The pulmonary hila:

a. The bronchi account for most of the hilar opacity.

b. The hilar point is defined as the junction between the inferior lobe pulmonary vein and the superior lobe pulmonary artery.
c. The undivided pulmonary artery lies entirely within the pericardial sac.
d. The right upper lobe bronchus lies above the right pulmonary artery.
e. The right upper lobe bronchus lies higher than the left.
Answer:
a. F The bronchi account for little of the hilar opacity since they are filled with air.
b. F The lower lobe pulmonary veins do not cross the the hila in their course to the left atrium and therefore do not
contribute to the hilar shadows. The lateral angle between the upper and lower portions of the right hilum is formed by the
superior pulmonary vein above and the descending pulmonary vein below. On the left most of the left upper pulmonary
vein lies behind the pulmonary artery so it accounts for little of the hilar contour.
c. T The undivided pulmonary artery is about 4 - 5cm in length and lies entirely within the pericardial sac as does its
bifurcation.
d. T The RUL bronchus lies above the right pulmonary artery and is therefore eparterial. The left main bronchus enters
the lung below the left pulmonary artery (hyparterial).
e. T Its end-on projection presents in the lateral view as a small circle superimposed over the lower trachea. About 2cm
below this is the similar projection of the LUL bronchus. Chest Roentgenology Benjamin Felson W.B. Saunders 1973.

Bronchopulmonary sequestration:
a. Is more common on the left.
b. May communicate with the oesophagus.
c. Intralobar is more common than extralobar sequestration.
d. Is more common in females.
e. May show multiple, fluid-filled cystic spaces on CT.
Answer:
a. T Usually the posterior basal segment of the left lower lobe.
b. T It arises as an accessory tracheobronchial foregut bud, hence its systemic arterial supply.
c. T Intralobar is about 3x more common and usually presents in adulthood. It is enclosed by the visceral pleura of the
affected pulmonary lobe. Systemic feeding vessels originate from the descending thoracic aorta. Vascular drainage into
the left atrium occurs through the normal pulmonary veins resulting in a left-to-left shunt. Associated congenital
abnormalities are rare. Extralobar sequestration has its own pleural sheath which prevents collateral air drift and usually
presents in neonates. 90% are contiguous with the left hemidiaphragm in the thorax. Systemic feeding vessels commonly
originate from the thoracic or abdominal aorta (80%), or from the splenic, gastric, subclavian or intercostal arteries.
Vessels drain into the systemic circulation through the IVC, azygos or hemiazygos veins. Associated congenital
abnormalities are frequent.
d. F Is more common in males.
e. T A plain chest radiograph often shows a sharply circumscribed, oval or triangular opacity at the left lung base. CT
demonstrates a low attenuation soft tissue mass. Cystic spaces, if present, represent dilated bronchioles filled with
gelatinous mucus or pus. CT may be useful in deciding which patients with a persistent basal pneumonia should go on to
angiography. This remains the only modality to demonstrate adequately unusual vascular sources such as the splenic,
gastric, subclavian or intercostal arteries. Danhert 5th Ed.

The following are causes of a pulmonary eosinophilia:
a. Aspergillus.
b. Toxocara canis.
c. Nitrofurantoin.
d. Methotrexate.
e. Busulphan.
Answer:
a. T Pulmonary eosinophilia can be defined as an eosinophilic pulmonary infiltrate usually associated with an excess of
eosinophils in the peripheral blood. The commonest causative agent in the UK is Aspergillus.
b. T
c. T Typically causes interstitial pulmonary oedema or a mixed alveolar and interstitial pattern.
d. F Causes an alveolitis without an associated eosinophilia.
e. F Causes an alveolitis without an associated eosinophilia.

