SECOND EDITION

LANGE Q&A

MAMMOGRAPHY
EXAMINATION

Olive Peart, MS, RT(R)(M)

Clinical Coordinator
Program in Radiography
Stamford Hospital
Stamford, Connecticut

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DOI: 10.1036/0071548351
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Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Patient Education and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2. Instrumentation and Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3. Anatomy, Physiology, and Pathology of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4. Mammographic Technique and Image Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

5. Positioning and Interventional Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

iii
iv Contents

6. Practice Test 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

7. Practice Test 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
 Preface
This book is a review and self-assessment manual
for radiologic technologists, its purpose being to
help technologists who are considering the advanced
level examination in mammography. The book fol-
lows the content category guidelines as specied in
the examinee handbook published by the American
Registry of Radiologic Technologists (ARRT).
The ARRT does not review, evaluate, or endorse
publications. Permission to reproduce ARRT copy-
righted materials within this publication should not
be construed as an endorsement of the publication by
the ARRT.
The first five chapters review the content
category guidelines: (1) Patient Education and
Assessment, (2) Instrumentation and Quality
Assurance, (3) Anatomy, Physiology, and Patho-
logy of the Breast, (4) Mammographic Technique
and Image Evaluation, (5) Positioning and Inter-
ventional Procedures ( 2005 by The American
Registry of Radiologic Technologists). Each chapter
provides a brief summary of the material, followed by
a question-and-answer section. The chapter sum-
maries highlight the major points and important
information in each content category; the question-
and-answer sections are fully explained and refer-
enced and cover all the information required by
the ARRT for the mammography examination.
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Chapters 6 and 7 each contain a complete prac-
tice mammography examination. The simulated
examinations, also available on CD, have been de-
signed to reduce examination jitters by providing a
true simulation of the actual certication examina-
tion. The CD will also allow the user to self-test in
the subject area of choice.
For the actual mammography examination, the
ARRT allots 2 1/2 hours to complete 115 questions
broken down as follows: category A, 18 questions;
category B, 25 questions; category C, 25 questions;
category D, 20 questions; and category E, 27 ques-
tions. Each examination will also include 20 unscored
or pilot questions. For each of these examinations,
the examinee should plan to spend up to 2 1/2 hours
in a distraction-free environment to practice pacing
and the economical use of time. Breast imaging is
nally keeping pace with technology. Electronic
imaging and image transfer will be the future of
breast imaging but the transition may be bumpy.
This text seeks to address both screen/lm and
electronic/digital technology. One thing to note is
that with the rapidly changing technology, the ter-
minology being used in electronic imaging has not
yet been standardized. This text has incorporated
terms such as imaging receptor when referring to
cassettes and imaging plate when referencing the
vi Preface

object used to record the latent image: the lm in peltrovijan@yahoo.com. Breast imaging can be a re-
screen/lm imaging or the detector in electronic warding and meaningful profession. Good luck!
imaging. Chapter 2 details other terms in current use.
It is my hope that users will reference this text as Olive Peart, MS, RT(R)(M)
an invaluable resource when studying for the Clinical Coordinator
ARRT advanced level mammography examination. Program in Radiography
For questions or comments please visit my web Stamford Hospital
site at http://www.opeart.com or email me at Stamford, Connecticut
 Acknowledgments
In preparing for this edition, I am indebted to the
many users of my rst edition. Many readers gave
me valuable insight and practical suggestions on
the review questions. Indeed, your questions, sugges-
tions, criticisms, corrections, comments, and com-
pliments were greatly appreciated and many have
been incorporated into this edition. I especially
wish to thank technologist Sherry Van Helvoirt for
her suggestions and ideas.
Special thanks to Dorothy Saia, program director
with the Radiography Program at Stamford Hospital.
She was always available as a consultant but just as
important was her role in encouraging me and
keeping me on task.
I am particularly grateful for the help that I received
from the following technologists: Beth Siegelbaum,
for her help in providing me with needed resource
material; Elizabeth Dwyer and Iole Del Toro, who
both reviewed digital quality control tests with me
and spent a considerable amount of time cheerfully
answering my numerous questions.
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Thanks also to radiologist Karen Greenberg for
her help and suggestions and physicist Jim Sum-
mers for his help with MQSA and related physics.
Students played a very important role in making
this book possible. I would like to thank the
radiography students at Stamford Hospital (class
of 2008), including Brandy M. Chass, Marilyn P.
DaSilva, Erica A. Guasco, Dawson C. Haffner, Kris-
tiann Kalinski, Carl J. Laguzzi, Tanja M. Albaner-
Lall, Lewis R. Pierpoint, Claudia V. Tu, and John D.
Velasco for their timely suggestions.
This text would certainly not be possible without
the care and commitment of my editors, Catherine
Johnson and Robert Pancotti. The entire production
team, including production supervisor Catherine
Saggese, production manager Vastavikta Sharma,
the copy editors, and other professionals at McGraw-
Hill, deserves a special thanks for their attention to
detail when preparing the nal manuscript.
And nally, my heartfelt thanks to my husband
and children for their patience and consideration.
vii
This page intentionally left blank
 Bibliography
This is a complete reference list of books, publica-
tions, and Internet sites used in compiling the text
and questions in this book. For your convenience,
the last line of each answer refers back to the book,
publication, or web site where the related informa-
tion was found. For example, (Shephard, p. 337)
refers to page 337 in the book Radiographic Image
Production and Manipulation by C. Shephard.
Food and Drug Administration (FDA) Internet.
Accreditation and Certication Overview. September
2007. Available at http://www.fda.gov/cdrh/
mammography/robohelp/nalregs.htm. Accessed
February 2007.
American Cancer Society (ACS). Breast Cancer Facts
& Figures 20052006. Atlanta, GA: American Cancer
Society Inc.
American Cancer Society. Detailed Guide: Breast
Cancer. 2007. Available at http://www.cancer.
org/docroot/CRI/CRI_2_3x.asp?dt=5. Accessed
November 2007.
American College of Radiology (ACR). Mammography
Quality Control Manual. Reston, VA: The American
College of Radiology; 1999.
Andolina VF, Lille SL, Willison KM. Mammographic
Imaging: A Practical Guide. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2001.
Bontrager KL, Lampignano JP. Textbook of Radi-
ographic Positioning and Related Anatomy. 6th ed.
St. Louis, MO: Elsevier Mosby; 2005.
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Burstein HJ. Aromatase inhibitor-associated arthralgia
syndrome. Breast. 2007 June 1;16(3):223234.
Bushong SC. Radiologic Science for Technologists
Physics, Biology and Protection. 8th ed. St. Louis,
MO: Mosby; 2004.
Carlton RR, Adler AM. Principles of Radiographic
Imaging: An Art and a Science. 4th ed. Albany, NY:
Delmar; 2001.
FDA Policy Guidance Help System. Available at
http://www.fda.gov/cdrh/mammography/
robohelp/START.HTM. Accessed November 14,
2007.
Harris JR, Lippman ME, Osborne CK. Diseases of the
Breast. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2000.
Herrmann VM, Borelli AJ. The role of MRI in breast
imaging. Commun Oncol. 2006 November 1;3(11):
727729.
Papp J. Quality Management in the Imaging Sciences.
3rd ed. St. Louis, MO: Mosby; 2006.
Peart O. Mammography and Breast Imaging: Just the
Facts. New York, NY: McGraw-Hill; 2005.
Sanders ME, Page DL. All radial scars/complex
sclerosing lesions seen on breast screening mammograms
should be excised. Breast Diseases: A Year Book
Quarterly. 2007 Jan 1.
Senior K. Benets of tamoxifen persist long after
treatment ends. Lancet Oncol. 2007 Apr;8(4):288.
ix
x Bibliography
Shephard C. Radiographic Image Production and
Manipulation. New York, NY: McGraw-Hill; 2003.
Steveb AT. Quality Management for Radiographic
Imaging. New York, NY: McGraw-Hill; 2001.
Tabr L, Dean PB. Teaching Atlas of Mammography.
3rd ed. New York, NY: Thieme; 2001.
Venes D, Biderman A, Adler E. Tabers Cyclopedic
Medical Dictionary. 18th ed. Philadelphia, PA: F.A.
Davis; 2001.
Tortora GJ, Derrickson B. Principles of Anatomy and
Physiology. 11th ed. New York, NY: John Wiley &
Sons; 2006.
Tucker AK, Ng YY. Textbook of Mammography. 2nd ed.
Edinburgh: Churchill Livingstone; 2001.
Yazici B, Sever AR, Mills P, et al. Scar formation after
stereotactic vacuum-assisted core biopsy of benign
breast lesions. Clin Imaging. 2006;30(6):438.
Zuley ML, Willison KM, Bonaccio E, et al. Full-eld
digital mammography on LCD versus CRT mon-
itors. AJR. 2006;187:14921498.
 CHAPTER 1
Patient Education and Assessment
Summary of Important Points
BREAST EXAMINATION
The American Cancer Society (ACS) guidelines for
breast examination and routine mammography
screening are as follows:
Women aged 20 and older should perform
breast self-examination (BSE) every month.
Women between ages 20 and 39 should have a
clinical breast examination (CBE) every 3 years.
Women aged 40 and older should have a
screening mammogram and a CBE every year.
Breast Self-Examination
A BSE is a check of your breast. It involves
Looking for changes in the breast
Feeling for changes in the breast
Clinical Breast Examination
A CBE is a check of the breast by a qualied health-
care professional. A thorough clinical examination will
locate any lumps or suspicious areas and any changes
in the nipples or skin of the breast. The lymph nodes
under the armpit and above the collarbone will also be
checked for enlargement or rmness.
Medical History and Documentation
Medical and family history will provide information
about symptoms and risk factors for breast cancer
and benign breast conditions. The history should
also include questions about other health problems.
Benets and Risks of Mammography
Mortality Reduction
Breast cancer in its early stages is asymptomatic.
Since the advent of modern mammography in the
late 1960s, studies have conclusively proven that
the mortality rate from breast cancer is signicantly
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
reduced with regular screening mammograms.
Although the mammogram will not detect all
cancers, its effectiveness and sensitivity increases
with age.
Risk from Radiation Exposure
A mammogram delivers very low doses of radia-
tion. In general, each projection in a screen-lm
mammogram will give about 0.10.2 rad average
glandular dose when a grid is used.
RISK FACTORS FOR BREAST CANCER
Gender: The biggest risk factor for breast cancer
is gender (female). Although men can also get
breast cancer, the disease is about 100 times
less common among men than among women.
Other relatively high-risk factors (with a rela-
tive risk > 4.0) include:
Aging: A womans risk of developing breast
cancer increases with age. Seventy-seven per-
cent of women are above 50 when they are
diagnosed with breast cancer.
Genetic risk factors: Genes known to be associ-
ated with breast cancer include the BRCA1 and
BRCA2 genes, which carry a high risk but are
rare in the general population. About 10% of
breast cancer cases are hereditary.
Family history of breast cancer: Breast cancer risk
is higher among women whose close blood rel-
atives have this disease. The risk is greater if
the breast cancer occurs in a relative before
age 50.
Personal history of breast cancer: A woman with
cancer in one breast has a greater risk of devel-
oping a new cancer in the other breast.
2 1: Patient Education and Assessment
Moderate risk factors (relative risk 2.14.0) include:
Having one rst-degree relative with breast
cancer
Atypical hyperplasia conrmed on biopsy
High-radiation dose to the chest areawomen
who have had chest area radiation from a pre-
vious cancer treatment are at increased risk
High bone density after menopause
Minor risk factors (1.12.0 relative risk) are associ-
ated with hormonal changes in the womans body or
hormonal use that may slightly increase a womans
chance of developing breast cancer. These include:
Not having children or having the rst child
after age 30
Not breast-feeding
Early menarche (before age 12) or late menopause
(after age 55)
Postmenopausal obesity
Recent and long-term use of hormone replace-
ment therapy (HRT) or oral contraceptive
Alcohol consumption
Obesity
BREAST DISEASE
Breast disease can be either benign or malignant.
Benign Breast Diseases
Like malignant conditions, benign diseases of the
breast can manifest themselves physically, such as
in a painful cyst or nipple discharge. Some breast
diseases, however, can be detected only on the
mammogram. Such breast disease will be seen as
asymmetric densities, calcications, circumscribed
tumors, lesions, or skin thickening.
Malignant Diseases
The two main classications of breast cancer are duc-
tal and lobular carcinoma. Ductal carcinoma is the
most common, occurring in about 90% of all cases.
The classications of ductal carcinoma are as follows:
Ductal carcinoma in situ: The cancer is confined
to the duct and does not invade the duct
walls. This is commonly referred to as Stage 0
carcinoma.
Invasive or inltrating ductal carcinoma: The can-
cer has spread from the ducts into the sur-
rounding stromal tissue and may or may not
extend into the pectoral fascia and muscle.
Lobular carcinoma accounts for 5%10% of all
breast cancers
Lobular carcinoma in situ is not seen mammo-
graphically in 50% of cases; the abnormal cells
grow within the lobules but do not penetrate
through the lobule walls.
Invasive lobular carcinoma is difcult to perceive
on the radiographs; it may show as a spider
web appearance or cause skin retraction.
Other Breast Carcinomas
Inltrating medullary, colloid comedo, tubular,
mucinous, papillary, and other carcinomas account
for less than 10% of total breast cancer cases and
most have a better prognosis than infiltrating
ductal or lobular cancers.
Appearance on Radiographs
Breast cancer may appear on the radiograph as
asymmetric densities, calcications, circumscribed
tumors or lesions, or skin thickening.
Malignant asymmetric densities are speculated or
stellate lesions with a solid central tumor and
radiating structuresthe larger the central
tumor, the longer the spicules.
Ductal calcications are granular or casting-type
calcications and most often will appear in
clusters.
Malignant circumscribed lesions are ill-dened
and high-density radiopaque lesions, except
for a few rare carcinomas that are low-density
radiopaque.
Skin thickening will appear in cases of advanced
breast cancer, small cancers in the axillary tail
or behind the nipple, breast carcinoma in a
large area, invasive comedocarcinoma, dif-
fusely invasive ductal carcinoma (ie, inamma-
tory carcinoma), secondary breast carcinoma,
or metastasis from the opposite side.
DIAGNOSTIC OPTIONS
The mammogram remains the single most-effective
tool in the detection of breast cancer. There are two
methods of mammography screening: conventional,
which uses an analogy method of imaging, and dig-
ital, which can be cassette-based or cassette-less.
Digital imaging replaced the film with an elec-
tronic detector. The electronic system of the

digital unit will collect a digital readout of the
latent image. This image information can be
electronically transmitted, manipulated, and
efciently stored using a variety of tools. Digi-
tal detectors are categorized as direct or indi-
rect. Both the direct and indirect systems are
considered cassette-less. Digital imaging also
has a cassette-based system (computed radiog-
raphy). The cassette-based system (computed
radiography) has the detector loaded into a
devise similar in shape and size of the conven-
tional cassettes. The cassette-like device is
called an image receptor (IR) and it holds a
exible imaging plate (IP) instead of the con-
ventional lm screen. The cassette-based sys-
tem exposes the IR with a conventional unit,
but after exposure the IR is placed in a com-
puter reader where the IP is retrieved and the
digital information analyzed.
Other Imaging options
Computer-aided detection (CAD) uses a com-
puter to analyze and in effect pre-read the
mammograms by scanning every part of the
radiograph and highlighting any suspicious
areas. CAD can be used with conventional as
well as digital images.
Ultrasound imaging utilizes high-frequency
sound waves and is based on the principle of
the piezoelectric effect. Piezoelectric crystals
are capable of converting energy from one
form to another. In conventional ultrasound,
crystal in a transducer will vibrate to produce
sounds that are sent through the tissues.
Returning echoes that are reected from the
tissue again cause a vibration in the crystals,
which is proportional to the strength of the
returning echo. A computer will analyze the
difference in returning signals to generate
images of the area of interest.
Color doppler ultrasound can be used to provide
an anatomic display of blood ow and can
therefore be used to outline the vascularity of a
lesion. The technology is based on the fact that
highly vascular lesions are often malignant.
Magnetic resonance imaging (MRI) technology
uses a powerful magnetic eld, radio waves,
and a computer to produce highly detailed
images of the breast. The technology is highly
sensitive and is based on the magnetic proper-
ties of hydrogen atoms in the body.
Summary of Important Points 3
Contrast digital mammography involves injecting
a contrast while the breast is under compres-
sion. Pre- and post-contrast images are taken.
Dual energy subtraction can be performed to
assess the contrast in tumors. Dual-energy sub-
traction is used to subtract high- and low-
energy images to separate soft tissue from con-
trast or calcium deposits. The technology can
also be used to enhance masses and eliminate
obscuring structures.
Nuclear medicine uses artificially produced
radioactive isotopes that can be introduced
intravenously into the body. The isotopes gen-
erally have an afnity to a specic organ or tis-
sue type. Nuclear imaging studies are not used
as screening tools but can complement the
mammogram. They include Positron Emission
Tomography or PET imaging, breast scintigra-
phy, and lymphoscintigraphy.
PET imaging, specically using uoro-
deoxyglucose (FDG), utilizes the need that
cancer cells have for sugar. Because FDG is
structurally similar to glucose, position-
emitting isotopes will attach to FDG mole-
cules. The technique can be used to display an
image of the tumor bed or to detect mediasti-
nal lymph node metastases in breast cancer.
Breast scintigraphy, also called scintimam-
mography and sometimes by the trade name
Miraluma, uses the radioisotope Technetium
Tc-99m sestamibi. The radioactive tracer is in-
jected into an arm vein and will concentrate in
malignant lesions in the breast. A gamma cam-
era is then used to image the area. Technetium
Tc-99m sestamibi is especially useful on patients
with dense breasts, implants, diffuse calcica-
tions, and breast tissue scarred by radiation or
surgery. The sensitivity of the technique is
limited with lesions less than 1 cm.
Lymphoscintigraphy or sentinel node mapping
involves the injection of a radioactive tracer
in the area around the tumor to identify the
path to the lymph nodes that cancer cells
take. The idea behind lymphoscintigraphy is
that the rst node, called the sentinel node
that receives drainage from a tumor can be
used to predict the presence or absence of
tumor in the remaining nodes. After the
injection of the radioactive isotope, the pa-
tient is sent to surgery. The surgeon will use
4 1: Patient Education and Assessment
a Geiger counter to locate and biopsy the radioac-
tive lymph nodes. Lymphoscintigraphy can be
used to reduce blind dissection of the axillary
nodes and the resultant side effects.
Computed tomographic (CT) laser mammography is
an experimental technology that shows promise
because no ionizing radiation is used. The tech-
nique is based on the principle that malignant
tumors develop numerous new vessels in a
process called angiogenesis. By scanning the
breast with a low-wavelength laser, a three-
dimensional image is generated that will show
temperature differences, indicating a growing
tumor. The technique can be used to differenti-
ate cystic versus solid lesions and to image
breast implants.
Digital tomosynthesis is a technology that may
soon achieve FDA approval. The x-ray tube ro-
tates in a 50-degree arc around the breast, imag-
ing it from 11 different angles with no movement
of the patient. Eleven low-dose images taken dur-
ing 711 seconds. The technology produces high-
resolution three-dimensional, cross-section im-
ages of the breast. It eliminates overlapping
structures and allows only one compression of
each breast.
INTERVENTION OPTIONS
Cyst aspiration involves the removal of the
content of a cyst and is often performed under
ultrasound guidance.
Fine needle aspiration (FNA) is ideal for cyst
evaluations and aspirations. The technique
uses a small (22- to 25-gauge needle) and gen-
erally requires cytotechnologist evaluation of
the sample.
Preoperative localization is a prelude to the
surgical biopsy. It is necessary if stereo local-
ization is not available. The procedure can be
performed under mammographic or ultra-
sound guidance.
Fine needle biopsy (FNB) also uses small
(2225 gauge) needles to remove cell samples
from nonpalpable lesions for cytological
analysis. The technique is often used with
stereo localization.
Stereotactic breast localization or biopsy is a
method of locating nonpalpable lesions by
using a computer to calculate the precise loca-
tion of the lesion within the breast. The lesions
can be biopsied after localization. Stereotactic
biopsy can be performed with an add-on or
dedicated units.
Core biopsy uses large-core needles (1116
gauge) to remove tissue samples. The core
biopsy needles have special cutting edges.
Core biopsy can be performed using stereo
localization with mammography, or using
ultrasound or MRI guidance.
Open surgical biopsy is recommended with le-
sions that are difcult to approach or close to
breast surface. The open biopsy is sometimes
used to conrm the nding of FNA and FNB.
Ductography is used to evaluate nipple dis-
charge, duct expansion, defects, or irregularities.
TREATMENT OPTIONS
Breast cancer can be treated with surgery, radiation,
and drugs (chemotherapy and hormonal therapy).
Doctors can use one or more of these treatments,
depending on the type and location of the cancer,
whether the disease has spread, and the patients
overall health status. Posttreatment can include
breast augmentation or reconstruction.
Mastectomy is the removal of the entire breast.
A radical mastectomy removes the entire breast,
lymph nodes, and chest wall muscles under
the breast. It is rarely performed today because
the modied mastectomy is just as effective. The
modied mastectomy is also less debilitating
and deforming.
A modied radical mastectomy removes the
breast tissue and some of the underarm lymph
nodes.
Lumpectomy is the most breast-conserving
surgery. It removes only the cancerous tissue
and the surrounding margins of normal tissue.
Lumpectomy is generally followed by radia-
tion treatment and or drug treatments.
Radiation therapy is treatment with high-energy
radiation to destroy cancer cells. External beam
radiation is the more common form of treat-
ment and can take 57 weeks, beginning about
1 month after surgery. Newer techniques in-
volve internal beam radiation that can begin
the day after surgery and last only for 79 days.

Chemotherapy is a systemic treatment, affecting
all the cells in the body. Many chemotherapy
drugs work to kill actively reproducing cells;
however, some drugs will work on cells in a
particular phase of the cell cycle.
Hormonal treatment involves the use of drugs
called selective estrogen receptor modulators, or
SERMs. These drugs are antiestrogen drugs to
prevent estrogen from latching onto tumor cell
receptors. They are used to shrink or stop the
recurrence of breast cancer or to lower the risks
of breast cancer recurrence in postmenopausal
women. Tamoxifen is a common antiestrogen
drug, but there are now a number of similar
drugs in the market with less toxic side effects
such as raloxifene. Aromatase inhibitors are also
antiestrogen drugs, but they work to block the
growth of tumors by lowering the amount of es-
trogen in the body. Another class of drugs such
as Herceptin can be used to treat HER2-positive
metastatic breast cancer.
Pain medication is available for patients in se-
vere pain from cancer. Newer pain medications
are even more potent than morphine.
POSTTREATMENT OPTIONS
Breast reconstruction aims to restore the appear-
ance of the breast.
Summary of Important Points 5
Surgical reconstruction uses saline or silicone
implants. Modern techniques (subpectoral or
retropectoral placement) place the implants
behind the pectoral muscle. Older techniques
(subglandular or retromammary placement)
placed the implants in front of the pectoral
muscle.
Flap surgery removes skin, fat, and muscle from
the abdomen, back, or buttock and uses it to
form a new breast. Flap techniques can either
leave the ap attached to its original blood sup-
ply and tunnels the ap under the skin to the
breast area, or remove the ap completely,
which would involve micro surgery to recreate
a blood supply to the ap when it is in position.
There are two common types of ap techniques:
TRAM ap (transverse rectus abdominis
muscle ap) using tissue from the abdomi-
nal area
Latissimus dorsi ap using tissue from the
upper back
Newer ap techniques:
DIEP (deep inferior epigastric artery perfora-
tor apusing skin and fat but no muscle
from the abdomen
Gluteal-free apusing the gluteal muscle
from the buttocks
 Questions

1. The biggest risk factor for breast disease is 5. Symptoms of benign breast disease not seen
(A) a family history of breast cancer mammographically can include
(B) a personal history of breast cancer 1. nipple discharge
(C) gender
2. skin thickening
(D) not breast-feeding
3. circumscribed tumors
2. One of the minor risk factors for breast can- (A) 1 only
cer could include (B) 3 only
(A) gender (C) 2 and 3 only
(B) aging (D) 1 and 3 only
(C) genetic risk factors
6. Symptoms of a malignant breast cancer can
(D) not breast-feeding
include
3. What is the approximate risk of developing 1. skin thickening
breast cancer for a woman whose fathers sis- 2. nipple discharge
ter has the disease? 3. calcications
(A) higher than normal risk (A) 1 only
(B) no signicant change in risk (B) 2 and 3 only
(C) lower than normal risk (C) 1 and 3 only
(D) none of the above (D) 1, 2, and 3

4. Seventy-seven percent of breast cancers are 7. Skin thickening can be malignant but could
discovered in women in which age group? also be caused by
(A) age 30 or below 1. a breast abscess
(B) above age 50 2. a calcied broadenoma
(C) between ages 30 and 40 3. postradiation
(D) above age 20 but below age 30 (A) 1 only
(B) 2 only
(C) 1 and 2 only
(D) 1 and 3 only

6
 Questions: 1 through 16 7

8. The two main classications of breast cancer are 12. A health-care provider should evaluate which
of the following breast changes?
1. ductal
2. lobular 1. lumps or swellings
3. medullary 2. skin irritation or dimpling
(A) 1 only 3. milky discharge from the nipple
(B) 2 only (A) 1 only
(C) 1 and 2 only (B) 1 and 2 only
(D) 1 and 3 only (C) 2 and 3 only
(D) 1, 2, and 3
9. MRI could be used
13. A CBE should be performed every
1. as a primary breast cancer detection tool
2. to image patients with breast implants to 1. year after age 40
evaluate ruptures 2. 3 years between ages 20 and 39
3. to determine tumor margins and the 3. month after age 50
extent of tumor spread (A) 1 only
(A) 1 only (B) 2 only
(B) 1 and 2 only (C) 1 and 2 only
(C) 2 and 3 only (D) 2 and 3 only
(D) 1 and 3 only
14. A CBE can be performed by which of the
10. Chemotherapy following?
(A) involves the use of drugs to treat cancer 1. the radiologist
that may have spread 2. the patient
(B) is the destruction of cancer cells using 3. a health-care professional
high-energy radiation (A) 1 only
(C) involves mapping the area around a (B) 2 only
tumor with the injection of a radioactive
(C) 2 and 3 only
tracer
(D) 1 and 3 only
(D) is the removal of only the cancerous tis-
sue from the breast
15. A BSE should be done regularly by
11. The ACS recommends that 1. the radiologist
1. All women should have a screening 2. the patient
mammogram every year. 3. a health-care professional
2. Women above 40 should have a screen- (A) 1 only
ing mammogram every year. (B) 2 only
3. New masses or lumps in the breast should (C) 2 and 3 only
be checked by a health-care provider. (D) 1 and 3 only
(A) 1 only
(B) 2 only 16. All women above the age _______ should
(C) 1 and 3 only perform a BSE regularly.
(D) 2 and 3 only (A) 20
(B) 30
(C) 40
(D) 50
8 1: Patient Education and Assessment
17. The two-step method of BSE is to
(A) look and feel for changes in the breast
(B) examine your breasts and have a regular
mammogram
(C) check for lumps in the breast and keep a
journal of changes in the breast
(D) examine your breasts and nipples
18. When visually inspecting the breast, the
changes that should be recorded include
1. changes in size and shape
2. changes in texture or color
3. indentations
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
19. The patients medical history and documen-
tation will
1. provide the radiologist with information
on the patients risk factors for breast
cancer
2. give the radiologist information about
general symptoms of breast cancer
3. provide information about possible
benign breast conditions of the patient
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
20. The importance of BSE and a CBE is stressed
because
1. both will detect benign breast diseases,
which are very common
2. both will help in the detection of malig-
nant breast conditions
3. a mammogram is not 100% effective
(A) 1 only
(B) 2 only
(C) 2 and 3 only
(D) 1 and 3 only
21. Which of the following are methods used
in BSE?
1. using the pads of the three middle n-
gers to palpate the entire breast
2. palpating around the breast in a vertical
pattern
3. using up varying degrees of pressure
while palpation of the breast
(A) 1 only
(B) 1 and 2 only
(C) 1 and 3 only
(D) 1, 2, and 3
22. For a menstruating woman, when is the best
time of the month to perform a BSE?
(A) 1 week before the start of menstruation
(B) on the rst day of the month
(C) on the last day of the month
(D) when the breast is least tender
23. Which of the following statements are true?
1. Breast cancer death rates in United
States are going down.
2. Breast cancer is the leading cause of can-
cer death in women in United States.
3. The second leading cause of cancer
death in women in United States is
breast cancer.
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
24. Postmenopausal obesity is associated with
(A) a relatively high risk of developing
breast cancer
(B) overall reduction in breast cancer risks
(C) circulating estrogen that is produced in
fat tissue
(D) a lower overall estrogen level
 Questions: 17 through 33 9

25. A process of removing tissue, muscle, and fat 30. During a mammogram, which of the follow-
from the belly and transferring that tissue to ing will affect the average glandular dose per
reconstruct the breast is called breast?
(A) TRAM ap 1. degree of breast compression
(B) latissimus dorsi ap 2. the half-value layer (HVL) of the x-ray
(C) implant placement beam
(D) silicone implant 3. breast size and composition
(A) 1 only
26. Antiestrogen drugs such as tamoxifen can be (B) 2 only
used to (C) 3 only
1. slow or stop the cancers growth (D) 1, 2, and 3
2. prevent breast cancer in high-risk
women 31. In general, the optimal duration of tamoxifen
3. prevent the recurrence of breast cancer treatment is
(A) 1 and 2 only (A) 2 years
(B) 2 and 3 only (B) 3 years
(C) 1 and 3 only (C) 4 years
(D) 1, 2, and 3 (D) 5 years

27. In routine mammography, the radiation dose 32. Lumpectomy describes the process of
per projection is generally about
(A) removing the entire breast including the
(A) 0.10.2 rad nipple
(B) 1.02.0 rad (B) removal of the breast cancer tumor and
(C) 0.010.02 rad surrounding margins of normal breast
(D) 23 mrad (C) making a small incision over or near the
site of breast lesion
28. Which age group is likely to get the most (D) removing benign lumps from the breast
radiation dose from a mammogram?
33. Radiation therapy can be used
(A) between 20 and 35
(B) between 40 and 50 1. combined with other treatment options
(C) between 55 and 60 2. to kill any remaining cancer cells in the
(D) above 70 breast, or chest wall area
3. to shrink the size of a tumor before
29. The 5-year survival rate for a patient with a surgery
stage 0 breast cancer is about (A) 1 and 2 only
(A) 49% (B) 2 and 3 only
(B) 76% (C) 1 and 3 only
(C) 88% (D) 1, 2, and 3
(D) 100%
10 1: Patient Education and Assessment

34. Chemotherapy is a class of drugs that can be 38. Ultrasound uses

used to
(A) high-frequency sound waves to image
(A) stop the spread of cancer to other parts the breast
of the body (B) low-frequency sound waves to image
(B) block estrogen from cancer cells the breast
(C) reduce estrogen levels in the body (C) longitudinal microwaves to image the
(D) kill cancer cells by using high-energy breast
radiation (D) radiofrequency waves to image the
breast
35. Breast reconstruction can involve the place-
ment of small uid-lled sacs behind the 39. MRI can be used to
pectoral muscle. Two common types of such
1. map the extent of a tumor
implants are
2. image patients with implants
(A) saline and ap surgery 3. evaluate patients with dense breast
(B) TRAM ap and silicone implant (A) 1 and 2 only
(C) silicone or saline implants (B) 2 and 3 only
(D) saline-lled implant and latissimus dorsi (C) 1 and 3 only
ap implant
(D) 1, 2, and 3
36. With its high sensitivity, MRI is ideal as
40. Conventional ultrasound imaging of the
(A) a routine screen tool for breast cancer breast is often used to
(B) a replacement for mammography (A) map the extent of a breast tumor
screening in detecting breast cancers
(B) verify that a lesion seen on the mammo-
(C) an adjunctive tool in detecting breast gram is solid or uid lled
cancer
(C) verify the presence of microcalcications
(D) a screening tool for older women
(D) biopsy a lesion seen only on MRI
37. MRI imaging involves the use of
(A) radiation to detect breast lesions
(B) sound waves in the imaging of the
breast
(C) magnetic properties plus radio waves to
image the breast
(D) strong sound and radio waves in
imaging the breast
 Answers and Explanations
1. (C) Risk factors increase a womans risk for
breast cancer. These are divided into major
and minor. Major risks are those outside of a
womans control, such as gender and age.
Minor factors are linked to cancer-causing
factors in the environment or may be related
to personal choices, such as using HRT. Sim-
ply being a woman is the main risk factor for
developing breast cancer. Breast cancer can
affect men, but this disease is much more
common among women than men (American
Cancer Society: Causes, Risk Factors and Prevention;
Peart, 2829).
2. (D) A risk factor is anything that increases a
persons chance of getting a disease. Major
risk factors cannot be changed. Minor factors
are linked to cancer-causing factors in the
environment or may be related to personal
choices, such as breast-feeding (American
Cancer Society: Causes, Risk Factors and Prevention;
Peart, 2829).
3. (A) Higher than normal or major risk factors
carry a signicantly higher risk for breast can-
cer than minor risk factors. Breast cancer risk
is higher among women whose close blood
relatives have the disease. Blood relatives can
be either from the mothers or fathers side of
the family (American Cancer Society: Causes, Risk
Factors and Prevention; Peart, 2829).
4. (B) A womans risk of developing breast can-
cer increases with age. Older women have
the greatest risk. Women younger than age
30 years account for only 0.3% of breast
cancer cases, and women in their thirties
account for about 3.5% of cases.
Below 300.3% of breast cancer cases
In thirties3.5% of breast cancer cases
In forties18% of breast cancer diagnosed
Above 5077% of breast cancer diagnosed
(American Cancer Society: Causes, Risk Factors and
Prevention; Peart, 2829).
5. (A) Whereas skin thickening or tumors will be
seen on a mammogram, nipple discharge is
not seen mammographically. Most nipple dis-
charges or secretions are not cancerous. In
general, if the secretion appears clear or milky,
yellow or green, cancer is very unlikely. Fur-
ther testing such as a ductogram or galac-
togram helps in determining the cause of nip-
ple discharge. The ducts can also be evaluated
using ultrasound (American Cancer Society: Non-
Cancerous Breast Conditions; Tabr, 1620).
6. (D) Unfortunately, breast cancer in its early
states is symptomless. As the cancer grows,
some symptoms may appear. These symp-
toms can include lumps in the breast, thick-
ening of the breast skin, puckering or dim-
pling of the breast, inverted nipples, or a
discharge from the nipples (Peart, 1523).
7. (D) Skin thickening or lymphedema of the
breast can indicate breast cancer, but may also
be because of a breast abscess located behind
the nipple, severe infection involving the axil-
lary nodes, mediastinal blockage owing to sar-
coidosis (advanced stages), Hodgkin disease,
lung cancer, bronchial cancer with mediastinal
metastases, esophageal cancer with mediastinal
metastases, right heart failure, advanced gyne-
cologic malignancy, or postoperative or postra-
diation lymphedema (Peart, 5960; Tabr, 240241).
11
12 1: Patient Education and Assessment
8. (C) Ductal carcinoma occurs in 90% of all
women with breast cancer. Lobular carci-
noma affects 5%10% of women with
breast cancer. Other forms of breast carci-
noma, including medullary carcinoma,
account for less than 10% of the total
breast cancer cases. (American Cancer Society:
What is Breast Cancer).
9. (C) There is no evidence at this time that
MRI will be an effective screening tool for
women at average risk for breast cancer. If
MRI is used, it should be in addition to, not
instead of a screening mammogram.
Although MRI is more sensitive than mam-
mograms, it also has a higher false-positive
rate, which would result in unnecessary
biopsies, and it still misses some cancers
that a mammogram would detect. The ACS
recommends that women at high risk (>20%
lifetime risk) should get an MRI and a mam-
mogram every year. Women at moderately
increased risk (15%20% lifetime risk)
should talk with their doctors about the ben-
efits and limitations of adding MRI screen-
ing to their yearly mammogram. Yearly
MRI screening is not recommended for
women whose lifetime risk of breast cancer
is less than 15%. MRI, however, is useful for
evaluating ruptures, leaks, free silicone in
the surrounding breast tissue, or the forma-
tion of silicone granulomas. Also, the tumor
margins and the extent of tumor spread are
often better defined on the MRI than on
mammography (American Cancer Society: Mam-
mograms and Other Breast Imaging Procedures;
Herrmann, 727729).
10. (A) Chemotherapy involves the use of drugs
to treat cancer that may have spread beyond
the breast. The chemotherapy treatments
may last 36 months depending on the inten-
sity of the chemotherapy drug and how far
the cancer has spread. Generally, chemother-
apy treatment is given in cycles, with a
period of treatment followed by a recovery
period (ACS 15; American Cancer Society: Treating
Breast Cancer; Peart, 35).
11. (D) The guidelines as suggested by the ACS are
Women aged 40 and older should have a
screening mammogram and CBE every
year.
Women between ages 20 and 39 should
have a CBE every 3 years.
Women aged 20 and older should perform
a BSE every month.
All lumps or suspicious areas and any
changes in the nipple or skin of the breast
should be reported to a health-care provider
(ACS, 13; American Cancer Society; Early Detection,
Diagnosis, Staging).
12. (B) Changes such as a lump or swelling, ten-
derness, skin irritation or dimpling, or nipple
pain or retraction should be evaluated as
soon as possible. In general, if the nipple dis-
charge is clear or milky, yellow, or green a
cancer is unlikely. If the discharge is red or
red-brown, suggesting blood, it could be
caused by either a malignant or a benign
condition and should be evaluated (ACS,
1213; American Cancer Society; Early Detection,
Diagnosis, Staging).
13. (C) A CBE is an examination of the breast by
a health-care professional such as a physi-
cian, nurse-practitioner, nurse, or physician
assistant. Between ages 20 and 39, women
should have a CBE every 3 years. After age
40, women should have a CBE every year
(ACS, 15; American Cancer Society; Early Detection,
Diagnosis, Staging).
14. (D) A CBE is an examination of the breast by
a health-care professional such as a radiolo-
gist, physician, nurse-practitioner, nurse, or
physician assistant. A similar examination,
performed by the patient on herself, is referred
to as the BSE (ACS, 15; American Cancer Society;
Early Detection, Diagnosis, Staging).
15. (B) A BSE should be done by the patient,
510 days after the start of the menstrual
period, or when the breasts are not tender or
swollen. For women not having regular men-
struation, the BSE should be done on the
same day every month (ACS, 1516; American
Cancer Society; Early Detection, Diagnosis, Staging).

