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Breast

Imaging

A Core Review
Breast Imaging

A Core Review
EDITORS
Biren A. Shah, MD
Senior Staff Radiologist, Division of Breast Imaging
Henry Ford Health System
Clinical Associate Professor
Wayne State University School of Medicine
Detroit, Michigan

Sabala R. Mandava, MD
Senior Staff Radiologist, Division of Breast Imaging
Director, Breast Imaging Fellowship
Associate Program Director, Womens Imaging Fellowship
Henry Ford Health System
Clinical Assistant Professor
Wayne State University School of Medicine
Detroit, Michigan
Senior Executive Editor: Jonathan W. Pine, Jr.
Product Manager: Amy G. Dinkel
Production Product Manager: Priscilla Crater
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Library of Congress Cataloging-in-Publication Data


Breast imaging (2013)
Breast imaging : a core review / editors, Biren A. Shah, Sabala R. Mandava. First edition.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4511-7639-1
I. Shah, Biren A., editor. II. Mandava, Sabala, editor. III. Title.
[DNLM: 1. Mammographymethods. 2. Breast Neoplasmsradiography. WP 815]
RG493.5.R33
618.1'907572dc23

2013018324
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of the information in a particular situation remains the professional responsibility of the practitioner.
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10 9 8 7 6 5 4 3 2 1
To my parents, Ashok and Jyoti Shah, to whom I owe everything I am.
They have guided me by their life principles and strong work ethic.
To my sister, Binita Ashar, for her sound advice and constant encouragement.
To my wife, Dharmishtha Shah, for her endless support and love.
To my two sons, Aren and Deven, who make life worthwhile.

BIREN A. SHAH

To my husband, Rajesh, and my children, Milind and Ariana, for their unwavering love and support.

SABALA R. MANDAVA
CONTRIBUTORS

Donovan M. Bakalyar, PhD, FACR


Senior Staff Scientist
Department of Diagnostic Radiology
Henry Ford Health System
Detroit, Michigan

Hassana Barazi, MD
Staff Radiologist
Valley Imaging Consultants, LLC.
Midwest Center for Advanced Imaging
Rush-Copley Medical Center
Aurora, Illinois

Brandon A. Behjatnia, DO, MPT


Clinical Instructor
Department of Radiology
Michigan State University
East Lansing, Michigan
Womens Imaging Radiologist
Diagnostic Center for Women
Miami, Florida

Amy S. Campbell, MD
Assistant Professor
Co-Director, Breast Imaging
Department of Radiology and Radiological Science
Medical University of South Carolina
Charleston, South Carolina

Walter Huda, PhD


Professor of Radiology
Department of Radiology and Radiological Science
Medical University of South Carolina
Charleston, South Carolina

Saumil R. Kadakia, MD
Radiologist
Associated Radiologists, Ltd.
Mesa, Arizona

Madelene C. Lewis, MD
Assistant Professor
Assistant Program Director, Diagnostic Radiology Residency Program
Department of Radiology
Medical University of South Carolina
Charleston, South Carolina

Ralph P. Lieto, MSE, FAAPM, FACR


Radiation Safety Officer/Medical Physicist
Radiation Safety Office
St. Joseph Mercy Health System
Ann Arbor, Michigan

Sabala R. Mandava, MD
Senior Staff Radiologist, Division of Breast Imaging
Director, Breast Imaging Fellowship
Associate Program Director, Womens Imaging Fellowship
Henry Ford Health System
Clinical Assistant Professor
Wayne State University School of Medicine
Detroit, Michigan

Colleen H. Neal, MD
Clinical Assistant Professor
Department of Radiology
University of Michigan
Ann Arbor, Michigan

Jay Prakash Patel, MD


Breast and Musculoskeletal Radiologist
Quantum Radiology
Marietta, Georgia

Elizabeth Popovski, MD, MSc


Radiologist
Department of RadiologyThe Permanente Medical Group
Kaiser Foundation Hospitals
Roseville and Sacramento, California

Jane G. Seto, DO
Staff Radiologist
Department of Radiology
Freeman Health System
Joplin, Missouri

Biren A. Shah, MD
Senior Staff Radiologist, Division of Breast Imaging
Henry Ford Health System
Clinical Associate Professor
Wayne State University School of Medicine
Detroit, Michigan

Emily C. Siegal, MD
Senior Staff Radiologist
Division of Breast Imaging Henry Ford Health System
Clinical Assistant Professor
Wayne State University School of Medicine
Detroit, Michigan

Paul J. Spicer, MD
Assistant Professor
Department of Radiology
University of Kentucky
Lexington, Kentucky

Afua Y. Thompson, MD
Assistant Professor
Department of Radiology
Meharry Medical College
Staff Radiologist
Department of Radiology
Nashville General Hospital
Nashville, Tennessee

Samantha Tunnecliffe, RT(R)(M)


Mammography Supervisor
Department of Radiology, Division of Breast Imaging
Henry Ford Health System
Detroit, Michigan

Jenny H. Wang, DO
Diagnostic Radiologist
Department of Radiology
Mercy St. Vincent Medical Center
Toledo, Ohio
SERIES FOREWORD

My idea for the series began when some senior residents asked our attending staff to help them prepare
for the new ABR Core Examination. At the time, I knew very little about the new format for the exam,
other than that it would be a computer-based exam with multiple-choice questions. I started looking for
resources that would help our residents prepare for this exam. As I researched, I found very little in the
way of review guides, banks of questions, etc. that the residents could use. And so the germ of an idea
began to take shape.
As my area of practice is predominantly breast imaging, I thought of putting together a bank of questions
in this subspecialty that would cover the curriculum tested on the ABR Core Exam. I discussed the
concept with my colleague, Sabala Mandava, who was also of a similar mind, and we decided to do a
question book that would be geared toward residents preparing for the Core Exam, but can also be useful
to any radiologist practicing Breast Imaging.
We were then fortunate to be able to enlist multiple colleagues who were interested in contributing to
the book. As this book developed, I started thinking about similar books for the other subjects tested on
the Core Exam. After several weeks of discussion with Jonathan Pine and Amy Dinkel, from Lippincott
William & Wilkins, the concept of a series of books was born.
I am very pleased that the Breast Imaging: A Core Review is the first in The Core Review Series.
There are multiple books such as Musculoskeletal Radiology, Neuroradiology, and others that are either
currently being worked on or in the near future will be added to series. The philosophy for each book in
the series is to review the important concepts tested with approximately 300 questions, in a format similar
to the new ABR Core Exam.
As Series Editor of The Core Review Series, it has been a great source of pleasure to not only be an
author of one of the books, but also to work with many outstanding colleagues across the country who
contributed to the series. This series represents countless hours of work and involvement by many and it
would not have come together without their participation.
My hope for this series is that it will prove to be a useful and comprehensive guide for all residents as
well as fellows and practicing radiologists.
Biren A. Shah
Series Editor
PREFACE

With the changing of the Boards format, these are uncertain times for radiology residents. The days of
preparing for the oral boards with multiple reviews of image interpretation will likely change. Instead,
the Boards are now geared to a more comprehensive understanding of disease processes, the physics
behind image acquisition, quality control, and safety. There is a paucity of study resources available for
residents.
With this in mind, we wanted to provide a guide for residents to be able to assess their knowledge and
review the material in a format that would be similar to the Boards. The questions are divided into
different sections, as per the ABR Core Exam Study Guide, so as to make it easy for the readers to work
on particular topics as needed. There are mostly multiple-choice questions with some extended matching
questions. Each question has a corresponding answer with an explanation of not only why a particular
option is correct but also why the other options are incorrect. There are also references provided for each
question for those who want to delve more deeply into a specific subject. This format is also useful for
radiologists preparing for Maintenance of Certification (MOC).
There are multiple colleagues, some of whom are our past fellows, who contributed to this publication.
This book could not have been finished without the efforts of all these people who took time from their
busy lives to research, write, and submit material in a timely manner. Our heartfelt thanks to all of them.
Many thanks to the staff at LWW, Jonathan Pine, Amy Dinkel, Jeff Gunning, Sree Vidya Dhanvanthri,
and Priscilla Crater for giving us this opportunity and guiding us along the way.
Last, but certainly not the least, we are grateful to our families, who have endured our long hours of
work and kept us smiling throughout the process.
We hope that this book will serve as a useful tool for residents on their road to becoming Board-
certified radiologists and will continue to be a reference in their future careers.
Biren A. Shah, MD
Sabala R. Mandava, MD
CONTENTS
Contributors
Series Foreword
Preface

1 Regulatory/Standards of Care

2 Breast Cancer Screening

3 Diagnostic Breast Imaging, Breast Pathology, and Breast Imaging Findings

4 Breast Intervention

5 Physics Related to Breast Imaging

Index
1 Regulatory/Standards of Care

QUESTIONS

1Which of the following is a Mammography Quality Standards Act (MQSA) requirement for
interpreting physicians?
A.15 category 1 continuing medical education (CME) credits per year
B.10 hours of initial new modality training (e.g., digital mammography)
C.Initial experience of 240 exams under direct supervision in the 6 months before starting to
interpret mammography
D.Continuing experience of interpretation of 960 exams/12 months
2For each diagnostic image, below, assign the likely BI-RADS assessment of either BI-RADS 2
(answer choice A) or BI-RADS 4 (answer choice B). Each option may be used once, more
than once, or not at all:
3The approximate expected number of cancers that should be found in 1,000 initial screening
mammograms is
A.1 to 2
B.6 to 10
C.11 to 14
D.15 to 19
E.20 to 24
4Over a year, 100 cancers are identified; 94 of these were identified based on biopsy
recommendations from a screening mammogram and an additional 6 cancers developed after a
negative mammogram. What is the sensitivity in this population?
A.6%
B.88%
C.90%
D.94%
E.96%
5When assessing for accurate positioning on mediolateral oblique (MLO) view, which of the
following is correct?
A.A large amount of the upper abdomen should be visible.
B.The breast should be pulled out and down.
C.The pectoral muscle should widen at the axilla and extend to the nipple, and the anterior
margin should be convex.
D.The inframammary fold should be neutral in position.
6A patient has a negative screening mammogram study and 8 months later develops a palpable mass
that is biopsied to reveal invasive ductal carcinoma. This is termed a
A.False negative
B.False positive
C.True positive
D.True negative
7Which of the following quality control tests are performed weekly for filmscreen mammography?
A.Darkroom cleanliness
B.Processor quality control
C.Screen cleanliness
D.Viewbox cleanliness
E.Fixer retention
8aAn 85-year-old female with history of left mastectomy. The patient presented for a screening
mammogram of the right breast. A radiopaque marker was placed on the nipple. Images are
provided below.
Based on the screening mammogram images, what is the most appropriate BI-RADS assessment?
A.BI-RADS 0
B.BI-RADS 1
C.BI-RADS 2
D.BI-RADS 3
E.BI-RADS 4
8bThe patient is called back for a repeat mediolateral oblique (MLO) image of the right breast (see
below):

The reason the mediolateral oblique view was repeated was because of
A.Hair artifact
B.Motion artifact
C.Chin artifact
D.Deodorant artifact
E.Skin artifact
9The posterior nipple line measures 13 cm on the mediolateral oblique (MLO) view. What is an
acceptable posterior nipple line measurement on the craniocaudal (CC) view?
A.8 cm
B.9 cm
C.10 cm
D.11 cm
E.12 cm
10In order to meet MQSA requirements, all mammography facilities must review medical outcomes
audit data for the aggregate of interpreting physicians as well as data for each individual
interpreting physician at that facility. How often must the medical outcomes audit data be
reviewed?
A.3 months
B.6 months
C.12 months
D.24 months
11Prior to independently interpreting any new mammographic modality the interpreting physician
must first obtain and document additional training in this modality. How many hours of training are
required?
A.4 hours
B.6 hours
C.8 hours
D.12 hours
12A screening mammogram contains significant motion artifact on one view. Which member of the
team is responsible for assuring appropriate corrective action is taken?
A.Interpreting physician
B.Radiologic technologist
C.Medical physicist
D.Equipment vendor
13aA 41-year-old female with history of a palpable lump in the right breast. Images are provided
below.
Based on the diagnostic mammogram images provided, what is the most appropriate next step?
A.Repeat MLO view due to possible artifact.
B.Proceed to a targeted right breast ultrasound of area that is palpable.
C.Request rolled craniocaudal views of the right breast.
D.Recommend return to annual screening mammography.
E.Refer the patient to see a breast surgeon.
13bThe patient is called back for a repeat mediolateral oblique (MLO) image of the right breast (see
below).

The reason the mediolateral oblique view was repeated was because of
A.Hair artifact
B.Chin artifact
C.Deodorant artifact
D.Suboptimal patient positioning
E.Motion artifact
14Which of the following is correct regarding screening mammography guidelines as recommended
by American College of Radiology?
A.Annual mammograms starting at age 40 until 80
B.Biannual mammograms starting at age 35 and annual after age 40
C.Annual mammograms starting at age 50
D.Biannual mammograms starting at age 40 and annual after age 50
E.Annual mammograms starting at age 40 until the individuals overall health allows
15Which of the following is correct regarding proper positioning of breasts in mammography?
A.The craniocaudal (CC) view is a projection parallel to the pectoralis major muscle.
B.On the CC view, the pectoralis major muscle is seen approximately 75% of the time.
C.On the mediolateral oblique (MLO) view, the pectoralis major should be concave anteriorly.
D.On the MLO view, the pectoralis major muscle should be seen above the level of the axis of
the nipple.
E.The nipple should be in profile on at least one view.
16Federal regulations require that follow-up on surgical and/or pathology results be performed for
patients with positive mammograms. How frequently are facilities required to conduct this
follow-up?
A.Daily
B.Weekly
C.Monthly
D.Yearly
17Failure to inform patients of their results in a timely manner is considered a significant violation.
What is the time limit set by the FDA to provide lay summaries to all patients?
A.7 days
B.14 days
C.30 days
D.60 days
18Which organization regulates mammography quality standards in the United States?
A.Food and Drug Administration
B.American College of Radiology
C.Department of Health and Human Services
D.Regulated by each state independently without federal involvement
19Ghosting artifact on MRI is caused by:
A.Wrong frequency-encoding direction
B.Wrong phase-encoding direction
C.Poor shimming
D.Patient motion
20The definition of positive predictive value 1 (PPV1) is:
A.Percentage of examinations with an abnormal final interpretation that result in a tissue
diagnosis of cancer within 1 year
B.Percentage of examinations with a normal initial interpretation that result in a tissue
diagnosis of cancer within 1 year
C.Percentage of examinations with an abnormal initial interpretation that result in a tissue
diagnosis of cancer within 1 year
D.Percentage of examinations with an abnormal final interpretation where it is known that a
biopsy was performed as a result of the abnormal diagnostic examination that result in tissue
diagnosis of cancer within 1 year
21Which of the following statements concerning BRCA-1 mutation carrier is correct?
A.It is autosomal recessive.
B.It is a tumor suppressor gene on chromosome 17.
C.Lifetime risk of breast cancer is 25% to 35% with the carrier.
D.It is also associated with an increased risk of lung cancer.
22What is the benchmark for the Cancer Detection Rate (CDR) according to the fourth edition of BI-
RADS?
A.15/1,000
B.110/1,000
C.210/1,000
D.>2.5/1,000
E.>5/1,000
23What is the benchmark for the recall rate in screening mammography according to the fourth
edition of BI-RADS ?
A.<10%
B.<20%
C.10% to 15%
D.5% to 12%
E.5% to 15%
24Which of the following is a requirement for continuing education in mammography?
A.Interpretation of at least 960 mammograms per year
B.15 hours of CME that are breast specific per year
C.Performance of at least 36 breast biopsies in 36 months
D.Interpretation of at least 100 breast ultrasound examinations in 1 year
25Which of the following describes the appropriate positioning for the MLO and CC views on a
screening mammogram?
A.The pectoralis muscle must always be present on both the MLO and CC projections.
B.The pectoralis muscle must only be present on the CC projection.
C.The difference between the line from the nipple to the back of the film on CC and the line
from the nipple to the pectoralis muscle on MLO is 2 cm.
D.The difference between the line from the nipple to the back of the film on CC and the line
from the nipple to the pectoralis muscle on MLO is 1 cm.
26Regarding compression plate and imaging receptor, which of the following is necessary?
A.Both 18 24 cm and 12 18 cm sizes are required.
B.Collimation to the breast contour
C.Compression force of 45 to 60 pounds.
D.A fixed grid is required for each receptor size.
E.Paddle advanced by a foot motor with hand compression adjustment
27The following study was performed to evaluate for silicone breast implant rupture.

This image depicts which artifact?


A.Susceptibility artifact
B.Wrap/aliasing artifact
C.Radiofrequency (RF) interference artifact
D.Silicone saturation artifact
28This table demonstrates data obtained from a breast care center of a community hospital in a 12-
month period.

28aWhat is the screening abnormal interpretation rate at this center?


A.4%
B.5%
C.6%
D.8%
E.12%
28bWhat is the cancer detection rate?
A.4/1,000
B.5/1,000
C.6/1,000
D.8/1,000
E.12/1,000
29The following image from a contrast-enhanced breast MR examination demonstrates which
artifact?

A.Chemical shift artifact


B.Wrap/Aliasing artifact
C.Susceptibility artifact
D.Motion artifact
30Regarding standardized film labeling for mammogram images, which of the following is correct?
A.Either the patients full name or a unique patient identification number needs to be on the
film.
B.The name and address of the facility is needed when a patient requests films for other
facilities.
C.Arabic number indicating the cassette should be on every image.
D.View and laterality placed near the nipple
E.The technologists employee number should be included.
31A 55-year-old woman is placed into a BI-RADS 3 category after a diagnostic workup. According
to the BI-RADS lexicon, a BI-RADS 3 finding has less than what percent chance of malignancy?
A.1%
B.2%
C.3%
D.4%
E.5%
32A 60-year-old female presents with a finding which is placed into a BI-RADS 5 category.
According to the BI-RADS lexicon, a BI-RADS 5 lesion has greater than or equal to what percent
chance of malignancy?
A.90%
B.93%
C.95%
D.97%
E.99%
33What artifact is noted on this study?

A.Hair artifact
B.Deodorant
C.VP shunt catheter
D.Jewelry
34What artifact is noted on this study?
A.Hair artifact
B.Deodorant
C.VP shunt catheter
D.Jewelry
35According to the American College of Radiology and the American Cancer Society, contrast-
enhanced screening breast MRI is recommended for women at what percentage lifetime risk of
developing breast cancer?
A.>10%
B.>20%
C.>50%
D.>75%
36What artifact is noted on this study?
A.Static artifact
B.Gridlines artifact
C.Hair artifact
D.Roller artifact
37A premenopausal woman requires a breast MRI with contrast. Which week of the menstrual cycle
is the best choice to perform the MRI?
A.Days 1 to 6
B.Days 7 to 14
C.Days 15 to 21
D.Days 22 to 28
38Which of the following is a clinical indicator of breast cancer risk according to the 2007
American Cancer Society (ACS) recommendations for performing a screening breast MRI as an
adjunct to mammography?
A.Hodgkin disease with mantle field radiation
B.History of neurofibromatosis type 1
C.Lifetime risk of breast cancer of 10% or more using standard risk assessment models
D.Breast density > 50%
39A phantom image obtained during a weekly check should show which of the following to meet
minimum acceptable criteria?
A.Two fibers, two microcalcification clusters, and two masses
B.One fiber, two microcalcification clusters, and one mass
C.Three fibers, three calcification clusters, and three masses
D.Four fibers, three calcification clusters, and three masses
40The view shown in the image below is suboptimal for evaluating which portion of the breast?
A.Inferior
B.Lateral
C.Medial
D.Superior
41Regarding contrast-enhanced breast MRI for the detection of breast cancer, which one of the
following statements is correct?
A.Cancer is excluded if a mass has hyperintense/fluid signal on the T2-weighted sequence.
B.Breast MRI is optimally performed in week 4 of a patients menstrual cycle.
C.T1-weighted nonfat saturation is the best sequence for identification of a fat-containing
mass.
D.A body coil is the optimal radiofrequency receiver coil for the exam.
E.An equivalent dose of a gadolinium-based contrast agent is used for breast MR patients.
42aThe following image from a contrast-enhanced breast MR examination demonstrates which
artifact?
A.Chemical shift artifact
B.Wrap/aliasing artifact
C.Susceptibility artifact
D.Patient motion/ghosting artifact
E.Inhomogeneous fat saturation artifact
42bWhat can reduce inhomogeneous fat saturation artifact on breast MRI?
A.Enlarging the field of view
B.Reducing patient motion
C.Shimming the magnet frequently
D.Increasing the bandwidth
E.Check for a leak in the radiofrequency (RF) shield
43The following image from a contrast-enhanced breast MR examination demonstrates which
artifact?

A.Chemical shift artifact


B.Wrap/aliasing artifact
C.Susceptibility artifact
D.Patient motion/ghosting artifact
E.Inhomogeneous fat saturation artifact
44Which one of the following artifacts is present on the axial postcontrast T1-weighted fat-saturated
MR image seen below?
A.Chemical shift artifact
B.Wrap/aliasing artifact
C.Susceptibility artifact
D.Patient motion/ghosting artifact
E.Inhomogeneous fat saturation artifact
45Based on the images, which one of the following breast imaging ultrasound lexicon terminologies
best describes the finding?
A.Oval isoechoic mass with a circumscribed margin
B.Lobular hypoechoic mass with associated skin thickening
C.Round, anechoic mass with posterior acoustic enhancement
D.Irregular hypoechoic mass with angular margins
46You are shown a left mediolateral oblique (MLO) and craniocaudal (CC) (zoomed) mammogram
images (Figures A and B). What is the MOST descriptive of the calcifications?

A.Amorphous
B.Pleomorphic
C.Punctate
D.Lucent centered
E.Dystrophic
47In a well-positioned mammogram, which of the following statements is correct?
A.The pectoralis muscle should be convex on the mediolateral oblique (MLO) view.
B.The pectoralis muscle should extend inferior to the posterior nipple line on the MLO view.
C.The pectoralis muscle thickness should be >1 cm on the craniocaudal (CC) view.
D.The CC view should be exaggerated to include the axillary tail.
E.The length of the posterior nipple line on the CC view should be 1 cm greater than on the
MLO view.
48The mediolateral oblique (MLO) image taken during a screening mammogram examination
demonstrates which type of digital mammogram artifact?
A.Motion artifact
B.Ghost image
C.Grid lines
D.Deodorant artifact
49The below mediolateral oblique (MLO) image was taken during a screening mammogram
examination demonstrates which type of digital mammogram artifact?

A.Dirt or dust on compression paddle


B.Ghost image
C.Readout failure
D.Dead pixels
E.Gridlines
50What is the artifact present on the following mediolateral oblique (MLO) image? The second
image denotes a part of the MLO view magnified.

A.Motion
B.Gridlines
C.Deodorant
D.Filtration artifact
51The universal amount of intravenous gadolinium used for contrast enhancement in breast MR
imaging is:
A.0.1 mmol/kg
B.0.2 mmol/kg
C.0.3 mmol/kg
D.0.4 mmol/kg
E.0.5 mmol/kg
52In order to ensure the quality of the mammographic images, the posterior nipple line on MLO and
CC projections should be within
A.0.5 cm
B.1.0 cm
C.1.5 cm
D.2.0 cm
E.It should be equal.
53aWhich one of the following artifacts is present on the T1-weighted nonfat-saturated localizer
image?
A.Chemical shift
B.Phase wrap/aliasing
C.Metallic susceptibility
D.Patient motion
53bWhat can reduce phase wrap/aliasing artifact on breast MRI?
A.Enlarging the field of view
B.Reducing patient motion
C.Shimming the magnet frequently
D.Increasing the bandwidth
E.Check for a leak in the radiofrequency (RF) shield
54Which feature of digital breast tomosynthesis allows it to decrease the effect of overlapping breast
tissue?
A.Higher radiation dose than in mammography
B.Reconstruction of the projections into the mediolateral oblique (MLO) and craniocaudal
(CC) views
C.Digital acquisition technique
D.Multiple exposures of the breast at different angles
E.Increased breast compression
55The above mediolateral oblique (MLO) image taken during a screening mammogram examination
demonstrates which type of digital mammogram artifact?
A.Detector interface line
B.Ghost image
C.Readout failure
D.Dead pixels
E.Gridlines

ANSWERS AND EXPLANATIONS

1Answer C.
References: www.fda.gov/cdrh/mammography
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:16.
2A.Answer A. BI-RADS 2Dermal calcifications
B.Answer A. BI-RADS 2Popcorn-like calcification
C.Answer A. BI-RADS 2Secretory calcifications
D.Answer A. BI-RADS 2Round calcification
E.Answer A. BI-RADS 2Lucent center calcification (oil cyst)
F.Answer B. BI-RADS 4Linear branching calcifications
G.Answer B. BI-RADS 4Fine pleomorphic calcifications
H.Answer B. BI-RADS 2Milk of calcium
Reference: American College of Radiology (ACR). BI-RADS-Mammography. The ACR Breast Imaging Reporting and Data
System (BI-RADS). Reston, VA: American College of Radiology; 2003:61107.
3Answer B.
Reference: Linver MN, Osuch JR, Brenner RJ, et al. The mammography audit: A Primer for the Mammography Quality Standards
Act (MQSA). AJR Am J Roentgenol 1995;165:1925.

4Answer D.Sensitivity is the probability of detecting a cancer when a cancer exists or the
number of cancers diagnosed after being identified at mammography in a population within 1 year
of the imaging examination, divided by all cancers present in that population in the same time
period.

Sensitivity = TP/(TP + FN); TP = True positive; FN = False negative


References: American College of Radiology (ACR). BI-RADSMammography. The ACR Breast Imaging Reporting and Data
System (BI-RADS). Reston, VA: American College of Radiology; 2003:231.
Linver MN, Osuch JR, Brenner RJ, et al. The mammography audit: A Primer for the Mammography Quality Standards Act
(MQSA). AJR Am J Roentgenol 1995;165:1925.

5Answer C.The appearance of the pectoral muscle is useful in assessing position on MLO
views. The breast should be pulled up and out, the inframammary fold should be open on MLO
views and neutral on craniocaudal views, and a small amount of the upper abdomen should be
visible on MLO views.
Reference: Cardenosa G. Breast Imaging Companion. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:7984.

6Answer A.A breast cancer diagnosed within a year of a negative screening mammogram is
considered a false negative.
Reference: BI-RADS-Mammography. The ACR Breast Reporting and Data System (BI-RADS). Reston, VA: American College of
Radiology.
Linver MN, Osuch JR, Brenner RJ, et al. The mammography audit: A Primer for the Mammography Quality Standards Act
(MQSA). AJR Am J Roentgenol 1995;165:1925.

7Answer C.
Quality Control (QC) Test Schedule for Film-Screen Mammography
TEST PERFORMED
Darkroom cleanliness Daily
Processor QC Daily
Screen cleanliness Weekly
Phantom images Weekly
Viewbox cleanliness and viewing checklist Quarterly
Repeat analysis Quarterly
Fixer retention Semiannually
Darkroom fog Semiannually
Screenfilm contact Semiannually
Compression Semiannually

Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:18.

8aAnswer A.Repeat imaging is required due to chin artifact on MLO view. BI-RADS Assessment
is 0.
8bAnswer C.Repeat imaging is required due to chin artifact on MLO view.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:25.

9Answer E.The posterior nipple line measurement difference between MLO and CC view
should not exceed more than 1 cm if there is adequate tissue exposure.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:57.

10Answer C.
Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/Guidance/PolicyGuidanceHelpSystem/ucm135427.htm

11Answer C.
Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/Guidance/PolicyGuidanceHelpSystem/ucm052165.htm

12Answer A.
Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/Guidance/PolicyGuidanceHelpSystem/ucm052779.htm

13aAnswer A.Repeat MLO view is needed due to high-density particles seen in the axillary region
that may represent deodorant artifact.

13bAnswer D.Images show no high-density particles in the axillary region, which proves the
findings seen previously were deodorant artifact.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed.
Springer; 2010:25.
14Answer E.Asymptomatic women 40 years of age or older should have an annual screening
mammogram. It is unclear at what age, if any, women cease to benefit from screening
mammography. Because this age is likely to vary depending on the individuals overall health, the
decision as to when to stop routine mammography screening should be made on an individual
basis by each woman and her physician.
Reference: American College of Radiology (ACR). ACR Practice Guidelines for the Performance of Screening and Diagnostic
Mammography. American College of Radiology; May 2013, http://amclc.acr.org/LinkClick.aspx?
fileticket=dQDASxSIrJ4%3D&tabid=61

15Answer E.The nipple should be in profile on at least one view. This may require an extra view
in addition to the typical CC and MLO views.
A.The MLO view is a projection parallel to the pectoralis major muscle.
B.On the CC view, the pectoralis major muscle is seen approximately 30%40% of the time.
C.On the MLO view, the pectoralis major should be convex anteriorlynever concave.
D.On the MLO view, the pectoralis major muscle should be seen to or below the level of the
axis of the nipple.
References: Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Philadelphia, PA: Lippincott Williams & Wilkins;
2007:569570.
Cardenosa G. Breast Imaging Companion. 3rd ed. Philadelphia, PA: Lippincott Williams & Willkins; 2008:7988.

16Answer D.
Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/Guidance/PolicyGuidanceHelpSystem/ucm135449.htm

17Answer C.
Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/FacilityScorecard/ucm113812.htm

18Answer A.The U.S. Congress appointed the Food and Drug Administration (FDA) to develop
guidelines to oversee the quality of mammography equipment and facilities after the enactment of
the Mammography Quality Standards Act (MQSA) in 1992. Various states have also been
certified to accredit mammography facilities; these are approved by the FDA.
References: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:267268.
Radiation-Emitting Products. www.fda.gov/radiation-emittingproducts/mammographyqualitystanda rdsactand program/default.htm

19Answer B.Ghosting from cardiac or respiratory motion occurs in the phase-encoding direction.
It can be prevented from obscuring breast tissue by proper selection of phase- and frequency-
encoding directions. Patient motion causes blurring of the poor shimming results in poor fat
suppression.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:197.

20Answer C.
Reference: ACR BI-RADSMammography. ACR Breast Imaging Reporting and Data System, Breast Imaging Atlas. 4th ed.
Reston, VA: American College of Radiology; 2003:230.

21Answer B.BRCA-1 is autosomal dominant and is a tumor suppressor gene on chromosome 17.
BRCA-2 is on chromosome 13. The lifetime risk of breast cancer is 50% to 85%. It is associated
with an increased risk of ovarian cancer and other cancers such as prostate cancer. There is no
known increased risk of lung cancer.
Reference: Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys;
2006:Chapter 2, 2526.

22Answer C.The current benchmark for CDR is 210/1000. It is expected with the BI-RADS 5th
edition, that this will be changed to >2.5/1000.
Reference: The ACR Breast Imaging Reporting and Data System (BI-RADS). BI-RADSMammography. Reston, VA: American
College of Radiology; 2003:234.

23Answer A.
Reference: The ACR Breast Imaging Reporting and Data System (BI-RADS). BI-RADSMammography. Reston, VA: American
College of Radiology; 2003:952, 234.

24Answer B.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:16.

25Answer D.The difference between the line from the nipple to the pectoralis muscle on MLO
and the line from the nipple to the back of the film on CC is 1 cm.
Good quality control for a properly positioned breast is essential for maximum tissue
evaluation on a screening mammogram. The CC projection should complement the MLO
projection, and the breasts should be positioned symmetrically to one another. It has been
established that the proper positioning of the CC and MLO projections is determined by the
difference in distance between the nipple to the pectoralis muscle on the MLO view (NL-MLO)
and nipple to the back of the film on CC (NL-CC) is 1 cm. In other words, NL-MLO minus NL-
CC is 1 cm. The pectoralis muscle can be seen in an estimate of 30% of the CC views.
References: Bassett LW, Hirbawi IA, DeBruhl N, et al. Mammographic positioning: Evaluation from the view box. Radiology
1993;188:803806.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 297298.

26Answer E.Mammography compression plate and imaging receptor needs both 18 24 cm and
24 30 cm size, with compression force 25 to 45 pounds, with a moving grid for each image
receptor size, and the collimation to the receptor while not the breast contour.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:5.
27Answer D.This artifact is caused by saturation of silicone signal, which can occur when
silicone is selected for saturation rather than fat. Fat and silicone resonate closely at 1.5 T. Note
that silicone was saturated in this image, but fat was not correctly saturated. As a result of silicone
saturation, a silicone breast implant will have dark signal and the examination will be rendered
nondiagnostic for evaluation of implant rupture. The inversion recovery (IR) sequence with water
saturation is a silicone-specific sequence (water and fat will be saturated) that is the most
important sequence of the examination. Silicone should appear white on this sequence, enabling
the detection of intracapsular and/or extracapsular rupture. Answer A is wrong because
susceptibility artifact is a signal void or field inhomogeneity caused by metal in or on the patients
body. Answer B is wrong because wrap or aliasing artifact occurs when tissue extends beyond the
field of view (FOV), causing signal from tissues outside the FOV to be superimposed on
structures within the FOV. It occurs in the phase encoding direction. This artifact can be seen with
patients arms in breast MRI practice. Answer C is not correct because RF interference is an
artifact that occurs due to incomplete shielding of the MRI suite (e.g., door ajar) or radiofrequency
disturbance within the MR suite (e.g., patient monitoring equipment). This artifact manifests as
repetitive lines extending across the image at a fixed interval.
Reference: Hendrick RE. Breast MRI: Fundamentals and Technical Aspects. New York, NY: Springer; 2008:187207.

28aAnswer D.Abnormal interpretation rate, also known as recall rate, in screening mammography
is the percentage of examinations interpreted as positive. For screening mammography, positive
exams include BI-RADS category 0, 4, and 5 assessments given based on screening mammograms.
Screening abnormal interpretation rate = (Category 0, 4, and 5 cases based on screening
mammograms)/(Total number of screening mammograms) = 400 + 0 + 0/5,000 = 400/5,000 = 0.08
= 8%.
For diagnostic mammography, abnormal interpretation rate or biopsy recommended rate is the
percentage of examinations interpreted as positive. For diagnostic mammography, positive exams
include BI-RADS category 4 and 5 assessments based on diagnostic workup.
Diagnostic abnormal interpretation rate = (Category 4 and 5 cases based on diagnostic
workup)/(Total number of diagnostic mammograms).
28bAnswer C.Cancer detection rate is the number of cancers correctly detected at mammography
per 1,000 patients examined at mammography.
Cancer detection rate = Positive biopsies/Total number of screening mammograms = 30/5,000
= 0.006 = 6/1,000.
Reference: American College of Radiology (ACR). ACR BI-RADSMammography. In: ACR Breast Imaging Reporting and
Data System, Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003:231.

29Answer C.This image demonstrates susceptibility artifact on the right breast due to metal on the
patients skin. A mammographic BB marker left on the patients skin prior to the MRI caused the
artifact. The BB has a metallic component, which can cause image artifacts manifesting as warped
images, signal voids, and signal flare. The artifact can vary based on which type of sequence is
performed. Metallic artifacts manifest as signal voids on gradient echo sequences. On spin echo
sequences, a signal flare component may be seen in addition to the signal void. Susceptibility
artifact is most commonly seen in breast MRI interpretation as a result of breast biopsy markers or
surgical clips. Answer A is wrong because chemical shift artifact is an artifact that results from
the different resonances of the hydrogen in fat and water. It is most commonly seen in nonfat-
suppressed sequences (e.g., nonfat-suppressed T1-weighted) and results in signal void or bright
signal at a fatwater interface. Answer B is wrong because wrap or aliasing artifact occurs when
tissue extends beyond the field of view (FOV), causing signal from tissues outside the FOV to be
superimposed on structures within the FOV. It occurs in the phase encoding direction. This artifact
can be seen with patients arms in breast MRI practice. Answer D is wrong. There is no
significant motion on this image. Motion artifact is one of the most commonly encountered artifacts
affecting breast MRI. Motion can arise from patient motion or cardiac, respiratory, or great vessel
motion. All motions propagate in the phase encoding direction despite the direction of the motion.
Phase encoding direction should be left to right for axial sequences and superior to inferior for
sagittal sequences to reduce the effect of cardiac and respiratory motion on the breasts.
References: Genson CC, Blane CE, Helvie MA, et al. Effects on breast MRI of artifacts caused by metallic tissue marker clips. AJR
Am J Roentgenol 2007;188(2):372376.
Harvey JA, Hendrick E, Coll JM, et al. Breast MR imaging artifacts: How to recognize and fix them. Radiographics 2007;27:S131
S145.
Hendrick RE. Breast MRI: Fundamentals and Technical Aspects. New York, NY: Springer; 2008: 187207.