In HRCT of the chest:
a. Radiation dose to the patient is increased compared with a conventional 10 mmcontiguous section protocol.
b. The majority of patients with fibrosing alveolitis show a predominantly 'ground glass' pattern.
c. 'Subpleural lines' are diagnostic of asbestosis.
d. Centrilobular emphysema typically has a surrounding wall of fibrous tissue which can measure up to 2mm.
e. Air trapping produces areas of increased lung attenuation.
Answer:
a. F The mean skin radiation dose to the patient from a standard HRCT protocol using 1.5 mm sections at 20 mm
intervals is estimated as little as 6% that of a standard 10 mm contiguous section protocol.
b. F The majority of patients with fibrosing alveolitis show a predominantly reticular pattern on HRCT but identifying the
15-20% of patients with a predominantly ground glass pattern is important. In these patients the ground glass pattern
most frequently represents increased cellularity in the interstitium or air spaces and are more likely to respond to
treatment.
c. F This finding is nonspecific and can be found in normal patients as a result of atelectasis within dependent lung (ie the
posterior lung when the patient is positioned supine). Such normal posterior lines or opacities are transient and disappear
in the prone position.
d. F Emphysema is defined as permanent abnormal enlargement of airspaces distal to the terminal bronchiole
accompanied by the destruction of the walls of the involved airspaces. It is usually distinguishable from honeycomb cysts
which possess thick walls of fibrous tissue.
e. F Areas of decreased lung attenuation that do not represent cystic lesions or emphysema can sometimes be
recognised on HRCT in patients who have diseases that produce air trapping, poor ventilation, or poor perfusion of the
lung parenchyma. The areas of decreased lung attenuation seen on HRCT can be focal, lobular or lobar, or multifocal.
This is most common in patients with bronchiolitis obliterans, although a similar finding has been reported with pulmonary
embolism.

Pulmonary calcification is seen in:
a. Alveolar cell carcinoma.
b. Wegener`s granulomatosis.
c. Rheumatoid nodules.
d. Metastatic papillary carcinoma of thyroid.
e. Histiocytosis X.
Answer:
a. F Presents as a diffuse, pneumonic ( 10 - 40%) or localised lesion (60 - 90%).When localised, a mass is the most
common presentation, usually well circumscribed and peripheral in location. It is more commonly ill defined. An air
bronchogram is common. There is no calcification. A pleural effusion is seen in about 5%. Mediastinal lymphadenopathy
is less common than with carcinoma of the bronchus. It accounts for about 20-25% of all primary lung cancers.
b. F The radiological features of WG are: patchy alveolar infiltrates; widely distributed irregular nodules of varying sizes;
thick-walled cavities; pleural effusion in 25%; lymphadenopathy is exceedingly rare. Calcification is not seen in the lung
parenchyma but may be present in the tracheal rings.
c. F Necrobiotic nodules in rheumatoid disease are rare. They are well circumscribed nodular masses in the lung, pleura
or pericardium which are identical to the subcutaneous nodules found in advanced rheumatoid arthritis. The nodules are
usually multiple, commonly located in the lung periphery and cavitation occurs. Calcification is not seen. Unlike the
incidence of rheumatoid arthritis itself, rheumatoid lung is much more common in men.
d. T Papillary carcinoma of the thyroid accounts for 60% of all thyroid carcinomas, usually in the 5th decade and more
common in females. Spread is usually to regional lymph nodes. Haematogenous spread to lung occurs in 4% and
calcification occurs. Generally, if calcification occurs in the primary tumour, then pulmonary metastases are likely to
calcify.
e. F Histiocytosis X characteristically is a fibrotic lung disease with increased lung volume in a third of cases. Changes
are usually bilaterally symmetrical with upper lobe predominance.The most common findings are a diffuse reticulonodular
pattern; ``honeycomb lung``; ill-defined stellate nodules; thin-walled cysts and rarely a pleural effusion. Calcification is not
a finding.

