FMGE 2023 — Radiology

Q: In the given barium swallow image, which of the following shows the left atrium impression on the esophagus?

3. ***Correct: Option 3*** - This pointer correctly identifies the impression on the esophagus caused by the **left atrium**, which is the most posterior chamber of the heart. - An enlarged left atrium, often seen in conditions like **mitral stenosis**, can cause a prominent posterior indentation on the esophagus at this level. - The left atrium impression is typically seen at the level of T4-T6 vertebrae on barium swallow studies. *Incorrect: None of them* - This option is incorrect as the image clearly shows normal anatomical impressions on the esophagus, and pointer 3 correctly identifies the left atrial impression. - A barium swallow is a standard radiological procedure to visualize these impressions from adjacent cardiovascular structures. *Incorrect: Option 1* - This pointer indicates the impression of the **aortic arch**, which is the first and most superior indentation seen on a lateral or oblique view of a barium swallow. - The aortic arch crosses the esophagus on its left side at approximately T4 level, creating a distinct notch as it arches posteriorly. *Incorrect: Option 2* - This pointer shows the impression made by the **left main bronchus** as it crosses anterior to the esophagus. - This indentation is located inferior to the aortic arch impression at approximately T5 level and is typically less pronounced than the aortic or left atrial impressions. [Practice more Radiology PYQs on OnCourse]

Q: Ground-glass appearance on HRCT is seen in which of the following conditions?

Silicosis. ***Silicosis***- While simple silicosis shows small, **fibrotic nodules**, acute or accelerated silicosis (**silicoproteinosis**) often presents with diffuse alveolar filling and inflammation, which manifests radiologically as prominent **ground-glass opacities** on HRCT.- Ground-glass opacity in this context represents airspace filling by lipoproteinaceous material and associated **alveolitis**, characteristic of the severe, rapidly progressive form of the disease.*Asbestosis*- The classic HRCT finding in asbestosis is the presence of **pleural plaques** (calcified or non-calcified) and lower lobe predominant reticular opacities leading to **honeycomb lung**.- Ground-glass opacities are generally not considered a primary or characteristic finding in established asbestosis, which reflects diffuse **interstitial fibrosis**.*Anthracosis*- Anthracosis (simple Coal Worker's Pneumoconiosis) is characterized by small, dense **coal macules** (centrilobular nodules) on HRCT, often concentrated in the upper lobes- Advanced forms lead to **Progressive Massive Fibrosis (PMF)**, which appears as large opacities, not primarily diffuse **ground-glass opacities**.*Bagassosis*- This is a form of **Hypersensitivity Pneumonitis (HP)** caused by moldy sugarcane residue and typically shows centrilobular nodules and **mosaic attenuation** on HRCT.- Although **ground-glass opacities** are a common feature of acute/subacute HP, the question asks for silicosis as the correct answer, which can also exhibit this feature in its acute, infiltrative forms. [Practice more Radiology PYQs on OnCourse]

Q: A patient who was diagnosed with prostate cancer is being investigated. The bone scan is reported as a super scan with increased uptake in the bones and reduced activity in the spleen. What is the reason for this super scan appearance?

Increased uptake due to diffuse metastasis. ***Increased uptake due to diffuse metastasis***- The **super scan** appearance is pathognomonic for **widespread skeletal metastasis**, particularly common in advanced prostate cancer, where nearly all the tracer is utilized by diffuse bony lesions.- The reduced or absent visualization of soft tissues (like the **spleen**, **kidneys**, and **bladder**) results from the extremely high proportion of the radiotracer being extracted by the vast surface area of the metastatic bone lesions.*Increased uptake by carcinoma prostate*- Bone scans (using Tc-99m MDP) primarily reflect **osteoblastic activity** in bone, not the direct uptake by the primary non-osseous tumor tissue in the prostate.- While uptake might occasionally be seen in the primary tumor due to adjacent bony involvement or calcification, this is not the cause of the diffuse **super scan** pattern across the entire skeleton.*Increased uptake by the bone*- While the super scan is characterized by increased uptake in the bone, this statement fails to detail the underlying pathological *reason*, which is the widespread **diffuse skeletal metastasis**.- Normal physiological uptake by bone would not lead to the non-visualization of the **kidneys** and **spleen**, which is a crucial defining feature of the super scan.*Decreased uptake by adrenal glands and kidney*- The non-visualization (or decreased uptake) in soft tissue organs, including the **kidneys**, is a *consequence* of the super scan pattern, not the underlying cause of the appearance.- The primary mechanism is the massive tracer uptake in the skeleton due to **diffuse pathological activity**, leaving insufficient free tracer for normal soft tissue background and excretion. [Practice more Radiology PYQs on OnCourse]