16. (A) The ACS recommends that the BSE
should be performed monthly beginning at
age 20, but it is only one part of a three-part
program: BSE, CBE, and mammogram. BSE
is useful before age 40 to help woman learn
both the appearance and feel of their breast.
After age 40 the BSE provides a safety net,
detecting cancers that may not be seen on the
mammogram (ACS, 1516; American Cancer Soci-
ety; Early Detection, Diagnosis, Staging).
17. (A) For BSE, the rst step is to look for
changes, either while standing or sitting. A
check should be made for indentations,
retracted nipples, dimpling, or prolonged skin
conditions. The next step is to lie supine and
feel for changes using light, medium, and rm
pressure with the pads of three ngers in an
up-and-down pattern. The entire breast must
be checked (Figure 1-1) (ACS, 1516; American
Cancer Society; Early Detection, Diagnosis, Staging).
18. (D) The visual stage of a BSE is a check for
signs of breast cancer. These signs can
include changes in size, texture, or color of
the breast; prolonged skin irritation; redness
or scaliness; dimpling; or nipple retraction
(ACS, 1516; American Cancer Society; Early Detec-
tion, Diagnosis, Staging).
19. (C) The rst step in evaluating a woman with
suspected breast cancer is a complete medical
history and physical or clinical examination.
A B
Figure 11. Breast self-examination (BSE) patterns showing (A) vertical, (B) circular, and
(C) wedge patterns of BSE.
Answers and Explanations: 8 through 20 13
The medical history will provide information
about the patients symptoms and any other
health problems and risk factors for benign
or malignant breast conditions. A clinical
examination will be done to locate any lump
or suspicious areas and examine the texture,
size, and shape of the breast. Any changes in
the nipples or skin of the breast will also be
noted. Once the medical and clinical exami-
nations are completed, biopsies or imaging
tests such as mammography can be per-
formed (ACS, 116; American Cancer Society; Early
Detection, Diagnosis, Staging).
20. (C) Authors of the CMAJ article (164[13]:
18371846) called for an end to routine
teaching of BSE to women aged 4069, say-
ing that studies on the topic suggest BSE
and BSE education do not reduce deaths,
but increase unnecessary biopsies and anxi-
ety. However, although the BSE and the
CBE cannot detect all malignant breast con-
ditions, they are primarily important as
complimentary tests. The ACS suggests that
both the BSE and CBE will compliment the
mammogram and help in the detection of
breast cancers. Unfortunately, the mammo-
gram is not foolproof. Even under ideal
conditions, the mammogram will not find
all breast cancers 100% of the time (ACS,
1516; American Cancer Society; Early Detection,
Diagnosis, Staging).
C
14 1: Patient Education and Assessment
21. (D) The ACS suggests examining the breast
with three different levels of pressure: light
pressure to feel the tissues closest to the skin;
medium pressure to feel a little deeper; and
rm pressure to feel the tissue closest to the
chest and ribs. The up and down pattern
(sometimes called the vertical pattern) is the
most effective pattern for covering the entire
breast without missing any breast tissue, and
the pads of the three middle ngers (not the
nger-tips) are most sensitive to palpate for
abnormalities. The patient should use small
dime-sized circular motion to examine the
entire breast (ACS, 1516; American Cancer Soci-
ety; Early Detection, Diagnosis, Staging).
22. (D) The patient should perform a BSE 510
days after the start of menstrual period, or
when the breasts are not tender or swollen
(ACS, 1516; American Cancer Society; Early Detec-
tion, Diagnosis, Staging).
23. (C) Although breast cancer is relatively com-
mon, it is only the second leading cause of
cancer death in women, after lung cancer.
About 178,480 women in the United States
will be found to have invasive breast cancer
in 2007. About 40,460 women will die from
the disease. In the United States, breast
cancer death rates are going down, possi-
bly because of finding cancers earlier and
improved treatment options (ACS, 37; Ameri-
can Cancer Society: Early Detection, Diagnosis, Stag-
ing; Tortora 1083).
24. (C) Circulating estrogen is mostly produced
in fat tissue, therefore in postmenopausal
women, having more fat tissue can lead to
increased estrogen levels. Weight gain is
therefore associated with increased estrogen
levels and increased likelihood of developing
breast cancer (ACS, 11; American Cancer Society:
Early Detection, Diagnosis, Staging).
25. (A) TRAM ap procedure uses tissue and
muscle from the lower abdominal wall to cre-
ate a breast shape. There are two types of
TRAM aps: the pedicle ap where the ap is
left with its original blood supply and tun-
neled under the skin to the breast area; and
the free ap where the tissue from the
abdomen is completely removed from its
original location. This process requires micro-
scopic surgery to reconnect a blood supply.
Latissimus dorsi ap involves the removal of
muscle and skin from the upper back to cre-
ate a breast shape. Implants can be silicone or
saline (American Cancer Society: Treating Breast
Cancer; Peart, 232234).
26. (D) Tamoxifen belongs to a class of drugs
called SERMs or selective estrogen receptor
modulators. Normally, the estrogen receptor
molecules in cancer cells will react with
estrogen in the body, allowing the cells to
grow. Antiestrogen drugs work by attaching
to the estrogen receptor molecule in breast
cancer cells that would normally react with
estrogen. This prevents the estrogen receptor
cancer cells from interacting with body estro-
gen and will slow or stop the cancers
growth and can also be used to prevent
breast cancer and the recurrence of breast
cancer at local, regional, and distal sites after
lumpectomy and radiation treatment (American
Cancer Society: Treating Breast Cancer; Peart, 228;
Senior; Tortora, 1096).
27. (A) The ACR recommends that the average
glandular dose on the mammogram be no
greater than 0.3 rads (300 mrad or 3 mGy)
with a grid or 0.1 rad (100 mrad or 1 mGy)
without a grid. With modern mammography
equipment, the patient will usually receive
only about 0.10.2 rads per projection
(Andolina, 124; Peart, 2324; Bushong, 590591).
28. (A) Although breast tissue composition is
affected by menarche, hormonal fluctuation
both normal and synthetic, pregnancy, lac-
tation, menopause, and weight gain or loss,
in general the breasts of young women are
denser than those of older women. Younger
breasts will therefore require more radia-
tion to penetrate and will absorb more radi-
ation than those of older women. Fortu-
nately, the incidence of breast cancer in this
age group is very low (American Cancer Society:
Causes, Risk Factors and Prevention; Andolina, 124;
Peart, 2324).

29. (D) A stage 0 carcinoma refers carcinoma in
situ, cancer that is still contained within the
duct or lobule. The prognosis for this type of
cancer is 100% survival after 5 years. Five-
year survival rate refers to the percent of
patients who live at least 5 years after their
cancer is diagnosed. Many of these patients
live much longer than 5 years after diagno-
sis, but 5-year rates are used to produce a
standard way of discussing prognosis. Five-
year rates will exclude from the calculations
patients dying of other diseases and is con-
sidered to be a more accurate way to
describe the prognosis for patients with a
particular type and stage of cancer (Table 1-1)
(American Cancer Society: Causes, Risk Factors and
Prevention; Peart, 2324).
TABLE 11. BREAST CANCER SURVIVAL BY STAGE
Stage
0 Carcinoma in situ
I Tumor = 2 cm; axillary node negative
IIA, IIB Tumor 25 cm with or without
positive nodes or >5 cm
without positive nodes
IIIA, IIIB >5 cm with positive nodes
Any size if spread to breast skin,
chest wall, or internal breast lymph
nodes
IV Any size if there is distant metastasis
(eg, to bone, lungs)
30. (D) The major factors affecting dose are
The imaging chainthe screen/lm combi-
nation and processing environment
The x-ray beam energythe higher the kVp
and HVL, the lower the patient dose
The compressiongreater compression will
result in decreased exposure and therefore
decreased dose
The patients breast tissue type (composition)
and thicknessdenser glandular breast
requires more exposure than fatter breast
(Peart, 2324)
31. (D) The optimal duration of tamoxifen in
postmenopausal women is 5 years. Studies
have conrmed that there is no benet of
Answers and Explanations: 21 through 34 15
giving tamoxifen longer. Tamoxifen will react
with the estrogen receptor in other areas of
the body, such as bone and the lining of the
uterus. With the cells in these areas, tamox-
ifen acts like estrogen to promote growth,
leading the increased bone density and a
high risk of uterine cancer. Other side effects
of tamoxifen include endometrial cancer, pul-
monary embolism, stroke, and deep vein and
thrombosis (American Cancer Society: Treating
Breast Cancer; Peart, 228; Senior, 288; Tortora, 1096).
32. (B) Lumpectomy is a breast-conserving
surgery whereby the breast tumor and sur-
rounding margin of normal tissue are
removed. Removing a benign lump does not
describe lumpectomy. The main advantage of
a lumpectomy is that it preserves most of the
breast. A disadvantage is the need for adju-
5-Year
vant therapy such as radiation therapy. Fac-
Relative tors that can affect the choice of lumpectomy
Survival over mastectomy include tumor size, tumor
Rate type, and cancer stage (American Cancer Society:
100% Treating Breast Cancer; Peart, 222; Tortora, 1096).
98%
88%, 76% 33. (D) Radiation will kill both normal and can-
cerous cells. In any radiation treatment, the
56%, 49% cell cycle is important because radiation usu-
ally works best on cells that are actively or
quickly dividing but does not work well on
cells that are in the resting phase (G0) or are
16%
dividing slowly. Radiation is often used after
surgery and in conjunction with other treat-
ment options to remove any remaining can-
cer cells in the breast, chest wall, and axilla
area but can be used before surgery to shrink
the tumor and allow a better cosmetic surgi-
cal result (Table 1-2) (American Cancer Society:
Treating Breast Cancer; Peart, 224).
34. (A) Chemotherapy is an adjuvant therapy
and involves the use of drugs to treat cancer
that may have spread beyond the breast. The
drug is distributed throughout the entire
body via the blood stream and tends to
attack cells that are rapidly dividing,
whether they are cancerous or not. Drugs
that block estrogen from latching onto to
cancer cells are antiestrogen drugs such as
tamoxifen and raloxifene. Another class of
16 1: Patient Education and Assessment

TABLE 12. THE CELL CYCLE

G0 phase (resting stage): Cells have not yet started to divide. Cells spend much of their lives in this
phase. Depending on the type of cell, this step can last for a few hours to many years. When the cell
is signaled to reproduce, it moves into the G1 phase.
G1 phase: During this phase, the cell starts making more proteins to get ready to divide. This phase
lasts about 1830 hours.
S phase: In the S phase, the chromosomes that contain the genetic code (DNA) are copied so that
both of the new cells formed will have the right amount of DNA. This phase lasts about 1820 hours.
G2 phase: The G2 phase is just before the cell starts splitting into two cells. It lasts from 210 hours.
M phase (mitosis): In this phase, which lasts only 3060 minutes, the cell actually splits into two
new cells.

drugsaromatase inhibitorsthat suppress
blood levels of estrogen are also available in
the ght against breast cancer. Radiation
therapy uses high-energy radiation to
destroy cancer cells (American Cancer Society:
Treating Breast Cancer; Burstein; Peart, 228229).
35. (C) Breast reconstruction can involve the
placement of saline or silicone-lled sac either
in front of or behind the pectoral muscle.
Implants placed behind the pectoral muscle
(subpectoral or retropectoral placement) are
becoming more popular than the older
method of placing the implants in front of the
pectoral muscle (subglandular or retromam-
mary placement). Subpectoral placement
allows easier imaging of the breast mammo-
graphically and is less prone to encapsula-
tion. Flap surgery uses skin, fat, or muscle
from other parts of the body to form a
natural-looking breast mound. Two common
ap techniques are the TRAM apusing
skin, fat, and muscle from the abdomen
and latissimus dorsi apusing tissue from
the upper back (American Cancer Society: Treating
Breast Cancer; Andolina, 298307).
36. (C) MRI can nd cancers that are missed on
mammography, but cannot replace mam-
mography because there are still some can-
cers that are detected mammographically but
not with MRI. The ACS now recommends
contrast-enhanced MRI in conjunction with a
mammogram for women with approximately
20%25% or greater lifetime risk of breast
cancer. The technology is not however rec-
ommended as a screening tool because of the
high cost and the modalitys lack of speci-
city, which often results in a high false-
positive rate on biopsies (American Cancer Soci-
ety: Early Detection, Diagnosis, Staging; Herrmann,
727729; Peart, 163177).
37. (C) MRI technology uses a powerful mag-
netic eld, radio waves, and a computer to
produce highly detailed images of the breast.
The technology is based on the magnetic
properties of hydrogen atoms in the body.
MRI technology is extremely sensitive and is
now recommended as an adjunctive screen-
ing tool for high-risk women. Ultrasound
uses high-frequency sound waves to image
the breast and mammography uses x-radiation
to image the breast (American Cancer Society: Early
Detection, Diagnosis, Staging; Herrmann, 727729;
Peart, 163177).
38. (A) Sound is a mechanical, longitudinal wave
that needs a medium to travel. Breast imag-
ing with ultrasound uses high frequencies,
above 20,000 Hz, which are beyond human
hearing. Microwaves are electromagnetic
waves with a short radiofrequency (Andolina,
322323; Peart, 148163; Tortora 1095).
39. (D) MRI is an imaging test that uses strong
magnets and radio waves to create very
detailed breast images. MRI is a promising
tool. Because of its sensitivity it can nd
tumors even in very dense breasts, and can
nd very small tumors. It can be used to
stage cancers, map the extent of the tumor,
evaluate the effectiveness of chemotherapy,
and distinguish postoperative or postradiation

scarring from recurrent cancer. MRI can also
be used to image implants for leakage or rup-
tures (American Cancer Society: Early Detection, Diag-
nosis, Staging; Herrmann, 727729; Peart, 163177).
40. (B) Ultrasound is an adjunctive modality and
is useful in determining whether the mass
seen on the mammogram is solid versus
cystic (malignant vs. benign). Ultrasound is
close to 100% accurate in diagnosing cysts
Answers and Explanations: 35 through 40 17
(uid-lled lesions), but the technology does
not image calcications well. Although ultra-
sound can be used to image dense breast and
to detect cancers missed on the mammogram,
the technology is not sensitive enough to map
the extent of a tumor. Lesions must be biopsied
in the modality in which they are visualized;
therefore a lesion seen only on MRI can only
be biopsied using MR technology (Andolina,
322323; Peart, 148162; Tortora, 1095).
This page intentionally left blank
 CHAPTER 2
Instrumentation and Quality Assurance
Summary of Important Points
DESIGN CHARACTERISTICS OF FILM-SCREEN
MAMMOGRAPHY UNITS
All mammography units are designed to image the
soft tissue of the breast while displaying the neces-
sary subtle contrast differences. Older mammogra-
phy generators were three-phase generators; all
modern generators are high-frequency generators.
Like the older units, these rectify the input to pro-
duce a direct current (DC) voltage waveform, but
the modern high-frequency generators essentially
provide a constant potential with about 1% ripple.
The high frequency allows more efcient x-ray pro-
duction and therefore produces a higher effective
energy x-ray beam. The result is higher x-ray out-
put for a given kVp (peak kilovoltage) and mA
(milliamperes) setting.
kVp Range
The kVp range will depend on the target/ltration
material available. The kVp use will depend on a
number of factors (eg, radiologist preference, equip-
ment calibration, manufacturers recommendations,
equipment design, characteristic curve of the screen-
lm combination, processing, and patient breast size
and thickness). The kVp selection can affect the radi-
ographic contrast because contrast is highest in thin-
ner breasts and lowest in thicker breasts. In the
thicker breast, more radiation is needed (more kVp)
and there is greater tissue absorption of the low-kVp
radiation. Increased kVp will allow lower dose but
will reduce contrast. Decreased kVp will increase
dose and increase subject contrast.
Mammography Tube (Anode, Filtration,
Window)
In mammography, special target materials and l-
trations are combined to provide the low-energy
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
beam needed. The target-lter combination will es-
sentially shape the x-ray beam, providing the nec-
essary kVp range to penetrate dense or fatty breast.
Common combinations include:
Molybdenum target with 0.03 mm (30 m)
molybdenum ltration or 0.05 mm rhodium
ltration
Rhodium target with 0.025 mm (25 m) rhodium
ltration (50 m rhodium ltration is some-
times recommended)
Molybdenum and tungsten alloy target with
molybdenum or rhodium ltration
Molybdenum and rhodium alloy target with
molybdenum or rhodium ltration
Tungsten target and silver or rhodium ltra-
tion (used on some digital units)
The material used for the exit port or window of
the x-ray tube is borosilicate glass or beryllium (Be).
A regular glass window would harden the emerging
beam by eliminating the soft characteristic radiation.
The intensity of the beam is less on the anode
side than on the cathode side because of the anode
heel effect. The cathode-side output of the x-ray
tube is always directed to the base; that is, the
thickness area of the breast.
Compression Devices
Compression in mammography is provided by a
flat-surfaced compression paddle. Important
design characteristics are:
The flat surface must be parallel to image
receptor (IR).
The chest wall edge of the compression paddle
should not extend beyond the chest wall edge
of the IR by more than 2% of the source-to-
image distance (SID).
19
20 2: Instrumentation and Quality Assurance
A shadow of the vertical edge of the compres-
sion paddle should not be visible on the image.
The lip along the chest wall should be 24 cm
in height.
The lip should have a right angle at the chest
wall.
Automatic Exposure Control
Automatic exposure control (AEC) is used in mod-
ern mammography units. AEC controls the length
of the exposure and will therefore determine the
density of the nal image. The type of AEC device
found in modern mammography units is:
The ionization chamber
The phototimer is an AEC device used in older
x-ray units
Underexposure is still a common problem in con-
ventional mammography and occurs when the AEC
cell is not placed over the densest area of the breast.
Grids
Grids are used to improve radiographic contrast by
decreasing the amount of scattered radiation that
reaches the IR. The use of grids will always result
in increased dose to the patient. General character-
istics of common mammography grids:
Thinner than conventional radiography grids
Linear focused grid-movement in one direc-
tion only and focused to the SID
Carbon ber or wood as the interspace material
Lead as the grid strip
3:1 to 5:1 grid ratio
3050 lines per centimeter grid frequency
Characteristics of the high-transmission cellular
(HTC) grid (specically designed for mammogra-
phy use)
A crossed grid. It can reduce scatter in two direc-
tions rather than the one direction of the linear
focused grid.
Copper as the grid strip.
Air as the interspace material.
3.8:1 grid ratio.
Beam Restriction Devices
Beam-restricting or -limiting devices are cones, col-
limators, or diaphragms used to regulate the size
and shape of the x-ray beam. There are three facts
to consider when using beam-restricting devices in
mammography.
The entire lm should be exposed (extraneous
light will compromise the perception of ne
detail).
Collimation should not extend beyond any
edge of the IR by more than 2% of the SID.
Decreasing the x-ray eld will require an increase
in exposure to maintain constant density.
SYSTEM GEOMETRY (SID, OID, MAGNIFICATION)
Focal Spot Size
The recommended focal spot sizes in mammogra-
phy are:
0.4 mm or smaller for routine work (the most
commonly used is 0.3 mm).
0.15 mm or smaller for magnification (the
most common focal spot size in magnification
is 0.1 mm).
Size and shape of the focal spot are determined
by the
Size and shape of electron beam hitting the
anode
Design and relationship of the lament coil to
the focusing cup.
Angle of the anode.
Source-to-Image Distance
In mammography the aim is to have the smallest
focal spot coupled with the longest SID. The SID in
mammography is xedgenerally 5080 cm.
Object-to-Image Distance
The object-to-image distance (OID) should be as
small as possible. The only exception is micro focus
magnication.
Magnication will reduce scatter, but the
greater the magnication factor the greater the
skin dose to the patient.
Magnication causes decrease in image resolu-
tion. This is compensated by using a small focal
spot size.
A common magnication factor is 1.5 times.
Other factors can be 1.6, 1.7, 1.85, or 2 times.
Other factors affecting image quality are
Motion owing to long exposure times
Poor screen-lm contact
Increase in the focal spot size
Increase in the OID
Decrease in the SID

The relationship between the OID and the SID
Characteristics of the screen (faster screens have
a lower spatial resolution)
Imaging Components
There are two imaging systems in current use:
Screen-lm system
Digital system
Film
The lm can be used to record the image, display the
image, and provide archival storage. Mammography
lms are single emulsion and high contrast. High-
contrast lms generally have limited exposure lati-
tude. Other lm characteristics such as speed must
also be taken into account to reduce patient dose.
Screens
Single-screen cassette systems are used in mam-
mography to provide the best spatial resolution.
Cassettes or Image Receptor
Cassette or IR holds and stores the film during
exposure. Single-screen IRs are matched with the
single emulsion mammography lms. They can be
designed for either daylight or darkroom use. All
IRs must have an identication system slot, capable
of recording patient information on the image.
Processors
Mammography images should be processed in
dedicated lm processors. There are two common
options:
Standard 90-second processing
Extended processing. This extends the devel-
oping time to improve image contrast and reduce
patient dose.
Factors affecting lm processing include: devel-
oper time, developer temperature, and chemistry
composition (developer and xer).
DIGITAL MAMMOGRAPHY
Digital imaging offers the ability to manipulate or
post process the nal image. There are two main
digital mammography systems in the market: a
cassette-less system and a cassette-based system;
however, cassette-less systems can be considered to
be direct or indirect conversion systems.
Summary of Important Points 21
In the direct system, x-rays are absorbed by the
detector and the electrical signal is created in one
step. Amorphous selenium is the at-panel detec-
tor often used. Thin-lm transistor (TFT) arrays are
then used to transfer the electronic signals from the
selenium photoconductor to a computer.
The indirect digital systems use a two-step
process. A scintillator such as cesium iodide doped
with thallium absorbs x-rays and generates a light
scintillation that is then detected by an array of
thin-lm diodes (TFDs) or charge-coupled devices
(CCDs). Signals from the TDSs or CCDs are col-
lected, converted to electronic signals, and trans-
ferred to a computer.
The cassette-based system is similar to the com-
puted radiography system used in general radiog-
raphy. Here the same conventional mammography
unit is used but the cassettes are replaced by an IR,
which holds an imaging plate during the exposure.
The imaging plate has a photostimulable phosphor
with an active ingredient-europium-activated bar-
ium uorohalidewhich is activated when exposed
to x-rays. After exposure, the IR is transported to a
computer reader (CR), which uses laser light to
read the emission from the image plate.
In all digital systems the spatial resolution will
depend on pixel size. A pixel is the smallest dis-
crete picture element of an image, usually a single
dot. Increased pixel size will increase resolution but
will also increase noises that can deteriorate image
quality.
Digital and Computer-Aided Detector
Digital signals are sent to a computer-aided detec-
tor (CAD) reader. The computer prereads the mam-
mograms, identifying areas of suspicion or areas
needing additional workup.
Digital and Picture-Achieving and
Communication System
Digital signals are sent to a picture-achieving and
communication system (PACS), enabling teleradi-
ography and lmless libraries, which can be accessed
via telephone, the Internet, or any other off-site
location.
Digital systems approved by the Food and Drug
Administration (FDA):
GE Senographe 2000D (approval date: 1/28/00)
Fischer Imaging SenoScan (approval date: 9/25/01)
22 2: Instrumentation and Quality Assurance

Lorad Digital Breast Imager (approval date: QUALITY CONTROL TESTS FOR BOTH DIGITAL AND
3/15/02) FILM-SCREEN
Hologic/Lorad Selenia FFDM System (approval View boxes and viewing conditions Weekly
date: 10/02/02) Phantom images Weekly
GE Senographe DS (approval date: 02/19/04) Visual checklist Monthly
Siemens Mammomat Novation DR (approval date: Repeat/reject analysis Quarterly
08/20/04) Compression Semiannually
GE Senographe Essentials (approval date: Review of medical physicists Yearly
04/11/2006) annual survey report
Fuji Computed Radiography Mammography Suite
ALL TESTS ARE
(FCRMS) (approval date: 07/10/06)
MEDICAL PHYSICIST TEST DONE ANNUALLY

QUALITY ASSURANCE Mammographic unit assembly

evaluation
Quality assurance and processor quality control are Collimation assessment (eld
absolutely essential in producing quality images. light and x-ray congruence)
Guidelines determined by the Mammography Evaluation of system resolution
Quality Standards Act and the American College of AEC system performance
Radiology provide the standard criteria. These cri- Uniformity of screen speed
teria exceed the criteria for processing of radi- Artifact evaluation
ographic studies done in a diagnostic radiology Image quality evaluation
department. Mammographers must be aware of all kVp accuracy and reproducibility
performance evaluations and quality control (QC) Beam quality assessment
testings for lm-screen or digital system. Breast exposure and AEC
reproducibility
FILM-SCREEN QUALITY CONTROL TEST FREQUENCY Average glandular dose
Darkroom cleanliness Daily Radiation output rate
Processor quality control Daily Measure of view-box luminance
Mobile unit quality control Daily and room illuminance
Screen cleanliness Weekly The medical physicist must all perform all the
Analysis of xer retention in lm Quarterly manufacturer-recommended digital quality control
Darkroom fog Semiannually tests. Some of these are similar to the digital tests
Screen-lm contact Semiannually performed by mammographers.
DIGITAL QUALITY CONTROL TEST
Monitor cleaning Monthly Radiologist (Interpreting Physician)
Compression indicator Weekly Primary responsibilityinterpreting the mam-
Laser imager test (including SMPTE Weekly mography and ensuring that they are of opti-
detector calibration/at eld) Weekly or mal diagnostic quality.
Signal-to-noise measurement, biweekly Responsible for a yearly review of the medical au-
contrast-to-noise measurement Weekly dit with the lead quality-control mammographer.
modulation transfer function (MTF)
Automatic optimization of Weekly or Testing Details
parameters (AOP) monthly
Monitor calibration and SMPTE Monthly Darkroom Cleanliness
pattern Weekly Purpose: To minimize artifacts on radiographs
caused by bits of dust, dirt, or food between the
Note: Digital quality controls can vary and are
screen and lm.
manufacture dependent. Other tests can include a
This is extremely important when using single
weekly artifact evaluation for the printer and elec-
emulsion lm, as in mammography, not only
tronic detector.
because they are more obvious, but because they

can look like microcalcications and lead to misdi-
agnosis or repeat examinations.
Processor Quality Control
Purpose: To conrm and verify that the processor
chemical system is working properly according to
specications.
Processor quality control should be carried out
daily, at the beginning of the day before processing
any lms.
Required: A 21-step sensitometer and a
densitometer.
Processor quality control records should be
saved for 1 year. Sensitometric images should be
saved for the last full month.
Screen Cleanliness
Purpose: To ensure the screens are free of dust or
other potential artifacts.
Screens should be cleaned at least weekly, but
also anytime when dust or other artifacts are noted
by the mammographer or radiologist.
Illuminators/Viewing Conditions
Purpose: To ensure optimal viewing conditions.
Viewing conditions can be extremely critical in
mammography. High-luminance view boxes with
proper masking of each image are essential. Typi-
cally, view boxes should have a luminance level of
approximately 1500 candela per square meter
(cd/m2). For mammography, the luminance level
should be at least 3500 cd/m2. (The unit candela
per meter is sometimes referred to as the nit. The
older unit is the footlambert (fL). 1fL = 3.43 cd/m2.)
Phantom Images
Purpose: To ensure that image density, contrast,
uniformity, and image quality are maintained at
optimum levels.
Required: A mammographic phantom (4- to 4.5-cm-
thick tissue equivalent breast phantom), with an
acrylic disc 4-mm thick permanently xed on the
phantom, in a position that does not obscure any
phantom detail. (Digital phantom imaging does not
always use the acrylic disc.)
Note: The mammographic phantom should
always be viewed by the same person, on the same
view box, under the same viewing conditions,
using the same type of magnifying glass at the
same time of day.
Summary of Important Points 23
Visual Checklist
Purpose: To ensure the mechanical integrity and
safety of the mammographic equipment and acces-
sory devices.
The system indicator lights, displays, mechani-
cal locks, and detents are all checked.
Reject/Repeat Analysis
Purpose: To determine the number and cause of
repeated mammograms and rejected lms.
The overall repeat rate ideally should not
exceed 2%, but a rate lower than 5% is acceptable
once the quality assurance program is operational.
To be statistically meaningful, a volume of at least
250 patients needs to be measured. The percentage
of repeats from each category should be close. If
one category is signicantly higher than the others,
it should be targeted for improvement.
Analysis of Fixer Retention in Film
Purpose: To determine the quantity of residual xer
(hypo) in the processed lm.
The amount of xer (hypo) retention in any
processed lm is an indication of the length of time
that film will retain its archival quality (image
quality). Excess residual fixer can degrade the
quality of the image.
Required: Residual hypo test solution, available
commercially, or hypo estimator (eg, Kodak Hypo
Estimator, publication N-405, or equivalent). If there
is an excess of hypo retained on the lm, the proces-
sor wash tanks and water ow rates, in addition to
xer replenishment rates, need to be assessed.
Darkroom Fog
Purpose: To ensure that the lm is not fogged as a
result of cracks in the safelight or other light
sources in and out of the darkroom.
Required: Mammographic or routine x-ray unit,
densitometer, a radiopaque card, and a watch or timer.
Screen/Film Contact and Identication
Purpose: To assure optimum contact between
screens and lm in each cassette.
Screen-film contact will influence image
sharpness. Poor contact will impact image qual-
ity. It is important to be able to identify each
screen-cassette combination. If a problem occurs
with one of the cassettes, for example, if an artifact
24 2: Instrumentation and Quality Assurance
is detected in one of the cassettes, appropriate iden-
tication will allow the mammographer to locate
the cassette and correct the problem. Each screen
should be marked with a unique identication
number near the left or right edge of the screen,
using a marker approved by the screen manufac-
turer. The same identication number should be
placed on the outside of each cassette.
Required: Mammographic lm, a densitometer,
and copper wire mesh screens with at least 40 wires
per inch grid density. These are commercially avail-
able. The mesh can be placed between two thin
sheets of acrylic to protect it.
The optical density of the nal image must be
measured using a densitometer with at least a 2-
mm diameter aperture. The density should be
between 0.70 and 0.80 when measured near the
chest wall side of the lm. A thin sheet of acrylic
can be placed near the x-ray tube window to adjust
the density to the ideal level. Any cassette having a
large area (>1 cm in diameter) of poor contact that
cannot be eliminated should be replaced. Multiple
small areas of poor contact (>1 cm) are considered
acceptable.
Compression
Purpose: To ensure that the mammographic system
can provide adequate compression in both manual
and automatic mode and that too much compres-
sion cannot be applied. The compression should be
adequate to separate glandular tissue without caus-
ing injury to the patient or damage to the compres-
sion device.
Required: Bathroom scale and several towels.
Adequate compression ranges from 2545 lb
in automatic mode (111200 newton). The initial
automatic compression should not exceed 45 lb of
pressure.
Digital Quality Assurance
Note: Digital quality assurance is manufacturer spe-
cic. Test can include:
SMPTE testscheck communication between
AWS (acquisition work station), detector, and
printer
Automatic optimization of parameters (AOP)-
checks auto-timing with auto kVp and/or auto-
selection of target and lter
Signal-to-noise ratio (SNR)/contrast-to-noise
ratio (CNR)
Checks consistency of the CNR
Ensures contrast is within acceptable range
Phantom test on monitor and/or printer
Veries consistent quality of images acquired
by the detector and displayed on the AWS
monitor and/or printer
Artifact evaluation checks for artifacts on
printer and detector
Detectorconrms that there are no artifacts
resulting from the detector
Printer-conrms that there are no artifacts
resulting from the printer
Compression indicatorveries the compres-
sion indicator is working
Flat eld calibration for the detectorchecks
the image quality of the detector including:
Brightness nonuniformity
High-frequency modulation (HFM)
SNR nonuniformity
Bad region of interest (ROI)
Bad pixel verication
MAMMOGRAPHY QUALITY STANDARDS ACT
Accreditation and Certication
The Mammography Quality Standards Act
(MQSA) was enacted on October 27, 1992 to estab-
lish minimal national quality standards for mam-
mography.
Agencies: The Food and Drug Administration
(FDA) and the States as Certiers (SAC) are the
only organizations authorized to issue MQSA certi-
cation.
Process: Before a mammography facility can
legally perform mammograms, it must be certied.
The facility must rst contact an accreditation body.
Provisional certication (valued for 6 months) is
usually issued by the FDA as soon as the accredita-
tion has been accepted. The accreditation body will
then accept clinical images and other data from the
facility to complete the accreditation process.
Key Components of the MQSA
The interpreting physician, the physicist, and the
mammographer must meet the education and
training requirements of the MQSA. All are also
required to interpret/inspect/image a minimum
number of mammograms or sites per year and
obtain a minimum number of continuing education

units within a specic period. All mammographers
(radiographer performing mammograms) must
meet the training requirements of the MQSA.
Certificate placementMust be prominently
displayed.
Consumer complaints mechanismFacility must
have a system in place to collect and resolve
serious consumer complaints.
Self-referralsA facility can decide to accept or
not to accept self-referrals, but the policy must
be stated.
Record keepingMammograms and medical
records of patients must be kept for a period of
not less than 5 years, or not less than 10 years if
no additional mammograms of the patient are
performed at the facility (longer if mandated
by state or local law). Records must include:
name of patient plus an additional patient
identier, date of examination, name of radiol-
ogist interpreting the mammogram, and a nal
assessment nding.
Infection controlAll facilities should have a pol-
icy in place to prevent and control the spread
of infection to employees, patients, and visitors
within the mammography facility.
Communication of resultsAll facilities must send
each patient a summary of the mammography
report written in lay terms within 30 days of
the mammographic examination. Either verbal
or written results are acceptable. Results must
Summary of Important Points 25
be sent to the physician. Concerned ndings
must be sent within 35 days.
Assessment categoriesAll reports must have an
assessment category. The most commonly used
is the Breast Imaging Reporting and Database
(BIRAD) system.
Medical auditAll facilities must keep a medical
outcomes audit to follow positive mammogra-
phy results and to correlate pathology results
with the interpreting physicians findings.
The Health Insurance Portability and Ac-
countability Act (HIPAA) does not affect
medical audit because in MQSA documenta-
tion patient information can be released with-
out patient authorization.
Notes on Digital Terminology
Unfortunately the terminology being used in digi-
tal imaging has not yet been standardized. The fol-
lowing is a list of terms in current use.
The cassette in computed radiography (CR)
has been replaced by a structure similar to the
screen-lm cassette. It is sometimes called imaging
plate (IP) or image receptor (IR). This text uses IR.
The film in CR and DR has been replaced by a
storage phosphor screen. It is often called photo-
stimulable phosphor (PSP), storage phosphor
screen (SPS), image recorder (IR) or image or
imaging plate (IP). This text uses IP.
 Questions
1. In mammography, selecting extremely low
kVp values
(A) reduces contrast and lowers patient dose
(B) increases contrast but increases patient
dose
(C) reduces contrast but increases patient
dose
(D) increases contrast and reduces patient
dose
2. What target-ltration combination provides
the best penetration for dense or thick breast?
(A) molybdenum target with molybdenum
ltration
(B) rhodium target with rhodium ltration
(C) tungsten target with tungsten ltration
(D) molybdenum target with appropriate
K-edge ltration
3. The material used for the exit port of the
mammography tube is necessary because
(A) The intensity of the beam is less on the
anode side than on the cathode side.
(B) Regular glass would harden the emerg-
ing beam.
(C) The intensity of the beam is more on the
anode side than the cathode side.
(D) Regular glass would soften the emerg-
ing beam.
26
4. The intensity of the x-ray beam from the
cathode side of the tube is generally higher
because
(A) Soft characteristic radiation emerges
from the anode side.
(B) The cathode side is directed to the thick-
est part of the breast.
(C) The heel effect causes variation in the
intensity of the x-ray beam.
(D) The heel effect increases the intensity of
the beam at the anode side.
5. The design of the lip of the compression pad-
dle (both height and angle along the chest
wall) affects all of the following except that it
(A) prevents the posterior and axillary fat
from overlapping the body of the breast
(B) allows uniform compression of the pos-
terior breast tissue
(C) helps to increase structural strength of
the compression paddle
(D) ensures greater compression of the ante-
rior breast tissue
6. The primary goal of compression is to
(A) reduce the OID of the lesion
(B) allow uniform penetration of structures
within the breast
(C) reduce the possibility of motion during
the exposure
(D) reduce the radiation dose to the breast
 Questions: 1 through 15 27

7. AEC failure, resulting in an underexposed 11. As the size of the x-ray eld decreases, to
radiograph, can be caused by maintain a constant image density the expo-
sure will
(A) processing deciencies such as uctuat-
ing developer temperature (A) increase
(B) improper placement of the dense breast (B) decrease
tissue/size over the detector (C) not change signicantly
(C) decreased radiographic contrast (D) decrease inversely
(D) inadequate breast compression
12. The chest wall edge of the compression pad-
8. Most AEC circuitry in modern mammo- dle should be aligned just beyond the chest
graphic imaging has at least three detectors. wall edge of the IR to
Three or more detectors are recommended
(A) avoid pushing the patients chest away
because
and losing breast tissue
(A) Multiple detectors allow for maximum (B) properly position and compress the
variations in breast size and tissue den- breast
sity. (C) permit uniform exposure and reduce
(B) AEC detectors eliminate the guesswork patient discomfort
in determining the proper exposure fac- (D) avoid projecting the chest wall edge of
tor for each patient. the paddle on the mammogram
(C) Detectors have the ability to terminate
the exposure by back-up timer when a 13. Which of the following affects focal spot size?
maximum exposure time or maximum
milliamperes (mA) per second is (A) angle of the anode
reached. (B) a decrease in the SID
(D) All AEC detector systems provide con- (C) decreasing the size of the collimated
sistent image densities because of the beam
high-contrast mammography lms. (D) changing the relationship between the
OID and the SID
9. The major difference between the general
radiography grid and the grid used in mam- 14. In mammography, the commonly used focal
mography is that the spot size for routine work is
(A) grid used in general radiography causes (A) 3 mm
an increase in exposure (B) 0.3 mm
(B) grids used in general radiography have (C) 1 mm
higher ratios (D) 0.1 mm
(C) use of a grid in mammography increases
patient dose 15. Which of the following characteristics are
(D) grids in mammography improve the unique to mammography cassettes?
radiographic image contrast
(A) must be easy to open
10. The grid ratio can vary in modern mammog- (B) should be durable
raphy units. A common grid ratio used is (C) generally have a single intensifying
screen
(A) 8:1
(D) should have low absorption characteristics
(B) 6:1
(C) 4:1
(D) 2:1
28 2: Instrumentation and Quality Assurance
16. Two main disadvantages of extended pro-
cessing are
(A) decreased film speed and increased
film fog
(B) increased film speed and decreased
film fog
(C) increased processing artifact and
increased lm fog
(D) decreased processing artifact and
increased lm speed
17. In digital mammography, both the lm and
cassette can be replaced by
(A) a detector and electronic system
(B) the CAD technology system
(C) a exible storage phosphor
(D) photostimulable plates
18. The greatest difference between digital tech-
nology and conventional mammography
imaging is
(A) The higher resolution system results in
an increase in patient dose in digital
technology.
(B) There is no latent image formation when
using digital technology.
(C) In digital technology, the nal image can
be manipulated.
(D) The image can never be displayed on a
lm in digital technology.
19. All of the following are characteristics of
double emulsion lm/screens combination.
Which characteristic makes these systems
undesirable in mammography use?
(A) They are less susceptible to imaging
dust and dirt than the single emulsion
systems.
(B) They do not require extended processing
times to develop optimum contrast and
speed.
(C) The screens are very efcient at convert-
ing x-ray energy to visible or ultraviolet
light.
(D) The system has a lower spatial resolu-
tion than the single emulsion systems.
20. Film fog is best demonstrated on the charac-
teristic curve as
(A) the straight-line portion of the graph
(B) the toe of the graph
(C) the shoulder of the graph
(D) the shift of the graph to the left
21. The characteristic curve, obtained by plotting
density values from a sensitometer, can be
used to assess all of the following except
(A) to compare two different types of lms
(B) to compare the same lm under differ-
ent processing conditions
(C) to compare the x-ray beam quality with
different lms
(D) to monitor the daily processing conditions
22. The characteristic curve of two lms is plot-
ted. The curve of lm A is positioned to the
left of the curve of lm B.
1. lm A is faster than lm B
2. lm B is faster than lm A
3. at any optical density, lm A will require
less exposure than lm B
(A) 1 only
(B) 2 only
(C) 2 and 3 only
(D) 1 and 3 only
23. Which of the following mammographic qual-
ity control tests is performed monthly?
(A) phantom images
(B) visual checklist
(C) repeat analysis
(D) screen cleanliness
24. Adequate air bleed time refers to the
(A) elapsed time between lm loading and
exposure
(B) time taken to release air from the proces-
sor drain tank
(C) time taken to remove air from the water
tank
(D) time taken to empty or bleed the proces-
sor chemistry
 Questions: 16 through 35 29

25. Which of the following quality control tests (C) clean the cassette screens with screen
does not require a densitometer? cleaner
(A) darkroom fog (D) check the cassettes for dirt or lint
(B) screen-lm contact
31. The phantom image background optical den-
(C) screen cleanliness sity should never be
(D) phantom images
(A) more than 1.20
26. The criteria to pass the ACR Mammography (B) less than 1.20
Accreditation on conventional phantom (C) more than 1.40
imaging require a minimum of _______ masses. (D) less than 1.40
(A) two
32. In the darkroom fog test, the optical density
(B) three
difference between fogged and unfogged
(C) four areas of the lm should not exceed
(D) ve
(A) 1.20
27. In establishing processing quality control (B) 0.15
operating levels, the speed index is designated (C) 0.05
as the density (D) 0.02
(A) closest to but not less than 2.20
33. In viewing phantom image, which of the fol-
(B) closest to but not less than 1.20
lowing viewing conditions need not apply?
(C) closest to but not less than 0.45
(D) 2.20 or higher (A) on the same view box
(B) using the same type magnier
28. For the daily quality control testing, the base- (C) at the same time of day
plus-fog level should remain within (D) using the same lm emulsion batch
(A) +0.15 of the established levels
34. In the test for screen contact there were multi-
(B) +0.10 of the established levels
ple points of small areas (<1 cm in diameter)
(C) +0.30 of the established levels of poor contact. The corrective action is to
(D) +0.03 of the established levels
(A) replace the cassettes; this result is not
29. The screen-cleaning test should be carried acceptable
out whenever (B) repeat the test
(C) return the cassette to clinical use
(A) there is an upward drift in the operating
data levels (D) clean the screens, wait 15 minutes, then
repeat the test
(B) there is a change in the types of chemical
used
35. One of the two reasons towels are used in the
(C) there is a change in lm brand or type compression test is to
(D) a mammographer notices dust artifacts
on the image (A) protect the cassette holder
(B) ensure that the compression is adequate
30. Before processing the sensitometric strip each (C) force slower application of compression
day, the mammographer should (D) simulate 4 cm of compressed breast
(A) check the developer temperature
(B) be sure the view boxes are clean
30 2: Instrumentation and Quality Assurance

36. For the repeat analysis to be meaningful, a 41. If, after examining a phantom image, the
patient volume of at least _______ patients is number of visualized bers or masses has
needed. changed signicantly, the next step is to
(A) 50 (A) record the new values
(B) 100 (B) call the medical physicist
(C) 250 (C) call the equipment service personnel
(D) 300 (D) check the mammography unit or the
image processor
37. Daily processing control can involve all of the
following except 42. Repeated lms are

(A) cleaning the processor feed tray (A) lms used for processor cleaning
(B) using the sensitometer to measure the (B) lms used for quality control
densities on the strip (C) lms that involve exposure to the
(C) recording the temperature of the devel- patient
oper tank (D) all discarded lms
(D) mixing the chemicals
43. If the patient volume at a mammography site
38. Proving that a darkroom fog failure is a result is 200 patients per week, the repeat/reject
of safelight problems involves analysis should be done every

(A) moving the safelight at least 6 ft from (A) week

the work surface (B) 2 weeks
(B) repeating the test with the safelights off (C) 2 months
(C) checking for light leaks around the (D) 3 months
doors and passbox
(D) changing the lter on the safelight 44. All the uorescent tubes in the mammogra-
phy view box should be replaced at the same
39. The darkroom fog test is performed time because

(A) semiannually (A) Fluorescent tubes decrease in brightness

with age.
(B) monthly
(B) Fluorescent tubes will only last about
(C) weekly
1824 months.
(D) daily
(C) They have a higher luminescence than
conventional tubes.
40. Daily processor control is used to
(D) It saves time to replace them all at the
1. determine the lm speed same time.
2. check the lm contrast
3. check the stability of the processor 45. In imaging the phantom, the technical factors
(A) 1 and 2 only used should be the same as those used clini-
cally for a ______ -cm-thick breast of medium
(B) 2 and 3 only
glandularity.
(C) 1 and 3 only
(D) 1, 2, and 3 (A) 6.06.5
(B) 5.05.5
(C) 4.04.5
(D) 3.03.5
 Questions: 36 through 50 31

