finding. The presence or absence of peritonitis cannot be determined with this
radiopharmaceutical, and would require other imaging, such as an In-111 leukocyte
study or CT imaging of the abdomen and pelvis.
4. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
228. You are shown serial 3 minute posterior static images and renogram curves
from a Tc-99m mercaptoacetyltriglycine (MAG3) renal scan (Figures 4A and 4B)
performed in an adult with left hydronephrosis. Repeat images and curves
obtained after intravenous administration of 40mg of furosemide (LasixR) are
also shown (Figures 4C and 4D). Which one of the following statements is
CORRECT?
A. There is left ureteropelvic junction obstruction.
B. There is no evidence of anatomic obstruction.
C. The study is non-diagnostic because of renal insufficiency.
D. 24 hour delayed images are necessary for a definitive diagnosis.
FINDINGS: The baseline study demonstrates prompt MAG3 uptake and excretion by
the right kidney, with minimal retention of activity within the right upper and mid-pole
calyces, without calyceal dilatation. On the left, there is decreased initial tracer uptake,
with prominent photopenic areas in the left renal medullary region, consistent with
dilated calyceal structures, and with progressive accumulation of activity with dilated left
renal calyces and a dilated left renal pelvis. There is high-grade drainage impairment
noted at the left ureteropelvic junction, which persists on an upright post-void image.
There is borderline asymmetry in renal function, with the left kidney providing
approximately 45% of renal function. The post-diuretic study demonstrates relatively
prompt clearance of remaining activity from the left renal collecting system, with a
clearance half-time after furosemide administration of approximately 7 minutes, which is
normal. There is no evidence of anatomic obstruction on either side.
RATIONALES
A. Incorrect. The baseline study is consistent with high-grade left ureteropelvic (UPJ)
obstruction. However, on the diuretic portion of the study, there is prompt clearance of
activity from the left renal calyces and renal pelvis, with a clearance half-time of 7
minutes, which is normal (normal < 10 minutes). Based on these results, there is no
evidence of significant anatomic obstruction, and the findings are consistent with
dilatation of the left renal collecting system without obstruction.
B. Correct. See discussion in A above.
C. Incorrect. If there is renal insufficiency, then the diuretic study may produce a false-
positive result for obstruction, because the affected kidney(s) may be unable to respond
to the loop-acting diuretic. Renal insufficiency would not produce a false negative result
(ie. apparent non-obstruction in the face of significant anatomic obstruction).
Furthermore, there is only mild impairment in left renal function, with normal right renal
function in this case, thus this option is not a plausible explanation for the findings
demonstrated.
5. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
D. Incorrect. The diagnosis of a dilated, non-obstructed left renal collecting system can
be made on the basis of the available images alone, as discussed above, without the
need for further delayed views, which would add nothing to the diagnosis in this case.
229. You are shown multiple static images from a Tc-99m macroaggregated
albumin (MAA) pulmonary perfusion scintigram (Figure 5). What is the MOST
LIKELY explanation for the image findings?
A. Tc-99m sulfur colloid was injected instead of Tc-99m MAA.
B. There is significant alumina breakthrough in the radiopharmaceutical.
C. Blood clot was introduced into the syringe during radiopharmaceutical
injection.
D. The patient has multiple pulmonary arteriovenous malformations.
FINDINGS: There are focal areas of increased tracer uptake noted in the left mid-lung
field, near the left major fissure, and also in right middle lobe. There are no significant
perfusion defects demonstrated.
RATIONALES
A. Incorrect. If sulfur colloid were injected instead of MAA, then the biodistribution of
the tracer would follow that of the smaller sulfur colloid particles, resulting in uptake
within the liver, spleen and bone marrow, without significant pulmonary uptake. Focal
areas of increased activity within the lungs would not result.
B. Incorrect. Alumina breakthrough can result in particle formation in a non-particulate
radiopharmaceutical or formation of larger particles in a particulate radiopharmaceutical.
For example, excessive alumina breakthrough can result in significant pulmonary
uptake on a sulfur colloid liver-spleen scan. However, alumina breakthrough is unlikely
to produce particles sizes large enough to result in the focal “hot spot” artifacts noted in
this case. The findings in the present case are much more commonly produced via the
mechanisms discussed below, namely, aggregation of MAA particles secondary to
formation of blood clots in the syringe or from settling of the suspended particles (see C
below).