Q: A 55-year-old male patient presents with hematuria and a mass in the left kidney on a CT scan, as shown below. What is the diagnosis?

Renal angiomyolipoma. ***Renal angiomyolipoma*** - This is a benign renal tumor composed of three tissue types: blood vessels (**angio**), smooth muscle (**myo**), and fat (**lipoma**). The presence of macroscopic fat on a CT scan is a key diagnostic feature. - Patients can be asymptomatic or present with **hematuria** or flank pain, particularly if the tumor is large. There is a strong association with **tuberous sclerosis**. *Renal cell carcinoma* - This is the most common malignant kidney tumor in adults, often presenting with **hematuria**, flank pain, and a palpable mass (the classic triad). - On imaging, it typically appears as a heterogeneously enhancing solid mass and crucially, **lacks macroscopic fat**, which helps differentiate it from an angiomyolipoma. *Renal oncocytoma* - This is a benign epithelial tumor that can be difficult to distinguish from renal cell carcinoma on imaging alone. - It may show a characteristic **central stellate scar** on contrast-enhanced CT, but it does not contain significant fat tissue. *Renal cyst* - A simple renal cyst appears on CT as a well-defined, thin-walled, non-enhancing lesion filled with fluid of **water density**. - The image and description indicate a solid, **neovascular mass**, which is inconsistent with the avascular nature of a simple cyst. [Practice more Radiology PYQs on OnCourse]

Q: Which of the following is the best imaging modality to diagnose neuroendocrine tumors (NETs)?

PET. ***PET***- **PET** imaging, particularly using tracers like **Gallium-68 DOTATATE** or **DOTATOC**, is the best modality because it targets the **somatostatin receptors (SSTr)** highly expressed on most well-differentiated neuroendocrine tumors (NETs).- This molecular imaging technique offers the highest **sensitivity and specificity** for identifying the primary tumor, effectively staging the disease, detecting occult metastases, and assessing therapeutic response.*USG*- **Ultrasound (USG)** is often limited to screening the abdominal organs (like the liver or pancreas) but lacks the anatomical comprehensiveness and sensitivity required for definitive staging of systemic NET disease.- Its performance is highly **operator-dependent**, and it is generally poor for evaluating deeply located tumors or detecting **pulmonary** or **osseous** involvement.*CT*- **CT scans** provide excellent anatomical information, are essential for tumor size measurement (using **RECIST criteria**), and are often used as the anatomical backbone to complement functional imaging like PET/CT.- However, CT relies on structural changes (size and density) and is significantly **less sensitive** than somatostatin receptor PET for finding small primary tumors or widespread, metabolically active metastases.*MRI*- **MRI** offers superior soft tissue contrast compared to CT, making it highly valuable, especially for evaluating complex areas like the **liver parenchyma** for metastatic disease or specific NETs (e.g., pancreatic NETs).- Like CT, MRI is a structural modality and fails to provide the **functional information** that PET offers regarding the presence and density of **somatostatin receptors**, limiting its use for overall tumor burden assessment and staging compared to PET. [Practice more Radiology PYQs on OnCourse]

12 Previous Year Questions with Answers & Explanations

Questions

In the given barium swallow image, which of the following shows the left atrium impression on the esophagus?

Ground-glass appearance on HRCT is seen in which of the following conditions?

A patient who was diagnosed with prostate cancer is being investigated. The bone scan is reported as a super scan with increased uptake in the bones and reduced activity in the spleen. What is the reason for this super scan appearance?

A 55-year-old male patient presents with hematuria and a mass in the left kidney on a CT scan, as shown below. What is the diagnosis?

