Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана
.pdf
Appropriatedescriptorsoftheabnormalityinclude:
A.ColumnofBertin
B.Encapsulated
C.Peripheral
D.Infiltrative
ANSWERSANDEXPLANATIONS
1. AnswerC. Sagittal images of both kidneys show generalized increased echogenicity of the renal
pyramids and associated posterior acoustic shadowing, consistent with calcium deposition. Color
Dopplerimageoftherightkidneyshows“twinkle”artifactfromtherenalcalcifications.Thefindingsare
consistent with medullary nephrocalcinosis. The common causes of medullary nephrocalcinosis in the
orderoffrequencyareasfollows:40%,primaryhyperparathyroidism;20%,renaltubularacidosistypeI;
and 20%, medullary sponge kidney. Other causes such as hypervitaminosis D states and milk–alkali
syndrome are less common. Chronic glomerulonephritis results in cortical nephrocalcinosis (and not
medullarynephrocalcinosis).
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:130–131.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:346–348.
2a. AnswerA. Bladder cancer isusuallyseen as a sessile or pedunculated mass projecting intothe
bladderlumen.Immobilityandpresenceofinternalvascularityareusefuldistinguishingfeatures.Fungus
ballsandbloodclotsare mobile masseswithoutvascularity. Bladder stonesaremobileand echogenic
andshowposterioracousticshadowing.
2b. Answer B. Approximately 90% of bladder tumors are transitional cell carcinoma (TCC). The
majority of TCCarise at the trigoneand along the lateral andposterior bladder walls. Squamouscell
carcinomasaccountfor5%to8%ofallbladdertumors.Adenocarcinomaofthebladderisrare(~2%of
all bladder tumors) and tends to occur in urachal remnants and in bladder exstrophy. Neuroendocrine
(smallcell)tumorofthebladderisrarer,accountingfor<0.5%ofallbladderneoplasms.
2c. Answer A. The pathogenesis for urothelial tumors is direct prolonged contact of the bladder
urotheliumwithurinecontainingexcretedcarcinogens.Themostwell-establishedriskfactorforbladder
canceriscigarettesmoking.Cigarettesmokingaccountsforone-thirdtoone-halfofallcasesofbladder
cancer. There is also a well-documented causal link between urothelial cancer and a variety of
occupational and environmental chemicals such as aniline, benzidine, aromatic amines, and azo dyes.
Therefore,occupationalexposure tochemicalcarcinogensisthesecondmostimportantriskfactorafter
smoking,estimatedtoaccountforasmuchas20%ofallbladdercancer.Chronicirritationfrombladder
calculiandrecurrenturinarytractinfectionsisstronglyassociatedwithsquamouscellcarcinoma.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:167–168.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:359–360.
Wong-You-CheongJJ,WoodwardPJ,ManningMA,etal.Neoplasmsoftheurinarybladder:radiologic-pathologiccorrelation.Radiographics
2006;26:553–580.
3.AnswerC.Abilobedthin-walledanechoicadrenallesioncontainingathinseptationwithnointernal
colorDopplersignalisshown.Athinsmoothwallandlackofasolidcomponentfavorsanadrenalcyst,
pseudocyst, or parasitic cyst. Whereas true adrenal cysts are lined by endothelium, pseudocysts are
surrounded by a fibrous capsule and are usually the sequelae of adrenal hemorrhage or infection. In
addition,neoplasmsincludingadrenocorticalcarcinoma,pheochromocytoma,andadenomasmayundergo
necrosis or degeneration leading to cystic components, which may be extensive especially in larger
tumors. Careful inspection on contrast-enhanced CT or MRI should be performed to exclude a solid
tumoralcomponent.Therehaveonlybeenafewreportedcasesofentirelycysticpheochromocytoma.
References:NewhouseJH,HeffessCS,WagnerBJ,etal.Largedegeneratedadrenaladenomas:radiologic-pathologiccorrelation.Radiology
1999;210(2):385–391.