30Answer C.Correct film labeling should include all of the following: the patients first and last
name as well as unique patient identification number, name and address of the facility,
mammography unit, date of the exam, view and laterality placed near the axilla, Arabic number
indicating the cassette, and technologists initials.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:7, 12.

31Answer B.A BI-RADS 3 category finding should have a less than 2% chance of malignancy.
The finding is not expected to change over the time interval of the BI-RADS 3 follow-up. BI-
RADS 3 findings include the noncalcified circumscribed solid mass, the focal asymmetry, and the
cluster of round and punctate calcifications.
Reference: American College of Radiology (ACR). ACR BI-RADSMammography. In: ACR Breast Imaging Reporting and
Data System, Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003:194197.

32Answer C.BI-RADS 5 lesions have a > 95% chance of malignancy. The level of suspicion is
high enough in these lesions that they could be taken to surgery without preoperative biopsy;
however, current oncologic evaluation may require a tissue biopsy to adequately plan the patients
treatment course before surgery.
Reference: American College of Radiology (ACR). ACR BI-RADSMammography. In: ACR Breast Imaging Reporting and
Data System, Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003:194197.

33Answer A.Hair artifact is noted on the CC view but is not seen on the MLO view. Hair artifact
often creates a swirl pattern on the image. By simply repeating the image, with attention to
clearing the hair from the field of view, the artifact will be eliminated.
Reference: Cardenosa G. Breast Imaging. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:4548.

34Answer C.A VP shunt catheter is noted on this study. Note that the catheter is seen extending
into the abdominal wall on the ML view.
Reference: Chatell T, Shah B. Review of common mammographic artifacts on both digital and analog mammograms. AJR Am J
Roentgenol 2010;194(5 Suppl):A100A115.

35Answer B.The current recommendations of the American Cancer Society and American
College of Radiology for screening breast MRI are for women with a high risk of breast cancer,
estimated at a > 20% lifetime risk of having the disease, based on multiple different mathematical
models outlined in the papers cited below. Other groups for which screening breast MRI is
recommended include patients with known genetic mutations, including BRCA-1 and BRCA-2,
and a family history that suggests a genetic predisposition (=2 first-degree relatives with breast
cancer or a single firstdegree relative with premenopausal breast cancer or a family history of
breast and ovarian cancer). There are other cases in which the ACR and ACS do not recommend
for or against screening due to limited information including those patients with a 15% to 20%
lifetime risk including those with prior personal history of breast cancer, history of ADH or
lobular neoplasia, or more limited family histories.
References: Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: Recommendations from the Society of
Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of
clinically occult breast cancer. J Am Coll Radiol 2010;7(1):1827.
Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to
mammography. CA Cancer J Clin 2007;57(2):7589.

36Answer D.Roller artifact lines coursing longitudinally are seen on the right mediolateral
oblique and right craniocaudal views.
Reference: Chatell T, Shah B. Review of common mammographic artifacts on both digital and analog mammograms. AJR Am J
Roentgenol 2010;194(5 Suppl):A100A115.

37Answer B.Estrogen can cause contrast enhancement of benign breast parenchyma in


premenopausal females. This enhancement is greatest in weeks 1 and 4 of the cycle, assuming a 4-
week cycle. This enhancement can make interpretation of normal background enhancement from
pathological enhancement difficult. Physiologic enhancement is the least during the 2nd week;
therefore, this is the preferred week to perform breast MRI.
Reference: Morris EA, Liberman L, eds. Breast MRI: Diagnosis and Intervention. New York, NY: Springer; 2005:3638.

38Answer A.The 2007 American Cancer Society Guidelines recommend the use of screening
MRI in patients with a history of Hodgkin disease, particularly those with a prior history of mantle
field radiation. Neurofibromatosis is an incorrect answer. Although there has been a recognized
link between neurofibromatosis type 1 and breast carcinoma, current guidelines do not recommend
the use of screening MRI in this patient population. The ACS guidelines also recommended the
use of screening breast MRI in patients with a 20% to 25% or greater lifetime risk of breast
cancer. As such, C would also be an incorrect choice. Heterogeneously dense breasts (>50%
breast density) has not been shown to be a clinical indicator of breast cancer risk. Multiple
studies have shown, however, that women with >75% breast density have a fivefold increased
risk of breast cancer.
References: Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct
to mammography. CA Cancer J Clin 2007;57:7589.
Sharif S, Moran A, Huson SM, et al. Women with neurofibromatosis type 1 are at moderately increased risk of developing breast
cancer and should be considered for early screening. J Med Genet 2007;44(8):481484.

39Answer D.Phantom images should be carried out weekly, after equipment service or whenever
image quality problems are suspected. The phantom is evaluated for background density, contrast,
uniformity, and number of objects seen. The phantom simulates a 4.0 to 4.5 cm compressed breast
with six different fibers, five groups of microcalcifications, and five masses. ACR criteria require
a minimum score with visibility of at least four fibers, three microcalcifications, and three masses.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:275277.

40Answer C.The MLO view provides the greatest amount of coverage for a single projection. In
positioning the patient, care must be taken to make sure the medial breast tissue is not pulled out of
the field of view. The medial breast tissue is tethered along the sternum, which can easily slide out
of view if proper care is not taken with positioning.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 286288.

41Answer C.T1 without fat saturation is the optimal sequence to identify a fat-containing mass,
such as an intramammary lymph node or fat necrosis, which are benign findings; BI-RADS
category 2. Answer A is incorrect. A cancer cannot be completely excluded if a mass has
hyperintense signal on the T2 sequence. Classically, mucinous variants of ductal carcinoma have
been described as having high T2 signal. In addition, invasive breast cancers such as invasive
ductal carcinoma not otherwise specified can have high T2 signal. Therefore, hyperintense signal
on T2 does not rule out cancer in an enhancing mass. Answer B is incorrect. Breast MRI is
optimally performed during week 2 of patients menstrual cycles. This timing will minimize
proliferative changes of the breast tissue and resultant background enhancement. Answer D is
incorrect. A breast-specific coil is the optimal radiofrequency receiver coil for breast MRI. It is
the coil best designed to fit the relevant anatomy without including additional tissue. The inclusion
of additional tissue will decrease the signal-to-noise ratio in the breasts. In addition, a body coil
would compress the breast tissue, limiting visualization and evaluation. Finally, answer E is
incorrect. Contrast-enhanced breast MRI for the detection of breast cancer is performed using a
gadolinium-based contrast agent via intravenous injection. However, an equivalent dosage of a
gadolinium-based contrast agent is not used for all patients. Manufacturers of the gadolinium-
based contrast agents recommend a weight-based dosage (such as 0.1 mmol/kg). Larger patients
should receive a higher dosage of the contrast agent than smaller patients.
References: Hendrick RE. Breast MRI Fundamentals and Technical Aspects. New York, NY: Springer; 2008:34, 35.
Morris EA, Liberman L. Breast MRI Diagnosis and Intervention. New York, NY: Springer; 2005:9, 17, 21, 85, 152, 428.
Santamara G, Velasco M, Bargall X, et al. Radiologic and pathologic findings in breast tumors with high signal intensity on T2-
weighted MR images. Radiographics 2010;30:533548.

42aAnswer E.Fat saturation is important for breast cancer detection on MRI. High signal of fat
interferes with the detection of enhancing lesions. MR imaging unit software automatically
identifies the water peak as the highest signal peak, and fat is suppressed by applying saturation
pulses at a frequency of 3.5 ppm (224 Hz at 1.5 T) below the water peak. To effectively suppress
the protons in the fat molecules, the correct range of frequencies must be selected. Sometimes in
the presence of an unexpected variation in the magnetic field, there will be protons in fat that are
precessing out of the range of frequencies included in the suppression pulse. These protons will
not be suppressed, and the fat containing these protons will maintain its brighter signal. This
phenomenon results in inhomogeneous suppression of the fat signal within the breast.
Inhomogeneous fat saturation is a common problem and cannot be corrected for. However,
shimming the magnet (optimizing field homogeneity) of an MR imaging unit can correct some of
the artifact.
Answer choice A is incorrect because chemical shift artifact is an artifact that results from the
different resonances of the hydrogen in fat and water. It is most commonly seen in nonfat-
suppressed sequences (e.g., non fat- suppressed T1-weighted) and results in signal void or bright
signal at a fatwater interface. Answer choice B is incorrect because wrap or aliasing artifact
occurs when tissue extends beyond the field of view (FOV), causing signal from tissues outside
the FOV to be superimposed on structures within the FOV. It occurs in the phase-encoding
direction. This artifact is commonly seen with patients arms in breast MRI practice.
Susceptibility artifact is usually due to metallic artifact(s) that appear as signal voids on gradient-
echo sequences. On spin-echo sequences, a signal flare component may be seen in addition to the
signal void. Answer choice D is incorrect. There is no significant motion on this image. Motion
artifact is one of the most commonly encountered artifacts affecting breast MRI. Motion can arise
from patient motion or cardiac, respiratory, or great vessel motion. All motions propagate in the
phase-encoding direction despite the direction of the motion. Phase-encoding direction should be
left to right for axial sequences and superior to inferior for sagittal sequences to reduce the effect
of cardiac and respiratory motion on the breasts.
42bAnswer C.Shimming the magnet (optimizing field homogeneity) of an MR imaging unit can
sometimes correct inhomogeneous fat saturation artifact.
Answer choice A is incorrect because enlarging the field of view can correct wrap or aliasing
artifact. Answer choice B is incorrect because reducing patient motion can prevent phase-
encoding or ghosting artifact. Answer choice D is incorrect because increasing bandwidth per
pixel of the imaging sequence can reduce chemical shift artifact. Answer choice E is incorrect
because checking the radiofrequency (RF) shield for a leak might be the cause for RF interference.
References: Harvey JA, Hendrick E, Coll JM, et al. Breast MR imaging artifacts: How to recognize and fix them. Radiographics
2007;27:S131S145.
Ojeda-Fournier H, Choe KA, Mahoney MC. Recognizing and interpreting artifacts and pitfalls in MR imaging of the breast.
Radiographics 2007;27:S147S164.

43Answer D.The patient was coughing during the exam, and therefore the ghosting artifact seen on
the image is due to patient motion. Artifact from patient motion propagates in the phase-encoding
direction, regardless of the direction of the motion. Motion can result in blurring of moving tissues
but can also cause a structured noise pattern, resulting in ghosting of brighter moving tissues in
the phase-encoding direction.
Answer choice A is incorrect because chemical shift artifact is an artifact that results from the
different resonances of the hydrogen in fat and water. It is most commonly seen in nonfat-
suppressed sequences (e.g., non fat- suppressed T1-weighted) and results in signal void or bright
signal at a fatwater interface. Answer choice B is incorrect because wrap or aliasing artifact
occurs when tissue extends beyond the field of view (FOV), causing signal from tissues outside
the FOV to be superimposed on structures within the FOV. It occurs in the phase-encoding
direction. This artifact is commonly seen with patients arms in breast MRI practice. Answer
choice C is incorrect. Susceptibility artifact is usually due to metallic artifact(s) that appear as
signal voids on gradient-echo sequences. On spin-echo sequences, a signal flare component may
be seen in addition to the signal void. Answer choice E is incorrect. The fat saturation is
homogeneous on this T2 STIR image.
References: Harvey JA, Hendrick E, Coll JM, et al. Breast MR imaging artifacts: How to recognize and fix them. Radiographics
2007;27:S131S145.
Ojeda-Fournier H, Choe KA, Mahoney MC. Recognizing and interpreting artifacts and pitfalls in MR imaging of the breast.
Radiographics 2007;27:S147S164.

44Answer C.There is a local signal intensity void with a partially surrounding area of high signal
intensity and image distortion in the sternum. This represents metallic susceptibility artifact from
sternotomy wires.
References: Harvey JA, Hendrick E, Coll JM, et al. Breast MR imaging artifacts: How to recognize and fix them. Radiographics
2007;27:S131S145.
Ojeda-Fournier H, Choe KA, Mahoney MC. Recognizing and interpreting artifacts and pitfalls in MR imaging of the breast.
Radiographics 2007;27:S147S164.

45Answer D.The lesion shown is an irregular hypoechoic mass with angular margins. This mass
is suspicious (BI-RADS 4), and tissue sampling was recommended. The mass was invasive ductal
carcinoma.

American College of Radiology BI-RADS Ultrasound Lexicon Descriptors

References: American College of Radiology (ACR). The ACR Breast Imaging Reporting and Data System (BI-RADS). BI-RADS-
Ultrasound. Reston, VA: American College of Radiology; 2003:952.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:97100.

46Answer D.The calcifications shown are lucent centered and are often pathognomonic for
dermal calcifications. Dermal calcifications are most commonly seen along the inframammary
fold parasternally, axilla, and areola. Unusual forms can be confirmed as skin calcifications by
performing a dermal calcification study. Dermal calcifications will be in the skin directly under
the skin marker on the tangential mammogram view.
References: American College of Radiology (ACR). The ACR Breast Imaging Reporting and Data System (BI-RADS). BI-RADS-
Mammography. Reston, VA: American College of Radiology; 2003:61107.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:7679.

47Answer B.On a mediolateral oblique (MLO) projection view the pectoralis muscle should be
concave and extend inferior to the posterior nipple line (PNL). The PNL describes an imaginary
line drawn from the nipple to the pectoralis muscle or film edge and perpendicular to the
pectoralis muscle. The length of the PNL on the CC view should be 1 cm or less of its length on
the MLO view. The pectoralis muscle should be seen whenever possible on the craniocaudal
view and therefore there is no required thickness. When the pectoralis muscle is seen, one can be
confident that the posterior tissue has been adequately included on the image. The CC view is not
exaggerated to include the axillary tail. This view is that of an exaggerated craniocaudal lateral
view (XCCL).
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011: 6, 51.
48Answer A.There is blurring of the image due to patient motion during the mammogram exam.
Answer choice B is incorrect because ghost image is when the image receptor retains a ghost
image of a previous image and becomes visible on the next image taken. This finding is caused by
low detector temperature. Allowing the detector to warm up properly usually clears the problem.
With improvement of detector technology and systems that better regular detector temperature, this
problem is less common.
Answer choice C is incorrect because gridlines are subtle cross-hatch pattern lines on an
image. Gridlines are caused by the grid speed parameter set incorrectly. Grid speed parameter is
set by a service engineer and cannot be changed by the technologist.
Answer choice D is incorrect because no radiopaque particles are seen in the axillary region.
References: Geiser WR, Haygood TM, Santiago L, et al. Challenges in mammography: Part 1, artifacts in digital mammography. AJR
Am J Roentgenol 2011;197(6):W1023W1030.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:25.

49Answer C.

This case demonstrates a readout failure artifact. There is a line artifact that was caused by
software processing failure (see red arrows). This error can correct itself, or a new detector
readout sequence file can be installed.
Reference: Geiser WR, Haygood TM, Santiago L, et al. Challenges in mammography: Part 1, artifacts in digital mammography. AJR
Am J Roentgenol 2011;197(6):W1023W1030.

50Answer B.Gridlines resemble grid artifacts in screen film. There is miscalibration in the gain
calibration file resulting in gridlines on all subsequent images.
Reference: Geiser WR, Haygood TM, Santiago L, et al. Challenges in mammography: Part 1, artifacts in digital mammography. AJR
Am J Roentgenol 2011;197(6):W1023W1030.

51Answer: A. Breast MRI that is performed to evaluate a patient for breast cancer requires the use
of a contrast agent. Gadolinium contrast is generally not necessary in the evaluation of implant
integrity and rupture. Breast MRI is most commonly performed using one of the gadolinium-based
low-molecular-weight MRI contrast agents. Gadolinium contrast should be given as a bolus with a
standard dose of 0.1 mmol/kg followed by a saline flush of at least 10 mL.
Reference: American College of Radiology ACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic
Resonance Imaging (MRI) of the Breast. 2013. www.acr.org/~/media/ ACR/Documents/PGTS/guidelines/MRI_Breast.pdf

52Answer B.The perpendicular distance from the nipple to the pectoralis muscle on the MLO is
used as a reference for adequacy of the CC view. The measurement on the CC view (taken as the
distance from the nipple to the pectoralis or the back of the image) should be within 1.0 cm of the
MLO measurement.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:57.

53aAnswer B.Phase wrap, also known as aliasing artifact or wraparound artifact, occurs when not
all of the signal-producing tissue is within the field of view (FOV). This artifact occurs in the
phase-encoding direction. The signal from the excited tissue outside the FOV becomes
superimposed on structures within the FOV through misregistration during Fourier transform
reconstruction.
Fat saturation is important for breast cancer detection on MRI. High signal of fat interferes with
the detection of enhancing lesions. MR imaging unit software automatically identifies the water
peak as the highest signal peak, and fat is suppressed by applying saturation pulses at a frequency
of 3.5 ppm (224 Hz at 1.5 T) below the water peak. To effectively suppress the protons in the fat
molecules, the correct range of frequencies must be selected. Sometimes in the presence of an
unexpected variation in the magnetic field, there will be protons in fat that are precessing out of
the range of frequencies included in the suppression pulse. These protons will not be suppressed,
and the fat containing these protons will maintain its brighter signal. This phenomenon results in
inhomogeneous suppression of the fat signal within the breast. Inhomogeneous fat saturation is a
common problem and cannot be corrected for. However, shimming the magnet (optimizing field
homogeneity) of an MR imaging unit can correct some of the artifact.
Answer choice A is incorrect because chemical shift artifact is an artifact that results from the
different resonances of the hydrogen in fat and water. It is most commonly seen in nonfat-
suppressed sequences (e.g., nonfat-suppressed T1-weighted) and results in signal void or bright
signal at a fatwater interface. Answer choice C is incorrect because susceptibility artifact is
usually due to metallic artifact(s) that appear(s) as signal voids on gradient echo sequences. On
spin echo sequences, a signal flare component may be seen in addition to the signal void. Answer
choice D is incorrect. There is no significant motion on this image. Motion artifact is one of the
most commonly encountered artifacts affecting breast MRI. Motion can arise from patient motion
or cardiac, respiratory, or great vessel motion. All motions propagate in the phase-encoding
direction despite the direction of the motion. Phase-encoding direction should be left to right for
axial sequences and superior to inferior for sagittal sequences to reduce the effect of cardiac and
respiratory motion on the breasts.
53bAnswer A.Increasing the number of sampling points in the phase-encoding direction or
enlarging the FOV can correct phase wrap artifact.
Answer choice B is incorrect because reducing patient motion can prevent phase encoding or
ghosting artifact. Answer choice C is incorrect because shimming the magnet (optimizing field
homogeneity) of an MR imaging unit is performed to try to correct inhomogeneous fat saturation
artifact. Answer choice D is incorrect because increasing bandwidth per pixel of the imaging
sequence can reduce chemical shift artifact. Answer choice E is incorrect because checking the
radiofrequency (RF) shield for a leak might be the cause for RF interference.
References: Harvey JA, Hendrick E, Coll JM, et al. Breast MR imaging artifacts: how to recognize and fix them. Radiographics
2007;27:S131S145.
Ojeda-Fournier H, Choe KA, Mahoney MC. Recognizing and interpreting artifacts and pitfalls in MR imaging of the breast.
Radiographics 2007;27:S147S164.

54Answer D.The advantage of breast tomosynthesis is a reduction in overlapping tissue, which


often obscures lesions on 2-D mammography, especially in patients with dense breast
parenchyma. In digital breast tomosynthesis, images are acquired at different angles and are then
reconstructed. This technique allows overlapping structures from different planes to be separated
out. In digital breast tomosynthesis, compression is required to immobilize the breast. However,
because digital breast tomosynthesis already reduces tissue overlap, the degree of compression
potentially can be decreased; this is a topic of ongoing investigation.
References: Baker JA, Lo JY. Breast tomosynthesis: state-of-the-art and review of the literature. Acad Radiol 2011;18(10):1298
1310.
Park JM, Franklin EA Jr, Garg M, et al. Breast tomosynthesis: present considerations and future applications. Radiographics
2007;27:S231S240.

55Answer A.The mediolateral oblique view shows a detector interface line (see red arrows in
image below) from a selenium-based detector. This artifact is due to a slight difference in
calibration of two halves of the detector and relatively high exposure for imaging a very dense
breast tissue.

Reference: Geiser WR, Haygood TM, Santiago L, et al. Challenges in mammography: part 1, artifacts in digital mammography. AJR
Am J Roentgenol 2011;197(6):W1023W1030.
2 Breast Cancer Screening

QUESTIONS

1 Which is an American Cancer Society (ACS) recommendation, based on evidence from


nonrandomized screening trials and observational studies, for performing a screening breast MRI
as an adjunct to mammography?
A.Heterogeneously or extremely dense breast on mammography
B.Women with a personal history of breast cancer, including ductal carcinoma in situ (DCIS)
C.Lifetime risk 15% to 20%, as defined by BRCAPRO or other models that are largely
dependent on family history
D.First-degree relative of BRCA carrier but untested
E.Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
2Regarding the structure marked in the image below, which of the following statements is correct?

A.Described as cigar shaped


B.Present in males and females
C.Seen on the CC and true lateral projections only
D.Associated with tubular carcinoma
3aA 61-year-old female presents for a screening mammogram. Patients most recent prior
mammogram from 2 years ago was negative. What is the most appropriate BI-RADS classification
based on this single right MLO view?
A.0
B.2
C.3
D.4
E.5
3bAdditional views were performed. What is the most appropriate description of these
calcifications?

A.Fat necrosis (dystrophic, rim, and lucent centered)


B.Pleomorphic, fine linear branching
C.Skin calcifications
D.Coarse/popcorn-like
E.Rod-like/secretory
4A 62-year-old female presents for her annual routine screening mammogram. The interval between
the two studies is 13 months. The patient has no current complaints. Comparing the current study
with the prior, what is the MOST likely cause of the change in her mammogram in the interval?

A.Hormone replacement therapy


B.Weight loss
C.Inflammatory breast cancer
D.Breast edema from congestive heart failure
5A 57-year-old female presents for an annual routine screening mammogram. Which of the
following statements is correct regarding this patients prior breast surgical history?
A.If fat necrosis is to occur mammographically, it typically occurs within the 1st year.
B.Nipple elevation occurs because there is more skin inferior to the nipple than superior.
C.Architectural distortion commonly presents as a swirled fibroglandular pattern in the inferior
and lateral breast.
D.There is parenchymal redistribution of the fibroglandular tissue, as the residual breast tissue
is shifted from the upper outer breast to the upper inner breast.
6A 30-year-old female has a family history of breast cancer in her mother at age 45 and her sister at
age 42. She undergoes genetic testing and discovers she is a carrier of the BRCA2 mutation. At
what age should she begin screening mammography?
A.30
B.32
C.35
D.40
7Breast MRI has proven to be a powerful adjunct to screening mammography in women considered
to be at increased risk for breast cancer. Current guidelines recommend screening breast MRI to
begin at the age of 30 for which of the following groups?
A.Proven carriers of the BRCA mutation
B.Women with >10% lifetime risk for breast cancer on the basis of family history
C.Women with history of chest irradiation
D.Women with a personal history of biopsy proven atypical ductal hyperplasia (ADH)
8Which of the following is correct regarding performing periodic mammographic surveillance of a
BI-RADS 3 (probably benign) lesion versus performing tissue biopsy?
A.Decreased call-back rates
B.Increased costs
C.Increased false positives
D.Increased morbidity
E.Increased positive predictive value
9Which one of the following breast lesions can be appropriately categorized as a BI-RADS 3
(probably benign) lesion?
A.A nonpalpable, circumscribed mass on a baseline mammogram
B.A nonpalpable, circumscribed mass, new since the last mammogram
C.A nonpalpable, circumscribed mass, unchanged for 2 years
D.A nonpalpable, noncircumscribed mass on a baseline mammogram
E.A palpable, noncircumscribed mass, new since last mammogram
10Which statement is correct regarding computer-aided detection (CAD) in mammography?
A.CAD sensitivity is greater for masses than calcifications.
B.Breast cancer detection rate increases with CAD.
C.Use of CAD decreases the recall rate.
D.CAD can be used as a primary tool in reading mammograms.
E.CAD makes no false-positive or false-mark findings.
11Which statement is correct regarding male breast cancer?
A.Gynecomastia is a known risk factor.
B.Male breast cancer is about 10% of all male cancers in the United States.
C.Female relatives of men with breast cancer have no increased risk of breast cancer.
D.It has no associations with BRCA2 gene mutation.
E.Testicular diseases such as undescended testes and testicular injury are considered risk
factors for male breast cancer.
12Which is the most common cancer found in men?
A.Invasive ductal carcinoma
B.Invasive lobular carcinoma
C.Paget disease of the nipple
D.Atypical ductal hyperplasia
13Which BI-RADS assessment category is inappropriate to assign to a screening mammogram?
A.0
B.1
C.3
D.5
14A 43-year-old female presents for a screening mammogram. No prior studies are available. Based
on these images, what would be a possible associated finding in this patient?

A.Bilateral acoustic neuromas


B.Increased risk for meningiomas
C.Ependymomas
D.Lisch nodules
15A 46-year-old Asian female presents for a screening mammogram. Patient recently moved to the
United States and prior imaging studies were not available for comparison. Ultrasound
demonstrates diffuse shadowing. Which of the following is correct?
A.Patient has cafe au lait spots and similar mammographic imaging findings in family members.
B.Patient experiences cyclic breast pain predominantly during her premenstrual phase.
C.Patient has a history of prior malignant skin lesion on the sole of her foot.
D.Patient has a history of prior breast procedure.
E.Patient has a history of renal transplant with cyclosporin A therapy.
16aA 42-year-old female requests contrast-enhanced MRI of the breasts. The patients medical
history includes a history of fibromyalgia, which makes mammograms very uncomfortable. The
patient has a family history of breast cancer affecting her maternal aunt and cousin. The patients
last screening mammogram demonstrated heterogeneously dense breasts. She has a history of non-
Hodgkin lymphoma as a teenager, in complete remission since. Surgical history includes bilateral
silicone breast implant placement at 27 years of age. Which of the following is correct?
A.The test is not indicated, and advise the patient to consult with her primary care physician for
follow-up, including a clinical breast exam.
B.The test is not indicated, and recommend routine annual screening mammogram.
C.The test is indicated, and advise the patient to schedule her MRI during days 4 to 11 of her
menstrual cycle.
D.The test is indicated, and advise the patient to schedule her MRI during days 21 to 28 of her
menstrual cycle.
16bWhich of the following is an indication for contrast-enhanced screening MRI in this patient?
A.Her family history of breast cancer
B.Heterogenously dense breasts
C.History of fibromyalgia, making mammograms very uncomfortable
D.History of non-Hodgkin lymphoma
E.Bilateral silicone breast implants
17An 82-year-old female asks her internist if she needs to have a yearly screening mammogram
done. What are the ACS guidelines?
A.No need to have a screening mammogram done after age 75.
B.She should have a screening mammogram done, but once every 2 years.
C.Continue having yearly screening mammograms until age 90, then stop.
D.Continue having yearly screening mammograms done as long as she is in otherwise good
health.
18A 45-year-old female presents for a screening mammogram. A mass is noted and after further
imaging and biopsy proves to represent an invasive ductal carcinoma. Which of the following
statements is correct regarding the location of this mass?

A.Approximately 10% of all breast cancers occur in the subareolar location.


B.Breast cancers in the subareolar location are more common in women than in men.
C.Breast cancers in the subareolar region are easy to detect, due to a lack of superimposed
breast tissue in this location.
D.Breast cancers in this location are associated with earlier lymphatic spread via the
retroareolar Sappey plexus.
19A 55-year-old female presents for a screening mammogram. A mass is detected, which after
further evaluation and biopsy proves to be invasive ductal carcinoma. What percentage of breast
cancers in females is detected in this location?
A.7%
B.17%
C.27%
D.37%
20A 60-year-old female presents for a mammogram. A mass is detected at the site of the palpable
abnormality in the upper outer quadrant. What percentage of breast cancers in females occurs in
the upper outer quadrant?

A.21%
B.41%
C.61%
D.81%
21A 29-year-old female presents with a palpable abnormality in the right breast. Given the
ultrasound image below, what is the most likely diagnosis?

A.Galactocele
B.Lipoma
C.Hamartoma
D.Lymph node
22A 56-year-old female presents for a baseline screening mammogram. What is the appropriate BI-
RADS classification?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4A
23A 62-year-old female presents for an annual screening mammogram.
23aBased on the images, what is the BI-RADS Category assessment?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
23bBased on the images, what is the recommendation?
A.IncompleteNeeds additional workup
B.BenignRecommend annual screening in 1 year
C.Probably benignFollow-up in 6 months
D.SuspiciousRecommend biopsy under stereotactic guidance.
24aMammograms from 2011 are on the left and those from 2012 are on the right. The first pair
represents CC projections, and the second pair represents MLO projections. The images are
magnified to show the area of interest. What is the name of the radiologic sign that these images
demonstrate?
A.Cord sign
B.Cluster sign
C.Mirror sign
D.Tattoo sign
24bWhat type of calcifications is represented in the above images?
A.Secretory calcifications
B.Fibroadenoma calcifications
C.Dermal calcifications
D.Milk of calcium calcifications
E.Fat necrosis calcifications
25A 45-year-old asymptomatic female presents for a screening mammogram. craniocaudal (CC) and
mediolateral oblique (MLO) views are shown below:
What BI-RADS assessment would you give?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
26Based on the location of the lesion in the left breast shown below, how do you expect the lesion to
shift on a mediolateral (ML) view?
A.Inferior
B.Lateral
C.Medial
D.Superior
27Which of the following is correct about human epidermal growth factor receptor 2 (HER2)?
A.HER2 positive breast cancers usually demonstrate rapid growth and spread.
B.HER2 negative breast cancers are more aggressive than HER2 positive cancers.
C.Approximately 60% of newly diagnosed breast cancer is HER2 positive.
D.ER negative, PR negative, and HER2 negative cancers have a better prognosis.
E.HER2 positive breast cancers are more responsive to hormonal treatment.
28aScreening breast MRI was performed on a high-risk patient with history of right breast cancer and
mastectomy. Based on the following images, what is the best BI-RADS assessment to assign this
patients breast MRI?
A.0
B.2
C.3
D.4
E.5
28bWhat is the best follow-up recommendation for this patient?
A.Focused ultrasound
B.Surgical referral
C.MRI-guided biopsy
D.6-month follow-up MRI
E.Annual follow-up MRI
29A 52-year-old female presents with a painless, swollen, and erythematous left breast.

Based on the images above, what is the most appropriate next step?
A.Recommend follow-up imaging after antibiotic treatment
B.Biopsy
C.Breast MRI
D.Annual screening mammography
30Which of the following is true regarding breast-specific gamma imaging (BSGI)?
A.BSGI is less sensitive in women with dense breasts.
B.BSGI cannot distinguish and differentiate between scar tissue and recurrence in a patient
with a history of breast cancer with lumpectomy.
C.BSGI uses technetium-99m-sestamibi.
D.BSGI has lower lifetime attributable risk of mortality when compared to radiation exposure
from a four-view screening digital mammogram.
E.BSGI does not involve whole body radiation exposure.
31Match the anatomic structure to the appropriate numerical location on the sonographic image of a
normal breast.

A.Coopers ligament
B.Subcutaneous fat
C.Pectoralis muscle
D.Skin
32Based on the images below, what is the most likely location on the craniocaudal (CC) view for the
lesion shown?
A.Lateral and posterior
B.Medial and posterior
C.Lateral and anterior
D.Medial and anterior
33What is the initial imaging modality for evaluation of a palpable breast lesion in a 29-year-old
male patient?
A.Ultrasound
B.Mammography
C.Contrast-enhanced MRI
D.Contrast-enhanced CT
E.Breast-specific gamma imaging
34Which of the following is considered a second-degree relative?
A.Father
B.Daughter
C.Aunt
D.Sister
35Which of the following is true of surveillance and treatment for breast cancer in treated Hodgkins
survivors?
A.Peak incidence of breast cancer is 25 to 30 years after treatment.
B.No significant increased risk of breast cancer if treated before the age of 30.
C.Preferred treatment in these patients is mastectomy in conjunction with radiation.
D.If treated for Hodgkins before the age of 30, begin annual screening mammography 8 years
after radiation exposure.
36Which of the following is a risk factor for breast cancer?
A.Family history of breast cancer in cousin
B.Late menarche
C.First childbirth after age 30
D.Prior history of chemotherapy
37Which of the following concerning interval cancers is correct?
A.Breast cancer found during regular interval mammographic examinations with prior
mammogram prospectively having been interpreted as negative
B.Increases ductal histology
C.Incidence of interval cancers has no relation to density of breast tissue.
D.Interval cancers can be mammographically occult or a new mammographic finding.
38With regards to the nipple on screening mammographic views, which of the following statements
is correct?
A.Nipple should be in profile on both MLO and CC projections of both breasts.
B.Nipple should be in profile on either CC or MLO projection of both breasts.
C.Nipple does not need to be in profile on either CC or MLO projections.
D.Nipple should be in profile for one breast but need not be in profile for the other breast.
39Regarding the use of compression while obtaining mammographic images, which of the following
statements is correct?
A.It helps maintain the nipple in the midline on the images.
B.It is less painful during the second half of the menstrual cycle.
C.It reduces the amount of radiation needed.
D.It helps reduce the number of technical recalls.

ANSWERS AND EXPLANATIONS

1Answer D.
Reference: Saslow D, Boetes D, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct
to mammography. CA Cancer J Clin 2007;57:7589.

Recommendations for Breast MRI Screening as an Adjunct to Mammography


a Evidence from nonrandomized screening trials and observational studies.
Based on evidence of lifetime risk for breast cancer.

2Answer B. Sternalis muscle is a normal variant of an anatomic chest wall musculature. It is


located medially adjacent to the sternum and is seen only on the CC mammogram medially. It is
present in both males and females.
Reference: Berg A, Birdwell R, Gombos E. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys; 2008:IV:3:4041.

3aAnswer A.
3bAnswer B. Although these calcifications appear suspicious on the provided screening mammogram,
it is important to remember the steps required in the workup of an abnormality seen at screening.
BI-RADS 0, incomplete, is the appropriate first step in diagnosis. The patient can then return for
additional views. These calcifications are highly suspicious; thus, the term pleomorphic fine
linear branching is the best answer for description. Stereotactic or surgical biopsy should be
recommended.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:530543.

4Answer B. The important findings to detect in this case include a bilateral increase in breast
density, loss of fat, and decrease of breast size. The differential diagnosis for increased breast
density includes hormone replacement therapy, endogenous hormonal stimulation such as in
pregnancy and lactation, bilateral breast edema such as from congestive heart failure, bilateral
breast trauma, weight loss, and bilateral inflammatory breast cancer. Of these, bilateral
inflammatory breast cancer. Of these, bilateral inflammatory breast cancer is the rarest. In this
case, the decreased breast size and loss of fat combined with the increased breast density are most
consistent with weight loss. The patient in this case reported a 90-pound weight loss between the
two studies. Hormone replacement therapy and endogenous hormonal stimulation are typically
associated with increased breast size.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:5-48IV:549.

5Answer B. This is an example of a mammogram in a woman who has had a previous bilateral
reduction mammoplasty. The nipple is elevated because there is more skin inferior to the nipple
than superior to the nipple. In these cases, the residual fibroglandular breast tissue is redistributed
from the upper outer quadrant to the inferior inner quadrant to replace the tissue that was removed.
This creates a swirled fibroglandular tissue pattern in the inferior inner quadrant. The
calcifications associated with fat necrosis are visible mammographically; later, they are seen in
only 50% of cases by 2 years after the surgery.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:4-32IV:435.

6Answer A. Carriers of the BRCA1 or BRCA2 mutation should begin annual routine screening
mammography at age 30 years. Women with mothers or sisters with breast cancer should begin
annual routine screening at age 30 (but not before age 25) or 10 years earlier than the age of their
relatives diagnosis, whichever is later. In this case, if the patient was not a BRCA2 mutation
carrier she would have begun screening at age 35 based on her mothers history and at age 32
based on her sisters history. Forty is the age when women who do not have an increased risk of
breast cancer to begin screening.
Reference: Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: Recommendations from the Society of
Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of
clinically occult breast cancer. J Am Coll Radiol 2010;7:1827.

7Answer A.
B.MRI is recommended in women with >20% lifetime risk for breast cancer on the basis of
family history.
C.Women with a history of chest irradiation should begin screening MRI 8 years after the
completion of radiation therapy, not necessary at age 30.
D.Women with a history of biopsy-proven ADH should be considered for screening MRI only
if other factors make their overall lifetime risk between 15% and 20%.
Reference: Lee CH, Dershaw D, Kopans D, et al. Breast cancer screening with imaging: Recommendations from the society of
breast imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of
clinically occult breast cancer. J Am Coll Radiol 2010;7:1827.

