Figure 1A
32. You are shown a PA chest radiograph and CT image (Figures 1A and 1B) from a 51-year-old man with shortness of breath. What is the MOST LIKELY diagnosis? A. B. C. D. Pulmonary alveolar proteinosis Cardiogenic pulmonary edema Idiopathic pulmonary fibrosis Pneumocystis carinii pneumonia
Figure 1B
Figure 2A
33. You are shown two images from a high-resolution CT (Figures 2A and 2B) of the chest of a 40year-old female smoker with a 1-year history of increasing shortness of breath. What is the MOST LIKELY diagnosis? A. B. C. D. Centrilobular emphysema Lymphangioleiomyomatosis Langerhans cell histiocytosis Lymphocytic interstitial pneumonia
Figure 2B
Figure 3A
Figure 3B
7 American College of Radiology
Figure 3C
34. You are shown three CT images (Figures 3A, 3B, and 3C) of a 59-year-old man with cough and stridor. What is the MOST LIKELY diagnosis? A. B. C. D. Squamous cell papilloma Carcinoid Adenoid cystic carcinoma Tracheobronchopathia osteochondroplastica
Figure 4
35. You are shown a CT image (Figure 4) of a 63-year-old man who underwent heart transplantation for ischemic cardiomyopathy two years ago. What is the MOST LIKELY diagnosis? A. B. C. D. Bronchiolitis obliterans Post-transplant lymphoproliferative disease Cryptogenic organizing pneumonia Bronchogenic carcinoma
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Figure 5A
Figure 5B
36. You are shown a CT image (Figure 5A) and two images from an F-18 FDG (fluorodeoxyglucose) PET scan (Figure 5B) of a 71-year-old man. What is the MOST LIKELY diagnosis? A. B. C. D. Benign nodule Stage I lung cancer Stage II lung cancer Stage IV lung cancer
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D. Correct. The adrenal gland is one of the most common sites of metastasis from bronchogenic carcinoma and may be seen in otherwise Stage I disease. This tumor is T1N0M1 or Stage IV.
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Figure 6
37. You are shown a PA chest radiograph (Figure 6) of a 54-year-old woman with shortness of breath and cough. What is the MOST LIKELY diagnosis? A. B. C. D. Miliary tuberculosis Pulmonary alveolar microlithiasis Lymphangitic carcinomatosis Idiopathic pulmonary hemosiderosis
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Question #39 Rationales: A is Correct. Fibrosing mediastinitis is a rare disorder characterized by chronic inflammation and fibrosis of mediastinal soft tissues. There are many causes of fibrosing mediastinitis. The most frequently implicated process is infection, of which Histoplasma capsulatum is the most common cause. Complications of fibrosis within the mediastinum lead to encasement and compression of mediastinal structures. Those that are particularly involved include superior vena cava, trachea and bronchi, and pulmonary artery and veins. Aorta and great vessel involvement is extremely rare. B, C and D are Incorrect.
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Question #40 Rationales: A. Incorrect. See correct answer. B. Incorrect. See correct answer. C. Incorrect. See correct answer. D. Correct. According to the inverse square law, if the exposure-rate from a source is X1 at distance d1, the exposure rate X2 at another distance d2 will be X2=X1(d1/d2)2. Therefore, Increasing the SID requires an increased output from the X-ray tube. Using the inverse square law, you have two equations, (Xpatient90/X90)=(d90/d65)2 and (Xpatient120/X120)=(d120/d65)2. A constant dose rate is necessary at the image intensifier at any SID since auto brightness control is being used so X90=X120. So when you plug this into the equations and rearrange, you get (Xpatient120/Xpatient90)=(120/90)2 1.8.
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Question #41 Rationales: A, B and D are Incorrect. C is Correct. Small cell carcinoma is a form of lung cancer. It accounts for 15 20% of all lung cancers. It is characterized by rapid growth, early metastasis and extremely poor prognosis. It is associated with paraneoplastic syndromes, including Cushings syndrome and inappropriate ADH secretion. Inappropriate ADH secretion results in hyponatremia. Hypoglycemia, Brachial plexopathy and pupillary constriction are not clinical features of small cell carcinoma. The most common tumor responsible for hypoglycemia in the thorax is Solitary fibrous tumor of the pleura. Brachial plexopathy and pupillary constriction are more likely to occur with superior sulcus tumor.