LeeTH,SlywotzkyCM,LavelleMT,etal.BestcasesfromtheAFIP.Radiographics2002;22(4):935–940.
4a. AnswerD. A large echogenic suprarenal massis shown with associated impairmentof acoustic
penetration,indicatingthepresenceoffat.Althoughgascanresultin“dirty” acousticshadowing,linear
high-amplitudereflectionsareexpectedalongtheboundaryclosesttotheprobe.Bloodproductscanhave
a variety of appearances but would not be expectedto shadow.Large calcifications typically produce
cleanacousticshadows.
4b. Answer B. The average velocities of sound in fat and soft tissue are 1,450 and 1,540 m/s,
respectively. Speed errors result when the actual propagation speed through a tissue varies from the
calibratedvelocityusedbythesystem(1,540m/s).Thisleadstoinaccuratemeasurementsbetweentissue
boundaries. As a result of slower propagation of sound through the fatty mass, the portion of the
diaphragm–lunginterfacedeeptothemyelolipoma(yellowline)isincorrectlypositionedfurtherfromthe
probethantheadjacentinterfacedeeptotheliver(whiteline).Althoughthediaphragm–lunginterfaceis
smoothandcontinuousinreality,ittakesonanartifactualstair-steppedappearanceonultrasound.
4c. Answer A. Although renal cell carcinomas may contain fat (from lipid-producing necrosis,
intratumoralosseousmetaplasiawithfattymarrowelements,andentrapmentofperirenalorsinusfat),we
wouldnotexpectthemtobecomposedprimarilyoffat.Renalangiomyolipomas,adrenalmyelolipomas,
andretroperitoneal liposarcoma can be mostly or purely composed of fat on imaging. There are case
reportsofadrenalcorticalcarcinomacontainingmacroscopicfat,butinvirtuallyallcases,thepresence
ofmacroscopicfatwithinanadrenalmasspermitsadiagnosisofabenignlesion.
4d.AnswerA.Thereisnorecognizedmalignantpotentialforadrenalmyelolipomas.
References:KenneyPJ,WagnerBJ,RaoP,etal.Myelolipoma:CTandpathologicfeatures.Radiology1998;208(1):87–95.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:3–4.
5.AnswerC.Rootcauseanalysisisastructuredmethodborrowedfromanalysisofindustrialaccidents
to evaluate serious adverse events. It is a comprehensive process requiring data collection, event
reconstruction,recordreview,andinterviews.Bothactiveerrors,thoseleadingdirectlytotheevent,and
latent errors, hidden errors within the health care system contributing to the error, are studied. This
information isanalyzedbya multidisciplinaryteam todetermine howandwhy the event occurred. The
ultimategoal ofRCAis toeliminate the variouslatenterrors, which contribute toanincreased risk of
similarfutureerrors.Ratherthanasinglerootcause,oftenadverseeventsarecausedbymultipleerrors
andsystemflaws.
Reference: AmericanBoard of Radiology.Quality and Safety Domain Specification and Resource Guide, Core Exam Study Guide.
Tucson,AZ:ABR,2016:28.
6.AnswerD.Between2004and2014,therewere1,072reportsofwrong-patient,wrong-site,wrong-
procedure sentinel events, representing the largest category. Radiation overdoses, anesthesia-related
eventsandmedicationerrorsaccountedfor36,104and428events,respectively.
Reference: AmericanBoard of Radiology.Quality and Safety Domain Specification and Resource Guide, Core Exam Study Guide.
Tucson,AZ:ABR,2016:26.
7a.AnswerD.ImagesshowaFoleyballoonposteriortothebladderwithcatheterextendingcaudallyin
thevagina.