Recognised features of PCP:
a. Discrete pulmonary nodules.
b. Pleural effusions.
c. Nephrocalcinosis.
d. Interstitial pattern.
e. Pneumothorax.
Answer:
a. T PCP is the most common cause of interstitial pneumonia in immunocompromised patients. It is particularly common
in the AIDS population with approximately 60 - 80% of all patients suffering at least one episode of PCP during the course
of their illness and 40% of patients having recurrent PCP. Discrete pulmonary nodules are a less common manifestation
of PCP.
b. T Recognised but rare.
c. T AIDS patients undergoing treatment with prophylactic nebulised pentamidine are more likely to develop atypical
disease including an apical pattern of involvement, calcified hilar and abdominal nodes and viscera and pulmonary cystic
disease.
d. T An interstitial pattern is recognised in about 20% on CT. This may be bilaterally symmetric or asymmetric with linear
and reticular markings.
e. T Thin walled cavities may develop, and although appearances may return to normal some residual scarring and cyst
formation is not uncommon. Pneumothorax is a well recognised complication of cystic change.
S. Padley SPR Brompton. Pulmonary infection in the Immunosuppressed

The following patterns of bronchiectasis are correctly linked:
a. Allergic bronchopulmonary aspergillosis : lower lobe, cylindrical bronchiectasis.
b. Post-pertussis : unilobar, cystic bronchiectasis.
c. Cystic fibrosis : lower lobe, varicose bronchiectasis.
d. Hypogammaglobulinaemia : lower lobe, cylindrical bronchiectasis.
e. Japanese panbronchiolitis : panlobular cylindrical bronchiectasis.
Answer:
a. F ABPA is more commonly proximal, upper lobe, varicose bronchiectasis. Lower lobe, cylindrical bronchiectasis is a
feature of hypogammaglobulinaemia.
b. T
c. F Cystic fibrosis is more commonly pan-lobar (predominantly upper lobe), cylindrical bronchiectasis.
d. T
e. T The conjunction of widespread centrilobular opacities and panlobular cylindrical bronchiectasis are the features of
J apanese panbronchiolitis.

In CT scanning of the mediastinum:
a. Anatomical staging influences the prognosis in small cell lung cancer.
b. 50% of nodes 1 - 1.5 cmin diameter are involved by tumour.
c. Contiguity of tumour mass with mediastinal pleura indicates unresectability.
d. CT is more accurate than mediastinoscopy at assessing nodal involvement.
e. Persistent left superior vena cava may mimic a mediastinal mass.
Answer:
a. F Anatomical staging influences the prognosis in squamous, large cell and adenocarcinoma. TNM staging is not
relevant in the vast majority of patients with small cell lung cancer because of the systemic nature of the disease.
b. T The involvement of nodes on CT is assessed predominantly by size and the CT criteria are:
1 cm diameter - commonly not involved.
1 - 1.5 cm diameter - 50% involved.
>1.5 cm diameter - 95% involved.
(Webb et al. 1975; Khan et al. 1985)
False positive mediastinal nodes on CT were found in 25% of cases in one series (Spiro and Goldstraw 1984) and this is
often due to reactive hyperplasia and similarly, small nodes <0.5 cm diameter may contain metastatic deposits.
c. F Contiguous invasion of the mediastinum with involvement of the heart, great vessels, trachea or oesophagus
precludes resection. Invasion of the mediastinal pleura or pericardium does not prevent resection, although significant
invasion of mediastinal fat usually does. As seen on CT, contiguity of tumour mass with the mediastinal pleura or
thickening of the mediastinal pleura does not indicate mediastinal extension or unresectability. However, a significant
mediastinal mass contiguous with a lung tumour, which results in compression of mediastinal vessels or oesophagus, or
replacement of mediastinal fat by soft tissue density is strong evidence.
d. F The measured sensitivity of CT by using total nodal sampling as the gold standard is lower than evaluation by
mediastinoscopy or palpation at surgery. Although mediastinoscopy is more accurate than CT, some regions of the
mediastinum are not accessible; CT is generally used to guide mediastinoscopy.
e. T A persistent left sided SVC usually drains into the coronary sinus after coursing backwards as it tracks through the
mediastinum. There is usually a coexistent right SVC and left innominate vein. Axial CT sections may confuse this with a
lymph node metastasis adjacent to the aortic arch.
Appropriate use of CT and MRI in Lung Cancer International London Annual Course 1994