Which of the following is the best imaging modality to diagnose neuroendocrine tumors (NETs)?

A 30-year-old woman presented with complaints of bone pain and abdominal cramps. Her family says she has a history of abnormal behavior. The consultant doctor arrived at a provisional diagnosis based on the clinical features. Which of the following would be the best investigation to arrive at a definitive diagnosis?

A cancer patient undergoing radiotherapy is given a dose of 1.8 to 2 Gy once daily for 5 days per week for a duration of 6 to 8 weeks. What is this type of radiotherapy called?

Identify the rib highlighted in the X-ray.

Whole-body CT scan protocol for a trauma patient includes all, except

Q10

Identify the part of the bowel in the barium study given below.

FMGE 2023 - Radiology FMGE Practice Questions and MCQs

Question 1: In the given barium swallow image, which of the following shows the left atrium impression on the esophagus?

A. None of them
B. 1
C. 2
D. 3 (Correct Answer)

Explanation: ***Correct: Option 3*** - This pointer correctly identifies the impression on the esophagus caused by the **left atrium**, which is the most posterior chamber of the heart. - An enlarged left atrium, often seen in conditions like **mitral stenosis**, can cause a prominent posterior indentation on the esophagus at this level. - The left atrium impression is typically seen at the level of T4-T6 vertebrae on barium swallow studies. *Incorrect: None of them* - This option is incorrect as the image clearly shows normal anatomical impressions on the esophagus, and pointer 3 correctly identifies the left atrial impression. - A barium swallow is a standard radiological procedure to visualize these impressions from adjacent cardiovascular structures. *Incorrect: Option 1* - This pointer indicates the impression of the **aortic arch**, which is the first and most superior indentation seen on a lateral or oblique view of a barium swallow. - The aortic arch crosses the esophagus on its left side at approximately T4 level, creating a distinct notch as it arches posteriorly. *Incorrect: Option 2* - This pointer shows the impression made by the **left main bronchus** as it crosses anterior to the esophagus. - This indentation is located inferior to the aortic arch impression at approximately T5 level and is typically less pronounced than the aortic or left atrial impressions.

Question 2: Ground-glass appearance on HRCT is seen in which of the following conditions?

A. Bagassosis
B. Anthracosis
C. Asbestosis
D. Silicosis (Correct Answer)

Explanation: ***Silicosis***- While simple silicosis shows small, **fibrotic nodules**, acute or accelerated silicosis (**silicoproteinosis**) often presents with diffuse alveolar filling and inflammation, which manifests radiologically as prominent **ground-glass opacities** on HRCT.- Ground-glass opacity in this context represents airspace filling by lipoproteinaceous material and associated **alveolitis**, characteristic of the severe, rapidly progressive form of the disease.*Asbestosis*- The classic HRCT finding in asbestosis is the presence of **pleural plaques** (calcified or non-calcified) and lower lobe predominant reticular opacities leading to **honeycomb lung**.- Ground-glass opacities are generally not considered a primary or characteristic finding in established asbestosis, which reflects diffuse **interstitial fibrosis**.*Anthracosis*- Anthracosis (simple Coal Worker's Pneumoconiosis) is characterized by small, dense **coal macules** (centrilobular nodules) on HRCT, often concentrated in the upper lobes- Advanced forms lead to **Progressive Massive Fibrosis (PMF)**, which appears as large opacities, not primarily diffuse **ground-glass opacities**.*Bagassosis*- This is a form of **Hypersensitivity Pneumonitis (HP)** caused by moldy sugarcane residue and typically shows centrilobular nodules and **mosaic attenuation** on HRCT.- Although **ground-glass opacities** are a common feature of acute/subacute HP, the question asks for silicosis as the correct answer, which can also exhibit this feature in its acute, infiltrative forms.

Question 3: A patient who was diagnosed with prostate cancer is being investigated. The bone scan is reported as a super scan with increased uptake in the bones and reduced activity in the spleen. What is the reason for this super scan appearance?