Bladder diverticula typically occur in the setting of bladder outlet obstruction. Connection to the
bladderis usuallyseensonographically.Urethraldiverticulaarisefromandare immediately associated
withtheurethra.Theyarebestseenonultrasoundbytransvaginalortransperinealimaging.Ureteroceles
areformedfromcysticdilatationoftheintravesicalsegmentoftheureter.Onultrasound,theyappearas
cysticstructuresintheposterolateralbladder(expectedinsertionofureter).Urachalcystsoccurbecause
ofincompleteclosureoftheurachusandare therefore locatedalongtheanteriorandsuperioraspectof
the bladder.AlthoughGartnerductcystsare located in thislocation(anterior lateral vagina abovethe
pubicsymphysis),thestructureshowninthisimageisclearlyaFoleycatheterwithballooninthemidline
vaginaandcathetersegmentextendingthroughtheballoonandcaudallyinthevagina.
7b.AnswerA.90%oftumorsthatarisewithinaurachalremnantareadenocarcinoma.
7c. AnswerA. Gartnerductcystsare typicallylocated intheanterior lateralvaginalwallabove the
pubicsymphysis.Theymaybeseeninassociationwithotherwolffiananomaliessuchasrenalagenesis
and ectopic ureter. Urethral diverticula can be confused with Gartner duct cysts because of similar
locationandappearance.Urethraldiverticulawillshowdirectcommunicationwiththeurethra.Bartholin
ductcystsare located in theposterior lateral inferior third of the vagina below thelevel of the pubic
symphysis.Nabothiancystsarelocatedwithinthewallofthecervix.
References: Berrocal T, López-Pereira P,Arjonilla A, et al. Anomalies of the distal ureter, bladder, and urethra in children: embryologic,
radiologic,andpathologicfeatures.Radiographics2002;22(5):1139–1164.
Chaudhari VV, Patel MK, Douek M, et al. MR imaging and US of female urethral and periurethral disease. Radiographics
2010;30(7):1857–1874.
YuJ-S,KimKW,LeeH-J,etal.Urachalremnantdiseases:spectrumofCTandUSfindings.Radiographics2001;21(2):451–461.
8.AnswerA.Spatial compoundingcombinesimagesobtainedfromdifferentscananglesintoasingle
frame.Byutilizingmultiplescanangles,lesionmarginsarebetterdelineatedbecausemoreofthelesion
marginiscloseto90degreestotheultrasoundbeam.Orientationofaspecularreflector90degreestothe
beammaximizestheamountofreflectedacoustic energyreturningtothe probe,leadingtomoredistinct
boundariesforcystsandothermasses.Additionally,althoughdesirableacousticinterfacessuchasthose
foundinrenalcystsarereinforcedthroughthesummingoftheimages,randomlylocatedspecklenoiseis
notreinforced,resultinginasignificantlyincreasedsignal-to-noiseratio.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:14–16.
9.AnswerA.Sidelobesarelocatedoutsideoftheprimarydesiredacousticbeambutmayinteractwith
tissues and return as an echo to the probe, thus creating artifactual low-level echoes, which are best
appreciatedwithinanechoiccysticandfluid-filledstructures.Forexample,side-lobeartifactcanresultin
theappearanceofgallbladdersludge.
Reference:RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:17.
10a.AnswerC.Theimagesshowahomogeneouslyechogeniclesionattheupperpoleoftheleftkidney,
withamaximaldiameterofslightly<3cm.Theimagingfeaturesarecharacteristicofanangiomyolipoma.
AMLsarebenigntumorscomposedofdysmorphicvessels,smoothmuscle,andmaturefat.Eightypercent
are sporadic, mostfrequentlyin middle-aged women, andtheother20% are associatedwith tuberous
sclerosis(TS).PatientswithTSoftenhavementalretardation,seizures,andfacialsebaceousadenomas.
Therefore,Cisthecorrectanswer.NoneoftheotherchoicesareassociatedwithTS.
