A CT scan of the chest was performed. What is the significant finding in the above CT scan?
A 29 year old female presented to the ER with a complaint of headache and right axillary fullness. The right axillary fullness had lasted for about 6 months and was slightly tender. She had not noticed any fevers, sweats, chills, appetite changes or pruritis. On exam, she was noted to have enlarged axillary lymph nodes in her right axilla.
Question 1 - Single Best Answer
Based on the above history and physical, what is in the differential diagnosis?
A) Non-Hodgkin's Lymphoma
B) Hodgkin's Lymphoma
C) Granulomatous infection
D) Metastatic adenopathy from breast cancer
E) all of the above
Question 2 - Single Best Answer
A CT scan of the chest was performed. What is the significant finding in the above CT scan?
A) right axillary adenopathy
B) left axillary adenopathy
Question 3 - Single Best Answer
A CT scan of the abdomen was also performed. What is the significant finding in the above CT scan?
A) enlarged spleen with multiple lesions
B) enlarged liver with multiple lesions
Question 4 - Single Best Answer
What is the next step in the workup of this patient?
A) core biopsy of the lymph node
B) MRI of the chest
Question 5 - Single Best Answer
Given the two images above (the chest and abdominal CT's), at what stage is her Hodgkin's lymphoma.
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A 20 yo female presents to the ER with shortness of breath, wheezing. She also reported a one year history of a dry cough. She denied weight loss, fever, or anorexia.
Question 6 - Single Best Answer
What is the significant finding on the above PA/LAT CXR?
A) widened mediastinum
B) Blunting of left costophrenic angle
Question 7 - Single Best Answer
What is the differential diagnosis for an anterior mediastinal mass?
A) Thyroid mass
B) Thymoma
C) Teratoma and germ cell neoplasms
D) Lymphoma
E) All of the above
Question 8 - Single Best Answer
What is the next step in the workup of this mediastinal mass?
A) MRI of the chest
B) Guided biopsy of the mass
C) Bronchoscopy with bronchial lavage for cytology
Question 9 - Single Best Answer
The patient underwent a guided biopsy of her anterior mediastinal mass. This diagnostic procedure resulted in a complication shown in the post procedure CXR and CT scan above. The arrows point to the complication. What is the complication?
A) Rib fracture
B) Seeding of tumor cells
C) Pneumothorax
D) Diffuse alveolar hemorrhage
A clinical pearl: when poking a needle through the chest wall, between ribs, remember to pass the needle above the rib. Remember from anatomy that the intercostal neurovascular structures run underneath the ribs.
Question 10 - Single Best Answer
The patient underwent treatment for her pneumothorax. This image demonstrates how she was treated. What is the significant finding? (Click on image for better view)
A) Chest tube placement
B) Dobhoff feeding tube placement
Clinical history: 60 yo female with a long history of Sjogren's syndrome presented with a 4 month history of intermittent fevers, weight loss and persistent cervical lymphadenopathy.
Question 11 - Single Best Answer
What is the significant finding on the above CT cross section?
A) Dissection in the aorta
B) Abdominal aortic aneurysm
C) Periaortic lymphadenopathy
D) Hypodensities in the spleen
Question 12 - Single Best Answer
The patient underwent needle biopsy of a cervical lymph node which gave the diagnosis of Non-Hodgkin's lymphoma. Thereafter, the patient received several courses of chemotherapy. Which of the following would be best to follow and restage her disease?
A) History and Physical exam
B) Ultrasound
C) MRI
D) CT
Question 13 - Single Best Answer
The patient underwent intensive chemotherapy treatment. After completion of her treatment she continued to have periodic body CT scans. What is the significant finding in the above post treatment image in comparison to her pre treatment image?
A) Unable to compare because the images are at different cross sectional levels.
B) Persistent retrocrural lymphadenopathy
C) Reduction of the periaortic lymphadenopathy
Clinical pearl: Patients with primary Sjogren's syndrome are at increased risk of developping lymphoma. In one study the incidence of lymphoma among Sjogren's patients was 2.5%. The relative risk of developing lymphoma was estimated to be greater than 40. Sjogren's syndrome is a chronic inflammatory disorder characterized by lymphocytic infiltration of the exocrine glands, ie. lacrimal and salivary glands.
Clinical history: 59 yo male with a history of chronic left abdominal pain.
Question 14 - Single Best Answer
What is the significant finding on the above CT image?
A) Enlarged spleen
B) Aortic Dissection
C) Perinephric soft tissue mass
D) Intraabdominal femur bone
The rest of the CT scan revealed that the soft tissue mass extends from the left inguinal canal up to the LUQ, encasing not only the left kidney, but also the pancreas, left adrenal gland, and the left renal artery and vein. There were no other significant findings. Biopsy of the mass revealed diffuse large cell Non Hodgkin's Lymphoma.
Question 15 - Single Best Answer
Which of the following best describes the location of the patient's disease?
A) The lymphoma is found in an extranodal location.
B) The lymphoma is found in the left kidney.