8Answer E. The positive predictive value (PPV) of biopsy will be increased because of a
substantial reduction in the number of interventional procedures that produce benign results.
A.Periodic mammographic surveillance does not affect call-back rates.
B.Operating costs will decrease substantially because (1) the cost of diagnostic examinations
usually is much lower than that of imaging-guided interventional procedures and (2)
surveillance adds cost only to the extent that it requires examinations in between those
performed for routine screening, which for most follow-up protocols involves only one
additional examination.
C.False-positive results will be reduced, similar to increase in PPV, due to reduction of the
number of interventions that produce benign results.
D.Surveillance is associated with reduced morbidity, especially when compared to open
surgical biopsy but also when compared to percutaneous imaging-guided tissue sampling.
Reference: Sickles EA. Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up
protocol? Radiology 1999;213:1114.

9Answer A. According to BI-RADS manual, lesions appropriately placed in BI-RADS category 3


include a nonpalpable, circumscribed mass on a baseline mammogram (unless it can be shown to
be a cyst, an intramammary lymph node, or another benign finding), a focal asymmetry that
partially thins on spot compression, and a cluster of round punctate calcifications. Answer choices
B, D, and E should be given a BI-RADS 0 category assessment and be called back for additional
imaging, and if persist, undergo biopsy. Answer choice C is a benign lesion.
Reference: American College of Radiology (ACR). BI-RADS Mammography: Guidance Chapter.
Reston, VA: American College of Radiology; 2012:254255.

10Answer B. Computer-aided detection (CAD) mammography increases breast cancer detection


rate ~7% to 20%.
A.CAD sensitivity is greater for calcifications than masses.
C.Use of CAD increases the recall rate by about 8.2%.
D.CAD is to provide spell check while looking at screening mammograms, after independent
or unaided case assessment by radiologist. It is not a primary tool in reading mammograms.
E.CAD makes about 2.0 false marks per every four-view negative mammogram. However,
with experience, overwhelming majority of false CAD marks are readily dismissed.
Reference: Birdwell RL, Bandodkar P, Ikeda DM. Computer-aided detection with screening mammography in a university hospital
setting. Radiology 2005;236:451457.
11Answer E. Known risk factors of male breast cancer include advance age, Klinefelter syndrome,
BRCA2, family history, obesity, treatment with estrogen for prostate cancer, excess alcohol
consumption, head trauma resulting in increased prolactin production, and testicular diseases such
as undescended testes, orchiectomy, mumps orchitis, and testicular injury.
A.Gynecomastia is not considered a risk factor for male breast cancer by most authorities.
B.Male breast cancer is <1% of all male cancers in the United States, and 0.2% to 0.9% of
breast cancers in the United States.
C.Female relatives of men with breast cancer have increased risk of breast cancer equivalent
to increased risk with female breast cancer.
D.Approximately 18% to 33% of male breast cancer patients have BRCA2 gene mutation.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006:IV:5:5457.

12Answer A. Invasive ductal carcinoma is the most common type of breast cancer in both women
and men. Since breast cancer in women and that in men are indistinguishable histologically, all
ductal subtypes of breast cancer (including medullary and mucinous) have been described in men.
Most male breast cancers are detected when they are still intraductal.
B.Invasive lobular carcinoma is an uncommon type of breast cancer in men because lobule
formation in men is rare.
C.Paget disease of the nipple makes up about 12% of all male breast cancers. It is considered a
carcinoma in situ involving the nipple epidermis, and the malignant cells extend through the
ducts.
D.Atypical ductal hyperplasia (ADH) is a high-risk lesion that increases the risk for
developing invasive breast cancer by four to five times. Twenty-two percent of male breast
cancer (invasive carcinoma) has associated ADH.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. 1st ed. Salt Lake City, UT: Amirsys; 2006:IV:5:5457.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:675676.

13Answer C. BI-RADS 3 is used for findings that are almost certainly benign, with <2% chance of
malignancy. Additional mammographic views and/or ultrasound is required to evaluate
abnormalities discovered on a screening mammogram before an assessment of BI-RADS 3 is
assigned. These findings are reassessed in the short term with the initial follow-up period, usually
at 6 months.
A.BI-RADS 0, incomplete. This category can be used to recall a patient for additional views
or if retrieval of prior films is required.
B.BI-RADS 1 is used when the screening mammogram is negative, and there is no evidence to
suggest malignancy.
D.BI-RADS 5 is used for lesions that are almost certainly breast carcinoma with classic
features present. These lesions have a >95% chance of malignancy. The recommendation is
to obtain histologic diagnoses by biopsy.
Other BI-RADS assessment categories:
BI-RADS 2 is used as a normal assessment of the screening mammogram like category 1, but
the interpreter may choose to describe a completely benign finding.
BI-RADS 4 is used for a suspicious abnormality, when a finding does not demonstrate classic
malignant characteristics but has a probability of malignancy that is greater than category 3 (>2%).
Category 4 can be subdivided into 4A-low suspicion, 4B-intermediate suspicion, or 4C-high
suspicion, which can guide the decision for plan of action.
BI-RADS 6 is used when there is an imaging finding that is already biopsy proven to be a
malignancy but prior to definitive therapy.
Reference: American College of Radiology (ACR). ACR BI RADSMammography. In: ACR Breast Imaging Reporting and
Data System, Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003:194197.

14Answer D.There are multiple neurofibromas consistent for neurofibromatosis type 1 (NF1).
NF1 is associated with Lisch nodules (hamartomas of iris), freckling in the iris. NF2 is associated
with bilateral acoustic neuromas, increased risk for meningiomas, and ependymomas.
Reference: Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007:233237.

15Answer D. Neurofibromatosis, breast cysts, melanoma, and fibroadenomas are all in the
differential for multiple bilateral breast masses. It is the diffuse shadowing or snowstorm
appearance on ultrasound that is classic for free silicone. Free silicone injection into the breasts is
not approved in the United States, but is still practiced in other parts of the world, such as Asia
and South America. Free silicone injection can present as large high density masses, some with
curvilinear calcification. Masses demonstrate foci of low signal intensity on fat-suppressed T1-
weighted images and high signal intensity on water-suppressed T2-weighted images, and MRI
may be essential in evaluating for malignancy.
References: Caskey CI, Berg WA, Hamper UM, et al. Imaging spectrum of extracapsular silicone: correlation with US, MR imaging,
mammographic, and histopathologic findings. Radiographics 1999;19:S39S51.
Cheung YC, Su MY, Ng SH, et al. Lumpy silicone-injected breasts: enhanced MRI and microscopic correlation. Clin Imaging
2002;26:397404.
Leibman AJ, Misra M. Spectrum of imaging findings in the silicone-injected breast. Plast Reconstr Surg 2011;128:28e29e.

16aAnswer C. The test is indicated in this patient. Due to increased parenchymal enhancement during
the secretory phase, there is increased risk of false-positive MRI results. Optimal timing of an
MRI study of the breasts is during the 2nd week of the menstrual cycle.
Reference: Morris EA, Bassett LW, Berg WA, et al. ACR Practice Guideline for the Performance of Contrast-Enhanced
Magnetic Resonance Imaging (MRI) of the Breast. Reston, VA: American College of Radiology (ACR); 2008:7.
www.acr.org/secondarymainmenucategories/quality_safety/guidelines/breast/mri_breast.aspx

16bAnswer D. The patients history of treated non-Hodgkin lymphoma places the patient at a >20%
lifetime risk of breast cancer, due to exposure to mantle radiation. Although breast augmentation
can also be an indication, it is typically performed without contrast.
Reference: Morris EA, Bassett LW, Berg WA, et al. ACR Practice Guideline for the Performance of Contrast-Enhanced
Magnetic Resonance Imaging (MRI) of the Breast. Reston, VA: American College of Radiology (ACR); 2008:7.
www.acr.org/secondarymainmenucategories/quality_safety/guidelines/breast/mri_breast.aspx

17Answer D. Yearly mammograms are recommended starting at age 40 and continue as long as the
woman is in good health.
Reference: http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-
early-detection-of-cancer

18Answer D. Breast cancers in the subareolar region are subject to the rich lymphatics of the
Sappey plexus; therefore, they are at risk of earlier metastatic spread compared to other breast
cancers. Breast cancers in this location are more common in the male population than in females.
In females, breast cancer in the subareolar region constitutes ~1% of all breast cancers. Breast
cancers in this location are often difficult to detect due to breast tissue summation artifact,
particularly due to retroareolar fibrosis.
Reference: Tabar L, Tot T, Dean P. Breast Cancer the Art of and Science of Early Detection with Mammography. New York,
NY: Thieme; 2005:259, 346.

19Answer B. The mass is located in the upper inner quadrant, which is the second most common
location for breast cancers after the upper outer quadrant. Approximately 17% of all breast cancer
in women occurs in the upper inner quadrant. The retroglandular clear space, the space between
the posterior border of the glandular tissue and the anterior border of the pectoralis major muscle,
and the medial breast are important locations to evaluate for an abnormality on the CC view,
which is the location of the finding on the CC view in this case.
Reference: Tabar L, Tot T, Dean P. Breast Cancer the Art of and Science of Early Detection with Mammography. New York,
NY: Thieme; 2005:259.

20Answer C. Sixty-one percent of all breast cancers in females occur in the upper outer quadrant,
making this the most common location for breast cancer. It is important to evaluate the
retroglandular clear space on the MLO view for a potential finding. The retroglandular clear
space is the predominately fatty tissue between the posterior border of the glandular tissue and the
anterior border of the pectoralis major muscle on the MLO view, which is the location of the mass
in this case.
Reference: Tabar L, Tot T, Dean P. Breast Cancer the Art of and Science of Early Detection with Mammography. New York,
NY: Thieme; 2005:259.

21Answer C. On ultrasound, hamartomas present as an encapsulated heterogeneous masses with


both fibroglandular tissue and fat. This is easily distinguished from the other fat-containing masses
provided as possible answers. The most appropriate BI-RADS classification for this lesion is BI-
RADS 2, benign. This is considered a dont touch lesion, and further intervention is unnecessary
unless the patient is bothered by the mass and desires surgical resection.
Reference: Appleton CM, Wiele KN. Breast Imaging Cases (Cases in Radiology). New York, NY: Oxford University Press;
2012:2122.

22Answer B. These are classic secretory calcifications and are benign. No additional evaluation is
needed. They develop from the calcification of debris within dilated ducts. Secretory
calcifications typically present as coarse rod-like branching calcifications in a ductal distribution.
It is important to understand that these are not the calcifications of DCIS, which are more likely to
present as fine, pleomorphic calcifications.
Reference: Evans AJ. Breast Calcifications: A Diagnostic Manual. San Francisco, CA: Cambridge University Press; 2002:1618.

23aAnswer B.
23bAnswer B. These are bilateral secretory calcifications. They have a classic thick rod-shaped
appearance and often, but not always bilateral. They can be seen converging toward the nipple.
They are always benign and do not need any further evaluation.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:67.

24aAnswer D.
24bAnswer C. The tattoo sign is a finding seen on mammograms. It appears as calcifications that
maintain a fixed and reproducible relationship to one another on mammograms obtained with
similar projections at different times. In addition to the tattoo sign, there is another similar
unnamed mammographic sign that also indicates the presence of dermal calcifications, and it
should be applied in all cases of peripheral calcifications. The tattoo sign is made up of
calcifications that maintain a fixed and reproducible relationship to one another on mammograms
obtained with similar projections at different times. The unnamed sign is made up of
microcalcifications that maintain a fixed relationship to one another on mammograms obtained
with different projections during the same examination.
Reference: Loffman Felman RL. Signs in imaging. Radiology 2002;223:481482.

25Answer B. Multiple partially circumscribed masses are a relatively common occurrence, with
studies estimating a rate close to 2% for every 100 screening mammograms. The vast majority of
these masses represent cysts or fibroadenomas. There is no increased risk of cancer in women
with multiple partially circumscribed breast masses if management was limited to annual
mammography follow-up.
Reference: Leung JW, Sickles EA. Multiple bilateral masses detected on screening mammography: assessment of need for recall
imaging. Am J Roentgenol 2000;175(1):2329.

26Answer A. Lesions laterally in the breast project higher on the mediolateral oblique (MLO) view
than they are actually located in the breast and lesions in the medial breast project lower on the
MLO view than they are actually located. Lateral lesions shift lower in position on the ML view.
Lesions in the medial breast shift higher on the ML view. Lead (lateral) sinks, muffins (medial)
rise. Of note, lesions located more centrally in the breast shift little or not at all between the
MLO and ML views.
Reference: Harvey JA, Nicholson BT, Cohen MA. Findings early invasive breast cancers: A practical approach. Radiology
2008;248:6176.

27Answer A. HER2 positive breast cancers usually demonstrate rapid growth and spread.
Approximately 20% of newly diagnosed breast cancer is HER2 positive. HER2 breast cancers
are more aggressive than HER2 negative cancer and are less responsive to hormonal treatment.
Triple negative breast cancers do not have a good prognosis.
Reference: Lakhani SR, Van De Vijver MJ, Jacquemier J, et al. The pathology of familial breast cancer: Predictive value of
immunohistochemical markers estrogen receptor, progesterone receptor, HER-2, and p53 in patients with mutations in BRCA1 and
BRCA2. J Clin Oncol 2002;20:23102318.

28aAnswer B. This breast MRI demonstrates left duct ectasia, which is a benign finding, BI-RADS
category 2. Duct ectasia is a common, benign finding seen on breast MRI. It may be seen unilateral
or bilateral, focal or diffuse. Duct ectasia is ductal dilatation with internal proteinaceous content
or debris; it is characterized by high T1 signal in a ductal distribution on the precontrast T1
sequence. Because the proteinaceous content has inherent high T1 signal, it will also be high
signal on the postcontrast T1. However, since the finding is due to precontrast signal and not truly
enhancing, high signal will not be seen in the area on the subtraction sequence. It is important to
examine the subtraction sequence closely to ensure that no actual enhancement is present. Answer
choice A is incorrect because the finding is not incomplete (BI-RADS category 0); no additional
imaging is necessary. Answer choices C, D, and E are not correct; short-term follow-up or biopsy
is not indicated.
28bAnswer E. The correct follow-up recommendation for this patient based on the included images is
an annual screening breast MRI in addition to her annual left mammogram. Answer choice A is
incorrect as additional ultrasound evaluation is not needed to further characterize the finding.
Surgical referral is not necessary for this finding. As long as the patient is stable and
asymptomatic, she can continue with her standard clinical follow-up. Therefore, answer choice B
is incorrect. Answer choice C is not correct because MRI biopsy is not necessary. Duct ectasia
alone is not a suspicious finding on MRI. Again, it is important to examine the area closely for
enhancement on the subtraction sequence. DCIS may also present with high T1 signal on the
precontrast sequence with possible blood/debris in the duct. However, it would be seen as high
T1 signal on both pre- and postcontrast T1 as well as concomitant high signal/enhancement on the
subtraction sequence. Answer choice D is incorrect; this is a benign finding. Annual, rather than 6-
month follow-up breast MRI is indicated.
Reference: Morris EA, Liberman L, eds. Breast MRI Diagnosis and Intervention. New York, NY: Springer; 2005:2526, 437440.

29Answer B. This patient has inflammatory carcinoma. The findings of a dominant mass in the upper
outer quadrant of the breast in the presence of skin and trabecular thickening confirm the
diagnosis. This patient requires a core biopsy of the mass to confirm the diagnosis. In the absence
of a dominant mass, mastitis may be considered as the working diagnosis. If, however, the findings
persist on follow-up mammogram after antibiotic treatment, the diagnosis is inflammatory
carcinoma unless proven otherwise. At that point the patient should have a punch biopsy. Punch
biopsy will often demonstrate tumor cells invading the dermal lymphatics and will confirm the
diagnosis of inflammatory carcinoma. Although breast MRI may reveal the dominant mass, it is
not the most cost-effective step in diagnosis. Returning the patient to annual screening
mammography is only appropriate when a mammogram is clearly negative or benign and should
not be recommended in this setting. Even if a dominant mass were not present and one suspects a
benign entity like mastitis, follow-up should be recommended after treatment to exclude an
underlying malignancy.
References: Gunhan-Bilgen I, et al. Inflammatory breast carcinoma: Mammographic, ultrasonographic, clinical and pathologic
findings in 142 cases. Radiology 2002;223:829838.
Kushwaha AC, et al. Primary inflammatory carcinoma of the breast. Retrospective review of radiological findings. AJR Am J
Roentgenol 2000;174:535538.

30Answer C. There is whole-body radiation exposure from BSGI, with greatest effect on the bowel
wall. BSGI has a lifetime attributable risk of mortality that is ~20 to 30 times greater than that of a
complete screening digital mammogram. The density of breast tissue does not affect sensitivity,
and BSGI is equally sensitive in dense and fatty breasts.
References: Brem RF, Rechtman LR. Nuclear medicine imaging of the breast: A novel, physiologic approach to breast cancer
detection and diagnosis. Radiol Clin North Am 2010;48:10551074.
Hendrick RE. Radiation does and cancer risks from breast imaging studies. Radiology 2010;257:246253.

31
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:151.

32Answer B. If a lesion is visible only on mediolateral oblique (MLO) and true lateral views, the
triangulation method is used to locate the lesion on the craniocaudal (CC) view. With the MLO
view in the middle, a line drawn through the lesion in the MLO and true lateral views and
extending through to the CC view will intersect lesion location on the CC view.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;II:013.

33Answer B. Mammography is the first imaging test of choice for a clinically suspicious mass in a
male. A palpable mass that is occult or incompletely imaged on mammography warrants a targeted
ultrasound.
Reference: Nguyen C, Kettler MD, Swirsky ME, et al. Male breast disease: Pictorial review with radiologic-pathologic correlation.
Radiographics 2013;33(3):763.

34Answer C. First-degree relatives include mother, father, sister, and daughter. Second-degree
relatives include grandmother, aunt, and niece.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;II:024.

35Answer D. Peak incidence of breast cancer in these patients is at 15 years after treatment. They
have an increased risk if radiation exposure is before 30 years of age. Preferred treatment is
mastectomy with chemotherapy. Radiation is contraindicated.
References: Alm El-Din MA, Hughes KS, Raad RA, et al. Clinical outcome of breast cancer occurring after treatment for
Hodgkins lymphoma: case control analysis. Radiat Oncol 2009;4:19.
Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:4-58.

36Answer C. Risk factors for breast cancer include early menarche, late menopause, nulliparous,
atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), personal history of breast
cancer, first-degree relative with breast cancer, first birth after age 30, BRCA1 and BRCA2,
radiation exposure at a young age.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:2425.

37Answer D. Interval cancers are defined as breast cancers presenting with chemical findings
during the interval between recommended screenings. They can be mammographically occult or
missed on prior mammography. Usually presenting as a new palpable lump compared to screen-
detected cancers, there is an increased incidence of lobular and mucinous histology. There is a
lower rate of ductal carcinoma in situ (DCIS). Women with very dense breasts have a higher
incidence than those with fatty breasts. Prognosis for interval cancers is similar to symptomatic,
unscreened breast cancers.
References: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirysis Inc;
2006;IV:2:140143.
Buist DS, et al. Factors contributing to mammography failure in women aged 4049 years. J Natl Cancer Inst 2004;96:14321440.
Ikeda DM, et al. Analysis of 172 subtle findings on prior normal mammograms in women with breast cancer detected at follow up
screening. Radiology 2003;226:494503.

38Answer B. The nipple should be seen on profile in at least one view to assess the subareolar area.
Reference: Bassett L, Hirbawi I, DeBruhl N, et al. Mammographic positioning: Evaluation from the viewbox. Radiology
1993;188:803806.

39Answer C. Adequate compression when obtaining mammograms is important for a number of


reasons. It prevents motion, reduces scatter and spreads out the tissues better. It reduces the
amount of radiation needed. Compression is usually less painful during the first half of the
menstrual cycle and if the compression is applied gradually.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsis Inc.; 2006:I1:0-2
I1:0-3.
Diagnostic Breast Imaging, Breast Pathology, and Breast
3
Imaging Findings

QUESTIONS

1Based on this image, what is the most likely diagnosis?

A.Radial fold
B.Capsular contracture
C.Intracapsular rupture
D.Extracapsular rupture
2What is the most common location for an intramammary lymph node?
A.Upper outer quadrant
B.Upper inner quadrant
C.Lower outer quadrant
D.Lower inner quadrant
3aBased on the following images, the dominant finding is
A.Subareolar region nonmass-like enhancement
B.Enhancement of the pectoralis muscle
C.Unilateral skin thickening
D.Architectural distortion in the superior right breast
3bWhat would be an appropriate differential diagnosis for the previous finding?
A.Related to phase of menstrual cycle
B.Mastitis
C.Hormone therapy
D.Renal failure
4aA 16-year-old female presents with a palpable finding in her right breast. What is the most
appropriate imaging test?
A.Unilateral right mammogram
B.Bilateral mammogram
C.Unilateral right ultrasound
D.Bilateral ultrasound
E.Unilateral right mammogram and ultrasound
4bWhich of the following statements regarding fibroadenomas is correct?
A.Giant fibroadenomas are more common in the Asian population.
B.Most fibroadenomas in teenagers are adult type.
C.Fibroadenomas are more common in postmenopausal women.
D.Fibroadenomas can be found equally in males and females.
4cBased on the following image, what would be the most likely diagnosis?
A.Fat necrosis
B.Lymph node
C.Hematoma
D.Juvenile fibroadenoma
5A 49-year-old female with no history of prior breast concerns or a family history of breast cancer
presents with new onset right bloody nipple discharge. Based on the ultrasound images below,
what is the most likely diagnosis?

A.Intraductal carcinoma
B.Duct ectasia with debris
C.Fibrocystic change
D.Intraductal papilloma
6aBased on the following images, what would be the appropriate BI-RADS category?
A.BI-RADS 2
B.BI-RADS 3
C.BI-RADS 4
D.BI-RADS 5
6bWhat is the appropriate recommendation?
A.Annual screening mammography
B.Short-term follow-up in 6 months
C.Core needle biopsy
D.Surgical excisional biopsy
7A 45-year-old female presents with a palpable abnormality in the right breast. Based on the
ultrasound image below, what is the most appropriate BI-RADS assessment?

A.BI-RADS 2
B.BI-RADS 3
C.BI-RADS 4
D.BI-RADS 5
8A 35-year-old female with a history of a left lumpectomy, radiation therapy, and chemotherapy at
age 29 presents for her annual diagnostic mammogram. Based on the magnification images of the
lumpectomy site, what is the most appropriate next step?

A.6-month follow-up
B.MRI
C.Stereotactic core biopsy
D.Annual screening mammogram
E.Annual diagnostic mammogram
9A 40-year-old female was recalled from screening for calcifications in the right breast. Based on
the magnification views, what is the most appropriate BI-RADS lexicon description for the
calcifications?
A.Coarse heterogeneous
B.Secretory
C.Punctate
D.Pleomorphic
10aA 50-year-old female was recalled from screening for a mass within the left breast. Based on
images A and B, what is the best description of the mass shape and margins using the BI-RADS
lexicon?

A.Round, obscured
B.Irregular, microlobulated
C.Irregular, spiculated
D.Round, speculated
10bAn ultrasound of mass was performed. Based on images A and B, what is the best BI-RADS
lexicon description of the shape and margins of the mass?

A.Oval, spiculated
B.Oval, angular
C.Irregular, angular
D.Irregular, speculated
10cThe mass was also examined by elastography. Given the image below, which statement is correct?

A.The mass measures cystic or soft by elastography.


B.The mass measures hard or stiff by elastography.
C.The mass is indeterminate for stiffness by elastography.
D.The mass stiffness suggests malignancy by elastography.
11aA 65-year-old female with a history of right mastectomy, contralateral prophylactic mastectomy,
and bilateral TRAM flap reconstruction for right breastinvasive ductal carcinoma and DCIS
presents for surveillance breast MRI. Axial T1-weighted and axial postcontrast subtraction
images are provided. What is the most likely diagnosis?
A.Recurrent invasive ductal carcinoma
B.Fat necrosis
C.Breast abscess
D.Postsurgical seroma
11bThe patients left mammogram is also shown. No prior mammogram is available for comparison at
this time. What is the most appropriate BI-RADS classification?

A.BI-RADS 2, benign
B.BI-RADS 3, probably benign
C.BI-RADS 4, suspicious
D.BI-RADS 6, known malignancy
12A 29-year-old female, who is 35 weeks pregnant, presents with a palpable lump in the right breast
with associated pain. She denies any fevers. No skin erythema is seen on physical examination.
Ultrasound images of the palpable lump are provided. No mammogram was performed due to
patients age and pregnancy. What is the most appropriate next step?
A.Probable abscess, treat with antibiotics and short interval follow-up ultrasound.
B.Probable abscess, recommend drainage/aspiration.
C.Probably benign, lactating adenoma, or fibroadenoma, recommend short interval follow-up
ultrasound in 6 months.
D.Suspicious mass, recommend ultrasound-guided core biopsy.
13A 51-year-old female presents for a diagnostic mammogram, no prior studies are available for
comparison. Based on images, what is the most likely diagnosis?

A.HIV
B.Tuberculosis
C.Metastases
D.Sarcoidosis
E.Rheumatoid arthritis
14aA 70-year-old female presents for breast MRI to assess for possible implant rupture. Bilateral
axial T1-weighted and left breast axial T2-weighted STIR water saturation images are provided.
What type of implant is present?
A.Saline, prepectoral
B.Saline, retropectoral
C.Silicone, prepectoral
D.Silicone, retropectoral
14bWhich statement best describes the finding seen in the axial T2W STIR water-saturated image of
the left implant?
A.Intact implant with normal radial folds
B.Intracapsular rupture only
C.Intact implant with capsular contracture
D.Intracapsular and extracapsular rupture
15A 65-year-old male is diagnosed with breast cancer. Regarding breast cancer in males, which
statement is correct?
A.Breast cancer in males in general has a better prognosis than in females due to the
malignancy typically being in an earlier stage at the time of diagnosis.
B.Approximately 20% have axillary adenopathy at the time of diagnosis.
C.Approximately 15% have DCIS associated with their malignancy.
D.Infiltrating lobular carcinoma is less common in men than women.
16What is the protocol for performing rolled craniocaudal (CC) views?
A.Always roll superior half of the breast medial and lateral.
B.Always roll inferior half of the breast medial and lateral.
C.Always roll medial half of the breast superior and inferior.
D.Always roll lateral half of the breast superior and inferior.
17A 50-year-old female presents with a right breast palpable abnormality at 9 oclock. Based on the
ultrasound image below, what is the most likely diagnosis?
A.Extracapsular silicone implant rupture
B.Intact silicone implant with a focal bulge
C.Intact saline implant with a focal bulge
D.Intracapsular silicone implant rupture
E.Saline implant rupture
18A cluster of calcifications are seen in the medial breast on the CC view but not seen on the MLO
view. What additional mammographic view would be helpful to localize the calcifications?
A.Medial lateral (ML) view
B.Lateral medial (LM) view
C.Spot compression view
D.Cleavage view
E.Exaggerate craniocaudal outer view
19Mondors disease of the breast is typified by which of the following statements?
A.Easily differentiated from inflammatory breast cancer
B.Common disorder characterized by thrombophlebitis of the subcutaneous veins of the
anterolateral chest wall
C.Presents as a tender palpable cord corresponding to a superficial tubular density on
mammography and a subcutaneous vessel on ultrasound without Doppler vascular flow
D.Rare malignant breast condition that requires biopsy or excision
20A 56-year-old woman presents for a screening mammogram. Based on the two standard
mammographic views A and B, what is the most likely diagnosis?
A.Lymph node
B.Invasive ductal carcinoma
C.Radial scar
D.Inframammary fold
E.Sternalis muscle
21You are shown a standard screening mammogram. What is the MOST appropriate NEXT step?

A.1 year follow-up


B.6-month follow-up
C.Spot-magnification views
D.MRI
22A 76-year-old male presents with a painless palpable breast lump. Based on the mammograms A
and B, what is the most likely diagnosis?
A.Abscess
B.Hematoma
C.Mastitis
D.Breast carcinoma
E.Gynecomastia
23Diabetic fibrous mastopathy (DFM) is classically associated with which type of diabetes
mellitus?
A.Type I
B.Type II
C.Type III
D.Type IV
24Amongst the choices given below, what is the most common malignancy to metastasize to the
breast?
A.Lung
B.Ovarian
C.Melanoma
D.Pancreatic
E.Stomach
25You are shown standard CC and MLO views of a screening mammogram. Which of the following
is the MOST LIKELY diagnosis?
A.Steatocystoma multiplex
B.Metastasis
C.Neurofibromatosis Type I
D.Silicone injection granulomata
26A 65-year-old male with history of coronary artery bypass surgery, thyroid disease, and
depression presents with painful, tender subareolar masses. What is the best next step, based on
the provided mammographic images?
A.Ultrasound
B.Breast MRI
C.Obtaining careful drug history
D.Spot compression views
E.Biopsy and cytological analysis
27Patient was diagnosed with right breast cancer and elected to undergo bilateral mastectomies with
DIEP (deep inferior epigastric perforator) reconstructions. She now presents to her surgeon with
persistent right breast skin thickening and heaviness. A bilateral breast MRI with contrast was
ordered. Selected images from that examination are shown.
What is the most likely explanation for the patients symptoms?
A.Postoperative seroma
B.Fat necrosis
C.Recurrent tumor
D.Flap edema
28aA 31-year-old female presents with a palpable lump in the upper left breast. Her mother was
diagnosed with breast cancer at age 46. Targeted ultrasound of the area of palpable abnormality
was performed. What is the MOST LIKELY diagnosis based on the ultrasound finding?
A.Complicated cyst
B.Fibroadenoma
C.Invasive ductal carcinoma
D.Phyllodes tumor
E.Simple cyst
28bWhat are the typical MRI features of this mass, if this patient had a breast MRI done?
A.Enhancing mass with nonenhancing internal septations
B.Low T1-weighted and high T2-weighted signal intensity with no enhancement
C.Multiple small fluid intensity components within a heterogeneous mass
D.Type 3 enhancement kinetic curve
E.Signal loss on fat-saturated sequences
29Which benign lesion is most likely to demonstrate a classically malignant characteristic on MRI?
A.Fibroadenoma
B.Fat necrosis
C.Simple cyst
D.Hamartoma
30aA 28 year-old, 38-week G2P1 female presents with a painful, erythematous mass in the right
breast. Which imaging modality is most appropriate for evaluating this patient?
A.Mammogram
B.Ultrasound
C.MRI
D.Chest radiograph
30bAn image from a targeted ultrasound is shown.
What is the most likely diagnosis?
A.Enlarged duct
B.Abscess
C.Malignancy
D.Hematoma
31Which of the following would you expect to present as a spiculated mass on mammogram?
A.Medullary carcinoma
B.Papillary carcinoma
C.Phyllodes tumor
D.Tubular carcinoma
32A 62-year-old female presents for additional views for a mammographic finding. What is the
diagnosis?
A.Skin calcifications
B.Oil cyst
C.Milk of calcium
D.Vascular calcifications
33Approximately what percentage of all breast cancers occurs in MEN?
A.1%
B.5%
C.10%
D.15%
34Calcifications are seen on a poststereotactic biopsy radiograph of the specimen. However, the
pathologist states no calcifications are seen in the specimen provided. What is the next BEST
step?
A.Accept the pathology results.
B.Recommend 6-month follow-up mammogram.
C.Analyze specimen using polarized light microscopy.
D.Recommend rebiopsy.
35You are shown a screening mammogram and CC and MLO projection magnification views. What
is the MOST appropriate BI-RADS designation?
A.Category 0
B.Category 2
C.Category 3
D.Category 5
36aA 50-year-old female presents for a screening mammogram.

What is the salient finding?


A.Intracapsular rupture
B.Capsular calcification
C.Distortion of the implant contour
D.Free silicone with intracapsular and extracapsular rupture of the implant
36bWhat is the BI-RADS assessment?
A.0
B.2
C.3
D.4
37Which of the following is a high-risk lesion?
A.Peripheral duct papilloma
B.Intraductal papilloma
C.Intracystic papilloma
D.Papillary carcinoma in situ
38aA 20-year-old female presenting with a new palpable abnormality in her right breast. Sonographic
evaluation of the palpable area was performed.

Which of the following is the best description of the sonographic finding?


A.Hypoechoic mass, smooth thin wall, sharp posterior border, posterior acoustic enhancement
B.Anechoic mass, smooth thin wall, sharp posterior border, posterior acoustic enhancement
C.Hypoechoic mass, smooth thin wall, sharp posterior border, increased through transmission
D.Anechoic mass, smooth thin wall, sharp posterior border, posterior acoustic shadowing
38bWhat is the most likely diagnosis?
A.Solid mass
B.Complicated cyst
C.Complex cyst
D.Simple cyst
39What is the most likely diagnosis for an encapsulated mass with breast-within-a-breast
appearance on mammogram?
A.Fat necrosis
B.Fibroadenoma
C.Fibroadenolipoma
D.Galactocele
E.Lipoma
40A 57-year-old female presents with a new palpable left breast mass that she states has grown
rapidly over a period of <4 months. Her last screening mammogram was 6 months ago and
interpreted as negative. Images from her most recent left breast diagnostic mammogram and
ultrasound are shown.
The most likely diagnosis is
A.Fibroadenoma
B.Hamartoma
C.Metaplastic carcinoma
D.Tubular adenoma
41A 45-year-old female with a history type I diabetes presents with multiple palpable right breast
masses that are firm on exam. Diagnostic imaging of the right breast was performed. Mammogram
and ultrasound are shown.
All of the masses were similar in appearance sonographically so a single mass was selected to
sample under ultrasound guidance. Pathology demonstrates fibrous stromal proliferation and
perivascular lymphocytic infiltrate consistent with diabetic mastopathy. The correct
radiologic/pathologic correlation is
A.Concordant; excision recommended
B.Concordant; clinical follow-up recommended
C.Discordant; excision recommended
D.Discordant; repeat biopsy recommended
42Shown below is a targeted ultrasound image of a 48-year-old female with clinical presentation of
spontaneous left nipple yellow colored discharge. What is the most likely diagnosis?
A.Duct ectasia
B.Ductal carcinoma in situ
C.Papilloma
D.Papillary carcinoma
E.Paget disease of the nipple
43Screening and diagnostic mammograms of a 52-year-old female demonstrate a spiculated mass
with a central lucent area. Core biopsy of the mass proved it to be a radial scar. Subsequently,
surgical excision was performed. What specific type of breast cancer may coexist with radial
scar?
A.Ductal carcinoma in situ
B.Infiltrating lobular carcinoma
C.Inflammatory carcinoma
D.Medullary carcinoma
E.Tubular carcinoma
44Approximately what percentage of all invasive breast malignancies are invasive lobular cancer?
A.<1%
B.10%
C.50%
D.90%
45A 44-year-old female presents for additional views of an abnormality seen on screening
mammography. Spot compression CC and MLO views are shown in images A and B. Prior
comparison mammogram was negative in this location. Focused ultrasound was performed and
demonstrates no sonographic abnormality. What is the most appropriate BI-RADS category given
that the finding is not seen on ultrasound?
A.0, incomplete, breast MRI recommended
B.2, benign, return to screening in 1 year
C.3, probably benign, 6-month follow-up mammogram recommended
D.4, suspicious, biopsy is recommended
46Which postconservation therapy change on MRI is considered a BI-RADS 4 finding and warrants
tissue sampling to exclude recurrence?
A.Architectural distortion
B.Edema
C.Mass-like enhancement
D.Signal void or signal flare
E.Skin thickening
47A 29-year-old female presents with a palpable mass in the right breast. The patient has ultrasound
of the palpable lump. Findings are considered suspicious for malignancy. What is the
recommended next step in evaluation of the suspicious mass?
A.MRI breast without and with contrast
B.Fine needle aspiration
C.Core biopsy
D.Diagnostic mammography
E.Stereotactic biopsy
48A 77-year-old female with the following imaging finding.
What is the most likely diagnosis?
A.Fibroadenoma
B.Tubular carcinoma
C.Complex cyst
D.Mucinous carcinoma
E.Lobular carcinoma
49What is the diagnosis based on the following images?