10b. Answer B. Although a homogeneous, highly echogenic mass is very suggestive of AML,
approximately10%ofrenalcellcarcinoma(RCC)canmimicthisappearance.Onedistinguishingfeature
seeninupto30%ofAMLsisacousticshadowing,whichisextremelyrareinRCC.Hyperechoicmasses
that show no acoustic shadowing require further characterization with CT or MRI to demonstrate fat.
Choice B is the correct answer. Choice A is not correct because the lesion is neoplastic, not
inflammatory.ChoiceCwouldnotbethemostappropriatenextstepbecausethelesionisstatisticallyan
AML,andconfirmation of fatis likelyall that is needed. Although bleeding is a seriouscomplication
relatedtoAMLs,itisrarewhenthelesionsare<4cm.Therefore,choiceDisincorrect.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:122–123.
11a.AnswerD.Theimagesshowanabsentkidneyintherightrenalfossa.Therearetwonormal-sized
kidneysbroadlyfusedtogetherintheleftrenalfossa.Atrealtime,thekidneysinthispatientextendedinto
theleftlowerpelvis.Apelvicrightkidney(choiceA)isincorrectbecausepelvickidneysarenotfusedto
the contralateralkidney. Theyremain ontheipsilateral sideof the bodybutare found more inferiorly.
Horseshoekidneysareusuallyfusedatthelowerpolesandlocatedmoreinferiorlythannormal,buteach
renalmoiety will remain in the correctside ofthe body(optionB). Diffuse compensatory hypertrophy
resultsin ipsilateralrenalenlargementwhen thecontralateral kidneyisabsent or dysfunctional(option
C), particularly when the renal insultoccurs in utero or early in life. The right kidney in this case is
presentandnormalappearing,butisabnormallypositioned.
11b. Answer C. Crossed renal ectopia occurs when there is in utero fusionof the metanephrogenic
blastema,notallowingforproperrenalrotationorascent.Theureterovesicaljunctionsarenotaffected,
andbothareinnormalanatomicallocation.Thisisusefultorememberwhenthesepatientspresentwith
renalcolic.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:103–106.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:324.
12.AnswerA.Thetwobroadcategoriesofradiologisterrorareperceptualandcognitive(interpretive)
errors.Perceptualerroroccurswhenanabnormalitythatcanbeseeninretrospectwasnotidentifiedby
the interpreting radiologist at the time of the initial interpretation. “Satisfaction of search,” in which
identification of one abnormality results in a second abnormality being overlooked, is one of many
potential causes ofperceptualerror.Perceptualerrors accountfor 60% to80% ofradiologists’errors.
Cognitiveerroroccurswhentheradiologistidentifiesafindingbutrendersanincorrectinterpretation.
Reference: AmericanBoard of Radiology.Quality and Safety Domain Specification and Resource Guide, Core Exam Study Guide.
Tucson,AZ:ABR,2016:26.
13.AnswerB.Theultrasoundshowsashadowingstonethatwasglimpsedonthesagittalandtransverse
viewsintheproximaltransplantureterresultinginmildhydronephrosis.Thisismostlikelythecauseof
the elevated creatinine level. The ultrasound images also reveal a simple-appearing deep perinephric
collectionneartherenalvein.AlthoughcolorDoppleraliasingandperhapssomeluminalcompressionof
therenalveinmaybepresent,anglecorrectionwasnotappliedandavelocitygradientwasnotmeasured,
so the provided images are not sufficient to diagnose severe renal vein stenosis (option A). The
perinephric fluid collection shown remained stable 1 year later and was thought to represent a
lymphocele. Subcapsular hematoma and solid masses, as can be seen with posttransplant
lymphoproliferativedisease,areabsent(optionsCandD).
The clinical diagnosis ofobstructive uropathyafter renal transplant isdifficult becausethe graft is
denervatedandpatientsareasymptomatic.Thediagnosismayremainunsuspecteduntilhydronephrosisor
decliningrenalfunctionisdiscoveredincidentally.Mild,nonobstructivepelvicaliectasisiscommonafter
renaltransplant.
