Lymphangiography — MCQs

10 questions

Which of the following group of lymph nodes does NOT receive direct lymphatic drainage from the perineum?

During rounds, your senior was discussing the given image. Which of the following investigations does this image represent?

Gadolinium is a contrast agent used for:

A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

Identify the condition given in the image below?

Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

To obtain adequate diagnostic imaging in a morbidly obese patient, what modification to X-ray technique is most important?

Which is the investigation of choice for fat embolism?

Q10

Which of the following statements on lymphoma is not true?

Lymphangiography Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following group of lymph nodes does NOT receive direct lymphatic drainage from the perineum?

A. Superficial inguinal
B. Internal iliac
C. External iliac (Correct Answer)
D. Deep inguinal

Explanation: ***External iliac*** - The external iliac lymph nodes do **NOT receive direct lymphatic drainage** from the perineum. - They primarily receive lymph from the **deep inguinal nodes**, pelvic organs (bladder, upper vagina), and lower anterior abdominal wall [1]. - Perineal lymphatics drain to superficial inguinal, deep inguinal, or internal iliac nodes first, making external iliac a **secondary or tertiary drainage station** rather than a direct recipient. *Superficial inguinal* - These are the **primary drainage site** for lymph from the superficial perineum. - They receive direct lymphatic vessels from the **vulva, distal vagina, labia majora**, scrotum, and skin of the perineum. - This is the main first-line drainage pathway for superficial perineal structures. *Internal iliac* - Internal iliac lymph nodes receive **direct lymphatic drainage** from the deep perineum, including the **male urethra, prostate**, and deep structures [2], [3]. - They serve as primary drainage for pelvic visceral structures and deep perineal tissues [3]. *Deep inguinal* - Deep inguinal lymph nodes receive lymph from the **superficial inguinal nodes** and from deep structures of the lower limb. - They are part of the drainage pathway from the perineum via the superficial inguinal nodes.

Question 2: During rounds, your senior was discussing the given image. Which of the following investigations does this image represent?

A. Contrast Dye study
B. CT scan (Correct Answer)
C. Angiography
D. X-ray

Explanation: ***CT scan*** - The image shows multiple **axial slices** with detailed cross-sectional anatomy of the abdomen, which is characteristic of a **Computed Tomography (CT) scan**. - CT scans provide excellent detail of both **soft tissues** and **bone structures** in cross-sectional format, which is the standard appearance of abdominal CT imaging. *X-ray* - Plain X-rays produce **2D projection images**, not the axial cross-sectional slices seen here. - While CT technology uses X-rays, in medical terminology **"X-ray"** refers to conventional radiographs, not cross-sectional imaging. *Contrast Dye study* - This is **not an imaging modality** but rather an enhancement technique used with various imaging methods. - **Contrast agents** improve visualization but don't define the type of investigation being performed. *Angiography* - Angiography is specifically designed to visualize **blood vessels**, often using contrast injection. - This image shows comprehensive **abdominal anatomy**, not the focused vascular imaging typical of angiographic studies.

Question 3: Gadolinium is a contrast agent used for:

A. CT - angiography
B. Bronchography
C. MRI - Imaging (Correct Answer)
D. Contrast Sonography

Explanation: ***MRI - Imaging*** - **Gadolinium** is a paramagnetic substance commonly used as a contrast agent in **Magnetic Resonance Imaging (MRI)**. - It works by altering the **T1 relaxation times** of protons in tissues, enhancing the signal and improving the visibility of certain structures or pathologies like **tumors** or **inflammation**. *CT - angiography* - **CT angiography** typically uses **iodine-based contrast agents**, not gadolinium, to visualize blood vessels. - Iodine contrast agents work by absorbing X-rays, making blood vessels appear bright on CT images. *Bronchography* - **Bronchography** is an older imaging technique that involved introducing an **iodinated contrast medium** directly into the bronchial tree. - It has largely been replaced by **high-resolution CT scans** for evaluating airways. *Contrast Sonography* - **Contrast-enhanced ultrasound (CEUS)**, or contrast sonography, primarily uses **microbubble contrast agents** made of inert gas. - These microbubbles enhance the reflectivity of blood, improving visualization of blood flow and organ perfusion.