A.Intracapsular implant rupture


B.Intact implant with radial folds
C.Extracapsular implant rupture
D.Silicone gel bleed
E.Intra- and extracapsular rupture
50aA 55-year-old high-risk patient presents for screening breast MRI. No comparison available. The
following contrast-enhanced breast MR images are available:
The appropriate BI-RADS category is
A.0
B.1
C.2
D.3
E.4
50bWhat is the next most appropriate step?
A.6-month follow-up breast MRI
B.Focused ultrasound/mammography
C.Annual screening breast MRI
D.MRI-guided breast biopsy
E.Repeat breast MRI
51a
Based on the images, what is the appropriate BI-RADS assessment?
A.BI-RADS 2
B.BI-RADS 3
C.BI-RADS 4
D.BI-RADS 6
51bBased on the images, what is the most common diagnosis?
A.Intraductal papillary carcinoma
B.Intraductal papilloma
C.Ductal carcinoma in situ
D.Invasive ductal carcinoma
52A 56-year-old female arrives to the mammography department and tells the technologist that she
feels a lump in the right upper outer breast. Upon diagnostic workup, several bilateral masses
were visualized. The masses were oval in shape, similar in size, and >80% of the margins were
visualized. Upon review of prior studies, similar findings were seen 3 years prior. What is the
appropriate BI-RADS category?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
E.BI-RADS 6
53A 45-year-old female had a biopsy of a hypoechoic mass-like area in the right breast, and the
pathology result was radial scar. Which of the following statements about radial scar is correct?
A.There is skin retraction and thickening associated
B.Incidence is 0.1 to 2 per 1,000 screening mammograms
C.Related to prior surgery or trauma
D.No association with cancer
54A 56-year-old female presents with a palpable finding in the right breast. Patient states she takes
Coumadin. Mammogram images A and B and ultrasound image C are given.

What is the BI-RADS assessment?


A.BI-RADS 1
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
E.BI-RADS 0
55A 52-year-old woman had a stereotactic core biopsy of the following calcifications results were
atypical ductal hyperplasia. What is the next appropriate step in the management?
A.No further intervention is required.
B.Follow-up in 6 months
C.Follow-up in 12 months
D.Surgical excision
56Regarding fibrocystic changes, which of the following is a correct statement?
A.More common in patients younger than 30 years of age
B.Enhances homogenously on T1-weighted sequence of breast MRI
C.Thick peripheral enhancement suggests simple cyst
D.Cysts originate from terminal lobules
E.Size of the cysts gets bigger with time
57What is the most common pleural presentation of breast cancer?
A.Pleural effusion
B.Pleural-based soft tissue nodules
C.Round atelectasis
D.Pleural and pulmonary metastatic nodules
E.Interstitial reticulonodular changes extending to the pleura
58A stereotactic breast biopsy shows radial scar. What is the most appropriate treatment?
A.6-month follow-up
B.Resume yearly routine screening mammogram
C.Surgical excision
D.Second-look ultrasound
E.Rebiopsy
59In breast MRI, which one of the following is a feature of malignant finding?
A.Lobulated border of a lesion
B.Dark internal septations without significant enhancement
C.Thick rim enhancement
D.A lesion parallels Cooper ligament
E.Microcysts
60Regarding phyllodes tumor, which one of the following is a correct statement?
A.The pathology is usually very different from fibroadenoma.
B.It is considered a benign neoplasm, although the size at presentation is usually large and is
rapidly growing.
C.Complete surgical excision often curative, but chemotherapy and radiation therapy are
usually needed at the same time.
D.It is a biphasic neoplasm with double-layered epithelial component surrounded by
overgrowing stroma.
E.It will not affect the skin as breast cancer does, such as skin ulceration or dimpling.
61Regarding male breast cancer, which one of the followings is correct?
A.It is not associated with Klinefelter syndrome.
B.The most common location is upper inner breast.
C.Most patients do not have BRCA gene mutations.
D.It is associated with gynecomastia.
E.Majority of the carcinoma is ductal carcinoma in situ (DCIS).
62aA patient is called back for additional views for a one-view finding on screening mammography
in the central breast on the craniocaudal (CC) view. The asymmetry persists on spot compression
views but is not seen on either the mediolateral oblique (MLO) or the true lateral projection, what
is the next best step?
A.Perform ultrasound of the 12:00 and 6:00 positions, as well as the retroareolar plane.
B.Request the patient to return for a short interval follow-up in 6 months.
C.Recommend a breast MRI.
D.Perform rolled views.
62bRolled views were performed. On the CC rolled lateral (CC RL) view, the lesion moves laterally,
this indicates that
A.The lesion is in the superior breast.
B.The lesion is in the inferior breast.
C.The lesion is in the central breast.
D.The lesion location cannot be determined based on the information provided.
63A 72-year-old female presents with two new groups of suspicious calcifications in the right breast
on screening mammogram. A two-site stereotactic core biopsy was performed. Pathology results
of the core biopsy of both sites demonstrate atypical ductal hyperplasia (ADH). What is the next
best step for management of this patient?
A.Return to annual screening.
B.Recommend 6-month follow-up mammogram of the right breast.
C.Recommend surgical excision of both sites.
D.Recommend MRI to evaluate for underlying malignancy.
E.Recommend surgical excision of one site.
64A 40-year-old female with a palpable lump presents for diagnostic mammogram and ultrasound
for an abnormality seen on screening mammogram. Mammogram demonstrated a circumscribed
oval mass (not shown). Ultrasound image is shown. The lesion was biopsied, and pathology
results were pseudoangiomatous stromal hyperplasia (PASH). Regarding PASH, which is the most
accurate statement?

A.Usually presents as a spiculated mass.


B.Usually presents with calcifications.
C.Can present as a circumscribed mass but is often incidentally found on biopsy.
D.Is only an incidental finding and cannot present as a mass lesion.
65An ultrasound was performed for a persistent focal asymmetry with associated pleomorphic
calcifications. Based on the ultrasound image below, what is the next appropriate step in
management?

A.Ultrasound-guided core biopsy


B.Stereotactic core biopsy
C.MRI
D.6-month follow-up
E.Annual diagnostic mammogram
66A 60-year-old female presents for a diagnostic mammogram to workup calcifications in the lower
inner quadrant of the left breast seen on recent screening mammogram. Skin calcifications are
suspected. What is the most appropriate next step in determining the true nature of the
calcifications?
A.Spot compression CC
B.True ML
C.Tangential view
D.Repeat MLO
67Breast edema as the result of lymphatic obstruction and the presence of elongated, serpentine,
nonductal calcifications on mammography most likely are due to:
A.Staphylococcus aureus infection
B.Streptococcus species infection
C.lymphoma
D.filariasis
E.congestive heart failure
68A 65-year-old male with a strong family history of breast cancer presents for a diagnostic
mammogram for palpable abnormalities in both breasts. Based on the images, what is the most
likely diagnosis?

A.Gynecomastia
B.Fibrocystic change
C.Normal fibroglandular tissue
D.Breast cancer
69A 50-year-old female presented for a screening mammogram, the MLO views of which are shown.
What is the diagnosis?
A.Neurofibromatosis
B.Steatocystoma multiplex
C.Malignancy
D.Silicone granulomas
70Which of the following is correct about invasive lobular carcinoma (ILC)?
A.Higher false-negative rates are reported with ILC, than with any other forms of cancer.
B.ILC most commonly presents as calcifications.
C.MR imaging usually does not affect management of patients with ILC.
D.ILC has a lesser rate of multiplicity and bilaterality than invasive ductal carcinoma.
71Which of the following statements is correct about inflammatory carcinoma of the breast?
A.It is considered a stage T1 lesion.
B.Most common presentation is skin erythema.
C.Majority of patients have axillary nodal involvement at presentation.
D.Inflammatory carcinoma accounts for 10% of breast cancers.
72Regarding pregnancy-associated breast cancer, which of the following statements is correct?
A.It represents <1% of the breast cancers.
B.Breast cancer is the most common cancer during pregnancy.
C.At the time of diagnosis, pregnant women have larger and more advanced
cancers than nonpregnant women of the same age.
D.The average age of diagnosis is 40 to 45 years.
73An MRI is shown from a patient with a palpable abnormality in the right breast. Based on these
images, what is the most likely pathologic diagnosis?
A.Invasive ductal carcinoma
B.Invasive lobular carcinoma
C.Fibroadenoma
D.Phyllodes tumor
74In patients undergoing neoadjuvant chemotherapy, which is the best at assessing response to
therapy?
A.Clinical exam
B.Mammography
C.Ultrasound
D.MRI
75An MRI was performed in a patient with biopsy-proven breast cancer along the chest wall to
evaluate for invasion of the pectoralis muscle. Which of the following criteria is most predictive
of chest wall invasion?
A.Enhancement of the pectoralis muscle
B.No intervening fat plane between the mass and muscle
C.There is no predictive criteria.
D.Vessels extending from the mass into muscle
76Which of the following statements is correct about recurrent breast cancer?
A.Local recurrence rate after breast conservation therapy is 10% to 20%.
B.Most cases of recurrence occur within the first 2 years of treatment.
C.MRI offers an advantage over other modalities in assessing recurrence.
D.On MRI, physiologic enhancement at the surgical site is seen up to 2 months after surgery.
77A 39-year-old female with a strong family history of breast cancer presents for diagnostic
mammogram for left breast pain. Based on the images, what is the most likely diagnosis?
A.Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction
B.Poland syndrome
C.Mastectomy
D.Reduction mammoplasty
78The following images from a contrast-enhanced breast MRI are provided. In the central right
breast, there is clumped nonmass enhancement. Kinetic assessment of the nonmass enhancement
using CAD (computer-aided detection) processing software demonstrates which type of curve?
A.Initial slow, delayed washout
B.Initial rapid, delayed persistent
C.Initial rapid, delayed plateau
D.Initial rapid, delayed washout
E.Initial slow, delayed plateau
79The most common malignant breast mass in a pregnant and postpartum patient is:
A.invasive medullary carcinoma
B.invasive lobular carcinoma
C.invasive ductal carcinoma
D.invasive mucinous carcinoma
E.invasive tubular carcinoma
80A 55-year-old female was recently diagnosed with an invasive ductal carcinoma of two masses in
the left breast. Mass A is 3.1 cm in greatest diameter and is located in the left upper outer quadrant
at posterior depth. Mass B is 4 cm in greatest diameter and located in the left lower inner quadrant
at middle depth. Which statement is correct?

A.The patient is a candidate for whole-breast radiation therapy.


B.The patient is a candidate for breast conserving surgery.
C.The findings are suspicious for multifocal invasive breast cancer on MRI.
D.The findings are suspicious for multicentric invasive breast cancer on MRI.
81
81aA 34-year-old female presents with a palpable lump in her left breast. Based on the mammogram
and ultrasound images, which one of the following is the most appropriate BI-RADS category
assessment?
A.BI-RADS 1
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
81bBased on the ultrasound images, what is the most likely diagnosis?
A.Hamartoma
B.Galactocele
C.Intramammary lymph node
D.Lipoma
E.Fat necrosis
82A 41-year-old female presents with a palpable lump in her left breast. Based on the images, what
is the most appropriate management?
A.No further evaluation
B.Cyst aspiration for diagnosis
C.Core needle biopsy
D.Antibiotic therapy
83The most common mammographic finding of pregnancy associated breast cancer is:
A.microcalcifications
B.edema
C.architectural distortion
D.mass
E.axillary adenopathy
84Shown is a spot magnification view of axillary lymph nodes along with ultrasound images taken of
the left axillary region. These lymph nodes were seen on ultrasound as well. If this is a new
finding in a patient that has a history of ipsilateral breast cancer, what is the BI-RADS category
assessment?
A.BI-RADS 2
B.BI-RADS 3
C.BI-RADS 4
D.BI-RADS 6
85Shown is a breast MRI image demonstrating a mass in the right breast at 7 oclock at a middle
depth. The timeintensity kinetic curve showed a type I curve. Which of the following is the most
appropriate next step?
A.Recommend a follow-up 6-month breast MRI to document stability.
B.The mass should be categorized as BI-RADS 2, and continued risk-appropriate screening
should be recommended.
C.Biopsy should be performed despite benign kinetics.
D.The study is limited due to suboptimal technique and should be repeated.
86Based on the diagnostic ultrasound images, which one of the following is the most appropriate BI-
RADS category assessment?

A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
87A 46-year-old female presents with two sets of bilateral screening mammograms that are 2 years
apart. Based on the images, what is the appropriate BI-RADS category assessment?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
E.BI-RADS 6
88Based on the images, what is the correct breast finding?
A.Intracapsular rupture of the right breast implant
B.Radial fold of the right breast implant
C.Collapse/rupture of the right breast implant
D.Capsular contracture of the right breast implant
89A 48-year-old female complains of a palpable cord-like area in her left breast. Based on the
diagnostic mammogram and ultrasound images, what is the appropriate clinical management?
A.Refer patient to a breast surgeon for surgical excision and axillary node sampling.
B.Ultrasound-guided core biopsy is recommended.
C.Assure the patient that the condition is self-limited and will resolve.
D.Breast MRI is recommended.
E.Wide local excision should be performed.
90A 40-year-old female comes for a baseline screening mammogram. Based on the mammogram
images, what is the appropriate BI-RADS category assessment?
A.BI-RADS 0
B.BI-RADS 2
C.BI-RADS 3
D.BI-RADS 4
91Poland syndrome can be associated with increased incidence of which of the following cancer?
A.Hodgkin lymphoma
B.Ovarian cancer
C.Thyroid cancer
D.Breast cancer
E.Hepatocellular cancer
92
92A 34-year-old female presents with history of a palpable abnormality in the left breast. Based on
the images, what is the most appropriate management?
A.No further evaluation
B.Cyst aspiration for diagnosis
C.Core needle biopsy
D.Antibiotic therapy
93What is the inheritance pattern of Poland syndrome?
A.Mitochondrial inheritance
B.Autosomal dominant
C.Autosomal recessive
D.X-linked dominant
E.X-linked recessive
94An 87-year-old female presents with a palpable lump (triangular skin marker). Six years ago she
was diagnosed with breast cancer and had a subsequent lumpectomy, followed by radiation
therapy. The most likely diagnosis is
A.Intramammary lymph node
B.Hemangioma
C.Lipoma
D.Fat necrosis
E.Hamartoma
95A 57-year-old postmenopausal female with a recent breast biopsy diagnosis of focal fibrosis is
likely taking which one of the following medications?
A.High-dose aspirin
B.Corticosteroids
C.Thyroid replacement therapy
D.Hormone replacement therapy
E.Insulin
96Molecular breast imaging in a 45-year-old woman shows bilateral, extensive, patchy uptake of the
isotope. The most likely diagnosis is
A.Active fibroglandular breast tissue
B.Simple breast cysts
C.Fibroadenomas
D.Chronic fat necrosis
E.Postoperative scar tissues
97What is the most common cancer to spread to the breast?
A.Melanoma
B.Breast cancer
C.Lung cancer
D.Medullary thyroid cancer
E.Endometrial cancer
98Shown are diagnostic mammogram and ultrasound images of a 52-year-old female with history of
a palpable lump in the left breast. The patient underwent an ultrasound-guided core needle biopsy.
Pathology results came back as phyllodes tumor. Based on imaging finding and pathology results,
which of the following statement is most appropriate recommendation?
A.Surgical excisional biopsy
B.Breast-specific gamma imaging (BSGI)
C.Breast MRI
D.Follow-up diagnostic ultrasound in 6 months
99Which condition most commonly causes bilateral breast edema?
A.Inflammatory breast cancer
B.Superior vena cava syndrome
C.Mastitis
D.Trauma
E.Coumarin necrosis
100 A 28-year-old female presents with a palpable abnormality in the left breast. Based on the images,
what is the most appropriate management?

A.No further management


B.Cyst aspiration
C.Core needle biopsy
D.Antibiotic therapy
101 After lumpectomy and radiation therapy the enhancement of the postoperative cavity site begins to
subside on postcontrast breast MRI after how many months?
A.35 months
B.67 months
C.89 months
D.1018 months
102 The statement Multiple, bilateral, circumscribed, noncalcified masses is given a BI-RADS of:
A.1
B.2
C.3
D.4
103 A 78-year-old male presents with a palpable lump in the right breast. Based on the diagnostic
mammogram and ultrasound images, what is the most likely diagnosis?

A.Invasive ductal carcinoma


B.Cyst
C.Lipoma
D.Fibroadenoma
E.Gynecomastia
104 A 2.5 cm in greatest dimension malignant mass with metastasis to a level 2 movable ipsilateral
level 1 axillary lymph node and with no clinical or radiographic evidence of distant metastasis
has a TNM staging classification of
A.T1a, N2, M0
B.T2, N1, M0
C.T3, N3, M0
D.T2, N2a, M1
E.T4, N3, M0
105 The calcifications seen on the mammogram below are dermal in nature. What is the cause?
A.Calcium carbonate
B.Methyl salicylate
C.Zinc oxide
D.Glycerol
106 Based on the mammographic and sonographic images below, what is the most likely diagnosis?

A.Sebaceous cyst
B.Normal breast tissue
C.Scar
D.Invasive lobular carcinoma
107a The first set of mammographic images is from 3 years ago. After this mammogram, asymmetry in
the upper outer quadrant was excised demonstrating pseudoangiomatous stromal hyperplasia
(PASH). Patient returns for annual screening mammogram. What is the appropriate BI-RADS
category assessment?

A.0
B.1
C.3
D.4
107b Additional views and ultrasound images are given below. What is the next step in management?
A.Refer to surgeon for excision
B.Needle core biopsy
C.Return to annual screening
D.Short-term follow-up mammogram in 6 months
107c Needle core biopsy was performed, and pathology is pseudoangiomatous stromal hyperplasia
(PASH). You are asked to do radiologypathology correlation. What is your assessment and
recommendation?
A.Concordant benign radiologypathology results. Return to annual screening mammography.
B.Concordant benign radiologypathology results. Recommend surgical excision.
C.Concordant benign radiologypathology results. Recommend short-term follow-up
mammogram.
D.Discordant radiologypathology results. Recommend surgical excision.
108 A 44-year-old woman presents with a palpable finding in the right breast since 2 months. Based
on the mammogram and ultrasound images below, what is the most likely diagnosis?
A.Fibroadenoma
B.Complicated cyst
C.Mucinous carcinoma
D.Oil cyst
E.Lipoma
109 If calcifications that are biopsied are calcium oxalate, how can they be identified by pathology?
A.Use hematoxylin and eosin (H&E) staining on the slides.
B.Do serial thin sections of the specimen.
C.Use polarized light on the slides.
D.Radiograph the paraffin block.
110 Which of the following statements about the mass depicted in the ultrasound images is correct?
A.Most common breast mass in women under the age of 35 years
B.Demonstrates rim enhancement on contrast-enhanced breast MRI
C.Benign tumor composed of mature adipose cells
D.Has a breast-within-a-breast appearance on mammogram
111 Which of the following statements is correct about the lesion depicted in the images below?

A.Fat and fibroglandular tissue are surrounded by a thin capsule or rim.


B.It never calcifies.
C.It is hard and immobile.
D.Mammography and ultrasound are usually needed to make the diagnosis.
112 A 62-year-old male presents with a palpable finding without history of trauma. What is the
assessment and recommendation?

A.BI-RADS 2. Benign. No further follow-up needed.


B.BI-RADS 2. Benign. Referral to surgeon.
C.BI-RADS 3. Probably benign. Short-term follow-up in 6 months.
D.BI-RADS 4. Suspicious. Biopsy recommended.
113 Based on the images below, what is the assessment and next appropriate step in management?

A.BI-RADS 2. Benign. Return to annual screening mammography.


B.BI-RADS 3. Probably benign. Short-term follow-up in 6 months.
C.BI-RADS 4A. Low suspicion. Recommend biopsy.
D.BI-RADS 4C Moderate suspicion. Recommend biopsy and scan the ipsilateral axilla.
114 Match the lymph nodes draining the breast to their location.
1. Level I nodes A. Behind the pectoralis minor muscle
2. Level II nodes B. Infralateral to lateral edge of the pectoralis muscle
3. Level III nodes C. Medial to pectoralis muscle
D. Between pectoralis minor and subclavius muscle

115 Images below represent a mass in the upper outer quadrant of the left breast. This was biopsied.
Pathology results are malignant phyllodes.
Which of the following statements concerning malignant phyllodes tumor is correct?
A.About half of all phyllodes tumors are malignant.
B.Most common sites for metastases are axillary lymph nodes.
C.There are no hereditary factors associated with these tumors.
D.Treatment of choice is neoadjuvant chemotherapy.
116 Which of the following statements concerning invasive lobular carcinoma (ILC) is correct?
A.Grows as single-file linear columns of tumor cells with intervening stroma.
B.It comprises sixty to seventy percent of all invasive breast cancers.
C.Microscopically, proliferating epithelium is present in villous-like projections.
D.Slow growing with as 95% to 98% 5-year survival.
117 Which of the following statements about the lesion seen on the MRI is correct?
A.Most commonly seen in young women
B.Occurs as a result of hormone replacement therapy
C.Uniformly echogenic on ultrasound
D.Most commonly seen in the upper outer quadrant
118 Which of the following can be a cause for the finding below?

A.Implant rupture
B.Lymphoma
C.PASH
D.Mastitis
119 Based on the images from screening mammogram below, what is the appropriate BI-RADS
category? The patient has known lymphoma.
A.BI-RADS 0
B.BI-RADS 1
C.BI-RADS 2
D.BI-RADS 3
E.BI-RADS 4
120 A 43-year-old female presents with new right breast nipple retraction. What is the appropriate
next step in the patients management?
A.Galactography of the retracted nipple
B.Surgical consultation for duct excision
C.Breast MRI
D.Spot compressionmagnification views of the retracted nipple
121 Which of the following types of calcifications can have a radiolucent center?
A.Milk of calcium
B.Ductal carcinoma in situ (DCIS)
C.Calcifications of fibrocystic change
D.Dermal calcifications
122 Regarding the finding seen on the image below, which of the following statements is correct? The
patient was recently in a car accident.
A.The trauma that causes this injury can be blunt or penetrating.
B.Most common cause of fat necrosis is surgery.
C.Usually is seen in the upper inner quadrant on the right when the trauma is sustained by the
driver.
D.History does not help in diagnosis.
123 Which of the following statements concerning neoadjuvant chemotherapy (NAT) for breast cancer
is correct?
A.Major use is in primary inoperable locally advanced breast cancer (LABC).
B.Primary goal is to shrink tumor for the potential for breast conservation surgery.
C.Size of tumor is most accurately determined by ultrasound.
D.Accuracy in preoperative size on mammography is best for invasive lobular carcinoma.
124 Which of the following pathologies from core needle biopsy of a lesion, that has been increasing
in size, is a reason for surgical excision?
A.Pseudoangiomatous stromal hyperplasia (PASH)
B.Apocrine cyst
C.Fat necrosis
D.Steatocystoma multiplex
125a Based on the images below, which of the following statements regarding the findings is correct?
A.Architectural distortion with associated skin thickening
B.Focal asymmetry with associated skin thickening
C.Trabecular thickening with associated skin thickening
D.Segmental calcifications with associated skin thickening
125b Based on the findings, which of the following diagnoses is the most likely?
A.Invasive ductal carcinoma
B.Reduction mammoplasty
C.Seat-belt injury/trauma
D.Mastitis
126a A 40-year-old female presents for baseline screening mammogram.
What is the BI-RADS category?
A.BI-RADS 0
B.BI-RADS 1
C.BI-RADS 2
D.BI-RADS 3
E.BI-RADS 4
126b Additional mammographic views and ultrasound images of the mass are shown. Which of the
following statements concerning the mass depicted is correct?
A.Core needle biopsy or fine needle aspiration can be performed for diagnosis.
B.Occurs with the same frequency in males and females
C.Up to 5% may undergo malignant transformation.
D.Most common location is in the breast.
127 Which of the following conditions can lead to skin thickening in the breast?
A.Ovarian carcinoma
B.Silicone implant rupture
C.Psoriasis
D.Tuberculosis

ANSWERS AND EXPLANATIONS

1Answer C.Intracapsular rupture of a double-lumen breast implant is the disruption or tear of an


implant shell in which silicone gel moves outside of the implant shell but stays within the fibrous
capsule. Intracapsular rupture is more commonly seen than extracapsular rupture.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:205206, 236.

2Answer A.The most common location for an intramammary lymph node is in the upper outer
quadrant. Approximately 90% of the intramammary lymph nodes are present here.
Reference: Berg A, Birdwell R, Gombos E. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys; 2008;IV:18.

3aAnswer C.The dominant finding is unilateral right breast skin thickening most pronounced
medial and lateral to the nipple.
3bAnswer B.Differential diagnosis for skin thickening includes unilateral edema (focal or
diffuse), mastitis, inflammatory carcinoma, postprocedural skin thickening, abscess, and
underlying malignancy. Breast parenchymal enhancement may vary with the phase of the menstrual
cycle, but skin thickening will not occur.
Reference: Berg A, Birdwell R, Gombos E. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys; 2008;IV:3-26IV:3-
27.

4aAnswer C.A targeted ultrasound exam is recommended as an initial test for women <30 years
of age, pregnant, or lactating.
Reference: Berg A, Birdwell R, Gombos E. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys; 2008;II:032.

4bAnswer B.Major types of fibroadenomas are adult type and juvenile. Most fibroadenomas in
teenagers are of the adult type. Giant fibroadenomas are more common in African American
women. Giant fibroadenomas are defined as being greater than 8 cm or larger in size.
Fibroadenomas are the most common breast mass in women under 35 years of age. They comprise
10% of breast masses in postmenopausal women. They are present almost exclusively in females.
4cAnswer D.Color Doppler ultrasound demonstrates a solid, hypoechoic, oval, circumscribed,
vascular mass with long axis parallel to the skin surface that has an appearance of a
fibroadenoma. The most common solid benign tumor in young female is a fibroadenoma. Juvenile
fibroadenoma occurs usually been in the age of 10-20, rare above the age of 45. Because juvenille
fibroadenomas can grow to a large size, they can be called a giant fibroadenomas. However, not
all giant fibroadenomas are juvenile fibroadenomas. The appearance of fat necrosis on ultrasound
evolves over time. The sonographic spectrum can range from anechoic, echogenic, irregular
hypoechoic mass and a complex cystic and solid mass. Lymph nodes will have an echogenic
central vascular hilum on sonography.
References: Berg A, Birdwell R, Gombos E. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys; 2008;IV:2-24IV:2-
35.
Ikeda DM. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:117.

5Answer D.Unilateral, spontaneous, serous, or bloody nipple discharge is a worrisome clinical


finding and warrants imaging evaluation. Intraductal papillomas are epithelial proliferations of the
duct, which usually have a central vascular stalk. They are the resultant cause of ~34% of nipple
discharge. Fibrocystic change (25%), ductal ectasia (13%), and carcinoma (10%) are in the
differential diagnosis of intraductal lesions leading to nipple discharge but are less common than
intraductal papillomas.
Reference: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:157160.

6aAnswer A.The images demonstrate round and smudgy calcifications on the CC view that have a
curvilinear appearance on the ML view. These are representative of milk of calcium, which are
benign. Milk of calcium is sedimented calcium oxalate calcifications within microcysts and
dilated lobules.
6bAnswer A.Milk of calcium is a benign entity, and therefore no further workup or intervention is
necessary.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:2829.
7Answer A.Sonographically, lymph nodes resemble kidneys. They are elliptical in shape with a
hypoechoic cortex and an echogenic fatty hilum. On color or power Doppler, a feeding artery
entering the hilum can be seen. The outer cortex should be smooth, without eccentric thickening.
The appearance of the lymph node in this image is benign. A palpable lymph node, which is
benign in appearance by ultrasound, does not require additional workup or biopsy.
Reference: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004: 838845, 855870.

8Answer C.On initial review of the images, the pleomorphic microcalcifications near the
lumpectomy bed are the most obvious finding. These were new compared to the prior study, and
images of the prior study were not provided. However, on more careful inspection, there is a focal
asymmetry associated with the calcifications, making the findings even more concerning for
malignancy. The findings are concerning for malignancy; therefore, an annual screening
mammogram, annual diagnostic mammogram, and 6-month follow-up are inappropriate. MRI may
be beneficial after the biopsy is performed if there is a concern for multicentric disease. Of the
answer choices provided, stereotactic core biopsy of the calcifications is the most appropriate
answer.
References: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:967969.
Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:600602, 609, 838845.

9Answer D.The calcifications demonstrated on the magnification views are pleomorphic in


shape, meaning they vary in size and shape but are typically <0.5 mm in diameter. They are linear
in distribution, meaning they are arrayed in a line, which may have branch patterns. The other
answer choices describe benign calcifications. By mammographic criteria, calcifications which
are pleomorphic have a 25% to 41% chance of being malignant, while calcifications in linear
distribution have a 68% chance of being malignant. These were biopsied and the pathology results
yielded DCIS with invasive ductal carcinoma.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:04.
Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:989.

10aAnswer C.Masses are described by both their shape and margins. Terms used to describe the
shape of a mass included round, oval, lobular, and irregular (mneumonic: ROLI). Terms used to
describe the margins of a mass include circumscribed, obscured, microlobulated, indistinct, and
spiculated (mneumonic: COMIS). In this case, the best description of the shape would be
irregular, meaning the shape cannot be characterized by any of the other descriptors. The best
description of the margins would be spiculated, meaning there are thin lines radiating from the
margin of the mass. An irregular mass with spiculated margins is a concerning finding and
requires further workup. By mammographic criteria, a mass with spiculated margins has an 81%
to 97% chance of being malignant.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:0-2IV:0-3.
Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:984986.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:233.

10bAnswer D.Masses are described on ultrasound by multiple descriptors, two of which are shape
and margins. The ultrasound descriptors are somewhat different than the mammographic
descriptors. The shape of a mass is described as oval, round, or irregular. The margin is
described as either circumscribed or not circumscribed. Noncircumscribed masses are then
further divided into indistinct, microlobulated, angular, and spiculated. In this case, the best
description of this mass would be an irregular shape with spiculated margins. This is a suspicious
finding and requires biopsy. By ultrasound criteria, masses with an irregular margin have a 62%
chance of being malignant while masses with spiculated margins have an 86% chance of being
malignant. This underwent biopsy that yielded invasive lobular carcinoma.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:0-10IV:0-11.

10cAnswer B.Elastography measures the stiffness of a lesion compared to the surrounding tissues.
Cysts are typically less stiff than the surrounding tissue, while solid masses are typically more
stiff than the surrounding tissue. On the image provided, the color image is the elastography image.
The scale to the right of the image has the abbreviation SF at the top of the scale, meaning soft.
The abbreviation HD at the bottom of the image means hard. The mass in question is blue on
elastography, which corresponds to hard or stiff on the elastography scale. Therefore, this mass is
more stiff than the surrounding breast tissue and represents a solid mass requiring biopsy.
References: Burnside ES, Hall TJ, Sommer AM, et al. Differentiating benign from malignant solid breast masses with US strain
imaging. Radiology 2007;245:401410.
Regner DM, Hesley GK, Hangiandreou NJ, et al. Breast lesions: Evaluation with US strain imagingclinical experience of multiple
observers. Radiology 2006;238:425437.

11aAnswer B.
11bAnswer A.Fat necrosis can have a variety of appearances on breast MRI. The most common is
a fat-containing cyst, which may or may not have a fat-fluid level within it. There is usually thin or
thick rim enhancement, but this can also be absent. Enhancement can sometimes be seen for many
years following surgery and can demonstrate persistent, plateau, or washout kinetics. Overall, an
internal signal characteristic consistent with fat is key to diagnosis. Unenhanced T1 fat-saturated
images can thus be very helpful. Fat necrosis can also present as a spiculated mass on MRI,
mimicking new or recurrent malignancy when the macroscopic fat content is low. In these
situations, biopsy may be necessary for diagnosis. On mammogram, fat necrosis can present as
calcifications, usually curvilinear or eggshell but can mimic linear pleomorphic calcifications
early in development. Fat necrosis can also present on mammography as lipid cysts, focal
asymmetries, and spiculated masses.
References: Daly CP, Jaeger B, Sill D. Variable appearances of fat necrosis on breast MRI. AJR Am J Roentgenol
2008;191(5):13741380.
Taboada JL, Stephens TW, Krishnamurthy S, et al. The many faces of fat necrosis in the breast. AJR Am J Roentgenol
2009;192(3):815825.

12Answer D.Although this patient is quite young, this mass was indeed invasive ductal
carcinoma. Breast cancer is uncommon in women in their 20s but can occur, with an annual risk of
developing breast cancer of ~1/20,000 (as compared to 1/667 and 1/370 for women in their 40s
and 50s, respectively). Breast cancer is one of the more common malignancies diagnosed during
pregnancy. Although abscess would be reasonable to consider in a woman of this age, there is no
clinical history of fever or breast erythema. In addition, although abscesses may have peripheral
rim enhancement due to inflammation, internal flow, such as was seen in this case, should not be
present. This mass was an invasive ductal carcinoma. Pregnancy should not prevent or delay
workup of a suspicious mass. Excisional and core biopsies under local anesthesia are safe to
perform during pregnancy.
References: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:89, 579603.
Litton JK, Theriault RL, Gonzalez-Angulo AM. Breast cancer diagnosis during pregnancy. Womens Health 2009;5(3):243249.
Trop I, Dugas A, David J, et al. Breast abscesses: Evidence-based algorithms for diagnosis, management, and follow-up.
Radiographics 2011;31:16831699.
13Answer C.The relevant finding on these images is the unilateral axillary adenopathy on the left
MLO image. The differential diagnosis for unilateral adenopathy includes metastases, reactive
adenopathy from inflammation or infection, or silicone from an implant rupture or leak. The
differential diagnosis for bilateral axillary adenopathy includes HIV, lymphoproliferative
disorders such as lymphoma or leukemia, rheumatoid arthritis and other collagen vascular
diseases, and tuberculosis or sarcoidosis. This lymph node was biopsied and was consistent with
metastases from ovarian carcinoma. The ovarian malignancy was known prior to the mammogram
and was the reason this diagnostic mammogram was performed.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:331.

14aAnswer C.
14bAnswer D.On the axial T1-weighted image, we can see the pectoral muscle clearly, indicating
that this is a prepectoral implant. The second image is a water-saturated image, but the implant
still has high signal, indicating that this is a silicone implant. The keyhole sign is present,
consistent with intracapsular rupture. In addition, silicone is noted outside the implant capsule
posterior, indicative of extracapsular rupture as well.
References: Berg WA, Caskey CI, Hamper UM, et al. Diagnosing breast implant rupture with MR imaging, ultrasound and
mammography. Radiographics 1993;13:13231336.
Liberman L, Morris E. Breast MRI Diagnosis and Intervention. 1st ed. New York, NY: Springer; 2005:245252.
Yang N, Muradali D. The augmented breast: A pictorial review of the abnormal and the unusual. AJR Am J Roentgenol
2011;196:W451W460.

15Answer D.Infiltrating lobular carcinoma is rare in males because the male breast lacks lobules.
Exceptions would include males with exogenous estrogen stimulation, such as transsexuals on high
dose estrogen therapy. It can also be seen in males treated with diethylstilbestrol (DES) for
prostate cancer. Males with breast cancer typically have a worse prognosis due to a later stage at
the time of diagnosis. Approximately 35% to 50% of male breast cancer is associated with DCIS.
Approximately 50% have axillary adenopathy at the time of diagnosis.
Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:5-54IV:5-57.

16Answer A.By convention, rolled CC views are performed with the superior half of the breast
rolled medial (CCRM) and lateral (CCRL) prior to convention. These are performed when a
lesion is seen on the CC view but not the MLO view and are useful to determine if a lesion is real
and to locate in the sagittal plane.
Reference: de Paredes ES. Atlas of Mammography (electronic resource). 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2007:37.

17Answer A.The classic appearance of an extracapsular silicone rupture on ultrasound is the


snowstorm appearance, in which the extracapsular silicone creates dirty shadowing. The
extracapsular silicone can form silicone granulomas, which may present as palpable masses. The
presence of extracapsular silicone does imply that there is a simultaneous or preexisting
intracapsular rupture, though this may not be visualized by ultrasound. On this single image, the
extracapsular silicone is visualized by the dirty shadowing; however, the intracapsular rupture is
not visualized.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:4-28IV:4-31.
Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:838845, 240243.

18Answer B.A lateral-medial (LM) view would be preferred because the calcifications would be
closer to the image receptor and this view will assist in localizing the calcifications. The cleavage
view provides better visualization of the medial and posterior breast tissue but would not assist in
localization of the finding. Spot compression view, if magnified, would provide information as to
the morphology of calcifications but would not improve in providing information of the
localization of the calcifications.
Reference: Sickles EA. Practical solutions to common mammographic problems: Tailoring the examination. AJR Am J
Roentgenol;151:3139.

19Answer C.Mondors disease is a rare benign disorder characterized by thrombophlebitis of the


subcutaneous veins of the anterolateral chest wall. A tender palpable cord in the breast
corresponding to a superficial tubular density on mammography and a subcutaneous vessel on
ultrasound, with or without absent Doppler vascular flow, confirms the diagnosis of Mondors
disease of the breast. Awareness of clinical presentation, pathophysiology, and radiological
findings of Mondors disease enables accurate diagnosis and avoids the potential pitfall of
mistaking this finding for a dilated duct or inflammatory breast carcinoma.
References: Ikeda DM. Breast Imaging: The Requisites. St. Louis, MO: Elsevier Mosby; 2004:305306.
Shetty MK, Watson AB. Mondors disease of the breast: Sonographic and mammographic findings. AJR Am J Roentgenol
2001;177:893896.
Soler-Gonzalez J, Ruiz MC. Mondors disease. N Engl J Med 2005;352:1024.
Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:429435.

