Header Endocrine.png
Sample Teaching CasesUSA Online.png

While all modalities play a role in assessment of endocrine and reproductive pathologies, CT, MR, NM, and US are most frequently used for diagnostic imaging.

Red Border.png

Case 1

Case submitted by Dr. Shikha Gupta.

Two modalities are used to evaluate a thyroid goiter.

Case 2.1.jpg

Case 2.2.jpg

Questions

1. Which of the following statements about autonomous, semiautonomous and non-autonomous thyroid nodules is true?

  1. Autonomous nodules do not respond to thyroid stimulating hormone (TSH).
  2. Autonomous nodules respond to thyroid stimulating hormone (TSH).
  3. Semiautonomous nodules do not respond to thyroid releasing hormone (TRH).
  4. Semiautonomous nodules respond to thyroid stimulating hormone (TSH).
  5. Non-autonomous nodules do not respond to thyroid releasing hormone (TRH).

2. Based on the provided images, what is the diagnosis?

  1. Compensatory nodular hyperplasia
  2. Hyperfunctioning follicular adenoma
  3. Papillary thyroid carcinoma
  4. Physiologic thyroid hyperplasia  

Answer Arrow.png


Case 2

Case ERI 2.png
History

The patient is a 47-year-old with history of serendipitous discovery of an adrenal mass, during a prior CT for an unrelated indication. The adrenal mass was indeterminate (19 HU) on the prior noncontrasted CT (not shown). 

Questions

1. In what "space" is the adrenal gland located?

  1. Anterior pararenal space
  2. Gerota's space
  3. Perirenal space
  4. Posterior pararenal space
  5. Zuckerkandl's space

2. What technique is illustrated by the provided images?

  1. Multiphase contrasted CT with arterial and 3-minute delatyed images
  2. Multiphase contrasted CT with arterial and 10-minute delatyed images
  3. Multiphase contrasted CT with portal venous and 3-minute delatyed images
  4. Multiphase contrasted CT with portal venous and 10-minute delatyed images

3. Can a definitive diagnosis be rendered based on the provided images?

  1. Yes
  2. No

4. If so, what is the diagnosis? 

  1. Adrenal adenocarcinoma
  2. Adrenal adenoma
  3. Adrenal myelolipoma
  4. Nodular adrenal hyperplasia
  5. Unable to determine 

Answer Arrow.png


Case 3

Case ERI 3.pngHistory

The patient presented with abdomen pain, leukocytosis and an elevated bHCG.

Questions

1. Based on the provided images, which of the following is the most likely diagnosis?

  1. Blighted ovum
  2. Endometrial carcinoma
  3. Gestational trophoblastic disease
  4. Heterotopic pregnancy
  5. Spontaneous abortion

2. What is the most benign form of gestational trophoblastic disease?

  1. Complete hydatiform mole 
  2. Epithelioid trophoblastic tumor
  3. Invasive mole
  4. Partial hydatiform mole
  5. Placental-site trophoblastic tumor

3. What distinguishes a partial molar pregnancy from a complete molar pregnancy?

  1. Appearance on magnetic resonance imaging is pathnogmonic.
  2. Appearance on ultrasound is pathognomonic.
  3. Identification of karyotype on histopathological exam. 
  4. Identification of gestational trophoblastic disease on histological exam.
  5. Identification of neoplasm on histological exam.

4. which of the following is not a complication or sequelae of gestational trophoblastic disease? 