C. Correct. The focal areas of increased tracer uptake demonstrated in the left mid-
lung field, near the major fissure, and in the right middle lobe are consistent with focal
areas of aggregation of the MAA particles, most likely due either to introduction of blood
into the radiopharmaceutical syringe during injection (ie., drawing blood into the syringe)
or failure to properly suspend the particles or re-suspend them, if the syringe had been
left sitting in the radiopharmacy for a long period of time prior to injection.
D. Incorrect. The findings in this case are consistent with a radiopharmaceutical
artifact, as discussed above. Furthermore, pulmonary arteriovenous
malformations (AVMs), when large enough to resolve, would present as focal
areas of decreased tracer uptake, secondary to shunting of blood via the AVMs
6. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
from the venous to arterial circulation, bypassing the pulmonary capillary bed,
and thus not trapped within it. Therefore, the presence of multiple pulmonary
AVMs is not a viable explanation for the findings in this case.
230. You are shown maximum intensity projection (MIPS) coronal, transaxial and
sagittal F-18-fluorodeoxyglucose (FDG) PET images obtained in an adult patient
(Figure 6). What is the MOST LIKELY diagnosis?
A. Bronchogenic carcinoma
B. Breast carcinoma
C. Hodgkin’s Disease
D. Malignant melanoma
FINDINGS : There are numerous focal areas of increased tracer uptake noted in the
chest, abdomen and pelvis, many of which are clearly located in the subcutaneous
tissues of the abdominal wall and chest wall, best seen on the selected transaxial and
sagittal images provided.
RATIONALES
A. Incorrect. While several of the lesions demonstrated do project over the lung fields
on the MIPS image, the sagittal image demonstrates that at least several are located in
the soft tissues of the posterior chest wall, rather than in the lungs. In addition, there is
no single dominant lesion that appears to be within a lung. While not excluded,
bronchogenic carcinoma is a less likely etiology for these findings than melanoma.
B. Incorrect. As discussed in A above, the predominance of subcutaneous lesions is
less characteristic of metastatic breast carcinoma than of melanoma. There is no lesion
demonstrated in the breast, and there is also no evidence of axillary adenopathy or
hepatic metastases, which would also commonly occur in metastatic breast carcinoma.
Therefore, while not excluded, metastatic breast carcinoma is a less likely etiology for
the findings than melanoma.
C. Incorrect. As discussed above, the pattern of subcutaneous lesions is more
characteristic of melanoma than lymphoma, particularly in the absence of significant
lymph node involvement. While some non-Hodgkin’s lymphomas may primarily involve
the skin, this pattern of involvement is not common in Hodgkin’s disease.
D. Correct. Metastatic malignant melanoma is the most likely diagnosis. The
pattern of extensive, markedly hypermetabolic lesions in the subcutaneous soft
tissues is most characteristic of metastatic malignant melanoma.
7. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
231. Which of the following statements about Y-90-ibritumomab tiuxetan
(ZevalinR) radioimmunotherapy (RIT) for indolent non-Hodgkin’s lymphoma is
TRUE?
A. It targets CD-15 receptors on immature B cells.
B. Tc-99m labeled ZevalinR is used for imaging prior to therapy.
C. Unlabeled rituximab (RituxanR) must be intravenously infused before therapy.
D. Bone marrow involvement of less than or equal to 50% is a prerequisite.
RATIONALES:
A. INCORRECT. Y-90 ZevalinR targets CD-20 receptors on mature B-cells.
B. INCORRECT. Pre-RIT imaging is performed using In-111 labeled ZevalinR.
ZevalinR is not available labeled with Tc-99m.
C. CORRECT. Rituximab is given prior to administration of Y-90 ZevalinR to
deplete binding sites on circulating B-cells, which would otherwise bind to the
radiopharmaceutical and reduce the effectiveness of the RIT.
D. Bone marrow involvement must be less than 25%, not 50%.
References:
Biodistribution and dosimetry results from a phase III prospectively randomized
controlled trial of Zevalin radioimmunotherapy for low-grade, follicular, or
transformed B-cell non-Hodgkin's lymphoma. Crit Rev Oncol Hematol. 2001 Jul-
Aug;39(1-2):181-94.PMID: 11418315
8. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
232. Which of the following statements regarding F-18-fluorodeoxyglucose PET
imaging in lymphoma is TRUE?
