RADIOLOGY OSCE COMPILED FILE

Dec 20,2021
Self-assessment questions with answers
• These questions test your ability to present a chest
radiograph and recognise pathology.
• They are presented in the same format as an objective
structured clinical examination (OSCE) or viva station,
so to make it as real as possible there are no multiple-
choice questions (MCQs).
• There are 18 questions, each based on one chest
radiograph.
• Remember to use the ABCDE approach when
presenting and remember there may be more than
one pathology in a single radiograph.
• Part (a) of each question tests your ability to correctly
present the radiograph using the ABCDE method and at
the same time recognise pathology.
• Parts (b) onward are typical questions you may get
asked in an OSCE and do not necessarily test facts
learnt from this book.
• They are designed to test and teach you more general
knowledge relating to the patient’s pathology.
• Note: Any initials, ages and dates used are purely
fictitious and are not related to the patient’s radiograph
in question.
 Question 1

• Figure 1 Name:Ms LA, Age:

35.Date taken: 27 July. Presented
with shortness of breath
(a). Present this radiograph.
(b). Where is the anterior part of the
left 2nd rib?
(c). Where is the border of the right
atrium?
(d). Why is the right ventricle not
visible on this radiograph?
Answer 1
(a). This is a PA chest radiograph of
LA, taken on 27 July.
• The radiograph is not rotated and
there is adequate inspiration.
A. The trachea is central.
B. The lungs are uniformly expanded,
and the lungs are clear.
C. The heart size is normal.
- There is no mediastinal shift.
- The mediastinal contours and hila
appear normal.
D. There is no fracture or bone
abnormality.
E. There is no evidence of gas under the diaphragm,
subcutaneous emphysema or any foreign body.
• In summary, this is a normal chest radiograph.
(b). The anterior part of left 2nd rib is shown in yellow.
(c). The border of the right atrium is the right heart
border. It is shown with a red line.
(d). The right ventricle is not visible as it lies anteriorly
and so does not have a border on a PA chest
radiograph.
Question 2

• Figure 2 Name: Mr CC, Age:

32. Date taken: 30
September. Presented with
acute shortness of breath
(a). Present this radiograph.
(b). What would you do next?
 Answer 2
(a). This is a PA chest radiograph of CC,
taken on 30 September.
• The radiograph is not rotated and there is
adequate inspiration.
A. The trachea is deviated to the left (outlined
with a white dotted line and shown in blue).
B. There is a large Rt sided pneumothorax
(blue)
- There is loss of normal lung markings on
the Rt side as the right lung is collapsed
medially.
- The right hemidiaphragm is depressed (2).
The left lung is clear.
C. The heart and mediastinal structures are shifted to the left
(normal position of the right heart border (1)).
D.There is no fracture or bone abnormality.
E.There is no evidence of gas under the diaphragm, surgical
emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph, showing a
right-sided tension pneumothorax.
(b). Immediately review the pt as a tension pneumothorax is a
life-threatening medical emergency and a delay in treatment
could lead to death.
- Signs on clinical examination include tracheal deviation to the
left, reduced chest movement on the right side, hyper-
resonance on percussion of the right hemithorax, reduced or
absent breath sounds on auscultation of the right hemithorax
and hypotension.
- I would treat this immediately by inserting a large bore
cannula into the right2nd intercostal space, mid-clavicular
line. This will release the pressure in the right hemithorax and
buy some time for definitive treatment with a right-sided
intercostal chest drain
Question 3

• Figure 3 Name: Ms HA, Age: 55.

Date taken: 1 July. Admitted with a
history of collapse. Complete heart
block was diagnosed, and a
pacemaker inserted.
- This radiograph was taken prior to
discharge.
(a). Present this radiograph.
(b). What is the likely cause of this
patient’s pathology?
(c). What would be the next step in
this patient’s management?
 Answer 3

(a).This is a PA chest radiograph of

HA, taken on 1July.
• The radiograph is not rotated and
there is adequate inspiration.
A.The trachea is central.
B. There is a left-sided pneumothorax
(blue). The lung edge is seen on the
left side and there are no lung
markings beyond the lung edge.
- The right lung is clear.
C. The heart size is normal; no
mediastinal shift. The mediastinal
contours and hila appear normal.
D. There is no fracture or bone abnormality.
E. There is a cardiac pacemaker in situ and three ECG leads
overlying the patient.
- There is no evidence of gas under the diaphragm,
subcutaneous emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph showing a
left-sided pneumothorax and a cardiac pacemaker.
(b).Pneumothorax secondary to recent pacemaker insertion.
(c). Insert an intercostal chest drain (with an underwater seal)
into the left pleural space.
Question 4

• Figure 4 Name: Ms NM, Age: 60.