20Answer E.The sternalis muscle is best seen only on the CC view as a well-defined mass in the
posterior medial breast measuring typically 3 to 15 mm with smooth, round, or bulging contours.
Depending on the amount of traction placed on the medial breast, it may or may not be seen on
prior or subsequent exams. Since the medial breast tissue is a potential blind spot on MLO
projection, the sternalis muscle is not identified on the MLO view. It is a thin accessory muscle in
the chest that runs in a craniocaudal direction, parallel and adjacent to the sternum. The reported
prevalence of the sternalis muscle ranges from 1% to 11% and varies by population. It can be seen
bilaterally but more commonly presents unilaterally. The sternalis muscle is a normal variant that
can mimic breast pathology and create a diagnostic dilemma. Confirmatory imaging with CT or
MRI may corroborate the presence of this muscle.
References: Bradley FM, Hoover HC Jr, Hulka CA, et al. The sternalis muscle: An unusual normal finding seen on mammography.
AJR Am J Roentgenol 1996;166:3336.
Demirpolat G, Oktay A, Bilgen I, et al. Mammographic features of the sternalis muscle. Diagn Interv Radiol 2010;16:276278.

21Answer C.There is an area of architectural distortion in the upper outer quadrant of the right
breast at middle to posterior depth that requires further evaluation. Spot compression
magnification views and targeted ultrasound can further define this finding.
Reference: Cardeosa G. Breast Imaging Companion. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:112145.

22Answer D.The mammogram images show an irregular mass at approximately 3 oclock middle
depth of the left breast corresponding to the area of palpable abnormality, idicated by a triangular
skin marker. The most common presentation of breast cancer in men is a painless or tender
palpable breast mass, classically eccentric to the nipple. The subareolar region is the most
common site of involvement. Invasive ductal carcinoma is the most common type of cancer in
men, accounting for 99% of cases. Imaging findings and staging are the same as in women. Breast
cancer in males is rare and accounts for ~1% of all breast cancers.
References: Cardeosa G. Clinical Breast Imaging: A Patient Focused Teaching File. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007:308309.
Weiss JR, et al. Epidemiology of male breast cancer. Cancer Epidemiol Biomarkers Prev 2005;14:2026.
23Answer A.Diabetic fibrous mastopathy is a benign breast disorder found most commonly in
patients with type I diabetes mellitus. It can mimic malignancy both clinically and
radiographically and typically requires a biopsy. While thought of as being a rare disorder, some
studies have shown prevalence as high as 13% in long-standing type I diabetic patients.
References: Feder JM, et al. Unusual breast lesions: Radiologypathology correlation. Radiographics 1999;19:S11S26.
Shaffrey JK, et al. Diabetic fibrous mastopathy: Case reports and radiologicpathologic correlation. Breast J 2000;6:414417.

24Answer C.Melanoma is the most common malignancy to produce metastasis to the breast.
Primary breast malignancy is much more common.
Reference: Arora R, Robinson W. Breast metastases from malignant melanoma. J Surg Oncol 1992;50:2729.

25Answer D.Direct paraffin or silicone injections can result in multiple eggshell-type


calcifications that obscure underlying breast tissue. This classic appearance is diagnostic on
mammogram for silicone injection granulomata.
Reference: Scaranelo AM, et al. Sonographic and mammographic findings of breast liquid silicone injection. J Clin Ultrasound
2006;34(6):273277.

26Answer C.This patients clinical and mammographic findings are consistent with unilateral
gynecomastia. Therefore, no further imaging or intervention is needed at this point. The left
mediolateral oblique mammograms demonstrate fan- or flame-shaped densities, emanating from
nipples, and blending into surrounding fat. Approximately 70% of the gynecomastia cases are
unilateral, and if bilateral, 70% are asymmetric. Broad category of conditions can cause
gynecomastia, one of which is drug related. In this patient with multiple comorbidities, obtaining a
full past medical and drug history is crucial. This patient was on prednisone, Zoloft, and a
tricyclic antidepressant, all of which are listed as causes of drug-induced gynecomastia. Hyper-
/hypothyroidism, liver disease, renal failure, COPD, and diabetes are physiologic causes of
gynecomastia. Hormonal causes of gynecomastia include estrogen therapy, testicular failure,
hypogonadism, and Klinefelter syndrome.
References: Bembo SA, Carlson HE. Gynecomastia: Its features, and when and how to treat it. Cleve Clin J Med 2004;71(6):511
517.
Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:5,5052.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:279280.

27Answer D.The right breast demonstrates skin thickening and increased T2 signal consistent
with edema. There is no enhancement of the skin or underlying tissues on postcontrast images to
suggest recurrence.
References: Kang BL, Jung JI, Park C, et al. Breast MRI findings after modified radical mastectomy and transverse rectus
abdominis myocutaneous flap in patients with breast cancer. J Magn Reson Imaging 2005;21:784791.
Peng C, Chang CB, Tso HH, et al. MRI appearance of tumor recurrence in myocutaneous flap reconstruction after mastectomy.
AJR Am J Roentgenol 2011;196:W471W475.

28aAnswer B.Typical ultrasound features of a fibroadenoma include circumscribed or gently


lobulated oval hypoechoic mass, parallel to skin surface.
A.A complicated cyst is a cyst containing internal echoes and/or thin internal septations on
ultrasound. This mass is a solid mass with no cystic features.
C.Invasive ductal carcinoma is a malignant solid lesion which most commonly presents as a
shadowing solid mass with angular or spiculated margins, antiparallel to the chest wall.
D.Phyllodes tumor is usually a large solid mass with low-level internal echoes and small fluid-
filled spaces or cysts which are typically seen in middle-age patients.
E.Simple cysts are anechoic with posterior acoustic enhancement.
References: Berg WA, Birdwell RL, et al. Diagnostic Imaging: Breast. Amirsys; IV:2-33IV:2-34.
Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:589.

28bAnswer A.Fibroadenomas are typically oval or macrolobulated smooth enhancing masses with
variable enhancement and may contain nonenhancing septations.
B.This choice describes typical MRI appearance of a simple cyst.
C.This choice describes typical MRI appearance of a phyllodes tumor.
D.Type 3 curves with rapid uptake followed by washout correspond with cancer in 87% of
lesions.
E.Fat containing lesions such as fat necrosis demonstrate signal loss on fat-saturated sequences.
References: Berg WA, Birdwell RL, et al. Diagnostic Imaging: Breast. Amirsys; IV:233IV:234.
Hendrik RE. Breast MRI Fundamentals and Technical Aspects. New York, NY: Springer; 2010: 119120.

29Answer B.Like invasive ductal carcinomas, fat necrosis can demonstrate rim enhancement.
Heterogeneous enhancement on MRI, including rim enhancement, is more characteristic of a
malignant finding. Potential pitfalls for evaluation of rim-enhancing masses include benign entities
such as an inflammatory cyst and benign fat necrosis. Invasive ductal carcinoma may exhibit other
findings suggestive of malignancy such as nonuniform signal intensity with enhancing septations or
central enhancement.
Homogeneous enhancement and lack of enhancement are more suggestive of a benign finding.
For example, hyalinized fibroadenomas may be nonenhancing. Another classic finding for
fibroadenomas is dark internal septations. Simple cysts also do not demonstrate enhancement.
Hamartomas are usually diagnostic mammographically, and MRI is generally not necessary for
diagnosis. When imaged on MRI, the glandular elements within hamartomas show slight
enhancement.
References: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:520528.
Morris EA, Liberman L. Breast MRI Diagnosis and Intervention. New York, NY: Springer Science + Business Media; 2005:152
153, 472476.

30aAnswer B.Ultrasound is the best modality for a pregnant female patient under 30 years old.
30bAnswer B.Breast abscess, hematoma, and malignancy can all have similar appearances. The
internal echoes and irregular thick walls may represent various entities in each process. History
helps distinguish an abscess if there is increased redness, tenderness, warmth to the area, and skin
thickening. A common presentation is a post- or peripartum female. A malignancy will likely have
vascularity in the soft tissue components of a complex mass. Hematomas may present after a
history of trauma to the breast.
If an abscess is the likely diagnosis, an attempt at aspiration and drainage is reasonable,
although it is not entirely possible to determine whether the hypoechoic material can be aspirated
or if it is phlegmonous material that cannot be drained through a needle.
References: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:588589, 607, 612613.
Trop I, et al. Breast abscesses: evidence-based algorithms for diagnosis, management and follow-up. Radiographics 2011;31:1683
1699.

31Answer D.Tubular carcinoma is slow growing and the most likely diagnosis of the given
options when a very small (5 mm) spiculated lesion is found by mammography. The majority of
tubular carcinomas are <1 cm at diagnosis and have a central mass with ill-defined or spiculated
margins. Axillary lymph node metastases are rare. Although not a characteristic feature, some
contain microcalcifications.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:860.

32Answer C.There are many types of calcifications with the breast, some of which are classically
benign. These include skin calcifications, oil cysts or fat necrosis, milk of calcium, and vascular
calcifications. Skin calcifications are lucent-centered and usually distributed medially. Oil cysts
are rim or eggshell calcifications that may be due to previous trauma. Milk of calcium is a
precipitate that layers in cystically dilated acini of lobules. On the CC view, they appear as
amorphous, smudgy calcifications, while on the lateral view, the layering of calcifications become
more crescentic in shape, sometimes referred to as teacup shaped. Vascular calcifications occur
along the walls of arterial vessels and have a parallel train track appearance. In a young (under
40 years old) woman, vascular calcification is likely an indication of diabetes mellitus.
References: Berg WA, Birdwell RL. Diagnostic Imaging: Breast. 1st ed. Salt Lake City, UT: Amirsys; 2006:IV:66122.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:482, 489502.

33Answer A.According to data from the American Cancer Society (ACS), ~1% of all breast
cancers occur in men.
Reference: American Cancer Society. Cancer Facts & Figures 2012. Atlanta, GA: American Cancer Society; 2012.
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf

34Answer C.Calcifications are seen in the postbiopsy mammogram, thus you are sure the
specimen has calcifications in it despite the pathologists initial conclusion. Calcium oxalate
crystals can be seen in benign and secretory processes that may not show up on standard H&E
stains but are birefringent on polarized light microscopy.
35Answer B.Mammographic images demonstrate a classic breast hamartoma with a breast in
breast appearance. Hamartomas are benign breast lesions containing fat, fibrous connective
tissue, and varying amounts of disorganized glandular tissue. Routine annual mammogram is
appropriate, and this should be given a BI-RADS category 2benign finding category
assessment.
Reference: Basset LW. Diagnosis of Diseases of the Breast. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.

36aAnswer D.The high-density material in the breast tissues, outside of the implant, indicates free
silicone. The silicone is much more uniformly dense than the surrounding fibroglandular tissue.
Free silicone indicates implant compromise and can only occur with both intracapsular and
extracapsular rupture. If there was only intracapsular rupture of the implant shell, the silicone
would likely have been contained by the fibrous capsule without definitive mammographic
evidence of the implant integrity abnormality. Implant contour irregularity is an unreliable sign of
rupture.
No mass is present in this case, although free silicone can eventually lead to a silicone
granuloma. Calcifications around the implant can often be seen, although the important finding in
this case is the free silicone.
36bAnswer B.Although a mammographic abnormality is identified, the ruptured implant with
resultant free silicone in the breast tissue does not indicate a malignancy. BI-RADS assessment is
for evidence of malignancy, which there is not in this case.
References: Berg WA, et al. Diagnosing breast implant rupture with MR imaging, US, and mammography. Radiographics
1993;13:13231336.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

37Answer A.According to the BI-RADS Manual, fourth edition, high-risk lesions include atypical
ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS),
peripheral duct papillomas, and phyllodes tumor (not specified as malignant). Intracystic
papilloma and intraductal papilloma are benign and papillary carcinoma in situ is malignant.
Reference: American College of Radiology (ACR). ACR BI-RADSMammography. ACR Breast Imaging Reporting and Data
System, Breast Imaging Atlas. 4th ed. Reston, VA: American College of Radiology; 2003:300.

38aAnswer B.
38bAnswer D.According to well-established sonographic criteria for simple cysts and the BI-
RADS lexicon description for simple cysts set forth by Stavros, a mass is classified as a simple
cyst when these features are met: anechoic, well circumscribed with a thin echogenic capsule,
increased through transmission (or posterior acoustic enhancement), and thin edge shadows (sharp
border). A simple cyst confers an assessment of BI-RADS 2, benign finding, and the patient can
return to routine screening or ageappropriate follow-up.
References: Hines N, et al. Cystic masses of the breast. Am J Roentgenol 2010;194:W122W133.
Rumack CM, et al. Diagnostic Ultrasound. 3rd ed. St. Louis, MO: Elsevier Mosby; 2005:811,823.

39Answer C.Fibroadenolipoma or hamartoma of the breast was first described in 1971 as a


benign proliferation of fibrous, glandular, and fatty tissue surrounded by a thin capsule of
connective tissue. Its appearance has led some to describe it with the key term breast-within-a-
breast. The majority of these lesions occur in women over 35 years of age. At mammography,
they are typically well-circumscribed, round to oval masses containing both fat and soft-tissue
density with a thin, radiopaque pseudocapsule that becomes visible around a portion of the mass
when fat is present on both sides. None of the other answer choices fit the described keywords.
Be aware that because these lesions are made-up of otherwise normal breast tissue, breast cancer
of any type can arise in hamartomas.
References: Cardeosa G. Clinical Breast Imaging: A Patient Focused Teaching File. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007:200.
Feder JM, De Paredes ES, et al. Unusual breast lesions: Radiologicpathologic correlation. Radiographics 1999;19:S11S26.

40Answer C.The history of a rapidly growing mass in a postmenopausal female with the above
imaging characteristics is most likely a metaplastic carcinoma.
References: Gunhan-Bilgen I, Aysenur M, Ustun EE, et al. Metaplastic carcinoma of the breast: Clinical, mammographic and
sonographic findings with histopathologic correlation. AJR Am J Roentgenol 2002;178:14211425.
Irshad A, Ackerman S, Pope T, et al. Rare breast lesions: Correlation of imaging and histologic features with WHO classification.
Radiographics 2008;28:13991414.
Leddy R, Irshad I, Rumboldt T, et al. Review of metaplastic carcinoma of the breast: Imaging findings and pathologic features. J
Clin Imaging Sci 2012;2:21.
Soo MS, Dash N, Bentley R, et al. Tubular adenomas of the breast: Imaging findings with histologic correlation. AJR Am J
Roentgenol 2000;174:757761.

41Answer B.The histopathologic findings at core biopsy are consistent with diabetic mastopathy
in a patient with a known history of diabetes. Diabetic mastopathy is a benign process with no
known malignant potential; therefore, these patients can be followed rather than undergoing
surgical excision.
References: Camuto PM, Zetrenne E, Ponn T. Diabetic mastopathy: A report of 5 cases and a review of the literature. Arch Surg
2000;135:11901193.
Sakuhara Y, Shinozaki T, Hozumi Y, et al. MR imaging of diabetic mastopathy. AJR Am J Roentgenol 2002;179:12011203.
Wong KT, Tse GMK, Yang WT. Ultrasound and MR imaging of diabetic mastopathy. Clin Radiol 2002;57:730735.

42Answer A.Duct ectasia is nonspecific ectatic dilatation of the major collecting ducts that can be
seen by mammography and ultrasound as tubular structures beneath the nipple. Ectatic ducts may
be found deeper in the breast as well. The etiology of duct ectasia has not been clearly elucidated.
Duct ectasia may present clinically by nipple discharge or bleeding.
B.Ductal carcinoma in situ (DCIS) usually appears as a dilated duct with indistinct walls on
ultrasound. Isolated single or multiple dilated duct(s) is an uncommon presentation of DCIS.
C.The most common cause of a unilateral, single-duct discharge is a large duct papilloma.
These are benign hyperplastic growths with a fibrovascular core. They have no known
predisposition toward malignancy and usually occur within a few centimeters of the nipple,
in the large ducts. The discharge from a papilloma may be serous or sanguineous. Although
papilloma cases often present with spontaneous bloody nipple discharge, there is no
intraductal mass on the presented ultrasound to suggest papilloma.
D.Papillary carcinoma usually presents as a complex cystic and solid mass in elderly patients.
No mass is identified in this case.
E.These patients usually present with serous or bloody nipple discharge, with nipple and
areolar thickening. Paget disease per se is not identifiable on ultrasound.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:1,4546.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:792794.

43Answer E.Radial scar is one of the few benign lesions that can form spiculations that are
indistinguishable from those formed by some cancers. Therefore, upon diagnosis, surgical
excision is recommended. Tubular carcinoma can coexist with radial scar. Tubular carcinoma is a
well-differentiated form of invasive ductal carcinoma. It makes up 0.6% of invasive breast
cancers and 6% to 8% of all cancers (invasive plus DCIS). Although it is an invasive cancer, its
differentiation results in the production of what appear to be poorly formed ductal structures
consisting of haphazardly arranged tubules lined by a single layer of cuboidal epithelium.
Although sometimes palpable, the lesions are frequently detected by mammography. They are
slow growing and are usually very small when detected. Perhaps because of its differentiation,
tubular cancer has a favorable prognosis with a low metastatic potential, and the axillary nodes
are rarely involved.
References: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;IV:2,8486.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:859.

44Answer B.Approximately 10% of all invasive breast malignancies are invasive lobular
carcinoma. Invasive ductal carcinoma is the most common, representing at least 55% of all cases
when the diagnosis is purely invasive ductal carcinoma or up to 80% when combined with other
subtypes. Less common invasive breast carcinomas include inflammatory, medullary, mucinous,
and tubular carcinomas as well as breast sarcomas.
Reference: Rubin R, Strayer DS. Rubins Pathology: Clinicopathologic Foundations of Medicine. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2007:850853.

45Answer D.The spot views demonstrate an irregular mass with indistinct margins. Per history,
the prior mammogram was negative in this location. The absence of a sonographic correlate
should not prevent biopsy of a suspicious finding on mammography. Stereotactic core biopsy can
be used to biopsy masses and focal asymmetries in addition to the more common indication of
calcifications. This mass was an invasive ductal carcinoma.
46Answer C.Any mass-like enhancement, new or increasing areas of enhancement, or nonmass-
like enhancement should be considered suspicious. Skin thickening, architectural distortion,
resolving edema, signal voids, or signal flare from surgical or biopsy clips or from prior bleeding
(hemosiderin) are considered benign postconservation therapy findings. The majority of these
findings progressively decrease over time.
Reference: Drukteinis JS, Gombos EC, Raza S, et al. MR imaging assessment of the breast after breast conservation therapy:
Distinguishing benign from malignant lesions. Radiographics 2012;32:219234.

47Answer D.According to American College of Radiology (ACR) Appropriateness Criteria,


bilateral diagnostic mammography should be performed after ultrasound of a suspicious palpable
mass, to help characterize the mass and evaluate for any additional lesions. Core biopsy is
recommended after bilateral diagnostic mammographic evaluation.
Reference: Parikh JR, Bassett LE, Mahoney MC, et al. Expert Panel on Breast Imaging. ACR Appropriateness Criteria Palpable
Breast Masses. Reston, VA: American College of Radiology; 2009.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/PalpableBreastMasses.pdf, Accessed August 31, 2012.

48Answer D.Given the patients age and sonographic findings of hypoechoic mass with
microlobulations and posterior acoustic enhancement, the most likely diagnosis is mucinous
carcinoma.
Reference: Lam WW, Chu WC, Tse GM, et al. Sonographic appearance of mucinous carcinoma of the breast. AJR Am J
Roentgenol 2004;182(4):10691074.

49Answer E.The images are both STIR (water and fat suppressed) sequences that highlight
silicone. The coronal and sagittal STIR sequences both demonstrate intracapsular rupture as
evidenced by the presence of the subcapsular line sign. This is one of the signs of intracapsular
rupture. Loss of integrity of the silicone elastomer implant shell has caused silicone to extend
outside the implant shell and become located between the fibrous capsule and the implant shell.
Another earlier sign of intracapsular rupture is the keyhole sign, which is also known as the
noose or lasso sign. Keyhole sign results from a mild loss of integrity of the implant shell that
results in small amounts of silicone gel to extend outside the implant shell and become trapped
within the folds of the implant. Another sign of intracapsular rupture is the linguine sign, which
represents more advanced degradation. The implant shell becomes collapsed within the silicone
gel and is seen as stacked hypointense lines within the high signal silicone gel. In these examples
of intracapsular rupture, the silicone gel is still contained within the fibrous capsule. When
silicone extends outside the fibrous capsule, it is known as extracapsular rupture. The provided
example demonstrates extracapsular rupture as evidenced by the presence of bright signaled
silicone in the breast tissue on the superior aspect of the implant. Answer choices A and C are not
correct by themselves, because both of the types of rupture are present. Answer choice B is not
correct because the implant is not intact. Subcapsular line sign is present, indicating the presence
of intracapsular rupture. A radial fold is a normal infolding (with no intervening silicone gel) of
the silicone implant shell in an intact implant. Occasionally, complex radial folds are difficult to
distinguish from intracapsular rupture. Actively scrolling through the examination and evaluating
the implant in multiple planes can assist with the proper diagnosis. Answer choice D is not
correct. Gel bleed is the transudation of microscopic amounts of silicone gel through an intact
implant shell.
Reference: Liberman L, Berg WA. Magnetic resonance imaging in women with breast implants. In: Liberman L, Morris EA, eds.
Breast MRI: Diagnosis and Intervention. New York, NY: Springer Science; 2005:238265.
50aAnswer E.This finding is suspicious; BI-RADS category 4. It is a new enhancing irregular
mass in a high-risk patient and is therefore considered suspicious by MRI.
50bAnswer B.The next most appropriate step is focused ultrasound or mammography. Since the
finding is suspicious, a recommendation for 6 month follow-up (A) is not appropriate because this
finding has a higher than 2% chance of being breast cancer. A recommendation for annual
screening breast MRI (C) is similarly inappropriate. Although the finding may result in an MRI-
guided breast biopsy (D), an initial attempt should be made to call the patient back for focused
ultrasound or mammography for biopsy planning purposes. This additional second-look imaging
may identify a potential correlate to the MRI finding and the resultant ultrasound or stereotactic
breast biopsy is generally a more tolerable biopsy modality. Repeat breast MRI (E) will not be
helpful in this instance and is not a sensible use of resources.
51aAnswer C.
51bAnswer B.The images show an abrupt filling defect immediate past the tip of the 30-gauge
blunt-tipped sialogram needle. A filling defect, an abrupt duct cut-off, or luminal irregularity and
distortion on galactography are considered a positive study which could be due to
Intracystic papilloma (most common mass producing a bloody nipple discharge)
Intraductal papillary carcinoma
Blood clot
Inspissated material
Air bubble

The clinical indications for galactography are single-duct spontaneous bloody, serous, or clear
nipple discharge. Procedural steps for galactography are:
Obtain informed written consent.
Breast placed on magnification stand (or patient placed in supine position) with gooseneck light
positioned to illuminate the nipple.
Nipple is cleansed.
Duct opening is identified by squeezing nipple to express a small drop of nipple discharge.
The cannula is connected to the tubing and syringe containing 1 to 3 mL of Optiray contrast.
A blunt (27- or 30-gauge), straight or right-angle cannula, connected to tubing and a contrast-
filled syringe, is inserted into the duct opening.
The cannula is taped in place to the patients breast.
Contrast is injected slowly into the duct until the patient feels fullness in her breast or there is
reflux of contrast from the duct.
Special attention is made not to inject air into the duct, as it can mimic a filling defect on
mammogram.
If resistance occurs while injecting, it may be the result of the cannula being placed against the
wall of the duct or extravasation of contrast outside of the duct. Stop injection, and reposition
cannula.
Once contrast has been injected, a magnification craniocaudal and lateral view is obtained.
Images are assessed for a filling defect within the duct or abrupt termination of the duct. Both
findings will require biopsy.
Galactography can assess for a mass within or compromising a duct, but cannot differentiate
benign or malignant etiology.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:383389.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:231234.

52Answer A.Study is incomplete. Additional imaging evaluation is recommended. Although


bilateral similar-appearing masses are considered benign, the patient presented with a palpable
lump. Complete diagnostic workup of a palpable lump would include an ultrasound of the
palpable area.
Reference: Parikh JR, Bassett LE, Mahoney MC, et al. Expert Panel on Breast Imaging. ACR Appropriateness Criteria
Palpable Breast Masses. Reston, VA: American College of Radiology; 2009.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/PalpableBreastMasses.pdf, Accessed August 31, 2012.

53Answer B.Radial scars are not truly scars. Instead they are idiopathic entities unrelated to prior
surgery or trauma. Proposed possible causes include localized inflammatory reaction and chronic
ischemia with subsequent slow infarction. The prevalence is 0.1 to 2 per 1,000 mammograms.
Their major clinical significance pertains to an association with ADH and carcinoma that is seen
in up to 50% of cases.
Reference: Alleva DQ, Smetherman DH, Far GH Jr, et al. Radial scar of the breast: Radiologic pathologic correlation in 22 cases.
Radiographics 1999;19:S27S35.

54Answer C.This is a hematoma. Short term follow up is usually performed to assess resolution
because it can often mimic a malignancy.
55Answer D.The finding of ADH at needle biopsy raises concern about concomitant presence of
carcinoma in the lesion sampled by the needle. The incidence of coexistent DCIS or invasive
carcinoma is about 20% to 25%. For this reason, a diagnosis of ADH on stereotactic core biopsy
is an indication of surgical excision.
Reference: Eby PR, Ochsner JE, DeMartini WB, et al. Frequency and upgrade rates of ADH diagnosed at stereotactic vacuum
assisted core biopsy. AJR Am J Roentgenol 2009;192(1):229234.

56Answer D.Fibrocystic change is more common in patients older than 30 years. The cysts
originate from terminal lobules. They appear anechoic on ultrasound, and have high T2 signal
intensity, and without enhancement or thick peripheral enhancement on MRI. The fluctuation of the
size of the cysts is common.
Reference: Ikeda DM. The Requisites: Breast Imaging. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:6270, 198205.

57Answer A.The most common pleural presentation of breast cancer is malignant pleural
effusion. In fact, thoracentesis with cytology can be performed to help diagnose metastatic
disease.
Reference: Banerjee AK, Willetts I, Robertson JF, et al. Pleural effusion in breast cancer: A review of the Nottingham experience.
Eur J Surg Oncol 1994;20(1):3336.

58Answer C.Although radial scar is a benign proliferative breast lesion, it cannot be


differentiated from breast cancer with mammography and frequently requires biopsy. It may
contain or be associated with atypical ductal hyperplasia or low-grade DCIS, and therefore,
surgical excision is needed.
Reference: Ikeda DM. The Requisites: Breast Imaging. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:99, 103.

59Answer C.Features suggesting malignancy on breast MRI include bright enhancement,


spiculated margins, rim enhancement (beware of fat necrosis and inflamed cyst that can do this),
heterogeneous enhancement, enhancing septations, ductal/linear-branching/segmental
enhancement, associated enhancement of adjacent tissue region, enlarged feeding blood vessel.
Reference: Ikeda DM. The Requisites: Breast Imaging. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:250253.

60Answer D.Phyllodes tumor has a spectrum from benign to borderline to malignant. Typical
presentation is large and rapidly growing in size (more than 20% increase in diameter in 6
months). Typically, they do not have calcifications. The median age is 45 to 49 years, with 21%
risk of recurrence mostly within the first 2 years of excision. Radiation therapy reduces the risk of
recurrence, and surgical excision is usually curative.
Reference: Ikeda DM. The Requisites: Breast Imaging. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:110114.

61Answer C.Male breast cancer is mostly sporadic and most commonly presents in the upper
outer quadrant or subareolar region eccentric to the nipple in the upper outer quadrant. Majority of
the male breast carcinoma is invasive ductal carcinoma (IDC), which associated DCIS in 35% to
50% of the time. Pure DCIS is only 7% to 11%.
Reference: Ikeda DM. The Requisites: Breast Imaging. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:279287.

62aAnswer D.
62bAnswer A.Rolled views are useful for determining the location of a lesion seen only in the CC
projection. The top of the breast can be rolled laterally or medially, and the technologist should
label the image appropriately to indicate which way the breast was rolled (CC RL and CC RM,
respectively). If the top of the breast is rolled laterally and the lesion moves laterally, then it can
be inferred that it is located in the superior breast. Conversely, if the lesion moves medially on the
CC RL view, it can be inferred it is in the inferior breast. Although ultrasound can be performed to
locate a one-view finding, it is best to perform the rolled views first to more accurately determine
the location to be evaluated sonographically.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:766772.

63Answer C.Atypical ductal hyperplasia (ADH) is considered a high-risk lesion as these lesions
are considered along a spectrum of pathology that can develop into intraductal malignancy.
Women with a diagnosis of ADH are thought to have a five- to sixfold increased risk of
developing breast cancer in 10 years over the normal population. In addition, when ADH is
diagnosed at core needle biopsy rather, even with a 9-gauge vacuumassisted device, excision
should be recommended as studies have shown approximately one in five cases of ADH
diagnosed at core needle biopsy demonstrate DCIS or invasive malignancy at final excision.
References: Eby PR, Oschner JE, DeMartini WB, et al. Frequency and upgrade rates of atypical ductal hyperplasia diagnosed at
stereotactic vacuum-assisted core biopsy: 9 versus 11 gauge. AJR Am J Roentgenol 2009;192(1):229234.
Liberman L, et al. Atypical ductal hyperplasia diagnosed at stereotaxic core biopsy of breast lesions: An indication for surgical
biopsy. AJR Am J Roentgenol 1995;164(5):11111113.
Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:797798.

64Answer C.PASH is a benign entity of myofibroblasts in a background of collagen, which can


simulate vascular spaces. PASH is often an incidental finding associated with another lesion, with
benign breast tissue, or also can present as a mass. If presenting as a mass, as in this case, PASH
usually has benign features such as circumscribed margins, an oval shape, hypoechoic appearance,
and no posterior shadowing. It can contain slitlike vascular spaces. If imaging features are benign
in appearance such as with this case, then this diagnosis can be considered concordant and
surgical excision is not needed. If any suspicious imaging features are present, such as suspicious
calcifications or a spiculated mass, excision should be performed to exclude malignancy.
References: Hargarden GC, et al. Analysis of the mammographic and sonographic features of pseudoangiomatous stromal
hyperplasia. AJR Am J Roentgenol 2008;191(2):359363.
Jesinger RA, et al. Vascular abnormalities of the breast: Arterial and venous disorders, vascular masses, and mimic lesions with
radiologic-pathologic correlation. Radiographics 2011;31:E117E136.

65Answer A.The ultrasound images demonstrate an irregular mass with spiculated margins that
corresponds to the focal asymmetry seen on mammography. This requires a biopsy and would be
easiest for the radiologist and the patient to be performed under ultrasound guidance. The mass
was biopsied and the pathology yielded invasive ductal carcinoma. The findings are concerning
for malignancy; therefore an annual diagnostic mammogram or 6-month follow-up is
inappropriate. MRI may be beneficial after the biopsy is performed if there is concern for
multicentric disease, but the ultrasound and subsequent biopsy are more appropriately performed
first.
Reference: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:620626, 838845.

66Answer C.Tangential view. Although skin calcifications are a frequent finding on mammograms
and are generally easily distinguished by their lucent centers, occasionally the diagnosis can be a
difficult one. When unclear, tangential views can confirm the diagnosis of dermal calcifications.
The technologist does this generally by placing a grid on the breast in the area of the
calcifications, a BB placed over the calcifications and an image taken with the BB in tangent.
References: Evans A. Breast Calcifications: A Diagnostic Manual. Cambridge University Press, 2002:20.
Andolina VF, Lille SL. Mammographic Imaging, a Practical Guide. Lippincott Williams & Wilkins; 2010:196205.

67Answer D.Filariasis is a systemic parasitic infection that is rare in Western countries but
endemic in the tropics and parts of Africa. It is caused by the parasite Wuchereria bancrofti. With
infiltration, the parasite can cause lymphatic obstruction in the subcutaneous tissues, leading to
breast edema. As the parasite dies, it be comes calcified and may be visible on mammography as
elongated, serpentine, nonductal calcifications.
Common causes of breast infections are Staphylococcus aureus and Streptococcus species. Skin
thickening and underlying trabecular thickening may be seen on mammography in Staphylococcus
aureus and Streptococcus species infections. A focal abscess can also be identified as a mass on
both mammography and ultrasound.
On mammography congestive heart failure can appear as bilateral, and sometimes unilateral,
breast enlargement with associated skin and trabecular thickening. Distended veins often are
visualized as well.
Axillary lymphadenopathy can sometimes result in lymphatic obstruction. On mammography,
this can present as diffuse skin and trabecular thickening with overall engorgement of the breast
and enlarged dense lymph nodes in the lower axilla on the affected side
References: Mashankar A, Khopkar K, Parihar A, Salkade P. Breast filariasis. Indian J Radiol Imaging 2005;15:203204.
Ikeda DM. Breast Imaging: The Requisites. St. Louis, MO: Elsevier Mosby; 2004:389394.

68Answer A.The areas of palpable abnormalities in both breasts correspond to the flame-
shaped densities seen in the subareolar region of the breasts bilaterally. This is the characteristic
appearance of gynecomastia which represents the overproduction of stroma in the breast leading
to enlargement. The causes are varied and include use of certain medications/illicit drugs as well
as a myriad of systemic illnesses. Clinical management is indicated to identify the precipitating
factor.
Reference: Appleton CM, Wiele KN. Breast Imaging Cases (Cases in Radiology). New York, NY: Oxford University Press;
2012:1112.

69Answer B.Steatocystoma multiplex is a rare familial hamartomatous malformation of the


pilosebaceous duct junction that is characterized by the presence of multiple intradermal cysts that
usually appear during adolescence and then progress mammography showed characteristic
subcutaneous oil cysts as multiple small, round forms with a circumscribed margin, central fat
density, and a peripheral high-density rim, which is in agreement with reported descriptions.
Multiple steatocystoma multiplex nodules showed typical locationsnamely, at the axillae and
the anterior chest wallwhich was diagnostically helpful. Although the characteristic location of
steatocystoma multiplex is the dermis, some lesions resembled intraparenchymal nodules on
routine mammography.
Reference: Park KY, et al. Steatocystoma multiplex: Mammographic and sonographic manifestation. AJR Am J Roentgenol
2003;180(1):271274.

70Answer A.Higher false-negative rates (up to 19%) are reported for invasive lobular carcinoma
(ILC) than for other invasive cancers at mammography, because ILC is often difficult to diagnose
mammographically.
B.ILC most commonly manifests as a mass (44% to 65% of cases), usually with spiculated or
ill-defined margins.
C.MR imaging has been shown to affect clinical management in 50% of patients with ILC,
leading to changes in surgical management in 28% of cases.
D.ILC is associated with a higher rate of multiplicity and bilaterality than are the usual type
invasive ductal carcinomas.
Reference: Lopez K, Bassett LW. Invasive lobular carcinoma of the breast: Spectrum of mammographic, US, and MR imaging
findings. Radiographics 2009;29:165176.

71Answer C.Inflammatory carcinoma of the breast is considered a stage T4 lesion. Most common
presentation is skin thickening. The vast majority of patients with inflammatory breast carcinoma
present with skin thickening. Inflammatory breast cancer accounts for 1% to 4% of breast cancers.
Reference: Gnhan-Bilgen I, et al. Inflammatory breast carcinoma: Mammographic, ultrasonographic, clinical, and pathologic findings
in 142 cases. Radiology 2002;223:829838.

72Answer C.Pregnancy-associated breast cancer accounts for 3% of breast cancers. Breast


cancer is the second most common cancer during pregnancy, cervical cancer being the most
frequent. At the time of diagnosis, pregnant women have larger and more advanced cancers than
nonpregnant women of the same age. This is thought to be related to the delayed presentation and
to a more aggressive growth pattern due to the biological effects of pregnancy. The average age of
diagnosis is 32 to 38 years.
References: Ahn BY. Pregnancy- and lactation-associated breast cancer: Mammographic and sonographic findings. J Ultrasound
Med 2003;22:491497.
Sabate J, et al. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics 2007;27:S101S124.
Yang WT, et al. Imaging of breast cancer diagnosed and treated with chemotherapy during pregnancy. Radiology 2006;239:5260.

73Answer B.When invasive lobular carcinoma (ILC) is large, the affected breast may appear to
be decreasing in size on mammogram and/or MRI; this has been termed the shrinking breast.
The shrinking breast is an imaging and not a clinical finding of ILC. Clinically, the size of the
breast is not different; however, the patient may have clinical symptoms, such as skin thickening or
a palpable lump.
Reference: Harvey J. Unusual breast cancers: Useful clues to expanding the differential diagnosis. Radiology 2007;242:683694.

