Miscarriage can be diagnosed with certainty on ultrasound in which of the following situations?

• a)
  

  Gestational age greater than 9 weeks.

  
  
• b)
  

  The presence of an embryo measuring 10 mm with no evidence of cardiac activity.

  
  
• c)
  

  A gestational sac with yolk sac measuring more than 12 mm.

  
  
• d)
  

  An empty uterus on the follow-up scan in a woman diagnosed with an intrauterine pregnancy on a previous scan.

  
  
• e)
  

  A falling serum βHCG measurement over 48 hours in a Pregnancy of Unknown Location (PUL).

Which of the following is/are true about the diagnosis of ovarian torsion?

• a)
  

  Clinical symptoms are less important than ultrasound findings.

  
  
• b)
  

  Measuring intra-ovarian blood flow enables conclusive diagnosis of torsion.

  
  
• c)
  

  The ‘Whirlpool’ sign is a useful feature.

  
  
• d)
  

  Endometriomas tent to tort more often than dermoid cysts.

  
  
• e)
  

  Pain that resolves in suspected torsion is usually due to death of the ovary.

Which of the following is/are true about the diagnosis of multiple pregnancy?

• a)
  

  Chorionicity cannot be determined before 7 weeks’ gestation.

  
  
• b)
  

  Monozygotic twins are always monochorionic.

  
  
• c)
  

  The T sign is helpful in determining amnionicity before 9 weeks of gestation.

  
  
• d)
  

  The number of yolk sacs may be used to determine amnionicity.

  
  
• e)
  

  Gestational measurements of CRL in twins uses different reference ranges compared to singletons at 7 weeks.

Which of the following is/are true about the safety of ultrasound in the first trimester of pregnancy?

• a)
  

  M-mode is safe to assess heart rate.

  
  
• b)
  

  Doppler ultrasound produces higher energy output than M-mode.

  
  
• c)
  

  Three-dimensional ultrasound increases the risk to the embryo.

  
  
• d)
  

  The mechanical index should always be displayed on ultrasound machine.

  
  
• e)
  

  A rise in tissue temperature up to 5°C is safe for the embryo.

Which of the following statements is/are correct regarding investigation of the endometrium?

• a)
  

  It is safe to refrain from endometrial sampling in women with postmenopausal bleeding and endometrial thickness 4 mm or less.

  
  
• b)
  

  It is safe to refrain from endometrial sampling in women with postmenopausal bleeding and endometrial thickness 5 mm or more if the endometrium has regular echogenicity and is poorly vascularised at colour or power Doppler ultrasound.

  
  
• c)
  

  The absence of focal lesions at saline-contrast sono-hysterography in women with postmenopausal bleeding is a strong sign of normality.

  
  
• d)
  

  In women with postmenopausal bleeding and endometrial thickness 5 mm or greater focal lesions in the uterine cavity should be hysteroscopically resected under direct visual control.

  
  
• e)
  

  If the endometrium is not seen at transvaginal ultrasound in a woman with postmenopausal bleeding it means that it is thin, and so the risk of endometrial malignancy is low and no endometrial sampling is needed.

Which of the following statements is/are correct further regarding investigation of the endometrium?

• a)
  

  Endometrial thickness measurements with transvaginal ultrasound play a pivotal role in the triage of women with irregular bleeding before the menopause.

  
  
• b)
  

  At ultrasound examination, the endometrium is hyperechogenic throughout the menstrual cycle.

  
  
• c)
  

  Endometritis has a typical appearance at transvaginal ultrasound examination.

  
  
• d)
  

  Intracavitary lesions with the appearance of an endometrial polyp at saline-contrast sonohysterography may regress if left in situ.

  
  
• e)
  

  In premenopausal women, endometrial polyps are typically surrounded by a ring of colour at power Doppler ultrasound examination.

Which of the following statements is/are correct further regarding investigation of the endometrium and myometrium?

• a)
  

  Magnetic resonance imaging is superior to ultrasound for diagnosing adenomyosis.