46. Mammography facilities can receive certica- 49. Digital images can be viewed on a computer
tion from monitor or printed using
1. the ACR (A) dry laser technology
2. the FDA (B) single emulsion mammography lm
3. an SAC state (C) single emulsion laser lm
(A) 1 and 2 only (D) double emulsion lm, sensitive to the
(B) 2 and 3 only red-light spectrum emitted by lasers
(C) 1 and 3 only
50. Hardcopy viewing of the digital imaging
(D) 1, 2, and 3 only
describes
47. An MQSA certicate is issued when a mam- (A) displaying the image on the mammog-
mography facility has been accredited. This rapher s workstation for further
certication is valued for enhancement
(A) 1 year (B) the only image viewed by the mammog-
rapher
(B) 2 years
(C) the image that is sent for interpretation
(C) 3 years
(D) the ability to reduce the cost associated
(D) 4 years
with repeats
48. If any of the visual checks fail, the first step
is to
(A) correct or replace the item
(B) call the medical physicist
(C) call the processor service
(D) call the equipment service representative
 Answers and Explanations
1. (B) The kVp controls the wavelength or the
penetrating power of the beam. Increasing
the kVp will decrease the contrast. The kVp
will therefore ultimately control the subject
contrast, exposure latitude, and image con-
trast. Remember, however, that as the kVp is
reduced, the penetrating ability of the beam
is also reduced leading to the use of higher
mAs. Higher mAs use increases patient dose
(Bushong, 327340; Peart, 6585).
2. (B) All mammography units are manufac-
tured with tungsten, molybdenum, or
rhodium targets matched with the appro-
priate K-edge filters. These targets have dif-
ferent atomic numbers and therefore differ-
ent emission spectrums. The characteristic
energies of molybdenum are most effective
for fatty breast tissue. The characteristic
x-rays produced using rhodium targets
with rhodium filtration are similar to those
from molybdenum but, because rhodium
has a slightly higher atomic number, more
bremsstrahlung x-rays are produced. How-
ever, the energy of the K-characteristic
x-rays will be 23 keV higher, which pro-
vides a better penetration of dense breast
although it generally results in lower con-
trast images. Tungsten targets with tung-
sten filtration are not used in conventional
mammography units because here brems-
strahlung x-rays will predominate at
energies above and below the 17- to 24-keV
range. The x-rays most useful in maximiz-
ing contrast in breast tissue are in the 17- to
24-keV range (Bushong, 327340; Peart, 6585).
32
3. (B) Mammography uses very low energy
x-ray beams and it is important that the x-ray
tube window does not attenuate the low-
energy photons therefore hardening the
beam. The proper lter shapes the emission
spectrum of the x-ray beam and makes it
compatible with the IR and breast character-
istics of each patient. In general, mammogra-
phy units either have borosilicate or beryl-
lium as port windows (Bushong, 327340).
4. (C) The heel of the anode will reduce the
intensity of the x-ray beam on the anode side
only. When comparing the beam intensity on
the cathode versus the anode side, the inten-
sity on the cathode side will be higher. To
compensate for this varying intensity, the
mammography tube is turned to position the
thickest portion of the breast (posterior) at
the cathode end of the tube. In general, the
smaller the anode angle, the larger the heel
effect because there is increased absorption
of the rays (Figure 2-1) (Bushong, 327340; Peart,
6585).
5. (D) Both the height and angle of the compres-
sion paddle make a difference in the nal
image and the overall design is considered to
increase the structural strength of the compres-
sion paddle. A compression device with a
rounded or gently sloping posterior edge does
not allow uniform compression of the poste-
rior area of the breast. The height of the com-
pression reduces the chance of chest tissue
overlapping on the mammogram. The design
of the lip has a lesser effect on the anterior
aspect of the breast (ACR, 3033; Peart, 6585).

x-ray tube tilted from the horizontal
Horizontal
Target
Vertical beam
parallel to the
chest wall
Compression plate
Breast
Image receptor
Figure 21. Heel effect. A portion of the beam is absorbed by the
anode (target). This results in the lower energy beam at the anode
end of the tube. This effect is minimized in mammography by tilting
the tube and placing the anode toward the nipple (lower density)
area of the breast.
6. (B) Compression does all of these, but its
primary goal is to reduce the breast thickness
uniformly-(separate breast structures) and
allow uniform penetration by the x-ray beam
(ACR, 3033; Peart, 6585).
7. (B) The most common cause of failure of the
AEC is improper placement of the detector.
Processing affects the mammographic image
after exposure and mammographic quality
control ensures correct processing conditions.
Decreased radiographic contrast is a result of
underexposure, not the cause, and inade-
quate compression, although it causes uneven
densities on the mammogram, does not result
from AEC failure (ACR, 92; Peart, 6585).
8. (A) The multiple detector system of the AEC
allows the unit to respond to different breast
composition and various breast sizes. If the
detector is placed over fatty breast tissue, the
glandular tissue will be underexposed. To
produce an adequate exposure, the detector
must be placed over the densest or most
glandular areas of the compressed breast
(Bushong, 327340; Peart, 6585).
Answers and Explanations: 1 through 11 33
Parallel grid line Crossed grid lines
A B
Grid height
C Width of interspace material = d
Cross-section of the grid showing the grid strips between the
interspace material
Grid ratio = h/d
Grid frequency = number of grid strips per inch or per centimeter
Figure 22. Schematic diagram showing (A) a parallel grid
typical of mammography grids and (B) the cross grid such as
the HTC grid. (C) Represents a cross-section of a typical grid.
9. (B) All grids result in increased exposure and
patient dose, but improve contrast. The mam-
mography grid, however, has a lower grid ratio
than general radiography grids. The grid ratio
of mammography grids ranges from 3:1 to 5:1
versus the 6:1 to 16:1 ratio of grids used in gen-
eral radiography (Grid ratio = height of the lead
strips/the distance between the strips [h/d])
(Bushong, 327340; Peart, 6585) (Figure 2-2).
10. (C) Higher grid ratios will require too large
an increase in exposure. On an average, the
grids used in mammography range from 3:1
to 5:1, with frequencies of 3050 lines per
centimeter. Typically, a mammography grid
may have a grid ratio of 4:1, and although
such a grid will double the patient dose
when compared to a nongrid exposure, the
increased contrast will be signicant (Bushong,
327340; Peart, 6585) (Figure 2-2).
11. (A) Collimating or decreasing eld reduces
scatter and therefore improves the contrast.
However, because collimating reduces the scat-
tered radiation density to the area, the exposure
must be increased (Bushong, 327340; Peart, 6585).
34 2: Instrumentation and Quality Assurance
12. (D) The compression plate is specifically
designed to properly position and compress
the breast while reducing discomfort to the
patient. The placement of the lip, just beyond
the chest wall edge of the IR, prevents the
projection of an image of the chest wall edge
of the paddle on the mammogram (AEC, 3033;
Peart, 6585).
13. (A) The focal spot size is the area that elec-
trons strike on the target. In the design
known as the line-focus principle, the target
is angled allowing a larger area for the elec-
trons to strike while maintaining a small,
effective focal spot. The effective focal spot
size is the area projected onto the patient or
IR. It is also the value quoted when identify-
ing a small or large focal spot. The smaller
the target angle, the smaller the focal spot
size. Although the spatial resolution (the abil-
ity to image small objects that have high con-
trast) is directly related to the focal spot size,
changes in the SID, OID, and size of the colli-
mated eld do not affect the focal spot size
(Bushong, 327340; Peart, 6585).
14. (B) Mammography machines generally have
two focal spot sizes. The large focal spot may
be 0.4 or below (generally 0.3 mm) and the
small focal spot ranges from 0.150.1 (gener-
ally 0.1 mm). Routine work utilizes the large
focal spot size (Bushong, 327340; Peart, 6585).
15. (C) All cassettes are easy to open, durable,
and have low absorption characteristics rela-
tive to the kVp. Mammography cassettes are
designed for use with a single emulsion lm
and are therefore matched with a single
intensifying screen (Bushong, 327340; Peart,
6585).
16. (C) An increase in processing time generally
increases the developer time with further
increase in contrast and lm speed. The dis-
advantage of this system is the increased risk
of processing artifacts and the increase in
lm fog (Bushong, 342356; Peart, 87111).
17. (A) Digital mammography systems utilize
a detector and electronic system instead
of a cassette. CAD technology refers to
computer-assisted diagnosis, a technology
used to preread mammograms. CAD can be
used with both conventional and digital
mammography systems. Storage phosphors
are used with computed radiography sys-
tems; the imaging plates or imaging detectors
are coated with storage phosphors or pho-
tostimulable plates. X-rays will react with
the imaging plate to form the latent image
(Figure 2-3) (Bushong, 327340; Peart, 179191).
18. (C) One of the greatest advantages of digital
technology is the ability to manipulate the
nal image. The image can be adjusted for
contrast or brightness or magnied to zoom-
in on areas of interest. Digital mammograms
allow the same or lower patient dose and
although the technology is digital, a digital
latent image will form in the digital detector.
The image is converted to a manifest image
after digital processing. Digital images can be
viewed on a computer monitor or printed
using laser print technology (Figure 2-4)
(Bushong, 327340; Peart, 179191).
19. (D) Despite the numerous advantages of the
double emulsion system, these advantages
are outweighed by the single largest disad-
vantage: the system has a lower spatial reso-
lution than the single emulsion system. In
double emulsion systems, the emulsions of
both screens are activated by the x-rays and
will emit light. This crossover light compro-
mises image quality (Peart, 7983).
20. (B) The characteristic curve plots the relation-
ship between the optical density of the lm
and its exposure. The straight-line portion of
the curve records the useful range of optical
densities. The lowest exposure (base plus
fog) is the reading recorded at the toe of the
curve, and the highest exposure level is
recorded at the shoulder of the curve. A
graph shift to the left or right indicates differ-
ing lm speeds (Figure 2-5) (Bushong, 272283;
Peart, 8081).
21. (C) In conventional mammography, the char-
acteristic curve is used in quality control to
 A

B C

Figure 23. (A): A cross-section of an imaging plate. Computer radiography differs from conventional lm-screen imaging in the acquisition
stage. Instead of a lm-screen as the image detector, computer radiography uses a exible imaging place (IP) coated with storage phosphors
or photostimulable plates. The imaging plates are less than 1 mm thick. They absorb x-ray energy and form a latent image in much the same
way a lm does. The difference is the wide latitude of the storage phosphors. The higher sensitivity of the imaging plates demonstrates a lin-
ear response (input to output) to the intensity of x-ray exposure over a broad range. The IP is constructed much like a conventional screen.
Both have a protective laminate to protect the phosphor layer. The IP has a conductive layer to conduct away static; a exible support layer,
which allows IP exibility; and a backing layer to prevent damage to the IP. The barcode reader on the IP allows for patient information and
identication. With such a similar structure, the IP can be placed in modied cassettes and exposed with standard x-ray equipment. The x-ray
passes through the patient and reacts with the IP to form the latent image. (B): R2 ImageChecker DMax, a CAD device use to preread con-
ventional mammogram. Images are fed into the CAD reader and a monitor will highlight suspicious areas of calcication or mass densities.
(C): R2 CAD marks on Hologic SecurViewDX.
(Figures 3B and 3C used with permission from Hologic R2.)

35
36 2: Instrumentation and Quality Assurance

monitor processing conditions by recording

changes in the density values. Because of the
wide range of variables in x-ray-generating
equipment, the sensitometer and not the step
wedge is used to produce a uniform optical
step wedge on a lm, from which the charac-
teristic curve can be plotted. This removes
the x-ray unit from the equation. The charac-
teristic curve is then used to interpret
characteristics of the lm, such as contrast:
the steeper the slope the higher the contrast.
By plotting the characteristic curves of two
lms, the speeds of the different lms can be
compared. A characteristic curve obtained
by exposing a step wedge or penetrometer,
however, is capable of monitoring both the
x-ray equipment and lm-screen combina-
tion (Bushong, 272283; Peart, 8081).

22. (D) By plotting the characteristic curves of

two lms, the speed of the different lms can
be compared: the curve of the faster lm will
be positioned to the left of the curve of the
slower lm (Figure 2-6). The faster lm will
require less exposure than the slower lm to
produce any optical density (Bushong, 272283;
Peart, 8081).

Figure 24. (A): Actual computer reader. The IP is inserted into the reader, which converts the latent image to a manifest image. (B) Schematic
diagram of a computer reader. To read the latent image, the IP is inserted into an imaging plate reader or computer reader. The computer
reader then scans the image with a laser beam to initiate the emission of light from the storage phosphors. This stored energy leaves the IP in
the form of ultraviolet light. The intensity of light emitted from the IP is proportional to the amount of radiation absorbed by the storage phosphor.
During the reading process, the light emitted from the IP is collected and sent to a photomultiplier tube. The signal from the tube is amplied
and sent to an analog-to-digital converter where it is converted to a digital or electrical signal. The resultant digital information can then be
electronically transmitted, manipulated, and stored. The IP can be erased and used again and again by exposing them to strong light.
 Answers and Explanations: 22 through 26 37

4.0 mammography quality control tests and fre-

D quency are listed in the Summary of Impor-
tant Points in the beginning of the chapter on
page 22 (ACR, 119; Peart, 92112).
3.0
D 24. (A) The cassette should be loaded with a lm
e
n for at least 15 minutes before testing to
s 2.0 release any trapped air. This is the air-bleed
i
t time and refers to the time taken for the air
y
y
y trapped in the cassette to dissipate (ACR, 141;
C= x
Peart, 92112).
1.0

BF 25. (C) Screen cleanliness requires screen wipes

x and canned air or a screen cleaner. The den-
0 sitometer is needed for darkroom fog test to
1.0 SP 2.0 3.0 4.0
measure the density of the fogged versus the
Log relative exposure unfogged area of the image. In assessing the
screen-lm contact, the density at the chest
Figure 25. Characteristic curve. Normal H & D curve showing
base-plus-fog (BF), speed (SP), contrast (C), and maximum density
wall area of the wire-mesh image should be
(D) for a single exposure. between 0.7 and 0.8. In phantom image tests,
the densitometer is needed to measure the
background density and the density inside
23. (B) The visual checklist is performed the disk (ACR, 165166; Peart, 92112).
monthly, the phantom image check is taken
weekly, the repeat/reject analysis is per- 26. (B) The criteria for the number of objects on
formed quarterly, and screen cleanliness is the phantom necessary to pass the ACR are
performed weekly. The complete list of a minimum of four largest fibers, three
largest speck groups, and three largest
masses (Figure 2-7). The only exceptions to
4.0

0000 0000
3.0
D
e
n
s 2.0
i
t
y

1.0

A B

0
1.0 2.0 3.0 4.0

Log relative exposure

Figure 26. H & D curve-lm speed. Graph of H & D curves for

two different types of radiographic lms. Film A has a faster speed
than lm B because its speed point is the left of lm B. Film B has Figure 27. Diagram of phantom. A schematic diagram of the
a higher contrast than lm A because the slope of its curve is phantom showing the relative position of the different objects embed-
steeper than that of lm A. ded within the phantom.
38 2: Instrumentation and Quality Assurance
date are the Hologic and Siemens digital
units which require 5 fibers, 4 speck groups,
and 4 masses. In addition, the number of
test objects of each group type (fibers,
specks, and masses) visible in the phantom
image should not decrease by more than
one-half (ACR, 268; FDA; Peart, 92112).
27. (B) In establishing processing controls,
decide which sensitometer step has an aver-
age density closest to but not less than 1.20
(Figure 2-8). This is the mid-density (MD)
step, sometimes recorded as the speed index.
Decide which step has a density closest to
2.20, and which step has a density closest to
but not less than 0.45. The difference in
densities between these two is the density
Figure 28. Sensitometer strip.
In conventional imaging the sensit-
ometer will produce a step-wedge
pattern of 21 different optical densi-
ties. A densitometer is then used to
record the base-plus-fog value and
the high-, medium-, and low-density
measurements. These results are
then plotted on the daily processor
quality assurance chart.
difference (DD) or contrast index. Suggested
performance criteria for the MD and DD are to
be within 0.15 optical density units of the oper-
ating level. If the MD or DD exceeds the operat-
ing limits by 0.15, corrective action needs to be
taken. Changes in density can be because of
chemistry, temperature, replenishment, or dark-
room fog (ACR, 149164; Peart, 92112).
28. (D) The base plus fog (B + F) should remain
within +0.03 of the established levels. If B + F
exceed the normal level by 0.03, immediate
corrective action must be taken. Changes in
B + F can be owing to chemistry, temperature,
replenishment, or darkroom fog (ACR, 149164;
Peart, 92112).
29. (D) Although recommended weekly, this test
must be carried out whenever dust or any
other artifact is seen on the image. Changes
in the lm brand, processing chemistry, or
processing quality control will not affect
screen cleanliness (ACR, 165; Peart, 92112).
30. (A) The sensitometer strip is used to verify
that the processor is operating within normal
limits. Of all these answers, only a too high
or too low developer temperature will have
an impact on the density of the sensitometric
strip (ACR, 149164; Peart, 92112).
31. (B) The background optical density on the
phantom should never be less than 1.2 and
should not vary by more than 0.2 (Figure 2-9).
The mAs should not vary by more than 15%
from test to test. Optical density should be at
least 1.4 (ACR, 268269; Peart, 92112).
32. (C) The optical density difference between
the fogged and unfogged areas of phantom
in the darkroom fog test should not exceed
0.05 (Figure 2-10) (ACR, 189193; Peart, 92112).
33. (D) Different individuals will always perceive
an image differently. Because of this, the phan-
tom should always be viewed by the same
individual, using the same view box and view-
ing conditions, such as magnication. In addi-
tion, the criteria used for viewing the phantom
images should be the same as that used when
 Answers and Explanations: 27 through 36 39

Figure 210. Darkroom fog test. Phantom images showing dark-

room fog. A densitometer is used to measure close to the edge
separating the fogged and unfogged portions of the phantom
image. The density should not be measured over any test object in
the phantom.
A

cleaning the cassette, means the cassette has

failed (ACR, 194198; Peart, 92112).

35. (A) The towels protect the cassette holder

and prevent damage to the compression
device. The amount of automatic compres-
sion applied is a function of the unit and will
not be altered by the presence or absence of a
towel. However, the force of the compression
device hitting the cassette holder could dam-
age both (ACR, 199201; Peart, 92112).

36. (C) The repeat analysis is used to identify

problem areas within the department
(Figure 2-12). However, for the analysis to be

Figure 29. (A): Radiograph of phantom. An actual radiograph of

a phantom with 1-cm diameter, 4-mm-thick disc. This disc is used
for contrast measurement. Arrows indicate points where density
measurements should be made. The image is scored based on
what is seen on the lm. (B) Radiograph of a digital phantom. In
digital imaging the acrylic disc is not always needed.

reading mammograms. Because a box of lms

will not last forever, a new box, and therefore, a
different lm emulsion will eventually be nec-
essary (ACR, 167187; Peart, 92112).

34. (C) Multiple small areas of poor contact (<1 cm

Figure 211. Screen-film contact. A screen should be replaced
in diameter) are acceptable (Figure 2-11). if it has an area (>1 cm in diameter) of poor contact that cannot be
Large areas (>1 cm in diameter) of poor con- eliminated. Multiple small areas are considered acceptable
tact, which remain unchanged even after (sample area shown is 1 cm in diameter).
40 2: Instrumentation and Quality Assurance

Figure 212. Repeat analysis. A sample of the repeat/reject chart used by mammographers to chart the reasons for rejected lms. The nal
percentage of repeats and rejects is calculated as a percentage of the total lms used. The percentage of each category of repeated lm is
calculated as a percentage of the total repeat rate.

meaningful a sufcient patient volume is
needed. The MQSA recommends a meaningful
volume of at least 250 patients (ACR, 202203;
Peart, 92112; Stevens, 275370).
37. (B) A sensitometer is designed to expose a
uniform optical step wedge onto a lm; the
densitometer is an instrument that measures
the degree of blackening (density) on a lm.
Daily processing control is a means of ensur-
ing that the slight changes in lm processing
will be corrected before they have an impact
on the image quality. The developer tempera-
ture and the chemistry of the solutions can
both impact image contrast. Keeping a clean
feed tray reduces lm artifacts (ACR, 339;
Peart, 92112).
38. (B) The simplest way to conrm that the
darkroom fog testing failed because of a safe-
light problem is to repeat the test with the
safelight off. If the test passes, then the safe-
light is the problem and the lter could be
changed or the light moved to a different
location. If the test with the safelight off fails,
other areas to check include light leaks
around the doors and passbox (ACR, 192;
Peart, 92112).
39. (A) Darkroom fog test is performed semian-
nually to ensure that the darkroom safelights
or other source of light leaks are not fogging
the mammographic lm. Film fog will result
in loss of contrast and therefore loss of diag-
nostic information. This test should also be
performed whenever the safelight bulb or l-
ters are changed (ACR, 119; Bushong, 342356;
Peart, 92112).
40. (D) The processor quality control test is used
to determine that the processor and processor
chemistry are stable and consistent. At the
beginning of each day, a sensitometric strip is
exposed and processed following MQSA
guidelines. The medium density evaluates
lm speed, the density difference evaluates
image contrast, and the base-plus-fog value
evaluates the level of fog present in the pro-
cessing chain. By checking and correcting
any value that exceeds the normal limits,
Answers and Explanations: 37 through 44 41
mammography lm will be processed only
under optimal conditions to enhance contrast
(Figure 2-13) (ACR, 149; Bushong, 342356; Peart,
92112).
41. (D) Because the purpose of quality control
testing is to ensure optimal conditions before
clinical images are processed, signicant
changes must rst be corrected. Whenever a
test fails, the rst corrective action is to verify
that the equipment is operating correctly, and
then repeat the test to determine whether the
change is real or not. However, the phantom
test is a check of the mammography unit and
the processing. It will therefore assess the
image density, contrast, and uniformity. The
phantom test should therefore be performed
only after the daily processor quality check.
Although this will not totally rule out the
processor as the cause of the problem, it will
direct attention to the mammography unit.
The medical physicist or the equipment ser-
vice personnel should be called if the prob-
lem cannot be isolated or corrected by the
mammographer (ACR, 186; Bushong, 342356;
Peart, 92112).
42. (C) Repeated lms are those that had to be
repeated and resulted in additional exposure
to the patient, for example, double exposed
lms or lms with motion. Rejected lms are
all discarded lms, including repeated lms.
Rejected lms can include lms used for
quality control or processor cleaning (ACR,
202; Peart, 92112).
43. (D) Repeat analysis testing is carried out
every 3 months (quarterly), unless the patient
volume is less than 250 in the quarter (ACR,
202; Peart, 92112; Stevens, 275370).
44. (A) Because uorescent tubes decrease in
brightness with age, changing the tubes all at
the same time ensures that the mammograms
or phantom images are always viewed under
identical conditionsuniformity in color and
luminance. In addition, it is advisable to
replace uorescent tubes every 1824 months.
View boxes used for mammography should
be capable of producing a luminance of at
42 2: Instrumentation and Quality Assurance

Figure 213. Sample processor control chart. The sensitometer strip is exposed and processed each day and the data evaluated and plot-
ted. The result is the processor control chart. Data out of the control limits are circled and the test repeated. The cause of the problem and
corrective action is recorded in remarks section of the control chart.
 Answers and Explanations: 37 through 44 43

Figure 214. Sample phantom control chart. The weekly phantom evaluation checks the lm optical density, contrast (density difference),
and number of fibers, speck groups, and masses. The results are plotted. Data out of the control limits are circled and the test repeated.
The cause of the problem and corrective action is recorded in the remarks section of the control chart.
44 2: Instrumentation and Quality Assurance
least 3000 cd/m2. The illumination levels
should be 50 lux or less (equivalent to a
moonlit room). Luminance is the amount of
light either scattered or emitted by a surface
and is measured in cd/m2 (candela per meter
square). Illuminance is the intensity of light
striking a surface and is measured in lux
(1 lux = 1 lumen/m2; 1 lx = 1 lm/m2) (ACR,
209; Peart, 92112; Stevens, 275370).
45. (C) The mammographic phantom is equiva-
lent to a 4.2-cm-thick compressed breast con-
sisting of 50% glandular and 50% adipose tis-
sue. The technique used should be the same
as that used clinically and the lm should be
processed just like a clinical mammogram.
Phantom images are taken to ensure that the
optical density contrast and image quality are
at optimal levels (Figure 2-14) (ACR, 167;
Bushong, 342356; Peart, 92112).
46. (B) Under MQSA rules, accreditation and
certication are two separate processes. Both
are required by the FDA. Effective on May
2002, certication is permitted only by the
FDA or certain statesStates as Certiers
(SAC). The SAC permitted are Illinois, Iowa
and South Carolina. States can certify only
facilities within their state. Accreditation is a
process administered by an FDA-approved
accreditation body, which can be a private,
nonprot organization or a state agency
approved to accredit mammography facili-
ties. The FDA has approved four accredita-
tion bodiesthe American College of Radiol-
ogy (ACR) and the states of Arkansas, Iowa,
and Texas. State accreditors can only accredit
facilities within their state. These four bodies
all have the authority to implement the
MQSA standards through the accreditation
process (FDA).
47. (C) After completing the accreditation
process, the FDA or States as Certiers, SAC
state will issue a certication that is valid for
3 years and can be renewed as long as the
facility remains properly accredited and
demonstrates that it meets the MQSA stan-
dards during annual inspections (FDA).
48. (A) Examples of visual checklist items are a
check of mechanical locks or display lighting.
Many items are for the mammographers
convenience; some, however, are essential for
patient safety and the production of quality
images. If the technologist cannot replace or
repair missing or broken items, the equip-
ment service personnel should be called
(ACR, 213; Peart, 92112; Stevens, 275370).
49. (A) Most digital hard copy printing is done
using a dry processing laser printer. This elim-
inates the chemical solutions by using a heat-
sensitive lm that contains the processing
chemicals. Also, this type of lm can be han-
dled in room light. In dry processing laser
printer, heating the lm produces the manifest
image. These systems do not use chemicals
and need no water hook up. Disadvantages of
the laser-printed lm are: expense and the
lower optical density and latitude. Film-screen
mammography uses single emulsion lms.
Because of their lower spatial resolution, dou-
ble emulsion lms are not used in mammog-
raphy. In the past, the laser printer used a
single emulsion lm that is sensitive to the
red light emitted by the laser, similar to how
blue- and green-sensitive lms are used in
conventional systems. These laser lms must
be handled in total darkness and were used
mainly in computed tomography (CT) imag-
ing (Bushong, 199; Peart, 187; Shephard, 359362).
Figure 215. A soft copy viewer (digital LCD monitor) in the x-ray
room. The digital image can be viewed within seconds.

50 (C) In digital imaging, the image is available
for viewing within seconds. This initial view-
ing is often referred to as soft copy viewing
by the mammographer. At the soft copy
viewing station, the mammographer can
enhance the image, modify patient demo-
graphics, or accept/reject the image based on
standard positioning criteria, before sending
the image to the radiologist workstation or to
Answers and Explanations: 45 through 50 45
the site of hardcopy viewing. Before the
advent of high-resolution monitors, the nal
hard copy viewing of the digital images was
in printed form. Now, however, the hard
copy viewing can be on an LCD monitor at
the radiologists desk. Typically monochrome
monitors, minimum 2,500 2,500 pixels
(5-megapixel) are recommended (Peart, 181182;
Shephard, 335340; Zuley, 14921498) (Figure 215).
This page intentionally left blank
 CHAPTER 3
Anatomy, Physiology,
and Pathology of the Breast
Summary of Important Points
LOCALIZATION TERMINOLOGY
The breast is generally described in terms of the
face of a clock, and can also be divided into four
quadrants.
External Anatomy
In the female, breasts are accessory glands of the
reproductive system with the function of secreting
milk for nourishment of the newborn. The female
breast is spherical in shape, and size varies with
age, menstrual cycle, and lactation. Hormonal stim-
ulation causes the breasts to grow. The breast is
loosely attached to the fascia, covering the pec-
toralis major muscle.
The skin of the breast, like the skin of the body,
is lled with sweat glands, sebaceous glands (oil
glands), and hair follicles that open to form the skin
pores. The nipple lies at the center point of the
breast. The areola is the smooth, circular darkening
surrounding the nipple that contains many small
protrusions on its surface (Morgagni tubercles).
The nipple itself contains multiple crevices, within
which are 1520 orices, or collecting ducts that
transfer milk from the lactiferous ducts.
Location
The breasts lie anterior to the pectoralis major. Sep-
arating the breast from the pectoral muscle is a
layer of adipose tissue and connective fascia
referred to as the retromammary space.
Internal Anatomy
The breast is made up of a varying mixture of adi-
pose or fatty tissue, glandular or secretory compo-
nents, connective tissue, lymphatic vessels, and
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
blood vessels. Cooper ligaments are the supportive
structures of the breast. Fibrous and glandular tissues
are usually described together as broglandular. The
pattern and distribution of the glandular tissue is usu-
ally the same bilaterally.
Blood Supply to the Breast
The breast receives its arterial supply from
branches of the internal mammary and lateral tho-
racic arteries. Veins that drain the breast form a
venous network under the nipple. This network
then drains into the axillary and internal mammary
veins. Veins are usually larger than arteries and are
located more peripherally.
Lymphatic Drainage of the Breast
The primary lymphatic drainage of the breast is to
the axilla. There is also cross-mediastinal drainage
from the medial portion of the breast to the other
breast. The majority of normal axillary lymph
nodes is less than 2 cm in size and has a kidney-
shaped appearance (Figure 3-1).
Histology
The average female breast consists of 1520 lobes
containing numerous glandular lobules held
together by connective tissue, blood vessels, and
branching ducts (lactiferous ducts). Each of the
1520 lobes in the breast contains a treelike pat-
tern of ductal structures radiating out from the
nipple.
Factors Affecting Tissue Composition
The normal physiological changes that take place
in the breast are related to the onset of menarche,
the amount of hormone uctuation whether normal
47
48 3: Anatomy, Physiology, and Pathology of the Breast
Lobule containing alveoli
Mammory duct (segmental ducts)
Lactiferous sinus (ampulla)
Lactiferous duct or connecting duct
Nipple
Figure 31. A schematic diagram of the breast showing the
branching distribution system of a collecting duct. The nomencla-
ture of the duct system is varied.
or synthetic, pregnancy, lactation, and menopause.
Also, because the breast has a high fat content,
weight gain or weight loss will affect breast tissue
composition.
Malignant Conditions and Mammographic
Appearances
Mammographically, the breast will be visualized as
less dense areas of fat (which appear black on the
radiograph) and denser glandular areas (which
appear white or gray on the radiograph). Often
blood vessels can be seen, especially if they are cal-
cied, and occasionally lymph nodes are visualized
within the breast as kidney-shaped oval densities
with lucent centers.
The majority of breast diseases occur in the ter-
minal duct lobular units (TDLUs); however, the
brous or connective tissue can also be involved.
Other lesions occur in the larger ducts.
Malignant and benign breast lesions can be placed
in ve categories:
Circular/oval lesion may be poorly outlined: cir-
cular, oval, or lobulated; and solitary or multiple.
Spiculate/stellate lesions are radiating struc-
tures with ill-dened borders.
Calcications may or may not be associated
with a tumor.
Thickened skin syndrome may present over
the entire breast and may or may not be associ-
ated with an increased density.
There may be any combination of two or more
of the above lesions.
Characteristics of Malignant Circular/
Oval Lesions
High densitystructures such as veins and
trabeculae cannot be seen through the lesion
Smooth or lobulated and randomly orientated
not aligned along the trabecular structure of
the breast
Characteristics of Malignant Spiculated/
Stellate Lesions
Have a distinct central mass.
Sharp, dense, ne lines of variable length radi-
ating in all directionsthe larger the central
tumor mass, the longer the spicules.
If spicules reach the skin or muscle, it may
cause localized skin thickening or skin dim-
pling (retraction).
Commonly associated with malignant-type
calcications.
Characteristics of Malignant Calcication
There are three basic forms of malignant
calcifications:
Casting-type calcicationsne linear branch-
ing calcications seen on the mammogram as
linear, fragmented, or occasionally branching
calcications with irregular contours.
Granular-type calcicationsirregular in form,
size and density. They resemble granulated sugar
or crushed stone. They are usually grouped very
close together in single or multiple clusters.
Powderlike calcicationsmultiple clusters of
powderlike calcications
Skin Thickening Syndrome
Skin thickening may be caused by either benign or
malignant conditions.

The skin will appear obviously thickened, gen-
erally in the lower dependent portion of the
breast.
The overall density of the breast is increased
owing to the high uid content (seen as a
coarse reticular pattern on the mammogram).
BENIGN CONDITIONS AND MAMMOGRAPHIC
APPEARANCE
See Figure 3-2.
Characteristics of Benign Circular/Oval
Lesions
Radiolucent, for example, lipoma, oil cyst,
galactocele
Radiolucent and radiopaque combined, for
example, lymph node, broadenolipoma,
galactocele, and hematoma
Low density, therefore the surrounding parenchy-
mal structures can be seen through the lesion, for
example, broadenoma, cyst
Spherical or ovoid with smooth borders gener-
ally aligned in the direction of the nipple along
the trabecular structure of the breast, for exam-
ple, cyst
A halo sign which is seen as a narrow radiolu-
cent ring or ring segment around the circum-
ference of the lesion, for example, cyst
A capsule which is a thin curved radiopaque
line surrounding the lesion, for example,
broadenoma
Summary of Important Points 49
Some exceptions to these rules are abscess, cal-
cied hematoma, and sebaceous cyst.
Characteristics of Benign Spiculated/Stellate
Lesions
No solid, dense, or distinct central mass, for
example, radial scar.
May have translucent oval or circular area at
the center, for example, radial scar.
Very ne linear densities or lower density
spicules, for example, radial scars or traumatic
fat necrosis.
Never associated with skin thickening or skin
retraction. The exception is traumatic fat necrosis.
Characteristics of Benign Calcication
Smooth contours, high uniform density, for ex-
ample, plasma cell mastitis
Evenly scattered homogenous, for example,
calcied arteries
Sharply outlined, spherical, or oval, for exam-
ple, calcied hematoma
Pear-like densitiesresemble teacups or pearl
drops on the lateral projection, for example,
milk of calcium
Bilateral and evenly scattered following the
course of the ducts throughout much of the
parenchyma, for example, plasma cell mastitis
Ringlike, hollow, for example, sebaceous gland
calcications
Eggshell-like, for example, oil cyst, papilloma
Large size, bizarre shape, for example, heman-
giomas
50 3: Anatomy, Physiology, and Pathology of the Breast

A B C D

E F G

I J K L

M N O P

Figure 32. Picture summary of breast lesions. (A) Benign-type calcications. (B) Cyst. (C) Deodorant calcications. (D) Benign calci-
cations: developing oil cysts and calcied hematomas. (E) Fibroadenoma. (F) Epidermoid cyst in posterior breast. Lucency represents air, post
biopsy. (G) Calcified galactocele. (H) Lymph nodes. (I) Lymph nodes. (J) Calcified sebaceous glands. (K) Malignant-appearing stellate
lesion. (L, M, N) Malignant-type calcications. (O) Microhematoma. (P) Scar marker. (Q) Oil cystbenign calcications. (R) Plasma cell
mastitisbenign calcifications. (S) Skin folds. (T) Skin mole. (U, V) Skin thickening. (W) Specimen. (X) Spot compression of an oval lesion.
(Y) Stellate lesion. (Z) Stellate lesion. (AA) Sellate lesion. (BB) Veins, calcied. (CC) Keratosis.
 Summary of Important Points 51

Q R S T

U V W
X

Y
Z AA BB CC

Figure 32. (continued)

 Questions

1. A lesion located in the upper outer quadrant 6. The structure that gives the breast its support
of the right breast is located in the and shape is called
(A) 5-oclock position (A) Montgomery ligament
(B) 2-oclock position (B) Cooper ligament
(C) 10-oclock position (C) broglandular tissue
(D) 7-oclock position (D) fatty tissue

2. Morgagni tubercles are usually found 7. The breast extends vertically from the
(A) on the nipple (A) rst through the ninth rib
(B) on the lateral border of the breast (B) second through the tenth rib
(C) in the terminal duct lobular unit (TDLU) (C) second through the sixth rib
(D) on the skin of the areola (D) third through the tenth rib

3. An inverted nipple 8. The thickest portion of the breast is the

(A) always indicates breast cancer (A) areola
(B) sometimes indicates breast cancer (B) nipple
(C) never indicates breast cancer (C) tail of Spence
(D) usually indicates breast cancer (D) inframammary crease

4. Compression of the breast is most effective and 9. Cooper ligaments attach anteriorly to the
most comfortable when applied against the
(A) deep fascia of the lobes
(A) medial and lateral aspects (B) fascia of the skin
(B) inferior and superior aspects (C) posterior surface of the breast
(C) medial and superior aspects (D) connective and supporting stroma
(D) inferior and lateral aspects
10. Fatty tissue is generally _______ and on the
5. The normal breast may have mammogram is seen as areas of _______ opti-
cal density.
(A) 05 lobes
(B) 1520 lobes (A) radiolucent/lower
(C) 3040 lobes (B) radiopaque/higher
(D) 340350 lobes (C) radiolucent/higher
(D) radiopaque/lower

52
 Questions: 1 through 20 53

11. Typically, a patient with dense brous and 17. The TDLU consists of the
glandular tissue throughout the entire breast
(A) mammary ducts and the extralobular
on a baseline mammogram is
terminal ducts (ETDs)
(A) age 20 or younger (B) intralobular terminal duct (ITD) and the
(B) between age 50 and 60 segmental ducts
(C) above 70 (C) the ETDs and the lactiferous ducts
(D) below 45 (D) both the ETDs and the ITDs

12. Glandular tissue is usually found in the 18. A patient began taking synthetic hormones
_______ of the breast. 6 months prior to her current mammogram.
The mammogram is most likely to
(A) medial and lower inner quadrant
(B) central and upper outer quadrant (A) be unchanged from the previous year
(C) medial and lower outer quadrant (B) show increased glandular tissue com-
(D) central and upper inner quadrant pared to her previous mammogram
(C) show decreased glandular tissue com-
13. Lymph drainage from the medial half of the pared to her previous mammogram
breast is generally directed to the (D) show increased fatty tissue compared to
her previous mammogram
(A) internal mammary lymph nodes
(B) external mammary lymph nodes 19. A baseline mammogram shows that the
(C) axillary lymph nodes patients breast consists primarily of adipose
(D) axilla tissue. This patient is most likely to be
(A) on hormone therapy
14. Immediately behind the nipple, the connect-
ing duct widens to form the (B) above 60
(C) below 20
(A) lactiferous sinus
(D) above 35
(B) ampulla acinus
(C) TDLU 20. A patient is to have a routine baseline mam-
(D) segmental duct mogram, but it is determined that the woman
is lactating. What should be done and why?
15. The portion of the breast that holds the milk-
(A) Lactating breasts are extremely sensitive
producing element is the
to compression; the mammogram
(A) ampulla should be postponed.
(B) segmental duct (B) The mammogram should be done;
(C) lobule radiation has no effect on lactation.
(D) lactiferous sinus (C) Although lactating breasts are extremely
dense, the mammogram should not be
16. Veins are normally located rescheduled.
(D) Lactation causes increased glandularity;
(A) in the periphery of the breast
the mammogram should be postponed.
(B) central areas of the breast
(C) in the axilla area of the breast
(D) in the medial areas of the breast
54 3: Anatomy, Physiology, and Pathology of the Breast

21. The craniocaudad mammograms of the same 25. An asymptomatic patient presents with an
woman prior to menopause and 1 year after oval, lobulated tumor with unsharp margins.
the onset of menopause are compared. The There is no evidence of a halo sign.
woman has never taken synthetic hormones.
(A) If the lesion is also radiolucent it is likely
What is the most likely difference?
to be benign.
(A) The mammogram taken prior to (B) The lesion could be malignant.
menopause shows signs of atrophy. (C) All oval lesions are benign.
(B) The mammogram taken after the onset (D) The absence of a halo indicates
of menopause shows signs of atrophy. malignancy.
(C) There will be little or no change in the
glandularity of the breast. 26. The tumor seen in Figure 3-3 is characteristic of
(D) The mammogram taken after menopause
(A) invasive ductal breast carcinoma
will show increased glandularity.
(B) a mammographically malignant tumor
22. Which of the following will affect the ratio of (C) a mammographically benign tumor
glandular tissue to total breast tissue? (D) a low-density tumor typical of benign
lesions
1. the womans genetic predisposition
2. ratio of total body adipose tissue to total
body weight
3. drastic weight gain or weight loss
(A) 1 only
(B) 1 and 2 only
(C) 2 and 3 only
(D) 1, 2, and 3

23. Hormone replacement therapy could be rec-

ommended to?
1. relieve insomnia symptoms
2. prevent osteoporosis
3. reduce weight gain
(A) 1 only
(B) 1 and 2 only
(C) 2 and 3 only
(D) 1, 2, and 3

24. A woman is referred to as nullipara. This

means
(A) she has never given birth to a viable
offspring Figure 33
(B) the woman has had only one child
(C) the woman has given birth to more than
one viable offspring
(D) she carried a pregnancy past the point of
viability regardless of the outcome
 Questions: 21 through 30 55

27. The calcications seen in Figure 3-4 have the 29. The calcications seen in Figure 3-5 have the
typical appearance of typical appearance of
(A) mammographically malignant-type (A) an oil cyst
calcications (B) plasma cell mastitis calcication
(B) mammographically benign-type (C) a small calcied hematoma
calcications (D) a calcied sebaceous gland
(C) calcications typical of an oil cyst
(D) calcied microhematomas