Date taken: 20 March. Presented
with dyspnoea.
(a). Present this radiograph.
(b). What is the likely cause of the
abnormality in the lower zone of
the left lung?
(c). Other than a staging CT scan,
what would be the next step in this
patient’s management and what
tests would you specifically send
for?
Answer 4
(a).This is a PA chest radiograph of NM,
taken on 20March.
• The radiograph is not rotated and there is
adequate inspiration.
A. The trachea is central.
B. There is a left-sided pleural effusion
(green).
- This is a homogenous, dense opacity in
the left lower zone with loss of the left
costophrenic angle & hemidiaphragm.
- The upper edge is concave in shape and
a meniscus is seen laterally.
- There is also a large mass lesion in the
left mid-zone highly suggestive of
malignancy (red). The right lung is clear.
C. The heart size is difficult to assess accurately as the left
heart border is hidden by the pleural effusion. There is no
mediastinal shift. The mediastinal contours and hila appear
normal.
D. There is no # or bone abnormality.
E. There is no evidence of gas under the diaphragm,
subcutaneous emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph showing a
left-sided pleural effusion and a left-sided mass lesion, highly
suggestive of a primary lung malignancy.
 (b). The pleural effusion is most likely a malignant pleural
effusion secondary to a lung malignancy.
(c).The next step in this patient’s management would be to
obtain a sample of pleural fluid by performing an ultrasound-
guided pleural aspirate.
This should be sent to:
• cytology – to look for malignant cells;
• biochemistry – to determine protein content to see if the fluid is
an exudate or transudate;
• microbiology – to culture the fluid for infective organisms and
determine antibiotic sensitivities;
• pH– low pH (<7.2) is associated with empyema & malignancy.
Question 5

• Figure 5 Name: MsVW, Age:

58. Date taken: 27 August.
Post-op after major surgery.
(a). Present this radiograph.
(b). If the radiograph was
repeated in one months’ time,
what change(s) would you
expect to see?
Answer 5

(a).This is a PA chest radiograph of

VW, taken on 27 August.
• The radiograph is slightly rotated to
the left and there is adequate
inspiration.
A. The trachea appears to the left of the
spinous processes;however, the
radiograph is rotated to the left so this
is to be expected.
B. There is a left-sided hydropneumothorax.
- There is diffuse opacification (fluid, green) in the inferior two
thirds of the left hemithoraxand gas (pneumothorax, blue) in
the superior third of the left hemithorax.
- There is a horizontal air–fluid level (1) where the fluid meets
the gas. The right lung is clear.
C. The heart size cannot be assessed as the left heart border is
hidden by the fluid in the left hemithorax.
- There is mediastinal shift to the left as you cannot see the
right heart border.
D. There is no fracture or bone abnormality.
E. There is no evidence of gas under the diaphragm;
however, there is subcutaneous emphysema (yellow)
overlying the left hemithorax.
- There is also a line of staples from the recent surgery
(2).
• In summary, this is an abnormal chest radiograph
showing a recent left-sided pneumonectomy.
(b). You would expect the surgical staples to
have been removed and the gas in the left
hemithorax to have been absorbed by the
body and replaced with fluid, giving a total
whiteout of the left hemithorax.
- The volume loss on the left side would remain
(as the left lung has been removed) and
therefore you would still expect to see
mediastinal shift to the left.
Question 6

• Figure 6 Name: Ms NC, Age:

29. Date taken: 27 Sep. A
patient with type 1 diabetes
presents to the emergency
department with diabetic
ketoacidosis.
(a). Present this radiograph.
(b). Which lobe of the lung is
affected?
Answer 6