A. It has the same sensitivity for the detection of Hodgkin’s disease and non-
Hodgkin’s lymphoma.
B. Higher standardized uptake values are associated with mucosa-associated
lymphoid tumor (MALT) lymphoma than with other cell types.
C. It can be used to assess the effectiveness of chemotherapy after as few as
two treatment cycles.
D. While it is more sensitive than Ga-67 citrate imaging for the primary staging of
lymphoma, it is less sensitive for the detection of recurrent disease.
RATIONALES:
A. INCORRECT. While both Hodgkin’s disease (HD) and non-Hodgkin’s
lymphoma (NHL) are accurately assessed using F-18 FDG PET, HD has
significantly higher sensitivity and specificity than NHL overall. This difference is
due to the fact that low-grade NHLs demonstrate lower FDG uptake.
B. INCORRECT. In one study of 10 patients, MALT lymphoma did not reveal
any significant F-18 FDG uptake. While other studies have produced variable
results, nevertheless, the FDG avidity for MALT lymphomas is overall
significantly lower than for many other cell types.
C. CORRECT. FDG PET can be used with high positive predictive value to
assess the response to chemotherapy, even after only one or two cycles of
treatment.
D. INCORRECT. FDG PET has been demonstrated to be more sensitive than Ga-67
citrate scintigraphy for the diagnosis, staging and re-staging of both HD and NHL.
References:
Israel O, Keidar Z, Bar-Shalom R. Positron Emission Tomography in the
Evaluation of Lymphoma. Semin Nucl Med 34:166-179, 2004.
9. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
233. Which of the following is the MOST appropriate pharmacologic stress agent
for patients undergoing myocardial perfusion imaging who have severe
bronchospasm?
A. Dypyridamole
B. Adenosine
C. Dobutamine
D. Aminophylline
RATIONALES:
A. Incorrect: Dypyridamole is a commonly used agent for pharmacologic stress
in conjunction with myocardial perfusion imaging. It inhibits reabsorption of
adenosine back into the myocytes, increasing blood and tissue levels of
adenosine. Dipyridamole and adenosine increase coronary blood flow 3-4 times
in normal vessels, but stenosed vessels are unable to respond, resulting in a
relative “steal” phenomenon, unmasking areas of myocardial ischemia.
However, both dypyridamole and adenosine are contraindicated in those patients
with known severe bronchospasm, as they can trigger further bronchospasm.
B. Incorrect: See rationale for item A above. Adenosine does increase coronary
blood flow, but is also contraindicated in patients with severe bronchospasm,
asthma or wheezing.
C. Correct: Dobutamine has major B1 agonist properties and only mild (not clinically
significant) B2 properties. It also has Alpha 1 agonist properties. It increases both the
inotropic and chronotropic action of the heart. It is appropriately employed in those
patients who cannot perform exercise or those with contraindications to adenosine and
dypyridamole (eg., because of bronchospastic pulmonary disease) or in patients who
recently received xanthine derivatives or have ingested caffeine within 24 hours of the
study.
D. Incorrect: Aminophylline and other xanthines block adenosine receptors. It is not a
cardiac pharmaceutical stress agent. This is why intake of xanthines is contraindicated
at least 24 hours before an adenosine or dypyridamole pharmacologic stress
myocardial perfusion imaging study. Aminophylline is used to prevent and treat
wheezing, shortness of breath, and difficulty breathing caused by asthma, chronic
bronchitis, emphysema, and other lung diseases. Furthermore, it is used as an antidote
in patients developing adverse reactions during dipyridamole infusion studies.
References:
Sandler, Diagnostic Nuclear Medicine. 4rth Ed. Lippincott Williams & Wilkins,
Philadelphia, PA. 2003.Williams, Scott. Aunt Minnie.com (Reference: Nuclear
Medicine). 10September 2005 Update
10. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
234. Analysis of an equilibrium multigated-acquisition (MUGA) radionuclide
cardiac study is performed, with the background region of interest placed over
the spleen. The resulting calculated left ventricular ejection fraction will be:
A. Artifactually reduced.
B. Artifactually elevated.
C. Unchanged.
D. Variably affected.
RATIONALES:
A. Incorrect. Selection of a non-representative high count region of interest for
the background region will result in an artifactual increase in the ejection fraction
calculation, not a decrease.