A. Increased uptake due to diffuse metastasis (Correct Answer)
B. Increased uptake by carcinoma prostate
C. Decreased uptake by adrenal glands and kidney
D. Increased uptake by the bone

Explanation: ***Increased uptake due to diffuse metastasis***- The **super scan** appearance is pathognomonic for **widespread skeletal metastasis**, particularly common in advanced prostate cancer, where nearly all the tracer is utilized by diffuse bony lesions.- The reduced or absent visualization of soft tissues (like the **spleen**, **kidneys**, and **bladder**) results from the extremely high proportion of the radiotracer being extracted by the vast surface area of the metastatic bone lesions.*Increased uptake by carcinoma prostate*- Bone scans (using Tc-99m MDP) primarily reflect **osteoblastic activity** in bone, not the direct uptake by the primary non-osseous tumor tissue in the prostate.- While uptake might occasionally be seen in the primary tumor due to adjacent bony involvement or calcification, this is not the cause of the diffuse **super scan** pattern across the entire skeleton.*Increased uptake by the bone*- While the super scan is characterized by increased uptake in the bone, this statement fails to detail the underlying pathological *reason*, which is the widespread **diffuse skeletal metastasis**.- Normal physiological uptake by bone would not lead to the non-visualization of the **kidneys** and **spleen**, which is a crucial defining feature of the super scan.*Decreased uptake by adrenal glands and kidney*- The non-visualization (or decreased uptake) in soft tissue organs, including the **kidneys**, is a *consequence* of the super scan pattern, not the underlying cause of the appearance.- The primary mechanism is the massive tracer uptake in the skeleton due to **diffuse pathological activity**, leaving insufficient free tracer for normal soft tissue background and excretion.

Question 4: A 55-year-old male patient presents with hematuria and a mass in the left kidney on a CT scan, as shown below. What is the diagnosis?

A. Renal cell carcinoma
B. Renal oncocytoma
C. Renal angiomyolipoma (Correct Answer)
D. Renal cyst

Explanation: ***Renal angiomyolipoma*** - This is a benign renal tumor composed of three tissue types: blood vessels (**angio**), smooth muscle (**myo**), and fat (**lipoma**). The presence of macroscopic fat on a CT scan is a key diagnostic feature. - Patients can be asymptomatic or present with **hematuria** or flank pain, particularly if the tumor is large. There is a strong association with **tuberous sclerosis**. *Renal cell carcinoma* - This is the most common malignant kidney tumor in adults, often presenting with **hematuria**, flank pain, and a palpable mass (the classic triad). - On imaging, it typically appears as a heterogeneously enhancing solid mass and crucially, **lacks macroscopic fat**, which helps differentiate it from an angiomyolipoma. *Renal oncocytoma* - This is a benign epithelial tumor that can be difficult to distinguish from renal cell carcinoma on imaging alone. - It may show a characteristic **central stellate scar** on contrast-enhanced CT, but it does not contain significant fat tissue. *Renal cyst* - A simple renal cyst appears on CT as a well-defined, thin-walled, non-enhancing lesion filled with fluid of **water density**. - The image and description indicate a solid, **neovascular mass**, which is inconsistent with the avascular nature of a simple cyst.

Question 5: Which of the following is the best imaging modality to diagnose neuroendocrine tumors (NETs)?

A. MRI
B. PET (Correct Answer)
C. CT
D. USG

Explanation: ***PET***- **PET** imaging, particularly using tracers like **Gallium-68 DOTATATE** or **DOTATOC**, is the best modality because it targets the **somatostatin receptors (SSTr)** highly expressed on most well-differentiated neuroendocrine tumors (NETs).- This molecular imaging technique offers the highest **sensitivity and specificity** for identifying the primary tumor, effectively staging the disease, detecting occult metastases, and assessing therapeutic response.*USG*- **Ultrasound (USG)** is often limited to screening the abdominal organs (like the liver or pancreas) but lacks the anatomical comprehensiveness and sensitivity required for definitive staging of systemic NET disease.- Its performance is highly **operator-dependent**, and it is generally poor for evaluating deeply located tumors or detecting **pulmonary** or **osseous** involvement.*CT*- **CT scans** provide excellent anatomical information, are essential for tumor size measurement (using **RECIST criteria**), and are often used as the anatomical backbone to complement functional imaging like PET/CT.- However, CT relies on structural changes (size and density) and is significantly **less sensitive** than somatostatin receptor PET for finding small primary tumors or widespread, metabolically active metastases.*MRI*- **MRI** offers superior soft tissue contrast compared to CT, making it highly valuable, especially for evaluating complex areas like the **liver parenchyma** for metastatic disease or specific NETs (e.g., pancreatic NETs).- Like CT, MRI is a structural modality and fails to provide the **functional information** that PET offers regarding the presence and density of **somatostatin receptors**, limiting its use for overall tumor burden assessment and staging compared to PET.