Figure 35
Figure 34

28. Characteristics of a malignant stellate tumor
include which of the following?
1. The spicules are generally bunched
together.
2. The presence of a central tumor mass.
3. The larger the tumor, the longer the
spicules.
30. The radial scar or sclerosing duct hyperplasia
1. can sometimes be mistaken for
carcinoma
2. sometimes has a solid dense central
tumor
3. is usually not associated with skin thick-
ening or dimpling over the lesion

(A) 1 only (A) 1 only

(B) 1 and 2 only (B) 1 and 2 only
(C) 2 and 3 only (C) 2 and 3 only
(D) 1 and 3 only (D) 1 and 3 only
56 3: Anatomy, Physiology, and Pathology of the Breast

31. A mammogram shows a low-density 36. A benign self-limiting breast tumor that is the
radiopaque tumor. It is oval, lobulated, and a result of new disorganized cell growth
halo is seen along one border only. The next
(A) sarcoma
step should be
(B) radial scar
(A) pneumocystogram (C) invasive lobular carcinoma
(B) ultrasound (D) hamartoma
(C) biopsy
(D) no further testing; the tumor is benign 37. An infusa-port can be used to
(A) provide radiation therapy treatment
32. A galactocele
(B) allow repeated access to the venous
(A) is always radiolucent system
(B) is usually associated with trauma (C) infuse radioactive tracers directly into
(C) is associated with nursing the breast lesion
(D) usually has irregular borders (D) infuse drugs directly into the arterial
system
33. A lipoma
38. The low-density radiopaque lesions seen in
(A) is generally seen as a high-density
Figure 3-6 suggests a
radiopaque lesion on the mammogram
(B) can be a huge encapsulated lesion occu- (A) benign broadenoma
pying the entire breast (B) skin mole
(C) may have irregular borders typical of (C) galectocele
malignant lesions (D) keratosis
(D) is usually difcult to image
mammographically

34. A rare form of cancer that presents with

swelling, warmth, or erythema and mammo-
graphically with skin thickening is
(A) inammatory carcinoma
(B) invasive ductal carcinoma
(C) lobular carcinoma in situ
(D) papillary carcinoma

35. Sometimes described as an oil cyst, this

lesion represents an encapsulated area on the
mammogram and can be caused by surgery,
biopsy, trauma, or radiation therapy.
(A) stellate lesion
(B) galactocele
(C) fat necrosis
(D) lipoma
Figure 36
 Questions: 31 through 40 57

39. The right craniocaudal (RCC) of the routine 40. The circular mixed-density lesions seen in
imaging series showed a small, irregular- Figure 3-8 suggests a
shaped lesion at the edge of the image plus
(A) calcied microhematomas
scattered calcications including calcication
clusters (Figure 3-7). The next immediate step (B) galactocele, calcied
would be (C) malignant calcication
(D) epidermoid cyst
1. spot compression including magnica-
tion
2. additional imaging to include the mar-
gins of the lesion
3. ultrasound
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only

Figure 38

Figure 37
 Answers and Explanations
1. (C) Each breast can be divided into four
quadrants: the upper outer quadrant (UOQ),
upper inner quadrant (UIQ), lower outer
quadrant (LOQ), and lower inner quadrant
(LIQ). The exact locations within the quad-
rant are represented by viewing each breast
(separately) as a clock face (Figure 3-9).
Lesions can also be described in relation to the
nipple (eg, subareolar or below the nipple)
(Peart, 3544).
Right Left
12 12
UOQ UIQ UIQ UOQ
9 3 9 3
LOQ LIQ LIQ LOQ
6 6
Figure 39. Breast localization pictures. The breast can be
viewed in different ways: (1) As a clock with clock-time descriptions
within the breast. (2) Using the four-quadrant method: the upper-
outer quadrant (UOQ), the upper-inner quadrant (UIQ), the lower-
outer quadrant (LOQ), and the lower-inner quadrant (LIQ). Note
that the 4-oclock position on the right breast represents the lower-
inner quadrant but on the left breast would indicate the lower-outer
quadrant.
2. (D) Morgagni tubercles are elevations
formed by the opening of the ducts of the
Montgomery glands, which are specialized
sebaceous-type glands found on the areola,
not the nipple. The terminal ductal lobular
unit (TDLU), also called the lobule, is located
58
at the very end of the ductal system (Peart,
3544; Tortora, 1083).
3. (B) The normal nipple can be either attened
or inverted, both unilaterally and bilaterally.
However, a nipple that suddenly becomes
inverted or attened can indicate malignancy
(Peart, 3544; Tortora, 1083).
4. (D) The breast is most secured at the superior
and medial aspects. The lateral borders of the
breast and the inferior aspect (inframammary
crease) are the most mobile portions. To max-
imize compression of breast tissue, the com-
pression should be applied against the most
movable margins (Peart, 3544; Tortora, 1083).
5. (B) On an average, a breast has 15 lobes. The
number can, however, be as low as 10 or as
high as 20 (Peart, 3544; Tortora, 1083, 13).
6. (B) Cooper ligaments are a network of
brous and elastic membranes. They incom-
pletely sheath the lobes of the breast. The lig-
aments start at the most posterior portion
(base) of the breast and extend outward to
attach to the anterior supercial fascia of the
skin. Fibroglandular and fatty tissues make
up the breast parenchyma. Montgomery is a
gland, not a ligament. It is located on the are-
ola (Peart, 3544; Tortora, 1083).
7. (C) The breast extends vertically from the
clavicle (the second or third rib) to meet the
abdominal wall at the level of the sixth or
seventh rib and horizontally from the mid-
sternum to the midaxillary line (the latissimus
dorsi muscle). However, breast tissue can

form anywhere along the milk ridge or line,
also called the mammary line. This line
extends from the armpits in the axilla to the
groin region of the body (Figure 3-10)
(Andolina, 139154; Peart, 3544; Tortora, 1083).
Milk lines
Figure 310. Picture showing the milk line; the milk ridge or
line, also called the mammary line. This line extends from the
armpits in the axilla to the groin region of the body.
8. (C) The upper outer quadrant, which
extends toward the axilla, is known as the
axillary tail or the tail of Spence. It is the
thickest portion of the breast. Thorough
knowledge of the anatomic extent of the
breast is critical in breast imaging. The nipple
is the center point of the breast and it is sur-
rounded by the areola. The inframammary
fold or crease (IMF) is the lowest extent of the
breast where it attaches to the chest wall
(Andolina, 139154; Peart, 3544; Tortora, 1083).
9. (B) Cooper ligaments are strands of connec-
tive tissue that run between the skin and
deep fascia to support the lobes of the
breast. They start at the most posterior por-
tion (base) of the breast, extend outward,
and attach to the anterior fascia of the skin
(Andolina, 139154; Peart, 3544; Tortora, 1083).
Answers and Explanations: 1 through 15 59
10. (C) Fatty tissue is radiolucent and will there-
fore show as higher optical density areas on
mammograms (black). Fibrous and glandular
tissues are less radiolucent and will show as
lower optical density on the mammograms
(white or gray) (Andolina, 139154; Peart, 3544;
Tortora, 1083).
11. (D) In general, the amount of fat and glandu-
lar tissue varies with age. Glandular tissue
predominates in younger women, whereas
fatty tissue predominates in older patients. A
patient below 20 is unlikely to have regular
mammograms (Andolina, 139154; Peart, 3544;
Tortora, 1083).
12. (B) The majority of glandular tissue is distrib-
uted in the breast bilaterally and is located
centrally and laterally toward the upper outer
quadrant, extending toward the axilla. Most
breast cancer arises from the glandular tissue
(Andolina, 139154; Peart, 3544; Tortora, 1083).
13. (A) The main direction of drainage from the
lateral half of the breast tends to be into the
pectoral group of axillary lymph nodes and
from the medial half of the breast into the inter-
nal mammary lymph nodes. However, there
can be cross-mediastinal drainage from the
medial portion of one breast to the opposite
breast (Andolina, 139154; Peart, 3544; Tortora, 1083).
14. (A) From the nipple orice a connecting or lac-
tiferous duct immediately widens into the lac-
tiferous sinus (or ampulla). The ampulla is a
pouch-like structure that holds milk (when it
is being produced). The ampulla then narrows
to become the segmental or mammary ducts.
These will branch into smaller ducts with
decreasing diameter until becoming a lobule
(Andolina, 139154; Peart, 3544; Tortora, 1083).
15. (C) From the nipple, the mammary ducts
become smaller and smaller until becoming a
lobule. The lobule is also called the TDLU.
The TDLU is lined with a single layer of
epithelial cells and a peripheral layer of
myoepithelial cells and can be further
divided into extralobular terminal ducts
(ETD), which is a small duct leading into the
60 3: Anatomy, Physiology, and Pathology of the Breast
terminal ductules, and the intralobular termi-
nal ducts (ITD), located at the end of the ter-
minal ductules. The ITDs hold the alveolar
glands, which are the milk-producing elements
of the breast (Figure 311). (Andolina, 139154;
Peart, 3544; Tortora, 1083).
16. (A) Veins are larger than arteries. Unlike arter-
ies, they are normally located peripherally and
easily seen. Mammographically they appear
as low-density, radiopaque vessels. Both arter-
ies and veins can be outlined by calcications
(Andolina, 139154; Peart, 3544; Tortora, 1083).
17. (D) The TDLUs are further divided into the
ETD, which is a small duct leading into the ter-
minal ductules, and the ITD, located at the end
of the terminal ductules. The ETD is sur-
rounded by elastic tissue and lined by colum-
nar cells. The ITD has no surrounding elastic
tissue and contains cuboidal cells (Figure 3-11).
Ductules (acinus)
Extralobular Intralobular
terminal duct terminal duct
(ETD) (ITD)
Terminal ductal
lobular unit
(TDLU)
Figure 311. Picture of TDLU. The TDLU increase and
decrease in size and number, depending on menstrual cycle, preg-
nancy, lactation, and hormone use. The TDLUs are responsible for
milk production and it is here that most cancers originate. The duc-
tal system ends at the TDLU. The unit is further divided into ETD
and ITD.
The ITD holds the milk-producing elements
of the breast, called the ductules or acinus
(plural, acini). Each lobule can have 10100
terminal ductules (Andolina, 139154; Peart,
3544; Tortora, 1083).
18. (B) Increased or decreased glandularity of the
breast is a part of the normal physiological
changes that take place. Glandularity can be
related to menarche, hormonal uctuation
whether normal or synthetic, pregnancy, lac-
tation, or menopause; however, increasing
glandularity is usually related to an increase
in any of the two most prominent hormones
active in the breast. These are estrogen
(responsible for ductal proliferation) and
progesterone (responsible for lobular prolif-
eration and growth) (Andolina, 139154; Peart,
3544; Tortora, 1083).
19. (B) As a person ages, there is a decline in hor-
mones (perimenopause) eventually leading
to menopause after which the glandular
breast tissue will atrophy. The breast then
looses its supportive and connective tissue to
fat. Patients above 60 will most likely have
fatty breast; glandular tissues predominate in
young women and adipose tissue (fat) pre-
dominate in older women. Patients below 20
usually have dense breast, but are also less
likely to have a mammogram. Hormone ther-
apy is likely to increase the glandular nature
of the breast (Andolina, 139154; Peart, 3544;
Tortora, 1083).
20. (D) Ideally, a mammogram should not be
scheduled during lactation unless the patient
is symptomatic, has a personal history of
breast cancer, or is very high risk. In such
cases, the total time of lactation may exceed
the recommended time interval for screening.
If a mammogram must be done during lacta-
tion, the patient should nurse just prior to the
mammogram to remove superimposed milk
and improve visualization of breast tissue.
Because this is a routine baseline mammo-
gram on an asymptomatic patient, the mam-
mogram should be postponed. During lacta-
tion, the increased blood supply, milk
production, and overall physiologic changes

cause increased glandularity that reduces the
accuracy of the mammogram, making it less
effective as a diagnostic tool. Also, the
increased density results in increased radia-
tion exposure to the patient (Andolina, 139154;
Peart, 3544).
21. (B) Generally, atrophy of mammary struc-
tures begins at menopause and ends 35
years later. After menopause, the breast loses
its supportive tissue to fat, producing a
smaller breast, or a larger, more pendulous
one. This process is called involution
(Andolina, pp. 139-154; Peart, 3544).
22. (D) The total amount of glandular tissue
increases and decreases with hormonal uc-
tuations, use of synthetic hormones, and
menopause. The amount of glandular tissue
versus fatty tissue will also depend on a
womans genetic predisposition and total
body fat. It is therefore possible to nd young
women with fatty breast and older women
with extremely dense, glandular breast.
Weight gain and loss also increase or
decrease the fat content of the breast tissue,
thereby affecting the overall glandularity of
the breast (Andolina, 139154; Peart, 3544).
23. (B) Hormone replacement therapy (HRT) will
relieve symptoms of menopause which can
include hot ashes, sleep disturbance,
fatigue, osteoporosis, and insomnia. HRT can
cause increase in glandular tissue, increase in
broadenomas, and increase in development
of breast cyst but it can inhibit involution
process. The negative effects of HRT can be
severe and include breast and uterine cancer,
asthma, dementia, heart attacks, strokes, and
blood clots. Most women are now advised to
consult their doctors on long-term solutions
not involving HRT (Andolina, 139154; Peart,
3544).
24. (A) Nulliparous is the condition of not hav-
ing given birth to a viable offspring. Nulli-
para would then refer to a woman who has
never produced a viable offspring. Parity is
the terminology used if a woman carries a
pregnancy to a point of viability (20 weeks of
Answers and Explanations: 16 through 27 61
gestation) regardless of the outcome. Other
terminology is multiparity, regarded as hav-
ing carried one or more fetuses to viability
regardless of the outcome, and primipara, a
woman who has delivered a child of 500 g (or
of 20 weeks gestation) regardless of its viabil-
ity (Andolina, 139154; Peart, 3544; Venes, 1598).
25. (B) Although a halo is typically present in
benign lesions, absence of a halo does not
necessarily prove malignancy. However, any
circumscribed radiopaque tumor with
unsharp borders and no demonstrable halo
sign should lead to suspicion of malignancy,
regardless of density (Figure 3-12) (Peart,
4763; Tabr, 1792).
Round Oval Lobulated Irregular Spiculated
architectural
distortion
Figure 312. Breast masses. The borders or shape of breast
masses may be round, oval, lobulated, irregular, or spiculated. A
spiculated border is a strong indication for malignancy, whereas a
smooth border is a strong indication for a benign abnormality.
These, however, are indicators and will not necessarily determine
the presence or absence of carcinoma.
26. (B) The mammogram shows a stellate tumor.
Although the mammogram can suggest car-
cinoma and may be highly suspicious for car-
cinoma, only a microscopic analysis (histo-
logical or cytological analysis) will reveal the
exact type. The presence of a central tumor
mass with associated spicules is typical of
malignant stellate tumors. The spicules are
dense and sharp, radiate from the tumor sur-
face, and usually are not bunched together.
When they extend to the skin or areolar
region, they cause retraction and local thick-
ening. In general, the larger the tumor, the
longer the spicules (Peart, 4763; Tabr, 93147).
27. (A) These calcications are typical of mam-
mographically malignant-type casting or
granular microcalcications. Casting calci-
cations are produced when carcinoma in situ
62 3: Anatomy, Physiology, and Pathology of the Breast
lls the ducts and their branches. The shape
of the cast is determined by the uneven pro-
duction of calcications and the irregular
necrosis of the cellular content. (The cells are
reproducing or growing at such a fast rate
that they outstrip their blood supply and
diethe results seen as calcications.) The
contours of the cast are always irregular in
density, size, and length and the casts are
always fragmented. A calcication is seen as
branching when it extends into adjacent
ducts. Also, the width of the ducts deter-
mines the width of the castings. Granular-
type calcications are seen as mammographi-
cally similar in appearance to granulated
sugar or crushed stones. These are also
malignant-type calcications. Oil cysts are
generally seen mammographically as
eggshell-like calcications and a microhe-
matoma or calcied microhematoma can be
high-density or a mixed-density oval or cir-
cular calcication (Peart, 4763; Tabr, 149238).
28. (C) A typical malignant stellate tumor has a
central tumor with dense spicules radiating
in all directions. The spicules are separate
and increase in length with increased tumor
size. If the spicules reach the skin, there is
localized dimpling or skin thickening (Peart,
4763; 93147).
29. (A) This calcication has the typical appear-
ance of an oil cyst. Oil cysts are generally
seen mammographically as eggshell-like cal-
cications. Plasma cell mastitis calcications
follow the course of the ducts. Some may be
elongated and branching, some needlelike,
and some ringlike or oval, but all are sharply
outlined, high density, and have smooth bor-
ders. If they are periductal, they have central
lucencies. Calcied sebaceous glands are typ-
ically ringlike oval calcications with lucent
centers; there are two types, depending on
where the calcications started. Calcications
within a sebaceous gland are hollow or ring-
like calcications; calcications within the
cavity are punctate calcications. A microhe-
matoma or calcied microhematoma can be
high-density or a mixed-density oval or cir-
cular calcication (Peart, 4763; Tabr, 149238).
30. (D) Radial scar is benign and rarely palpable.
It is often mistaken for carcinoma and its
exact nature is the subject of some contro-
versy among pathologists. Recent studies
suggest that a radial scar may increase a
womans risk of developing breast cancer.
Generally, the radial scar has no central
tumor. There can be translucent, oval, or cir-
cular areas at the center of the lesion and the
lesions appearance varies from one mam-
mography projection to another. Regardless
of the size of the lesion, there is generally no
associated skin thickening or dimpling and
no discernible palpable mass (American Cancer
Society; Peart, 4763; Tabr, 93147).
31. (B) Most highly suspicious lesion will be rec-
ommended for biopsy, but if the lesion is sus-
pected to be benign further test is done to
prove the benign nature of the lesion. A par-
tial halo around a lesion suggests a mammo-
graphically benign tumor. An ultrasound
would be the best next step to differentiate
solid versus a cyst. After the ultrasound, a
pneumocystogram could be used to assess
the inside margins of the tumor (Peart, 4763;
Tabr, 1792).
32. (C) A galactocele is a benign, milk-lled cyst
with high fat content. These lesions are gen-
erally associated with lactation. They are usu-
ally circular, with sharply dened borders
and have densities that are a combination of
radiolucent and radiopaque. They are often
left alone, but if painful they can be drained
using needle puncture. Often they yield a
yellow uid. The galactocele can calcify to a
high-density circular or oval radiopaque
lesion (Peart, 4763; Tabr, 1792).
33. (B) A lipoma is a fatty tumor. It is radiolucent
and may be huge, with smooth borders and
occupying the entire breast. It is easily seen
mammographically and is not metastatic
(Peart, 4763; Tabr, 1792, Venes, 1253).
34. (A) Inflammatory carcinoma is a rare form
of invasive carcinoma accounting for 1%4%
of all breast cancers. It generally presents
with swelling, warmth, erythema, and skin

thickening. The symptoms result from vascu-
lar or lymphatic invasion of the carcinoma but
are unfortunately very similar to symptoms of
a severe infection. Invasive ductal carcinoma
accounts for more than 60% of all breast can-
cers. It usually presents as a central tumor
with radiating spicules and often the associ-
ated malignant microcalcications. Invasive
ductal carcinoma is the most common of all
breast cancers. This form of cancer is often
associated with a tumor and malignant
appearing calcications. Lobular carcinoma in
situ is most often asymptomatic. The cells
grow within the lobules but do not penetrate
through the lobule walls. This form of cancer
is not seen mammographically in all cases and
is often an incidental nding on biopsies. Pap-
illary carcinoma is frequently seen as a cir-
cumscribed mass on older women. It is often
indistinguishable from a cyst mammographi-
cally, but on ultrasound is identied as a com-
plex or solid mass. It is a slow-growing tumor
with good prognosis (Peart, 4763).
35. (C) Fat necrosis can be caused by surgery,
biopsy, trauma, or radiation therapy. At the
site of the injury there may be hemorrhage,
then as the tissue dies, liqueed fat necrotic
material and blood remains. The area
becomes encapsulated by a thin layer of calci-
cation, which appears on the mammogram
as eggshell-like calcication described as an
oil cyst. Stellate lesions such as invasive duc-
tal carcinoma have a distinct central mass
and sharp, dense ne lines of variable length
radiating in all directionsthe larger the cen-
tral tumor mass, the longer the spicules. A
galactocele is a benign, milk-lled cyst with
high fat content. These lesions are generally
associated with lactation and can calcify to a
high-density radiopaque circular or oval
lesion. A lipoma is a fatty tumor. It is radiolu-
cent and may be huge, occupying the entire
breast. It is easily seen mammographically
and is not metastatic (Peart, 4763; Venes, 1435).
36. (D) Hamartomas result from an abnormal
formation of normal tissue. The cells of the
tumor grow in a disorganized mass and are
composed of tissue elements normally found
Answers and Explanations: 28 through 37 63
at the site. Unlike a cancerous tumor, the
hamartoma rarely invade or compress sur-
rounding structures. The cells grow sponta-
neously, reach maturity, and then do not
reproduce. This growth is self-limiting and
benign. Radial scars are complex sclerosing
lesions. They are not truly scars and are some-
times unrelated to prior surgery or trauma.
Some possible cause of the radial scar is local-
ized inammatory reaction or chronic
ischemia with slow infection. The radial scar
is a benign condition, but can be associated
with premalignantatypical ductal hyperpla-
siaand malignant condition. A benign
radial scar has no central tumor, although
there may be long spicules radiating from the
center of the lesion. Regardless of the size of
the spicules in the benign radial scar, there is
no associated skin thickening, dimpling, or
nipple reaction. The benign radial scar often
resolves over time, but because of the possible
association with malignancy it is recom-
mended that all stellate lesions including
radial scars should be excised. A sarcoma is a
cancerous tumor from mesenchymal tissue
such as muscle or bone. Lobular carcinomas
are often difcult to diagnose. Invasive lobu-
lar carcinoma is a malignant condition where
the cancer has spread from the lobular into
the surrounding tissue. On the mammogram
this can show as a spiderweb appearance or
cause skin retraction (Peart, 4763; Sanders,
358359; Venes, 1943, 925; Yazici, 438).
37. (B) Infusa-ports are designed to permit
repeated access to the venous system for the
parenteral delivery of medications, uids,
and nutritional solutions and for the sam-
pling of venous blood. In the treatment of
breast cancer the infusa-port or port-a-cath
are often used to deliver chemotherapy treat-
ment and are sometime referred to as central
venous access devices (CVAD). They are sur-
gically implanted completely under the skin.
Patients with infusa-ports can leave the hos-
pital and continue their treatment at home.
The infusa-port must be inspected daily for
signs of infection. Radiation treatment
exposes a specic body area to various high-
energy radiations to destroy cancer cells.
64 3: Anatomy, Physiology, and Pathology of the Breast
Radioactive tracers or radioactive isotopes are
injected directly into the breast tissue in a
technique known as lymphoscintigraphy or
sentinel node mapping, the idea being to
track the path of metastatic cancer. Injecting
medication directly into the arterial system in
rarely done. Intra-arterial chemotherapy can
be used to give very high doses of chemother-
apy to the tumor. The drug is injected directly
into the arteries that are close to the cancer
through a tube inserted under local anesthetic
(Peart, 223; Venes, 11041106).
38. (B) The skin markers suggests that these are
visible skin lesions. Epidermoid cysts, kerato-
sis, moles, calcied sebaceous glands, and
skin tags are the most common. These are
skin moles. The epidermoid cyst appears as
rm, round, mobile lumps just below the
skin surface. These cysts are often incorrectly
referred to as sebaceous cysts but they are not
of sebaceous origin. Mammographically, they
are seen as mixed-density circular or oval
lesion and can be mistaken for an internal
lesion if not marked. The keratosis often pre-
sents as a raised lesion on the skin surface.
Unlike warts, which they resemble, they are
not caused by the human papilloma virus.
They tend to have a very rough surface with
bumps and crevices. Mammographically,
they appear as oval mixed-density lesions,
often radiolucent but the crevices will
appear as higher density areas on the mam-
mogram. Moles, known medically as nevi,
can come in a range of colors, but are usually
dark brown spots. In rare cases, a mole can
become cancerous, but usually they are
harmless clusters of pigmented cells. Mam-
mographically, the mole will can appear as a
radiolucent circumscribed lesion and can be
mistaken for an internal lesion if not identi-
ed. Calcied sebaceous glands are typically
ringlike oval calcications with lucent cen-
ters. A skin tag is a benign skin growth that
looks like a small piece of hanging skin.
Mammographically, it is seen as a low-
density circumscribed lesion and can be mis-
taken for an internal lesion if not identied.
The broadenoma is a benign radiolucent
and radiopaque combined lesion within the
breast. The galactocele is often circular or
oval with mixed density and is also located
within breast tissue. It is associated with lac-
tation (Peart, 4763; Tabr, 149238; Venes, 1171).
39. (A) Further imaging could include spot com-
pression and magnication. Whenever possi-
ble, imaging should demonstrate a lesion in
its entirety. Before moving to another modal-
ity, the radiologist is likely to recommend
further imaging to demonstrate the margins
of the lesion and magnication to assess the
calcications (Peart, 4763; Tabr, 149238).
40. (D) Epidermoid cysts are often incorrectly
referred to a sebaceous cysts, but they are not
of sebaceous origin. The epidermoid cysts
appear as rm, round, mobile lumps just
below the skin surface. Mammographically,
they are seen as mixed-density circular or
oval lesion and can be mistaken for an inter-
nal lesion if not marked. A microhematoma
or calcied microhematoma can be mixed-
density or a high-density oval or circular cal-
cication. A galactocele is a benign, milk-
lled cyst with high fat content. These lesions
are generally associated with lactation. They
are usually circular, with sharply dened
borders and have densities that are a combi-
nation of radiolucent and radiopaque. The
calcied galactocele is usually seen mammo-
graphically as a circular or oval high-density
radiopaque lesion. Malignant-type calcica-
tions are often seen in clusters and are typi-
cally casting or granular in appearance. Cast-
ing calcications are produced when
carcinoma in situ lls the ducts and their
branches. The shape of the cast is determined
by the uneven production of calcications
and the irregular necrosis of the cellular con-
tent. The contours of the cast are always
irregular in density, size, and length and the
casts are always fragmented. A calcication
is seen as branching when it extends into
adjacent ducts. Also, the width of the ducts
determines the width of the castings. Granular-
type calcications are seen as mammographi-
cally similar in appearance to granulated
sugar or crushed stones (Peart, 4763; Tabr,
149238; Venes, 1171).
 CHAPTER 4
Mammographic Technique
and Image Evaluation
Summary of Important Points
BREAST COMPRESSION
Before applying compression, the mammographer
should consider the natural mobility of the breast.
When applying compression, in order to optimize
the amount of tissue under the compression paddle,
the compression should not push the breast tissue
against its xed margins. The most movable margins
are the lateral and inferior and the xed margins are
the medial and superior. The initial automatic com-
pression should never exceed 45 lb (200 newtons) of
pressure; the patient should not be in pain, but the
breast must be taut to ngertip contact.
Compression
The main reason for breast compression is to
allow a more uniform density by attening the
base of the breast to the same degree as the
more anterior regions, permitting optimal
exposure of the entire breast in one image.
Other reasons for breast compression:
Reduces dose to the breast by reducing tissue
thickness
Brings lesions closer to the image receptor for
more accuracy when evaluating size
Decreases motion unsharpness because the
breast is immobilized
Increases subject contrast, reducing the
amount of scattered radiation by decreasing
thickness
Separates superimposed areas of glandular tis-
sue; compression spreads apart overlapping
tissue, reducing confusion caused by superim-
position shadows, and allowing visualization
of the borders of circumscribed lesions
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
MAGNIFICATION
Magnication is ideal in imaging small areas, such
as areas of suspicious microcalcications or lesions,
specimen radiographs, or at surgical sites. Unfortu-
nately, the use of magnication increases patient
dose because the breast is placed much closer to the
source of radiation.
A grid is not necessary with magnication.
A small focal spot must be used with
magnication.
Selection of Technical Factors
The kVp (peak kilovoltage) selection or pene-
trating power of the beam will inuence the
subject contrast and exposure latitude, and
therefore the image contrast. Consideration
should also be given to the patients breast tis-
sue structure. Too high kVp will result in loss
of contrast (image too dark or gray). Too low
kVp will be high subject contrast in the
medium-density range, but result in loss of
detail visibility in the dense breast tissue.
For a given kVp, increasing the mAs (mil-
liamperes per second) alters the optical density
of the nal mammogram. In general, increas-
ing the mAs increases the mA but not the
exposure time.
The reciprocity law states that the density pro-
duced on the radiograph is equal to any com-
bination of mA and exposure time as long as
the product of mAs is equal. However, the reci-
procity law fails at long and short exposures
because the lm is exposed to light from the
intensifying screens. With long and short expo-
sures, reduced lm speed and an increase in
65
66 4: Mammographic Technique and Image Evaluation
exposure factors are required. Most modern
automatic exposure control (AEC) systems
provide automatic correction for lm reciproc-
ity failure. If necessary, using a higher kVp,
varying the target and/or ltration material, or
using a faster screen-lm combination will cor-
rect reciprocity failure. Also, the length of the
exposure time must always be considered
because of the possibility of motion unsharp-
ness.
When using AEC, the position of the detector
varies depending on breast size and tissue
composition. AEC selection choices can be:
Full automatic modeall the parameter are
automatically selected.
Semiautomatic modethe operator sets the
kVp and possibly the lter and target.
Manual modethe operator sets everything
including the kVp, lter, target, and mAs.
Evaluation of Image Quality
Positioning
The routine series for breast imaging is the cranio-
caudal (CC) and the mediolateral oblique (MLO).
The CC projection should always demonstrate as
much medial tissue as possible because this area is
most likely to be distorted on the MLO. The MLO
will visualize the maximum amount of breast tissue
if the angle used is parallel to the pectoral muscle.
Compression
Compression produces a uniform tissue thickness
and reduces the overall thickness of the breast.
Improperly compressed breast tissue will result in
overlapping tissue structures, nonuniform expo-
sure (especially of the denser breast tissue), over-
penetration of the thinner breast tissue, poor pene-
tration of the thicker portion, and motion
unsharpness.
Exposure
With adequate exposure, it is difcult to see the skin
and subcutaneous tissue until the images are masked
to block out extraneous view box light. Areas of the
image with optical densities less than 1.0 are gener-
ally underexposed. The densest area on the image is
the area of pectoralis muscle and it is the only area
that should have an optical density less than 1.0.
Contrast
Radiographic contrast is a product of the subject
contrast and the lm contrast. In breast tissue, con-
trast is usually highest in thinner breast and lowest
in thicker breast owing to more scattered radiation
and greater tissue absorption of low-kVp radiation
in the thicker breast. Without contrast, breast
parenchyma with different tissue densities will have
very similar optical densities.
Sharpness
The ability of the mammographic system to capture
ne details in the image is dened as sharpness. If
the image is not sharp, it is referred to as unsharp.
Unsharpness may be the result of motion blur, poor
screen-lm contrast, characteristics of the screen
(faster screens and double emulsion systems results
in more unsharpness), and geometric factors such
as larger focal spot size, increase in object-to-image
receptor distance (OID), or decrease in source-to-
image receptor distance (SID).
Noise
Radiographic noise is represented as nonuniform
or nonhomogeneous appearances on the recorded
image (similar to snow on a television screen).
There are four factors contributing to radiographic
noise: lm graininess, structural mottle, quantum
mottle, and scatter radiation.
Artifacts
Any variation of density on the image that is not a
reection of the attenuation differences in the sub-
ject can be considered artifacts. Examples of arti-
facts are pick-off, scratches, ngerprints, dirt, lint,
or dust.
Collimation
In mammography, collimation is limited to the size
of the image receptor and not to the breast.
Labeling
Standardized labeling in mammography is impor-
tant because mammograms can be legal documents
and it is important that the radiographs are not
misinterpreted. In the nal rules of the Mammogra-
phy Quality Standards Act (MQSA), labeling is
divided into required, highly recommended, and
recommended.
 Questions

1. Which of the following statements is (are) true? 4. Manual compression in mammography

1. Compression increases image sharpness (A) must be between 25 and 45 lb
by reducing the focal spot size. (B) depends solely on breast size
2. Compression increases subject contrast (C) depends on breast size and the patients
by reducing the thickness of the pene- pain tolerance
trated tissue. (D) generally depends on the patients pain
3. Compression increases the uniformity of tolerance
the image-making diagnosis easier.
(A) 1 only 5. Some considerations that could be given to
women with painful breasts include
(B) 1 and 2 only
(C) 2 and 3 only 1. having the patient take ibuprofen prior
(D) 1, 2, and 3 to the mammogram
2. scheduling the mammogram just after
2. The compression force should not exceed the menstrual cycle
_______ on the initial power drive (auto- 3. explaining, before the examination, the
matic) mode. importance of compression
(A) 25 lb (A) 1 only
(B) 35 lb (B) 1 and 2
(C) 40 lb (C) 2 and 3
(D) 45 lb (D) 1, 2, and 3

3. In assessing the degree of compression for 6. Compression will do all of the following
any one patient, the mammographer should except
take into consideration
(A) bring tissue closer to the image receptor
1. the maximum to which the patients (B) reduce patient dose
breast can actually be compressed (C) improve image subject contrast
2. the amount of compression the patient (D) decrease spatial resolution
can tolerate
3. compression that should be just suf- 7. Compression reduces radiation to the breast by
cient to immobilize the breast
(A) providing a uniform breast thickness
(A) 1 only (B) decreasing breast thickness
(B) 1 and 2 only (C) decreasing motion unsharpness
(C) 1 and 3 only (D) separating superimposed areas of glan-
(D) 2 and 3 only dular tissue

67
68 4: Mammographic Technique and Image Evaluation

8. What principle does compression use to visu- 12. With calcications, magnication can be used
alize the borders of circumscribed lesions? to assess
1. It brings the lesion closer to the image 1. the number
receptor. 2. morphology
2. It spreads apart overlapping tissue. 3. distribution
3. It separates superimposed areas of glan-
(A) 1 only
dular tissue.
(B) 1 and 2 only
(A) 1 only (C) 2 and 3 only
(B) 1 and 2 only (D) 1, 2, and 3
(C) 2 and 3 only
(D) 1, 2, and 3 13. In general, greater magnication will require
the use of a
9. Ideally, breast compression is maximized
(A) larger focal spot size
when
(B) smaller OID
1. accompanied by a thorough explanation (C) smaller focal spot
to increase patient cooperation
(D) larger SID
2. the exposure is made on arrested inspi-
ration to reduce motion 14. A grid is not necessary during magnication
3. the patient recognizes the advantage of because
compression in reducing radiation dose
(A) grid use decreases spatial resolution
(A) 1 and 2 only (B) the small focal spot used will compen-
(B) 2 and 3 only sate for the loss of image detail
(C) 1 and 3 only (C) the large OID produces the same effect
(D) 1, 2, and 3 as a grid
(D) magnication will magnify the normally
10. Patients who are allowed to play an active invisible grid line
role in applying the compression are usually
1. less likely to tolerate the compression 15. The air gap in magnication increases subject
contrast by
2. more likely to tolerate the compression
3. more relaxed during the compression (A) increasing scatter
(B) reducing scatter
(A) 1 only
(C) reducing motion
(B) 2 only
(D) increasing motion
(C) 1 and 3 only
(D) 2 and 3 only 16. If the magnication mammography is per-
formed without using a small focal spot, the
11. Magnication can be used to assess the resulting image will be magnied
(A) margins of a lesion (A) and blurred
(B) size of a lesion (B) and sharply outlined
(C) location of a lesion (C) with increased subject contrast
(D) density of a lesion (D) with increased detail
 Questions: 8 through 26 69

17. At higher magnication factors there is 22. In conventional imaging, some causes of
underexposure include
1. higher skin dose
2. increased scatter 1. processing deciencies
3. decrease source-to-object distance (SOD) 2. inadequate compression
3. improper AEC setting
(A) 1 and 2 only
(B) 2 and 3 only (A) 1 only
(C) 1 and 3 only (B) 1 and 2 only
(D) 1, 2, and 3 (C) 2 and 3 only
(D) 1, 2, and 3
18. Magnication is benecial in all of the fol-
lowing situations except 23. To select a 12% increase in mAs before expo-
sure, the mammographer could
(A) imaging the surgical site of a patient
with a lumpectomy (A) use the density compensation circuit
(B) imaging a specimen radiograph (B) double the selected mAs
(C) evaluating microcalcications in a lesion (C) activate the backup timer
(D) routine imaging (D) readjust the AEC selector

19. Using a small focal spot size is recommended 24. In conventional imaging, the leading cause of
for magnication false-negative mammograms in dense breast
tissue is
(A) to reduce the resultant loss of image
detail (A) motion
(B) because of increased patient dose (B) overexposure
(C) to compensate for the small OID (C) underexposure
(D) to compensate for motion unsharpness (D) grid lines

20. The greatest disadvantage of magnication is 25. In conventional imaging, overexposure is

sometimes called the recoverable error
(A) increased OID
because
(B) increased patient dose
(C) decreased subject contrast (A) it can be corrected during developing
(D) increased risk of motion unsharpness (B) high illumination and masking can over-
come it
21. Optical densities less than 1.0 in the dense glan- (C) magnication can overcome it
dular tissue of the breast is considered a/an (D) the use of small focal spot sizes will
reduce it
(A) underexposure
(B) overexposure 26. Increased kVp during mammography is
(C) normal exposure sometimes necessary to penetrate dense
(D) above average but not overexposure broglandular tissue. Increased kVp, however,
generally causes
(A) increased subject contrast
(B) decreased subject contrast
(C) motion unsharpness
(D) less scatter
70 4: Mammographic Technique and Image Evaluation

27. Rhodium is not used as the primary anode 31. If the AEC cell is placed over an area of adi-
material when imaging thinner breast pose tissue on a breast with a mixture of adi-
because pose and glandular tissue, the areas of glan-
dular tissue will be
(A) rhodium has an emission spectrum simi-
lar to tungsten (A) underexposed
(B) the higher energy of the rhodium beam (B) overexposed
is unsuitable for thinner breast (C) normally exposed
(C) the lower energy of the rhodium beam (D) the AEC cell position will not affect the
is unsuitable for thinner breast exposure
(D) rhodium anodes are more expensive
32. Causes of poor subject contrast include all of
28. If the backup time stops a breast exposure, the following except
the mammographer can repeat the radi-
(A) inadequate exposure
ograph using a
(B) lower kVp
(A) higher kVp setting (C) inadequate compression
(B) greater density compensation (D) failure to use a grid
(C) higher mAs setting
(D) different AEC setting 33. The use of low kVp and high mAs will serve to
(A) reduce radiographic noise and increase
29. The type of x-rays created from displacement
subject contrast
of K-shell-binding electrons in the molybde-
num atom are called (B) reduce subject contrast and reduce radi-
ographic noise
(A) coherent scattering (C) increase radiographic noise and reduce
(B) characteristic radiation subject contrast
(C) Compton effect (D) increase subject contrast and increase
(D) bremsstrahlung radiation radiographic noise

30. The function of the lter in mammography is 34. A highly recommended labeling that is not
to remove required by the MQSA is
1. low-energy x-rays not needed to pro- (A) technologist/mammographer
duce the breast image identication
2. high-energy x-rays that cause a reduc- (B) date stickers
tion of subject contrast (C) technical factors
3. low-energy x-rays that increase patient (D) ash card identication system
dose
(A) 1 only 35. Lack of breast compression is most likely to
cause
(B) 2 and 3 only
(C) 1 and 3 only (A) geometric unsharpness
(D) 1, 2, and 3 (B) screen unsharpness
(C) motion unsharpness
(D) parallax unsharpness
 Questions: 27 through 40 71

