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
suggestiveofpresenceofgas.Thefindingsareconsistentwithemphysematouspyelonephritis.
Emphysematouspyelonephritisisalife-threateningnecrotizinginfectionofthekidneyscharacterized
by gas formation within or surrounding the kidneys. The majority (~90%) of patients have poorly
controlled diabetes. Nondiabetic patients either are typically immunocompromised or have associated
urinary tract obstruction secondary to urinary calculi, neoplasm, or sloughed papilla. Most patients
complainoffevers,chills,flankorabdominalpain,nausea,andvomiting.Themostcommonlyidentified
organisms are E coli, Klebsiella pneumoniae, and P. mirabilis. Candida is a rare cause. Laboratory
testing usually reveals hyperglycemia, leukocytosis, elevated serum creatinine, and pyuria.
Emphysematouspyelonephritisisseenmorecommonlyinwomenthanmen.
Promptdiagnosisandtreatmentarenecessarybecauseofassociatedhighmorbidityandmortality.In
thepast,treatmentofemphysematouspyelonephritisusuallyinvolvednephrectomyoropendrainagealong
withsystemicantibiotics.However,therehasrecently beenashift towardanephron-sparingapproach,
including percutaneous drainage andantibiotic therapy with or without elective nephrectomyata later
stage.
References:CraigWD,WagnerBJ,TravisMD.Pyelonephritis:radiologic-pathologicreview.Radiographics2008;28(1):255–276.
HammondNA,NikolaidisP,MillerFH.Infectiousandinflammatorydiseasesofthekidney.RadiolClinNorthAm2012;50(2):259–270.
WeintrobAC,SextonDJ.Emphysematousurinarytractinfections.
48. AnswerD. The patient has developed hydronephrosis containing low-level echoes andmultiple
roundedechogeniclesionswithinrightrenalcollectingsystem. The roundedcalyceallesionsare highly
concerningforfungalballs.Thelow-levelechoesareconcerningforadditionaldebriswithintheurine,
potentially representing pyonephrosis. The other differential consideration would be blood clots.
Althoughupper urinarytract urothelial tumorcould have a similar appearance, this would be unlikely
giventherecentnormalultrasound.Thesedonothavetheappearanceofcalculiastheydonotshadow.
Becauseofthepossibilityofpyonephrosisandfungalballsinthesettingofaureteralobstruction,the
firstpriorityistodecompressthecollectingsystemwithanephrostomytubeorbyreplacingtheureteral
stent. Once access to the renal collecting system is achieved, a specimen can be obtained. Systemic
antifungaltherapyshouldbeadministered,andlocalantifungaltherapycanalsobegiven.Anephrostomy
tubemayalsoprovideaccessfordirectextractionoffungalballs.
Fungal infection of the urinary tract can occur as a result of hematogenous dissemination or by
ascendinginfection.The most common fungal organism toaffect theurinary tractis Candida albicans.
Risk factors include diabetes mellitus, chronic indwelling catheters, malignancy, chronic antibiotic or
steroidtherapy,immunosuppressivetherapy,andIVdrugabuse.
References:PrazV,BurruniR,MeidF,etal. Fungalball inurinarytract,arareentity,whichneedsaspecific approach.Can UrolAssoc J
2014;8(1–2):e118–e120.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:338.
49a.AnswerD.Alargesolidmasswithintheupperpolecenteredwithintherenalsinusisconcerning
for a malignant lesion within the collecting system. The differential diagnosis for lesions within the
collectingsystemincludesbloodclots,fungusballs,fibroepithelialpolyps,malakoplakia,andcalculi.An
exophyticrenalcellcarcinomaprotrudingintotherenalsinuscouldalsohavethisappearance.Themost
commonurothelialtumoristransitionalcellcarcinoma(90%),followedbysquamouscellcarcinomaand
adenocarcinoma. Transitional cell carcinomas (TCCs) are divided into papillary and nonpapillary.