(a). This is an PA chest radiograph

of NC, taken on 27September.
• The radiograph is not rotated and
there is adequate inspiration.
A. The trachea is central.
B. There is poorly defined
opacification in the left lower zone
(green). The lungs are otherwise
uniformly expanded.
C. The heart size is normal.The
mediastinal contours and hila
appear normal.
D. There is no fracture or bone abnormality.
E. There is no evidence of gas under the diaphragm, surgical
emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph showing
left lower lobe consolidation.
(b). Left lower lobe. The left heart border (white dotted
line, 1) can be clearly seen as there is gas in the lung
adjacent to it (the lingula). Although the medial aspect
of the left hemidiaphragm is seen (black dotted line,
2), the lateral aspect of the left hemidiaphragm is
poorly defined.
- This is a good example of the silhouette sign.
- This indicates that the pathology is in the lung
immediately adjacent to the left hemidiaphragm, i.e.
the left lower lobe. Therefore, the consolidation is
within the left lower lobe.
• Figure 7 Name: Ms DR, Age: 60.
Date taken: 26 August. Presented
with abdominal pain.
(a). Present this radiograph.
(b). The patient is complaining of
severe abdominal pain. Given this
radiograph, give three possible
causes for this patient’s pain.
(c). What are the causes for unilateral
hilar lymphadenopathy?
 Answer 7

(a). This is a PA chest radiograph

of DR, taken on 26August.
- The radiograph is not rotated and there
is adequate inspiration.
A. The trachea is central.
B. The lungs are uniformly expanded,
and the lungs are clear.
C. There is cardiomegaly. width of the
heart (shorter red arrow, 1) is greater
than half the width of the thoracic
cavity (longer black arrow, 2).
- no mediastinal shift. There is a large opacification
(orange) in the Rt upper mediastinum with a smooth
lobular outline consistent with right hilar LAP
D. There is no fracture or bone abnormality.
E. There is gas (blue) under the right hemi-diaphragm
(white arrowheads) in keeping with
pneumoperitoneum.
- There is no surgical emphysema or any foreign body.
• In summary, this is an abnormal chest radiograph
showing cardiomegaly, right hilar lymph node
enlargement, and pneumoperitoneum.
 (b). Possible causes of abdominal pain with a
pneumoperitoneum are
- perforated hollow viscus (such as a perforated peptic
ulcer, appendix or bowel diverticulum),
- post-surgery to the abdomen or trauma (e.g. stabbing
involving the peritoneal cavity).
(c). Causes of unilateral hilar LAP are
- infection (e.g. tuberculosis),
- malignant spread from a primary lung tumour or
lymphoma.
- Sarcoidosis is another possible cause; however, it is
rarely unilateral
Question 8

• Figure 8 Name: Ms ES, Age:

56. Date taken: 3 April.
Presented with chest pain.
(a). Present this radiograph.
(b). Give three causes for
pleural effusions.
(c). How might you distinguish
between them?
 Answer 8
(a). Thisis a PA chest radiograph of ES,
taken on 3April.
-The radiograph is not rotated and there is
adequate inspiration.
A. The trachea is central.
B. There are bilateral pleural effusions
(green). The RT-sided effusion is larger
than the left.
- This is shown by a homogenous,dense
opacity in both lower zones with loss of
costophrenic angles & hemidiaphragms
- The upper edges are concave in shape
and menisci are seen laterally.
C. The heart size is difficult to assess accurately as the
right heart border is hidden by the pleural effusion.
There is no mediastinal shift. The mediastinal
contours and hila appear normal.
D. There is no fracture or bone abnormality.
E. There is no evidence of gas under the diaphragm,
subcutaneous emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph
showing bilateral pleural effusions.
(b) Heart failure, liver failure, renal failure.
(c).
1. Heart failure: ECG findings, Echo & raised brain
natriuretic peptide levels may point towards this dx.
2. Liver failure: elevated liver biochemistry and/or a
low serum albumin.
3. Renal failure: renal function – looking for raised
creatinine and sodium/potassiumimbalance. Low
albumin may also be present in nephrotic
syndrome
Question 9

• Figure 9 Name: Ms RR,

Age: 38. Date taken: 12
February. Presented with
abdominal pain.
(a).Present this radiograph.
(b).What is the diagnosis?
(c).Give three possible causes
of pneumoperitoneum?
Answer 9