In the clinical staging of lymphoma:
a. The presence of B symptoms is of prognostic significance in NHL.
b. Intra-thoracic HD typically involves the hilar and subcarinal nodes.
c. Pleural effusions are seen in 50% of patients with intra-thoracic NHL at presentation.
d. CT can reliably differentiate radiation pneumonitis frompulmonary involvement.
e. Bone marrow involvement is found in 20-40% of patients at presentation in HD.
Answer:
a. F The Anne Arbor system of staging is of less value in NHL than HD. Whereas in HD the prognosis is distinctly worse
with each progressive stage, the course of NHL is more dependent on tumour bulk, specific histological grade and
specific organ involvement. The presence of B symptoms (ie systemic signs, eg fever, night sweats, weight loss of 10%
or more in the six months prior to admission) is of prognostic significance in HD, but tends not to effect outcome in NHL.
b. F Intra-thoracic involvement at the time of initial presentation is found in 65-85% of patients with HD and 25-40% of
patients with NHL. In HD, mediastinal lymphadenopathy is common and typically affects paratracheal and anterior
mediastinal nodes. In the absence of mediastinal disease, hilar adenopathy is uncommon and involvement of the lung
parenchyma rare in HD, unless there has been previous radiotherapy to the mediastinum.
c. F The pattern of of NHL is less predictable than HD. Isolated pulmonary disease may occur. Pleural effusions may
occur in 7-10% of untreated adult patients. They are not of prognostic importance unless associated with a pleural mass,
since they rarely contain malignant cells and usually resolve following treatment of the adenopathy.
d. F Lung manifestations include direct extension from involved nodes, pulmonary nodules with or without cavitation,
collapse from bronchial infiltration by tumour or obstruction by nodes and rarely interstitial infiltration. When the above
changes are seen in the untreated patient, pulmonary involvement can be diagnosed with confidence. In the treated
patient, however, biopsy may be needed to differentiate relapse from infection, radiation pneumonitis or drug-induced
lung disease.
e. F Bone marrow involvement is rare at presentation in HD so marrow biopsies are not indicated as part of initial staging.
During the course of illness, 5-15% of HD patients will develop marrow involvement. However, bone marrow involvement
is found in 20-40% of NHL patients at presentation. This indicates Stage IV disease and is associated with a worse
prognosis than involvement of liver, lung or osseous bone.

Clin. Rad. Staging of lymphoma in adults. (1994) 49, 149-161.
Persistent truncus arteriosus:
a. Is associated with a VSD.
b. Is associated with a right sided aorta.
c. May display a concave pulmonary bay radiographically.
d. The pulmonary arteries may arise fromthe upper descending thoracic aorta.
Answer:
a. T A spiral septum develops during weeks 4 - 8 of intrauterine life and divides the foetal truncus arteriosus into a
separate aorta and pulmonary artery. If this septum does not develop, the foetal truncus arteriosus persists as the sole
ventricular outflow. There is almost invariably a high VSD above which the truncus arises, collecting the total outflow from
both ventricles.
b. T The truncal arch is right sided in 30 to 40% of cases, a greater incidence than in any other condition.
c. T In Type I the pulmonary arteries may be large with pulmonary arterial plethora. In Types II, III and IV all the
pulmonary arteries are small and there may be radiologically demonstrable pulmonary oligaemia.
d. T In Truncus Type IV the pulmonary arteries arise not from the ascending truncus but as 4 to 8 branches sometimes
regarded as hypertrophied `bronchial` arteries from the upper descending thoracic aorta.

Posterior tracheal indentation and anterior oesophageal impression may be caused by:
a. Aberrant left pulmonary artery.
b. Double aortic arch.
c. Left aortic arch with aberrant right subclavian artery.
d. Common origin of innominate and left common carotid artery.
e. Right aortic arch with aberrant left subclavian artery.
Answer:
a. T The pulmonary sling is a failure of development of the left 6th aortic arch followed by development of a collateral
branch of the right pulmonary artery to supply the left lung. The left PA passes above the right main stem bronchus and
between the trachea and oesophagus to the left lung.
b. F This causes anterior tracheal indentation and a large posterior oesophageal impression.
c. F This is a cause of dysphagia lusoria - a small posterior oesophageal impression.
d. F This produces anterior tracheal indentation.
e. F The left subclavian artery connects with the left pulmonary artery. This is another cause of an anterior tracheal
indentation with a large posterior oesophageal impression.