74Answer D.One of the roles for breast MRI is monitoring the results of neoadjuvant
chemotherapy. Clinical examination was originally used to track tumor response but several
studies have shown that MRI is the best for monitoring response to chemotherapy.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

75Answer A.The only reliable MRI finding to indicate tumor muscle invasion is muscle
enhancement.
Reference: Morris EA, Schwartz LH, Drotman MB, et al. Evaluation of pectoralis major muscle in patients with posterior breast
tumors on breast MR images: Early experience. Radiology 2000;214:6772.

76Answer C.Local recurrence after breast conservation therapy is 1% to 2%. Most cases of
recurrence occur 4 to 6 years after treatment. MR does offer an advantage over other methods in
assessing recurrence. On MRI, physiologic enhancement at the surgical site can be seen up to 18
to 24 months.
Reference: Macura KF, Ouwerkerk R, Jacobs MA, et al. Patterns of enhancement on breast MR images: interpretation and imaging
pitfalls. Radiographics 2006;26:17191734.

77Answer B.Poland syndrome is a rare congenital anomaly. Patients with Poland syndrome are
born with breast and pectoralis musculature hypoplasia or aplasia and often have hypoplasia of
the ipsilateral upper extremity. TRAM flap would be an incorrect answer as a TRAM would
appear as diffusely fatty breast compared to the contralateral side. Mastectomies are generally not
imaged, and reduction mammoplasty appears as symmetric, increased density along the inferior
margins of both breasts.
References: Moir CR, Johnson CH. Polands syndrome. Semin Pediatr Surg 2008;17(3):161166.
Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: Evaluation and treatment of the chest wall in 63 patients. Plast Reconstr Surg
2010;126(3):902911.

78Answer B.Kinetic interrogation of the nonmass-like enhancement in the central right breast
demonstrates initial rapid and delayed persistent enhancement kinetics, also known as a type I
curve. On this enhancement graph, the vertical axis is the percentage change of enhancement and
the horizontal axis indicates time in seconds. Early/initial enhancement is <2 minutes. After 2
minutes, the kinetic curve is in its delayed phase. Several postcontrast scans are performed at
early (1 to 2 minutes) and delayed (2 to 5 minutes) phases to provide enhancement behavior of a
mass or area of enhancement over time. CAD postprocessing software programs can then be used
to create subtraction series and provide kinetic information. The provided kinetic curve
demonstrates rapid change in the slope of enhancement of the nonmass enhancement (initial rapid
enhancement). Therefore, answer choices A and E are incorrect. The delayed component of the
enhancement curve is persistent meaning that the percentage change of enhancement continues to
increase over time, though at a smaller slope than the initial phase. Therefore, answer choices C
and D are incorrect. A delayed plateau kinetic curve is an enhancement pattern that plateaus and
does not exhibit percentage change in enhancement in the delayed phase. This type of curve is
known as a type II curve. A delayed washout kinetic curve demonstrates a continuous decrease in
enhancement in the delayed phase. This type of delayed washout curve is a type III curve; it is
classically described in association with breast cancer.

References: Macura KJ, Ouwerkerk R, Jacobs MA, et al. Patterns of enhancement on breast MR images: interpretation and
imaging pitfalls. Radiographics 2006;26:17191734.
Liberman L, Morris, eds. Breast MRI Diagnosis and Intervention. New York, NY: Springer Science; 2005:238265.

79Answer C.Invasive ductal carcinoma of the breast not otherwise specified is the most common
type of invasive breast cancer to occur in pregnant and postpartum patients. A few other cancers
have been reported but are significantly less frequent.
References: Sabate JM, Clotet M. Torrubia S, et al. Radiographic evaluation of breast disorders related to pregnancy and lactation.
Radiographics 2007;27:S101S124.
Yang WT, Dryden MJ, Gwyn K, et al. Imaging of breast cancer diagnosed and treated with chemotherapy during pregnancy.
Radiology 2006;239:5260.
Ahn BY, Kim HH, Moon WK, et al. Pregnancy and lactation-associated breast cancer: Mammographic and sonographic findings. J
Ultrasound Med 2003;22:491497.

80Answer D.The breast MRI images demonstrate a mass in the left upper outer quadrant at
posterior depth and a mass located in the left lower inner quadrant at middle depth, which is
consistent for multicentric disease. Multicentric disease refers to more than one lesion in more
than one quadrant of the breast. Multifocal disease refers to more than one lesion in a single
quadrant of the breast. Since the masses are 3 to 4 cm on opposite sides of the breast, this patient
would likely be treated with a mastectomy. Contraindications to whole-breast radiation therapy
are
Pregnancy
Previous breast radiation
Multicentric or diffuse disease
Collagen vascular disease
Poor cosmetic result (relative contraindication)
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:301.

81aAnswer B.
81bAnswer B.A galactocele is typically seen in lactating or postlactating women. A galactocele is
a focal collection of breast milk. On mammography, a galactocele appears as a low- or equal-
density mass with a pathognomonic fat-fluid appearance on the horizontal beam imaging
(lateral/medial or medial/lateral view). On ultrasound, there can be varying appearances
depending on the content of fluid and solid milk components. Pathognomonic appearance on
ultrasound is a fluid debris level with the fat rising on top of the galactocele and the milk/fluid
layering dependently below. Galactoceles usually resolve spontaneously within a few weeks to
months. Aspiration is usually therapeutic.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:379380.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:2527.

82Answer A.A simple breast cyst is fluid collection with an epithelial lining. It is the most
common breast mass in women. Simple cysts usually have a round, oval, or lobular appearance on
mammography but cannot be distinguished from a solid mass without use of ultrasound. On
ultrasound, a simple cyst is by definition a mass that is anechoic with imperceptible walls, a sharp
back wall, through transmission, and enhanced posterior transmission of sound. A simple cyst can
be left alone or can be aspirated if symptomatic.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:137139.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:8081.
83Answer D.Several published studies have reported on the mammographic appearance of
pregnancy-associated breast cancer, and the most common mammographic finding was a mass
with or without calcifications followed by calcifications alone or associated with other findings
such as architectural distortion or diffuse increase in breast density.
References: Sabate JM, Clotet M. Torrubia S, et al. Radiographic evaluation of breast disorders related to pregnancy and lactation.
Radiographics. 2007;27:S101S124.

84Answer C.Calcifications in axillary lymph nodes can be due to many reasons. Differential
diagnosis includes granulomatous disease and metastatic disease from breast cancer or ovarian
cancer. New development of calcifications in axillary lymph nodes should be biopsied to exclude
metastatic disease from breast or ovarian cancer.
References: Dunnington GL, Pearce J, Sherrod A, et al. Breast carcinoma presenting as mammographic microcalcifications in
axillary lymph nodes. Breast Dis 1995;8:193198.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:396.

85Answer C.The breast MRI image shows an irregular breast mass with spiculated margins. If a
mass has clear malignant features on morphology assessment, the mass should be biopsied
irrespective of a benign kinetic curve.
Reference: Morris EA, Liberman L. Breast MRI: Diagnosis and Intervention. New York, NY: Springer; 2005:99.

86Answer B.Ultrasound images show a superficial oval complicated cystic mass with posterior
acoustic enhancement along with a hypoechoic structure extending from the mass to the skin that is
characteristic for either a sebaceous cyst (arising from a sebaceous gland) or an epidermal
inclusion cyst (obstructed hair follicle). Clinically and on imaging, sebaceous cysts and epidermal
inclusion cysts are indistinguishable from each other and usually require no treatment. Excision
may be warranted if persistently painful or enlarge. There is no malignant potential for sebaceous
cysts, and it is extremely rare in epidermal inclusion cysts. Therefore, a BI-RADS 2 category is
the appropriate assessment following diagnostic workup.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:188189.

87Answer B.There has been interval decrease in size of both breasts on the current screening
mammogram as compared to the 2-year prior screening mammogram. There are swirled areas of
architectural distortion in the lower breast bilaterally on the MLO views and centrally on the CC
views. There is an oval radiolucent mass in the lower inner right breast that represents fat
necrosis. Findings are consistent for bilateral reduction mammoplasty.
Other characteristic mammogram findings seen are
Elevation of the nipple with more skin inferior than superior
Redistribution of fibroglandular tissue from upper outer quadrant to lower inner quadrant
Fat necrosis can be an associated finding seen in reduction mammoplasty.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:4950.

88Answer C.The images shown are that of bilateral subpectoral saline breast implants. There is a
normal subpectoral saline implant in the left breast. When a saline breast implant ruptures, the
saline disperses in the breast tissues and the envelope/shell of the implant shrinks back against the
chest wall. Radial fold is infolding of the implant envelope/shell that is a normal finding seen in
silicone breast implants. Radial folds appear as dark lines on MRI that extend to the periphery of
the implant. Capsular contracture occurs when normal scar tissue forms a capsule around the
breast implant and tightens/squeezes the breast implant. Capsular contracture may occur several
months to years and can result in change in the breast shape, sensation of hardness of the breast,
and/or breast pain.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:341.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:236237.

89Answer C.Mondors disease is a focal thrombophlebitis of a superficial vein in a breast. It can


clinically present as a palpable cordlike mass with associated pain, tenderness, and erythema.
Mondors disease is a rare condition that can be associated with trauma, breast surgery, and
extreme physical activity. Treatment is not needed as it is self-limited, and the palpable finding
resolves in 2 to 12 weeks. Supportive care is the appropriate treatment.
On mammography, Mondors disease can have negative mammogram or rarely a long tubular
structure corresponding to the thrombosed vein.
On ultrasound, Mondors disease appears as a noncompressible tubular superficial structure
with or without color Doppler flow depending on the degree of recanalization.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:399400.

90Answer A.Classic features of neurofibromatosis type 1 (NF 1), also known as von
Recklinghausen disease, have neurofibromas and caf au lait spots. NF 1 is associated with
neoplasms such as meningiomas, optic gliomas, neurofibrosarcomas, and pheochromocytomas.
Neurofibromas can project over the breast and have an appearance of masses within the breast on
mammography. However, a skin lesion can be differentiated from a mass in the breast by looking
for a radiolucent halo around the mass.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:4142.

91Answer D.Poland syndrome is either congenital unilateral hypoplasia or absence of the


pectoralis major muscle.
Poland syndrome is associated with increased incidence of:
Breast cancer
Leukemia
Non-Hodgkin lymphoma
Lung cancer
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:8283.

92Answer A.A galactocele is a focal collection of breast milk that is typically seen in a lactating
or postlactating woman. On mammography, a galactocele presents as a low- or equal-density mass
with a fat-fluid level best appreciated on a lateral view mammogram. On ultrasound, fluid debris
is seen with the fat rising to the top of the galactocele and the milk/fluid layering dependently at
the bottom. Galactoceles usually spontaneously resolve within a few weeks or months but can be
aspirated for symptomatic relief.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:2527.

93Answer C.Poland syndrome is either congenital unilateral hypoplasia or absence of the


pectoralis major muscle. The inheritance pattern for Poland syndrome is autosomal recessive.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:8283.

94Answer D.The mammogram findings reveal an oval mass in the area of palpable abnormality in
the retroareolar region of the right breast. This mass is of fat density with associated dystrophic
calcifications. On ultrasound, there is an oval mass of heterogeneous echogenicity that does not
demonstrate internal vascularity. Based on the mammogram findings, ultrasound, and clinical
history of lumpectomy surgery, these findings are consistent for an area of fat necrosis.
References: Hogge JP, Robinson RE, Magnant CM, et al. The mammographic spectrum of fat necrosis of the breast.
Radiographics 1995;15:13471356.
Soo MS, Kornguth PJ, Hertzberg BS. Fat necrosis in the breast: sonographic features. Radiology 1998;206:261269.
Taboada JL, Stephens TW, Krishnamurthy S, et al. The many faces of fat necrosis in the breast. AJR Am J Roentgenol
2009;192:815825.

95Answer D.Focal fibrosis, also known as fibrous mastopathy or fibrous tumor, usually occurs in
premenopausal women. When focal fibrosis occurs in postmenopausal women, these women are
likely taking hormone replacement therapy. When palpable, focal fibrosis clinically manifests as a
firm mass. Mammographic features are variable, and can present as either an ill-defined or a
well-circumscribed mass, asymmetry, or architectural distortion. On ultrasound, a hypoechoic
mass usually is seen, although heterogeneous echogenicity also can occur.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:246
IV:249.

96Answer A.Unilateral or bilateral patchy isotope uptake frequently corresponds to active


fibroglandular tissue or hormonal activity. Therefore, it is preferable to perform the study between
day 2 and day 12 of the patients menstrual cycle, if possible. If there is diffuse patchy uptake, the
test may have to be considered indeterminate.
References: Brem R, Fishman M, Rapelyea J. Detection of ductal carcinoma in situ with mammography, breast specific gamma
imaging and magnetic resonance imaging: A comparative study. Acad Radiol 2007;14:945950.
Brem R, Ioffe M, Rapelyea J, et al. Invasive lobular carcinoma: Detection with mammography, sonography, MRI, and breast-specific
gamma imaging. AJR Am J Roentgenol 2009;192:379383.

97Answer B.The most common cause of metastatic involvement of the breast is from contralateral
breast cancer. The most common nonbreast cancer to metastasize to the breast is melanoma.
Reference: Akcay MN. Metastatic disease in the breast. Breast 2002;11(6):526528.

98Answer A.Phyllodes tumors are large, rapidly growing circumscribed masses without
associated calcifications. Ten percent of phyllodes tumors are malignant. Phyllodes tumors tend to
recur in the biopsy site and therefore should be completely excised by surgery. Therefore, all
phyllodes tumors should be excised.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New
York, NY: Springer; 2010:180181.

99Answer B.Causes of bilateral breast edema: congestive heart failure, anasarca, renal failure,
lymphadenopathy, superior vena cava syndrome, and liver disease.
Causes of unilateral breast edema are mastitis, abscess complicating mastitis, recurrent
subareolar abscess, inflammatory breast cancer, trauma, coumarin necrosis, unilateral lymph node
obstruction, and radiation therapy.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:389390.
100Answer A.The images shown are of a benign intramammary lymph node. No further
management is warranted. Benign-appearing intramammary lymph nodes can be seen on up to 5%
of screening mammograms. Typically, a circumscribed mass measuring <1 cm with reniform shape
and a radiolucent hilar notch is seen in the upper outer quadrant on mammography, although less
commonly it may be located in other quadrants. On ultrasound, an intramammary lymph node
appears as a well-circumscribed mass with gentle lobulations, a hypoechoic cortex, and an
echogenic central hilum with central feeding vessels. When intramammary lymph nodes enlarge,
there is generalized or focal cortical thickening (>3-mm cortical thickness), or the node becomes
rounded with loss of the normal fatty hilum. A core biopsy should be considered if there is
suspicion for metastatic involvement in an intramammary lymph node.
References: Mainiero MB, Cinelli CM, Koelliker SL, et al. Axillary ultrasound and fine-needle aspiration in the preoperative
evaluation of the breast cancer patient: An algorithm based on tumor size and lymph node appearance. AJR Am J Roentgenol
2010;195:12611267.
Svane G, Franzen S. Radiologic appearance of nonpalpable intramammary nodes. Acta Radiol 1993;34:577580.

101Answer D.Up to 9 months after lumpectomy and radiation therapy, there is strong enhancement
at the lumpectomy site. From 10 to 18 months after lumpectomy and radiation therapy, the
enhancement slowly subsides, with no significant enhancement in 94% of cases.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:307309.

102Answer B.Multiple bilateral similar findings suggest a benign etiology. At least three total and
at least one in each breast must be present. This excludes palpable findings.
Reference: Leung JW, Sickles EA. Multiple bilateral masses detected on screening mammography: Assessment of need for recall
imaging. AJR Am J Roentgenol 2000;175:2329.

103Answer C.The mammogram image reveals a radiolucent (fat density) mass with an apparent
fibrous capsule within the right pectoralis major muscle corresponding to the patients palpable
abnormality as indicated by the triangular skin marker. The ultrasound images reveal an oval
circumscribed mass that is nearly isoechoic or slightly hyperechoic to subcutaneous fat. Based on
the imaging findings and answer choices, the findings are most likely of the diagnosis of a lipoma.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:256
IV:257.

104Answer B.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:299300.

105Answer C.These are pseudocalcifications due to the presence of zinc oxide in certain
ointments such as Desitin and Calamine lotions. The mammogram should be repeated after having
the patient wipe her breasts clean.
Reference: de Paredes ES. Atlas of Mammography (electronic resource). 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2007:238240.

106Answer C.A post-surgical scar on ultrasound has a track to the overlying skin incision site on
ultrasound. Posterior acoustic shadowing is more common in lumpectomy, post-radiation scars
than benign surgical scars. Post-surgerical scar should decrease over time.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:1164.

107a Answer A.There is an increasing asymmetry in the upper outer quadrant, which needs to be
evaluated with additional imaging and ultrasound.
107b Answer B.Although nothing specific is seen on ultrasound, there is a developing and increasing
asymmetry on the mammogram. The cause needs to be determined. The easiest way is to do a
needle biopsy under either stereotactic or ultrasound guidance. An excisional biopsy can also be
done but is more invasive.
107c Answer B.PASH is a benign entity. Wide local excision is indicated if the mass is enlarging, if
there are patient concerns over symptomatic mass, or if imaging features are atypical. Local
recurrence is common if excision is incomplete.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:268.

108Answer D.At the site of the palpable marker is an oval lesion with a thin rim of calcification
surrounding a lucent tissue. This is the characteristic appearance of an oil cyst/fat necrosis on
mammography. Sonographically, they can have a variable appearance ranging from sonolucent
masses (like simple cysts) to having internal echoes and posterior acoustic shadowing.
Fibroadenoma, complicated cyst, and mucinous carcinoma would all appear dense on
mammography.
Reference: Hines N, et al. Cystic masses of the breast. AJR Am J Roentgenol 2010;194:122133.

109Answer C.Calcium phosphate calcifications are easily seen on H&E staining. Calcium oxalate
is not visualized with H&E staining and requires a special polarized light to show the
calcifications. If calcifications are still within the paraffin blocks, then radiographing the blocks
will show them. Resectioning of that particular block will show the calcifications.
References: Dondalski M, Bernstein JR. Disappearing breast calcifications: Mammographic-pathologic discrepancy due to calcium
oxalate. South Med J 1992;85:12521254.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:168.

110Answer A.The image depicts a fibroadenoma, which is the most common breast mass in
younger women. On ultrasound, fibroadenomas are usually circumscribed round to ovoid masses
of uniform hypoechogenicity. Sometimes a thin echogenic rimpseudocapsule may be seen
sonographically. Typically fibroadenomas do not show rim enhancement on MRI. They contain
nonenhancing septations, which if seen on MRI, are pathognomonic. Masses that do show rim
enhancement on MRI include complicated cysts, carcinomas, and fat necrosis. Lipomas are
composed of adipose cells, and the breast within a breast appearance is indicative of hamartomas.
On ultrasound, hamartomas can have a heterogeneous echotexture and also have wide sonographic
variability in their appearance.
References: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:2
28,34,56.
Chao TC, Chao HH, et al. Sonographic features of breast hemartomas. J Ultrasound Med 2007;26(4):447452.
Morris EA, Liberman L. Breast MRI: Diagnosis and Intervention. New York, NY: Springer; 2005:427431.

111Answer B.The mass in the mammogram is a lipoma. These are fatty masses containing a
radiolucent center that may or may not have a discrete rim. Unlike oil cysts, they never calcify. As
with lipomas elsewhere in the body, they are freely mobile and soft. Ultrasound is usually not
indicated because the lesion is clearly benign by mammography.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:122.
Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:553554.

112Answer D.Majority of male breast cancer is invasive ductal carcinoma. It usually presents as a
firm, tender, subareolar mass typically eccentric to the nipple. Mean diameter at diagnosis is 2.0
to 3.5 cm. Calcifications are uncommon. Diffuse gynecomastia may obscure the cancer.
Differential diagnosis includes gynecomastia and fat necrosis.
References: Applebaum A, et al. Mammographic appearances of male breast disease. Radiographics 1999;19:559568.
Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:554.

113Answer A.Apocrine cyst cluster is a cluster of tiny anechoic foci, 1 to 7mm individually with
thin intervening septae. No solid components are present. They have a typical appearance on
ultrasound. No further intervention/ workup is needed. They are in the lobular portion of the
terminal ductal lobular unit (TDLU). One can may see milk of calcium in microcysts. Short-term
follow-up can be done if suboptimally seen or individual microcysts are complicated. Biopsy if
solid component is present.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:1.

114Answer 1B, 2A, 3D.


References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:183186.
Nathanson SD, Wachna DL, Gilman D, et al. Pathways of lymphatic drainage from the breast. Ann Surg Oncol 2001;8:837843.

115Answer C.Phyllodes tumors are uncommon, and most are benign. They usually occur in
women in their fifth decade and can be very large when first detected. About 10% of phyllodes
tumors are malignant. Most common sites for metastases are the lung and bone. Axillary node
metastases are uncommon. Five-year survival is 55% to 75%.
Treatment of choice is wide local exercise for mastectomy for very large tumors. Radiation
treatment reduces local recurrence. There is no benefit from chemotherapy.
References: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:2-96
IV:2101.
Gordon PB, et al. Solid breast masses diagnosed as FA at fine needle aspiration: Acceptable rates of growth at long term following-
up. Radiology 2003;229(1):233238.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:111113.

116Answer A.The images depict a shrinking breast, which is indicative of bilaterality,


multicentricity, and multifocality. It represents 10% of all breast cancer. Its size is often
underestimated on mammography and ultrasound. Tubular carcinomas have a 95% to 98% 5-year
survival rate. Proliferating epithelium in villous-like projections is as seen in papillary
carcinomas.
References: Bassett LW, et al. Diagnosis of Diseases of the Breast. Philadelphia, PA: WB Saunders; 2005: Chapter 27, 506507.
Evans WP III, et al. Invasive lobular carcinoma of the breast: Mammographic characteristics and computer aided detection.
Radiology 2002;225:182189.
Mercado CL, et al. Papillary lesions of the breast at percutaneous core needle biopsy. Radiology 2006;238:801808.

117Answer D.The mass seen on the MRI is an intramammary lymph node. It is bright on T2-
weighted images and demonstrates washout enhancement. It may be possible to see the fatty hilum
on nonfat sat T1-weighted images to confirm the diagnosis. Sometimes a vessel can be seen going
to the fatty hilum. Correlation with mammograms is also helpful in confirming the diagnosis.
Reference: Morris EA, Liberman L. Breast MRI: Diagnosis and Intervention. New York, NY: Springer; 2005:427431.

118Answer A.Calcific particles in axillary lymph nodes can be caused by a metastatic


calcifying cancer and granulomatous infectious like tuberculosis (TB). Other entities like migrated
silicone from implant rupture and gold particles from rheumatoid arthritis therapy may mimic
calcifications in lymph nodes. Usually the clinical history can help with the diagnosis.
Microcalcifications in lymph nodes rather than pleomorphic calcifications can suggest tuberculous
mastitis, but biopsy is needed to exclude metastatic breast cancer.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:304.

119Answer C.In cases where there is an explanation for the bilateral axillary adenopathy, such as
lymphoma or rheumatoid arthritis, no further evaluation is warranted. If there is no such history,
then further evaluation with ultrasound is recommended. In this case, the screening mammogram
would be given a BIRADS 0.
Reference: Chelten A, Nicholson B, et al. Is screening detected bilateral axillary adenopathy on mammography clinically significant?
The Breast Journal 2012;18:582587.

120Answer D.When nipple retraction is new, causes may be due to periductal mastitis, duct
ectasia, or a malignancy. Cancers that typically occur in the retroareolar region are invasive
ductal carcinoma or invasive lobular carcinoma. Both of these cancers, if close to the nipple, can
cause the nipple to retract. The first step in the workup of nipple retraction is diagnostic
mammography, including spot compressionmagnification views in the subareolar region.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:2636.
Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex: Normal anatomy and benign and malignant processes.
Radiographics. 2009;29(2):509523.

121Answer D.Milk of calcium calcifications are dense and curvilinear on the mediolateral
projection. On the craniocaudal projection, they have a smudgy appearance. DCIS calcifications
are linear, sometimes branching, and pleomorphic. Skin calcifications often have a calcific rim
surrounding a radiolucent center. Oil cysts also have lucent centers.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:73.
Lanyi M. Diagnosis and Differential Diagnosis of Breast Calcifications. New York, NY: Springer-Verlag; 1988.

122Answer A.The above finding is caused by seat-belt injury. This can be seen in any type of
injuries to the breast whether caused by blunt or penetrating trauma. Without a history of trauma,
developing densities will be suspicious and may require biopsy. An asymmetry is seen on the left
side when trauma is sustained by the driver and on the right by the passenger.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:520
IV:521.

123Answer A.NAT is systemic chemotherapy with or without hormonal treatment of breast cancer
prior to definitive breast surgery. Primary goal of NAT is to facilitate clear margins at surgery by
clearing skin/chest wall invasion. Size of the tumor is most accurately determined by MRI.
Mammography is not very accurate for determining preoperative size of the tumor and is
particularly inaccurate for invasive lobular carcinoma.
References: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;V:128
V:131.
Yeh E, et al. Prospective comparison of mammography, sonography and MRI in patients undergoing neoadjuvant chemotherapy for
palpable breast cancer. AJR Am J Roentgenol 2005;184:868877.

124Answer A.Lesions requiring surgical excision or rebiopsy after core biopsy include ductal
carcinoma in situ (DCIS), atypical ductal hyperplasia (ADH), papillary lesions with atypia,
phyllodes tumor, cancer (even if an entire lesion appears to be removed), insufficient samples,
and noncongruent results of pathology. Growing PASH should be excised because of overlap with
low-grade angiosarcoma. Steatocystoma multiplex consists of multiple, bilateral oil cysts that are
benign and do not require excision. A small percentage of phyllodes tumors may be malignant and
can sometimes only be diagnosed by a complete histologic examination.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:183184.
Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. 1st ed. New York, NY:
Springer; 2010:109.

125a Answer C.The mammogram demonstrates diffuse increased trabecular thickening and skin
thickening of the left breast which was due to extrinsic compression on the left subclavian vein
obstruction from a mediastinal mass.
125b Answer D.The mammogram demonstrates diffuse increased trabecular thickening and skin
thickening. Main differential diagnoses for these findings are inflammatory carcinoma and
mastitis. Clinical symptoms are the key to diagnosis. Punch biopsy to exclude inflammatory
carcinoma. Most common agents for mastitis are Staphylococcus aureus and streptococcal
bacteria.
Reference: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;V:610V:6
13.

126a Answer A.There is a mass seen in the left breast superiorly on the mediolateral oblique (MLO)
view with associated calcifications, which needs additional imaging.
126b Answer B.Images depict a partially calcified epidermal inclusion cyst. It is a benign cutaneous
or subcutaneous epithelial cyst arising from an obstructed hair follicle. Biopsy/fine needle
aspiration should be avoided as the contents can be irritating to surrounding tissues, sometimes
even leading to abscess formation. They are more common in other parts of the body such as the
face, neck, and trunk.
References: Berg WA, Birdwell R, Gombos EC, et al. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006;IV:316
IV:319.
Celik V, et al. Epidermal inclusion cyst of the breast: Clinical, radiologic and pathologic correlation. Breast J 2004;10(1):57.

127Answer C.Thickening of the skin can have many causes. It can be focal or diffuse, unilateral or
bilateral. It can occur as a result of tumor invasion, tumor in the dermal lymphatics, or lymphatic
congestion by obstruction of lymphatic drainage. Differential diagnosis includes malignancy,
infection, nonspecific inflammation, primary skin processes like psoriasis, systemic diseases like
scleroderma, dermatomyositis, and causes of vascular obstruction like CHF, superior vena cava
syndrome, and anasarca.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:339341.
4 Breast Intervention

QUESTIONS

1A 50-year-old female with a mass is scheduled for ultrasound-guided wire localization. Based on
the image below, which letter denotes the wire tip?

A.A
B.B
C.C
D.D
2You are attempting a stereotactic biopsy on a patient with calcifications very close to the chest
wall and difficult to image with the patient prone. What is the best option?
A.Recommend an MRI.
B.Use towels to compress the breast side to side to push the front of the breast out.
C.Retarget to get as close as possible.
D.Place the patients arm and shoulder through the hole in the stereotactic table.
3You are performing an ultrasound-guided biopsy on a patient with a lesion close to the chest wall.
Which of the following is the best option?
A.Roll the patient and approach at an angle so the needle is parallel to the chest wall.
B.Explain to the patient the likely risk of pneumothorax.
C.Schedule the patient for wire localization instead.
D.Aim for the periphery of the lesion.
4Cytologic analysis should be performed for fluid removed during an ultrasound-guided cyst
aspiration, if the fluid appears
A.Bright red
B.Green
C.Thick and maroon or dark brown
D.Yellow
5What is the standard degree difference between the two stereotactic pair images obtained during
stereotactic needle biopsy?
A.20 degrees
B.30 degrees
C.50 degrees
D.60 degrees
6What is the purpose of using a spinal needle for anesthesia during a stereotatic vacuum-assisted
biopsy?
A.To create a tract for the biopsy needle
B.To form the skin wheal
C.To inject beyond the area being biopsied because of the dead space of the needle distal to the
sample notch
D.To reduce the burn associated with lidocaine injection
7You recommend a breast biopsy on a patient but discover she is on aspirin. What is the next best
step in management?
A.Counsel patient for increased risk of hematoma/hemorrhage.
B.Cancel biopsy and instead recommend follow-up in 6 months.
C.Stop ASA for 7 days and then biopsy.
D.Do nothing.
8You perform a stereotactic biopsy, and specimen x-ray demonstrates the calcifications in question;
however, pathology reports no calcifications seen. What do you recommend?
A.Recommend repeat biopsy.
B.Follow-up mammogram in 6 months.
C.Recommend surgical excision of the biopsy site.
D.X-ray the pathology blocks and check with polarized light for calcium oxalate.
9The immediate subareolar area is difficult to adequately anesthetize. Which of the following is the
simplest and most effective way to achieve full anesthesia of the nipple areolar complex?
A.Double the amount injected of 1% lidocaine.
B.Apply topical lidocaine to the nipple 30 minutes prior to biopsy.
C.No need to do anything additional.
D.Buffer with sodium bicarbonate.
10When targeting a lesion for stereotactic core biopsy, images are obtained at +15 and 15 degrees.
The images obtained show apparent movement of the target lesion, known as parallax shift. The
distance of apparent lesion movement is used to calculate which coordinate?
A.x (horizontal)
B.y (vertical)
C.z (depth)
11An axial CT image of a postlumpectomy patient is shown. What is the most common complication
of breast surgery?

A.Abscess/infection
B.Hemorrhage
C.Lymphedema
D.Necrosis
E.Seroma
12What is the best technique to attempt if the stereotactic needle is in the breast at the appropriate
depth and the lesion is too far from it?
A.Completely withdraw the needle out of the skin and make a second skin opening.
B.Change only the z coordinate.
C.Change the x and y coordinates after retargeting the lesion.
D.Cancel the procedure.
13aA 42-year-old female presents for a screening mammogram. Thin linearbranching calcifications
were noted in the left upper outer breast, new from a prior study. There is no family history of
breast cancer. The patient is asymptomatic. What is the appropriate next step?
A.Clinical breast exam to detect any underlying masses
B.Stereotactic biopsy
C.Referral to surgery for excisional biopsy
D.Additional mammographic imaging
E.Short-term 6-month follow-up to assess stability
13bWhat is the appropriate BI-RADS category?
A.BI-RADS 0
B.BI-RADS 1
C.BI-RADS 2
D.BI-RADS 3
E.BI-RADS 4
13cAfter diagnostic mammogram, calcifications were noted to span a distance of 6 cm. What is the
next appropriate step?
A.Refer to surgery for lumpectomy.
B.Refer to surgery for left breast mastectomy.
C.Refer to surgery for left breast mastectomy and preventative right breast mastectomy.
D.Stereotactic biopsy
14Which one of the following patients can still be qualified for radiation therapy?
A.Patient with multicentric or diffuse disease
B.Pregnant patient
C.Patient who has had previous radiation therapy
D.Patient with collagen vascular disease
E.Patient with axillary lymphadenopathy
15Which of the following is considered a contraindication to breast-conserving therapy (lumpectomy
and radiation)?
A.Breast cancer diagnosed in the third trimester of pregnancy
B.Axillary metastases
C.Prior history of radiation and lumpectomy in the contralateral breast
D.Two or more separate tumors in different quadrants of the same breast
16Stereotactic biopsy of the following calcifications was performed. Specimen radiograph
confirmed that two calcifications were present in the specimens.

Core biopsy pathology results returned as benign, fibrocystic changes with microcalcifications.
What is the next most appropriate step?
A.Annual screening mammogram
B.Recommendation for surgical biopsy
C.6 month follow-up postprocedure mammogram
D.Repeat stereotactic biopsy
E.Breast MRI
17A patient presents prior to a planned lumpectomy for wire localization of a 3-cm extent of
previously biopsied, known malignant, calcifications in the left breast. The best course of action
is
A.Place a wire in the center of the calcifications
B.Place a wire at one of the margins of the calcifications and provide measurements and
instructions to the surgeon on what nearby tissue to excise
C.Place two wires, using the bracketing technique, at each edge of the calcifications
D.Cancel the procedure and call the surgeon, this extent of disease is too large for lumpectomy
and mastectomy should be considered
18Of the following choices, which needle biopsy device is considered most effective for use during
stereotactic-guided breast biopsy of microcalcifications?
A.14-gauge or smaller gauge spring loaded
B.14-gauge or smaller gauge vacuum assisted
C.11-gauge or larger gauge spring loaded
D.11-gauge or larger gauge vacuum assisted
19What is the most appropriate indication to perform galactography?
A.Single duct nonspontaneous and spontaneous bloody, milky, or clear nipple discharge
B.Single duct spontaneous bloody, milky, or clear nipple discharge
C.Single duct nonspontaneous and spontaneous bloody, serous, or clear nipple discharge
D.Single duct spontaneous bloody, serous, or clear nipple discharge
E.Single duct spontaneous bloody, serous, or milky nipple discharge
20A mammographic wire localization is being performed for biopsy-proven invasive ductal
carcinoma. The distance from the tip of the needle to the mass is 3 cm. Based on the image below,
what is the next most appropriate step?
A.The patient goes to the OR; procedure is complete.
B.Return to the ML view for repositioning.
C.Retract the needle slightly, and take another image.
D.Place the wire, and take another image.
21A specimen radiograph postwire localization was performed. A new nurse in the OR calls into the
reading room with some questions. Which of the following is most accurate regarding specimen
radiographs?
A.Routinely performed after the patient leaves the OR
B.Only performed for masses
C.Accurately determines if the surgical margins are negative
D.Performed with magnification
22When performing a stereotactic biopsy, what is stroke margin?
A.The distance from the image receptor to the tip of the needle postfire
B.The distance from the image receptor to the tip of the needle prefire
C.The distance of the lesion to the tip of the needle postfire
D.The distance of the lesion to the tip of the needle prefire
23The image shown below is an ultrasound of the axilla in a patient with biopsy-proven breast
cancer. A core needle biopsy was performed. Pathology shows benign reactive lymph node. The
patient will receive which of the following procedures along with her lumpectomy?

A.None
B.Rebiopsy is indicated prior to surgery.
C.Sentinel lymph node biopsy
D.Axillary dissection
24Regarding stereotactic-guided breast biopsy, which of the following is correct?
A.A negative stroke margin is necessary to perform the biopsy.
B.Postprocedure mammogram is not necessary.
C.The most common complication is infection.
D.Specimen radiograph is performed to evaluate for adequate sampling.
E.The optimal needle approach is lateral.
25Pathology for a core biopsy of this lesion imaged showed florid epithelial hyperplasia. What is
the appropriate recommendation?