36. Increasing the kVp by two points will 39. The last degree of compression should be
applied
(A) force a doubling of exposure time
(B) reduce the exposure time by half (A) using manual compression
(C) have no effect on the exposure time (B) after the breast is released from com-
(D) increase the subject contrast pression
(C) with the automatic compression device
37. The mammographer can differentiate motion (D) with the mammographers hand
unsharpness from screen unsharpness because between the breast and the compression
paddle
(A) motion unsharpness is generally local-
ized to a small area
40. Anatomic parts with low subject contract will
(B) screen unsharpness is generally local- have
ized to a small area
(C) motion unsharpness will result in blurring (A) sharp difference in x-ray absorption
(D) screen unsharpness is less likely at expo- (B) very little difference in x-ray absorption
sures below 2 seconds (C) the same x-ray absorption characteristics
(D) similar x-ray absorption characteristics
38. Increasing the kVp will inuence the
1. optical density on the image
2. penetrating power of the beam
3. subject contrast and exposure latitude
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
 Answers and Explanations
1. (C) Compression makes the breast tissue more
uniform and reduces the thickness through
which the x-ray beam must pass. This pro-
duces uniform densities that are easier to inter-
pret. Although compression increases image
sharpness, compression has no impact on the
focal spot size (ACR, 199).
2. (D) According to the MQSA guidelines, the
compression force for the initial power drive
must be between 111 and 200 newtons (25
and 45 lb). Manual compression should not
exceed 45 lb. Too little compression will com-
promise the image; too much can damage
breast tissue (ACR, 200201).
3. (B) Ideally, compression should be applied
until the breast tissue is taut. But if the patient
is in pain at maximum compression, this will
be a disincentive to return for annual mammo-
grams. The patient will generally be able to tol-
erate more compression if they are prepared for
it, and if it is applied slowly. Although com-
pression immobilizes the breast and reduces
motion, compression just adequate to immobi-
lize the breast is usually insufcient to separate
breast tissue (ACR, 3033).
4. (C) The initial compression in mammography
should be between 25 and 45 lb in the auto-
matic mode. Manual compression should not
exceed 45 lb. In general, the amount of man-
ual compression depends on the patients
breast size and patients tolerance for com-
pression. Some patients may require more
manual compression to adequately compress
the breast (ACR, 199; Peart, 6585).
72
5. (D) Often the patient will be able to tolerate
more compression if the need for compres-
sion is explained to the patient. Patients with
particularly sensitive breasts will benet
from pain medication prior to the mammo-
gram. (The patient must consult their physi-
cian before taking any medication.) Also, the
breast is often more sensitive to pain just
before or during the menstrual period and is
least sensitive 710 days after the start of the
period (ACR, 33; Peart, 117).
6. (D) The spatial resolution is the ability to
image high-contrast small objects such as of
microcalcications. The spatial resolution of
the image is limited mainly by the effective
focal spot size. Spatial resolution is stated as
the number of line pairs per millimeter
(lp/mm) that are imaged. A high spatial res-
olution means smaller objects can be imaged
clearly. The compression increases spatial
resolution by reducing patient thickness; the
tissue is therefore closer to the image recep-
tor. The tissue is thinner; there is therefore
less scatter and the subject contrast is
improved. Less radiation dose is used to
penetrate the thinner breast tissue (Bushong,
219227, 327340).
7. (B) Although the primary goal of compres-
sion is to provide a uniform breast thickness,
compression will also decrease motion
unsharpness by immobilizing the breast and
it will separate superimposed areas of glan-
dular tissue. Compression also reduces radia-
tion dose to the breast by decreasing the
thickness through which the radiation must

pass, thus allowing less exposure (Andolina,
184; Bushong, 334335; Peart, 117).
8. (D) Compression separates overlapping and
superimposed areas of glandular tissue and
will bring lesions closer to the image recep-
tor. This action allows visualization of the
borders of lesions (Andolina, 184; Bushong,
334335; Peart, 117).
9. (C) Often, the patient is able to tolerate more
compression if the need for compression is
explained. Knowledge of the procedure gen-
erally alleviates fears, especially fears of the
unknown. Any explanation should include a
statement on how compression will reduce
the radiation dose to help alleviate fears of
radiation dangers. Throughout the examina-
tion, the patient should be encouraged to
relax. Having the patient take a deep breath
prior to holding the breath during the expo-
sure is generally contraindicated. The patient
may alter her position as the lungs expand,
and the expanding ribs and lungs generally
contract the pectoral muscles increasing dis-
comfort during the mammogram. The
patient should be simply advised to stop
breathing without moving her body or rst
taking a deep breath (Peart, 117118).
10. (D) Studies have shown that if a patient plays
an active role in applying the compression
that patient will be able to tolerate the com-
pression better and will be more relaxed dur-
ing the compression. The more the patient
knows about compression and understands
the procedure, the more she will be relaxed. To
give the patient an active role in compression,
the mammographer can allow the patient to
apply the compression or constantly monitor
the patient, stopping the compression when
the patient indicates (Peart, 117118).
11. (A) Magnication cannot be used to assess
lesion size because it gives a magnied image
of the area which will not be a true represen-
tation of size. Location and density are also
not easily assessed using magnication
because the magnied image does not
Answers and Explanations: 1 through 14 73
include the entire breast, and density compar-
isons will be difcult if other densities are not
present on the image. Magnication is, how-
ever, capable of providing accurate assess-
ment of the margins of a lesion (Figure 4-1)
(ACR, 5960).
X-ray tube
SOD
SID Object
OID
Image receptor
Figure 41. Schematic diagrams showing the large OID used in
magnication mammography. Note the small SOD which places the
breast closer to the x-ray source.
12. (D) Morphology is the form or structure of the
calcication. By magnifying the area of inter-
est, magnication provides images that can be
used to assess the number, distribution, and
morphology of the calcications (ACR, 5960).
13. (C) To achieve magnication, the OID is
increased. As the magnication factor
increases, the focal spot must be reduced or
the thickness of the part decreased to main-
tain sharp images. Both of these factors are
used in breast magnication. The SID in
mammography units is xed and cannot be
adjusted. Magnication factor = SID/SOD or
image size/object size (Figure 4-1) (Andolina,
6364; Bushong, 336; Peart, 118).
14. (C) Magnication mammography is neces-
sary to enhance microcalcications or the
borders of a lesion. Grids are necessary in
routine mammography image to improve
contrast and spatial resolution; however, with
74 4: Mammographic Technique and Image Evaluation
magnication a smaller effective focal spot is
used to compensate for the loss of image
detail and the air gap (large OID) acts like a
grid in reducing the amount of scattered radi-
ation reaching the lm or electronic detector.
The main disadvantage of magnication
mammography is the high patient dose
(almost double the routine skin dose because
the breast is closer to the radiation source).
Grid use in magnication would further
increase exposure times, increasing tube load-
ing, and thus increasing motion artifact
owing to long exposure times. Radiation dose
to the patient would also increase (Figure 4-2)
(Andolina, 6364; Bushong, 272, 336; Peart, 7879).
Radiation source
X-ray traveling at
an angle will be
absorbed
Grid h with a lumpectomy, specimen radiography,
X-ray traveling
d
straight will be
transmitted
(Image Grid ratio = height/distance
receptor) between lead strips
Figure 42. Schematic diagram demonstrating the use of a grid.
The grid strips will transmit x-rays traveling straight while absorbing
any scattered rays.
15. (B) The large air gap acts like a grid and
reduces scatter, thus improving subject con-
trast. Positioning the breast away from the
image receptor takes advantage of the inverse
square law: the intensity of the scattered radi-
ation is reduced because the distance between
the image receptor and the object is increased.
In magnication, mammography motion is
controlled by vigorous breast compression.
Grid use in magnication would further
increase overall technical factors including the
exposure times (Figure 4-1) (ACR, 5960;
Bushong, 336).
16. (A) Whenever the relationship between the
source, object, and image are altered, as in
magnication, there is an increase in focal
spot blur. To keep focal spot blur at a mini-
mum, to maintain subject contrast and image
detail, and to compensate for the reduced
resolution during magnication, a small focal
spot must be used (Andolina, 6364; Bushong,
336; Peart, 7879).
17. (C) The magnication factor equals the
source-to-image receptor distance divided by
source-to-object distance (SID/SOD). Radia-
tion intensity is related to the square of the
distance; therefore, as the patients breast is
moved closer to the x-ray tube the SOD
decreases and patients dose increases. With a
greater magnication factor, there is a greater
skin dose because the SOD will be smaller.
Also, as the magnication factor increases, a
small focal spot must be used to maintain a
sharp image. Scatter is insignicant during
magnication because of the air gap (Bushong,
321322; Peart, 7879).
18. (D) Magnication is ideal for imaging small
areas such as the surgical site of a patient
or microcalcications. With magnication,
microcalcications that would otherwise be
missed can be seen. Magnication should not
be used in routine imaging because the entire
breast may not be imaged, and patient dose
is increased (Bushong, 336; Peart, 7879).
19. (A) The focal spot blur (penumbra or geometric
unsharpness are the old terms) is caused by a
large effective focal spot. Whenever the rela-
tionship between the source, object, and
image is altered, as in magnication, there is
an increase in focal spot blur. To keep focal
spot blur at a minimum, a small focal spot is
used. The small focal spot necessitates a
lower mA output and thus results in
increased exposure time and risk of motion.
Motion unsharpness is controlled by vigor-
ous compression. The increase in patient
dose is related to the smaller SOD used in
magnication (Bushong, 326356).
20. (B) Unfortunately, magnification increases
patient skin dose. Using a magnification

factor of 1.4 may actually double the radia-
tion dose to the patient because the breast is
placed closer to the radiation source. The
OID must be increased to achieve magnica-
tion. In magnication, subject contrast and
motion unsharpness are controlled by using a
small focal spot size with vigorous breast
compression (Bushong, 284, 336; Peart, 7879).
21. (A) Normally, optical densities on the mam-
mogram should never fall below 1.01.25 or
go above 2.503.0. The optimum is 1.60. In
conventional imaging, the trend clinically is
to have higher optical densities to adequately
penetrate the glandular tissue and produce
high-contrast images (ACR, 92; Peart, 7477).
22. (D) All cause a reduction in the density of the
image, which can causes a radiograph to
appear underexposed. If the developer tem-
perature decreases, the lm speed decreases,
resulting in lower lm density. Poor com-
pression causes uneven densities, leading to
underpenetration of portions of the breast.
Improper selection of the AEC results in
inadequate x-ray penetration of the glandular
tissue of the breast (ACR, 97; Peart, 116117).
23. (A) Modern mammography machines are all
equipped with a density compensation cir-
cuit. The density compensation circuit allows
the selection of at least two steps above and
two steps below the normal setting. Each
step translates to a 12%15% increase or
decrease in the mAs or a 0.15 change in the
optical density. The AEC produces a diagnos-
tic density determined by the tissue placed
directly over the AEC cells. The backup timer
will prevent gross overexposure. In the older
mammography units the backup timer for
grid technique is preset at 600 mAs and for
nongrid at 300 mAs. In the newer units, a test
exposure is delivered to check for adequate
penetration. The backup timer is activated
and the unit will not complete the exposure if
the mAs is inadequate. In both cases, if the
backup timer is reached during an exposure
then the selected mA is too low. To avoid get-
ting the backup times, the kVp setting must
be increased because the unit is already
Answers and Explanations: 15 through 27 75
exposing at the maximum mA (ACR, 97; Peart,
116117).
24. (C) Underexposure of dense breast tissue is
the leading cause of false-negative mammo-
grams. If the area is slightly overexposed,
high illumination and masking can be used
to visualize the image. If the area is underex-
posed, calcications or even subtle density
differences are not detected in the glandular
breast tissue. With the moving reciprocating
grid systems of modern mammography
units, grid lines are not a problem (ACR, 97;
Peart, 6586).
25. (B) Overexposure can sometimes be over-
come by using high illumination and mask-
ing. Modern automatic processing makes cor-
recting techniques during developing
unworkable and adjusting the focal spot size
or magnication will not correct for overex-
posure. Underexposure is an unrecoverable
error in which lost contrast cannot be
restored in underexposed areas of the image.
The radiograph has to be repeated with
increased technical factors. Note that extreme
overexposure decreases subject contrast (ACR,
98; Peart, 6586).
26. (B) The kilovoltage (kV) primarily inuences
the quality of the x-ray beam. As the kVp
increases, the penetrating quality of the beam
increasesmore x-rays pass through the
breast and reach the lm at higher kVp.
There is, therefore, less differential absorp-
tion and thus a reduction in subject contrast.
Motion unsharpness is owing to movement
of the patient during the exposure and scatter
radiation increases at higher kVp levels
(Bushong, 327340; Peart, 6586).
27. (B) Rhodium targets with rhodium lters
have an emission spectrum similar to molyb-
denum, not tungsten. However, rhodium has
an atomic number of 45 compared to 42 for
molybdenum. This means that the emission
spectrum for a molybdenum target ltered
with 30 m of molybdenum will have an
emission of characteristic x-rays with energies
of 19 keV (resulting from K-shell interactions)
76 4: Mammographic Technique and Image Evaluation
and almost no bremsstrahlung x-rays. The
emission from rhodium will be slightly
higher (23 keV) and there will be more
bremsstrahlung x-rays. Bremsstrahlung x-rays
are produced more easily in target atoms
with a high atomic number. The signicance
of this in mammography is that the keV
energy of the rhodium is designed to pene-
trate thicker, more dense breast tissue
whereas molybdenum is used to image fatty
breast. Bremsstrahlung x-rays will predomi-
nate in the tungsten target (Bushong, 327340;
Peart, 6584).
28. (A) In newer mammography units the
backup timer is activated if the initial test
exposure, delivered to check for adequate
penetration, fails. The density compensation
circuit and the mAs should not be increased;
because the primary reason for backup time
is that the beam has low-energy photons that
are unable to penetrate the breast. Increasing
the compensation circuit does not increase
the energy of the beam. Each step on the
compensation circuit generally results in a
12%15% change in mAs. Increasing the mAs
increases the overall lm density, but similar
to the compensation circuit, this does not
increase the penetrating power of the beam.
Selecting another AEC setting may result in
an underpenetrated image if the new AEC
setting is placed over a less dense area of the
breast (Peart, 6584).
29. (B) The molybdenum anode will produce x-ray
photons with energies in the range of 1720 keV
(kilo electron volt). The most prominent of
these x-ray photons are characteristic and will
account for 30% of the total x-rays in the
molybdenum beam at 30 kVp. The emission
spectrum shows almost no bremsstrahlung
x-rays because bremsstrahlung x-rays are pro-
duced more easily in target atoms with high
atomic numbers, such as tungsten. Coherent or
classical scattering describes the interaction of
very low-energy x-rays with atoms in the tar-
get. These energies are too low to impact breast
imaging. Compton is the most common scat-
tered radiation in imaging. The Compton effect
occurs when the incident x-ray interacts with
an outer-shell electron and ejects it from the
atom, ionizing the atom. The ejected electron is
called a Compton electron or secondary elec-
tron. Compton-scattered x-rays can deect in
any direction and can retain up to two-thirds of
its original energy (Bushong, 327340; Peart, 6584).
30. (D) The most useful energy range for maxi-
mizing breast tissue is 1724 keV. To achieve
this, added ltration must be used at the tube
port window on all mammography machines.
It is important that the inherent ltration of
the x-ray tube window does not lter out any
of the useful energy beam. Energies below
the useful range will contribute to skin dose
and energies above will reduce differential
absorption in breast tissue. The x-ray tube
port is therefore made of beryllium or borosil-
icate glass and not regular glass. Most mam-
mography tubes have an inherent ltration
the equivalent of 0.1 mm Al. The total inher-
ent ltration cannot be less than the equiva-
lent of 0.5 mm Al. The added ltration must
be the same element as the x-ray tube target
to allow the K-characteristic x-rays to expose
the breast while stopping the lower or higher
bremsstrahlung x-rays (Figure 4-3) (Bushong,
327340; Peart, 6584) .
100%
Unfiltered Mo beam
Percent photons in beam
Filtered Mo beam
(mirror, breast, thick
compression device,
or glass tube window)
15 20 25 30
keV (energy)
Figure 43. Showing the emission spectrum of molybdenum
beam ltered and unltered. Note that the lter beam removes the
lower energies (16 keV) that would contribute only to skin dose.
 Answers and Explanations: 28 through 34 77

31. (A) The AEC detects the beam after the x-ray
passes through the breast. Because the AEC
stops the exposure when it estimates that the
correct exposure is reached, positioning the
AEC over fatty breast tissue stops the expo-
sure before there is sufcient exposure to
penetrate the denser tissue. The result will be
an underexposed radiograph (ACR, 97).
Noise denes the ability to see minute struc-
tures on the image and is reected as random
uctuations in optical density. Reducing
noise mostly involves reducing the scattered
radiation and quantum mottle. Noise is
therefore lowest when using lower kVp and
higher mAs (ACR, 100; 105; Bushong, 272273,
290; Peart, 115118) (Figure 4-4).

32. (B) Radiographic contrast is the product of

subject contrast and lm contrast. In general,
lower kVp improves subject contrast,
although some mammographic lm now
allows signicantly higher kVp without sacri-
cing image contrast. Subject contrast refers
to the contrast of the radiograph when it is
viewed on the illuminator. This is the differ-
ence in quantity of radiation transmitted by a
particular structure or body part as a result of
the difference in absorption characteristics of
the tissues and structures making up that
part. Subject contrast, often simply referred to
as contrast, is most affected by the selected
kVp but body tissue thicknessdependent
on breast compressionand the attenuating
characteristic of the part will also affect the
contrast. The impact of the mAs on contrast is Figure 44. The increased graininess on this image demon-
strates quantum mottle.
small. However, too low a mA setting will
result in low optical density (OD) and there-
fore reduced radiographic contraststraight
line portion of the H & D curve (characteristic
curve) is attened. Also, too high mAs result 34. (D) The labeling guideline under MQSA rules is
in high OD and loss of radiographic contrast. divided into three areas: required, strongly rec-
Film contrast represents inherent properties ommended, and recommended. The ash
of the lm such as speed latitude and the dif- card patient identication system is strongly
ferent quantities and qualities of radiation recommended because it is the most perma-
effect on them. Low-contrast mammograms nent and will be reproduced on a copy,
will have a uniform appearance, making it unlike the stick-on labels.
difcult to differentiate between different Required labeling includes:
breast tissue thicknesses. Other causes of poor name of patient (rst and last) and addi-
contrast include processing deciencies, lack tional patient identier such as a unique
of a grid (which will result in increased scat- medical record number
tered radiation), improper target material, date of examination
and/or ltration (ACR, 100101; Bushong, 272296; projection and laterality (right or left)
Peart, 115118). (placed near the axilla using the standard-
ized codes approved by the FDA)
33. (A) Contrast (subject contrast) is the ability to facility name and location, including the
see subtle density differences and will be city, state, and zip code
higher at lower kVp, where there is great tis- technologist/mammographer identication
sue absorption and less scattered radiation. cassette/screen identication
78 4: Mammographic Technique and Image Evaluation
mammography unit identicationif there
is more than one unit
Strongly recommended labels include:
a ash card with a permanent patient iden-
tication system
Recommended labeling includes:
Date stickersenable easy reading of
dates with overhead lights.
Technical factors (including target lter,
kVp, mAs and exposure time)
Compression force
Compressed breast thickness
Degree of obliquity
(ACR, 2627)
35. (C) Sharpness is the ability to see ne detail
on the mammography image, and patient
motion is the most common form of unsharp-
ness. Motion blurring is common with expo-
sure above 2 seconds and can be prevented
by proper communication. Good compres-
sion will reduce breast thickness, therefore
allowing shorter exposure times. Screen
unsharpness is a result of poor screen-lm
contact and can be caused by air trapped
between the lm and the screen during load-
ing. Geometric unsharpness or focal spot blur
is caused by increase in focal spot size or OID
or by a decrease in SID. Parallax unsharpness
results from the use of double emulsion lms
and is generally not a factor in mammography
imaging (ACR, 102; Peart, 115118).
36. (B) The kVp can have a major impact on the
exposure time and dose. As the kVp is
increased, the exposure time decreases
rapidly50% for every two-point drop in
kVp. The dose will also decrease by 15%20%
for a two-point drop in kVp because a higher
kVp setting will allow the use of lower mAs
and therefore lower patient doses. As the
kVp increases, however, there is less differen-
tial absorption leading to a reduction in sub-
ject contrast (ACR, 101; Bushong, 290).
37. (B) In screen unsharpness there is a further
spread of light from the screen before it
reaches the lm. This type of unsharpness is
independent of the exposure time and unlike
motion unsharpness, which covers a wider
area, unsharpness because of poor screen con-
tact is usually localized. All unsharp images
are referred to as blurry (ACR, 104105).
38. (B) The kVp controls the wavelength or pene-
trating power of the beam. Increasing the
kVp inuences the subject contrast and expo-
sure latitude, therefore also affecting the
image contrast. Latitude refers to the range of
exposures over which the lm responds with
optical densities in the acceptable diagnostic
range. Wider latitude allows more variation
in mAs while still producing an acceptable
image. Higher contrast generally results in
lower latitudes. The main factor inuencing
the optical density is the mA. Increasing the
mA will increase the quantity of the electron
beam (Bushong, 290; Peart, 116).
39. (A) In applying compression, the mammog-
rapher needs to be as gentle as possible. The
automatic compression should be applied
with the mammographers hand between the
breast and the compression plate until the
plate touches the back of the hand. Only then
should the mammographer remove the hand,
pulling the breast out, and applying the nal
degree of compression slowly. Always apply
the last degree of compression using the
manual rather than the automatic compres-
sion paddle to avoid unnecessary pain to the
patient (Peart, 115118).
40. (B) Subject contrast is a result of differences
in attenuation in body tissue and is greatly
affected by the effective atomic number of the
tissue being radiographed. Subject contrast is
also affected by the size, shape, and energy of
the x-ray beam (kVp). Anatomic parts with
high subject contrast will have sharp differ-
ence in x-ray absorption, for example, bone
and soft tissue. Anatomic parts with low sub-
ject contrast will have very little difference in
x-ray absorption, for example, breast (Bushong,
290; Peart, 116).
 CHAPTER 5
Positioning and Interventional
Procedures
Summary of Important Points
STANDARD PROJECTIONS
Craniocaudal
Exposure made on suspended respiration.
Image receptor (IR) positioned at the level of
the raised inframammary crease.
The patients head is turned away from the
side being examined.
The patients feet are apart with weight
equally distributed, for stability.
The patients arm closest to breast being exam-
ined is placed by the patients side.
The contralateral arm is raisedholding the
bar on the unit will provide support.
Dense areas of the breast are well penetrated.
The nipple imaged in prole, centered on the IR.
The medial and lateral aspects of the breast
included in the collimated area. (The pectoralis
major muscle is seen approximately 20% of the
time.)
The craniocaudal (CC) projection (Figure 5-1)
should include, within 1 cm, the amount of tis-
sue measured on the mediolateral oblique
(MLO) image.
Appropriate markers and labeling as required
by the American College of Radiology (ACR).
Mediolateral Oblique (MLO)
Exposure made on suspended respiration.
The tube angulation will vary between 30 and
60 degrees depending on patient size; thin
patients require steeper angulation than heavier
patients.
Arm closest to the breast being imaged is
draped over the top of IR. The upper border of
the IR ts in the armpit.
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Compression must adequately support the
anterior breast tissue to prevent sagging and
distortion of the ductal architecture. The
mammographer supports the anterior breast
with one hand during compression and uses the
other hand to adjust the skin over the sternum
and clavicle to reduce the pulling sensation.
The convex-shaped pectoral muscles demon-
strated to level of the nipple.
Appropriate markers and labeling as required
by the ACR.
Common Problems Associated with MLO
Imaging
Drooping breastanterior breast poorly com-
pressed
Abdominal tissue included on the mammogram
Posterior breast is not imaged or poorly
imagedinsufcient pectoral muscle
ADDITIONAL POSITIONS/PROJECTIONS
Supplemental projections become useful when the
standard projections or are difcult to obtain. Other
reasons include:
A suspicious area is seen in one of the routine
projections but not on the second.
Additional imaging allows the patient to avoid
an invasive procedure such as needle localiza-
tion (eg, a spot compression may prove an area
of suspicious density to be overlapping tissues).
Exaggerated Craniocaudal (XCCL)
To image lesions in the lateral aspect of breast
not seen on the CC projection
79
80 5: Positioning and Interventional Procedures

A B

C D

Figure 51. Complete four-projection series mammogram. A routine mammogram showing the normal appearance of (A) RCC, (B) LCC,
(C) RMLO, and (D) LMLO.

Mediolateral (ML) 90 degree
To verify a nding or localize a lesion in
another dimension (necessary during needle
localizations)
To locate a lesion not seen on a CC projection if
lesion is seen only on the MLO projection
medial lesions move up on the lateral from
their position on the MLO
lateral lesions move down on the lateral from
their position on the MLO
central lesions do not move signicantly
from the MLO to the ML
To prove benign breast calcications (eg,
teacup-shaped calcications)
Caudocranial or From Below (FB)
To image small breast
To image the kyphotic patient
To image patients with pacemakers
To better visualize lesions in the superior or
upper quadrants of the breast
Lateromedial (LM)
To improve detail of a lesion located in the
medial aspect of the breast
To perform preoperative localization of an
inferior and/or lateral lesion
To image the nonconforming patient
Axillary Tail (AT)
A 20-degree oblique projection used to visualize
the tail of the breast
Cleavage (CV) or Valley View
To show deep medial lesions in the CC position
Tangential (TAN) Projection
To demonstrate an area in question without
superimposition of breast tissue
To locate skin calcications or lesions near the skin
Lateromedial Oblique (LMO)
To image the nonconforming patient when the
standard MLO projection is difcult
To image patients with a pacemaker
To image patients with chest surgery
To image patients with a prominent sternum
To evaluate the medial aspect of the breast
Summary of Important Points 81
Superior-Inferior Oblique (SIO)
The beam is directed from superior lateral aspect to
the inferior medial aspect.
Demonstrates the upper-inner and the lower-
outer quadrant
Especially useful in imaging encapsulated
implants
MODIFICATIONS
Magnication (M)
To improve imaging of ne detail, especially
when analyzing calcications
Rolled Lateral (RL) or Rolled Medial (RM)
The breast is rolled laterally or medially from the
CC position.
This image removes superimposed tissue
when imaging dense breast (the lesion is
rolled off or away from the dense tissue).
Rolled Superior (RS) or Rolled Inferior (RI)
The breast is rolled superiorly or inferiorly from the
lateral position.
This image removes superimposed tissue when
imaging dense breast (the lesion is rolled off
or away from the dense tissue).
Spot Compression
Applies more compression to a localized area
of interest using a smaller compression paddle
Localization of suspected abnormality
To evaluate a suspicious area
Imaging performed in any projection, with or
without magnication
Breast Implant Imaging
The standard series include: the routine CC
and MLO projection with modied compres-
sion plus implant displaced (ID) projections.
Standard imaging taken to demonstrate the
posterior breast tissue surrounding the mar-
gins of the implant. Compression is used for
immobilization only. Vigorous compression
can rupture the implant.
Implant-displaced imaging requires pulling the
natural breast tissue forward while simultane-
ously pushing the implant back toward the chest
wall. Compression is applied only to the breast
82 5: Positioning and Interventional Procedures
tissue. ID projections are taken in the CC,
MLO, and sometimes the ML and SIO projec-
tions (Figures 5-2a and b).
SPECIAL SITUATIONS
Imaging the Nonconforming Patients
Small Breast
Manual techniqueif the breast does not cover
the rst photocell
Use spatula if necessary
Roll/Tilt patient to affected side
MLO and or FB are generally easier to perform
Male Breast
Similar to small female breast
FB an option
Chest hair and pectoral muscle can present
problems
Large or Wide Breast
Use sectional imaging
The breast tissue must overlap.
Label all radiographs for proper evaluation
(eg, MLO upper or MLO lower)
Kyphotic Patients
FB replaces CC imaging or two CC projections
(medial and lateral imaging)
LMO replace MLO imaging
Pectus Excavatum (Depressed Sternum)
Two CC projectionsto image medial and lat-
eral portions of the breast
CV can be used to image medial breast
LMO replace the MLO imaging
Pectus Carinatum (Pigeon ChestProminent
Sternum) and Barrel Chest (Prominent Ribs
and Sternum)
Routine CC imaging for medial breast plus
XCCL for lateral breast tissue
Routine MLO plus AT to image missed tissue
Elderly Patient
Chair examination if necessary
Document limitations
Postsurgical Breast
Postlumpectomy imaging can include CC and
ML or MLO of the surgical site.
May or may not include magnication
Postmastectomy imaging or visual inspection
by oncologist.
Other imaging may include a spot compres-
sion of the area of concern, and/or an AT
projection
Irradiated Breast
Mammograms can be performed 612 months
after completion of radiation treatment.
Infection control critical
Stretcher/Cart Patients
CC imagingpatient supine on the stretcher
The x-ray tube is rotated 90 degrees.
CC imagingpatient lateral on the stretcher
Tube rotated 90 degrees. Image FB or CC
MLO imaging with the tube is positioned at 0
degree.
The patient is semiprone or lateral.
Wheelchair Patients
Use FB or LM if possible
Bolster back of patient or have patient sit
upright
Support/Restrain patient if chair arm is
removed
Transfer patient or build up the patient in
case of nonremovable wheel chair arms
Solving Special Problems
Nipple Not in Prole
Always image the entire breast rst.
If necessary, image the nipple separately
nipple in prole projections.
Use of nipple markers can prevent unneces-
sary imaging
Skin Folds or Wrinkling of the Breast
Skin folds or wrinkling may be impossible to
avoid in the elderly
Smooth folds or wrinkles using the index n-
ger during compression.
Avoid pushing folds or wrinkle outside of the
compression eld.
 Summary of Important Points 83

A B

C D

Figure 52. Complete implant series. Modied compression technique (Eklund method) (AD) and implaced ID projections (EH).
84 5: Positioning and Interventional Procedures

E F

G H

Figure 52. (continued)


Eliminated breast tissue must be imaged
separately.
Patients with Uneven Breast Thickness
Reevaluate the patient.
Imaging for the MLO projection should place
the IR parallel to the pectoral muscle.
IR should be positioned in the axilla for MLO
imaging.
Two images for each routine projectionpos-
terior and anterior breastmay be necessary.
Flex paddle avoids overcompression of pos-
terior breast tissue to achieve adequate com-
pression of anterior breast.
Patients with Protruding Abdomen
CC imaging with patient standing away from
the unit and leaning forward
MLO imaging using reduce tube angulation
Patients with Frozen Shoulder
Reverse LMO or LM replace the MLO
SPECIMEN RADIOGRAPHY
The specimen is the breast tissue sample removed
during a biopsy. A radiograph of the specimen is
necessary to ensure the area under suspicion is
totally removed and the margins are clean. In imag-
ing the specimen:
Speed and efciency are important because the
patient may be under anesthesia.
Always use compression when imaging larger
specimens.
Magnication may help to visualize microcal-
cications.
Interventional Procedures
Ductography
Cannulation of the lactiferous ducts and the
injection of a contrast agent
Used to evaluate abnormal nipple discharge,
lling defects, or irregularities.
Radiographs are taken in the CC and ML
(90 degree) positions to determine the loca-
tion and number of lesions.
Summary of Important Points 85
The examination cannot determine if the
lesion is malignant or benign.
Ultrasound can be used to image the ducts.
Cyst Aspiration
Drainage or emptying of a cyst using a needle
Cyst aspiration/pneumocystography is per-
formed either under mammographic or ultra-
sound guidance.
A pneumocystograph can be performed after
the aspiration.
Pneumocystography
Injection of air in an aspirated cyst to evaluate
the cyst cavity for debris or inner wall of the
cyst for abnormal growth.
Ultrasound or mammographic guidance
needed
Preoperative Needle Localization
Localization of a nonpalpable abnormalities
(lesions or microcalcications) prior to a surgi-
cal biopsy
Used if stereo localization is not available
Performed under mammographic or ultra-
sound guidance
Stereostatic Localization
Use of computerized stereostatic equipment to
localize a nonpalpable lesion.
Image taken at different angles to triangulate
the exact coordinates of the area.
Computer calculates the precise location of
lesions within the breast.
Stereotactic biopsy can be the prelude to an
FNA, FNB, or core biopsy.
Fine Needle Aspiration/Fine Needle Biopsy
(FNA/FNB)
Use of a small-gauge needle to remove cellular
material from the breast for cytological analy-
sis, possibly reducing the necessity for a surgi-
cal breast biopsy
Core Biopsy
Use of a large-gauge needle to remove core
samples from the breast. Tissue samples are
obtained with an 11- to 14-gauge needle and
sent for histological analysis.
86 5: Positioning and Interventional Procedures
Commercial modifications of the basic core
biopsy technique include minimally inva-
sive breast biopsy (MIBB); vacuum-assisted
core biopsy (VACB); and advanced breast
biopsy instrumentation (ABBI).
Large-Core Biopsy
Removal of 520 mm of breast tissue under
local anesthesia
Not popular because of signicant scaring
and complication that can result
Radio Frequency Biopsy
Use of a radiofrequency (RF) device to remove
areas of suspicion
Electrosurgical introducer with a stainless
steel cutting edge inserted into the breast
after local anesthesia
Introducer positioned under ultrasound
guidance
Nipple Aspiration
Removal of uid from the nipple in a process
called ductal lavage.
Open Surgical Biopsy
Removal of lesion under general anesthesia
Use for difcult-to-approach lesions or lesions
close to the breast surface
Lymph Node Biopsy
Method used to determine if cancer has spread
to the lymph nodesaxillary node dissection
Generally performed during a mastectomy or
lumpectomy
Ultrasound Biopsy
The use of high-frequency sound waves to
evaluate lesion in the breast
Used to determine if a mass is solid or uid
lled
Commonly used with FNA/FNB or core biopsy
Magnetic Resonance (MR) Biopsy
MR imaging takes advantage of the magnetic
properties of hydrogen in the body. Imaging uses
a strong magnetic and radiofrequency pulses.
MR-guided biopsy used to evaluate lesions
seen only on MR imaging
All equipment used must be MR compatible
 Questions

1. Which projection is used to determine if a 5. In positioning for the CC projection, if the C-

lesion is medial or lateral to the nipple? arm of the mammography unit is raised too
high the IMF is overelevated, resulting in
(A) CC
loss of
(B) MLO
(C) TAN 1. superior breast tissue
(D) ML 2. inferior breast tissue
3. posterior breast tissue
2. If any breast tissue is poorly imaged or (A) 1 and 2 only
missed on the MLO projection it is likely to be
(B) 2 and 3 only
(A) medial breast tissue (C) 1 and 3 only
(B) lateral breast tissue (D) 1, 2, and 3
(C) inferior breast tissue
(D) superior breast tissue 6. The single projection that will best visualize
the maximum amount of breast tissue is the
3. The posterior nipple line (PNL), visualized (A) CC
on the ML, should be within how many cen-
(B) MLO
timeters of the PNL on the CC?
(C) ML
(A) 0.25 (D) XCCL
(B) 0.50
(C) 1.00 7. In general, when imaging tall, thin patients
(D) 1.50 the angulation is adjusted to
(A) below 30 degrees
4. Which of the following conditions must be
(B) between 30 and 40 degrees
met when imaging the breast in the MLO?
(C) close to 60 degrees
1. The pectoral muscle should extend to or (D) almost 70 degrees
below the PNL.
2. Visualized fat should be posterior to all 8. The position used to determine whether an
the broglandular tissues. abnormality is superior or inferior to the
3. The inframammary fold (IMF) should be nipple is the
open.
(A) CC
(A) 1 and 2 only (B) MLO
(B) 2 and 3 only (C) XCCL
(C) 1 and 3 only (D) TAN
(D) 1, 2, and 3

87
88 5: Positioning and Interventional Procedures

9. The principle of mobile versus xed tissue is 13. When positioning for the right CC, where is
used in mammography imaging to image the the patients left arm placed?
maximum
(A) Brought back. This action rotates the
(A) medial breast on the MLO projection shoulder to remove it from the imaging
(B) inferior breast on the CC projection area.
(C) superior breast on the MLO projection (B) Brought forward. The patient can hold
(D) medial tissue on the CC projection the handle bar of the unit.
(C) Brought forward. The patient can hold
10. In the CC projection of the breast, the IR is the IR.
positioned (D) Remains at the patients side.
(A) at the level of the raised inframammary
14. Your patient has had recent chest surgery
crease
and has a scarred and painful area running
(B) below the level of the raised inframam- along the sternum. With the medial aspect of
mary crease the breast immobile, which of the following
(C) at the level of the inframammary crease is an alternative to the RMLO?
(D) just below the level of the inframam-
(A) RLMO
mary crease
(B) LMLO
11. In positioning for the MLO, the tube is (C) LLM
always angled (D) RML
(A) 90 degree
15. Which projection is best used to visualize the
(B) 60 degree tail of the breast?
(C) 50 degree
(A) LMO
(D) none of the above
(B) TAN
12. What projection/position is shown in Figure 5-3? (C) LM
(D) AT
(A) CC
(B) MLO 16. Calcications seen on the mammogram are
(C) CV suspected to be in the skin. The best projec-
(D) XCCL tion necessary to prove this theory is the
(A) LMO
(B) TAN
(C) LM
(D) AT

17. The projection best used to demonstrate the

true representation of medial breast struc-
tures in relation to the nipple is the
(A) LM
(B) AT
(C) ML
(D) TAN

Figure 53. ( 2000 The American Registry of Radiologic

Technologists.)
 Questions: 9 through 25 89

18. A lesion on the lateral aspect of the breast is 23. Identify the position/projection shown in
not seen on the CC. An additional projection Figure 5-4.
used to image the lesion could be the
(A) FB
(A) CV (B) XCCL
(B) XCCL (C) ML
(C) FB (D) AT
(D) TAN

19. Which projection can be used instead of the

CC to image patients with severe kyphosis?
(A) ML
(B) TAN
(C) FB
(D) CV

20. A lesion moved up on the ML projection

from its original position on the MLO. The
location of the lesion within the breast is
(A) laterally
Figure 54. ( 2000 The American Registry of Radiologic
(B) medially Technologists.)
(C) inferiorly
(D) superiorly
24. A barrel-chested patient whose chest wall
21. Which projection is used to prove breast cal- protrudes outward may have breast tissue
cications are benign (teacup type)? extending laterally under the arm. What pro-
jection, used to image the breast with the
(A) CC beam directed superiorly to inferiorly, should
(B) XCCL be taken in addition to the CC?
(C) FB (A) AT
(D) ML (B) XCCL
(C) CV
22. Which projection is used to give a prole
image of the area in question without super- (D) MLO
imposition of breast tissue?
25. The FB projection can be useful in imaging
(A) CV
1. nonconforming patients
(B) TAN
2. abnormalities high on the chest wall or
(C) LMO
superior aspect of breast
(D) AT
3. inferior lesions or lesions near the IMF
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
90 5: Positioning and Interventional Procedures

26. Identify the projection shown in Figure 5-5. 29. In which modied projection is the superior
aspect of the breast rolled medially?
(A) MLO
(B) CV (A) RM
(C) LM (B) RL
(D) ML (C) M
(D) LM

30. In the LMO projection, the beam is directed

from the
(A) upper inner aspect to the lower outer
aspect of the breast
(B) inner outer aspect to the upper outer
aspect of the breast
(C) lower outer aspect to the upper inner
aspect of the breast
(D) superolateral aspect to the inferomedial
aspect of the breast

31. Identify the projection shown in Figure 5-6.

(A) MLO
Figure 55. ( 2000 The American Registry of Radiologic
Technologists). (B) CV
(C) LM
(D) ML
27. Why is the MLO preferred to the ML as a
routine projection?
(A) The MLO visualizes the medial breast.
(B) The ML does not visualize the medial
breast.
(C) The ML poorly visualizes the posterior
and lateral breast.
(D) The MLO does not distort the anterior
structure of the breast.

28. Which projection best shows the extreme

medial aspect of the breast?
(A) CC
(B) MLO Figure 56. ( 2000 The American Registry of Radiologic
Technologists.)
(C) ML
(D) CV
32. Identify the projection shown in Figure 5-7.
(A) RM
(B) CV
(C) RL
(D) MLO
 Questions: 26 through 39 91

35. All of the following statements about magni-

cation are true except
(A) With magnication, patient dose
increases.
(B) Magnication can be used to image
specimen radiographs.
(C) Magnication can be used to assess sus-
picious lesions.
(D) Magnication images the entire breast
with one exposure.

Rolled Lateral 36. In the RS position, the surface __________ the

(RL) IR is rolled _______.
Figure 57. ( 2000 The American Registry of Radiologic (A) furthest from/inferiorly
Technologists.)
(B) closest to/superiorly
(C) furthest from/superiorly
(D) closest to/inferiorly
33. Which projection is especially useful when
analyzing calcications? 37. Which technique accurately describes how
(A) RM the breast is rolled for the RM?
(B) M (A) The superior surface is rolled medially
(C) LM and the inferior surface does not move.
(D) ML (B) The superior surface is rolled laterally
and the inferior surface is rolled medially.
34. Identify the projection shown in Figure 5-8. (C) The inferior surface is rolled medially
and the superior surface does not move.
(A) RM
(D) The inferior surface is rolled laterally and
(B) CV
the superior surface is rolled medially.
(C) RL
(D) MLO 38. A patient with pectus excavatum may pre-
sent a positioning problem because the
patient has
(A) extensive pectoral muscle
(B) barrel chest
(C) kyphosis
(D) depressed sternum

39. In imaging the augmented breast in the CC

position, using the modied implant-
displaced technique, the breast tissue is
pulled/pushed
(A) anteriorly
(B) posteriorly
(C) inferiorly
Figure 58. ( 2000 The American Registry of Radiologic
Technologists.) (D) superiorly
92 5: Positioning and Interventional Procedures

40. A routine series on patients with encapsu- 46. The standard projection taken on patients
lated implants could include an additional with breast implants requires compression
projection such as the
1. for immobilization only
(A) AT 2. to separate the breast tissue
(B) CC 3. to assess areas of lumps
(C) MLO
(A) 1 only
(D) ML
(B) 2 only
41. Which of the following is used to spread out (C) 1 and 3 only
the tissue and improve resolution on a local- (D) 2 and 3 only
ized area of interest?
47. The specimen is radiographed to
(A) CV
(B) AT (A) conrm that the lesion was removed
(C) TAN (B) compare various needle localization
techniques
(D) spot compression
(C) magnify the lesion to assess any possible
42. How many projections are routinely required microcalcications
to image a patient with implant augmented (D) check the position of the lesion
breasts?
48. The specimen is compressed to
(A) 5
(B) 6 (A) reduce motion unsharpness
(C) 7 (B) reduce radiation exposure
(D) 8 (C) reduce tissue thickness
(D) reduce the magnication factor
43. When is imaging of the irradiated breast
recommended? 49. Which procedure is performed to obtain cel-
lular material from a suspicious area for cyto-
(A) immediately after treatment logical analysis?
(B) 12 months after treatment
(A) Ductography
(C) 612 months after treatment
(B) Needle localization
(D) 12 years after treatment
(C) Pneumocystogram
44. Which of the following can be used with any (D) Fine needle aspiration (FNA)
projection with or without magnication?
50. Preoperative localization will
(A) spot compression
(B) XCCL 1. direct the surgeon to the area requiring
biopsy
(C) AT
2. help the surgeon to excise a smaller
(D) CV
specimen
45. In addition to the routine series, many post- 3. ensure that the correct area was
mastectomy patients will also need a removed

(A) CC (A) 1 and 2 only

(B) MLO (B) 2 and 3 only
(C) ML (C) 1 and 3 only
(D) CV (D) 1, 2, and 3
 Questions: 40 through 60 93

51. Core biopsy techniques developed as an alter- 56. Biopsy performed using a 14-gauge needle to
native to surgical biopsy because this tech- remove tissue samples from the breast is
nique provided a larger sample of the area of termed
suspicion and thus more information than
(A) core biopsy
(A) ductography (B) cytology
(B) needle localization (C) ductography
(C) pneumocystogram (D) aspiration
(D) FNB
57. Which of the following techniques use a
52. An ultrasound of a lesion showed a spherical small-gauge needle to obtain cellular samples
mass with smooth regular borders, anechoic from a lesion?
interior, and acoustic enhancement. The
(A) core biopsy
lesion is likely to be a
(B) FNB
(A) broadenoma (C) ductography
(B) abscess (D) ductal lavage
(C) simple cyst
(D) ductal carcinoma 58. Stereotactic breast localization is used to
(A) obtain two-dimensional information on
53. In ultrasound, the term acoustic enhancement
palpable breast lesions
refers to
(B) calculate the vertical position of nonpal-
(A) a structure without internal echoes pable lesions
(B) a structure with internal echoes (C) obtain a three-dimensional image of the
(C) the amount of sound passing through a breast
structure (D) calculate the horizontal, vertical, and
(D) few echoes within a structure depth position of nonpalpable lesions

54. A procedure whereby the lactiferous duct is 59. A cyst aspiration can only be performed
cannulated and a small amount of contrast
(A) under ultrasound guidance
agent is injected into the duct is termed
(B) using mammographic imaging
(A) ductography (C) using MRI guidance
(B) needle localization (D) none of the above
(C) pneumocystogram
(D) FNA 60. Which of the following biopsy techniques is
most accurate?
55. A patient had an ultrasound, which con-
(A) FNB
rmed the presence of a cyst in the breast.
The radiologist wished to rule out intracystic (B) open surgical biopsy
tumor. What additional study could be (C) core biopsy
recommended? (D) MRI core biopsy
(A) ductography
(B) needle localization
(C) pneumocystogram
(D) FNA
 Answers and Explanations

1. (A) CC projection determines whether the

lesion is medial or lateral and how far it is
from the nipple. The MLO or ML determines
if the abnormality is superior or inferior to
the nipple and how far posterior it is. The
TAN projection skims the area of interest and
is best used to determine if a suspected
abnormality is located in the breast or the
skin of the breast (ACR, 4349; Peart, 115146).
PNL PNL

2. (A) The MLO best demonstrates the posterior

and upper-outer quadrants of the breast. A
good MLO must include both the superior
and inferior portions of the breast. However,
it may not be possible to image the medial
area on all patients in the MLO projection.
Often, the medial breast is distorted. The CC
projection will cover this portion of medial
tissue that is most likely to be missed on the
MLO (ACR, 43; Peart, 115146).