Typical plain film features of an ASD include:
a. Small aortic knuckle.
b. Kerley B lines.
c. Prominent central pulmonary vessels.
d. Left atrial enlargement.
e. Cardiac enlargement only if the left-to-right shunt is greater than 4:1.
Answer:
a. T The ascending aorta and its arch may appear smaller than normal probably due to the rotation of the ascending
aorta by the enlarged right atrium, causing sagittal alignment of the aortic arch.
b. F Septal oedema as evidenced by costophrenic septal lines when seen in a patient with ASD should always suggest
an associated mitral valve anomaly (endocardial cushion defect or Lutembacher`s syndrome).
c. T The central pulmonary vessels are enlarged and there is a variable degree of pulmonary plethora depending on the
size of the shunt.
d. F The left atrium is usually small as a result of decompression into a lower pressure right atrium.
e. F If the left-to-right shunt is greater than 2:1 then the heart is usually obviously enlarged, involving the RA and RV.
There is no enlargement of the LA except in some cases of ECD or in Lutembacher`s syndrome.

Concerning atrial septal defects:
a. The most common defect is of the ostiumprimumtype.
b. The Gerbode defect is due to an opening in the ostiumprimum.
c. A patent foramen ovale may lead to a left to right shunt in later life.
d. The sinus venosus defect is immediately below the SVC opening.
e. Ostiumprimumdefects are associated with left axis deviation on ECG.
Answer:
a. F The most common defect is the ostium secundum or fossa ovalis defect. This is situated in the upper part of the atrial
septum and accounts for 80 to 90% of all ASDs.
b. F The Gerbode defect is a left ventricular-right atrial septal defect resulting from maldevelopment of the downgrowth
from the undersurface of the AV cushions which forms the upper part of the membranous ventricular septum.
c. F Because of the flap construction of the foramen ovale it only permits a shunt from the right to the left atrium. The
patent foramen ovale in utero provides the only access of oxygenated blood into the systemic circulation. After birth the
foramen ovale is closed by the higher pressure in the LA. It may be capable of transmitting a right to left shunt if the RA
pressure is raised by a distal obstruction.
d. T This ASD is situated high on the interatrial septum immediately below the SVC opening. There is invariably drainage
of the right upper lobe pulmonary veins into the lower end of the SVC. Sinus venosus defects account for about 5% of
ASDs.
e. T These lesions account for 5-10% of ASDs and are situated low on the atrial septum, immediately above the AV
valves, due to lack of fusion of the septum primum with the AV cushions. There is usually left axis deviation due to
conduction abnormalities and mitral incompetence compared with right axis deviation in ostium secundum.

Concerning deep venous thrombosis (DVT) of the leg:
a. 10-20% of patients with symptomatic DVT have thrombi isolated to the calf.
b. Prophylaxis reduces the incidence of postarthroplasty DVT to less than 5%.
c. Ultrasound can reliably demonstrate calf vein deep venous thromboses.
d. Thrombus is initially echogenic then becomes hypoechoic over a couple of weeks.
e. In a patient with a past history of DVT, loss of compressibility is a sensitive and specific sign of new DVT at the same site.
Answer:
(a) True. This has lead many observers to suggest repeating ultrasound 1 week later to assess the small proportion that
will extend over that time. The yield from this is low (1-2% of those originally negative will be positive on second testing)
and costs approximately $390 000 per life year saved from fatal
pulmonary embolism, using 1992 figures.
(b) False. 15-45% will have venographic evidence of DVT. Most are only in the calf, are atypical in their distribution and
length and often resolve spontaneously.
(c) False. Most commentators believe that venography is still the only reliable method of demonstrating calf vein deep
venous thromboses. Disadvantages include radiation and contrast exposure, time and resource consumption, failure (up
to 20% fail to show all the veins in research studies) and promotion
or initiation of DVT (up to 2%).
(d) False. Thrombus is initially hypoechoic and becomes hyperechoic over the course of a few weeks and then
hypoechoic over months. By 2 years, 50% of patients will have normal appearances.
(e) False. DVT may persist indefinitely, therefore changes may be chronic. Increase in luminal size over time is a useful
sign. Baseline studies after anticoagulation may be helpful.
Reference: Deep venous thrombosis: recent advances and optimal investigation with US. Radiology 1999;211:9-24