Papillary lesions are exophytic polypoid tumors with a stalk. These tend to be slower growing and
develop metastases later. Nonpapillary lesions are sessile lesions that are usually high grade and
infiltratingatpresentation.Theyareoftenmoredifficulttodetectonimaging.
49b.AnswerC.Althoughthemassisdetectableonultrasound,furtherimagingisnecessarytoconfirm
the presenceof tissueenhancement expected in a neoplasm. Absence ofenhancement may allow for a
diagnosisofbloodclotorfungusball.Additionally,aCTurogramhelpsdistinguishbetweenarenalcell
carcinomaand a urothelialneoplasm, bydelineatingthe relationshipofthemass tothe renalcollecting
system.After all,the incidenceofrenalcell carcinoma(RCC)isfivetotentimes higherthanTCC, so
manycentrallylocatedrenalmassesareRCCs.Additionally,TCCshaveaso-calledfieldeffectinwhich
thepresenceofonetransitionalcellcarcinomaindicatesanincreasedriskformalignancyfortheentire
urothelium. Therefore, further imaging is necessary to identify synchronous tumors to guide potential
surgery.CTisalsosuperiortoultrasoundfortumorstaging.
49c.AnswerA. Invasion ofthe renal veinbyTCC israre,so the presenceoftumorthrombus would
stronglyfavora renalcellcarcinoma. Both centrallylocated RCCand TCCcanobstruct the collecting
systemandleadtohydronephrosis.Bothtumorshaveapropensityfornodalmetastases.Thepresenceof
intralesionalDopplerflowishelpfultoconfirmasolidmassbutdoesnotallowdistinctionbetweenRCC
andTCC.Additionally,theabsenceofDopplerflowdoesnotexcludethepossibilityofasolidneoplasm
whenthereisslowflow.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:120.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:354–360.
50a.AnswerB.Theimageshowsechogenicthrombusexpandingtheinferiorvenacava.Thrombusthat
expands the IVC is concerning for tumor thrombus. The presence of internal Doppler waveforms is
diagnostic of tumor thrombus. The most common causes for caval tumor thrombus are renal cell
carcinoma,hepatocellular carcinoma, and primary adrenal carcinoma.Although leiomyosarcoma is the
most common primary IVC tumor, it is rarely encountered compared to the other causes of tumor
thrombus.
50b.AnswerD.Imagesdemonstrateasuprarenalmixedsolidandcysticmassattheexpectedlocation
of the right adrenal gland. In light of the large mass size, complex solid and cystic appearance and
findings suggesting caval tumor thrombus, findings are highly concerning for an adrenal cortical
carcinoma.Plasma freemetanephrinesandnormetanephrineshavethehighestsensitivityand specificity
(97%to100%and85%to89%,respectively)andareconsideredtobethebestinitialscreeningtestfor
pheochromocytoma. Pheochromocytoma must be ruled out biochemically prior to an adrenal biopsy
becauseoftheriskoffatalhypertensivecrisisduringfineneedleaspiration.
References:RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:439.
Zeiger M,ThompsonG,DuhQ-Y,etal.American association of clinical endocrinologists andAmericanassociationofendocrine surgeons
medicalguidelinesforthemanagementofadrenalincidentalomas.EndocrPract2009;15(Suppl1):1–20.
51. AnswerA. In spatial compound imaging,multiple parallel ultrasoundbeams orientedindifferent
directions are averaged together to make a single image. This technique results in decreased image
speckle and noise but can also decrease posterior acoustic shadowing and posterior acoustic
enhancement.
Tissueharmonic imaging, a methodthat improves the signal-to-noise ratio of ultrasoundimagesby
reducingartifacts,worksbyusingreturningechoesattwicethefundamentalfrequencyofthetransmitted
echotogeneratetheimage.Increasingtheoverall gain is apostprocessingfunction thatwouldincrease
thebrightnessoftheimage.Ultrasoundelastographydisplaystherelativestiffnessoftissues.