3. (C) The PNL measures the perpendicular dis- PNL PNL

tance from the nipple to the visualized pectoral
muscle on the MLO or from the nipple to the
edge of the image on the CC (Figure 5-9). This
measurement on the MLO should be within
1 cm of the measurement on the CC projec-
tion. In 10% of cases, the PNL will be greater
on the CC (ACR, 4349; Peart, 115146).
Figure 59. Showing the PNL. Measurement of the posterior nip-
4. (D) In general, guidelines for the MLO include ple line (PNL) on the MLO projection should be within 1 cm of the
all of these statements. Additionally, the breast PNL measurement on the CC projection. In about 10% of cases,
should not droop on the image. It may not be the PNL will be greater on the CC projection.

possible to meet all these guidelines on all

patients. If one or more of these guideline ele- 5. (B) If the C-arm is raised too high, IR will ele-
ments are missing, the mammographer or radi- vate the patients inframammary fold or
ologist must determine whether a third projec- crease and the patient will be unable to lean
tion is necessary (ACR, 3442; Peart, 115146). forward and relax. This results in loss of the

94

posterior and inferior breast tissue. If the IR
is too low, the breast droops and superior
and posterior tissue is lost (Peart, 115146).
6. (B) The MLO best visualizes the posterior
and upper-outer quadrants of the breast
while allowing distortion and overlap of the
anterior structures. However, it is the single
best projection to visualize a maximum
amount of breast tissue. The CC does not
image the lateral breast while the ML does
not image the posterior breast. The XCCL
will miss the medial breast (ACR, 34; Peart,
115146).
7. (C) In imaging the MLO, the edge of the IR is
placed parallel to the oblique line formed by
pectoral muscle. This oblique line varies in
individuals; tall, thin patients require steeper
angulations (5060 degrees), average patients
require 4050 degrees and short, heavy
patients 3040 degrees. The angle is usually
the same for both breasts. Male breast may
require even steeper angulations (ACR, 6062;
Peart, 115146).
8. (B) The MLO or ML determines if the abnor-
mality is superior or inferior to the nipple and
how far posterior it is. The CC or XCCL pro-
jections determine whether the lesion is
medial or lateral and how far it is from the
nipple. The TAN projection skims the area of
interest and is best used to determine if a sus-
pected abnormality is located in the breast or
the skin of the breast (ACR, 4349; Peart, 115146).
9. (A) The breast is least mobile at the medial
and superior aspects and most mobile at the
lateral and inferior aspects. To image the max-
imum amount of breast tissue, the most
mobile parts of the breast must be placed
adjacent to the IR while applying compres-
sion from the least mobile aspect of the breast.
In most cases, compression is applied from
the superior aspect for the CC projections
(to image the maximum amount of superior
and posterior breast) and from the medial
aspect for the MLO projections (to image the
maximum amount of medial and posterior
breast) (ACR, 34; Peart, 115146).
Answers and Explanations: 1 through 14 95
10. (A) The IR must be placed at the level of the
elevated IMF or crease. If the IR is raised too
high, the patient will be unable to lean for-
ward and relax. This results in loss of poste-
rior and inferior breast tissue. If the IR is at
the IMF or is too low, the breast droops and
superior and posterior tissues will be lost
(Peart, 115146).
11. (D) In imaging for the MLO, the edge of the
IR is placed parallel to the oblique line
formed by pectoral muscle. This oblique line
varies in individuals; tall, thin patients
require steeper angulations (5060 degrees),
average patients require 4050 degrees and
short, heavy patients 3040 degrees. The
angle is usually the same for both breasts
(ACR, 6062; Peart, 115146).
12. (A) In the (CC) projection, the beam is
directed superiorly to inferiorly, without
angulation. The MLO uses tube angulation.
The CV shows the medial breast from the CC
position and the XCCL images the lateral
portions of the breast in the CC position (CR,
4349; Peart, 115146).
13. (B) Having the patient hold the supporting
bars with the contralateral hand stabilizes the
patient and helps to bring medial breast tis-
sue closer to the IR. This is important because
eliminating medial breast tissue from the CC
projection may eliminate this tissue from the
study. The patient holding the IR can project
body parts in the image (Peart, 115146).
14. (A) The right lateromedial oblique (RLMO) is
a useful alternative to the right mediolateral
oblique (RMLO) in patient with prior pace-
maker surgery, open-heart surgery, or any
other painful scarring along the sternum
where the compression paddle would cause
discomfort by pulling on scar tissue. The lat-
eromedial oblique (LMO) projection is a true
reverse of the MLO and will demonstrate the
same anatomical structures. The ML will not
demonstrate adequate posterior breast. The
LM can often be used to replace the MLO in
the nonconforming patient but in this example
a right LM would be needed (Peart, 115146).
96 5: Positioning and Interventional Procedures
15. (D) The AT or axilla projection demonstrates
the axillary contents or tail of the breast. It is
also called the tail of Spence. This projection is
especially useful in demonstrating swollen
lymph nodes (lymphadenopathy). The study
may be unilateral or bilateral. LMO is the
reverse of the MLO with an oblique beam trav-
eling from inferiolateral to superior-medial.
The TAN is used to image lesions in the skin
and the LM is a 90-degree lateral, which can be
used to image the medial breast (Peart, 115146).
16. (B) The TAN projection is used to skim the
area of interest. The projection demonstrates
skin calcications or areas free of superimpo-
sition. The TAN projection also brings the
area closer to the IR. Before obtaining a TAN
projection, the abnormality must be palpable
or visualized on another projection to deter-
mine its approximate location. In the LM,
the beam travels from lateral to medial at
90 degrees and best images the medial breast.
LMO is the reverse of the MLO with an
oblique beam traveling from inferiolateral to
superior-medial. The AT or axilla projection
demonstrates the axillary contents or tail of
the breast (Peart, 115146).
17. (A) With the nipple in prole, both the ML
and the LM are lateral projections that will
show the breast structures in relation to the
nipple. With the medial breast closest to the
IR, the LM projection is best suited to image
medially located abnormalities and will give
the best image detail; the ML images lateral
abnormalities best. In addition, unlike the
image produced with the ML, the resultant
image from the LM is similar to the MLO.
The AT images the tail of the breast and the
TAN best images skin lesion and calcica-
tions (Peart, 115146).
18. (B) The XCCL will best image the posterolat-
eral tissue of the breast, which may not be
visualized on the CC. The FB is the reverse of
the CC with the beam traveling from inferior
to superior (caudocranial). The TAN gives a
tangential projection of the area of interest
and the CV images the medial breast in the
CC position (Peart, 115146).
19. (C) A patient with kyphosis may also have
pectus excavatum (sunken chest), barrel-
chest or pectus carinatum (pigeon breast).
With these patients, it is rarely possible to
image the entire breast with the standard two
projections. An FB projection in such a situa-
tion is often useful. For the FB, the entire
mammography unit is rotated 180 degrees
and the IR is placed at the superior aspect of
the breast. If the FB is not possible because of
limitations of the mammography unit, the
CC should be performed to image as much
medial tissue as possible. Alternatively, the
CV can be used to image both medial breasts
with a right and left CC for the lateral por-
tion of the breast. In addition, the MLO,
LMO, or LM will complete the series (Peart,
115146; Venes, 1610).
20. (B) When comparing the MLO to the ML in
search for an abnormality, medial lesions
move up on the lateral from their position on
the MLO; lateral lesions move down on the
lateral from their position on the MLO. Cen-
trally located lesions show little or no move-
ment (Peart, 115146).
21. (D) Milk of calcium deposits are benign calci-
cations that occur in microcysts as
radiopaque particles mixed with uid. On the
CC, XCCL, or FB projections, they will appear
as ill-dened calcications. On a true lateral
projection, such as the ML, the radiopaque
particles settle to the dependent portion of
the cyst, forming crescent- or teacup-shaped
calcications. These may be clustered, scattered,
or occur bilaterally (Peart, 115146).
22. (B) The TAN projection is used to skim the
area of interest. The projection demonstrates
skin calcication or any area free of superim-
position. The TAN projection also brings the
area closer to the IR. The CV images the
medial breast, and both the LMO and the AT
are oblique projections (Peart, 115146).
23. (D) The AT projection is a 20-degree oblique
anterior-posterior projection used to visualize
the axillary area or tail of the breast. Gener-
ally, the degree of angulation can depend on

the patients body habitus. In the ML, the beam
travels from lateral to medial at 90 degrees
and best images the lateral breast. The XCCL
images the lateral portions of the breast in
the CC position, and the FB is a caudocranial
projection that best images the superior
breast tissue (Peart, 115146).
24. (B) The XCCL can be used to image the
extreme posterolateral tissue missed on the
CC. As with the CC projection, the beam is
directed superiorly to inferiorly. The CV
images the medial breast and the MLO and
AT are oblique projections (Peart, 115146).
25. (A) The caudal-cranial, FB, projection is the
reverse of the CC and can be used to image
nonconforming patients, such as those with
extreme kyphosis. The FB also places supe-
rior lesions that are high on the chest wall
closer to the IR, providing more detail of the
lesion. Inferior lesions are imaged furthest
from the IR (Peart, 115146).
26. (C) The LM projection gives a true representa-
tion of breast structure in relation to the nipple.
The LM places medially located lesions close
to the IR. For the LM, the beam is directed lat-
erally to medially. The CV shows the medial
breast from the CC position. In the ML, the
beam travels from lateral to medial at 90 degrees
and best images the lateral breast. The MLO is
a routine projection with the beam traveling
from superior-medial to inferiolateral (Peart,
115146).
27. (C) The MLO projection gives a distorted and
overlapping image of the anterior and medial
structures of the breast because it is an
oblique project. However, it is the single best
projection used to image the breast in its
entirety. The MLO is also best at visualizing
the posterior and upper-outer quadrants of
the breast. The ML is poor at visualizing the
most posterior and lateral parts of the breast
and is not useful in visualizing areas of the
breast missed on the MLO (Peart, 115146).
28. (D) The CV projection is the best at imaging
the extreme medial aspect of the breast with
Answers and Explanations: 15 through 32 97
the beam directed craniocaudal. The CC is a
routine projection and will image medial
breast tissue, but not extreme medial tissue.
The MLO distorts the medal breast and the
ML often misses the medial breast (Peart,
115146).
29. (A) The rolled image helps to move superim-
posed breast tissue away from a suspected
lesion. The breast is rolled in equal and oppo-
site directions through physical manipulation
of the patients breast. The rolled projections
can be performed in any direction. For the
RM, the breast is rst positioned for the CC
projection. The upper surface is then rolled
medially and the lower surface is rolled later-
ally. For the RL, the upper surface is rolled
laterally and the lower surface is rolled medi-
ally. M indicates magnication and ML is a
90-degree lateral projection (Peart, 115146).
30. (C) The LMO is a reverse of the MLO and
results in a similar image. For the LMO, the
beam is directed from the inferolateral (lower
outer) aspect of the breast to the superome-
dial (upper inner) aspect In the LM, the beam
travels from lateral to medial at 90 degrees
and best images the medial breast. The ML is
also a true lateral, with the beam traveling
from lateral to medial. The MLO is a routine
projection with the beam traveling from
superior-medial to inferiolateral (ACR, 71;
Peart, 115146).
31. (B) The CV is a cranialcaudal projection
used to image the extreme medial aspect of
the breast (Peart, 115146).
32. (C) In the rolled image, the breast is rolled in
equal and opposite directions via physical
manipulation of the patients breast. For the
RM, the patient is position for the CC projec-
tion. The upper surface of the breast is then
rolled medially and the lower surface is
rolled laterally. For the RL, the patient is also
positioned for the CC projection. The upper
surface of the breast is rolled laterally and the
lower surface is rolled medially. The MLO is
a routine projection with the beam traveling
from superior-medial to inferiolateral. The
98 5: Positioning and Interventional Procedures
CV shows the medial breast from the CC
position (Peart, 115146).
33. (B) Magnication mammography (M) is
especially useful in assessing or nding
breast calcications, or to better outline the
borders of masses. The other projection will
image the calcication but do not provide a
magnied image of the area of concern. The
MLO is a routine projection with the beam
traveling from superior-medial to inferiolat-
eral. The CV shows the medial breast from
the CC position (Peart, 115146).
34. (A) In the rolled image, the breast is rolled in
equal and opposite directions via physical
manipulation of the patients breast. For the
RM, the patient is positioned for the CC pro-
jection. The upper surface of the breast is
then rolled medially and the lower surface is
rolled laterally. For the RL, the patient is also
positioned for the CC projection. The upper
surface is rolled laterally and the lower sur-
face is rolled medially (Peart, 115146).
35. (D) With magnication, the breast may be
magnied up to twice its original size; there-
fore, the entire breast is rarely imaged. The
patients skin dose increases because the
breast is closer to the source plus additional
exposure is required because of reciprocity
law failure. Magnication can be used to
image specimens and lesions and to assess
the borders or the presence of calcications
(Bushong, 327340; Peart, 115146).
36. (C) For the RS, the patient is positioned for the
ML. The surface of the breast away from the IR
is rolled superiorly and the lower surface is
rolled inferiorly. For the RI, the patient is posi-
tioned for the ML. The surface of the breast
away from the IR is rolled inferiorly and the
lower surface is rolled superiorly (Peart, 115146).
37. (D) For the RM, the patient is positioned for
the CC projection. The upper (superior) sur-
face of the breast is rolled medially and the
lower (inferior) surface is rolled laterally. For
the RL, the patient is positioned for the CC
projection. The upper (superior) surface is
rolled laterally and the lower (inferior) sur-
face is rolled medially (Peart, 115146).
38. (D) A patient with pectus excavatum has a
sunken or depressed sternum and rib cage,
which make imaging the medial and lateral
breast tissue difcult on the routine CC projec-
tion. Extensive pectoral muscle is mainly a
problem when imaging males in the MLO pro-
jection. In barrel chest, the chest protrudes and
the kyphotic patient has exaggerated thoracic
curvature or rounded shoulders (Peart, 115146).
39. (A) In the modied ID projections, the pros-
thesis is displaced posteriorly and superiorly
against the chest wall while gently pulling
the breast tissue anterior away from the pros-
thesis, onto the IR. The implant or prosthesis
is held in place with the compression device
(ACR, 73; Peart, 115146).
40. (D) The routine series for an implant patient
includes the routine CC, routine MLO, CC
with ID, and MLO with ID. It may be difcult
to displace the implant on some patients,
especially if the implant is encapsulated. If it
cannot be adequately displaced, another pro-
jection (such as the 90-degree lateral with the
implant included) should be added to the rou-
tine CC and MLO projections of the implant.
Imaging the patient in three projections
ensures visualization of some parts of all four
quadrants of the breast. The AT could be used
to evaluate silicone spread into the lymph
nodes. Another useful projection to image
encapsulation is the SIO (ACR, 73; Peart, 115146).
41. (D) The spot compression projection focuses
the compression on a single area to improve
resolution and evenly spread out the breast tis-
sues. This is sometimes useful in eliminating
pseudomasses. The TAN images skin lesion.
The CV images the medial breast and the AT
images the axillary tail (ACR, 54; Peart, 115146).
42. (D) The routine series for an implant patient
includes the routine CC, routine MLO, CC
with ID, and MLO with ID. The total projec-
tions per patient would therefore be eight
(ACR, 73; Peart, 115146).

43. (C) Radiation-induced changes in the breast
usually peak at 6 months after treatment, but
may continue for up to 1 year. Initially, the
breast may exhibit erythema and edema, or it
may harden. The breast may also be extremely
sensitive and distorted because of surgery.
Although the mammography examination
must be adapted for each patient, a mammo-
gram is not recommended earlier than 6 months
after radiation treatment (Peart, 115146).
44. (A) Spot compression focuses compression on
a single area to improve resolution and evenly
spread out the breast tissues. This is sometimes
useful in eliminating pseudomasses. Spot com-
pression can be taken with or without magni-
cation and in any projection. XCCL, AT, and
CV are all specic supplementary projections
with set central ray directions and tube orien-
tations (ACR, 54; Peart, 115146).
45. (C) With postmastectomy imaging, it is no
longer possible to make a comparison between
two mirror-image breasts. Therefore, an
additional projection will give the radiologist a
better opportunity to diagnose cancer. The ML
or LM is often the preferred additional projec-
tion. The CC and the MLO are routine projec-
tions and the CV shows the medial breast from
the CC position (Peart, 115146).
46. (A) Caution should be used when compress-
ing implants to avoid implant rupture. Com-
pression should therefore be used for immo-
bilization only and not to separate breast
tissue structures. TAN projections and mag-
nication could be used to evaluate lumps
and calcications, respectively. The implant
displaced (ID) compression technique is used
to image portions of the breast that would
not be visualized because of superimposition
of the implant (Figure 5-10) (Peart, 115146).
47. (A) The specimen is radiographed to ensure
that the lesion was removed. The lesion
should be circled on the radiograph and all
the borders checked to conrm that the entire
lesion was removed. The specimen can be mag-
nied, especially if calcications are present to
count and conrm that all the calcifications
Answers and Explanations: 33 through 51 99
have been removed (Andolina, 313400; Peart,
115146).
48. (C) Compression of the specimen reduces tis-
sue thickness, thus improving subject con-
trast. Structures are spread out, and tissue
density is uniform with less superimposition
of structures. The specimen can also be mag-
nied to image calcications. The overall
effect is improved visualization and a more
uniform density. Motion unsharpness and
radiation reduction is not an issue in speci-
men imaging. Compression will improve
visualization of structures in the magnied
specimen but will not alter the magnication
factor (Andolina, 313400; Peart, 115146).
49. (D) FNA obtains cellular material for cyto-
logical analysis. FNA uses small-gauge nee-
dles (23 gauge), which limits the amount of
cells that can be aspirated. The accuracy of
the procedure depends on the radiologist
performing the examination and the cytolo-
gist interpreting the results. Ductography
cannulates a duct to introduce a contrast
agent. Needle localization positions a guide
wire in a nonpalpable lesion for surgical
removal. Pneumocstogram injects air in a
cyst for analysis of the inner lining of the cyst
(Andolina, 313400; Peart, 203217).
50. (D) Preoperative localization is performed on
nonpalpable lesions or suspicious areas that
are identied only mammographically. The
radiologist assists the surgeon by placing a
wire in the suspected tissue as a guide for the
surgeon. The surgeon is then able to excise
only the lesion and surrounding margins
rather than a larger area of the breast. Once
excised, the wire in the area of suspicion con-
rms that the correct area was removed
(Andolina, 313400; Peart, 203217).
51. (D) Core biopsy provides a larger sample of
breast tissue for histological study. The larger
sample (generally an 11- to 14-gauge needle
is used) offers a more denitive diagnosis
when compared with FNB. Ductography can-
nulates a duct to introduce a contrast agent.
Needle localization positions a guide wire in
100 5: Positioning and Interventional Procedures

Figure 510. Diagram of the Eklund method (ID technique). The ID or implant-displaced technique or Eklund method for implants displaces
the implant posteriorly and superiorly to image the breast tissue free of the implant. (A) Normal compression. (B and C) Displacing the implant
posteriorly and superiorly prior to compression. (D) Compression of the breast tissue free of implant.

a nonpalpable lesion for surgical removal.
Pneumocstogram injects air in a cyst for
analysis of the inner lining of the cyst
(Andolina, 313400; Peart, 203217).
52. (C) A broadenoma usually has low-level
internal echoes and the borders may be
smooth, round, or lobulated. An abscess will
be uid lled and usually has some internal
echoes. Their borders are generally well
dened, but irregular. Ductal carcinomas typ-
ically are taller than they are widebenign
masses spread out horizontally. Cancers have
a spiculated outline with alternating
echopenic and echogenic straight lines radiat-
ing from the surface of the mass (echopenic
means there are few echoes within a struc-
ture; echogenic describes a structure that pro-
duces echoes; anechoic means no internal
echoes). A cyst is usually uid lled with
smooth walls that allow transmission of
sound. Sound traveling through a uid-lled
structure is barely attenuated; the structures
distal to a cystic lesion appear to have more

echoes than neighboring areas. This process is
also referred to as distal echo enhancement. It
is rare for calcications in a cyst wall or
debris within the cyst to present through
transmission (Peart, 147162).
53. (C) If the sound traveling through a cyst is
barely attenuated then the structure distal to
the cyst appears to have more echoes than
neighboring areas. The phenomenon is
referred to as acoustic enhancement or
through transmission (Peart, 147162).
54. (A) Ductography or galactography can be
performed on patients with nipple discharge.
A small amount of contrast agent is injected
into the duct and radiographs are taken in the
CC and lateral positions. The contrast agent
outlines these structures to visualize any
pathology. Needle localization positions a
guide wire in a nonpalpable lesion for surgi-
cal removal. Pneumocstogram injects air in a
cyst for analysis of the inner lining of the cyst.
FNA removes uid from a cystic lesion for
cytologic analysis (Andolina, 313400; Peart,
203217).
55. (C) A pneumocystogram may be performed
in conjunction with cyst aspiration. Air is
injected into the cyst, which has been emp-
tied. The inner walls of the cyst can then be
assessed. In general, the air is reabsorbed by
the body within a week. Ductography exam-
ines the ducts; needle localization is used to
locate nonpalpable lesions, and FNA can be
used to remove the content of a cyst (Andolina,
313400; Peart, 203217; Tabr, 89).
56. (A) Breast biopsy is the taking of a sample
specimen of breast cells or tissue for cytologi-
cal or histological analysis. In a core biopsy, a
large-gauge needle (1116 gauge) is used to
remove tissue samples. The core biopsy nee-
dles can be mechanical or automatic core
guns with an inner needle. These needle
gun combinations are designed to move a
cutting needle rapidly through the breast to
obtain a tissue sample. Core biopsies can be
performed under mammography, ultra-
sound, or MRI guidance. Cytology refers to
Answers and Explanations: 52 through 57 101
the study of cells. Ductography is used to
evaluate patients with abnormal nipple dis-
charge. The lactiferous duct is cannulated
and a small amount of contrast agent is
injected before the area is imaged. Aspiration
is a method of removing uid from a cyst
using a needle (Figure 5-11) (Andolina, 313400;
Peart, 48, 203212).
A
B
C
D
Figure 511. Core biopsy gun (A) prere; (B) trough without the
needle; (C) postre into the lesionthe needle moves forward, ll-
ing the trough with breast tissue; and (D) postre the outer sheath
moves forward to cut the tissue and keep it in the trough.
57. (B) FNA is a technique used to obtain cellular
material from a lesion for cytological analy-
sis. FNA can reduce the need for a surgical
breast biopsy. Because the technique is per-
formed using a small-gauge needle (2025),
the accuracy of the procedure is dependent
on the skills of the radiologist or surgeon per-
forming the procedure. During the proce-
dure, the presence of a cytotechnologist or
cytopathologist is recommended to verify the
adequacy of the cell samples and to prepare
the slides. Core biopsies can be performed
under mammography, ultrasound, or MRI
guidance. Cytology refers to the study of
cells. Ductography is used to evaluate
patients with abnormal nipple discharge. The
lactiferous duct is cannulated and a small
amount of contrast agent is injected before
the area is imaged. Ductal lavage is a tech-
nique used to collect cells from the lining of
the milk duct (Andolina, 332; Peart, 209215).
102 5: Positioning and Interventional Procedures
58. (D) Stereology is the science of determining
the three-dimensional location of an object
based on two-dimensional images. Stereotac-
tic breast localizations can be used to locate
the horizontal, vertical, and depth position
of nonpalpable lesions. A computer performs
the necessary calculations therefore if the
input information is inaccurate, errors in
localization will result (Andolina, 334; Peart, 204).
59. (D) Cyst aspiration removes the contents of a
cyst for analysis. Although the technique is
often done with ultrasound guidance, aspira-
tions can be performed under mammo-
graphic guidance for nonpalpable lesions or
clinical guidance for large palpable cyst. MRI
aspirations are not common because often
cysts, if not visualized on mammography, are
visualized on ultrasound. The needle size
used depends on the viscosity and thickness
of the uid content of the cyst but generally a
small gauge (eg, 21 gauge) is used to reduce
patient discomfort (Andolina, 322; Peart, 204).
60. (B) The open surgical biopsy is the most inva-
sive procedure, but it has the lowest false-
negative rates. Open surgical biopsies will
need more hospital time, require anesthesia,
and will leave visible scars on the breast.
These factors all contribute to a higher compli-
cation rate with open biopsy than with the
other minimal invasive procedure. FNB is the
cheapest but least accurate biopsy method.
The main cause is insufcient samples because
of the small-needle gauge used. Core biopsy is
has a lower false-negative rate than FNB, but
again insufcient samples can reduce the
accuracy. MRI-guided biopsy is usually used
for lesions seen only on MR imaging. The
technique involves the removal of core sam-
ples and is considered a minimally invasive
procedure (Andolina, 313400; Peart, 203217).
 CHAPTER 6

Practice Test 1
Questions

1. A clinical breast examination (CBE) and 5. The large air gap used in magnication func-
breast self-examination (BSE) are similar in tions to
that both
1. increase scatter
(A) involve looking and feeling for changes 2. improve contrast
in the breast 3. reduce scatter
(B) are done by a trained medical profes-
sional (A) 1 and 2 only
(C) are done monthly (B) 1 and 3 only
(D) are done yearly (C) 2 and 3 only
(D) 1, 2, and 3
2. The most common cause of undercompres-
sion is 6. In high-contrast imaging or conventional
imaging
(A) a faulty compression paddle
(B) inadequate compression by the (A) skin detail is easily seen
mammographer (B) bright light is needed to see skin detail
(C) patient pain tolerance level (C) glandular tissue and skin detail are seen
(D) broken automatic compression device equally
(D) glandular tissue and skin detail are seen
3. In establishing processor quality control poorly
(QC), the high average density is generally
the density closest to 7. Which of the following could be used when
imaging extremely small breasts in the cran-
(A) but not less than 2.20 iocaudal (CC) position?
(B) but not less than 1.20
(A) spatula
(C) but not less than 0.45
(B) ML
(D) 2.20
(C) cleavage (CV)
4. Ductal papilloma is (D) exaggerated craniocaudal (XCCL)

(A) a benign proliferation of tissue in the

male breast
(B) a malignant tumor involving the ducts
(C) a collection of blood in the breast, which
can occur after surgery
(D) benign growths involving the milk ducts

103

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104 6: Practice Test 1

8. In the tangential (TAN) projection, any tube 12. One major difference between collimation in
angulation will depend on mammography and collimation in general
radiography is that
(A) the size of the patients breast
(B) the location of the abnormality (A) in mammography the entire image
(C) the location of the nipple in relation to receptor area is exposed
the abnormality (B) decreasing collimation increases expo-
(D) whether the abnormality is palpable or sure in mammography
nonpalpable (C) mammography uses a variety of beam-
limiting devices
9. A small but growing cancer is often not obvi- (D) in radiography the entire image receptor
ous to the individual because it often pre- area is always exposed
sents as
13. Two lm emulsions are compared on a char-
(A) skin irritation
acteristic curve. The higher contrast lm will
(B) inverted nipples
(C) a painless mass (A) have the steeper slope
(D) a painful mass (B) have a longer toe
(C) shift to the right of the lower contrast
10. Mammography is more accurate in lm
(D) shift to the left of the lower contrast lm
(A) premenopausal women
(B) postmenopausal women 14. When cleaning the intensifying screens, the
(C) women with brocystic breast loaded cassette is unloaded under safelight
(D) women with dense breast tissue conditions in the darkroom. The lm in the
cassette is
11. In taking medical history, hormones use
(A) stored in the lm bin during the clean-
(both natural and articial) are taken into
ing process
account because
(B) removed from the cassette and dis-
1. hormones cause breast cancer carded
2. early menarche can increase breast (C) returned to the cassette after cleaning
cancer risks (D) returned to the lm bin
3. contraceptive use can increase breast
cancer risk 15. The retromammary space is lled with
(A) 1 and 2 only (A) supportive and connecting tissue
(B) 2 and 3 only (B) adipose tissue
(C) 1 and 3 only (C) broglandular tissue
(D) 1, 2, and 3 (D) blood vessels
 Questions: 8 through 22 105

16. The fatty versus broglandular nature of

breast tissue is affected by which of the
following?
1. age
2. hormone use
3. number of pregnancies
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3

17. In compression on the XCCL projection, the

affected arm should
(A) not be raised, but rest along the top of
the image receptor
(B) be raised, with hand resting/holding on
bar of unit
(C) be place on the patients hips
(D) be placed according to the wishes and
comfort of the patient

18. In the CC position the pectoral muscle is seen Figure 61

(A) all the time

(B) rarely if ever
(C) about 30%40% of the time
(D) about 50% of the time 21. Regardless of the reason, if the proper
amount of compression cannot be applied
19. Between ages 20 and 39, a woman should which of the following must apply?
have a CBE every (A) the patient must be told
(A) year (B) the patients doctor must be told
(B) 2 years (C) the radiologist must be told
(C) 3 years (D) it must be noted on the patients
(D) 4 years history form

20. The lesion seen in Figure 6-1 is not palpable 22. Magnication is contraindicated
and is not associated with nipple or skin 1. when imaging the mastectomy site
changes. It is likely to be
2. in specimen radiography
(A) invasive ductal breast carcinoma 3. as a normal/routine screening tool
(B) a mammographically malignant tumor
(A) 1 only
(C) a mammographically benign tumor
(B) 3 only
(D) nonspecic; further testing is indicated
(C) 2 and 3 only
(D) 1 and 3 only
106 6: Practice Test 1

23. If no previous mammograms are available 26. Manual technique is sometimes necessary
for comparison, the automatic exposure con- when imaging implants because
trol (AEC) detector should be placed
(A) the implant covers the AEC detector
(A) in the central aspect of the compressed (B) patients with implants have small
area of the breast breasts
(B) as close to the chest wall as possible (C) patients with implants have large breasts
(C) toward the medial aspect of the breast (D) the implant does not cover the AEC
(D) anywhereplacement will not affect the detector
exposure
27. Which projection could be used to demon-
24. Which section of the breast is poorly visual- strate a deep medial lesion not seen on the CC?
ized on the CC projection?
(A) axillary tail (AT)
(A) medial (B) XCCL
(B) axial (C) CV
(C) lateral (D) MLO
(D) superior
28. After a routine four-projection mammo-
25. Identify the projection in Figure 6-2. graphic series, the nipple is not seen in pro-
le on any of the images. Additional projec-
(A) rolled medial (RM)
tions are done if
(B) mediolateral (ML)
(C) XCCL 1. the nipple is indistinguishable from a
mass
(D) mediolateral oblique (MLO)
2. a subareolar abnormality is suspected
3. the nipple is not marked with a BB
(lead shot)
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3

29. Identify the projection in Figure 6-3.

(A) TAN
(B) from below (FB)
(C) XCCL
(D) ML

Figure 62. ( 2000 The American Registry of Radiologic

Technologists.)
 Questions: 23 through 37 107

33. The operating level density difference (DD)

for the phantom should be at least
(A) 0.40
(B) 0.80
(C) 0.02
(D) 1.20

34. A lm was accidentally bent prior to loading

into the mammography cassette. If this lm
is used in mammography screening, an arti-
fact would appear as
(A) a minus-density artifact
Figure 63. ( 2000 The American Registry of Radiologic (B) a plus-density artifact
Technologists.) (C) static
(D) lines parallel to the direction of lm
travel
30. Your patients sister had breast cancer. Your
patient is considered to have 35. Montgomery glands are specialized
(A) a greater risk for breast cancer (A) sweat glands
(B) a lower risk for breast cancer (B) sebaceous gland
(C) no signicantly increased risk for (C) Cooper ligaments
breast cancer (D) hair follicles
(D) a personal history of breast cancer
36. A woman taking estrogen replacement ther-
31. The Mammography Quality Standards Act apy may notice changes in the breast such as
(MQSA) mandates that the average glandular
dose received per projection/position during 1. breast enlargement
routine screen-lm mammography cannot 2. lumpy breast
exceed 3. cysts
(A) 100 mrad (A) 1 and 2 only
(B) 200 mrad (B) 2 and 3 only
(C) 300 mrad (C) 1 and 3 only
(D) 400 mrad (D) 1, 2, and 3

32. When imaging an extremely dense breast 37. Paget disease of the breast is a(an)
using AEC, the exposure sometimes termi-
(A) inltrating carcinoma generally limited
nates, resulting in an underexposed image
to the breast
because of the action of the
(B) form of carcinoma associated with
(A) exposure timer changes of the nipple
(B) backup timer (C) benign breast condition that is relatively
(C) phototimer common
(D) device timer (D) malignant form of breast carcinoma
involving the lobules
108 6: Practice Test 1

38. Variation in compression levels causes 42. In which of the following modied projection
is the superior surface of the breast rolled
1. inadequate exposure on one portion of
medially?
the breast
2. over- or underexposure in other portions (A) RM
of the breast (B) RL
3. adequate exposure throughout the (C) M
breast (D) lateral medial (LM)
(A) 1 and 2 only
43. Factors that lower breast cancer risk include
(B) 2 and 3 only
(C) 1 and 3 only 1. having your rst child after age 30
(D) 1, 2, and 3 only 2. breast-feeding your child
3. late menarche
39. What is the major disadvantage of magni-
(A) 1 and 2 only
cation?
(B) 2 and 3 only
(A) reduced resolution of the image (C) 1 and 3 only
(B) increased patient dose (D) 1, 2, and 3
(C) increased scattered radiation
(D) none of the above 44. The minimum and maximum kilovoltage
peak (kVp) of a mammography unit depends
40. Selection of rhodium anode/lter combina- on which main factor(s)?
tion for a fatty breast
(A) Radiologist preference or
1. overpenetrates the fatty breast recommendations
2. alters the penetrating power of the beam (B) Characteristics of the screen-lm
3. results in loss of subject contrast combination
(C) Processing and the patients breast size
(A) 1 and 2 only
(D) Target and ltration material selected
(B) 1 and 3 only
(C) 2 and 3 only 45. For the daily processor QC, the mid-density
(D) 1, 2, and 3 should remain within

41. When imaging the breast using the MLO pro- (A) 0.15 of the established levels
jection, drooping breast can be a result of (B) 0.10 of the established levels
which of the following? (C) +0.30 of the established levels
1. too much compression of the anterior (D) +0.03 of the established levels
breast
46. Gynecomastia denes
2. too little compression of the anterior
breast (A) a localized abscess
3. too much axilla included in the compres- (B) increased breast tissue in the male breast
sion eld (C) decreased breast tissue in the female
(A) 1 and 2 only breast
(B) 2 and 3 only (D) a risk of carcinoma for the male patient
(C) 1 and 3 only
(D) 1, 2, and 3
 Questions: 38 through 53 109

47. Total ltration with a rhodium target ltra- Rib

tion combination is Pectoral muscle
Vein
(A) the added ltration plus the inherent l- Retromammary adipose tissue
tration A
(B) equal to the added ltration Subcutaneous adipose tissue

(C) equal to the inherent ltration

(D) the added ltration minus the inherent
ltration
B
C
48. According to MQSA regulations, which of
the following is not required on the nal D
mammographic image? Areola

(A) date of the examination

(B) technical factors used Glandular tissue
lobules
(C) mammographer/technologist identica-
Connective tissue
tion and adipose tissue
Artery
(D) cassette/screen identication

49. The inframammary crease is located at Figure 64

approximately the level of the
(A) second to third rib 51. Identify the lactiferous sinus in Figure 6-4.
(B) third to fourth rib (A) site A
(C) fourth to fth rib (B) site B
(D) sixth to seventh rib (C) site C
(D) site D
50. Identify Cooper ligament in Figure 6-4.
(A) site A 52. Scattered radiation is reduced during magni-
(B) site B cation mammography by
(C) site C (A) using a small focal spot size
(D) site D (B) using a grid
(C) using the air-gap technique
(D) increasing the source-to-image receptor
distance (SID)

53. Ductography can be used to determine

1. the location of the lesions in the ducts
2. if a lesion is benign or malignant
3. changes or abnormalities associated
with the ducts
(A) 1 only
(B) 1 and 2 only
(C) 1 and 3 only
(D) 2 and 3 only
110 6: Practice Test 1

54. In the CC projection, a technique especially 59. A palpable mass that is not seen on a diag-
useful in maximizing the amount of lateral nostic mammogram generally means
breast tissue imaged on the small-breasted
(A) breast cancer is ruled out; the mass is
patient with rounded shoulders is
probably benign
(A) 5-degree lateral tube angulation (B) other diagnostic testing must be considered
(B) 5-degree medial angulation (C) the mass is likely breast cancer
(C) using a straight tube (D) the mass is likely caused by uctuating
(D) the ML projection hormones

55. During magnication, positioning the breast 60. Which of the following patients has the great-
away from the image receptor utilizes which est risk for breast cancer?
law/principle in scatter reduction?
(A) A nulliparous woman at age 40
(A) inverse-square law (B) A never married woman
(B) reciprocity law (C) A woman, age 70
(C) heel effect (D) A woman, age 30
(D) line focus principle
61. A mammographer using a 0.1-mm focal spot
56. A woman with one rst-degree relative with size is most likely performing
breast cancer has a higher risk for breast cancer
(A) routine mammography work
than a woman with
(B) magnication imaging
1. early menarche, taking oral contraceptives (C) spot compression imaging
2. a personal history of breast cancer (D) stereotactic work
3. late menopause
(A) 1 and 2 only 62. The developer temperature should always be
(B) 2 and 3 only (A) 95C
(C) 1 and 3 only (B) 95F
(D) 1, 2, and 3 (C) 0.5F (0.3C) of the manufacturers
recommendation
57. The primary purpose of the grid in mam- (D) 5.0F (3.0C) of the manufacturers
mography is to recommendation
(A) improve image sharpness
63. One box of lm should be dedicated to pro-
(B) reduce the production of scatter
cessing QC because
(C) reduce patient dose
(D) increase the subject contrast (A) it is easier to track the repeat rate
(B) multiple boxes introduce multiple
58. The implant-displaced (ID) projection is pos- variables
sible on all of the following cases except (C) overall lm density may cause fogging
(A) implants placed posterior to the pectoral (D) lms need consistent handling
muscle
64. The base of the breast refers to the
(B) implants placed anterior to the pectoral
muscle (A) the nipple area of the areola
(C) soft implants (B) area adjacent to the chest wall
(D) encapsulated implants (C) axilla area of the breast
(D) lower outer quadrant of the breast
 Questions: 54 through 71 111

65. Fibrous tissues are presented radiographi- 68. In mammography, the AEC detector is placed
cally as directly
(A) black or radiolucent areas (A) above the image receptor
(B) gray and less dense areas (B) below the grid
(C) white or denser areas (C) above the grid
(D) black and less dense areas (D) below the image receptor

66. Figure 6-5 shows
(A) invasive ductal breast carcinoma
(B) mammographically malignant
calcications
(C) mammographically benign calcications
(D) numerous oil cysts
69. Since 1989, the death rate from breast cancer
has declined because
(A) more cancers are discovered at a later
stage
(B) more cancers are discovered at an earlier
stage
(C) the long-term survival rate for breast
cancer patients is stable
(D) patients who survive 5 years will
survive an additional 10 years