Regarding renal artery stenosis imaging with MR:
a. Contrast enhanced MR techniques have supplanted non-contrast techniques owing to fewer artefacts, such as signal loss at stenoses
in patients with poor cardiac output.
b. Care must be taken over the amount of MR contrast agent given in patients with renal failure.
c. Central k-space data should aimto be acquired at the moment of peak renal artery enhancement.
d. Severe spin dephasing seen in phase contrast images tends to underestimate the severity of stenoses.
e. 20% of patients with atherosclerotic renal artery stenosis will have no disease elsewhere.
Answer:
(a) True. Minor stenoses (,50%) tend to appear as normal. High dose gadolinium enhanced high resolution three-
dimensional spoiled gradient echo pulse sequences are preferred.
(b) False. Contrast doses used are not associated with worsening renal function, however, CT angiography is.
(c) True. This is in order to increase the signal and therefore improve contrast. This necessitates
either bolus tracking in the aorta or a test bolus.
(d) False. Spin dephasing is seen in moderate to severe stenosis, causes loss of signal and, therefore, overestimates the
degree of stenosis.
(e) True. Atherosclerotic renal artery stenosis most commonly occurs in the setting of generalized atherosclerosis, but
may be focal.
Reference: Diagnosis of renal vascular disease with MR angiography. Radiographics 1999;19:1535-54
Answer:
(a) True. Minor stenoses (,50%) tend to appear as normal. High dose gadolinium enhanced high resolution three-
dimensional spoiled gradient echo pulse sequences are preferred.
(b) False. Contrast doses used are not associated with worsening renal function, however, CT angiography is.
(c) True. This is in order to increase the signal and therefore improve contrast. This necessitates
either bolus tracking in the aorta or a test bolus.
(d) False. Spin dephasing is seen in moderate to severe stenosis, causes loss of signal and, therefore, overestimates the
degree of stenosis.
(e) True. Atherosclerotic renal artery stenosis most commonly occurs in the setting of generalized atherosclerosis, but
may be focal.
Reference: Diagnosis of renal vascular disease with MR angiography. Radiographics 1999;19:1535-54

Regarding Mycobacterium avium complex (MAC) infection in AIDS patients:
a. Most patients cannot be diagnosed with blood cultures, and therapy is instituted empirically.
b. Most frequent changes are centred in the lungs.
c. Lymphadenopathy is universal.
d. The involved lymph nodes characteristically demonstrate low attenuation centres on contrast enhanced CT.
e. It is a common AIDS-defining diagnosis.
Answer:
(a) False. Blood culture is the definitive diagnosis and is imperative as effective chemotherapy is available but not without
side effects.
(b) False. MAC presents as a disseminated infection with fever, weight loss, diarrhoea and abdominal pain as the most
frequent findings. It is centred in the abdomen. MAC can also be cultured from bone marrow, stool sputum and
broncoalveolar lavage.
(c) False. Initial reports did suggest that enlarged abdominal nodes were universal but later studies, possibly imaging the
patients earlier, have shown a lower incidence (42%). Other persistent findings are hepatomegaly, splenomegaly and
jejunal wall thickening.
(d) False. This is infrequently described in MAC.
(e) False. Most patients will have another AIDS defining diagnosis: candidal oesophagitis, PCP,
CMV retinitis or colitis or lymphoma at the time of diagnosis.
Frequency of abdominal CT findings in AIDS patients with M.avium complex bacteraemia. Clin Radiol 1998;53:816-9