Reference:HangiandreouNJ.AAPM/RSNAphysicstutorialforresidents:topicsinUS.Radiographics2003;23(4):1019–1033.
52.AnswerC.TheultrasoundimagesshowpowerDopplerimagingoftherenalartery.PowerDoppler
imaging estimates the power of the Doppler signal rather than the mean frequency shift. Because
frequencyshiftdataarenotdisplayed,thereisnoaliasing.Thepowerofthesignalisnotaffectedbythe
Doppler angle. In power Doppler, noise is assigned a homogeneous background color that does not
greatlyinterferewiththeimage.Thisallowsfortheuseofhighergainsettingsandincreasedsensitivity
forflowdetection.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:16.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:25.
53a.AnswerA.Thisisa large complex mass containingheterogeneousechogeniccontents.Posterior
acousticenhancementsuggestsacysticlesion.Becauseofnodetectableflow,asolid componentcannot
beconfirmedtoindicateacysticrenalcellcarcinoma.Thedifferentialdiagnosisincludesacomplexcyst
suchas ahemorrhagic cystorabscessandcystic renalcellcarcinoma.Further imagingwithacontrastenhanced study is necessary to determine if a solid component is present and to direct appropriate
management.Althoughasubsetofcomplexcysticlesionscanbefollowed,thisisonlydoneaftertheyare
characterizedasBosniakIIFwithCTorMRI.
53b. Answer B. Gray-scale images (left) show the large complex cystic renal mass. Microbubble
contrast-specificsequence(right)shows curvilinearenhancementofsolidtissuealong thedeepwallof
thecyst,confirmingacysticrenalcellcarcinoma.Contrast-enhancedUShasbeenshowntohaveavery
high sensitivity and specificity for characterizing indeterminate renal masses, allowing for lesion
classificationwithaveryhighlevelofcertainty.Contrast-enhancedUSishelpfulforidentifyingperfusion
thatmay betoominimaltodetectbyMRIorCTbecauseofblending ofenhancement withsurrounding
normaltissue.Microbubblecontrast-specificultrasoundsettingssuppressbackgroundtissue,resultingin
highersensitivityfordetectionofflowwithinhypovasculartumors.
References: BarrRG,Peterson C,HindiA.Evaluationofindeterminate renalmasses withcontrast-enhancedUS: a diagnostic performance
study.Radiology2014;271(1):133–142.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:53–75.
Tamai HT, Takiguchi Y, Oka M, et al. Contrast-enhanced ultrasonography in the diagnosis of solid renal tumors. J Ultrasound Med
2005;24(12):1635–1640.
54. AnswerD. A centrallylocatedheterogeneous infiltrativesolid tissuereplaces renalsinusfat and
extendsintothe renalparenchyma withill-defined nonencapsulatedmargins.Thestarred structuredoes
nothavetheappearanceofacolumnofBertin,asitisofheterogeneousechotextureunlikethatoftherenal
cortex. Additionally,acolumnwouldnot havea mass-likeconfiguration on thesagittalimage.Ithasan
elongated tubular configuration that contains color Doppler signal suggesting tumor within either the
collectingsystem orrenal vein.Thesagittalimage also shows a dilatedupper pole calyx. A contrastenhanced CT image shows the infiltrative tumor extending into the renal vein. Based on imaging, a
urothelial carcinoma was suspected, but pathology revealed an infiltrative renal cell carcinoma with
sarcomatoidfeatures.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:348–356.
4 Neck
Questions
1a.A21-year-oldfemalepresentswithapalpablepainlesslumpintheanteriorneck.Ultrasoundimages
oftheneckjustbelowthelevelofthehyoidboneareshown. Themostlikelydiagnosisis:
A.2ndbranchialcleftcyst
B.Thyroglossalductcyst
C.Suppurativelymphnode
D.Cysticnodalmetastasis
1b. In whichofthe following situationsis preoperative thyroidscintigraphyindicatedinpatientswith
thyroglossalductcysts?