70. Contaminated developer will likely result in

1. decreased lm speed
2. increased image receptor contrast
3. increased lm base density
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3

71. Spot compression

1. applies more compression to a localized
area
2. can be performed with magnication
3. employs a coned collimated eld to limit
the area of interest
Figure 65
(A) 1 only
(B) 1 and 2 only
67. The MLO projection demonstrates a large
(C) 2 and 3 only
encapsulated lesion occupying almost the
entire breast. The contour is sharp and the (D) 1, 2, and 3
lesion is radiolucent. This lesion is most
likely to be a(an)
(A) oil cyst
(B) hematoma
(C) broadenoma
(D) lipoma
112 6: Practice Test 1

72. Identify the projection in Figure 6-6. 75. Why is the specimen magnied?
(A) TAN (A) to ensure that the lesion has been com-
(B) FB pletely removed
(C) XCCL (B) to visualize the calcications within the
(D) RM specimen
(C) to compare the magnied and nonmag-
nied images
(D) to check the number and placement of
calcications

76. In digital mammography, a grossly underex-

posed image
(A) appears excessively noisy
(B) is too light
(C) is too dark
(D) appears correctly exposed

77. Which of the following patients is likely to be

diagnosed with pathological gynecomastia?
Figure 66. ( 2000 The American Registry of Radiologic (A) lactating woman
Technologists.)
(B) elderly man
(C) premenopausal woman
73. To reduce the possibility of imaging the (D) young man
abdomen in the MLO position, the mammo-
grapher could 78. Montgomery glands are located on the
(A) have the patient stand just at the image breasts
receptor and bend back (A) skin
(B) have the patient stand away from the (B) nipple
image receptor and bend forward (C) areola
(C) have the patient turn medially to image (D) muscle
the lateral breast on the CC
(D) discard the MLO and image the breast 79. Extended processing increases the amount of
in the lateral position instead time the lm is immersed in the

74. A four-projection mammography series (A) developer solution

shows a solitary tumor without calcication (B) xer solution
in the upper outer quadrant (UOQ) of the (C) dryer
left breast. Only the anterior margins are (D) both the developer and xer solutions
seen. The next recommended step is
(A) biopsy 80. If the humidity in the dark room drops lower
than 30%, the result is
(B) spot compression
(C) stereotactic localization (A) an increase in base fog
(D) aspiration (B) lm scratches
(C) static patterns on lm
(D) reduced lm speed
 Questions: 72 through 89 113

81. Over age 40, it is recommended that women 86. In imaging the breast in the MLO projection,
have a CBE every compression to the lower portion of the
breast is compromised if
(A) year
(B) 2 years 1. the image receptor is too high
(C) 3 years 2. the patient has a protruding abdomen
(D) 4 years 3. too much axilla and shoulder are under
compression
82. Fibrous and glandular tissues are more (A) 1 and 2 only
_______ than fatty tissue and result in areas
(B) 1 and 3 only
of _______ optical density on the radiograph.
(C) 2 and 3 only
(A) radiolucent/lower (D) 1, 2, and 3
(B) radiolucent/higher
(C) radiopaque/higher 87. Involution of the breast describes a process
(D) radiopaque/lower by which
(A) milk is removed from the breast by
83. Good compression results in suckling
1. increased spatial resolution (B) breast epithelium proliferates during
2. decreased spatial resolution menstruation
3. improved subject contrast (C) breast epithelium decreases because of
postmenopausal changes
(A) 2 only
(D) estrogen causes an overall density
(B) 3 only decrease in the breast
(C) 1 and 3 only
(D) 2 and 3 only 88. In imaging the breast for the CC projection,
what technique is used to minimize skin
84. Which of the following involves the use of a folds in the lateral aspect of the breast?
thin needle to remove cell samples from a
(A) lift the posterior lateral aspect of the
suspected cancerous lesion in the breast for
breast onto the image receptor
cytological analysis?
(B) drape the contralateral breast over the
(A) core biopsy corners of the image receptor
(B) excisional biopsy (C) have the patients head turned away
(C) needle localization from the breast being imaged
(D) ne needle aspiration (FNA) (D) on the side being imaged, the patients
arm hangs relaxed with humerus exter-
85. A lesion is superimposed by breast tissue in nally rotated
the CC projection. A projection used to
demonstrate the lesion in the same projection 89. In the dedicated mammography unit, the sin-
and free of superimposition is the gle intensifying screen is positioned in con-
tact with the lm emulsion on
(A) MLO
(B) ID (A) the side of the IR away from the x-ray
(C) XCCL source
(D) RM (B) the side of the lm facing the x-ray source
(C) the side of the IR facing the x-ray source
(D) either sidethe placement does not
matter
114 6: Practice Test 1

90. Grid use in magnication mammography is 93. Which statement best describes a parallel or
contraindicated because linear grid?
1. grid use increases subject contrast (A) Lead strips are aligned adjacent to one
2. scatter is already minimized another and placed lengthwise in the
3. the grid results in increased patient dose same direction within the structure of
the grid.
(A) 1 and 2 only (B) Lead strips are aligned at right angles to
(B) 2 and 3 only each other.
(C) 1 and 3 only (C) Lead strips are designed to take advan-
(D) 1, 2, and 3 tage of the divergence of the x-ray beam
as it leaves the x-ray tube.
91. The breast can be imaged in the FB projection (D) Lead strips are designed to move during
1. to improve visualization of lesions in the exposure.
uppermost aspect of breast by reducing
object-to-image receptor distance (OID) 94. Mercury in a glass-type thermometer is not
recommended for use in QC testing because
2. during needle localization to provide a
shorter route to inferior lesions 1. Mercury is potentially inaccurate.
3. to maximize the amount of tissue visual- 2. Mercury is a potential source of
ized in patients with kyphosis contamination.
(A) 1 and 2 only 3. Glass-type thermometers may break.
(B) 2 and 3 only (A) 1 and 2 only
(C) 1 and 3 only (B) 2 and 3 only
(D) 1, 2, and 3 (C) 1 and 3 only
(D) 1, 2, and 3
92. Identify the projection in Figure 6-7.
(A) TAN 95. What factors are used to maintain a sharp
image during magnication?
(B) FB
(C) XCCL 1. adjustable focal spot sizes
(D) ML 2. decreasing the thickness of the body part
3. decreasing the resolution
(A) 1 and 2 only
(B) 1 and 3 only
(C) 2 and 3 only
(D) 1, 2, and 3

96. The half-value layer (HVL) of the x-ray beam

is measured with a
(A) star pattern
(B) slit camera
(C) pinhole camera
Figure 67. ( 2000 The American Registry of Radiologic (D) quality-control dosimeter
Technologists.)
 Questions: 90 through 104 115

97. The repeat rate should be analyzed if the rate 101. Today all mammographers (radiographer
changes from the previous measure rate by performing mammograms independently)
more than must have
(A) 2% 1. satised the interim requirements of the
(B) 3% FDA
(C) 4% 2. completed at least 40 contact hours of
(D) 5% documented training in mammography
3. performed at least 25 examinations
98. A magnication image of breast shows sev- under direct supervision of a qualied
eral oval-shaped radiolucent lesions with mammographer
eggshell-like calcications. These are most (A) 1 and 2 only
likely to be
(B) 2 and 3 only
(A) ductal papilloma (C) 1 and 3 only
(B) broadenomas (D) 1, 2, and 3
(C) oil cysts
(D) hematomas 102. The criteria for a properly positioned MLO
includes
99. The image viewing environment 1. a concave pectoral muscle on the ante-
1. has no effect on the detection of cancer- rior border
ous lesions 2. fat visualized posterior to the broglan-
2. can obliterate the advantages of opti- dular tissues
mum image quality 3. an open inframammary fold (IMF)
3. should eliminate extraneous viewbox (A) 1 and 2 only
light
(B) 2 and 3 only
(A) 1 and 2 only (C) 1 and 3 only
(B) 1 and 3 only (D) 1, 2, and 3
(C) 2 and 3 only
(D) 1, 2, and 3 103. A benign inammatory condition of the lact-
iferous ducts leading to nipple discharge,
100. In general, ID series are taken in nipple inversion, or periareolar sepsis is
called
(A) AT and MLO projections
(B) CC and ML projections (A) ductal ectasia
(C) CC and MLO projections (B) Paget disease of the breast
(D) CC and LM projections (C) peau do range
(D) ductal papilloma

104. The cells lining the alveoli in the lobules are

called
(A) epithelial cells
(B) myoepithelial cells
(C) basement cells
(D) supercial cells
116 6: Practice Test 1

105. Using a cassette with poor lm screen contact 110. Imaging males will present the same dif-
will result in culty as imaging small, rm-breasted females.
An added problem may be that
(A) a noisy image
(B) localized unsharpness (A) males have more problems with the
(C) motion unsharpness compression
(D) a lower subject contrast (B) the male breast is smaller than the
smallest female breast
106. A technique describing reshaping of the (C) males have more muscular breast tissue
breast is called (D) hair on the chest of males makes com-
pression difcult
(A) reduction mammoplasty
(B) mammoplasty 111. For the SIO projection, the central ray (CR) is
(C) breast augmentation directed
(D) breast biopsy
(A) inferolateral to superomedial
107. A major cause of radiographic noise is (B) superomedial to inferolateral
(C) inferomedial to superolateral
(A) image graininess
(D) superolateral to inferomedial
(B) quantum mottle
(C) poor contrast resolution 112. Which of the following are considered agen-
(D) motion cies granting accreditation under the FDA
regulation?
108. Failure of the hyporetention test will result in
1. ACR
what type of long-term artifact marks on the
image? 2. ARRT
3. NY State Department of Health
(A) streaks of increased optical density
(B) areas of reduced density (A) 1 only
(C) yellow brown stains (B) 2 only
(D) round spots of increased density (C) 1 and 2 only
(D) 2 and 3 only
109. In positioning for the superior-inferior
oblique (SIO), the _________ of the breast will 113. Which alternative projection could be used,
rest on the image receptor. in addition to the CC, in imaging a patient
with a prominent pacemaker?
(A) lateral surface
(B) superior surface (A) ML
(C) medial surface (B) lateromedial oblique (LMO)
(D) inferior aspect (C) XCCL
(D) MLO
 Questions: 105 through 115 117

114. During needle localization, breast positioning 115. In addition to the patients name, all mam-
should provide the shortest skin-to- mographic reports should have the
abnormality distance in order to
1. nal assessment of ndings
1. minimize trauma to the breast 2. hospital number or additional patient
2. ensure minimal excursion of the biopsy identier
needle into the breast 3. name of the radiologist
3. reduce the possibility of needle
(A) 1 and 2 only
deection
(B) 1 and 3 only
(A) 1 and 2 only (C) 2 and 3 only
(B) 1 and 3 only (D) 1, 2, and 3
(C) 2 and 3 only
(D) 1, 2, and 3
 Answers and Explanations
1. (A) Both the CBE and the BSE are examina-
tions of the breast where changes in the
shape, contour, and texture of the breast are
assessed and the breast is checked for lumps.
The CBE is done by a health professional,
whereas the BSE is done by the woman on
herself. The BSE should always be done
monthly after age 20. The CBE is recom-
mended every 3 years for those below 40 and
every year for those over 40 (ACR, 10).
2. (B) Studies have shown that although there
are many reasons for undercompression, the
main reason is a lack of communication
between the mammographer and the patient.
The mammographer undercompresses the
breast either because the patient refuses fur-
ther compression, is unable to tolerate more
compression, or the mammographer wants to
protect the patient from further pain.
Patients generally tolerate more compression
if they fully understand the reason for the
compression. Faulty or broken compression
devices are generally easily repaired (ACR, 90;
Andolina, 184; Peart, 116117).
3. (D) In calculating the density difference, DD,
two average densities are used. The high
average density is the density closest to 2.20.
The low average density is the density closest
to but not less than 0.45. The difference
between these two densities is the DD (ACR,
151; Peart, 87112).
4. (D) An intraductal papilloma generally
occurs near the nipple within the larger ducts,
but can also occur deep within the breast. The
papilloma may produce spontaneous discharge
118
from the nipple or if deep within the breast
may appear radiographically as a mass. Duc-
tal papillomas are benign and can be visual-
ized with ductography or ultrasound (Andolina,
155173; Peart, 4762; Venes, 1584).
5. (C) The large air gap acts like a grid and
reduces scatter, thus improving subject con-
trast. Positioning the breast away from the
image receptor takes advantage of the inverse-
square law: the intensity of the scattered radia-
tion is reduced because the distance between
the image receptor and the object is increased
(ACR, 5960; Bushong, 327340; Peart, 6584).
6. (B) To visualize minimal changes in glandu-
lar structures, high-contrast conventional
mammography provides detail of glandular
tissue, but does not show skin detail. The
skin is only seen under bright light. If the
skin is seen normally, the image is underex-
posed, especially in the glandular regions;
detail is lost and lesions may be missed (ACR,
79110; Peart, 6584).
7. (A) The spatula can be used instead of the
mammographers ngers to pull extremely
small breasts into position for compression.
The ML is a lateral projection. CV images the
extreme medial breast in the CC projection
and XCCL images the extreme lateral breast
in the CC projection (Peart, 115145).
8. (B) In the TAN projection, the technique is to
take a skimming projection of the area of
interest. Because the TAN can be taken in any
projection, the degree of obliquity and the
projection depends on the location of the

abnormality. The TAN can be taken in any
projection (Figure 6-8) (Peart, 115145).
Figure 68. (( 2000 The American Registry of Radiologic
Technologists.)
9. (C) Although pain can be associated with
breast cancer; a painless mass is the more com-
mon symptom of breast cancer. Painful masses
are associated with cysts. Less common symp-
toms of advanced breast cancer include skin
thickening; skin irritation or distortion; and
sudden nipple inversion, discharge, erosion,
or tenderness (ACS, 117; Peart, 4762).
10. (B) On an average, a mammogram will
detect 90% of breast cancers in women with-
out symptoms and is more accurate in post-
menopausal compared to premenopausal
women. Some cancers are not detected mam-
mographically because of increased breast
density, as in the brocystic breast, faster
growth rate, or failure to recognize the early
signs of an abnormality (ACS, 117).
11. (B) Hormone use inuences breast cancer
risk, but does not actually cause breast can-
cer. All factors that affect the reproductive
hormones in a womans body increase risk
for breast cancer (ACS, 117).
12. (A) In general, the use of any beam-limiting
device in radiography or mammography
requires increased exposure. Both imaging
methods use varying sized beam-limiting
Answers and Explanations: 1 through 13 119
devices. However, unlike general radiogra-
phy where the beam should be limited to the
size of the part, in mammography the entire
eld (not just the breast) is exposed. This is
necessary to reduce extraneous light when
viewing the image (Peart, 6584).
13. (A) In conventional imaging, the characteristic
curves (also called D log E, sensitometric, or
Hurter and Drifeld [H&D] curve) describe
the relationship between the radiation expo-
sure and the optical density produced on an
image. At the toe and shoulder of the curve,
large variations in exposure result in little or
no change in density. In the straight-line por-
tion of the curve (the useful region), small
changes in exposure cause large changes in
density. Calculations of lm contrast use the
average gradient or slope between two points of
the curve. Films that have a steeper slope have a
higher contrast. Two characteristic curves can
also be used to compare lm speeds (Figure 6-9).
The curve that lies to the left (closer to the
density axis) is faster (Bushong, 272281).
4.0
3.0
D
e
n
s 2.0
i
t
y
1.0
A B
0
1.0 2.0 3.0 4.0
Log relative exposure
Figure 69. Characteristic curve (also called sensitometric curve
or Hurter and Drifeld [H & D] curve) from two different types of radi-
ographic lms. Film A has a faster speed than lm B because its
speed point is the left of lm B. Film B has a higher contrast than
lm A because the slope of its curve is steeper than that of lm A.
120 6: Practice Test 1
14. (B) The lm in the cassette should be dis-
carded because any attached dirt from the cas-
sette will be carried into the lm bin or
returned to the cassette (ACR, 149; Peart, 87112).
15. (B) The retromammary space separates the
breast from the pectoral muscle. It is lled
with a layer of adipose or fatty tissue as
opposed to the supporting and connective
tissue (stroma), blood vessels, and various
ductal structures that make up the glandular
and brous tissues of the breast (Peart, 3544).
16. (D) Generally, glandular tissues predominate
in younger women and adipose or fatty tis-
sues in older patients. This ratio is not xed,
and depends on the womans age and genetic
predisposition. It uctuates with hormone
levels, whether the hormonal changes are
caused by medication use or pregnancy, lac-
tation, or menopause (Peart, 3544).
17. (B) The purpose of the XCCL projection is to
image the lateral aspect of the breast. Raising
the patients arm on the ipsilateral side forces
more axilla under the compression paddle.
Keeping the ipsilateral arm down or placing
the hand at the patients hip does not allow
adequate compression of the lateral and ante-
rior aspects of the breast. The ipsilateral shoul-
der should be relaxed and down with the arm
raised (Andolina, 174245; Peart, 115145).
18. (C) Depending on patient body habitus, the
pectoral muscle is imaged on the medial
aspect of the breast in about 30%40% of all
CC projections. It may be visualized unilater-
ally or bilaterally. Routine CC imaging that
includes the pectoral muscle can indicate
faulty positioning with loss of medial or lat-
eral breast tissue (ACR, 79-110-310).
19. (C) The American Cancer Society (ACS)
guidelines for early detection of breast cancer
includes having a CBE every 3 years between
ages 20 and 39 and every year after age 40
(ACS, 117).
20. (D) Whenever a large radiating structure or
area of architectural distortion (even when
supercial) is not associated with skin
changes or nipple retraction, the mammo-
gram is considered nonspecic, and further
testing is indicated. If the lesion is palpable,
malignancy cannot be ruled out. However,
the lesion must be biopsied for a denitive
diagnosis. This lesion is a radial scar (see
Figure 6-1). Radial scars are rarely palpable
and never involve skin changes. Generally
the radial scar has no central tumor and its
appearance varies from one mammogram
projection to another. Some studies suggest
that a radial scar may increase a womans
risk of developing breast cancer (Peart, 4762;
Tabr, 93147; Tucker, 241280).
21. (D) Although the mammographer should
inform the radiologist and can also inform the
patient, anything unusual must be charted on
the patients medical or history form. The
patients records are a means of communica-
tion between the mammographer and the
radiologist and can be important legal docu-
ments used to dene what was or was not
done to a patient. Records can also be used as
evidence in court cases (Peart, 1331).
22. (B) Magnication techniques are useful in
mammography to assess microcalcications
or the border of a lesion, or to image a speci-
men to check for calcications. However,
magnication does not image the entire
breast and cannot be used as a screening tool.
Magnication can be used to image the rela-
tively small area of a mastectomy site. (The
site can also be imaged without magnica-
tion.) For a woman with thick, dense breast
tissue, magnication is sometimes con-
traindicated because long exposure times and
high kVp degrades the image. The patient
also receives an unnecessarily high radiation
dose (Bushong, 327340; Peart, 115145).
23. (A) If the detector is placed in a single region
of adipose tissue in an otherwise glandular
breast, the adipose area will be correctly
exposed but the glandular area will be under-
exposed resulting in an increased chance of
missed breast cancer. In imaging adipose and
glandular tissue, the detector must be under

glandular breast to obtain proper image den-
sity. Glandular tissue is distributed centrally
and laterally within the breast; therefore, the
AEC should be centrally placed behind the
nipple, making sure it is under an area of
compressed breast (Peart, 6584).
24. (C) All effort should be made to image the
medial breast tissue on the CC mammogram;
eliminating it could eliminate this area of the
breast from the study. The CC best demon-
strates the anterior, central, medial, and pos-
teromedial portions of the breast but is poor at
visualizing the lateral breast tissue. The patient
should be rotated slightly medially, even if this
means loosing some lateral breast tissue.
Although the medial breast is imaged on the
MLO, superimposition of glandular structures
and increased OID often causes distortion of
that area (Andolina, 174245; Peart, 115145).
25. (D) The MLO projection best demonstrates
the posterior and UOQ of the breast. This
projection images the breast entirely, but dis-
torts the anterior structures. The ML is a
90-degree lateral, the XCCL images the lat-
eral aspect of the breast in the CC position,
and the roll medial rolls the superior surface
of the breast, from the CC position (Andolina,
174245; Peart, 115145).
26. (A) If breast tissue is over the AEC detector,
automatic exposure is possible. AEC works on
the principle of terminating the exposure when
sufcient x-ray reaches the lm to produce a
preset optical density. Because implants are
basically radiopaque, if the implant is posi-
tioned over the AEC the tube will try to pro-
vide sufcient output to penetrate the implant
and also provide optimal density with this
action stopped only by the backup timer. This
generally leads to an excessive radiation dose
to the patient (Peart, 6584).
27. (C) The CV best images the medial breast.
The MLO will best demonstrate the posterior
and UOQ of the breast. The XCCL and AT
will demonstrate the lateral and axilla por-
tion of the breast, respectively (Andolina,
174245; Peart, 115145).
Answers and Explanations: 14 through 32 121
28. (D) Putting the nipple in prole is sometimes
counterproductive. Breast tissue is lost either
superiorly, inferiorly, laterally, or medially,
depending on the projection and the location
of the nipple on the breast. Missed tissue can
then lead to undetected breast cancer. If the
nipple is not in prole, additional images are
needed for the above reasons, but should not
be done solely to place the nipple in prole,
even if the nipple is not marked with a BB-
marker (small radiopaque marker) (Andolina,
246310; Peart, 115145).
29. (C) The XCCL projection best images the pos-
terolateral parts of the breast. The beam is
directed superiorly to inferiorly, similar to a
standard CC projection. The TAN gives a tan-
gential image of the area in question, the FB
image directs the beam caudocranially and
the ML is a 90-degree lateral projection
(Andolina, 174245; Peart, 115145).
30. (A) Although the biggest risk factor of breast
cancer is gender (female), having a sister
with breast cancer can signicantly increase a
persons risks for the disease. A personal his-
tory applies only if the patient has had breast
cancer (ACR, 89).
31. (C) The nal rule of mammography, dictated
by the MQSA, states that a single projection/
position screen-lm mammogram should not
give more that 300 mrad (3 mGy) per projec-
tion/position average glandular dose when a
grid is used and should not exceed 100 mrad
(1 mGy) per projection/position without a
grid (Bushong, 342356; Peart, 237256).
32. (B) Newer mammogram generators have a
backup timer that works with the conven-
tional AEC systems. The mammography
exposure timer selects the actual time of the
exposure which affect patient dose and
image optical density, while the AEC cuts the
exposure when the correct density is
achieved. The phototimer was a type of AEC
device used in older x-ray units. Currently
most AEC devices are ionization chamber
type. The backup timer stops the exposure
before the optimal density is reached if the
122 6: Practice Test 1
energy of the beam is too low. If the backup
time is reached during a breast exposure, the
mammographer should select a higher kVp
setting for the repeat radiograph. Only by
selecting a higher kVp is the mammographer
able to increase the beams energy. The back-
up timer is preset at 600 mAs for grid work
and 300 mAs for nongrid (magnication)
imaging (Peart, 6584).
33. (A) The MQSA requires that the density dif-
ference, DD, created by using the 4.0-mm
acrylic disk, should be at least 0.40, and
should not vary by more than 0.05 from the
operating level. Also, the phantom image
background optical density should be at least
1.40 and should not vary by more than 0.20
from the operating level (ACR, 186).
34. (A) White (minus-density) artifacts indicate
pressure on the emulsion before exposure
and dark (plus-density) artifacts indicate
pressure after exposure. Static is caused by
lm handling in low humidity. Improperly
cleaned or worn rollers cause repeating arti-
facts that run parallel to the direction of lm
travel (Andolina, 4494; Peart, 87112).
35. (B) The Montgomery glands (glands of Mont-
gomery) are seen as protrusions on the sur-
face of the areola and are actually specialized
sebaceous glands. (The openings to the pro-
trusions are called Morgagni tubercles.) They
usually become more prominent during
pregnancy and lactation and secrete a uid
which helps lubricate the nipple and areola
(Peart, 3544).
36. (D) Estrogen and progesterone are two of the
many hormones responsible for many physio-
logical changes in the breast. Estrogen is
responsible for ductal proliferation and proges-
terone for lobular proliferation. Once a woman
starts estrogen, the changes can be spotty, caus-
ing lumps or increased interstitial uids (cysts),
but will generally result in an overall increase
in glandular tissue (Peart, 3544).
37. (B) Paget disease of the breast (rst described
by Jean Paget in 1874) is a special form of
ductal carcinoma associated with eczematous
changes of the nipple. Generally it presents
as a malignant nipple lesion. Inltrating car-
cinoma implies that the cancer has left the
point of origin and is spreading into the sur-
rounding tissues (Venes, 1566; Peart, 4762).
38. (A) Compression should be applied evenly
over the breast by using a at paddle parallel
to the image receptor. Uneven compression
leads to false-negative or false-positive results
because comparison between relative mass
densities is not possible (Andolina, 174245;
Peart, 87112).
39. (B) The principle disadvantage of magnica-
tion is that the increased OID places the
patients breast very close to the x-ray tube.
Because the radiation intensity is related to
the square of the distance, magnication usu-
ally results in about twice the normal patient
dose. The small focal spot used in magnica-
tion compensates for the reduced resolution.
Magnication therefore does not decrease res-
olution. The air-gap technique reduces, rather
than increases, the amount of scattered radia-
tion reaching the image receptor (Bushong,
327340).
40. (D) Conventional mammography usually uses
either molybdenum or rhodium as target
materials. Molybdenum has an atomic number
of 42 versus rhodium with a slightly higher
atomic number of 45. The emission spectrum
from a molybdenum target tube has a slightly
lower K-edge and less bremsstrahlung x-rays
than that of rhodium. This difference in emis-
sion spectra allows for slightly higher kVp
selections when using rhodium targets. The tar-
get material then determines the kVp range and
thus the quality of the beam. Rhodium pro-
duces better images for thick, dense breast with-
out loss of contrast and with decreased patient
dose. However, if used on fatty breast, the con-
trast will be signicantly reduced with only a
minimal reduction in dose (Peart, 6584; Bushong,
327340).
41. (B) The breast droops in the MLO if adequate
compression is not applied to the anterior

breast. Compression should be applied
evenly throughout the anterior, posterior, and
lateral parts of the breast. If too much axilla is
included in the compression eld, the poste-
rior breast is adequately compressed, but
compression is inadequate for the anterior
breast (Andolina, 174245; Peart, 115145).
42. (A) In the rolled positions, the top half of the
breast is rolled in one direction and the bottom
half in the other direction. With the medial
roll, the top is rolled medially. In the lateral
roll, the top is rolled laterally. The medial and
lateral roll (RM and RL) are both useful in sep-
arating glandular structures of the breast to
clear questions of superimposition. The LM is
a lateral projection, with the x-rays traveling
from lateral to medial and magnication (M)
producing a magnied image of an area
(Andolina, 174245; Peart, 115145).
43. (B) Breast cancer risk decreases among
women who have a rst child prior to age 30,
breast-feed, and experience late menarche or
early menopause. Studies have suggested
that reproductive hormones inuence breast
cancer; therefore, factors that affect reproduc-
tive hormones (early menarche [before 12],
late menopause [after 55], late age at rst
full-term pregnancy [after 30], use of oral
contraceptives, and estrogen replacement
therapy) affect breast cancer risk (ACR, 89).
44. (D) All mammographic x-ray tubes are man-
ufactured with a tungsten, molybdenum, or
rhodium target. These targets have different
atomic numbers and therefore different emis-
sion spectrums. The emission spectrum of the
beam is shaped by altering a combination of
the target material and the ltration. How-
ever, these designs are built into the mam-
mography unit. Although the mammogra-
pher can select different targets, the he/she is
unable to alter the built-in target material
and therefore the emission spectrum of the
beam (Bushong, 327340; Peart, 6584).
45. (A) The MQSA requires that the mid-density
and density difference, DD be within 0.15 of
the established operating level. The base plus
Answers and Explanations: 33 through 50 123
fog must remain within +0.03 of the estab-
lished operating level (ACR, 159).
46. (B) Gynecomastia is a benign increase of tissue
in the male breast. It can occur bilaterally or
unilaterally. Gynecomastia does not increase
the risk of breast cancer for male patients
(Peart, 4762).
47. (A) The total ltration is a combination of
the inherent and any added ltration. In any
mammography unit, the inherent ltration
may fall in the region of 0.1 mm Al or equiv-
alent, but the total ltration should never be
lower than 0.5 mm Al or equivalent (Bushong,
327340).
48. (B) Although the MQSA recommends that
technical factors appear on the image, this is
not an MQSA requirement. Other recommen-
dations are
ash card ID versus stick-on labels because
the ash ID is more permanent
separate date stickers because they are easy
to read and can be color-coded by year
The requirements are
name of patient and additional patient
identier
date of examination
projection and laterality (right or left
marker)placed near the axilla using the
standardized codes
facility name and location (must include
city, state, and zip code)
mammographer identication
cassette/screen identication
mammography unit identication (if more
than one unit per site) (ACR, 2627).
49. (D) The breast can reach superiorly from the
clavicle (second or third rib), and inferiorly to
meet the abdominal wall at the level of the
sixth or seventh rib. This lowest point of the
breast is called the inframammary crease or
fold (Peart, 3544).
50. (A) The Cooper ligaments are brous mem-
branes that support the lobes of the breast.
The ligaments attach to the base of the breast
124 6: Practice Test 1
and extend outward attaching to the anterior
supercial fascia of the skin (Figure 6-10)
(Peart, 3544).
Rib
Pectoral muscle
Vein
Retromammary adipose tissue
Cooper ligaments
Subcutaneous adipose tissue
Mammary ducts or
segmental ducts
Ampulla or
lactiferous sinus
Areola Nipple
Glandular tissue
lobules
Connective tissue
Artery and adipose tissue
Figure 610. Diagram of the breast.
51. (C) Starting at the nipple, the collecting ductal
system immediately widens into an ampulla
called the lactiferous sinus. This is a pouch-
like structure that again narrows and joins
one or more segmental ducts, eventually
branching further until it ends at the terminal
ductal lobular unit (TDLU) (Peart, 3544).
52. (C) Scattered radiation is produced when-
ever the useful beam intercepts any object
causing it to diverge. There are two methods
of reducing the amount of scattered radia-
tion reaching the image receptor: limiting the
x-ray eld size (not an option in mammogra-
phy) and the use of grids. In magnication
mammography the large air gap acts as a
grid in reducing scattered radiation. Grid use
in magnication will therefore unnecessarily
increase the exposure dose to the patient.
Increasing the SID reduces magnication but
does not reduce the amount of scatter pro-
duction. It is not used in magnication mam-
mography. The small focal spot is necessary
to increase resolution, but this does not affect
the amount of scattered radiation reaching
the lm (Bushong, 327340).
53. (C) Ductography will not determine if a
lesion is malignant or benign, but it can
determine the location and number of lesions
or changes associated with the ducts. Only a
cytological or histological analysis can accu-
rately determine the true nature of the lesion
(Andolina, 313330; Peart, 203220).
54. (A) A 5-degree lateral tube angulation allows
the compression paddle to clear the humeral
head. The tube angled medially further pro-
jects the humeral head in the area of interest.
Using a straight tube is a routine CC projec-
tion and does not alter the imaging. Other
alternatives XCCL image the lateral breast or
ML change the orientation of any abnormality
in relation to the nipple (ACR, 60; Peart, 115145).
55. (A) Positioning the breast away from the
image receptor takes advantage of the
inverse-square law: the intensity of the scat-
tered radiation is reduced because the dis-
tance between the image receptor and the
object is increased. The heel effect describes
the process that causes the radiation intensity
at the cathode side of the x-ray eld to be
higher than that on the anode side. The line
focus principle is an angled design of the
tube target that allows a large area for heat-
ing while maintaining a small focal spot. The
reciprocity law states that the density pro-
duced on a radiograph is equal for any com-
bination of mA and exposure time as long as
the product of mA and the ms is equal (ACR,
5960; Bushong, 327340).
56. (C) Risk factors increases a womans risk for
breast cancer. Risks factors are divided into
relatively high risk, moderate risks, and
minor risks. High-risks factors include gen-
der (female), age, genetic factors, and family
or personal history of breast cancer. Moder-
ate risk factors include having one rst-
degree relative with breast cancer, having
atypical hyperplasia conrmed on biopsy,
high radiation dose to the chest area, high
bone density after menopause. Minor risk

factors are associated with hormonal use or
changes in the body and include not having
children or having the rst child after age 30,
not breast-feeding, early menarche (before
age 12) or late menopause (after age 55),
postmenopausal obesity, recent and long-
term use of hormone replacement therapy
(HRT) or oral contraceptive, alcohol con-
sumption, and obesity (ACS, 117).
57. (D) Grids do not improve image sharpness;
the sharpness of an image is affected by the
focal-spot size, SID, OID, type of intensifying
screens, and motion. Grids increase patient
dose and reduce the amount of scattered
radiation striking the lm, but do not affect
the production of scatter radiation. Grid use
will, however, result in increased subject con-
trast (Bushong, 327340; Peart, 6584).
58. (D) As long as the implant is soft and
remains free of encapsulation, the ID projec-
tions are possible. Once the implant is encap-
sulated, it is difcult if not impossible to dis-
place. Most modern implants are placed
behind the pectoral muscle (subpectoral or
retropectoral placement) versus placement in
front of the pectoral muscle (subglandular or
retromammary placement) that was done in
the past. The placement of the implant
behind the pectoral muscle allows better
imaging and better displacement of the
implants for the ID projections (Andolina,
174245; Peart, 115145).
59. (B) On an average, a mammogram detects
90% of breast cancers in women without
symptoms, and is more accurate in post-
menopausal than premenopausal women.
Some cancers are not detected mammograph-
ically because of high breast density, faster
growth rate, or failure to recognize the early
signs of an abnormality. If the mammogram is
normal and the patient feels a palpable mass,
the mass could be normal or abnormal. The
patient must contact her doctor immediately
for further testing (ACS, 117; Peart, 4762).
60. (C) Risk factors increases a womans risk for
breast cancer. Risks factors are divided into
Answers and Explanations: 51 through 64 125
relatively high risk, moderate risks, and
minor risks. High-risk factors include gender
(female), age, genetic factors, and family or
personal history of breast cancer. Moderate
risk factors include having one rst-degree
relative with breast cancer, having atypical
hyperplasia conrmed on biopsy, high radia-
tion dose to the chest area, high bone density
after menopause. Minor risk factors are asso-
ciated with hormonal use or changes in the
body and include not having children or hav-
ing the rst child after age 30, not breast-
feeding, early menarche (before age 12) or late
menopause (after age 55), postmenopausal
obesity, recent and long-term use of HRT or
oral contraceptive, alcohol consumption, and
obesity (ACR, 89; ACS, 116).
61. (B) The focal spot size is important in mam-
mography and many x-ray tubes have two
focal spot sizesone for routine and one for
magnication work. In routine work, the
focal spot size can be 0.4 or smaller. In mag-
nication work, the focal spot may be 0.15 or
smaller. Any work done with a 0.1-mm focal
spot size would be for magnication (Bushong,
327340; Peart, 6584).
62. (C) Although the majority of processing units
operate at a developer temperature of 95F,
some may not. The actual temperature is sug-
gested by the manufacturer and should be
within 0.5F of the value specied by the
manufacturer (ACR, 130, 215).
63. (B) Daily QC is used to assess consistency of
lm and lm processing. Introducing multiple
processing variables such as variations in lm
emulsion (by using a lm from a different box
each time) will muddle the results (ACR, 149).
64. (B) The breast includes the nipple, infra-
mammary fold, and tail of Spence. The tail of
Spence (tail, axilla, or axillary tail are other
names used) describes the area of the breast
stretching up into the axilla. The base
describes the region where the inframam-
mary fold is located, closest to the chest wall.
The apex is the nipple region, and the most
distal point of the breast (Peart, 3544).
126 6: Practice Test 1
65. (C) Fibrous tissue is usually described with
glandular tissue together as fibroglandular
densities. X-rays pass more easily through
fatty tissue than through fibrous or glandu-
lar tissue. Fatty areas appear radiolucent
(black or less dense area on the mammo-
gram). The fibroglandular or fibrous tissue
is more radiopaque than fatty tissue, and
shows as areas of lower optical density
(white or dense) on the mammogram (Peart,
3544).
66. (B) Figure 6-5 shows casting-type calcications
which are often malignant. The shape of the
cast is determined by the uneven production
of calcication and the irregular necrosis of the
cellular debris. The contours of the cast are
always irregular in density, width, and length,
and the cast is always fragmented. A calcica-
tion is seen as branching when it extends into
adjacent ducts. Also, the width of the ducts
will determine the width of the castings. A
diagnosis of invasive ductal carcinoma is only
made on cytological or histological analysis
(Tabr, 149238).
67. (D) The only huge radiolucent breast lesion
here is a lipoma, which is a common benign
tumor composed of fatty tissue. Another large
lesion is the broadenolipoma or hamartoma.
It is a benign proliferation of brous, glandu-
lar, and fatty tissue surrounded by a thin cap-
sule of connective tissue. The oil cyst is
benign and appears mammographically as
eggshell-like calcications. Both the broade-
noma and the hematoma are seen as circular-
oval lesions with mixed densities and gener-
ally will not occupy the entire breast (Tabr,
1792).
68. (D) The AEC detector is placed directly
below the image receptor or cassette in mam-
mography to minimize OID (in x-ray imag-
ing, the AEC detector is most often placed
above the image receptor). Because radiation
has to pass through the breast before reach-
ing the detector, the primary reason for
backup time and inadequate exposure is the
inability of low-energy photons to penetrate
the breast (Peart, 6584).
69. (B) The decline in breast cancer mortality is a
result of improvement in breast cancer treat-
ment and the benets of mammography
screening. Although there is no guarantee
that all patients will survive, the long-term
survival rates are actually improving because
cancers discovered at an earlier stage have a
better prognosis, giving women a better long-
term survival rate (ACS, 116).
70. (C) Contaminated developer can cause wet
lms, an increase in the base fog, or decreased
lm speed. Increased lm contrast represents
inherent properties of the lm speed latitude
and the different quantities and qualities of
radiating effect on them. Processing condition
such as the developer temperature being too
high, the replenishment rates being too high,
or improper mixing of the developer solu-
tion and overall radiographic quality will
also affect lm contrast (Bushong, 204217;
Peart, 6584).
71. (B) Spot compression increases compression
to the area of suspected abnormality, allowing
the tissue to spread more evenly and elimi-
nating pseudomasses. Because of the need to
reduce extraneous light (increase visualiza-
tion of breast tissue), coned collimated images
are no longer taken when imaging with spot
compression (Peart, 115145).
72. (B) The FB or caudal-cranial projection may
be useful in nonconforming patients or nd-
ing lesions high on the chest wall. In per-
forming the FB, the image receptor is above
the breast and compression is applied at the
inframammary fold. The TAN is used to
image skin lesions. The XCCL images the far
lateral breast in the CC position and RM is
the roll medial where the upper surface of
the breast is rolled medially (from the CC
position) (Peart, 1151457).
73. (B) If the patient stands away from the image
receptor and bends forward, her chest will be
brought forward and derriere back, removing
the abdomen from the imaging area. If this
does not achieve the desired results and the
abdomen still protrudes, the mammographer
 Answers and Explanations: 65 through 77 127

cannot sacrice posterior and lateral tissue to quantum mottle) (Figure 6-12) (Andolina, 437452;
image the anterior breast. Two projections Peart, 179194).
may be requireda lateral of the anterior
breast and the MLO for the posterior and
UOQ of the breast (Andolina, 246310; Peart,
115145).

74. (B) Spot compression increases compression

over the area of interest, spreading out the tis-
sue more evenly and allowing visualization of Intensity relative IP
the margins or borders of lesions. Biopsy is a of the luminosity
Film/Screen
surgical procedure. Aspiration is generally
done to remove the content of a cyst, and
stereotactic localization is used to localize
nonpalpable lesions. Mammography is the
rst line of defense against breast cancer.
Before further testing is undertaken, as much
Log of relative exposure
information on the lesion should be gathered
from mammography (Andolina, 174245; Peart, Figure 611. Characteristic curve (also called sensitometric curve
115145; Tucker, 241280). or Hurter and Drifeld [H & D] curve) from lm-screen versus digital
imaging. A graph of the optical density signal and the relative expo-
sure for a digital imaging plate (IP) has a linear response to x-ray.
75. (B) The specimen should always be com- This is unlike the curvilinear response of a lm-screen system.
pressed and radiographed to ensure that the
lesion was completely removed. If there are
calcications present, the lesion should be
magnied to ensure that all the calcications
were removed (Andolina, 331402; Peart, 203220;
Tucker, 241280).