(a). This is a PA chest

radiograph of RR, taken on
12February.
- The radiograph is not
rotated and there is
adequate inspiration.
A.The trachea is central.
B.The lungs are uniformly
expanded, and the lungs
are clear.
C. The heart size is normal; no mediastinal shift. The
mediastinal contours and hila appear normal.
D. There is no fracture or bone abnormality.
E. There is free gas under both hemidiaphragms (blue).
The thin line of the diaphragm between the lungs and
free gas in the abdomen is clearly seen on both sides
(arrowheads). There is no evidence of surgical
emphysema or any foreign body.
• In summary, this is an abnormal chest radiograph
showing pneumoperitoneum.
 (b). Pneumoperitoneum (free gas in the
peritoneal cavity).
1. A perforated hollow viscus such as a
perforated peptic ulcer, appendix, or
bowel diverticulum.
2. Post-surgery to the abdomen.
3. Trauma (e.g. stabbing involving the
peritoneal cavity).
• Figure 10 Name: Ms WC,
Age: 52. Date taken: 23 July.
Presented with a cough for 3
weeks.
(a). Present this radiograph.
(b). What is the diagnosis?
(c). What follow-up would you
recommend?
 Answer 10

(a). This is a PA chest

radiograph of WC, taken
on 23 July.
- The radiograph is not
rotated and there is
adequate inspiration.
A. The trachea is central.
B. There is a triangular opacity projected over the left
side of the heart (blue).
- The lateral margin of this opacity (1) together with the
left heart border (2) can both be seen separately giving
the ‘double heart border’ sign and the left
hemidiaphragm is elevated slightly. Appearances are
consistent with left lower lobe collapse.
- The right lung is clear.
C. The heart size is normal. There is no mediastinal shift.
The mediastinal contours and hila appear normal.
D. There is no fracture or bone abnormality.
E. There is no evidence of gas under the diaphragm,
surgical emphysema or any foreign body.
• In summary, this is an abnormal chest radiograph
showing left lower lobe collapse.
(b). Left lower lobe collapse.
• The main ddx is collapse secondary to infection or
bronchiectasis; however, bronchial obstruction due to a
lung malignancy can also cause collapse.
(c). A CT scan of the chest is recommended to look for
any underlying malignancy.
• Figure 11Name: MsRP,
Age: 38. Date taken:31
January.Patient involved in
a road traffic accident.
(a).Present this radiograph.
(b). In which lobe is the
main lung abnormality?
 Answer 11

(a). This is a PA chest radiograph

of Ms RP, taken on 31 Jan.
- The radiograph is not rotated
and there is adequate
inspiration.
A. The trachea is central.
B. There is heterogenous
airspace opacification (green)
in the right lower zone and no
loss of lung volume in
keeping with consolidation.
C. The heart size is normal. There is no mediastinal
shift.
D. There is an acute fracture of the right 3rd rib (marked
by a white circle).
E. There is a right-sided chest drain in situ with tip
projected over the apex if the right lung. There are
also three ECG leads overlying the patient.
Subcutaneous emphysema (yellow) is seen over the
right lateral chest wall. There is no evidence of gas
under the diaphragm or any foreign body.
• In summary, this is an abnormal chest radiograph
showing middle lobe consolidation, right 3rd rib
fracture and a right-sided chest drain with some
subcutaneous emphysemain the right lateral chest wall
around the site of drain insertion.
(b). Middle lobe. The right hemidiaphragm (white dotted line) can
be clearly seen as there is gas in the lung adjacent to it (the
right lower lobe). The right heart border is poorly defined.
- This is a good example of the silhouette sign. This indicates
that the pathology is in the lung immediately adjacent to the
right heart border, i.e. the middle lobe.
- Therefore, the consolidation is within the middle lobe.
• Figure 12 Name: Mr DC, Age:
62. Date taken: 11 December.
Patient with hypercalcaemia.
(a). Present this radiograph.
(b). What is a common cause of
this radiographic finding?
Answer 12