References: Rhee BD, Bretan PN Jr, Stoller ML. Urolithiasis in renal and combined pancreas/renal transplant recipients. J Urol
2005;161(5):1458–1462.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:679–681.
14. Answer A. Sonography is often used as a screening tool in patients presenting with elevated
creatininetoruleoutunderlyingmechanicalobstruction.Lackofobstructionusuallyindicatesthatrenal
parenchymaldiseaseispresent.Sonographicappearanceofvariousrenalparenchymaldiseases suchas
acutetubularnecrosis,glomerulonephritis,andacuteinterstitialnephritisaffectingthekidneysisdifficult
todistinguishon ultrasound. Patientsoftenpresentwithdiffuselyechogenickidneys, andbiopsymaybe
neededinselectpatientstoestablishaspecificdiagnosis.Theimagesshowamildlyenlarged,strikingly
echogenic cortex relative to the spleen (when the spleen is used as an external control) and the
hypoechoicrenalpyramids(whenusedasaninternalcontrol).
The colorDoppler imageof the renalveinconfirms patency, andthereisnodilatation oftherenal
pelvis(choicesBandCareincorrect).Thehypoechoicrimaroundthekidneyrepresentsperinephricfat,
which appears hypoechoic relative to the echogenic renal cortex. Diffuse xanthogranulomatous
pyelonephritisdoesnothavespecificsonographicfeaturesbutcanbesuggestedwhenrenalenlargement,
corticalthinning, dilated, debris-filled calyces, largecalculi, andperinephric fluidare present (option
D). This particular patient had a known history of idiopathic membranous glomerulonephritis, an
autoimmunedisease.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:131–132.
MakkerSP,TramontanoA.Idiopathicmembranousnephropathy:anautoimmunedisease.SeminNephrol2011;31(4):333–340.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:380–382.
15. Answer B. Sagittal ultrasound image of the left lower quadrant renal allograft shows a large
anechoic peritransplant fluid collection with few internal septations. This most likely represents a
peritransplant lymphocele. Lymphoceles arethemostcommonfluidcollectionsseen in renal transplant
recipients. They typically occur 1 to 3 weeks following surgery. They maybe asymptomatic or cause
localpainandtenderness.Septationsmaybeseenwithinlymphoceles,asinthiscase.Lymphocelesform
fromleakageoflymphfromrecipientlymphaticchannels.Largelymphocelesmayresultinimpairedgraft
function.
Urinomasaremuchlesscommon.Theyoccurbecauseofbreakdownoftheureterimplantationintothe
bladder. Therefore, they are usually in close proximity to and may exert mass effect on the bladder.
Hematomasarecommonintheearlypostoperativeperiod.Smallhematomasmaybeseenincidentallyat
imaging.Largehematomasmayresultinpain.Atultrasound,hematomasusuallyappearasheterogeneous
perinephric collections. Abscesses typically appear as complex fluid collections containing internal
debris.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:140–141.
MorenoCC,MittalPK,GhongeNP,etal.Imagingcomplicationsofrenaltransplantation.RadiolClinNorthAm2016;54(2):235–249.
16a.AnswerB. Theimages showanovoid circumscribed cysticlesioncontaininglow-levelinternal
echoes within the wall of the upper vagina. There is posterior acoustic enhancement and no internal
vascularity.Thetransvaginalprobeindentsthemass.
Thewolffian(mesonephric)ducts,embryologicprecursorstothevasdeferensandseminalvesicles,
regress in the absenceoftestosteroneand antimüllerian hormone. Gartner ductcysts (GDCs) are rare
remnantsofregressedwolffianducts.Theyareusuallysmall(<2cm)andlocatedwithintheanterolateral
aspectoftheuppervagina.
CTimageswithreformatsdemonstratetheGartnerductcyst(arrow).
Соседние файлы в папке Библиотека им академика М.И. Перельмана