  1. Choriocarcinoma
  2. Coagulopathy
  3. Hyperemesis
  4. Hyperparathyroidism
  5. Toxemia

Answer Arrow.png


Case 4

Case ERI 4.pngQuestions

1. In what group is primary vaginal malignancy most common?

  1. Adolescent females
  2. Post-menopausal females
  3. Reproductive-age females
  4. Sexually active young females

2. What is the most common primary vaginal neoplasm seen in 20-year-old women?

  1. Adenocarcinoma
  2. Lymphoma
  3. Melanoma
  4. Sarcoma
  5. Squamous cell carcinoma

3. What is the most common primary vaginal neoplasm seen in 60-year-old women?

  1. Adenocarcinoma
  2. Lymphoma
  3. Melanoma
  4. Sarcoma
  5. Squamous cell carcinoma

4. Which of the following is true?

  1. Vaginal adenocarcinoma has a better prognosis compared to vaginal squamous cell carcinoma.
  2. Anterior and inferior primary vaginal tumors are more common compared to posterior and superior tumors.
  3. Metastatic disease to the vagina is more common compared to vaginal primary malignancies. 
  4. Patient age is important in staging.
  5. Tumor size is not related to prognosis.

Answer Arrow.png

Red Border.png

Answers


Case 1

History Case 2.1.jpg

The patient states that she has had a "knot" in her neck for over 4 years; however, she believes that it is larger than previously. The patient’s laboratories reveal normal T4, mildly elevated free T3, and undetectable TSH. 131I thyroid uptake scan was normal.

Diagnosis

Thyroid adenoma

Findings

In the 99mTechnitium - Pertechnetate Thyroid Scan (Right), there is an ovoid region of increased uptake to the left of midline superior to the sternal notch with intense uptake associated with the solid components and low levels of uptake seen in the cystic regions. No activity is noted within the right thyroid lobe and isthmus. Findings are consistent with a “hot” thyroid nodule.

Case 2.2.jpgThyroid ultrasound shows that the left thyroid lobe has been almost completely replaced by a heterogeneous mixed cystic and solid mass, measuring 4.2 x 3.5 x 2.8 cm.

Answers

1. What is the difference between autonomous, semiautonomous and non-autonomous thyroid nodules? 

  1. Autonomous nodules do not respond to thyroid stimulating hormone (TSH).
  2. Autonomous nodules respond to thyroid stimulating hormone (TSH).
  3. Semiautonomous nodules do not respond to thyroid releasing hormone (TRH).
  4. Semiautonomous nodules respond to thyroid stimulating hormone (TSH).
  5. Non-autonomous nodules do not respond to thyroid releasing hormone (TRH).

Level of response to thyroid stimulating hormone (TSH). A hot nodule has greater activity than the surrounding thyroid tissue. It can be autonomous (non-responsive to TSH), semiautonomous (partially responsive), or non-autonomous (responsive). An autonomous nodule will continue to function and show uptake of iodine even when TSH has been suppressed by administering exogenous thyroid hormone. A toxic nodule is an autonomous nodule that produces enough thyroid hormone to cause thyrotoxicosis.

2. What is the diagnosis for this case?

  1. Compensatory nodular hyperplasia
  2. Hyperfunctioning follicular adenoma
  3. Papillary thyroid carcinoma
  4. Physiologic thyroid hyperplasia  

Benign hyperfunctioning follicular adenomas account for almost all hot nodules; 50% are autonomous. Patients can be euthyroid or hyperthyroid (Plummer's disease) as a result of the hyperfunctioning (toxic) nodule, which suppresses the remainder of the thyroid gland. As these nodules enlarge, they frequently undergo central necrosis and may be centrally photopenic. Adenomatous hyperplasia results from prolonged over-secretion of TSH-producing adenomatous changes and goiter. Compensatory hypertrophy is TSH-dependent nodular hyperplasia with intervening fibrosis. Compensatory hypertrophy can cause a palpable nodule which concentrates pertechnetate better than the surrounding tissue. Such hypertrophy is seen when there is widespread damage to the gland (Hashimoto's). Physiologic thyroid hyperplasia occurs in patients’ that have congenital lobar agenesis, more commonly the left lobe (~80%), or are post lobectomy. These may appear to have a hot nodule, suppressing the remainder of the gland.

Additional Reading

Next Arrow.png


Case 2

History

Adrenal Adenoma.png

The patient is a 47-year-old with history of serendipitous discovery of an adrenal mass, during a CT for an unrelated indication. The adrenal mass was indeterminate (19 HU) on the prior noncontrasted CT (not shown). The patient’s laboratories were within normal limits, and the patient was asymptomatic.

