GUTImagingNotes&PracticeQuizesMZeba

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RENAL Nephrometry Score (RNS) The RENAL score is a scoring system used to assess renal tumor complexity on CT/MRI and guide surgical planning (partial vs. radical nephrectomy). Components (Scored 1–3 Each) 🔹 R – Radius (Size): 1 = ≤4 cm, 2 = 4–7 cm, 3 = >7 cm 🔹 E – Exophytic/Endophytic: 1 = Mostly exophytic, 3 = Entirely endophytic 🔹 N – Nearness to Collecting System: 1 = >7 mm, 3 = <4 mm 🔹 A – Anterior/Posterior: A = Anterior, P = Posterior, X = Indeterminate 🔹 L – Location Relative to Polar Lines: 1 = Above/below, 3 = Central/sinus involvement Scoring & Surgical Complexity ✔ 4–6 (Low Complexity) → Partial nephrectomy preferred ✔ 7–9 (Moderate Complexity) → Partial or radical nephrectomy ✔ 10–12 (High Complexity) → Radical nephrectomy likely MZeba

Sentinel lymph node (SLN) mapping: The first group of lymphnodes showing lymphatic metastasis. 🌀Cervical Cancer: Parametrial, obturator, internal iliac, external iliac, and common iliac nodes. 🌀Endometrial Cancer: Pelvic lymph nodes, particularly the external iliac, internal iliac, obturator, and paraaortic nodes. 🌀Vaginal Cancer: Inguinal, femoral, and pelvic lymph nodes. The specific nodes can vary depending on the location of the primary tumor within the vagina. 🌀Ovarian Cancer: SLN mapping in ovarian cancer is complex due to the extensive lymphatic drainage. The primary SLNs can include the pelvic, paraaortic, and sometimes inguinal nodes. 🌀Prostate Cancer: The obturator, external iliac, internal iliac, and presacral nodes. 🌀Penile Cancer: Inguinal lymph nodes. 🌀Rectal Cancer: SLNs are often found in the mesorectal, internal iliac, and presacral nodes. MZeba

Suspicious Calcifications: Typically smaller and less regular compared to benign ones. 🌀BI-RADS 5th Edition Descriptors (Increasing Suspicion): 1. Coarse Heterogeneous: Irregular, generally 0.5-1 mm. 2. Amorphous: Indistinct, small ("powdery" or "cloudy")…

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BREAST ABSCESS 🌀USG ➖Hypoechoic, multiloculated collection with posterior acoustic enhancement (due to fluid). ➖Vascular rim surrounding the collection, but no vascularity within. 🌀Mammography ➖Rarely used; may be recommended for non-puerperal abscesses or abscesses in women >30 to rule out malignancy. ➖Findings can include skin thickening and asymmetric density; suspicious microcalcifications may suggest malignancy and warrant a biopsy. 🌀Treatment and Prognosis ➖Primary Treatment: Antibiotics with USG-guided aspiration; repeated aspiration is preferred over catheter placement due to the risk of fistula and discomfort. ➖Surgery: Reserved for cases where aspiration is ineffective. ➖Breastfeeding: Should continue to prevent milk stasis. 🌀DD ➖Malignancy, ➖Hematoma, ➖Galactocele on ultrasound. MZeba (Source: Radiopedia)

Ultrasound features that are suggestive of endometrial carcinoma as opposed to hyperplasia include: ➖Heterogeneous and irregular endometrial thickening ➖Polypoid mass lesion ➖Intrauterine fluid collection ➖Frank myometrial invasion MZeba (Source: Radiopedia)

Endometrial Hyperplasia 🌀Abnormal proliferation of endometrial glands and stroma; diffuse, smooth thickening >10 mm. 🌀Associations: ➖Unopposed estrogen stimulation (endogenous or exogenous sources). ➖Conditions include obesity, polycystic ovary syndrome, pregnancy (including ectopic). 🌀USG: ➖Best imaged on days 5-10 of the menstrual cycle. ➖Premenopausal: Normal thickness varies by cycle stage; <15 mm in the secretory phase is considered normal. ➖Postmenopausal: >5 mm thickness is abnormal. ➖Hyperplasia appears as smooth thickening but can also be asymmetric with surface irregularities or cystic changes, raising concern for carcinoma. 🌀MRI: ➖T2: Hyperplasia typically appears isointense to hypointense to normal endometrium. 🌀Management ➖Biopsy: Required for diagnosis, especially if malignancy is suspected (e.g., vaginal bleeding). 🌀DD: ➖Normal endometrial thickening (secretory phase) ➖Sessile endometrial polyps, ➖Submucosal fibroids, ➖Endometrial cancer, ➖Intrauterine blood clot, ➖Pregnancy (including ectopic), ➖Incomplete abortion, ➖Estrogen-secreting ovarian tumors, ➖Granulosa cell tumor ➖Tamoxifen use. MZeba (Source: Radiopedia)

Suspicious Calcifications: Typically smaller and less regular compared to benign ones. 🌀BI-RADS 5th Edition Descriptors (Increasing Suspicion): 1. Coarse Heterogeneous: Irregular, generally 0.5-1 mm. 2. Amorphous: Indistinct, small ("powdery" or "cloudy"), shape not easily determined. 3. Fine Pleomorphic: Variable shape ("shards of glass" or "crushed stone"), generally <0.5 mm. 4. Fine Linear or Fine-Linear Branching: Thin (<0.5 mm), linear, branching or irregular. 🌀Distribution Patterns (Increasing Suspicion): 1. Regional: Scattered in a larger volume (>2 cm) not following ductal distribution. 2. Grouped: Cluster of at least 5 within 1 cm, in an area ≤2 cm. 3. Linear: Arrayed in a line, suggestive of ductal deposition. 4. Segmental: Deposits in ducts and branches of a segment or lobe. 🌀Additional Considerations: ➖Punctate Calcifications: Generally benign but can be suspicious if new, increased, or linear/segmental. Source: Radiopedia MZeba