Question 4: A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

A. Blood pressure
B. ECG
C. Echocardiography (Correct Answer)
D. Blood tests for autoantibodies

Explanation: ***Echocardiography*** - The constellation of symptoms (red eyes, cracked lips, rash on hands and feet, cervical lymphadenopathy in a 5-year-old) is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysms** are the most serious complication of Kawasaki disease, making echocardiography crucial for early detection and management. *Blood pressure* - While important in any pediatric assessment, **blood pressure measurement** is not specific for diagnosing or monitoring the most critical complication of Kawasaki disease. - Hypertensive or hypotensive episodes are not classic features and do not directly assess **coronary artery involvement**. *ECG* - An **ECG** can detect arrhythmias or signs of myocardial ischemia, which might occur with **coronary artery pathology**. - However, it is less sensitive and specific than **echocardiography** for directly visualizing and quantifying **coronary artery aneurysms**. *Blood tests for autoantibodies* - Kawasaki disease is not an autoimmune condition primarily diagnosed by **autoantibodies**; it is a **vasculitis** of unknown etiology. - Blood tests for autoantibodies would not be the most important investigation to rule out its most serious complication.

Question 5: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |

A. A-1, B-3, C-2, D-4
B. A-4, B-1, C-3, D-2 (Correct Answer)
C. A-3, B-2, C-4, D-1
D. A-2, B-4, C-1, D-3

Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.

Question 6: Identify the condition given in the image below?

A. Chronic lymphedema (Correct Answer)
B. Cushing syndrome
C. Osteoporosis
D. None of the options

Explanation: ***Chronic lymphedema*** - The image shows a **swollen foot** with **thickened, dry, and hyperkeratotic skin**, and **deep skin folds**, particularly between the toes. This is characteristic of **chronic lymphedema** due to impaired lymphatic drainage. - The presence of the **Stemmer's sign** (inability to pinch and lift the skin at the base of the second toe) is a common finding in lymphedema, which can be inferred from the overall appearance of the toes. *Cushing syndrome* - Cushing syndrome is characterized by **central obesity**, **moon facies**, **buffalo hump**, and **thin, fragile skin** with **striae**, not typically severe localized edema and skin changes as seen in the image. - While fluid retention can occur, it does not manifest as the characteristic cutaneous changes of chronic lymphedema. *Osteoporosis* - Osteoporosis is a condition of **decreased bone density**, making bones fragile and prone to fractures. - It does not present with visible skin changes or edema as depicted in the image. *None of the options* - The image clearly shows severe manifestations identifiable as **chronic lymphedema**, therefore one of the provided options is correct.

Question 7: Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

A. Nipple
B. Axilla
C. Areola (Correct Answer)
D. Tail of spence

Explanation: ***Areola*** - The **areola** is the primary site for injecting dye in sentinel lymph node biopsy because it is rich in **lymphatic vessels** that directly drain into the regional lymph nodes. - This method ensures the dye follows the natural lymphatic drainage pathway, accurately identifying the **first lymph node** to receive drainage from the tumor. *Nipple* - While the nipple is part of the breast, it has a less dense network of **lymphatic vessels** compared to the areola. - Injection directly into the nipple may not consistently identify the sentinel lymph node as effectively as periareolar or intratumoral injections. *Axilla* - The **axilla** contains the regional lymph nodes that are the *target* for identification, not the site of dye injection. - Injecting dye directly into the axilla would bypass the lymphatic drainage from the tumor, making the biopsy ineffective. *Tail of spence* - The **tail of Spence** is an extension of breast tissue into the axilla, and while it contains breast tissue, it is not the most optimal or primary site for dye injection. - The lymphatic drainage from the tail of Spence would still rely on the broader lymphatic network, which is best accessed via the central breast regions like the areola.

Question 8: To obtain adequate diagnostic imaging in a morbidly obese patient, what modification to X-ray technique is most important?