A.Surgical excisional biopsy


B.Breast-specific gamma imaging (BSGI)
C.Breast MRI
D.Follow-up diagnostic ultrasound in 6 months
26Which of the following is a contraindication to whole-breast radiation therapy?
A.Axillary adenopathy
B.Collagen vascular disease
C.Residual microscopic disease
D.Younger women
27The maximum dose of 1% lidocaine with epinephrine used for deep local anesthesia is
A.7 mg/kg body weight, not to exceed 500 mg
B.7 mg/kg body weight, not to exceed 1,000 mg
C.10 mg/kg body weight, not to exceed 500 mg
D.10 mg/kg body weight, not to exceed 1,000 mg
28aA 47-year-old female with history of nipple discharge is referred from the breast surgeon for
ductography. Which of the following is correct?
A.Ductography is indicated for single pore spontaneous nipple discharge.
B.Ductography is the procedure used to biopsy an intraductal mass.
C.Suspicious discharge includes spontaneous unilateral green or white discharge.
D.The standard dose of contrast used for ductography is 5 mL.
28bThe following images are available from this patients ductogram. What is the next best step in
patient management?
A.Stereotactic breast biopsy
B.Diagnostic breast MRI
C.Repeat ductogram due to artifact
D.Surgical breast biopsy
29Which of the following statements concerning percutaneous biopsy is correct?
A.Correlation between pathology results and imaging studies does not have to be done for
asymmetries.
B.Surgical excision is always recommended for atypical ductal hyperplasia and atypical
lobular hyperplasia.
C.Pseudoaneurysms can occur in the breast after core biopsy.
D.Markers generally do not migrate after completion of stereotactic biopsy.
30During galactography, how much contrast material is injected into the duct?
A.<0.3 mL
B.0.3 to 1.0 mL
C.2 to 4 mL
D.3 to 6 mL
31A stereotactic biopsy was performed on a 47-year-old patient. The pathology results are atypical
ductal hyperplasia (ADH). What is the appropriate recommendation?
A.Surgical excision
B.MRI
C.6-month follow-up
D.Repeat stereotactic biopsy
32A 39-year-old female is scheduled for a contrast-enhanced breast MRI for high-risk screening
evaluation. She undergoes laboratory testing for renal function due to her history of diabetes
mellitus. Her laboratory results are creatinine of 1.8 mg/dL and a calculated GFR of 28
mL/min/1.73 m 2 . No prior laboratory data are available to review. Which of the following is the
most appropriate next step in the evaluation of this patient?
A.Consult with referring physician, and discuss riskbenefit ratio. If the examination is
essential, use the lowest possible contrast dose as possible.
B.Proceed with the breast MRI without use of gadolinium-based contrast agent.
C.Proceed with the breast MRI using a standard dose of gadolinium-based contrast agent.
D.Cancel the breast MRI study.
33Four days after a screening mammogram, a 40-year-old female discovers she is pregnant and
estimates that the fetus is in its 3rd week of gestation. Which of the following is the most
appropriate response regarding the amount of radiation the fetus received from the mammogram
exam?
A.The fetus is unharmed because there was no radiation exposure.
B.The fetus is at potential risk of embryologic demise.
C.The fetus is at negligible risk for potential radiation-induced malformation of organs.
D.The child will have a 1% risk of developing severe mental retardation.
E.There is a high likelihood of a radiation-induced malformation of organs.
34A 43-year-old female, with no known allergies or past medical condition, underwent an
uneventful right breast stereotactic core needle biopsy in the morning. After needle biopsy,
hemostasis was successfully achieved, and the patient was sent home. The patient returns to the
radiology department complaining of right breast pain at the breast biopsy site. There is no oozing
or unexpected bleeding or palpable lump at the biopsy site. Which of the following is the most
appropriate initial management of the patients breast pain?
A.Give a prescription of Tylenol 3 (acetaminophen with codeine) for the patient to take as
needed.
B.Give a prescription of Vicodin (acetaminophen with hydrocodone) for the patient to take as
needed.
C.Advise the patient to take acetaminophen initially and then every 6 hours as needed, up to
4/d.
D.Advise the patient to take aspirin initially and then every 4 to 6 hours as needed, up to 3/d.
35Which of the following situation can make stereotactic biopsy difficult, either requiring special
repositioning of the patient or technically impossible?
A.Patient with breast thickness of 3 cm on the craniocaudal and breast thickness of 3.5 cm on
mediolateral oblique view
B.A 2-mm cluster of pleomorphic microcalcifications in the central breast
C.Microcalcifications in the axillary tail region of the breast
D.A 3-cm segmental area of linear branching calcifications in the upper inner quadrant at a
middle depth
36A 31-year-old pregnant patient is discovered during her first trimester to have a breast cancer. The
treatment for her breast malignancy is
A.None until after delivery
B.Immediate radiation therapy
C.Immediate chemotherapy
D.Immediate surgical resection
37Which one of the following pathology results would most likely be considered discordant with the
imaging findings of an irregular spiculated mass?
A.Postsurgical lumpectomy scar
B.Radial scar
C.Tubular carcinoma
D.Pseudoangiomatous stromal hyperplasia

ANSWERS AND EXPLANATIONS

1Answer D. The needle used in this case was a 5-cm rigid needle and J wire. The hook wire
needle system is more commonly used. Both needle systems would look similar during the
localization process. The difference between the two systems is with the hook wire system the
needle is removed, leaving only the wire in the patient for surgery. The advantage is the patient
does not have a needle in her breast as she awaits surgery. With the rigid needle and J wire
system, both the needle and the wire remain in the patient, the advantage being the wire and needle
are less likely to be accidentally pulled out of position within the target or completely pulled out
of the breast while the patient awaits surgery. In this case, A is the needle shaft, B is the biopsy
clip marker, C is the needle tip, and D is the wire tip. The needle is advanced completely through
the lesion, and the wire is then advanced through the needle to ensure that the surgeon completely
excises the entire lesion.

Reference: Berg WA, Birdwell RL, eds. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2008;V:2-20V:2-21.

2Answer D. Placing the patients arm and shoulder through the hole in the table exposes more of
the deeper breast tissues.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:966.

3Answer A. Care must be taken when performing ultrasound-guided breast biopsies on patients
with deep lesions, especially given their supine position, to avoid directing the needle into the
mediastinum or lung. Rolling the patient and approaching at an angle as well as lifting the lesion
off the chest wall reduce the risk. Aiming for the periphery does not ensure the needle would not
hit the chest wall and may actually increase sampling error. It is not enough to obtain the patients
informed consent for risk of pneumothorax; the approach must be adjusted to minimize risk of
pneumothorax. If biopsy cannot be performed safely with ultrasound guidance, stereotactic maybe
a viable option as the lesion can be held in place off the chest wall.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:942944.

4Answer C. Multiple studies have shown that unless the fluid aspirated is maroon or dark brown
suggesting old blood and therefore suspicious for an intracystic process such as a papilloma or
carcinoma, sending the fluid for cytologic analysis is of no benefit.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:948949.

5Answer B. Stereo images are obtained by angling the x-ray tube 15 degrees to one side
perpendicular to the film plane and then 15 degrees to the other side resulting in a 30-degree
difference between the two.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:960.

6Answer C. The dead space of the biopsy needle can be up to 1 cm; therefore, at least 1.5 cm
beyond the biopsy site should be anesthetized. During stereotactic biopsy, you can inject from the
deepest part of the breast next to the Bucky out to the skin.
Reference: Flowers CI. Breast biopsy: Anesthesia, bleeding prevention, representative sampling, and rad/path concordance. Appl
Radiol 2012;41:913.

7Answer A. Several studies confirm that breast biopsies are safe in patients on antiplatelet or
anticoagulation therapy but not in patients taking clopidogrel.
Reference: Flowers CI. Breast biopsy: Anesthesia, bleeding prevention, representative sampling, and rad/path concordance. Appl
Radiol 2012;41:913.

8Answer D. If the pathology report is negative, an x-ray in two planesAP and lateralof the
specimen blocks can be performed. It is important to give the pathologist specific details about
which block contains the calcifications and at what depth they are located. If calcium oxalate
crystals are present, they are best seen under polarized light.
Reference: Flowers CI. Breast biopsy: Anesthesia, bleeding prevention, representative sampling, and rad/path concordance. Appl
Radiol 2012;41:913.

9Answer B. Topical lidocaine is available as viscous lidocaine or as a eutectic mixture of local


anesthetics cream (EMLA) and can be applied 30 minutes prior to a subareolar mass procedure or
for a ductogram.
Reference: Flowers CI. Breast biopsy: Anesthesia, bleeding prevention, representative sampling, and rad/path concordance. Appl
Radiol 2012;41:913.

10Answer C. The distance of shift allows for calculation of the lesion depth with respect to the
center of rotation.
Reference: Carr JJ, Hemler PF, Halford PW. Stereotactic localization of breast lesions: How it works and methods to improve
accuracy. Radiographics 2001;21:463473.

11Answer E. In most patients with history of breast cancer, imaging demonstrates thoracic changes
resulting from treatment, complications of treatment, or tumor recurrence or metastasis. The
postsurgical imaging appearance of the chest wall depends on the surgical method used (radical
mastectomy, modified radical mastectomy, breast-conserving surgery, or breast reconstruction).
The most common surgery-related complication is seroma. Radiation therapy frequently causes
radiation pneumonitis, which occurs ~4 to 12 weeks after the completion of therapy, and is
characteristically limited to the field of irradiation. Chemotherapy-related complications include
cardiotoxicity, pneumonitis, and infection.
Reference: Jung JI, Kim HH, et al. Thoracic manifestations of breast cancer and its therapy. Radiographics 2004;24(5):12691285.

12Answer C. Change the x and y coordinates after retargeting the lesion. By adjusting the x and y
coordinates after retargeting a lesion that is too far away from the needle to be adequately
sampled, a second skin opening or incision can be avoided. This adjustment can be performed by
withdrawing the tip of the needle so that it remains through the skin.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:966.

13aAnswer D. Although fine linear calcifications are considered suspicious, the next appropriate step
is additional mammographic imaging with diagnostic workup.
Reference: Comstock CH, DOrsi C, Bassett LW, et al. Expert Panel on Womens Imaging-Breast. ACR Appropriateness
Criteria Breast MicrocalcificationsInitial Diagnostic Workup. Reston, VA: American College of Radiology (ACR); 2009:12.

13bAnswer A. Incomplete needs additional imaging. Further evaluation with diagnostic


mammography should be performed prior to biopsy.
Reference: Comstock CH, DOrsi C, Bassett LW, et al. Expert Panel on Womens Imaging-Breast. ACR Appropriateness
Criteria Breast MicrocalcificationsInitial Diagnostic Workup. Reston, VA: American College of Radiology (ACR); 2009:12.

13cAnswer D. Tissue sampling of the most anterior and most posterior extent of the calcifications
with stereotactic biopsy is the next appropriate step.
Reference: Comstock CH, DOrsi C, Bassett LW, et al. Expert Panel on Womens Imaging-Breast. ACR Appropriateness
Criteria Breast MicrocalcificationsInitial Diagnostic Workup. Reston, VA: American College of Radiology (ACR); 2009:12.

14Answer E. After breast-conserving surgery, radiation therapy helps to control the microscopic
disease, which has a comparable overall survival rate to mastectomy. Contraindications of whole
breast irradiation include pregnancy, previous radiation, multicentric or diffuse disease, collagen
vascular disease, and poor cosmetic outcome. Axillary lymphadenopathy is not a contraindication.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:233, box 83.

15Answer D. According to the published guidelines by the American College of Radiology and the
American College of Surgeons, among others, the following are absolute contraindications to
breast-conserving therapy: early pregnancy (first or second trimester) as radiation cannot be
administered during pregnancy; women with two or more primary tumors in different quadrants; or
women with diffuse malignant-appearing microcalcifications, prior irradiation to the same area of
the affected breast, and persistent positive margins after reasonable surgical attempts. Relative
contraindications include collagen vascular disease, large tumors in women with small breasts
where good cosmesis could not be obtained with lumpectomy, and women with very large
pendulous breasts for whom consistent, reproducible radiation fields would be hard to obtain. If
breast cancer is diagnosed in the third trimester of pregnancy, breast-conserving therapy can be
considered as radiation could commence after delivery.
Reference: ACR-ACS-CAP-SSO Practice Guideline for Breast Conservation Therapy in the Management of Invasive Breast
Carcinoma; 2006. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Invasive_Breast_Carcinoma.pdf

16Answer B. The most appropriate next step is recommendation for surgical biopsy. A critical part
of image-guided breast biopsy is the follow-up of pathology results to determine whether
pathology results are concordant with the imaging findings. The pathology results of benign,
fibrocystic changes with microcalcifications are discordant with the imaging findings of this
example. The morphology of these calcifications is linear and branching, which has a higher
probability of malignancy, such as a BI-RADS 4B or 4C classification. Fine linear or linear
branching calcifications are of higher suspicion for ductal carcinoma in situ (DCIS). The benign
core biopsy result of fibrocystic change would be considered discordant with the imaging
findings. Imaginghistologic discordance is an indication for surgical excision due to potential
percutaneous undersampling. Therefore, the next most appropriate step would be referral to a
surgeon for surgical biopsy of the calcifications. A more thorough sampling of the calcifications is
in order to evaluate for malignancy. Answer choices A and C are incorrect. A 12- or 6-month
follow-up mammogram is not appropriate for this case since the pathology results are discordant
with imaging findings and the calcifications were likely inadequately sampled. Answer choices D
and E are incorrect. A reattempt at stereotactic biopsy or breast MRI are not advised because they
are not effective uses of time or resources. Definitive surgical biopsy is indicated.
Reference: Liberman L, Drotman M, Morris EA, et al. Imaginghistologic discordance at percutaneous breast biopsy. Cancer
2000;89(12):25382546.

17Answer C. Placing two wires with the bracketing technique is helpful in cases such as this of a
larger extent of nonpalpable calcifications. This helps guide the surgeon most accurately without
any guess work needed as to the extent of the disease. This technique will not ensure clean
surgical margins, but it will give the surgeon the best guidance of all the options. Mastectomy will
likely not be needed for a 3-cm extent of disease, so automatically cancelling the procedure would
be inappropriate. Many factors do need to be considered when determining appropriateness for
breastconserving therapy, including the size of the patients breast, the patients overall health, and
the patients willingness to undergo radiation.
Reference: Liberman L, Kaplan J, Van Zee KJ, et al. Bracketing wires for preoperative breast needle localization. AJR Am J
Roentgenol 2001;177(3):565572.

18Answer D. Although 14-gauge spring loaded and 14-gauge vacuumassisted biopsy devices can be
used for stereotactic biopsy, they are not the most optimal or effective choice, especially when
microcalcifications are the target. The false-negative rate and upgrade rates at final pathology are
lower when larger core vacuum-assisted biopsy is used.
References: ACR Practice Guideline for the Performance of Stereotactically Guided Breast Interventional Procedures; 2009.
http://www.acr.org/~/media/62F6E5A180134DF6A014447BDEB 5384D.pdf
Jackman RJ, Burbank F, Parker SH, et al. Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ
underestimation rates. Radiology 2001;218:497502.
Jackman RJ, Marzoni FA, Rosenberg J. False-negative diagnoses at stereotactic vacuum-assisted needle breast biopsy: long-term
follow-up of 1,280 lesions and review of the literature. AJR Am J Roentgenol 2009;192(2):341351.

19Answer D. Single-duct spontaneous bloody, serous, or clear nipple discharge is the only
indication to perform galactography.
Reference: Shah BA, Fundaro GM, Mandava S. Breast Imaging Review: A Quick Guide to Essential Diagnoses. New York, NY:
Springer; 2010:231.

20Answer C. The orthogonal view (in our case the CC view since the needle was introduced from a
medial approach) permits positioning of the needle depth (z coordinate). The needle tip should be
1 to 1.5 cm beyond the lesion so that the lesion remains along the needle shaft. Answer choice A is
incorrect because the wire has not yet been placed and the depth has not yet been adjusted.
Answer choice B is incorrect because the x and y coordinates have been confirmed and the needle
tip is through the lesion. Once the relationship of the needle to the lesion has been confirmed (x
and y coordinates), there is no reason to ever return to the first projection. Answer choice D is
incorrect because the needle tip is 3-cm distal to the mass. The needle needs to be retracted at
least 1.5 cm with the tip 1.5 distal to the mass. Answer choice C is correct. The needle tip was
adjusted to the tip 1- to 1.5-cm distal to the mass, and the wire was subsequently placed (see
images A and B).

Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:924.

21Answer D. Answer choice A is incorrect because a specimen radiograph should be performed


while the patient is still on the table with the cavity open in the operating room. The specimen
radiograph helps confirm the targeted abnormality has been removed. Answer choice D is correct.
Magnification radiography is preferable as it improves visualization specifically for
calcifications. Answer choice C is incorrect. The radiologist looks at the lesion compared to the
visible margins and alerts the surgeon if the lesion appears close to or abutting the surgical
margin. However, this is not sufficient for determining surgical margins as final pathology is the
gold standard. Answer choice B is incorrect. Specimen radiographs are performed for masses and
calcifications. The radiologists should comment on whether the specimen contains the lesion,
whether the lesion is at, is away from or is transecting the specimen edge, and whether the wire
including tip and biopsy clip (if present) are included.
References: Ikeda DM. The Requisites Breast Imaging. St. Louis, MO: Elsevier Mosby; 2004.
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:927929.

22Answer A. Stroke margin is the distance between where the needle tip is expected to end after
firing and the distance to the far side of the breast (image receptor).
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:963.

23Answer C. Sentinel lymph node biopsy has replaced axillary dissection in patients with
preoperative negative axillas. This has decreased patient morbidity. If an abnormal axillary lymph
node is seen on ultrasound, it often preoperatively undergoes core needle biopsy or fine needle
aspiration. If the node is metastatic, the patient undergoes axillary dissection. If the node is benign,
the patient is scheduled for sentinel node biopsy at the time of surgery. A benign percutaneous
biopsy of an axillary lymph node does not clear the axilla, and sentinel lymph node biopsy still
needs to be performed at the time of surgery.
Reference: Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:956957.

24Answer D. Stereotactic breast biopsy is performed for calcifications or a mass/asymmetry that


does not have a sonographic correlate. For preprocedure planning purposes, the optimal biopsy
approach is that in which the finding is closest to the skin. For example, if the suspicious finding is
in the upper breast and is closest to the superior skin surface, then the optimal needle approach
would be from superior approach with craniocaudal compression using a fenestrated paddle.
Therefore, answer choice E is incorrect; the optimal stereotactic approach is not always lateral,
but rather the approach where the finding can be reached by traversing the least distance of breast
tissue. The scout image confirms that the finding is present within the fenestrated portion of the
compression paddle. The stereotactic pair images are then performed at +15 degrees and 15
degrees, which the computer then uses to calculate the depth (z distance) of the finding based on
the parallax phenomenon. In addition to calculated depth of the lesion, the computer will also
inform the operator of the stroke margin. The stroke margin is the calculated distance between the
needle tip and the detector once the needle has been fired. Answer choice A is incorrect. A
positive (rather than a negative) stroke margin is desirable to perform the procedure. A positive
stroke margin indicates that there will be enough breast tissue to accommodate the needle without
traversing the entirety of the breast or damaging the detector. A compression thickness under 3 cm
may not have enough breast tissue to safely accommodate the biopsy needle. A radiograph of the
core specimens is performed following stereotactic biopsy to determine whether the suspicious
finding has been adequately sampled. This is most commonly used for calcifications. However, it
can also be used to a mass or asymmetry where pieces of focal density may be seen in the
specimens. Answer choice D therefore is correct. If the finding has not been sampled adequately,
biopsy sampling can continue focused to the residual finding. If the finding has been adequately
sampled, then a radioopaque biopsy marker is placed. An image is taken to ensure the clip
deployed, and the needle is removed with compression held to ensure hemostasis. Answer choice
B is incorrect. A postprocedure mammogram is indicated to check for residual suspicious finding
and the position of the biopsy marker, which can occasionally move away from biopsy site when
the patient is removed from compression. Answer choice C is incorrect. Infection is a rare
complication of stereotactic breast biopsy.
Reference: Cardenosa G. Breast Imaging Companion. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:533536.

25Answer A. The pathology and imaging findings are not concordant, and therefore a 6-month
ultrasound follow-up is not an appropriate recommendation. Breast MRI or breast-specific gamma
imaging (BSGI) is not indicated at this time. Regardless of the MRI or BSGI findings, a surgical
excisional biopsy is required to definitely diagnose this mass. If the mass is a cancer, breast MRI
or BSGI could be used for treatment planning.
Reference: Geller BM, Ichikawa LE, Buist DS, et al.; Breast Cancer Surveillance Consortium. Improving the concordance of
mammography assessment and management recommendations. Radiology 2006;241:6775.

26Answer B. Relative contraindications to radiation therapy include previous radiation therapy,


pregnancy, collagen vascular disease, and multicentric or diffuse disease. Axillary adenopathy is
not a contraindication. Whole-breast irradiation achieves control of residual microscopic disease.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:231233.

27Answer A.
References: Brem RF, Schoonjans JM. Local anesthesia in stereotactic, vacuum-assisted breast biopsy. Breast J 2001;7:7273.
Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:164.

28aAnswer A. Ductography is a procedure that can help to identify the cause of unilateral, single-
pore, spontaneous nipple discharge. If an abnormality is identified, it can be targeted for surgical
biopsy. Answer choice B is incorrect. Ductography is not used to biopsy an intraductal mass.
Rather, ductography can be used to identify and localize a potential intraductal mass that may be
causing discharge. Suspicious single-pore discharge for which ductogram is indicated includes
bloody, clear/serous, or serosan-guineous discharge. These are the discharge colors that have
been associated with breast cancer. White- and green-colored discharge is of benign etiology,
such as physiologic or fibrocystic in nature. Therefore, answer choice C is incorrect. In order to
begin the ductogram, the single-discharging pore is identified. If the discharging pore cannot be
reidentified, the procedure cannot proceed. If the discharging duct is identified, a small gauge
cannula tip (usually 30-gauge) is placed on the discharging duct with gentle pressure. When the
cannula is in the duct, a minimal amount of contrast material is administered (0.2 to 0.3 mL). Take
care to ensure that no air bubbles are present prior to injection. Therefore, answer choice D is
incorrect. A dose of 5 mL is too much contrast and could cause extravasation from the duct and
patient discomfort. Once the contrast is injected, the cannula is stabilized and postprocedure and
magnification craniocaudal and mediolateral mammograms of the retroareolar breast are obtained.
28bAnswer D. The patient should be referred back to a breast surgeon. In these images, an intraductal
filling defect/mass is identified at the 6:00 position retroareolar. Primary differential diagnosis is
papilloma or DCIS. Localizing this mass for a surgical breast biopsy will increase the probability
of removing the etiology of the discharge rather than a blind surgical duct excision. The intraductal
mass can be localized for subsequent surgical biopsy, either with a biopsy marker at the time of
diagnostic ductogram or with a repeat ductogram/wire localization on the day of surgical biopsy.
Answer choice A is incorrect. Stereotactic breast biopsy is not indicated in this instance. The
standard mammogram is most likely negative, which will make the intraductal mass difficult to
localize for stereotactic biopsy. Also, a percutaneous biopsy may not remove the entirety of the
mass. Chances are high that this mass represents a papilloma or breast cancer, both of which
would be referred to surgical excision following core biopsy. Therefore, direct referral to
surgical biopsy is better for the patient. Answer choice B is not indicated. An intraductal mass that
is likely contributing to the patients symptoms has already been identified. Breast MRI is not
needed to further characterize the finding. Finally, answer choice C is incorrect. A repeat
ductogram is not necessary. The filling defect in the duct in the provided images does not appear
to be artifactual due to an air bubble. Artifact due to potential air bubbles tend to be round with
contrast surrounding them and passing them.
Reference: Slawson SH, Johnson BA. Ductography: How to and what if? Radiographics 2001;21:133150.

29Answer C. Radiologypathology correlation should always be performed on all lesions to


establish concordance. Surgical excision is always done for atypical ductal hyperplasia (ADH).
Atypical lobular hyperplasia (ALH) is a high-risk marker for breast cancer, and controversy
remains over whether to excise. Complications after core biopsy include hematoma, infection,
pneumothorax, and pseudoaneurysm. Markers can migrate significantly sometimes even to other
quadrants in the breast.
References: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:183186.
Irfan K, Brem R. Surgical and mammographic follow up of papillary lesions and atypical lobular hyperplasia diagnosed with
sterotactic vacuum-assisted biopsy. Breast J 2002;8:230233.
30Answer B. 0.2 to 0.3 mL is injected. Rarely does the total contrast volume exceed 1 mL.
Reference: Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic Imaging Breast. 1st ed. Salt Lake City, UT: Amirsys;
2006:Section V2, 45.

31Answer A. The difference between atypical ductal hyperplasia (ADH) and ductal carcinoma is
often determined by the number of ducts involved. Therefore, a larger sample may result in the
diagnosis of DCIS when the core biopsy was ADH.
Reference: Kopans D. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:200.

32Answer A. Nephrogenic systemic fibrosis (NSF) is a rare but serious systemic disease
characterized by fibrosis of the skin and other tissues throughout the body. The first report on NSF
was published in 1997, and there is increasing evidence that this condition is associated with
renal failure and the administration of large amounts of gadolinium.
The Food and Drug Administration (FDA) has determined that the risk for patients with chronic
insufficiency is greatest when the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73
m 2. However, a discussion of the patients risk-benefit ratio with the referring physicians is
necessary to determine if the examination is essential. If intravenous gadolinium-based contrast
administration is needed, it is recommended that one use the lowest possible dose to obtain a
diagnostic study.
Answer choice B is incorrect because without the use of intravenous gadolinium-based
contrast, the breast MRI examination is not a diagnostic study for detection of breast cancer.
Answer choice C is incorrect because the patient has impaired renal function and therefore
giving a standard dose of gadolinium-based contrast would be inappropriate.
Answer choice D is incorrect because the GFR measurement is not an absolute
contraindication. While administration of intravenous gadolinium- based contrast is not
recommended, the study can be performed in instances when the benefits of the study outweigh the
risk of developing NSF.
References: American College of Radiology (ACR). Nephrogenic Systemic Fibrosis. ACR Manual on Contrast Media. Reston,
VA: America College of Radiology; 2010: chap 11, 53.
Juluru K, Vogul-Claussen J, Macura KJ, et al. MR imaging in patients at risk for developing nephrogenic systemic fibrosis: Protocols,
practices, and imaging techniques to maximize patient safety. Radiographics 2009;29:922.
www.kidney.org/professionals/tools/pdf/nsf_risk_red.pdf

33Answer C. The fetal dose from a screening mammogram is negligible at <50 mGy; 3 mGy (0.3
rad) is the FDA/MQSA regulatory limit for average glandular dose per mammogram exposure.
The risk of organ malformations (3rd to 8th weeks of gestation) has a threshold of 100 mGy. The
risk for severe mental retardation (8 to 15 weeks of gestation) has a threshold of 100 mGy.
References: http://www.radmd.org/resources/Resident-Resources/BWH-Fetal-Doses.pdf http://www.radiationanswers.org/radiation-
questions-answers/radiation-and-pregnancy.html Federal Register/Vol. 62, No. 208/Tuesday, October 28, 1997/Rules and
Regulations Quality Mammography Standards, Final Rule; 21 CFR (900.12)(e)(5)(vi)

34Answer C. Patient safety and comfort are paramount after every breast interventional procedure.
Part of patient recovery, especially after a breast biopsy, is pain control. If a patient does not have
an allergy to acetaminophen and has no liver problems, the first step in management of the
patients breast pain is to have the patient take acetaminophen initially and then every 6 hours as
needed, up to 4 g/d.
Answer choices A and B are incorrect because they are not the initial management of breast
pain. Tylenol 3 and Vicodin may be prescribed, but rarely is such stronger medication used.
Answer choice D is incorrect because aspirin or nonsteroidal anti-inflammatory drugs
(NSAIDS) withheld 7 days before biopsy should be avoided 3 days after biopsy to decrease risk
of bleeding.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:226229.

35Answer C. There are two basic designs of stereotactic breast biopsy units: the dedicated prone
table and upright add-on unit. Both units have advantages and disadvantages. When using a prone
table, the ability to visualize very posterior lesions and lesions located deep in the axillary tail
may be challenging or result in an unsuccessful biopsy or cancellation of the procedure. When
using the add-on stereotactic biopsy unit, patients with lesions located deep in the axillary tail of
the breast will likely require special positioning such as slight rolling of the breast forward from
the lateral decubitus position, which can help bring the lesion in the field of view and maintain its
position during biopsy.
References: Cousins JF, Wayland AD, de Paredes ES. Stereotactic breast biopsy units: Pros and cons. Appl Radiol 1998;27(9):8
14.
Reynolds A. Stereotactic breast biopsy: A review. Radiol Technol 2009;80(5):447M462M.

36Answer D. Surgical procedures such as breast conservation surgery, mastectomy, and axillary
lymph node sampling can be performed when the patient is pregnant. Radiation to the breast or
chest wall is postponed until after delivery. Chemotherapy is not given in the first trimester
because there is a significant risk of spontaneous abortion.
Reference: Hahn K, Johnson PH, Gordon N, et al. Treatment of pregnant breast cancer patients and outcomes of children exposed
to chemotherapy in utero. Cancer 2006;107(6):12191226.

37Answer D. The most common mammographic and sonographic imaging appearance for
pseudoangiomatous stromal hyperplasia (PASH) is a circumscribed mass that resembles a
fibroadenoma. Postsurgical scar, radial scar, and tubular carcinoma commonly present as an
irregular mass. Therefore, an irregular spiculated mass is most likely discordant with pathology
results of PASH.
References: Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of Diseases of the Breast. 2nd ed. Philadelphia, PA: Elsevier
Saunders; 2005:438439.
Goel NB, Knight TE, Pandey S, et. al. Fibrous lesions of the breast: Imaging-pathologic correlation. Radiographics. 2005;25:1547
1559.
5 Physics Related to Breast Imaging

QUESTIONS

1What is the primary purpose of using mammography grids?


A.Increase contrast
B.Decrease production of scatter
C.Decrease dose
D.Increase image sharpness
E.Decrease motion
2Adequate breast compression results in which of the following?
A.Increase in radiation dose
B.Magnification
C.Decrease in scatter radiation
D.Increase in dynamic range
3Which of the following is usually taken in consideration in the design of the mammography reading
room?
A.Monitors at a given station should be placed on the arc of a circle so that the viewer can
minimize head movement.
B.Walls should be a light gray to maintain the background light at a comfortable level for
viewing and for walking safely within the room.
C.Monitors for all the work stations should be along one wall only with all the viewing
surfaces in a line to avoid reflected light.
D.A mammography view box, placed in a room for viewing film from prior examinations,
should have one of its lights left on to provide illumination for moving about the room.
4Which target/filter combination is likely the most penetrating?
A.Mo/Mo
B.Mo/Rh
C.Rh/Rh
D.W/Ag
5For mammography, which of the following statements concerning scatter radiation is correct?
A.Though breast compression has many benefits, it increases the effect of scatter which is why
a grid is used in contact mammography.
B.One of the disadvantages of the low tube potentials used for mammography is that the
increased number of photons required for an exposure leads to higher scatter.
C.Because of breast compression, scatter is not an issue in mammography.
D.Scatter is enhanced during magnification mammography, which necessitates a grid for this
special examination.
E.Both breast compression and the use of a grid contribute to the reduction of scatter to the
image detector.
6Which of the following is usually involved in mammographic displays?
A.The higher the perceived brightness (luminance) of the display, the better since a brighter
display overcomes the effects of ambient light.
B.The higher the contrast ratio (luminance ratio), that is bright to dark ratio presented by the
display, the better since this allows us to perceive even small differences in tissue density.
C.A digital display should, at a minimum, have a luminance ratio corresponding to film density
ranges on a standard view box. On the other hand, if the contrast ratio is too high, it will
exceed the capabilities of the human vision system.
D.In the presentation of contrast between closely matching tissue, the best a modern liquid
crystal display (LCD) can do is mimic top quality mammography film.
7Which of the following is usually involved with contrast threshold, the fractional change in
luminance required to be perceivable?
A.The contrast threshold is highest when the screen is dim, dropping as the screen gets brighter
but changing very little for luminance values above 100 cd/m2.
B.The contrast threshold is lowest when the viewing surface is bright (e.g., the brightness of an
uncovered mammography view box).
C.The contrast threshold is almost constant throughout the brightness range perceivable by the
human vision system.
D.The contrast threshold is highest for dim screens and decreases linearly throughout the range
of brightness perceivable by the human visual system.
8For a fixed mAs, the x-ray tube potential increases from 25 to 29 kVp, an increase of 16%. The
measured increase in entrance exposure is 60%. Which of the following accurately describes the
mean glandular dose (MGD)?
A.The MGD increases by 16%.
B.The MGD decreases because of the higher kVp.
C.The MGD increases by 60%.
D.The MGD increases by more than 60% because of the increased penetration at higher kV.
E.The MGD increases by <60% because of the increased penetration at higher kV.
9Which material is least likely to be used in a mammography x-ray detector?
A.Csl
B.Nal
C.BaFBr
D.Se
10The soft tissue thickness (cm) that attenuates half the x-ray beam is likely:
A.0.5
B.1
C.2
D.3
11Which voltage (kV) would likely be used to image a dense 7-cm breast?
A.20
B.25
C.32
D.40
12Which value is least likely in a magnification mammogram?
A.Focus 0.1 mm
B.Voltage 28 kV
C.Current 100 mA
D.Exposure 3 seconds
13For a fixed mAs and at a constant kVp, a significant increase in exposure time will cause:
A.A significant increase in radiation exposure to the breast
B.A significant change in the level required for proper viewing if the window is the same as
for the first exposure
C.An increase in blur due to motion
D.An increased likelihood of damage to the detector
E.An increased heat load on the x-ray tube
14Microcalcifications that can readily be seen on a mammogram would likely not be visible at all on
a chest radiograph. The most important reason for this is:
A.The large region of coverage of the chest radiograph
B.The obfuscation of the microcalcifications by the spine
C.The large drop in the attenuation coefficient of calcium for the chest radiograph
D.The large drop in the attenuation coefficient of soft tissue for the chest radiograph
E.The large increase in exposure time required for the chest radiograph
15A grid is not used in magnification mammography. This is primarily because:
A.Grids are not used at all in mammography
B.The grid would be visible in the image due to the use of the small focal spot
C.The grid would be visible in the image due to the increase in contrast occurring in
magnification mammography
D.Adding a grid would increase the dose without significantly reducing scatter
E.Without the pressure of the compressed breast on the detector, the moving grid would vibrate
too freely
16In magnification mammography, the small focal spot is almost always used, whereas for contact
mammography and for the same patient, the large focal spot is the norm. Why?
A.We can tolerate the longer exposure time required for the small focal spot because
magnification reduces the effect of motion.
B.The reduction in exposure rate tolerated by the small focal spot is compensated by removal
of the grid.
C.In magnification, a smaller region of the breast is imaged and therefore not as much radiation
is required.
D.Compression is not used for magnification and thus less radiation is needed to capture the
magnified region of interest.
E.Because the image is magnified, a higher level of noise is acceptable, and thus, the smaller
focal spot can still deliver enough radiation in a short enough period of time (even though the
radiation rate is reduced).
17The tube voltage is generally set higher for thicker breasts. The primary reason for doing so is:
A.To reduce exposure time, thereby decreasing motion artifacts
B.To reduce radiation dose by increasing the penetration
C.To improve tissue contrast
D.To improve the spatial resolution of the image
E.To reduce the scatter by increasing the amount of energy per photon
18The compressed breast is estimated to almost 5-cm thickness. The mean glandular dose (MGD)
for a cranio-caudal view is lowest for which type of mammography system?
A.Film-screen
B.Computed radiography
C.Direct digital radiography
D.Xeroradiography.
19When compared to routine screening mammography, magnification views have which of the
following?
A.Less contrast
B.Less motion blur and less scatter
C.Longer exposure time
D.More scatter and less motion blur
E.More noise
F.Longer source-to-object distance
20Breast compression increases which of the following?
A.Scatter
B.Breast thickness
C.Noise
D.Image contrast
21The mammography operators are required to be monitored for radiation exposure by state
regulations. A female technologist declares she is pregnant. What is the applicable occupational
dose limit?
A.Same as a nonpregnant x-ray technologist
B.100 millirems to the fetus
C.500 millirems to the fetus
D.5,000 millirems per year
22Thyroid shielding during mammography should be used:
A.Always
B.Only for women of reproductive capacity
C.Only upon request
D.Never
23Which x-ray target and filter combination is best to image a thicker (7 cm), dense breast?
A.Molybdenum target/molybdenum filter
B.Molybdenum target/rhodium filter
C.Rhodium target/rhodium filter
D.Tungsten target/rhodium filter
24Which of the following is an advantage of screen-film mammography over digital mammography?
A.Improved throughput
B.Improved latitude
C.Higher spatial resolution
D.Decreased dose for comparable image quality
E.Image processing and digital archival
25For a 4-cm breast with a composition ratio of 50% glandular to 50% adipose, the magnitude of
dose reduction achievable for comparable image quality in the transition from screen/film to
digital mammography is approximately:
A.10%
B.20%
C.40%
D.60%
E.80%
26In digital mammography, the approximate mean glandular dose (MGD) for a 5-cm thick average
density breast imaged using automatic exposure control with a W/Rh target/filter combination
would be closest to:
A.100 millirads
B.100 millisieverts
C.2 milligray
D.300 millirads
27The technique factor that has the strongest impact on digital mammography image quality is:
A.Target/filter combination
B.Focal spot size
C.mAs
D.Field size
E.kVp
28In a digital mammography image, electronic magnification:
A.Results in reduced image noise
B.Leaves the spatial resolution unchanged
C.Lowers the needed radiation dose
D.Is the same as geometric magnification
29What grid ratio range is used for full-field digital mammography (FFDM)?
A.9:1 to 8:1
B.8:1 to 7:1
C.7:1 to 6:1
D.3:1 to 6:1
E.3:1 to 5:1
30What focal spot size is used for a standard mammogram (CC and MLO)?
A.0.1 mm
B.0.2 mm
C.0.3 mm
D.0.4 mm
E.0.5 mm
31What is the recommended source to image distance (SID) for mammography?
A.10 to 50 cm
B.20 to 50 cm
C.30 to 60 cm
D.40 to 50 cm
E.50 to 80 cm
32What focal spot size is used for magnification imaging in mammography?
A.0.1 mm
B.0.2 mm
C.0.3 mm
D.0.4 mm
E.0.5 mm
33What is the reason interpretation of digital mammography images should be done on a 5 megapixel
monitor?
A.Ghost image factor
B.Improved resolution
C.Improved contrast
D.Uniformity rule
E.Phosphor light transmission
34MQSA requirement for collimation test states that the x-ray field may not extend beyond any edge
of the image receptor by more than what percentage of the source-to-image (SID)?
A.0.5%
B.1.5%
C.2.0%
D.3.5%
E.4.0%
35What instrument is recommended by the ACR to determine focal spot size?
A.Phototimer
B.Densitometer
C.SMPTE pattern
D.Slit camera
E.Star-shaped camera
36What is the mammography phantom used for in digital imaging?
A.Daily testing of the AEC
B.Weekly testing the anode
C.Daily checking of the focal spot
D.Weekly testing of system resolution
E.Monthly checking image contrast
37The mammography tube has a window that consists of:
A.Beryllium
B.Molybdenum
C.Tungsten
D.Rhodium
E.Pyrex glass
38In mammography, the cathode side of the tube should be placed by the:
A.Nipple
B.Chest wall
C.Lateral aspect of breast
D.Medial aspect of breast
E.Adipose tissue
39What is the size of the large focal spot used for standard mammography?
A.0.1 mm
B.0.3 mm
C.0.7 mm
D.1.0 mm
40Why does mammography utilize a lower peak kilovoltage than conventional radiography?
A.To improve soft-tissue contrast
B.To reduce the mean glandular dose received by the patient
C.To decrease exposure time
D.To improve scatter rejection
41Which of the following is correct regarding the use of compression in mammography?
A.Increases image contrast and increased scatter radiation
B.Reduces breast thickness and requires a higher radiation dose
C.Reduces scatter radiation and decreases image contrast
D.Requires less kVp values and decreases motion blur
E.Spreads breast tissue to reduce superimposition and increase structural mottle
42Below is a mammographic view taken at 28 kVp, 42 mAs, 3.1-cm thickness. Altering the
parameters to 26 kVp, 110 mAs, and 3.1-cm thickness leads to which one of the following
changes?