A.Whenanormalthyroidglandisidentifiedbysonography
B.Whenanormalthyroidglandisnotidentifiedbysonography
C.Whenasolidvascularcomponentisidentifiedwithinthecyst
D.Whenasolidvascularcomponentisnotidentifiedwithinthecyst
2.Punctateechogenicfociareidentifiedwithinathyroidnodule.Identificationofwhichofthefollowing
additional imaging features would suggest the echogenic foci are colloid as opposed to
microcalcifications?
A.Posterioracousticshadow
B.Comet-tailartifact
C.Increasedthroughtransmission
D.Refractionartifact
3. Identification of which of the following imaging features in a cervical lymph node would be
concerningformalignancy?
A.Roundshape
B.6mmshort-axisdiameter
C.Hyperechoichilum
D.Hilarvessels
4. According to both the 2005 Society ofRadiologists in Ultrasound (SRU) consensus statement and
2015American ThyroidAssociation (ATA)guidelines,whatisthe nextbeststepinmanagementforthe
1.6cmthyroidlesionshown?
A.Fineneedleaspiration
B.MRIforfurthercharacterization
C.PET-CT
D.Noadditionalmanagementrequired
5a.TheAmericanCollegeofRadiologyformedanIncidentalThyroidFindingsCommitteeonmanaging
incidentalthyroidnodules(ITNs)detectedonimagingin2013.Accordingtotheguidelinespublishedin
February2015, incidentallydetectedthyroidnodulesonCT, MRI,andextrathyroid ultrasound(suchas
carotidDoppler)withoutsuspiciousfeaturesinthegeneralpopulationarestratifiedbasedonwhichtwo
maincriteria?
A.Clinicalsymptomsandpatientsex
B.Patientageandthyroidnodulesize
C.Theshapeandnumberofnodules
D.Riskstratificationandnoduleappearance
5b.A41-year-oldmanundergoesachestCTpulmonaryangiogramforshortnessofbreathwherea1.2-
cm incidental hypoattenuating nodule was found confined to the right thyroid lobe. Visualized lymph
nodesatthebaseoftheneckmeasured<8mminshortaxis.Accordingtothewhitepaperonincidentally
detectedthyroidnodulesmentionedabove,whatwouldbethemostappropriatenextstepinmanagement?
A.Recommendfurtherevaluationwiththyroidultrasound.
B.Recommendfurtherevaluationwiththyroidultrasoundandultrasound-guidedbiopsy.
C.Recommendreferraltoanendocrinologist.
D.Nofurtherevaluationisrecommended.
6a.A35-year-oldotherwisehealthyfemalewasreferredforultrasoundafterherthyroidwasnotedtobe
diffusely enlarged on physical exam and thyroid function tests were abnormal. After reviewing her
ultrasoundandfurtherquestioning,shereportsweightgainandconstipation. Themostlikelydiagnosisis:
A.Multinodulargoiter
B.Gravesdisease
C.Radiation/radioiodine-inducedhypothyroidism
D.Hashimotothyroiditis
E.deQuervain(subacutegranulomatous)thyroiditis
6b.Hashimotothyroiditisisassociatedwithanincreasedincidenceofwhattypeofmalignancy?
A.Anaplasticthyroidcarcinoma
B.Medullarythyroidcarcinoma
C.Non-Hodgkinthyroidlymphoma
D.Metastaticdiseasetothethyroid
7.A 46-year-oldwomanwithpainlessswellingofbothparotidglandsand drymouthwasreferredfor
neckultrasound.Afterreviewingherultrasound,themostlikelydiagnosisis:
A.HIV-relatedlymphoepithelialcysts
B.Sjögrensyndrome
C.Warthintumor
D.Pleomorphicadenoma
8a.An18-year-oldwomanpresentedtoherfamilyphysicianwithneckswelling.Imagesfromthethyroid
ultrasoundandthelateralcompartmentlymphnodesareprovided.Whatarethemostlikelydiagnosisand
appropriatemanagement?
Соседние файлы в папке Библиотека им академика М.И. Перельмана