  
  
• b)
  

  Transvaginal ultrasound is as good as magnetic resonance imaging in detecting uterine leiomyomas.

  
  
• c)
  

  Malignant uterine leiomyosarcomas have an ultrasound appearance that is distinctly different from that of benign uterine leiomyomas.

  
  
• d)
  

  Magnetic resonance imaging is superior to ultrasound for discriminating between uterine leiomyosarcomas and benign uterine leiomyomas.

  
  
• e)
  

  The typical ultrasound features of endometrial hyperplasia are the same in pre-and post-menopausal women.

Which of the following features of the myometrium is/are typically associated with adenomyosis?

• a)
  

  The presence of myometrial cystic areas.

  
  
• b)
  

  The presence of asymmetric myometrial walls.

  
  
• c)
  

  The presence of myometrial hypoechoic linear striations.

  
  
• d)
  

  The presence of diffusely scattered myometrial vascularity.

  
  
• e)
  

  The presence of round lesions with regular capsular vascularisation.

A deep infiltrating endometriotic nodule of the rectum appears as:

• a)
  

  A cyst with ground glass echogenicity.

  
  
• b)
  

  An ultrasound hypoechoic lesion with irregular borders, stellate margins, and few vessels at power Doppler evaluation.

  
  
• c)
  

  An ultrasound hyperechoic lesion with regular borders.

  
  
• d)
  

  An ultrasound hypoechoic lesion with abundant vessels at power Doppler evaluation.

  
  
• e)
  

  A cyst with irregular wall and papillary projections.

Pouch of Douglas obliteration diagnosed with transvaginal sonography using the sliding sign is an indirect sign of the presence of:

• a)
  

  Utero-vesical fold endometriosis.

  
  
• b)
  

  Ovarian endometriosis.

  
  
• c)
  

  Rectal endometriosis.

  
  
• d)
  

  Adenomyosis.

  
  
• e)
  

  Hydrosalpinx.

The junctional zone is seen on three-dimensional transvaginal ultrasound coronal view of the uterus as:

• a)
  

  A hyperechoic zone around the endometrium.

  
  
• b)
  

  Cystic areas around the endometrium.

  
  
• c)
  

  A hypoechoic zone around the endometrium.

  
  
• d)
  

  A zone with abundant irregular vessels.

  
  
• e)
  

  Myometrium with hypoechoic striation.

Which of the following second-stage tests are useful to improve characterisation of difficult masses after expert subjective assessment based upon the International Ovarian Tumor Analysis (IOTA) studies?

• a)
  

  Serum CA125.

  
  
• b)
  

  Serum human epididymis protein-4 (HE4).

  
  
• c)
  

  Combined serum CA125 and HE4.

  
  
• d)
  

  Risk of Malignancy Index (RMI).

  
  
• e)
  

  Risk of Ovarian Malignancy Algorithm (ROMA).

Which of the following typical morphological features is/are frequently seen in difficult tumours after transvaginal ultrasound (TVS)?

• a)
  

  Unilocular-solid or multilocular-solid appearance.

  
  
• b)
  

  Irregular walls and papillary projections.

  
  
• c)
  

  Multilocular cysts with more than 10 locules.

  
  
• d)
  

  Irregular solid tumours with ascites and at least moderate colour score.

  
  
• e)
  

  Unilocular tumours with ground glass appearance in premenopausal women.

In accordance with the IOTA simple rules, we can classify a lesion as a malignant tumour if:

• a)
  

  Ascites is present but the adnexal tumour contains no vascularisation (colour score 1).

  
  
• b)
  

  A unilocular cyst is accompanied by ascites.

  
  
• c)
  

  The adnexal mass contains a solid component, with a largest diameter of 5 mm, and acoustic shadows are present.

  
  
• d)
  

  The adnexal mass contains five papillary structures with vascular flow inside the papillae and ascites (but no other simple rules features are present).

  
  
• e)
  

  A smooth multilocular lesion less than 10 cm with abundant blood flow is present (colour score 4).