A. Increase MAS
B. Decrease KVP
C. Increase KVP (Correct Answer)
D. Decrease MAS

Explanation: ***Increase KVP*** - Increasing the **kilovoltage peak (KVP)** is essential for imaging morbidly obese patients because it increases the **penetrating power** of the X-ray beam, allowing adequate transmission through thick body tissues. - Higher KVP (typically 90-120 kVp range) ensures the X-ray beam can penetrate increased soft tissue thickness and reach the image receptor with sufficient intensity. - While higher KVP produces **longer scale (lower) contrast**, it is necessary for adequate **penetration** in obese patients - without sufficient KVP, the image would be underexposed and non-diagnostic. - In practice, both KVP and MAS are increased for obese patients, but **KVP increase is more critical** for penetration. *Increase MAS* - Increasing **milliampere-seconds (MAS)** increases the quantity of X-ray photons and image density (brightness), which is also helpful for obese patients. - However, MAS alone without adequate KVP cannot solve the penetration problem - the photons would still be too low energy to penetrate thick tissues effectively. - MAS increase without KVP increase would result in high patient dose with poor image quality. *Decrease KVP* - Decreasing KVP reduces **beam penetration**, which would be catastrophic for imaging an obese patient. - The X-ray beam would be absorbed by superficial tissues, resulting in a severely **underexposed** and non-diagnostic image. - While lower KVP produces higher contrast in theory, it is completely inappropriate for thick body parts. *Decrease MAS* - Decreasing MAS reduces the number of X-ray photons, resulting in an **underexposed, lighter** image. - This would make it even more difficult to obtain adequate imaging through increased body mass, resulting in a non-diagnostic radiograph with excessive quantum mottle.

Question 9: Which is the investigation of choice for fat embolism?

A. Arterial blood gas analysis
B. CT scan (Correct Answer)
C. Chest x-ray
D. MRI

Explanation: CT scan - **CT scans**, particularly of the chest, can visualize **ground-glass opacities** and consolidations, which are suggestive of fat emboli in the lungs. - While not universally diagnostic on its own, it is considered the most informative imaging modality for definitive diagnosis in the appropriate clinical context. *Arterial blood gas analysis* - **ABG analysis** can reveal **hypoxemia** and respiratory alkalosis in fat embolism syndrome, reflecting impaired gas exchange [1]. - However, these findings are non-specific and can be present in various respiratory conditions, making them unsuitable as a definitive diagnostic tool. *Chest x-ray* - A **chest X-ray** may show diffuse bilateral infiltrates, often described as a **"snowstorm" appearance**, in severe cases of fat embolism [1]. - This finding is often delayed and lacks the sensitivity and specificity of a CT scan for early or subtle changes. *MRI* - **MRI** is highly sensitive for detecting **cerebral fat emboli** (e.g., in the brain) and can show characteristic patterns like **"starfield" appearance** on diffusion-weighted imaging. - However, for pulmonary fat embolism, which is the most common and often the primary concern, CT scans are generally preferred due to their clear visualization of lung parenchyma and faster acquisition.

Question 10: Which of the following statements on lymphoma is not true?

A. In general, follicular (nodular) NHL has worse prognosis compared to diffuse NHL. (Correct Answer)
B. HD more often tends to remain localized to a single group of lymph nodes and spreads by contiguity.
C. Several types of non-Hodgkin's lymphoma (NHL) may have a leukemic phase.
D. A single classification system for Hodgkin's disease (HD) is almost universally accepted.

Explanation: ***In general follicular NHL has worse prognosis compared to diffuse NHL*** - Follicular Non-Hodgkin's lymphoma (NHL) typically has a **more indolent** course than diffuse lymphoma, leading to **better long-term survival** [1]. - Diffuse Large B-cell Lymphoma (DLBCL) is usually more aggressive and tends to have a **poorer prognosis** despite being treatable. *HD tends to remain localized to a single group of lymph nodes and spreads by contiguity* - Hodgkin's Disease (HD) is known for progressing in a **contiguous manner** [2], but it can **spread beyond localized regions** as well. - While it often starts in a single area, advanced stages may show **systemic spread**, contradicting the strict localization concept. *Several types of Non-Hodgkin's lymphoma may have a leukemic phase* - Certain Non-Hodgkin's lymphomas, such as **chronic lymphocytic leukemia (CLL)**, indeed can present with a significant **leukemic phase** [3]. - This characteristic differentiates them from other lymphomas that typically do not exhibit this phase. *A single classification system of Hodgkin's disease is almost universally accepted* - There are **multiple classification systems** for Hodgkin's Disease [4], including the Ann Arbor system and others, indicating no **universal acceptance**. - Ongoing research may lead to updates and varied classification approaches, showing the **evolution of diagnostic criteria**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 561-562. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 557-558. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 560-561. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 559-560.

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