B. Correct. In the formula for calculation of the ejection fraction, the background
counts in the numerator cancel out by subtraction, with the resultant formula for
the ejection fraction being: (ED counts – ES counts) / (ED counts – Bkgd
counts). Thus, placement of the background region of interest in an
unrepresentative area of high counts, such as the splenic blood pool, will
artifactually decrease of the denominator’s value in the equation. This relative
decrease in the denominator’s value will result in a spurious elevation of the
calculated ejection fraction. Typically, a crescentic background region of interest
with average of 2 to 3 pixel width is drawn adjacent to the lateral aspect of the left
ventricle.
C. Incorrect. See B above.
D. Incorrect. See B above.
References:
Http://www.auntminne.com/index.asp?sec=ref&sub=ncm&pag=car&itemid=5507
3
Sandler, Diagnostic Nuclear Medicine. 4rth Ed. Lippincott Williams & Wilkins,
Philadelphia, PA. 2003
11. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
235. Which of the following statements about agreement states is CORRECT?
A. They are states that agree to allow the Nuclear Regulatory Commission (NRC)
to regulate radioactive by product material within their boundaries.
B. They are states that agree to regulate radioactive by product material within
their borders on behalf of the NRC.
C. They are permitted to have less stringent regulations than the NRC.
D. A state can become an agreement state without prior notification of the NRC.
RATIONALES:
A. Incorrect. Agreement states regulate by-product material within their borders
in place of the NRC.
B. Correct
C. Incorrect. Regulations in agreement states must be as stringent as NRC
regulations, and can be more stringent.
D. Incorrect. Agreement states must demonstrate to the NRC that they have the
capabilities to assume the NRC's mission within their boundaries, and that the
intended regulations are consistent with NRC rules and regulations and are as
strict or more so.
References: Code of Federal Regulations
Wilson, Michael A., editor, Textbook of Nuclear Medicine. Lippincott-Raven,
Philadelphia, PA, 1998.
12. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
236. In nuclear medicine, what is the primary benefit for the use of a narrow
energy window?
A. Enhances count rate
B. Reduces dead time losses
C. Diminishes background radiation in image
D. Reduces scatter radiation in image
RATIONALES:
A. Incorrect. A narrow window would reduce the image count rate.
B. Incorrect. While the count rate for generating the image would be reduced,
the actual detected photon count rate would not be changed and the dead time
losses would not be reduced.
C. Incorrect. Background radiation counts would be reduced, but this is a minor
component compared with the scatter radiation coming from the patient.
D. Correct. Gamma rays are emitted at very specific energies. If the detected
photon has a lower energy, it may be assumed that the photon was from a
Compton scatter interaction and is not coming directly from the location of the
radionuclide tracer.
237. What is the maximum allowable total effective dose equivalent annual
occupational radiation exposure for an adult?
A. 5 mrem (0.05 mSv)
B. 5 rem (0.05 Sv)
C. 500 rem (5 Sv)
D. 5000 rem (50 Sv)
RATIONALES:
A, C & D.. Incorrect. Total annual limit for occupational exposure is 5 rem (5,000
mrem or 0.05 Sv or 50 mSv).
B. Correct.
Reference: Code of Federal Regulations 10 CFR 20 Subpart C 20.1201, (a),
(1), (i).
13. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
238. What is the critical organ for myocardial perfusion imaging using Tl-201
chloride?
A. Gallbladder wall
B. Upper large intestines
C. Kidneys
D. Urinary bladder
RATIONALES:
A. Incorrect. The gallbladder wall is the critical organ for Tc-99m tetrofosmin
(MyoviewR) myocardial perfusion imaging, not for Tl-201 scintigraphy.
B. Incorrect. The upper large intestines/colon is the critical organ for Tc-99m
sestamibi (CardioliteR) and Tc-99m teboroxine (CardiotecR).
C. Correct. The kidney is the critical organ for Tl-201 scintigraphy, receiving 5.1
rem from a typical 3 mCi dose of Tl-201.
D. Incorrect. The urinary bladder is the critical organ for Tc-99m methylene
diphosphonate bone scintigraphy.
REFERENCES:
DePuey EG, Garcia EV, Berman DS 2001 Cardiac SPECT Imaging 2nd ed.,
Lippincott Williams & Wilkins, Philadelphia, p. 118.
Mettler FA, Guiberteau MJ 2006 Essentials of Nuclear Medicine Imaging 5th ed.,
Saunders, Philadelphia, p. 105-107.
14. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
239. Which of the following factors contributes MOST to the specificity of Tc-99m
sestamibi scintigraphy for the detection of parathyroid adenomas?
A. Size of the parathyroid adenoma
B. Greater hypercellularity of parathyroid adenomas compared to thyroid
adenomas
C. Greater avidity of the radiopharmaceutical for parathyroid tissue than for
thyroid tissue
D. Longer retention of the tracer in parathyroid tissue than in thyroid tissue
RATIONALES:
A. Incorrect. Size of the adenoma affects sensitivity, not specificity. Parathyroid
adenomas must attain a size greater than ~500mg to be generally detectable,
although this is usually the threshold at which they are clinically (not chemically)
manifest.
B. Incorrect. This is frequently untrue and unrelated.
C. Incorrect. There is no in vitro evidence supporting this statement.
D. Correct. Slow Tc-99m sestamibi wash-out is the hallmark of a parathyroid
adenoma (or carcinoma) This phenomenon is specific for hypercellular
parathyroid neoplasms and is not a characteristic of thyroid neoplasms.
Reference:
Taillefer R., Boucher Y., et al. Detection and localization of parathyroid
adenomas in patients with hyperthyroidism using a single radionodule imaging
procedure with technetion 99m – sestamibi (double-phase study). J. Nuclear
Med. 1992; 33:
1801 – 1807.
15. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
240. Which of the following statements about the clinical evaluation of bone
mineral density using dual-energy x-ray absorptiometry (DEXA) and dual-photon
absorptiometry (DPA) is TRUE?
A. An advantage of DEXA over DPA is significantly reduced radiation exposure
to patients.
B. An advantage of DPA over DEXA is the ability to correct for soft tissue
attenuation.
C. The World Health Organization (WHO) criteria for the assessment of
osteopenia and osteoporosis were developed using the DEXA technique.
D. The radius (forearm) cannot be evaluated using either technique.
RATIONALES
A. Incorrect. There is no significant difference in radiation exposure between
DEXA and DPA techniques, and given the higher photon flux, DEXA may result
in a slightly higher exposure than DPA.
B. Incorrect. Soft tissue attenuation correction is needed for accurate density
measurement of bony structures such as the spine or hip. This is accomplished
with dual-energy techniques by assessing the differential attenuation of photons
by bone vs. soft tissue at different energies. Both DPA and DEXA are dual-
energy techniques that allow for such attenuation correction.
C. Correct. The WHO criteria were developed based on the DEXA technique.
D. Incorrect. The distal radius and/or ulna can be evaluated either by DPA or
DEXA techniques. Previously, the radius was also evaluated using I-125
absorptiometry.
REFERENCES:Zeissman HA, O’Malley JP, Thrall JH: Nuclear Medicine-The
Requisites. 3rd ed. Mosby. 2006.
16. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
241. Regarding bone scintigraphy in the evaluation of malignancy, which of the
following is TRUE?
A. A solitary “hot” lesion in the sternum of a patient with breast cancer has
approximately a 75% likelihood of being malignant.
B. Bone metastases are present in approximately 20% of patients with prostate
cancer and a prostate specific antigen (PSA) of <10 ng/mL.
C. The “flare” phenomenon can be excluded as the cause for interval worsening
of a bone scan in patients experiencing worsening of bone pain.
D. The role of bone scintigraphy in the evaluation of primary bone malignancy is
the pre-operative assessment of the extent of the primary tumor.
RATIONALES:
A. Correct. Based on a study by Kwai et al published in 1988. Lesions in the
sternum in breast carcinoma may be secondary either to hematogenous spread
or direct extension of tumor.
B. Incorrect. In this setting, the incidence of bone metastases is less than 1%.
C. Incorrect. The paradoxical worsening of the bone scan with the “flare”
phenomenon may also be accompanied by a worsening of bone pain as well as
increasing sclerosis on radiographs. The radiographic finding of sclerotic healing
of lesions and the time course following chemotherapy are better clues as to the
presence of a flare phenomenon. For this reason, follow-up bone scintigraphy in
patients with skeletal metastases is most often performed no sooner than 3
months and typically at 6-12 months or later.
D. Incorrect. Bone scintigraphy does not reliably determine the extent of primary
bone malignancies, and may overestimate the extent of involvement.
Assessment of the extent of the primary lesion is better accomplished with MRI
and plain radiographs. Bone scintigraphy is useful as a whole body survey to
assess for additional sites of involvement (metastatic or multicentric disease).