Which of the following is/are true about characterising adnexal masses with magnetic resonance imaging (MRI)?

• a)
  

  MRI is not compared with subjective ultrasound assessment by experts in studies assessing second-line imaging test for characterising ‘difficult to classify’ adnexal masses after TVS.

  
  
• b)
  

  The addition of dynamic contrast-enhanced and diffusion-weighted sequences increased the diagnostic accuracy of conventional MRI in some studies.

  
  
• c)
  

  The contribution of MRI to the evaluation of ‘difficult to classify’ adnexal masses is mainly to improve specificity.

  
  
• d)
  

  The A _DNEX MR _SCORING system is the first MRI-based scoring system that has been externally validated.

  
  
• e)
  

  Studies that evaluate test performance of MRI for characterising indeterminate masses after TVS provide distinct criteria that define this ‘difficult to classify’ adnexal mass compared with other masses in which ultrasound classification was more straightforward.

Which of the following is/are obstacles to ultrasound being a standard staging procedure in ovarian cancer worldwide?

• a)
  

  Expertise in interpreting ultrasound findings.

  
  
• b)
  

  Acoustic limitations (e.g. obesity, massive ascites, and multiple laparotomies).

  
  
• c)
  

  Missing reproducibility data.

  
  
• d)
  

  Availability.

  
  
• e)
  

  Cost.

What is/are the standard imaging techniques for pre-operative staging of ovarian cancer?

• a)
  

  Contrast-enhanced computed tomography of the abdomen and pelvis.

  
  
• b)
  

  Magnetic resonance imaging.

  
  
• c)
  

  Positron emission tomography and computed tomography.

  
  
• d)
  

  Intravenous urography.

  
  
• e)
  

  Routine chest radiograph.

What is/are considered limitations of contrast-enhanced computed tomography?

• a)
  

  Metastatic lesions smaller than 1 cm.

  
  
• b)
  

  Underestimation of tumour stage.

  
  
• c)
  

  Severe allergy to iodinated contrast agents or renal insufficiency.

  
  
• d)
  

  Pregnancy.

  
  
• e)
  

  Short examination time.

Which imaging technique is considered the gold standard for assessing the extent of cervical cancer?

• a)
  

  Ultrasound.

  
  
• b)
  

  Magnetic resonance imaging.

  
  
• c)
  

  Positron emission tomography.

  
  
• d)
  

  CT scan.

  
  
• e)
  

  Lymphoscintigraphy.

Which of the following is/are advantages of TVS over MRI as an imaging technique for the first diagnostic approach in evaluating cervical cancer?

• a)
  

  More available.

  
  
• b)
  

  Faster.

  
  
• c)
  

  Cheaper.

  
  
• d)
  

  Less contraindications.

  
  
• e)
  

  Dynamic examination.

Which of the following is/are correct regarding US for cervical cancer?

• a)
  

  On transvaginal or transrectal ultrasound examination, cervical cancer usually appears unvascularised on colour Doppler.

  
  
• b)
  

  Tumour infiltration of the parametria cannot be assessed on ultrasound examination.

  
  
• c)
  

  The accuracy of transvaginal or transrectal ultrasound examination in cervical cancer detection and paramatrial infiltration is similar to the accuracy provided by MRI for early disease.

  
  
• d)
  

  The accuracy of transvaginal or transrectal ultrasound examination in cervical cancer detection and paramatrial infiltration is similar to the accuracy provided by MRI for more advanced disease.

  
  
• e)
  

  The data comparing TVS and MRI in early disease is from multi-centre, prospective studies.

Which is/are the main key points in the ultrasound assessment of women with endometrial cancer?

• a)
  

  Subjective assessment of myometrial invasion.

  
  
• b)
  

  Subjective assessment of cervical invasion.

  
  
• c)
  

  Tumor size measurement in three dimensions.

  
  
• d)
  

  Endometrial thickness measurement.

  
  
• e)
  

  Vascular morphology assessment.

Which statement(s) is/are true about the ultrasound examination of endometrial cancer?