Question 6: A 30-year-old woman presented with complaints of bone pain and abdominal cramps. Her family says she has a history of abnormal behavior. The consultant doctor arrived at a provisional diagnosis based on the clinical features. Which of the following would be the best investigation to arrive at a definitive diagnosis?

A. MRI
B. Ultrasonogram
C. Sestamibi scan (Correct Answer)
D. CT scan

Explanation: ***Sestamibi scan*** - The clinical features (bone pain, abdominal cramps, abnormal behavior being "bones, groans, and psychic moans") strongly suggest **primary hyperparathyroidism** due to hypercalcemia, which requires definitive localization of the culprit adenoma. - The **Technetium-99m Sestamibi scan** is the best definitive investigation because it is a functional imaging study that specifically identifies hyperactive parathyroid tissue, showing increased, persistent uptake relative to the thyroid gland. *MRI* - MRI is primarily a **structural imaging** modality and is usually reserved for cases where initial localization studies (like Sestamibi and Ultrasound) are equivocal or to assess for **ectopic parathyroid tissue** located deep in the neck or mediastinum. - It lacks the high **functional specificity** of the Sestamibi scan required to definitively confirm that the identified mass is the hyperfunctioning parathyroid adenoma. *Ultrasonogram* - Ultrasound is often the **initial screening tool** for identifying parathyroid adenomas in the neck, being easily accessible and inexpensive, but it is **operator-dependent**. - It is not considered the single best definitive test because it often fails to localize small, posterior, or **ectopic adenomas** and provides only structural, not functional, information about the gland. *CT scan* - CT scans provide excellent **anatomical detail** and are helpful in complex cases or for locating mediastinal/ectopic glands, especially when planning highly focused surgery. - Like MRI, CT is a structural study that identifies masses but does not definitively prove the **hyperfunctionality** specific to parathyroid adenomas, making Sestamibi superior for definitive diagnosis.

Question 7: A cancer patient undergoing radiotherapy is given a dose of 1.8 to 2 Gy once daily for 5 days per week for a duration of 6 to 8 weeks. What is this type of radiotherapy called?

A. Hyper fractionated radiotherapy
B. Brachytherapy
C. Regular Fractionated radiotherapy (Correct Answer)
D. Accelerated fractionation radiotherapy

Explanation: ***Regular Fractionated radiotherapy***- This schedule uses biologically effective doses typically between **1.8 to 2.0 Gy** delivered once per day, 5 days per week, which is the standard of care for many cancers.- This conventional fractionation regimen allows for optimal **tumor cell kill** while providing sufficient time for normal tissues to repair sublethal damage between fractions (the principle of **Repair**).*Hyper fractionated radiotherapy*- This involves giving smaller doses per fraction (typically **<1.8 Gy**) delivered **more than once a day**.- The goal is often to reduce **late toxicities** to normal tissues while sometimes escalating the total dose delivered.*Accelerated fractionation radiotherapy*- This approach delivers the total treatment dose over a **significantly shorter overall treatment time** than standard fractionation, often involving multiple fractions per day or higher daily doses.- It is primarily used to counteract the effects of **accelerated tumor cell repopulation** during the course of treatment.*Brachytherapy*- This is a type of radiotherapy where the radiation source (sealed isotopes) is placed **inside or next to the tumor** (internal radiation), which is a delivery technique, not an external fractionation schedule.- It can be delivered as **High Dose Rate (HDR)** or **Low Dose Rate (LDR)** therapy.

Question 8: Identify the rib highlighted in the X-ray.