Concerning drugs and pulmonary disease:
a. Peripheral and upper lobe pulmonary opacities varying over time and responding to steroids are associated with non-steroidal anti-
inflammatory drugs.
b. Chemotherapeutic agents can lead to scattered heterogeneous opacities on chest X-ray which appear on HRCT to be scattered areas
of ground-glass opacity.
c. There is a good correlation between both dose and duration of therapy and cyclophosphamide induced lung injury.
d. Bronchiolitis Obliterans Organizing Pneumonia (BOOP) is most frequently caused by pamidronate, fentanyl and nevirapine.
e. Amiodarone pulmonary toxicity occurs in 5-10% of patients with non-specific interstitial pneumonia as the most common
manifestation.
Answer:
(a) True. This is the description of eosinophilic pneumonia. This is also seen with penicillamine, sulfasalazine and
nitrofurantoin.
(b) True. This is the description of early diffuse alveolar damage and may go on to fibrosis and honeycomb lung.
Cyclophosphamide and busulfan are the commonest agents involved.
(c) False.
(d) False. This is most commonly seen with bleomycin, gold salts, cyclophosphamide and methotrexate.
(e) True. Pulmonary changes usually begin within months. Other changes include BOOP, pleural effusions and high
density pulmonary opacities.
Pulmonary drug toxicity: radiologic and pathologic manifestations. Radiographics 2000;20:1245-59

Regarding bronchiolitis obliterans after lung transplantation:
a. Histopathologically there is obstruction of the bronchioles secondary to inflammatory infiltration of the lumen.
b. It is usually of minor clinical significance.
c. Mosaic perfusion is the most sensitive sign on high resolution CT.
d. Bronchial dilatation and thickening are features.
e. Mosaic perfusion is seen in 1% of controls.
Answer:
(a) False. There is concentric narrowing of the bronchioles owing to submucosal and peribronchial
fibrosis.
(b) False. It is the major cause of long-term mortality and morbidity in this population. It is thought to be a feature of
chronic rejection and is potentially reversible with alteration of immunosuppression.
(c) False. Sensitivity is 40%. Bronchial dilatation and air trapping both have sensitivities of 80%.
(d) True. Bronchial wall thickening is seen in 27% of cases.
(e) False. 22% of normals demonstrate this.
Reference: Bronchilitis obliterans after lung transplantation. AJ R 1997;169:673-7

Concerning asbestos related pleural disease:
a. Mesothelioma is declining in incidence.
b. Pleural plaques typically occur in the costophrenic angles.
c. Pleural plaques can cause restrictive lung defects.
d. Pleural exudates are commonly benign, especially within 20 years of asbestos exposure.
e. Crows feet are a recognized high resolution CT finding of visceral pleural fibrosis
Answer:
(a) False. It is estimated that the incidence of mesothelioma will continue to increase until 2020 in the UK.
(b) False. Typically they occur on the posterolateral chest wall, the costochondral junctions, the domes of the diaphragm
and the mediastinal pleura.
(c) False. In isolation pleural plaques do not cause lung restriction or symptoms although asbestosis rarely occurs in the
absence of pleural plaques. They are more strongly correlated with length of time from exposure than with amount of
exposure.
(d) True. After 20 years, mesothelioma becomes more likely. Benign pleural effusion is the commonest indicator of
asbestos exposure in the first 10 years. They most frequently resolve over months, many individuals are left with pleural
thickening.
(e) True. Crows feet are linear densities extending across lung fields to converge on one point of visceral pleural
thickening. The crows feet themselves are thought to be thickening of adjacent interlobular septa owing to fibrotic
reaction.
Reference: Peacock C, Copley SJ , Hansell DM. Asbestos related benign pleural disease. Clin Radiol 55;2000:422-32

Concerning the study of myocardial metabolism using PET:
a. 2-fluorodeoxyglucose (FDG) is labelled with fluorine-17.
b. FDG is metabolised via glycolysis and the Krebs cycle.
c. imaging begins 30 seconds after injection of FDG.
d. an oral glucose load maximises myocardial FDG uptake.
e. the usual dose of FDG is 350-400 MBq.
Answer:
a. F 18F is the positron-emitter.
b. F after phosphorylation by hexokinase no further metabolism occurs and the FDG is trapped in the cell.
c. F imaging commences after 40-60 minutes.
d. T uptake occurs via the GLUT-2 transporter on cell membranes.
e. T [Grainger & Allison p728]