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Question #42 Rationales: A, B and C are Incorrect. D is Correct. Pulmonary venoocclusive disorder is a rare disorder characterized by obliteration of small pulmonary veins. This leads to pulmonary hypertension. The causes are many and include viral infections, inhaled toxins and immune complex deposition within the lung to name a few. Diagnosis is suggested in a patient with pulmonary hypertension when radiographic features demonstrate enlarged pulmonary arteries, diffuse interstitial edema and small to normal sized left atrium.
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Question #43 Rationales: A, B and C are Incorrect. D is Correct. Kerley B lines are short horizontal lines that are visible on chest radiograph adjacent to the costophrenic sulcus. They are approximately 1 to 2 cm long and are noted to extend to the pleural surface. They represent thickened interlobular septa and are visible in patients with lymphangitic carcinomatosis and pulmonary edema.
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Question #44 Rationales: A. Incorrect B. Correct. Tear in the diaphragm results in herniation of viscera (bowel and solid organs) into the thoracic cavity. As the injured diaphragm no longer supports these structures posteriorly, they fall to a dependent position against the posterior ribs. Hence, the dependent viscera sign is observed in patients with diaphragmatic injury when they lie supine for a CT scan. C. Incorrect D. Incorrect
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Question #45 Rationales: A. Incorrect. Boerhaaves syndrome represents perforation of esophagus following severe episodes of vomiting. In this instance, pneumomediastinum rather than pneumothorax is the expected consequence. B. Incorrect. Recurrent pneumothorax may be associated with chronic infiltrative lung disease of any cause, but the prevalence is particularly high in two diseases; Langerhans cell histiocytosis (histiocytosis x) and lymphangioleiomyomatosis. Both of these entities are characterized by the presence of multiple lung cysts which may rupture through the visceral pleura causing a complicating pneumothorax. However, pneumothorax may be seen as a complication of the late stages of other types of infiltrative lung diseases that are associated with fibrosis and honeycombing. Desquamative interstitial pneumonia is not characterized by the presence of cysts. High resolution CT frequently demonstrates ground glass and alveolar opacities more marked in the mid and lower lung zones. Fibrosis and honeycombing are not features and the disease responds to steroid therapy. C. Correct. Malignant neoplasms, particularly metastatic sarcoma, are occasional causes of spontaneous pneumothorax. The most common tumor type is metastatic osteogenic sarcoma. The mechanism for the development of pneumothorax is not clear, but it may be related to the presence of cavitation and subsequent rupture into the pleural space. The presence of a spontaneous pneumothorax in a child in the setting of a primary osteogenic sarcoma should prompt a CT examination to search for the presence of metastatic disease. D. Incorrect. Pneumothorax which is unresponsive to chest tube drainage can be a feature of a ruptured bronchus which is sustained following blunt trauma usually in high speed motor vehicle accidents. However, the rupture must occur at a site in the bronchus which is contained within the mediastinal pleura. Thus tears close to the carina produce pneumomediastinum rather than pneumothorax.
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Question #46 Rationales: A. Incorrect. Bronchiectasis-- identified as parallel lines or as ring shadows larger than the accompanying pulmonary arteryusually is widespread on radiographs but tends to affect mainly the upper lobes. B. Correct. True statement. The Sweat Test is one of the ways that diagnosis of Cystic fibrosis is made. C. Incorrect. Cystic fibrosis is a relatively common hereditary disorder of recessive transmission. The disease is the most common lethal genetically transmitted disease among whites with an estimated incidence in this group of 1 per 2,000 to 3,000 live births. D. Incorrect. Hyperinflation is seen in about 80% of adult patients and tends to involve mainly the lower lobes.
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Question #47 Rationales: A, B and C are Incorrect. D is correct. Solitary pulmonary nodule is defined as a well circumscribed round or oval lesion measuring less than 3 cm in diameter. About half of the lesion are proven to be benign, about 40% are proven to be primary lung carcinoma and only about 10% are proven to be metastasis. A number of criteria have been described to help differentiate benign from malignant nodules. However, none have proven to be of very specific except presence of fat is suggestive of a benign lesion. Also, benign lesions have a doubling time of less than 1 month or greater than 16 months. Thus, nodules that are stable for over a 2 year period are considered benign.
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Question #49 Rationales: A. Incorrect. Bilateral hilar and right paratracheal adenopathy is common. Anterior mediastinal adenopathy / mass usually signify Lymphoma or Thymoma. B. Incorrect. The disease in sarcoidosis tends to be predominantly upper lobe in distribution. C. Correct. Peribronchovascular or perilymphatic nodules are typically seen in patients with sarcoidosis. Nodules in sarcoidosis are also noted in the subpleural location and along the interlobular septa. D. Incorrect. Random nodules usually represent hematogenous metastasis or miliary infection, such as Tuberculosis.