A. 3rd rib posterior part (Correct Answer)
B. 4th rib anterior part
C. 3rd rib anterior part
D. 1st rib anterior part

Explanation: ***3rd rib posterior part*** - On a posteroanterior (PA) chest X-ray, the **posterior ribs** are more prominent and have a more horizontal orientation as they articulate with the thoracic vertebrae, which matches the highlighted structure. - When counting from the top, the first rib is the highest and most curved. The highlighted rib is clearly the third one down from the apex of the thorax, confirming it as the **3rd posterior rib**. *3rd rib anterior part* - The **anterior parts** of the ribs are more difficult to visualize and course downwards and medially towards the sternum. The highlighted rib is oriented horizontally. - Anterior ribs connect to the sternum via **costal cartilage**, which is not as radiopaque as bone and thus appears less distinct on an X-ray than the highlighted structure. *4th rib anterior part* - This option is incorrect as the highlighted structure is a **posterior rib**, not an anterior one, based on its orientation. - Additionally, counting reveals the rib to be the third, not the fourth. The **fourth rib** would be located inferior to the highlighted one. *1st rib anterior part* - The **1st rib** is the most superior and has a very sharp curvature, often partially obscured by the clavicle. The highlighted rib is located below the first and second ribs. - This is also incorrect because the image highlights the **posterior aspect** of a rib, not the anterior aspect.

Question 9: Whole-body CT scan protocol for a trauma patient includes all, except

A. d.CT Abdomen
B. c.CT Limbs (Correct Answer)
C. b.CT Cervical spine
D. a.CT Head

Explanation: ***c.CT Limbs***- Whole-body CT in **polytrauma** focuses on detecting time-critical injuries in the **trunk** and **head** (head, chest, abdomen/pelvis, and spine). - Routine inclusion of **CT Limbs** is not standard unless there is specific clinical suspicion of a major fracture or vascular injury based on physical examination. *a.CT Head* - Essential for rapidly excluding **intracranial hemorrhage**, **subdural/epidural hematomas**, or significant **traumatic brain injury (TBI)**, which are major causes of trauma mortality. - Typically performed first in the whole-body protocol to assess the most immediately life-threatening injuries. *b.CT Cervical spine* - Crucial for identifying potentially unstable **spinal fractures** or **ligamentous injuries** that require immediate management and prevent secondary neurological injury. - High-energy trauma mandates comprehensive assessment of the **cervical spine** as part of the primary survey protocol. *d.CT Abdomen* - Necessary for detecting **solid organ injury** (e.g., liver, spleen lacerations) and **intraperitoneal/retroperitoneal hemorrhage**, which are common sources of **exsanguination** and shock. - The abdominal scan usually extends to include the **pelvis** to assess for **pelvic fractures** and associated bleeding.

Question 10: Identify the part of the bowel in the barium study given below.

A. Jejunum (Correct Answer)
B. Transverse colon
C. Ileum
D. Splenic flexure

Explanation: ***Jejunum*** - The barium study shows prominent, closely packed mucosal folds, known as **plicae circulares** (or valvulae conniventes), which create a characteristic **'feathery'** or **'stack of coins'** appearance distinctive to the jejunum. - Anatomically, the jejunum is primarily located in the **left upper quadrant** of the abdomen and has a wider diameter and thicker wall than the ileum, consistent with the radiographic findings. *Ileum* - The ileum has fewer, sparser, and less prominent **plicae circulares**, resulting in a smoother, more **'featureless'** appearance on a barium study compared to the jejunum. - It is typically located in the **right lower quadrant** of the abdomen, terminating at the ileocecal valve. *Transverse colon* - The transverse colon is part of the large intestine and is identified by its **haustra**, which are sacculations that give it a segmented appearance, not the fine, feathery pattern of the small bowel. - It generally has a larger caliber than the small intestine and is positioned more superiorly in the abdomen, spanning from the hepatic flexure to the splenic flexure. *Splenic flexure* - The splenic flexure is the sharp turn between the transverse colon and the descending colon, and like the rest of the colon, it would display **haustral markings**. - It is located high in the **left upper quadrant**, superior to where the jejunal loops are typically found.