(a). This is a PA chest

radiograph of Mr DC, taken
on 11 December.
- The radiograph is not
rotated and there is
adequate inspiration.
A.The trachea is central.
B. The lungs are uniformly
expanded, and the lung
fields are clear.
C. The heart size is normal. There is no mediastinal shift. The
mediastinal contours and hila appear normal.
D. There is widespread increased density throughout the
skeleton (red) in keeping with diffuse sclerosis.
More focal areas of sclerosis can be seen in both humeral
heads.
E. There is no evidence of gas under the diaphragm, surgical
emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph showing
sclerotic changes throughout the skeleton.
(b). Sclerotic bone metastases from prostate cancer.
• Figure 13 Name: Ms HJ, Age:
46. Date taken: 18 April.
Presented with a cough and
fever.
(a). Present this radiograph.
(b). What is the diagnosis?
(c ).What follow-up would you
recommend?
Answer 13
(a). This is an AP chest radiograph
of Ms HJ, taken on 18 April.
- The radiograph is not rotated and
there is adequate inspiration.
A. The trachea is central.
B. There is heterogenous airspace
opacification (green) in the right mid
zone and no loss of lung volume in
keeping with consolidation. The
inferior border of this consolidation is
well defined; the horizontal fissure
(marked with a white dashed line),
therefore it is in the right upper lobe.
The left lung is clear.
C. The AP projection means the heart size cannot be
accurately assessed. There is no mediastinal shift.
The mediastinal contours and hila appear normal.
D. There is no fracture or bone abnormality.
• There is no evidence of gas under the diaphragm,
surgical emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph
showing right upper lobe consolidation.
(b).Given the clinical history, pneumonia is the most
likely diagnosis.
(c). After appropriate antibiotic treatment, a repeat
chest radiograph should be performed 6
weeksafter clinical resolution to ensure that the
consolidation has resolved. If the consolidation
does not resolve by that time, then a CT of the
thorax should be considered asmalignancy can
sometimes look like consolidation on a chest
radiograph.
• Figure 14 Name: Mr AC,
Age: 62. Date taken: 30
August. Presented with
shortness of breath.
(a). Present this radiograph.
(b). What is the diagnosis?
(c). What is the next
appropriate imaging
investigation?
 Answer 14

(a).This is a PA chest radiograph of

Mr AC, taken on 30August.
- The radiograph is not rotated
and there is adequate
inspiration.
A. The trachea is deviated to the
left(blue and outlined with a
white dotted line).
B. There is increased density
throughout the entire left
hemithorax. The right lung is
clear.
C. The heart and mediastinum have moved from their
normal position (1) to lie in the left hemithorax (2).
D. There is no fracture or bone abnormality.
E.There is no evidence of gas under the diaphragm,
surgical emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph
showing signs of volume loss in the left hemithorax.
Given there is no evidence of a previous
pneumonectomy, appearances are in keeping with
complete left lung collapse.
(b). Complete collapse of the left lung.
(c).Given that one of the underlying causes of
lung collapse is a tumour obstructing the
main bronchus, a CT scanof the chest is
advised to lookfor malignancy. Some centres
also image the liver at the same time to look
for possible liver metastases.
• Figure 15 Name: Mr GB,
Age: 43. Date taken: 2
August. Presented with
cough and fever.
(a).Present this radiograph.
(b).What is the diagnosis?
(c). What follow-up/further
investigations would you
recommend?
 Answer 15
(a) This is a PA chest radiograph of GB,
taken on 2August.
• The radiograph is not rotated &
there is adequate inspiration.
A. The trachea is central.
B. There is a cavitating lung lesion in
the right upper lobe (yellow). It is
associated with an area of
consolidation fanning out from the
cavity towards the edge of the lung
(green).The left lung is clear.
C. The heart size is normal. There is no mediastinal
shift. The mediastinal contours and hila appear
normal.
D. There is no fracture or bone abnormality.
E. There is no evidence of gas under the diaphragm,
surgical emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph
showing a cavitating lung lesion in the right upper
lobe with an associated area of consolidation
 (b). Lobar pneumonia with cavitation.
• Given that a cavitating lung lesion is present, it
would be appropriate to request a CT of the
chest to investigate further to exclude
malignancy. A follow-up chest radiograph in 6
weeks after appropriate antibiotic treatment is
not appropriate in this case as there is already
radiographic suspicion of a cavitating mass
lesion, which may be malignant.
• Figure 16 Name: Mr MF,
Age: 67. Date taken: 6
March.Patient presenting
with right sided ptosis.
(a). Present this radiograph.
(b). What is the likely
diagnosis?
(c). What syndromes may be
associated with this
appearance?
Answer 16