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Question #50 Rationales: A. Incorrect. B. Incorrect. The left superior vena cava drains into the right atrium via the coronary sinus. C. Incorrect. The sinus of Valsalva is at the root of the aorta. D. Correct. The left superior vena cava (SVC) drains into the right atrium via the coronary sinus. A left-sided SVC, a normal anatomic variant, is found in 0.3% of normal individuals. 80% of such individuals also have a right-sided SVC and 60% have a left BCV connecting to the right and left SVCs.
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Question #51 Rationales: B & D ARE BOTH CORRECT A. Incorrect. Blood eosinophilia is not necessary to make the diagnosis of eosinophilic lung disease. The term pulmonary eosinophilia, synonymous with pulmonary infiltration with eosinophilia, describes a group of diseases in which blood and/or tissue eosinophilia affects major airways and lung parenchyma. B. Correct. True statement. Eosinophilic lung diseases are a group of pulmonary disorders that are characterized by abundant eosinophils in the pulmonary opacities. They are classified into groups with and without a specific cause. The specific causes include drugs, such as sulfonamides, parasites, and fungi. C. Incorrect. Chronic eosinophilic pneumonia has classic radiographic and chest CT findings of peripheral, nonsegmental, homogenous alveolar opacities, often with air bronchograms. D. Correct. Lofflers syndrome is characterized by blood eosinophilia, absence of or mild symptoms and signs (cough, fever, and dyspnea), one or more nonsegmental mixed interstitial and alveolar pulmonary opacities that are transitory or migratory, and spontaneous clearing of the opacities.
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Question #53 Rationales: A, C and D are incorrect. B is correct. Allergic bronchopulmonary aspergillosis is a complex hypersensitivity reaction to aspergillus organisms colonizing the bronchial lumen. The inflammatory reaction results in cellular infiltration and release of proteolytic enzymes which produce tissue damage in the bronchial wall. Excessive mucus production leads to mucoid impaction of the airways. The radiographic hallmark is central bronchiectasis. Air-crescent sign, pleural thickening, and halo sign are not features of allergic bronchopulmonary aspergillosis.
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Question #54 Rationales: A. Incorrect. It is a necrotizing vasculitis that is characterized clinically by asthma, fever and eosinophilia. Radiographic manifestation includes bilateral patchy consolidations but not air-trapping. B. Incorrect. It is an autoimmune disorder of unknown etiology that is characterized by repeated episodes of pulmonary hemorrhage. No air-trapping is noted. C. Incorrect. Also known as congenital pulmonary venolobar syndrome. It is a congenital anomaly that consists of hypoplasia of the right lung and the right pulmonary artery. There is anomalous venous drainage of the right lung into systemic venous system, usually below the diaphragm into the inferior vena cava. No air-trapping is noted. D. Correct. The syndrome is believed to be initiated by a viral bronchiolitis in childhood. It is characterized by hyperlucent lobe or lung. The hyperlucency is due to bronchiolar obliteration and this results in air-trapping on expiratory CT scan.
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Question #55 Rationales: C. Correct. Bronchogenic cysts are congenital lesions that result from an abnormality of budding of the tracheobronchial tree during embryologic development. They are most commonly found in the subcarinal location and thus there presence in this location will cause obliteration of the azygoesophageal interface. Azygoesophageal interface is formed by the interposition of the aerated lung and the lateral wall of the azygous vein and esophagus. A, B and D Incorrect. Anterior and Posterior junction lines are longitudinal opacities that are formed by the close apposition of the visceral and parietal layers of the pleura of both the lungs as they come together anteriorly and posteriorly to the mediastinum. Descending aortic interface is formed by the juxtaposition of the aerated lung and the soft tissue of the left lateral margin of the descending thoracic aorta.
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Question #56 Rationales: A. Incorrect. Very common in the later stages of asbestosis. B. Incorrect. Upper lung nodules are typical of silicosis and granulomatous disease, not asbestosis. C. Incorrect. This is the most common early manifestation of asbestosis and is best demonstrated by high resolution CT. With time, these progress to a coarse reticular pattern. D. Correct. Pleural plaques and pleural effusions are common findings in asbestosis.
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Question #57 Rationales: A. Incorrect B. Correct. It is situated between the aortic arch and the left pulmonary artery. The space contains mediastinal fat, ductus ligament, nodes and the left recurrent laryngeal nerve. Thus, mass in this location can involve the left recurrent laryngeal nerve resulting in vocal cord abnormalities, including hoarseness. C. Incorrect D. Incorrect
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