Diagnosis

Lipid-poor adrenal adenoma

Findings

Contrasted CT of the abdomen, timed in the portal venous phase, at the level of the left adrenal gland demonstrates a mass in the adrenal gland with soft tissue attenuation of 55 HU. After a ten-minute delay, imaging demonstrates that the mass has a soft tissue attenuation of 31 HU.

Answers

1. In what "space" is the adrenal gland located?

  1. Anterior pararenal space
  2. Gerota's space
  3. Perirenal space
  4. Posterior pararenal space
  5. Zuckerkandl's space

The retroperitoneum is classically divided into three spaces, namely the perirenal space and the anterior and posterior pararenal spaces. The perirenal space is a closed space bound by the perirenal fascia (Gerota's fascia anteriorly and Zuckerkandl's fascia posteriorly) and contains the adrenal glands and kidneys and their associated blood vessels. The anterior pararenal space is bordered by the parietal peritoneum anteriorly and perirenal fascia posteriorly and is continuous with the contralateral anterior pararenal space. It contains the duodenum, pancreas and retroperitoneal segments of the ascending and descending colon. The posterior pararenal space is bordered by the perirenal fascia anteriorly and transversalis fascia posteriorly. It contains fat. The anterior and posterior pararenal spaces are open inferiorly and communicate with the pelvis.

2. What technique is illustrated by the provided images?

  1. Multiphase contrasted CT with arterial and 3-minute delatyed images
  2. Multiphase contrasted CT with arterial and 10-minute delatyed images
  3. Multiphase contrasted CT with portal venous and 3-minute delatyed images
  4. Multiphase contrasted CT with portal venous and 10-minute delatyed images

The provided images are part of a multiphase contrasted CT with 10-minute delayed imaging, used to assess adrenal washout of an indeterminate adrenal mass. The first image was obtained in portal venous phase and the second image after a 10-minute delay. On NECT, adrenal adenomas exhibit homogenous hypoattenuation with lipid-rich adenomas measuring -20 to 10 HU and lipid-poor adenomas measuring about 10 to 30 HU. Lipid-poor nodules are considered indeterminate and require further workup. Multiphase CT is used for routine evaluation of indeterminate nodules. Contrasted CT will show rapid washout of contrast on 10-minute delayed images (AEW > 60%, REW > 40%), which characterizes lipid-poor adenomas. 

Adrenal Washout.png

In this case, the calculated values are as follows: 

AEW: 100 x 55 HU – 31 HU / 51 HU – 19 HU = 75%

REW: 100 x 55 HU – 31 HU / 51 HU = 43.6%

3. Can a definitive diagnosis be rendered based on these images?

  1. Yes
  2. No

4. If so, what is the diagnosis? 

  1. Adrenal adenocarcinoma
  2. Adrenal adenoma
  3. Adrenal myelolipoma
  4. Nodular adrenal hyperplasia
  5. Unable to determine 

The differential diagnosis includes metastasis, lymphoma, adrenal hyperplasia, adrenocortical carcinoma, myelolipoma, and pheochromocytoma. Based on this study, the diagnosis is a lipid-poor adrenal adenoma.

Additional Reading

Boland, GWL, etal. Incidental Adrenal Lesions: Principles, Techniques, and Algorithms for Imaging Characterization. Radiology, December 2008, 249:756-775.

Next Arrow.png


Case 3

Gestational Trophoblastic Disease.png

History

The patient presented with abdomen pain, leukocytosis and an elevated bHCG.

Diagnosis

Partial hydatiform mole

Answers

1. Based on the provided images, which of the following is the most likely diagnosis?

  1. Blighted ovum
  2. Endometrial carcinoma
  3. Gestational trophoblastic disease
  4. Heterotopic pregnancy
  5. Spontaneous abortion

2. What is the most benign form of gestational trophoblastic disease?

  1. Complete hydatidiform mole 
  2. Epithelioid trophoblastic tumor
  3. Invasive mole
  4. Partial hydatidiform mole
  5. Placental-site trophoblastic tumor

3. What distinguishes a partial molar pregnancy from a complete molar pregnancy?

  1. Appearance on magnetic resonance imaging is pathnogmonic.
  2. Appearance on ultrasound is pathognomonic.
  3. Identification of karyotype on histopathological exam. 
  4. Identification of gestational trophoblastic disease on histological exam.
  5. Identification of neoplasm on histological exam.