(a). This is a PA chest

radiograph of Mr MF, taken
on 6March.
A.Theradiograph is not rotated &
there is adequate inspiration.
B. The trachea is central.
C. There is a mass lesion at the
right apex (red) with
associated pleural thickening
(green). The left lung is clear.
D. The heart size is normal. There is no mediastinal
shift. The mediastinal contours and hila appear
normal.
E. There is complete lysis of the right 1strib and
erosions of the right transverse processes of the
upper thoracic vertebrae. There is also a fracture of
the right 9th rib (each marked by a white circle).
• There is no evidence of gas under the diaphragm,
subcutaneous emphysema, or any foreign body.
• In summary, this is an abnormal chest radiograph
showing a right-sided apical mass lesion with
associated pleural thickening and complete lysis of
the right 1strib, highly suggestive of a primary lung
malignancy. There is also a fracture of the right 9thrib,
which may be coincidental.
(b). Right-sided Pancoast tumour.
(c). Horner’s syndrome and Pancoast’s syndrome.
• Figure 17 Name: Ms MA, Age:
49. Date taken: 14 March.
Presented with chest pain.
(a).Present this radiograph.
(b).How may this patient have
presented clinically?
(c). What medication will this
patient need for life?
(d). Why is there widening of the
carinal angle?
Answer 17

(a). This is a PA chest radiograph

of MA, taken on 14 March.
(b). The radiograph is not rotated
and there is adequate inspiration.
A. The trachea is central. There is
widening of the carinal angle (A)
(trachea and mainstem bronchi
shown in blue and outlined with a
white dotted line).
B. The lungs are uniformly expanded, and the lungs are
clear.
C. There is cardiomegaly. The width of the heart
(shorter red arrow, 1) is greater than half the width of
the thoracic cavity (longer black arrow, 2). The
mediastinal contours and hila appear normal.
D. There is no fracture or bone abnormality.
E. There is a mechanical heart valve in situ and median
sternotomy wires are noted. There is no evidence of
gas under the diaphragm or surgical emphysema.
• In summary, this is an abnormal chest
radiograph showing widening of the carinal
angle, cardiomegaly, a mechanical heart valve,
and median sternotomy wires.
(b). Atrial fibrillation due to mitral valve disease.
(c). Lifetime anticoagulation.
(d). There was obviously previous mitral valve
disease (treated with mitral valve replacement),
which has caused left atrial enlargement. This will
in turn cause widening of the carinal angle.
• Figure 18 Name: Mr BW,
Age: 64. Date taken: 30 May.
Presented with confusion.
(a). Present this radiograph.
(b). What is the diagnosis?
(c). What is the likely cause of the
abnormality identified?
 Answer 18

(a). This is a PA chest

radiograph of BW, taken on
30May.
A. The radiograph is not rotated
and there is adequate
inspiration.
B. The trachea is deviated to the
right of the midline (1).
• There is right upper lobe collapse/consolidation
(blue). There is increased opacification in the right
upper zone with loss of definition of the upper right
mediastinal margin. The horizontal fissure has been
pulled upwards (normal position of the horizontal
fissure (2), abnormal raised position of the horizontal
fissure (3)).
• The heart size is normal.
• There is no fracture or bone abnormality.
• There is no evidence of gas under the diaphragm,
surgical emphysema or any foreign body.
• In summary, this is an abnormal chest radiograph
showing right upper lobe collapse/consolidation.
(b). Right upper lobe collapse/consolidation. This
is not total collapse of the right upper lobe as
the horizontal fissure is only marginally
displaced superiorly.
(C). In this adult patient the most likely cause would be
a central bronchial neoplasm causing narrowing of
the upper lobe bronchus with consequent infection. A
CT of the chest and referral to the respiratory team
for consideration of bronchoscopy would be the next
step to look for an underlying malignancy.