• a)
  

  Three-dimensional ultrasound is crucial in the assessment of myometrial invasion.

  
  
• b)
  

  Tumor–uterine anterio–posterior diameter is a valuable objective measurement to estimate the risk of deep myometrial invasion.

  
  
• c)
  

  A dynamic examination technique can be useful in assessing cervical invasion.

  
  
• d)
  

  In most cases, the best way to assess myometrial invasion in endometrial cancer is by trans-abdominal examination with a filled urinary bladder.

  
  
• e)
  

  The main advantages with ultrasound are low cost, high availability, no radiation, and no need for preparation or intravenous contrast.

Which of the following is/are the main imaging planes when carrying out magnetic resonance imaging (MRI) in uterine cancer?

• a)
  

  Sagittal.

  
  
• b)
  

  Axial.

  
  
• c)
  

  Coronal/frontal.

  
  
• d)
  

  Oblique.

  
  
• e)
  

  Transverse.

Which of the following is/are M-features (malignant) in the IOTA rules?

• a)
  

  Irregular solid tumour.

  
  
• b)
  

  At least 3 papillary structures.

  
  
• c)
  

  The presence of ascites

  
  
• d)
  

  Smooth multilocular tumour with largest diameter >100 mm

  
  
• e)
  

  Very strong blood flow

Which of the following is/are B-features (benign) in the IOTA rules?

• a)
  

  Smooth multilocular tumour with largest diameter <100 mm.

  
  
• b)
  

  Unilocular tumour.

  
  
• c)
  

  The presence of solid components where the largest solid component has a largest diameter >7 mm.

  
  
• d)
  

  Absence of acoustic shadows.

  
  
• e)
  

  No blood flow.

Which of the following is/are true regarding TVS for adnexal mass characterisation?

• a)
  

  Subjective assessment of gray scale and colour Doppler ultrasound findings with TVS is the first-line imaging technique for characterising adnexal masses.

  
  
• b)
  

  The optimal approach using ultrasound to discriminate between the benign or malignant nature of an adnexal mass should involve a level II examiner.

  
  
• c)
  

  In the International Ovarian Tumor Analysis (IOTA) five categories of diagnostic certainty have been described.

  
  
• d)
  

  “Probably malignant” is one of the IOTA categories of diagnostic certainty.

  
  
• e)
  

  When expert examiners are highly or moderately confident about the histological nature of an adnexal mass the diagnostic sensitivity is over 90%.

Which of the following is/are further true regarding TVS for adnexal mass characterisation?

• a)
  

  Less than 10% of masses cannot be confidently classified as benign or malignant by experienced ultrasound examiners.

  
  
• b)
  

  Sensitivity is lower with unclassifiable tumours.

  
  
• c)
  

  Specificity is higher with unclassifiable tumours.

  
  
• d)
  

  The ability to characterise adnexal tumours correctly with TVS improves with the level of experience of the ultrasound operator.

  
  
• e)
  

  There is no guidance in Europe on what training is required for different levels of ultrasound operator.

Which of the following is/are true regarding risk models for adnexal mass characterisation?

• a)
  

  The most recent systematic review and meta-analysis to address the performance of mathematical models and scoring systems reviewed a total of under 100 diagnostic accuracy studies.

  
  
• b)
  

  Under 50 different prediction models for characterising adnexal masses were considered.

  
  
• c)
  

  The RMI was the most frequently validated model in the meta-analysis.

  
  
• d)
  

  The IOTA logistic regression model LR2 was superior to all other models included in the meta-analysis in terms of sensitivity.

  
  
• e)
  

  The IOTA logistic regression model LR2 was superior to all other models included in the meta-analysis in terms of specificity.

Which of the following is/are part of the six IOTA LR2 variables?

• a)
  

  Menopausal status.

  
  
• b)
  

  The presence of ascites.

  
  
• c)
  

  The presence of acoustic shadows.

  
  
• d)
  

  Maximum diameter of any solid component.

  
  
• e)
  

  The presence of blood flow within a papillary projection.