REFERENCES:
Murray IPC, Ell PJ. Nuclear Medicine in clinical diagnosis and Treatment. 2nd
ed. Churchill Livingstone. 1998.
Zeissman HA, O’Malley JP, Thrall JH: Nuclear Medicine-The Requisites. 3rd ed.
Mosby. 2006.
17. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
242. An 8-year-old patient with suspected lower extremity osteomyelitis presents
with normal plain radiographs. Which one of the following is the MOST
appropriate next imaging study?
A. Tc-99m methylene diphosphonate (MDP) three-phase bone scintigraphy
B. Ga-67 citrate scintigraphy
C. In-111-labeled WBC scintigraphy
D. Tc-99m sulfur colloid bone marrow scintigraphy
RATIONALES:
A. Correct. A three-phase bone scan is almost always a good choice for the
initial evaluation of possible osteomyelitis, especially if the plain radiographs are
normal (and there is no other underlying bone pathology which would be likely to
cause increased bone uptake of the tracer and limit the usefulness of the exam).
It is both highly sensitive and has a very high negative predictive value for
osteomyelitis. The radiopharmaceutical is readily available, the exam is easily
performed, and the radiation dose is lower than for Ga-67 or In-111 labeled WBC
imaging. The normal increased radiopharmaceutical activity at the growth plates
is a potential limitation in pediatric patients, but this would also be a limitation
with Ga-67 citrate imaging.
B. Incorrect. A three-phase bone scan is the most appropriate next study. In
some settings, Ga-67 citrate may be used in addition to bone scan to improve
diagnostic accuracy, with the gallium scan performed after the bone scan.
C. Incorrect. In-111 WBCs are generally avoided in pediatric patients if there is a
good alternative, because of the high radiation-absorbed dose to the spleen. A
three-phase bone scan is a better choice.
D. Incorrect. A bone marrow scan can be used in conjunction with radiolabelled
WBC imaging to improve diagnostic accuracy in the evaluation of osteomyelitis,
but it has no role as an initial imaging agent in this setting.
REFERENCES:
Zeissman HA, O’Malley JP, Thrall JH: Nuclear Medicine-The Requisites. 3rd ed.
Mosby. 2006.
Treves, ST: Pediatric Nuclear Medicine. 2nd ed. Springer-Verlag. 1995.
18. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
243. Which one of the following is MOST LIKELY to produce a whole-lung
ventilation-perfusion (V/Q) mismatch on a ventilation-perfusion lung scan?
A. Swyer-James Syndrome
B. Fibrosing mediastinitis
C. Foreign body in a mainstem bronchus
D. Mucous plugging
RATIONALES
A. Incorrect. Swyer-James Syndrome is characterized by bronchiolitis obliterans, a
primary ventilatory disorder, which produces a whole-lung matching abnormality on the
V/Q scan.
B. Correct. This condition is associated with vascular compression or compromise,
without airway involvement, which can produce a whole-lung V/Q mismatch, mimicking
the presence of massive pulmonary embolism involving the ipsilateral main pulmonary
artery.
C. Incorrect. A foreign body produces a primary central airway obstruction, resulting in
a large ventilation defect, possibly involving the entire lung, if located in a mainstem
bronchus. There may be secondary diffuse hypoperfusion resulting from reflex
vasoconstriction, producing matching findings, but a V/Q mismatch (ie., abnormal
perfusion with normal ventilation) would not occur.
D. Incorrect. The pathophysiology of mucous plugging is the same as for a foreign
body (see C above), and may involve either selected segments, an entire lung or
portions of both lungs. Again, this is a primary ventilatory disorder, and V/Q mismatch
would not be observed.
References:
Mettler FA and Guiberteau MJ: Essentials of Nuclear Medicine Imaging, 5th ed.,
Saunders Elsevier, Philadelphia, pp. 187-194.
19. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
244. What type of radiation is detected in a positron emission tomography (PET)
scan?