A.Shorter exposure time


B.Increased spatial resolution
C.Decreased glandular dose
D.Increased contrast
E.Decrease density

ANSWERS AND EXPLANATIONS

1Answer A.Grids are used routinely in mammography to increase image contrast. Most
mammography systems have a moving grid with a ratio of 4:1 to 5:1 focused to the source to
image distance. Grids do not compromise spatial resolution, but they do increase patient dose.
However, the dose is still acceptably low, and the improvement in contrast is significant.
Reference: Bushong SC. Radiologic Science for Technologists: Physics and Protection. 10th ed. St. Louis, MO: Elsevier Mosby;
2013:381.

2Answer C.Breast compression results in decreased tissue thickness. The scatter to primary
ratio for a compressed breast is 0.4 to 0.5, whereas the scatter to primary ratio for a
noncompressed breast is 0.8 to 1.0. Reducing tissue thickness allows for use of lower mAs, which
results in decreased radiation dose. Compression results in reduced exposure dynamic range
because tissue is spread out creating a more uniform thickness. Magnification can be produced
with an air gap.
Reference: Bushberg JT, Seibert JA, Leidholt EM, et al. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2001:207.

3Answer C.A very good, short white paper on mammography reading room design is Albert
Xthona, Designing the Perfect Reading Room for Digital Mammography, Barco White Paper,
2003 and is available online at this link:
http://www.barco.com/barcoview/downloads/The_perfect_mammography_reading_room_2011_-
_White_paper.pdf. This is the primary resource for this question. The paper shows a long narrow
room with all workstations along one wall, emphasizing the need to reduce light falling from one
monitor to another. Thus, all the workstations are in a straight line.
A.Though workstations are sometimes placed angled slightly toward each other; this greatly
increases the background lighting at each monitor and substantially decreases the image
contrast.
B.Walls should be dark colored to reduce the ambient light. Light for walking safely should be
very near the ground, with low-level lamps placed below the desks and pointing toward the
floor.
D.Mammography view boxes are sometimes used as a source of light for writing or moving
about the room. This is not a good idea, and the reference shows how to better accommodate
these needs.
4Answer D.This covers the range of target/filter combinations used in digital mammography, and
the tungsten target + silver filter (k edge energy of 25 keV) will have the highest energy and
greatest penetrating power.
Reference: Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:5152.

5Answer E.Moving grids (Bushong, p. 200ff) are used in contact mammography (but not in
magnification mammography) solely for the reduction of scatter to the image receptor. Note that
the Mammography Quality Safety Act (MQSA) requires [900.12(b)(4)] that
1 (ii) Systems using screen-film image receptors shall be equipped with moving grids matched
to all image receptor sizes provided.
2 (iii) Systems used for magnification procedures shall be capable of operation with the grid
removed from between the source and image receptor.
Grids are generally used for the same reasons for machines with digital receptors as well.
Breast compression has many benefits including the reduction of scatter (Bushong, p. 380).
Answer choice A is wrong because compression results in thinner tissue and therefore less
scatter radiation (Bushong, p. 380). Scatter is higher at higher kV (Bushong, pp. 187, 188) and
so answer choice B is wrong. Answer choice C is a little tricky. Breast compression reduces the
scatter and thus the benefit of scatter reduction using a grid, but, in that, the use of grids during
(contact) mammography is routine (Bushong, p. 381), the grid still provides enough benefit to
warrant its use and so answer choice C is wrong. This subject is explored further in Gennaro et al.
for magnification mammography; however, the air gap sufficiently reduces the effects of scatter so
that the grid is not used (Bushberg et al., p. 210) and so answer choice D is incorrect.
References: Bushong SC. Radiologic Science for Technologists. 10th ed. St. Louis, MO: Elsevier; 2013.
Bushberg JT, Seibert JA, Leidholdt EM, et al. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2001.
Gennaro G, Katz L, Souchay H, et al. Grid removal and impact on population dose in full-field digital mammography. Med Phys
2007;34(2):547555.
MQSA: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand
Program/Regulations/ucm110906.htm

6Answer C.Many of the points in the discussion below are taken from an excellent tutorial on
mammographic displays by Ehsan Samei.
Many of the quantitative terms (and there are many) used in optics have evolved over centuries
of use and have a quaint, even charming, but often confusing feel to them. Luminance and
illuminance are two of these terms. While both now have official SI definitions, they still bear a
relationship to their everyday English meanings. Luminance is the perceived brightness of a
display and can apply to both view boxes and the monitors used for digital display. (Illuminance
describes the outside light falling on the display and while illuminance is good when reading a
book, it degrades the images from monitors used for mammographic displays by reducing the
perceived contrast.) Now on to the question.
The answer choice A is wrong because there is a limit to the brightness range comfortable (and
at extremes, safe) for the human vision system. (That is why we have sunglasses, for example.)
Answer choice B is somewhat better but again, as we go too high in the contrast ratio displayed,
we again reach the limits of the adaption capabilities of the human visual system. We also run into
problems due to the contrast reduction processes of veiling glare and reflection. The answer
choice D is incorrect because even the best mammographic film cannot compete with the dynamic
range in contrast of modern digital displays. (Film still beats digital displays in resolution,
however. That is it can see tiny objects of high contrast better than digital displays.)
Answer choice C is correct. Modern digital displays can easily, as previously stated, exceed
the contrast display capabilities of film so a good minimum contrast ratio is that of film on a
standard view box. However, it should not be too high for the reasons given above in discussing
answer choice B.
Reference: Samei E. Technological and psychophysical considerations for digital mammographic displays. Radiographics
2005;25:491501.

7Answer A.Imagine looking at a display with a uniform background of brightness L. The display
is divided into two sections but initially both are matched in brightness so that they appear as one.
Now imagine that one side (e.g., the left side) is very slowly made brighter while you are viewing
the display. At some point you perceive that there are two sections with the left half just barely
brighter than the right half. This difference in brightness L is just noticeable and so it is called
the just noticeable difference (JND). Dividing the JND by the luminance itself is called the
contrast threshold. In other words, the contrast threshold is the fractional change in luminance
L/L required to be just noticeable. If the contrast threshold was a constant, independent of the
luminance value, then Weber law would strictly hold for visual contrast perception. It is not true
but does provide us with a good starting point. (Weber law is a rough approximation which can be
applied to a number of sensory modalities, e.g., sound loudness perception.)
The plot of the gray-scale standard display function taken from the DICOM 14 document
(http://medical.nema.org/dicom/2004/04_14pu.pdf) shows that for dimly luminated displays, a
larger contrast is required to be perceptible than for brighter displays and so Weber law does not
hold. For brighter screens (above 100 cd/m2), the curve flattens out to the right edge of the
displayed range and beyond. (A bright mammography viewing box is 3,000 cd/m2) This is the
situation described in the correct answer choice A.
References: Samei E. Technological and psychophysical considerations for digital mammographic displays. Radiographics
2005;25:491501.

8Answer D.Note that mean glandular dose (MGD) is the average dose throughout the breast. The
dose at the beam entrance surface of the breast would be the highest. As the beam passes through
the breast, it is attenuated and so the dose decreases as it passes through the breast. Thus, the
average dose is lower than the dose near the beam entrance.
The problem states that the entrance exposure has increased by 60% with a 16% increase in
kVp. In addition, the penetrability (range of x-rays in tissue) goes up with kVp (Bushong, p. 140).
(This is equivalent to saying that the x-ray attenuation is less at higher kVp.) What effect does this
have? It means that as the radiation passes through the tissue, it does not get reduced as much as it
would at lower kVp. Thus, the mean (average) dose to the tissue is higher than it would have been
had the penetrability remained constant. Thus, the dose increases by more than 60%.
It is important to note that according to the problem, the mAs has been held constant. Normally,
if one chooses to increase the kVp, the system would automatically reduce the mAs.
Reference: Bushong SC. Radiologic Science for Technologists. 10th ed. St. Louis, MO: Elsevier; 2013.

9Answer B.CsI (indirect) is used by GE; Se (direct) is used by Hologics. BaFBr is used by FUJI
(photostimulable phosphor). NaI is used in gamma cameras, not mammography.
Reference: Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:53.

10Answer B.In conventional radiography (80 kV), about 2.5 to 3 cm of soft tissue attenuates half
the x-ray beam; in mammography, about 1 cm of soft tissue will reduce the primary x-ray beam
intensity to one half of its initial value.
Reference: Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:54.

11Answer C.Currently, in digital mammography, the typical x-ray tube voltage is 30 to 32 kV, with
the higher value used in thicker breasts. Twenty-five kV would be far too low, and 40 kV would
be far too high.
Reference: Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:54.

12Answer C.Tube currents are 100 mA for the large (0.3-mm focal spot) and only 25 mA for the
small focal spot (0.1 mm); as a result, to get a given mAs in magnification mammography, the
exposure time must be increased (threefold) to get the correct exposure at the image receptor.
Reference: Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:54.

13Answer C.mAs is an abbreviation for milliampere second, the units of measure of x-ray tube
current and exposure time (Bushong, p. 593). Thus, at fixed mAs, if the exposure time goes up, the
tube current must go down. At constant kVp, the dose to the breast is proportional to the mAs,
which has not changed. (It has just been delivered to the breast over a longer period of time but at
a lower rate.) Thus, answer choice A is incorrect. There would also be no difference in the total
amount of radiation impinging on the detector and so the viewing requirements should not change.
Thus, answer choice B is also incorrect. Answer choice C is the correct answer since motion blur
increases with exposure time (Bushong, pp. 181, 182). A fixed mAs means that for a longer
exposure time, the tube current is reduced. Thus, answer choices D and E are both wrong. If
anything, since the tube current and radiation rate have both been reduced, the exposure is gentler
on both the tube and the detector.
Reference: Bushong SC. Radiologic Science for Technologists. 10th ed. St. Louis, MO: Elsevier; 2013.

14Answer C.Calcium (Ca) has an atomic number of 20, whereas soft tissue has an effective
atomic number of about 7.4 to 7.6. Though the attenuation coefficient drops with increasing keV
for both calcifications (answer choice C) and normal breast tissue (answer choice D), the
photoelectric effect for calcium is affected far more, and so the contrast between
microcalcifications and normal breast tissue drops substantially as the photon energy increases
(see Wolbarst, Fig. 33.3). Thus, the correct answer is C. Answer choice A is incorrect even
though the large region of coverage for the chest radiograph might imply a decrease in resolution.
Even with high resolution, we still would probably not see calcium in a chest x-ray because of the
high kV. Answer choice B might be true except that the spine would generally not obfuscate the
breasts in a chest radiograph and so this answer is easily eliminated. The range of exposure times
can substantially overlap for mammograms and chest x-rays. Quite often, the exposure time will
be shorter for a chest x-ray than for a mammogram and thus choice E is incorrect.
Reference: Wolbarst A. Physics of Radiology. 2nd ed. Madison, WI: Medical Physics Publishing Corp.; 2000:355356.

15Answer D.Because of the air gap in magnification mammography, much of the scatter from the
breast does not reach the detector. Thus, there is little scatter reduction that can be accomplished
by using a grid. Yet the grid, if present, would still attenuate a significant fraction of the primary
beam, requiring an increase in breast dose for the same exposure to the detector. Thus, in
magnification mammography, the grid is left out since it does little good and requires more dose to
the breast. (None of this is unique to mammography.) Grids are used in contact (nonmagnification)
mammography and so answer choice A is wrong. If the grids were present, it would be moving
just as it does in contact mammography and so would be just as invisible as it would be in contact
mammography. Thus, answer choice B is wrong. The contrast really should not be affected by
magnification and so answer choice C is wrong. Answer choice E is more or less hogwash.
Reference: Bushberg JT, Seibert JA, Leidholdt EM, et al. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2001:207212.

16Answer B.Consider the geometry used for magnification mammography compared to imaging
with the breast in contact with the detector. Start with the contact mammography depicted in
Figure 5.1. The breast is compressed and in close contact with the detector. X-rays must penetrate
through the compressed breast. As they pass through the breast, a fraction is absorbed (resulting in
radiation dose to the breast.) After a sufficient amount of time, the detector receives enough
radiation for an image and the automatic exposure control (AEC) turns the radiation off.
Now for the magnification mammography shown in Figure 5.2, note that the breast is still
compressed (eliminating answer choice D) and the x-rays must still penetrate the same thickness
of breast tissue. The same area of the detector is irradiated, and thus, the total amount of radiation
received by the detector to make an image has not changed. However, the air gap in Figure 5.2
substantially reduces the amount of scatter reaching the detector while allowing all of the primary
radiation to reach the detector. However, in Figure 5.1, a great deal of scatter is generated near the
detector. For the geometry of Figure 5.1, this scatter would reach the detector and degrade the
image and so here, a grid is used. Unfortunately, this grid also reduces the primary radiation; to
make up for this, more radiation is required and thus a large focal spot is used so that this larger
amount can be delivered in a comparable period of time. Thus, answer choice B is the correct
answer. Answer choice A is wrong. Magnification enhances the effect of motion, not reduces it.
The geometry shows that answer choice C is wrong because the density of radiation reaching the
detector is what matters for making images. (If this is puzzling, think of film. The radiation density
reaching the film must be the same in both cases to cause the same amount of exposure. Similar
considerations apply to digital detectors.) The image of the magnified portion of the breast in
Figure 5.2 will be about the same size as the image of the whole breast in Figure 5.1 and so the
total radiation required by the detector should be about the same for both configurations. Finally,
answer choice E is wrong because the overall image quality needs to be the same for both
situations. (Thought question? What are the implications for radiation dose to the breast for both 1
and 2? What are the implications for total amount of radiation absorbed by the breast for both 1
and 2?)
Reference: Bushberg JT, Seibert JA, Leidholdt EM, et al. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2001:207212.

17Answer A.First consider answer choices C, D, and E. Answer choice C is wrong because
tissue contrast decreases with increased kV (Wolbarst, Fig. 33.3, p. 356). In considering answer
choice D, the spatial resolution can actually improve some at moderate and higher kV because at
low kV, a phenomenon called blooming can become significant (Wolbarst, p. 290). This occurs
because at lower kV, the electrons traveling from the cathode to anode have a little more time to
repel each other and spread apart more, slightly increasing the effective size of the focal spot.
Increasing the kV beyond 26 or so does not improve things much and so this is generally not an
important effect (and has nothing to do with breast thickness). Scatter itself generally increases
with kV, not decreases (Wolbarst, p. 314) and so choice E is wrong.
This leaves answer choices A and B. The correct answer is A. Higher penetration allows for a
shorter exposure time. (If possible, the exposure time should be kept below 2 seconds. Discuss
this with mammography radiologists for more insight.) Though answer choice B is also true the
most important reason is to keep the exposure time down to reduce motion artifacts.
Reference: Wolbarst A. Physics of Radiology. 2nd ed. Madison, WI: Medical Physics Publishing Corp.; 2000.

18Answer C.Xeroradiography is no longer available but had breast doses greater than film-
screen. Both CR and digital mammogram are about 30% less than that for film-screen with direct
digital almost one-half of film-screen.
References: Hendick RE, et al. Comparison of acquisition parameters and breast dose in digital mammography and screen-film
mammography in the American College of Radiology Imaging Network digital mammographic imaging screening trial. AJR Am J
Roentgenol 2010;194(2):362369.
Michigan Department of Licensing and Regulatory Affairs. MGD results from 427 mammography machines. January 2012.
Available at: http://www.michigan.gov/images/mdch/bhs_mammo_dose_220795_7.gif

19Answer C.When compared to routine screening, magnification views have longer exposure
time. They are also associated with more motion blur, less scatter, less noise, decreased source-
to-object distance and have no significant change in contrast.
References: Bushberg JY, Seibert JA, Leidholt EM, et al. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2001:210.
Huda W. Review of Radiographic Physics. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:5455.

20Answer D.Breast compression obviously reduces object thickness, which reduces scatter.
Lower scatter lowers image noise improving image contrast.
Reference: Barnes G. RSNA Categorical Course in Diagnostic Radiology Physics: Technical Aspects.
Haus A, Yaffe M, eds. Oak Brook, IL: RSNA; December 1992:5968.

21Answer C.This limit is specified in the NRC regulations for radioactive materials and adopted
into CRCPD Suggested State Regulations, which are adopted by states with regulations over
radiation machines. Is also the current standard of the National Council on Radiation Protection
and Measurements (NCRP).
Reference: Conference of Radiation Control Program Directors, Suggested State Regulations for Control of Radiation,
Standards for Protection Against Radiation, Part D; 2003. http://www.crcpd.org/SSRCRs/dpart.pdf

22Answer D.Since 2002, it has been shown that the thyroid dose is insignificant compared to the
breast dose. Most importantly, they are neither necessary nor helpful, and their use can result in
inadequate or repeat studies.
References: Kopans DB. Mammograms and thyroid cancer: the facts about breast-cancer screening. Available at:
http://www.massgeneral.org/imaging/about/newsarticle.aspx?id=2720
Whelan C, McLean D, Poulos A. Investigation of thyroid dose due to mammography. Australas Radiol 1999;43(3):307310.

23Answer D.The W target with Rh filter provides the highest effective energy to maximize
penetrability while minimizing the reduction in image contrast, which is critical breast imaging.
Reference: Pizzutiello R. RSNA Categorical Course in Diagnostic Radiology Physics: From Invisible to Visible. The Science
and Practice of X-ray Imaging and Radiation Dose Optimization. Frush D, Huda Q, eds. Oak Brook, IL: RSNA; December
2006:219234.

24Answer C.Film is the capture, display, and storage medium. Its spatial resolution is limited by
the phosphor particle size and screen characteristics, which is about 15 to 20 lp/mm. This exceeds
the pixel resolution characteristics of the image recording and display of the digital imaging chain.
References: Bushberg JT. The Essential Physics of Medical Imaging. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2001:293316.
Williams MB, Fajardo LL. Digital mammography: Performance considerations and current detector designs. Acad Radiol
1996;3:429437.

25Answer C.
Reference: Ranger NT, Lo JY, Samei E. A technique optimization protocol and the potential for dose reduction in digital
mammography. Med Phys 2010;37:962969.

26Answer C.The question tests knowledge of units and clinical absorbed dose from current
digital mammogram for an average breast. 100 millirad = 1 milligray = 1 millisievert; 300
millirads is the ACR limit for accreditation and represents a limit for an average breast that must
not be exceeded. 100 millisieverts is not a measure of absorbed dose and is a huge dose in worker
dose limit range. Clinical techniques for digital imaging are lower than filmscreen for the same
breast thickness. While film is in the 200- to 300-millirad range, digital is in the 150- to 200-
millirad or 1.5- to 2.0-milligray range.
Reference: Hendrick RE, Pisano E, Averbukh A, et al. Comparison of acquisition parameters and breast dose in digital
mammography and screen-film mammography in the American College of Radiology Imaging Network Digital Mammographic
Imaging Screening Trial. AJR Am J Roentgenol 2010;194:362369.

27Answer A.All factors affect the acquisition side of the imaging chain. Image quality is
maximizing signal-to-noise ratio (SNR) per unit of dose. Based on maximizing a figure of merit,
which is the ratio of SNR to MGD, very gradually decreases with kVp. Field size and mAs are
constant for a fixed breast thickness but increase MGD causing a decreased figure of merit
(FOM). For the same thickness, target/filter combo strongly affected the FOM as kVp increased.
References: Ranger NT, Lo JY, Samei E. A technique optimization protocol and the potential for dose reduction in digital
mammography. Med Phys 2010;37:962969.
Williams, et al. Optimization of exposure factors in full field digital mammography. Med Phys 2008;35:24142423.

28Answer B.Electronic magnification is a postacquisition processing technique that is analogous


to enlarging an already acquired picture. It does not affect the dose employed for the image or
affect the image resolution. Noise is increased with electronic magnification. Geometric
magnification is the actual image magnification based on imaging technique and will affect image
resolution.
Reference: Niklason L. RSNA Categorical Course in Diagnostic Radiology Physics: From Invisible to Visible. The Science
and Practice of X-ray Imaging and Radiation Dose Optimization. Frush D, Huda Q, eds. Oak Brook, IL: RSNA; December
2006:235241.

29Answer E.Honeycomb-type grids (HTC) 4:1 are used in mammography. Exposure doubles
even with a grid ratio of 4:1 compared to a nongrid exposure.
References: Huda W, Greene-Donnelly K. RT X-Ray Physics Review. Madison, WI: Medical Physics Publishing; 2011:180.
Bushong SC. Radiologic Science for TechnologistsPhysics, Biology and Protection. St. Louis, MO: Mosby; 2001:315.
Carlton RR, Adler AM. Principles of Radiographic Imaging. An Art and a Science. Albany, NY: Delmar; 2001:583.

30Answer C.Mammography uses two focal spot sizes: a large and a small. For the standard CC
and MLO, the large focal spot size is used, which is generally 0.3 mm.
Reference: Bushong SC. Radiologic Science for TechnologistsPhysics, Biology and Protection. St. Louis, MO: Mosby;
2001:311.

31Answer E.The recommended SID for mammography should be from 50 to 80 cm. It is best to
have a long SID and a small focal spot size for optimal sharpness and resolution.
Reference: Wentz G, Parsons WC. Mammography for the Radiologic Technologist. 2nd ed. New York, NY: McGraw-Hill;
1992:17.

32Answer A.The most common focal spot size used for magnification imaging in mammography is
0.1 mm.
Reference: Valerie F, Andolina RT, Shelly LL, et al. Mammographic Imaging: A Practical Guide. 2nd ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2001:64.

33Answer B.High-resolution monitors should be used for reading digital mammography to


appreciate fine detail. A 5-megapixel monitor (2,048 2,560 pixel samples in the horizontal and
vertical directions for portrait orientation) is recommended by the ACR.
Reference: ACRAAPMSIIM Practice Guideline for Determinants of Image Quality in Digital Mammography; 2012:6 section
4a resolution 36. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Image_Quality_Digital_Mammo.pdf

34Answer C.The x-ray field should not extend beyond the image receptor by more than 2% of the
SID.
Reference: Hendrick RE, Bassett L, Botsco MA, et al. ACR Committee on Quality Assurance in Mammography. Reston, VA:
Mammography Quality Control Manual; 1999:236.

35Answer D.Slit camera with a 10-m slit width.


Reference: Hendrick RE, Bassett L, Botsco MA, et al. ACR Committee on Quality Assurance in Mammography. Reston, VA:
Mammography Quality Control Manual; 1999:321322.

36Answer D.Weekly imaging of the ACR phantom is done to verify whether all aspects of the
imaging system are functioning properly: image quality, contrast, optical density, uniformity, and
scores of the detection limits of the phantom, which are required by the ACR: four fibers, three
speck groups, and three masses.
Reference: Bushong SC. Radiologic Science for Technologists: Physics and Protection. 10th ed. St. Louis, MO: Elsevier Mosby;
2013:391393.

37Answer A.Beryllium is a very low attenuating material that is used in the mammography tube
window.
Reference: Huda W, Greene-Donnelly K. RT X-Ray Physics Review. Madison, WI: Medical Physics Publishing; 2011:178.

38Answer B.Due to the anode heel effect, the cathode is placed at the chest wall.
Reference: Huda W, Greene-Donnelly K. RT X-Ray Physics Review. Madison, WI: Medical Physics Publishing; 2011:178.

39Answer B.The size of the large focal spot used in mammography is 0.3 mm; 0.1 mm is
incorrect. This smaller focal spot would typically be used for magnification mammography; 0.7
and 1.0 are entirely too large a focal spot for standard mammography.
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:3.

40Answer A.In mammography, the goal is to improve soft tissue contrast in order to distinguish
smaller, more dense lesions (such as tiny microcalcifications) from the surrounding fibroglandular
tissue. This is done by lowering the kVp (peak kilovoltage).
Reference: Ikeda D. Breast Imaging: The Requisites. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:24.

41Answer D.Breast compression allows lower kVp values to be used, due to decrease in the
thickness of the breast. Motion blur is decreased since the breast is less likely to move. There is
decreased scattered radiation which leads to improved contrast. The compression allows the
spread of overlying tissue, which reduces superimposition and decreases structural mottle.
Reference: Nickoloff EL. Radiology Review: Radiological Physics. New York, NY: Elsevier Saunders; 2005:156.

42Answer D.This image has a poor contrast because of the exposure factors (high kvP and low
mAs) for the thickness of the breast. Answer choice D is correct because of the decrease in kVp,
there is increase in contrast. The radiographic contrast is also dependent on the patient as well as
the image contrast. Contrast is affected by the breast thickness, density, and atomic differences of
the patient, kVp, contrast material, and scatter radiation.
Answer choice A is incorrect because the MAs is a combination of the mA tube current and
exposure time. Increasing the mAs increases the exposure time. Decreasing the kVp from 28 to 26
indirectly affects the exposure time in cases where phototiming is used. With a decrease in kVp,
there is a compensatory increase in mAs.
Answer choice B is incorrect because of the longer exposure time, the likelihood of motion
artifact increases. An exposure of 90 mAs is usually acceptable for most patients. A desired
exposure time is usually between 0.5 and 2 seconds. Shorter the exposure time, the greater the
production of noise artifacts and grid lines. The longer the exposure time, the increased risk of
motion and overexposure.
Answer choice C is incorrect because increasing mAs increases the radiation dose.
Answer choice E is incorrect because density refers to the blackness of an image. The degree of
image blackness is directly related to the intensity of the radiation reaching the film or intensifying
screen. Increasing mAs results in increase in density.
Reference: Curry TS III, Dowdey JE, Murry RC Jr. Christensens Physics of Diagnostic Radiology. 4th ed. Philadelphia, PA: Lea
& Febiger; 1990:149, 153.
INDEX

A
Abscess
Apocrine cyst cluster
Atypical ductal hyperplasia (ADH)

B
Bilateral breast edema
Bilateral diagnostic mammography
Breast cancer
abnormal interpretation rate
breast conservation surgery
calcific particles
detection rate
fat necrosis
fibrocystic change
histopathologic subtype
interval cancers
local recurrence, breast conservation therapy
lymph nodes draining
male
metastasis, contralateral breast primary
neoadjuvant chemotherapy
pleural effusion
pregnancy-associated
prevalence of
risk factor for
screening for
American Cancer Society (ACS) recommendations
anatomic structure, normal breast
BRCA1/BRCA2 mutation carriers
breast-specific gamma imaging
CC view, lesion location
decrease in breast density
differential diagnosis
HER2 positive
initial imaging modality
keyhole sign
linguine sign
milk of calcium
MRI (see Magnetic resonance imaging)
nipple elevation
pleomorphic calcifications
shape and margins of mass
simple cysts
sternalis muscle
subcapsular line sign
triangulation method
ultrasound
unilateral right breast skin thickening
unilateral/bilateral patchy isotope uptake
second-degree relative
surveillance and treatment for
TNM staging classification
Breast hamartoma
Breast intervention
antiplatelet/anticoagulation therapy
bracketing technique, wire placement
breast-conserving therapy, contraindications
calcium oxalate crystals
chest wall lesion
collagen vascular decrease
fluid aspiration
galactography
lidocaine with epinephrine dosage
percutaneous biopsy
sentinel lymph node biopsy
seroma
stereotactic biopsy
acetaminophen
atypical ductal hyperplasia (ADH)
device
florid epithelial hyperplasia
needle retraction
parallax shift
patient positioning
postwire localization
spinal needle use
stroke margin
surgical biopsy
x and y coordinates
x-ray tube angling
topical lidocaine
ultrasound-guided wire localization
Breast-conserving therapy
Breast-specific gamma imaging

C
Calcifications
calcium phosphate
dermal
fine pleomorphic
linear
linear branching
lucent centered
milk of calcium
pleomorphic
polarized light microscopy
popcorn-like
round
secretory
tangential view
tissue sampling

D
Diabetic fibrous mastopathy (DFM)
Diabetic mastopathy
Duct ectasia
Ductal carcinoma, invasive
retroglandular clear space
upper inner quadrant
Ductography

E
Elastography

F
Fat necrosis
Fibroadenolipoma
Fibroadenomas
Filariasis
Florid epithelial hyperplasia
Focal fibrosis

G
Galactocele
Galactography
Giant fibroadenoma
Gynecomastia

H
Hematoma

I
Infiltrating lobular carcinoma
Inflammatory carcinoma
Intracapsular rupture
keyhole sign
linguine sign
subcapsular line sign
Intramammary lymph node

J
Juvenile fibroadenoma

L
Lipoma
Lisch nodules
Lobular carcinoma, invasive

M
Magnetic resonance imaging (MRI)
BI-RADS category
breast cancer
age considerations
duct ectasia
Hodgkin disease, clinical indicator
indication for
lifetime risk percentage
optimal timing of
T1 without fat saturation
fat necrosis
flap edema
ghosting artifact
inhomogeneous fat saturation artifact
intramammary lymph node
intravenous gadolinium use
invasive lobular carcinoma
irregular breast mass, spiculated margins
mass-like enhancement
multicentric disease
multifocal disease
nonmass-like enhancement, kinetic interrogation
patient motion/ghosting artifact
phase wrap/aliasing artifact
postoperative cavity site
premenopausal
prepectoral implant
rim enhancement
silicone implant
susceptibility artifact
tumor muscle invasion, muscle enhancement
Mammography
accurate positioning, MLO views
American Cancer Society (ACS) recommendations
American College of Radiology guidelines
bilateral secretory calcifications
bilateral subpectoral saline breast implants
BI-RADS 2 assessment
BI-RADS 5 category
BI-RADS category
BRCA1/BRCA2 mutation carriers
breast hamartoma
breast positioning
cancer detection rate
cancer sensitivity
chin artifact, MLO view
compression
compression plate and imaging receptor
computer-aided detection (CAD)
continuing education requirements
decrease in breast density
deodorant artifact
detector interface line
diffuse increased trabecular thickening
document interpretation, additional training
epidermal inclusion cyst
false negative
fibroadenolipoma
film labeling
follow-up, positive mammograms
free silicone injection
free silicone, intracapsular and extracapsular rupture
galactocele
grid artifacts
gynecomastia
hair artifact
hematoma
image blurring
increased positive predictive value (PPV)
increasing asymmetry
inferior lesions
inflammatory carcinoma
irregular mass margins
lateral-medial (LM) view, calcifications
linear calcification
lipoma
Lisch nodules
lucent centered calcification
malignancy percentage
mass location
mass with calcifications
medial breast tissue
medical outcomes audit data
metaplastic carcinoma
milk of calcium
Mondor disease
motion artifact
neurofibromatosis type 1(NF1)
nipple elevation
oil cyst
organ malformations, fetus dose
palpable abnormality, upper outer quadrant
partially circumscribed masses
phyllodes tumors
physics related to
Albert Xthona
beryllium tube window
cathode side placement
contrast threshold
direct digital radiography
displays
electronic magnification
focal spot sizes
grids purpose
high-resolution monitors
honeycomb-type grids (HTC)
increase in contrast
lower peak kilovoltage
mA, exposure time
magnification values
mean glandular dose (MGD)
microcalcification
moving grids
Nal x-ray detector
occupational dose limit
phantom
routine screening vs. magnification views
screen-film vs. digital mammography
slit camera
soft tissue thickness
source to image distance (SID)
target/filter combination
thyroid shielding
tube voltage
voltage (kV) used
W target with Rh filter
pleomorphic calcification
Poland syndrome
posterior nipple line (PNL)
pseudocalcifications
quality control tests
quality standards in United states
radial scar, tubular carcinoma
readout failure
recall rate
rolled CC views
rolled views
roller artifact
scar
screening ratio
secretory calcifications
shrinking breast
silicone injection granulomata
silicone saturation artifact
spot compression magnification views
spot magnification
steatocystoma multiplex
stereotactic core biopsy
sternalis muscle
subareolar area, nipple
tattoo sign
time limit, lay summaries
tubular carcinoma
unilateral axillary adenopathy
unilateral gynecomastia
VP shunt catheter
Mammography Quality Standards Act (MQSA)
continuing education
continuing experience
credentials
initial experience
initial medical education
new modality training
Mastectomy
Melanoma
Mondor disease
Multicentric disease
Multifocal disease

N
Nephrogenic systemic fibrosis (NSF)
Nipple retraction

P
Papilloma, intraductal
Peripheral duct papilloma
Phyllodes tumors
Pleural effusion
Poland syndrome
incidence of
inheritance pattern
Postprocedural skin thickening
Pseudoangiomatous stromal hyperplasia (PASH)
Psoriasis

R
Radial scar
mammographic prevalence
surgical excision, stereotactic breast biopsy
tubular carcinoma
Regulatory/standards of care
BI-RADS assessment
BI-RADS ultrasound lexicon descriptors
BRCA-1 mutation carrier
breast tomosynthesis
cancer detection rate (CDR)
cancer sensitivity
Mammography Quality Standards Act (MQSA)
phantom images
PPV1 definition
screening ratio

S
Sentinel lymph node biopsy
Seroma
Silicone injection granulomata
Steatocystoma multiplex
Stereotactic biopsy, breast intervention
acetaminophen
device
florid epithelial hyperplasia
needle retraction
parallax shift
patient positioning
postwire localization
prone table
spinal needle use
stroke margin
surgical biopsy
topical lidocaine
upright add-on unit
x and y coordinates
x-ray tube angling

T
Trauma
Tubular carcinoma

U
Ultrasound
axillary lymph nodes calcifications
BI-RADS 2 category
breast abscess
breast cancer
diffuse shadowing and
hamartomas
juvenile fibroadenoma
lymph nodes
chest wall lesion
core biopsy
focal asymmetry
lump with pain
diabetic mastopathy
duct ectasia
extracapsular silicone rupture
fibroadenoma
galactocele
guided wire localization
increasing asymmetry
intraductal papilloma
lipoma
metaplastic carcinoma
mucinous carcinoma
oil cyst
painful, erythematous mass, right breast
scar
simple cyst