Extraperitoneal Bladder Rupture: 🌀80-90% of bladder ruptures; commonly associated with pelvic fractures. 🌀Typically managed conservatively. 🌀Radiological Sign: Molar Tooth Sign - Contrast seen in the prevesicle space of Retzius surrounding the bladder. Intraperitoneal Bladder Rupture: 🌀Less common. 🌀Radiological Sign: Contrast outlining bowel loops and seen in the paracolic gutters. 🌀Requires surgical intervention. MZeba

Testicular Torsion USG: 🌀Modality of Choice. 🌀Comparison with normal side is the key. 🌀Key Findings: ➖Whirlpool Sign: Concentric layering above the testis representing coiled spermatic cord: Most specific and sensitive finding. 🌀Blood Flow: ➖Incomplete Torsion: Elevated resistive index (RI >0.75); to and fro flow. ➖Complete Torsion: Absence of blood flow. 🌀Testis and epididymis enlarged. 🌀Echotexture Changes: ➖Homogeneous: Early finding, before necrosis. ➖Heterogeneous: Late finding, after 24 hours, indicates necrosis +/- hge due to reperfusion. 🌀Reactive Hydrocele 🌀Thickening of scrotal skin; hyperemia and increased flow on Doppler. 🌀Peripheral Neovascularization: Seen after days; indicates small peripheral collaterals. Source: Radiopedia MZeba

Testicle = 🧠 🌀Require continuous D flow 🌀In Torsion 3 patterns can be seen; ➖Classic absent A flow ➖High resistance A flow Reversed D flow ➖Monophasic A form (dicrotic notch = lost) MZeba CTC#437

Polycystic Ovarian Syndrome (PCOS): 🌀AKA hyperandrogenic anovulation. 🌀Chronic anovulation syndrome associated with androgen excess. 🌀Rotterdam Criteria: ➖Requires any two of the following: 1. Ovulatory Dysfunction: Oligo- and/or anovulation. 2. Hyperandrogenism: Clinical or biochemical signs. 3. Polycystic Ovarian Morphology (PCOM): Seen on ultrasound or elevated serum AMH. Exclude other conditions (e.g., CAH, Cushing syndrome). 🌀USG: PCOM Criteria for Diagnosis (>8 years post-menarche): ➖Follicle number per ovary (FNPO) ≥20 in at least one ovary. ➖Follicle number per section (FNPS) ≥10 in at least one ovary. ➖Ovarian volume ≥10 mL, excluding cysts, corpora lutea, or dominant follicles. Source: Radiopedia MZeba

Adenomyosis 🍂Enlarged uterus. 🍂Diffuse ➕ focal thickening of T2⬇ junctional zone>12mm 🍂Tiny T2⬆ foci scattered throughout thickened junctional zone(1/2of cases) 🍂Diffuse / Focal Oxf#103 MZeba

MLCN ♀:♂ 9:1 ⚀ Multi-locular cystic, hair-like septa& minimal mural C+ ⚁ ➕capsule ⚂ ➕Extension into central renal sinus ⚃ ~classified: Bosniak III MZeba

#CTC RCC High Yield Points: ☄️Solid Tumor o f Adolescent ☄️Most common in 2nd decade ☄️Translocation Subtype = Prior chemotherapy ☄️Medullary Subtype = Sickle Cell Trait, ☄️Clear Cell Subtype = VHL (these RCCs are usually bilateral) ☄️Nephrographic phase: the most sensitive phase ☄️Hypervascular mets. ☄️Always lytic when they met to 🦴 ☄️RCCs with macroscopic fat nearly always have some calcification/ossification - if they don’t it’s probably an AML. ☄️RCC is typically COLDER ❄️ than surrounding renal parenchyma on PET (Source: Crack The Core) MZeba

Imaging Features for RCC: USG: 🌀Variable appearance (solid/cystic, hyper-/iso-/hypoechoic). 🌀Tumor pseudocapsule (hypoechoic halo) has low sensitivity (~20%), improved with harmonic scanning (~85%). 🌀Contrast-enhanced ultrasound shows hypervascularity with early washout. CT: 🌀Soft tissue attenuation (20-70 HU); ~30% show calcification. 🌀Variable enhancement in corticomedullary phase; nephrographic phase best for detecting abnormal enhancement. 🌀Assess vascular involvement (renal vein/IVC). MRI: 🌀T1: Heterogeneous (necrosis/hemorrhage). 🌀T2: Varies by subtype (e.g., clear cell hyperintense). 🌀Useful for staging, visualizing tumor pseudocapsule, and thrombus evaluation. Nuclear Medicine (FDG-PET): 🌀Limited for primary diagnosis due to physiological FDG excretion. 🌀Useful for postoperative surveillance and differentiating benign vs. tumor emboli. (Radiopedia) MZeba

Renal Papillary Necrosis: 🌀Necrosis and sloughing of papillary tissue, leading to significant renal function loss. 🌀The renal medulla and papilla are particularly prone to ischemic necrosis due to their blood supply and hypertonic environment. 🌀Radiographic Features: ➖Fluoroscopy/CT: Necrotic cavities in the papillae visible with contrast material. ➖Contrast-enhanced CT or IVP reveals small collections of contrast in the papillary regions. ➖Classical Signs: Ball on tee, lobster claw sign, signet ring, sloughed papilla with clubbed calyx. (Source: Radiopedia) MZeba