A. Beta radiation
B. Two photons detected in coincidence
C. Two positrons detected in coincidence
D. A positron and an electron detected in coincidence
RATIONALES:
A. Incorrect.
B. Correct. In PET scanning a positron emitted by radioactive nucleus, travels up
to a few millimeters before losing all of its energy, attracts and combines with an
electron, and the particles annihilate producing two 0.511 MeV photons that
travel in opposite directions, which if both are detected at the same time (“in
coincidence”) indicates that the decay event occurred along a line between the
detectors
C. Incorrect.
D. Incorrect.
References:
The Essential Physics of Medical Imaging, 2nd edition. J.T. Bushberg, J.A. Seiabert,
E.M. Leidholdt, and J.M. Boone, Lippincott Williams & Wilkins (2002), Chap 22, p720.
Physics of Radiology, 2nd edition. Anthony Brinton Wolbarst, Medical Physics
Publishing, Madison WI (2005), Chap 43, p446.
20. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
245. Instant thin-layer chromatography is used to assess what parameter of
radiopharmaceutical quality assurance?
A. Radionclidic purity
B. Radiochemical purity
C. Chemical purity
D. Presence of pyrogens
RATIONALES
A. Incorrect. Radionclidic purity is typically evaluated by assessing for the presence of
high energy contaminants by means of counting radiopharmaceutical samples in a dose
calibrator, with and without lead shielding, or by using a multichannel analyzer to
identify the comtaminants.
B. Correct. Using different solvents, instant thin-layer chromatography can be used to
assess for and quantitate the presence of free Tc-99m pertechnetate and free
hydrolyzed reduced Tc-99m. In each case, the desired product radiopharmaceutical
and the contaminant demonstrate disparate Rf values, when the strips are cut up and
counted for radioactivity in a well counter.
C. Incorrect. Chemical purity is tested using chemical test strips that change color in
the presence of non-radioactive chemical contaminants, such as alumina from the Mo-
99/Tc-99m generator column or stannous ion (tin, used as a reducing agent) from the
radiopharmaceutical kits.
D. Incorrect. Pyrogen testing is performed using the limulus lysate test. It is not
routinely performed in daily clinical Nuclear Medicine practice, but is required of
radiopharmaceutical manufacturers and during the conduct of research with
investigational radiopharmaceutical agents.
References:
Mettler FA and Guiberteau MJ: Essentials of Nuclear Medicine Imaging, 5th ed.,
Saunders Elsevier, Philadelphia, pp. 43-46.
21. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
246. Regarding hepatobiliary scintigraphy in suspected biliary atresia in the
neonatal period, imaging should be carried out for at least:
A. 2 hours.
B. 4 hours.
C. 24 hours.
D. 48 hours.
RATIONALES
A. Incorrect. At 2 hours, biliary atresia and neonatal hepatitis may appear identical,
without visualization of the biliary tree or bowel.
B. Incorrect. As noted in A above, biliary atresia and neonatal hepatitis may be
indistinguishable at 4 hours as well.
C. Correct. In most cases, the diagnosis will be apparent by 24 hours, especially if
phenobarbital was given prior to the study to enhance hepatic biliary excretion. Beyond
24 hours, radioactive decay of the Tc-99m biliary tracer will limit the resolution of
images obtained.
D. Incorrect. As discussed above, in most cases, the diagnosis can be made in 24
hours, and the relatively short 6 hour half-life of Tc-99m limits the utility of imaging
beyond 24 hours as well.
References:
Mettler FA and Guiberteau MJ: Essentials of Nuclear Medicine Imaging, 5th ed.,
Saunders Elsevier, Philadelphia, p. 230.
22. 2007 ACR Diagnostic Radiology In-Training Exam Rationales
247. Gastric emptying of which of the following is associated with an exponential
pattern of gastric clearance?
A. Solids only
B. Liquids only
C. Both solids and liquids
D. Neither solids nor liquids
RATIONALES
A. Incorrect. Solid-phase gastric emptying studies typically demonstrate an initial lag
phase followed by linear gastric emptying in normal subjects.
B. Correct. Liquids follow a monoexponential pattern of gastric emptying normal. Liquid
gastric emptying studies are less sensitive than solid-phase studies for the assessment
of gastroparesis.
C. Incorrect. As discussed above, the normal patterns of gastric emptying are an initial
lag phase followed by linear emptying of solids and a monoexponential emptying of
liquids.
D. Incorrect. As discussed above, the normal patterns of gastric emptying are an initial
lag phase followed by linear emptying of solids and a monoexponential emptying of
liquids.
References:
Mettler FA and Guiberteau MJ: Essentials of Nuclear Medicine Imaging, 5th ed.,
Saunders Elsevier, Philadelphia, pp. 234-236.PEDIATRICS