4. which of the following is not a complication or sequelae of gestational trophoblastic disease? 

  1. Choriocarcinoma
  2. Coagulopathy
  3. Hyperemesis
  4. Hyperparathyroidism
  5. Toxemia

Gestational trophoblastic disease results from abnormal fertilization, creating a conceptus with only paternal DNA. Symptoms include vaginal bleeding, abdominal pain and hyperemesis. Females under 20 and over 40, those with previous GTD diagnosis, those with multiple spontaneous abortions and have blood type A are at greater risk

Laboratories reveal elevated B-hcg, which has a mild stimulating effect on the thyroid gland. Imaging findings include uterine enlargement greater than expect, a complex, central uterine mass. Ultrasound is usually the initial imaging study to assess for an intrauterine pregnancy and GTD can mimic an anembryonic gestation or missed or complete abortion.

The hydatidiform mole is the most common form with the complete mole having a diploid karyotype, while the partial mole is triploid or tetraploid karyotype. The complete hydatidiform mole can progress to an invasive mole or choriocarcinoma, representing gestational trophoblastic neoplasias. Placental site trophoblastic disease is a rare neoplasm, possibly a variant of choriocarcinoma. Epithelioid trophoblastic tumor is a rare GTD neoplasm with the potential to metastasize.

Additional Reading

Next Arrow.png


Case ERI.4

Vaginal squamous cell carcinoma.pngDiagnosis

Squamous cell carcinoma of the vagina

Findings

T1, T2, and post-contrasted MR imaging of the pelvis demonstrate a large vaginal mass with extension along tissue planes into the uterus. Enlarged pelvic sidewall lymph nodes were demonstrated (not shown).

Answers

1. In what group is primary vaginal malignancy most common?

  1. Adolescent females
  2. Post-menopausal females
  3. Reproductive age females
  4. Sexually active young females

2. What is the most common primary vaginal neoplasm seen in 20-year-old women?

  1. Adenocarcinoma
  2. Lymphoma
  3. Melanoma
  4. Sarcoma
  5. Squamous cell carcinoma

3. What is the most common primary vaginal neoplasm seen in 60-year-old women?

  1. Adenocarcinoma
  2. Lymphoma
  3. Melanoma
  4. Sarcoma
  5. Squamous cell carcinoma

4. Which of the following is true?

  1. Adenocarcinoma has a better prognosis compared to squamous cell carcinoma.
  2. Anterior and inferior tumors are more common compared to posterior and superior tumors.
  3. Metastatic disease to the vagina is more common compared to vaginal primary malignancies. 
  4. Patient age is important in staging and prognosis.
  5. Tumor size is not related to prognosis.

A primary vaginal malignancy originates in the vagina but does not involve the external os superiorly or the vulva inferiorly, which is less common than metastatic invasion into the vagina from the female urogenital tract. Squamous cell carcinoma is the most common primary vaginal cancer, reported in greater than 80% of cases of primary vaginal malignancies, more commonly seen in females who are 50 to70 years of age . In the 20-year-old female a majority of vaginal cancers are due to adenocarcinoma, which accounts for about 10% of primary vaginal cancers. Primary vaginal lymphomas, melanomas and sarcomas are rare.

Additional Reading

Back Arrow.png


USA Online.png

For access to the USA Radiology Teaching Case Library and the USA Radiology eClassroom, visit our eCampus at USAonline.

USA faculty, residents, and students can obtain access by contacting Dr. McQuiston. Upon registration for the Radiology Clerkship or Basic Radiology elective, USA College of Medicine students will be granted access to course materials.

Email Newsletters

Connect With Us