76. (A) Digital images generally will not appear

too light or dark because digital imaging has
the advantage of being able to manipulate
the nal image. In digital imaging, if a graph
of the optical density (called the signal) and
the relative exposure is plotted the relation-
ship is not the characteristic curve (also
called Hurter and Drifeld [H & D] or sensit-
ometric curve); rather, it is a straight line
(Figure 6-11). The digital image therefore has Figure 612. In conventional imaging, quantum mottle occurs
when there are not sufcient incident photons reaching the intensi-
much wider latitude than conventional mam- fying screen. The effect is similar in digital imaging.
mography. This ability to adjust the nal
image (thus reducing the need for repeats) is 77. (B) Gynecomastia is a benign proliferation of
one of the greatest advantages of digital tissue in the male breast. The condition usu-
imaging. The problem is that, although over- ally has a high rate of spontaneous regres-
exposure can be corrected, the patient dose is sion and can occur at birth, during teenage
high. The mammographer can encounter years (can last up to 18 months), or in males
problems with underexposed images, how- above age 50. It is often seen bilaterally but
ever. If the digital signal is not enough to can be unilateral. Gynecomastia is not asso-
produce a good image, the image appears ciated with increased risk for breast cancer in
excessively noisy (appearance similar to males (Peart, 4762; Venes, 918).
128 6: Practice Test 1
78. (C) The Montgomery glands (glands of
Montgomery) are seen as protrusions on the
surface of the areola. They are actually spe-
cialized sebaceous glands that usually
become more prominent during pregnancy
and lactation (Peart, 3544).
79. (A) Extended processing extends the time the
lm spends in the developer solution. It may
also raise the temperature of the developer
solution. The overall effect of extended pro-
cessing is to increase the speed and contrast
of some single emulsion lms. The lm
requires less exposure; therefore, the radia-
tion dose to the patient can be lowered
(Andolina, 4598; Peart, 6584).
80. (C) The humidity level in the darkroom
should be between 30% and 50%. Low
humidity (less than 30%) causes static and
high humidity (more than 50%) causes
clumping of the film emulsion from water
vapor clinging to the film. Dirty rollers may
cause scratches on the films. Changes in
developer temperature, improperly mixed
developer, or contaminated developer can
cause reduced film speed or increased base
fog (Figure 6-13) (Andolina, 4598; Peart, 6584).
Figure 613. Static is often the result of low humidity in the
darkroom.
81. (A) Above 40, it is recommended that a
woman have a CBE at about the same time as
the annual mammogram, even if the woman
has no symptoms and no signicantly higher
risk for breast cancer (ACR, 10).
82. (D) Fibrous and glandular tissue together are
described as broglandular densities. X-rays
will more easily penetrate through fatty tis-
sue than through brous or glandular tissue.
Fatty areas appear as radiolucent (black or
less dense) areas on the mammogram. The
broglandular tissue is more radiopaque
than fatty tissues and results in areas of lower
optical density on the mammogram (white or
denser areas) (Peart, 3544).
83. (C) Compression decreases the thickness of
the breast, bringing the breast closer to the
image receptor and increasing subject con-
trast. Spatial resolution (sometimes called
image detail) is the ability to image small
objects that have a high subject contrast, for
example, microcalcications in breast tissue,
and is most affected by focal-spot blur but
also improved with decrease geometric blur
and motion blur. Contrast resolution (some-
times called visibility of detail) is the ability
to distinguish anatomic structures of similar
subject contrast and is most affected by scat-
ter radiation and radiographic noise. Resolu-
tion affects the image appearance by demon-
strating ne detail of structures. Because
resolution improves when the OID decreases,
compression also increases spatial resolution
(ACR, 2377; Peart, 115145).
84. (D) A core biopsy removes a cylinder of tis-
sue using a 14- or higher gauge needle. The
sample from a core biopsy is larger than that
from FNA. Tissue samples from a core biopsy
are assessed histologically. FNA or ne nee-
dle aspiration cytology (FNAC) is more dif-
cult to perform. A 20- to 23-gauge needle is
used to remove cellular material for cytologi-
cal analysis. Excisional biopsy is a surgical
biopsy where the entire lesion as well as sur-
rounding margins of normal-appearing tis-
sue is removed. Wire localization is a proce-
dure during which nonpalpable lesions or

calcications in the breast are identied by
placing a thin needle into the breast. The nee-
dle is guided using mammograms or ultra-
sound, and a small hook wire is placed to
mark the site of the lesion before surgery
(Andolina, 313330; Peart, 203220).
85. (D) The rolled medial or the rolled lateral
(RM or RL) are both useful in separating glan-
dular structures of the breast to clear ques-
tions of superimposition. The ID projection is
used in imaging augmented breast clear of
the implants. The MLO is a routine projection
and would not be used as an additional pro-
jection. The XCCL is best for imaging the pos-
terolateral parts of the breast with the x-ray
traveling craniocaudal (Peart, 115145).
86. (C) The high placement of the image receptor
unnecessarily elevates the shoulder, pulling
breast tissue from the compression eld.
There will be poor pectoral muscle and possi-
ble missed posterior breast but compression
of the lower breast will not be compromised.
If, however, the patient has a protruding
abdomen the compression paddle hits the
abdomen, compressing the abdomen and not
the lower breast. If too much shoulder mus-
cle and axilla are allowed in the compression
eld, the axilla will be compressed but the
thickness of the axilla will not allow for com-
pression of the lower breast (Peart, 115145).
87. (C) As a woman ages, declining hormone
levels affect both the breast stroma and
epithelium. The breast loses its supporting
structure to fat, producing a smaller breast or
a larger, more pendulous breast because of
the loss of the epithelial structures and
stroma and gain of fat. The duct system
remains but the lobules shrink and collapse.
This process generally speeds up at
menopause and may continue for 35 years.
It is referred to as atrophy or involution.
Increased estrogen or hormone levels, which
occur during menstruation, result in an
increase in breast stroma and epithelium
leading to denser breast tissue (Peart, 1344).
Answers and Explanations: 78 through 90 129
88. (D) The arm position will help to minimize
skin folds. Sliding your nger under the com-
pression device to roll the folds laterally will
also help. (A) will maximize visualization of
the posterior lateral tissue. (B) and (C) will
improve visualization of the medial breast
(ACR, 3450).
89. (A) In conventional mammography imaging
the x-rays interacts primarily with the
entrance surface of the screen. If the screen is
between the x-ray tube and the lm, the
excess screen blur will cause increased spatial
resolution or image detail. This refers to the
ability to image small objects that have a high
subject contrast, for example, microcalcica-
tions in the breast. With the lm between the
x-ray tube and the screen (the lm is placed
with the emulsion side to the screen), screen
bloom is reduced and spatial resolution is
improved (Figure 6-14) (Bushong, 327340;
Peart, 6584).
90. (B) Although grids increase contrast, in mag-
nication mammography the large OID or air
gap acts like a grid in reducing scatter radia-
tion from reaching the lm. Grid use in mag-
nication would increase exposure times,
increase tube loading, and thus increase
motion artifact because of long exposure
times. Patient radiation dose is also increased
(ACR, 59; Peart, 6584).
X-ray tube
X-ray tube
Screen Screen
bloom bloom
Screen
Film
Film (base and
emulsion)
Incorrect screen position
Correct screen position
Figure 614. Position of the lm and intensifying screen is impor-
tant in mammography. In the incorrect position, the intensifying
screen is placed between the primary beam and the lm resulting
in excessive screen blur. Spatial resolution will improve if the lm is
placed between the primary beam and the intensifying screen.
130 6: Practice Test 1
91. (D) The FB best visualizes the central and
medial abnormalities high on the chest wall
and can be done for all these reasons. The
beam is directed inferiorly to superiorly
(ACR, 68; Peart, 115145).
92. (D) The ML provides a true representation of
the breast structures in relation to the nipple,
but should not be used as a routine projection
because it is poor at visualizing the posterior
and lateral aspects of the breast. TAN projec-
tion can be used to locate skin lesions. The FB
can replace the CC in the nonconforming
patient and the XCCL images the far lateral
breast tissue in the CC position (Peart, 115145).
93. (A) Parallel grid designs are common in
mammography. Here the lead strips are
aligned adjacent and parallel to each other
and placed lengthwise in grid structure. Par-
allel grids allow CR angulation in the direc-
tion of the lead strips only and will remove
scatter in one direction. Option (B) describes
the crossed (crosshatch or crisscross) grid
design. This is similar to having two linear
grids with their linear patterns at right angles
to each other. Crossed grids do not permit
any CR angulation and will clean up scatter
in both directions. Option (C) describes the
focused grid where the lead strips are virtu-
ally parallel in the midsection but at the
periphery they incline slightly toward the
center of the grid. The focused grid must be
used at its designed SID to avoid grid cutoff
and work will with mammography units
which are designed to operate at xed a SID.
Grid cutoff is the unwanted absorption of the
primary bema by the lead strips of the grid.
Option (D) describes the moving grid. Grids
can be stationary or moving. The stationary
grid will produce observable images of the
grid lines. The moving grid moves during
the exposure. In breast imaging, the grid is a
reciprocating grid that moves to and fro ver-
sus the oscillating grid that moves in the cir-
cular pattern (Bushong, 248261; Peart, 77).
94. (B) If the processor does not have an internal
digital thermometer, any regular digital ther-
mometer can be used. The mercury-in-glass
thermometers are easily broken and can dam-
age or contaminate the processor. Even small
amounts of mercury can permanently conta-
minate the processor (ACR, 130; Peart, 6584).
95. (A) Mammography units generally have two
sets of focal spot sizes, one for routine imaging
and the other for magnication. To maintain a
sharp image during magnication, a small
focal spot size is used. The small focal spot
size increases spatial resolution. Resolution is
also increased by decreasing the thickness of
the part under compression, thereby lessening
geometric unsharpness (Bushong, 327340; Peart,
6584).
96. (D) The half-value-layer (HVL) of the x-ray
beam is the thickness of absorbing material
needed to reduce the intensity of the beam to
half of its original value. Dosimeter equipment
and an ionization chamber are just two of a
number of methods that can be used to mea-
sure the radiation intensity for successively
thicker sections of lters. The slit camera is an
effective measuring tool used to determine the
focal spot size. The star pattern and the pin-
hole camera can also be used to measure focal
spot size (Bushong, 327340; Peart, 237256).
97. (A) The overall repeat rate should be approx-
imately 2% or less, but a rate of 5% is proba-
bly adequate. If the repeat rate exceeds the
acceptable level (2% or 5%) or if repeat or
reject rates change from the previously mea-
sured rate by more than 2%, the change
should be investigated and corrective action
taken (ACR, 207).
98. (C) Oil cysts show mammographically as
high-density tumors with lucent centers and
eggshell-like calcications. They usually form
as a result of fat necrosis or are calcied
hematomas. Fat necrosis is death of fatty tis-
sue in the breast that can occur spontaneously,
but is usually the result of a biopsy or injury.
When the fat tissue dies, it changes to oil. The
body then forms a capsule around the oil to
protect itself. The capsule generally has a thin
layer of calcications, which give an eggshell-
like appearance on the mammogram. Oil cysts

are benign. Ductal papillomas are benign
masses associated with the ducts and are not
seen mammographically. A broadenoma is a
benign radiolucent mass that may or may not
contain calcications. A hematoma is seen as a
circular-oval lesion with mixed density. It is a
benign mass associated with injury or surgery
(Peart, 4763; Tabr, 1792).
99. (C) The nal mammographic image should be
evaluated under ideal viewing conditions.
Excellent viewing conditions include low
ambient room light to minimize light reected
off the surface of the image. The view-boxes
should be cleaned and checked regularly
because they can become dirty or the lumi-
nance of the bulbs can fade. Masking the
image eliminates extraneous viewbox light,
which has not passed through the exposed
area of the lm, from reaching the eye. If the
extraneous viewbox light is blocked, it is often
possible to see the skin and subcutaneous tis-
sues (ACR, 92; Peart, 87112).
100. (C) The implant displaced (ID) projection is
a method of imaging the augmented breast.
The method displaces the implant posteri-
orly to exclude it from the compression
area. ID projections are taken in addition to
the routine projections. In general, the rou-
tine series of projection for a patient with
breast augmentation would be routine CC
of both breasts, routine MLO of both
breasts, CC with ID of both breasts, and
MLO with ID of both breasts (Peart, 115145).
101. (D) Under the nal regulations of the US Food
and Drug Administration (FDA), all mammo-
graphers satisfying the interim regulations
can still perform mammograms. All new
mammographers must:
complete at least 40 contact hours of docu-
mented training in mammography under
the supervision of a qualied instructor or,
before April 28, 1999, have satised the
requirements of the interim regulation of
the FDA
perform a minimum of 25 examinations
under direct supervision of a qualied
mammographer
Answers and Explanations: 91 through 104 131
have at least 8 hours of training in each
mammography modality in which the
technologist intends to practice (eg, digital-
vs. conventional screenlm systems) if the
mammographer started working in the
new modality after April 28, 1999
(Accreditation and Certication Overview: Technolo-
gist Training)
102. (B) For proper positioning of the MLO, the
pectoral muscle is wide superiorly with a
convex anterior border, extending to or
below the posterior nipple line. Other criteria
include that there is no evidence of motion
and deep and supercial tissues are well sep-
arated (ACR, 42).
103. (A) Ductal ectasia is a benign inammatory
condition of the ducts, which leads to nipple
discharge, nipple inversion, or periareolar
sepsis. The condition may resemble breast
carcinoma. Paget disease of the breast is a
special form of ductal carcinoma associated
with changes of the nipple. Peau do range is
a condition where the skin of the breast
becomes thickened and dimpled, resembling
an orange; this may be the result of either
benign or malignant conditions. Ductal papil-
lomas are benign masses associated with the
ducts and are not usually seen mammo-
graphically (Andolina, 155173; Peart, 3544).
104. (A) In the immature breast the ducts and
alveoli in the lobule are lined by a two-layer
epithelium of cells. After puberty this epithe-
lium proliferates, forming three alveolar cell
types: supercial (luminal) A cells, basal B
cells (chief cells), and myoepithelial cells
forming the innermost layer or basal surface
of the epithelium. Beneath the epithelium is
connective tissue that helps to keep the
epithelium in place. Between the epithelium
and the connective tissue is a layer called the
basement membrane. The basement mem-
brane provides support and acts as a semi-
permeable lter under the epithelium (Peart,
3544; Tortora, 1083).
132 6: Practice Test 1
105. (B) In this form of unsharpness there is a fur-
ther spread of light from the screen before it
reaches the lm. Unlike motion unsharpness,
which covers a wider area, unsharpness
because of poor screen contact is usually
localized. Noisy images are mainly because
of scatter or quantum mottle. Scatter radia-
tion provides no useful information on the
image and will also reduce subject contrast.
Most scatter in imaging is the result of
Compton effect, where an incident electron
interacts with an outer-shell electron and
ejects it from the atom, ionizing the atom.
The ejected electron is called the Compton
electron. When not enough photons are used
to form the image, the result is a greater
amount of quantum mottle. Subject contrast
refers to the variations of tissue density seen
on the image (ACR, 104105).
106. (B) Mammoplasty is the general term used
when describing reshaping of the breast. The
breast can be lifted to reduce a sagging breast,
enlarged (augmented), or reconstructed after
the removal of a tumor. Reduction mammo-
plasty is the term used to describe the reduc-
tion of the size of the breast by removing
excess breast tissue. A breast biopsy is the
removal of breast tissue for histological test-
ing (Peart, 220234; Tortora, 1096).
107. (B) Quantum mottle is one of the principal
causes of radiographic noise. Radiographic
noise is the undesirable uctuation in the den-
sity of the image because of uctuations in the
number of x-ray photons interacting with the
lm. The quantum mottle will be higher if
the x-rays are produced with few x-ray pho-
tons. Image graininess (lm graininess) is
the distribution in size and space of the sil-
ver halide grains in the emulsion, and contrast
resolution refers to the ability to visually
detect separate objects distinct from each
other. Contrast resolution is best improved
by using collimation. Motion results in blur-
ring unsharpness of the image (ACR, 102105;
Bushong, 272291).
108. (C) Yellow-brown stains on the lm are
caused by thiosulfate from the xer, left on
the lm because of improper washing. This
generally indicates a problem with hypo-
retention from the xer. The silver sulde
slowly builds up and appears as yellow in
the stored radiograph. Streaks on the lm can
result from light leaks in the cassette; a round
spot of increased density may be caused by
low humidity (static). Areas of reduced den-
sity could be caused by pressure on the lm
before exposure (Bushong, 204217).
109. (C) In the SIO projection, the beam is directed
from the superolateral to the inferomedial sur-
face of the breast; therefore, the medial breast
is closest to the image receptor (Peart, 115145).
110. (D) In general, male breast imaging will pre-
sent the same difculty as imaging a small,
dense female breast and the breast size of
males is sometimes no different than that of
females. However, because of chest hair on
males, the breast tends to slip from under the
compression (Andolina, 246310; Peart, 115145).
111. (D) In the SIO, the rays are directed from the
lateral portion of the upper axilla to the
lower medial portion of the breast, that is,
superiolateral to inferomedial. The supero-
medial to inferolateral is the routine MLO
and the inferolateral to superomedial is the
LMO. The inferomedial to superolateral has
no American College or Radiology (ACR)
label (Peart, 115145).
112. (B) Under current regulations, an accredita-
tion body can be a private, nonprot organi-
zation or state agency. Currently, the US Food
and Drug Administration (FDA)-approved
accreditation bodies are the American Col-
lege of Radiology (ACR) and the states of
Arkansas, Iowa, and Texas. Accreditation
bodies can accredit only those facilities
located within their respective states (Accredi-
tation and Certication Overview).
113. (B) The MLO is one of the routine imaging
projections. The reverse of this is the LMO.
This projection will give a mirror image of
the MLO and is useful in imaging patients
with pacemakers. The LMO and also the LM

are good alternatives to the routine images
and both can also be used for patients with
infusa-port (port-a-caths inserted for long-
term chemotherapy treatment), the kyphotic
patient, and patients with recent open-heart
surgery. The ML is not a good replacement
because it is poor at imaging the posterior
and lateral aspects of the breast. The XCCL
only images the posterolateral breast tissue
(Peart, 115145).
114. (D) In breast localization, the shortest skin-to-
abnormality distance should always be used
unless that projection will not demonstrate
Answers and Explanations: 105 through 115 133
the abnormality. In addition to these reasons,
the greater the distance the needle travels in
the breast, the greater the risk of deection
(Andolina, 313330; Peart, 203220).
115. (D) These are the MQSA requirements. The
assessment of ndings refers to the nal result
(eg, benign). Additional patient identiers
could be the patients age, date of birth, or
medical record number (Accreditation and Certi-
cation Overview: Record Keeping).
This page intentionally left blank
 CHAPTER 7

Practice Test 2
Questions

1. Radiation therapy is a treatment that utilizes 4. X-ray photons leaving the breast enter the
top of the cassette/image receptor
(A) drugs to treat cancer that may have
spread 1. to go through the intensifying screen
(B) high-energy radiation to destroy cancer before reaching the lm
cells 2. then go through the lm before reaching
(C) radioactive tracers to track the path of the intensifying screen
cancer to the lymph nodes 3. interact with the single intensifying
(D) potent pain medication to treat the screen of the cassette/image receptor
severe pain from cancer (A) 1 and 2
(B) 2 and 3
2. Between ages 20 and 30 an asymptomatic
woman should be having a mammogram (C) 1 and 3
every (D) 1, 2, and 3

(A) year 5. In quality control (QC), if the data consis-

(B) 2 years tently exceed the operating level the recom-
(C) 3 years mendation is
(D) none of the above (A) establish new operating limits
(B) narrow the control limits
3. Medical history may include questions on
hormone use because (C) widen the control limits
(D) improve QC procedures
(A) synthetic hormones such as hormone
replacement therapy (HRT) will always 6. A control lm crossover should be carried out
cause breast cancer
(B) reproductive hormones are a factor in (A) whenever the processing chemistry is
breast cancer risks changed
(C) family history of hormone use predis- (B) when a new box of lm is opened
poses a woman to cancer (C) if a new processor is installed
(D) personal history of hormone use decreases (D) if the control limits consistently exceed
a womans risk for breast cancer the normal values

135

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136 7: Practice Test 2

7. In digital imaging, a graph of the density

range to the log of relative exposure (the char-
acteristic curve or Hurter and Drifeld (H&D)
curve used in conventional imaging) shows a
(A) shallow sloping curve
(B) steep sloping curve
(C) linear response
(D) curve similar to conventional imaging

8. On the American College of Radiology

(ACR)-approved accreditation phantom, the
total number of bers, speck groups, and
masses are
(A) ve bers, ve speck groups, and ve
masses
(B) ve bers, six speck groups, and ve
masses
(C) six bers, ve speck groups, and ve
masses
(D) ve bers, ve speck groups, and six
masses
Figure 71
9. The circular pigmented area around the nipple
is called the
(A) skin
12. What immediate action is used to reduce
(B) areola
motion unsharpness in mammography?
(C) Montgomery gland
(D) ampulla (A) compression
(B) low mAs (milliamperes per second)
10. A keratosis is demonstrated mammographi- (C) low kVp (kilovoltage peak)
cally as a (D) small focal spot size
(A) sharply outlined multilobulated lesion
13. In magnication, what immediate role does
(B) sharply outlined lesion with a halo
the large object-to-image receptor distance
(C) mixed-density circular lesion with a (OID) play in reducing scattered radiation?
radiolucent center
(D) mixed-density oval lesion (A) The compressed breast allows lower
kVp values.
11. Figure 7-1 indicates (B) Exposure is reduced because a grid is
not needed.
(A) mammographically benign calcications
(C) Most of the scattered radiation misses
(B) malignant calcications the image receptor.
(C) keratosis (D) The larger source-to-image receptor
(D) broadenomas distance (SID) utilizes the inverse
square law.
 Questions: 7 through 22 137

14. Quantum mottle on the image is reduced by 18. In the rolled medial (RM) position, the
lower surface of the breast is rolled in which
(A) high kVp
direction?
(B) high mAs
(C) motion (A) laterally
(D) fast intensifying screens (B) medially
(C) inferiorly
15. What is the best placement for the needle (D) superiorly
wire during needle localization?
19. A radiopaque implant used in breast recon-
(A) The needle wire should pass immedi-
struction that easily adjusts for cup size after
ately below the lesion.
placement is the
(B) The needle wire should pass immedi-
ately above the lesion. (A) silicone gel implant
(C) The needle wire should pass through the (B) transverse rectus abdominis muscle
lesion. (TRAM) ap implant
(D) The needle wire should pass immedi- (C) silicone liquid implant
ately beside the lesion. (D) saline implant

16. Although it often means losing some of the
lateral breast tissue, in imaging for the cran-
iocaudal (CC) projection, most experts advise
a slight rotation of the patients body to max-
imize imaging of the medial breast tissue.
Why?
(A) Medial breast is imaged best on the CC.
(B) Medial breast is imaged only on the CC.
(C) Slight rotation avoids distorting the
medial breast.
(D) The slight rotation enables ease in
positioning.
17. Which is true for all tangential (TAN) projec-
tion positioning?
(A) The patient is always in the CC position.
(B) The central ray is always directed
vertically.
(C) The central ray is always parallel to the
plane of the breast.
(D) The central ray is always perpendicular
to the skin surface.
20. In addition to the routine CC and mediolateral
oblique (MLO), a routine series for a postmas-
tectomy patient could also include the
(A) axillary tail (AT)
(B) mediolateral (ML)
(C) TAN
(D) lateromedial oblique (LMO)
21. Men with a family history of breast cancer
will
(A) have a greater risk for breast cancer
(B) have a minor risk for breast cancer
(C) have no signicantly increased risk for
breast cancer
(D) always get breast cancer
22. The clinical breast examination (CBE) should
be performed
(A) at or near the time of the annual
mammogram
(B) only by the radiologist
(C) monthly, preferable at the same time of
the month
(D) at least twice a year
138 7: Practice Test 2

23. The absorbed dose in mammography is gen- 28. Densities on the sensitometric strip and
erally _______ the entrance skin exposure phantom image were recorded as follows:
(ESE). density inside the disk = 1.23, the mid-
density = 1.25, the background density =
(A) signicantly higher than
1.68, the density adjacent to the disk = 1.66,
(B) signicantly lower than and the highest density = 1.69. What is the
(C) about the same as density difference (DD) on the phantom
(D) slighter higher than image?
(A) 0.42
24. The Mammography Quality Standards Act
(MQSA) requires that the maximum com- (B) 0.43
pression for the initial power drive not (C) 0.44
exceed (D) 0.45
(A) 100 newtons
29. Breast tissue can extend medially to the
(B) 200 newtons
(C) 400 newtons (A) latissimus dorsi muscle
(D) 500 newtons (B) midsternum
(C) retromammary space
25. Collimation should not extend beyond any (D) inframammary crease
edge of the image receptor by more than
30. Which of the following hormones has the
(A) 1% of the SID
most inuence on the normal physiological
(B) 2% of the SID changes of the breast?
(C) 3% of the SID
1. prolactin
(D) 4% of the SID
2. estrogen
26. In conventional imaging, the characteristic 3. progesterone
curve of a particular lm describes the rela- (A) 1 and 2 only
tionship between the
(B) 2 and 3 only
(A) exposure the lm receives and the den- (C) 1 and 3 only
sity after processing (D) 1, 2, and 3
(B) x-ray beam quality of the mammo-
graphic unit and lm speed 31. Which of the following is (are) considered a
(C) speed of the lm and the density at dif- rst-degree relative?
ferent exposure levels
1. mother
(D) screen-lm combination as it relates to
2. aunt
the selected mAs
3. sister
27. Under which of the following circumstances (A) 1 only
is it necessary to reestablish processor QC (B) 1 and 2 only
operating levels?
(C) 2 and 3 only
(A) a change in lm volume (D) 1 and 3 only
(B) a change in mammographer
(C) an unexplained upward change in
the data
(D) using a different sensitometer
 Questions: 23 through 41 139

32. A woman should perform breast self- 37. The from below (FB) projection utilizes a
examination (BSE) monthly to beam directed
(A) become familiar with both of her breasts (A) perpendicular to the image receptor
(B) localize cancerous lumps (B) horizontally
(C) recognize breast dimpling (C) tangentially
(D) discover nipple discharge (D) parallel to the image receptor

33. The breast of a woman below age 35 is 38. Radiation changes that the breast may exhibit
include
(A) not related to radiation sensitivity
(B) less sensitive to radiation 1. erythema
(C) less sensitive to low-dose radiation 2. edema
(D) more sensitive to radiation 3. hardening
(A) 1 and 2
34. In the low kVp range using a molybdenum
(B) 2 and 3
target tube, what type of photon interaction
predominates? (C) 1 and 3
(D) 1, 2, and 3
(A) photoelectric interaction
(B) Compton interactions 39. Magnication in mammography can be useful
(C) Bremsstrahlung interaction in all of the following except
(D) Coherent interaction (A) specimen radiographs
(B) to dene borders of masses
35. In digital imaging a repeat analysis test is
(C) to assess calcication
(A) unnecessarydigital imaging automati- (D) routine screening
cally corrects exposure mistakes
(B) necessarydigital imaging cannot cor- 40. Which of the following projections could be
rect for overexposure used to replace the MLO in patients where
(C) unnecessarydigital imaging corrects the MLO is not possible?
unsharpness by altering the spatial dis-
(A) ML
play
(B) lateromedial (LM)
(D) necessarydigital imaging cannot cor-
rect factors such as motion unsharpness (C) rolled lateral (RL)
(D) AT
36. The same mammographer should view the
phantom images because 41. Contrast resolution in conventional imaging
refers to the ability to
(A) subjective judgment about images is
always difcult (A) image high-contrast small objects such
(B) it is not wise to have different individu- as microcalcications
als handling the phantom (B) distinguish anatomic structures with
(C) not all mammographers know the similar subject contrast
MQSA regulations (C) visualize recorded detail when image
(D) given set values, different mammogra- contrast and optical density are
phers will calculate the densities optimized
differently (D) visualize recorded detail
140 7: Practice Test 2

42. The best time for a woman to perform a BSE is 46. On a reject/repeat analysis, the rate was
lower than 5% but one category of the
(A) before the start of the monthly period
reject/repeat analysis is signicantly higher
(B) just after the period starts than others. What should be done?
(C) within 510 days after the start of the
period (A) Although the overall rate is less than 5%,
that one area should be targeted for
(D) anytime
improvement.
43. It may be necessary to use manual technique (B) If the other categories are within normal
with small breast because the limits, that area can be disregarded.
(C) Because the rate was more than 2%,
(A) multiple detectors can be moved accord- the entire department needs to be
ing to breast size reassessed.
(B) automatic exposure control (AEC) detec- (D) With an overall rate lower than 5%, one
tor may not cover the small breast tissue high rate is statistically meaningless.
area
(C) AEC detector cannot compensate for 47. Typically, grid ratios in mammography range
breast size from
(D) AEC cannot compensate for varying
(A) 7:1 to 8:1
breast tissue types
(B) 6:1 to 7:1
44. If an artifact is noted on some mammo- (C) 4:1 to 6:1
graphic images, which appropriate MQSA (D) 3:1 to 5:1
regulation will identify the dirty cassette/
image receptor quickly and easily? 48. Positron emission tomography (PET) imag-
ing is useful in staging tumors because
(A) processor QC test
(B) screen cleanliness (A) the positron emitting isotopes are
(C) visual checklist radioactive
(D) standardized image labeling (B) PET imaging can display an image of the
tumor bed
45. Which of the following tests are performed (C) the positron emitting isotopes destroy
monthly? the tumor bed
(D) PET imaging tracks the increased blood
(A) phantom images
ow from the cancerous tumor
(B) repeat/reject analysis
(C) compression check 49. Medical history is important in
(D) visual checklist
1. assessing risk factors for breast cancer
2. preventing breast cancer
3. evaluating treatment options
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
 Questions: 42 through 58 141

50. Unlike conventional x-ray tubes, some 54. What effect does compression have on Comp-
mammography tubes are tilted 7.512 degrees ton interactions?
from the horizontal. The effect of this is to
(A) The absolute number of Compton inter-
1. allow the use of smaller focal spot size actions increases.
2. minimize the heel effect (B) The absolute number of Compton inter-
3. increase resolution actions decreases.
(C) Compression has no affect on Compton
(A) 1 and 2 only
interactions.
(B) 2 and 3 only
(D) Compression affects Compton interac-
(C) 1 and 3 only tion only above 70 kVp.
(D) 1, 2, and 3
55. Visual inspection done during CBE involves
51. The retromammary space describes the area
(A) feeling for changes in the breast
(A) between the breast and pectoral muscle (B) looking for changes in the breast
(B) separating the skin of the breast from the (C) palpating the breast
deep fascia
(D) examining areas under the armpit
(C) separating the skin from the supercial
fascia 56. If the residual hypo in the mammography lm
(D) between the glandular tissue and the exceeds 0.05 g/m2 or 5 g/cm2, this can indicate
inframammary fold
1. improper washing of the lm
52. In which of the following are breast cysts 2. improper xer replenishment
more common? 3. the lm will have poor archival quality
1. young women in their early 20s (A) 1 and 2 only
2. premenopausal woman (B) 2 and 3 only
3. postmenopausal woman on estrogen (C) 1 and 3 only
therapy (D) 1, 2, and 3
(A) 1 and 2 only
57. Fatty tissue is generally radiolucent and will
(B) 2 and 3 only
show on the mammogram as
(C) 1 and 3 only
(D) 1, 2, and 3 (A) glandular areas
(B) high-density areas
53. The CC shows a circumscribed oval radiolu- (C) low-density areas
cent lesion. There was a denite halo sur- (D) medium-density areas
rounding the lesion. It is most likely to be a
(A) broadenoma 58. The mammogram of a woman age 50 who
has recently started estrogen replacement
(B) lymph nodes
therapy is likely to be
(C) cyst
(D) hematoma (A) more broglandular than her past mam-
mographic study
(B) more fatty that her previous mammogram
(C) less brous and less glandular than her
previous studies
(D) unchanged from her previous
mammograms
142 7: Practice Test 2

59. The mammogram shows an oval-shaped 64. The density difference, DD on the sensito-
lesion with mixed density. The lesion has a metric strip is the difference between
central radiolucent area and is freely mov-
(A) the average density closest to 2.20 and
able. This lesion is most likely to be a
the mid-density
(A) broadenoma (B) the mid-density and the base plus fog
(B) hematoma (C) the average density closest to 0.45 and
(C) lymph node the mid-density
(D) galactocele (D) the high and low average densities

60. If a cyst moves down on the ML from its 65. What is epithelial hyperplasia?
position on the MLO, the cyst is located
(A) A calcied hematoma resulting from
(A) centrally trauma
(B) medially (B) An oil cyst within the breast
(C) laterally (C) An overgrowth of cells in the ducts or
(D) at the areola lobules
(D) An epidermoid cyst on the skin of the
61. Increased OID causes loss of image detail in breast
magnication mammography. What factors
help to compensate for this loss of image 66. Figure 7-2 shows a (an)
detail?
(A) ruptured implant
1. compression of the part (B) encapsulated implant
2. decreased focal spot size (C) herniated implant
3. increased OID (D) implant removal
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3

62. What does the actual focal spot size measure?

(A) the area on the anode exposed to
electrons
(B) the area projected on the patient
(C) the area projected on the image receptor
(D) the nominal focal spot size

63. The mammography report has an assessment

nding of Breast Imaging Reporting and
Data System (BIRAD) 0. This means that
(A) the mammogram is negative
(B) there is a high probability of a benign
nding
(C) additional imaging is needed
(D) the ndings are suspicious

Figure 72
 Questions: 59 through 78 143

67. After a four-projection mammogram, calci- 73. During pregnancy and lactation, the breast
cations are visualized superior to the nipple
(A) shows increased density
but only on the MLO projection. What addi-
tional projection would best be used to locate (B) increases in fatty content
the position of the lesion? (C) atrophy of glandular structures
(D) shows decreased density
(A) exaggerated craniocaudal (XCCL)
(B) cleavage (CV) 74. Most of the glandular tissue is arranged in
(C) ML the breast around the
(D) AT
(A) medial and upper inner quadrants
68. Approximately how much contrast agent is (B) lateral and lower inner quadrants
injected into the breast during ductography? (C) central and upper outer quadrants
(D) medial and upper outer quadrants
(A) 15 cc
(B) 1525 cc 75. A beryllium (Be) window enhances contrast by
(C) 3040 cc
(A) increasing the output of the x-ray tube
(D) 50100 cc
(B) reducing production of scattered
69. What does the glandular dose measure? radiation
(C) transmitting more low-energy photons
(A) the average dose to the patients skin
(D) transmitting more high-energy photons
(B) the absorbed dose to the skin
(C) the absorbed dose at the tissue level 76. Proper compression of the breast is indicated
(D) the same as the entrance skin dose when the
(A) patient is in pain
70. Which of the following relationships does not
change when moving from routine to magni- (B) compression paddle stops
cation mammography? (C) breast is taut
(D) breast feels soft
(A) OID
(B) focal spot size 77. Which factors cause increased skin dose in
(C) SID magnication?
(D) source-to-object distance (SOD)
1. larger OID
71. Who performs the compression device check 2. smaller focal spot size
for mammography QC? 3. increased mAs

(A) physicist (A) 1 and 2 only

(B) staff technologist (B) 2 and 3 only
(C) radiologist (C) 1 and 3 only
(D) mammographer (D) 1, 2, and 3

72. A galactocele is 78. In radiology, according to the line focus prin-

(A) a lesion associated with trauma to the
breast
(B) a benign milk-lled cyst
(C) associated with eggshell-like calcication
(D) associated with a central radiolucent hilus
ciple, the effective focal spot is
(A) larger than the actual focal spot
(B) smaller than the actual focal spot
(C) the same as the actual focal spot
(D) decreased as the target angle increases
144 7: Practice Test 2

79. Figures 7-3A and 7-3B are mammograms of 80. In the optimum position of the patient for the
the same patient. Figure 7-3B was taken 6 CC projection, the patients head is turned
months after Figure 7-3A. These mammo-
(A) toward the side under examination
grams demonstrate a
(B) away from the side under examination
(A) resolving oil cyst (C) depending on the preference of the
(B) galactocele mammographer
(C) radial scar (D) to the patients right
(D) hematoma
81. Which of the following projections would
best separate superimposed 12-oclock and
6-oclock masses?
(A) MLO
(B) XCCL
(C) CC
(D) AT

82. In positioning terminology, CV means

(A) compressed position
(B) Cleopatra view
(C) cleavage view
(D) compression view

83. Malignant casting-type calcications appear

on the mammogram as
A (A) granulated sugar or crushed stone
calcications
Figure 73A (B) eggshell-like calcications
(C) elongated, branching, and needlelike
calcications
(D) fragmented, linear branching
calcications

84. The functional milk-producing units of the

breast are contained within the
(A) lactiferous sinuses
(B) lobules
(C) ampulla
(D) areola

Figure 73B
 Questions: 79 through 91 145

85. If the nipple is not imaged in prole on the four- 88. The patient had trauma to the breast 1 month
projection series, indications to take additional ago and has developed a lump. Such an
projections with the nipple in prole include injury may show mammographically as a
1. the nipple cannot be differentiated from (A) galactocele
a mass (B) hematoma
2. the patient has a possible retroareolar mass (C) lymph node
3. the patient is male (D) broadenoma
(A) 1 and 2 only
89. In mammography imaging, exposure factors
(B) 1 and 3 only
used depends on all of the following except
(C) 2 and 3 only
(D) 1, 2, and 3 (A) the patient
(B) target material
86. The AT projection best demonstrates the (C) screen/lm combination
(D) viewing conditions
(A) subareolar area
(B) medial aspect of the breast
90. If too much upper axilla and shoulder are
(C) axillary aspect of the breast under the compression paddle when imaging
(D) lower inner quadrant of the breast for the MLO, the effect is to

87. The area of minus density in the upper part (A) inhibit proper compression of the upper
of Figure 7-4 best represents breast
(B) inhibit proper compression of the lower
(A) the patients shoulder breast
(B) a pressure artifact occurring after the (C) ensure equal compression of the upper
exposure and lower breast
(C) the patients chin (D) ensure proper compression of the lower
(D) malposition of the mirror supplying breast
illumination
91. Of these four, which would best demonstrate
microcalcications within the breast?
(A) ultrasound
(B) spot compression
(C) spot magnication
(D) TAN projection

Figure 74
146 7: Practice Test 2

92. The area of minus density in the upper part 95. Which projection gives a mirror image of the
of Figure 7-5 best represents MLO?
(A) a pacemaker (A) ML
(B) the patients chin (B) LM
(C) a hematoma (C) LMO
(D) port-a-cath (D) AT

96. The nominal focal spot size of the mammog-

raphy unit is 0.3. This means that the
(A) actual focal spot size is 0.3
(B) effective focal spot size is 0.3
(C) both effective and actual focal
spot size is 0.3
(D) actual focal spot is smaller than 0.3

97. Women with lumpectomy should have mag-

nied images taken of the tumor bed to
1. conrm the removal of the cancer
2. check calcium deposits that may result
from radiation and surgical changes
3. check for recurrence of the cancer
(A) 1 and 2
(B) 2 and 3
(C) 1 and 3
Figure 75 (D) 1, 2, and 3

98. A lesion is present on the MLO but is not

93. A rolled projection can be performed to seen on the CC projection. What projection
1. remove superimposed tissues could best be used to determine whether the
2. separate superimposed breast tissue lesion is laterally or medially located?
3. determine the location of a nding seen (A) XCCL
only on one of the standard projection (B) CV
(A) 1 and 2 only (C) ML
(B) 1 and 3 only (D) AX
(C) 2 and 3 only
99. Delaying the processing of lms will affect the
(D) 1, 2, and 3
1. speed of the lm
94. Ideally, in an open surgical biopsy, when 2. lm contrast
should a breast tissue specimen be imaged? 3. density of the lm
(A) immediately after surgery (A) 1 and 2 only
(B) within 24 hours of the surgery (B) 2 and 3 only
(C) while the patient is still in the recovery (C) 1 and 3 only
room
(D) 1, 2, and 3
(D) before the surgery is terminated
 Questions: 92 through 109 147

100. When imaging a small breast, scattered radi- 104. After parturition, contraction of which cells
ation can be minimized by help to eject milk from the alveoli?
1. increasing compression (A) epithelial cells
2. reducing kVp (B) myoepithelial cells
3. reducing eld size (C) basement cells
(A) 1 and 2 only (D) supercial cells
(B) 2 and 3 only
105. A nding of BIRAD 1 on the mammogram
(C) 1 and 3 only means that the mammogram
(D) 1, 2, and 3
(A) cannot accurately evaluate the breast
101. The purpose of the certication and accredi- (B) showed benign ndings
tation process is to (C) showed suspicious ndings
(A) provide legal mammography services (D) is suggestive for malignancy
(B) establish minimum national quality
106. Erythema of the breast generally indicates
standards for mammography
(C) ensure that all women have access to a (A) inammatory breast cancer
certied mammography facility (B) breast abscess
(D) authorize certain states to certify mam- (C) breast infections
mography facilities and conduct (D) further testing of the breast is necessary
inspections
107. Which of the following is used as a treatment
102. A facility has a sign posted advising patients for estrogen-dependent tumors in post- and
to contact a designated person within the premenopausal women?
organization with comments. This facility is
meeting the U.S. Food and Drug Administra- (A) radiation therapy
tion (FDA)s (B) chemotherapy
(C) tamoxifen
(A) medical outcome audit program
(D) antibody therapy
(B) record-keeping program
(C) patient communication of results 108. Causes of radiographic noise include
program
(D) customer complaint program 1. quantum mottle on the image
2. scattered radiation
103. A hamartoma is 3. lm graininess
(A) a malignant tumor of the breast (A) 1 and 2 only
(B) a benign tumor of the breast (B) 2 and 3 only
(C) associated with trauma of the breast (C) 1 and 3 only
(D) associated with nursing (D) 1, 2, and 3

109. A thin supportive layer located between the

basal surface of the epithelium and the con-
nective tissue layer of the lobule is called
(A) chief cells
(B) myoepithelial
(C) basement membrane
(D) supercial A cells
148 7: Practice Test 2

110. A camels nose breast contour can be pre- 113. Under the MQSA, how long are facilities
vented in the MLO projection by required to maintain the records of a patient
who died shortly after her rst mammogram?
(A) including all of the breast under the
compression paddle (A) 5 years
(B) angling the image receptor parallel to (B) 10 years
the pectoralis muscle (C) 20 years
(C) properly supporting the breast during (D) permanently
compression
(D) ensuring that the nipple remains in pro- 114. Under what circumstances are triangulation
le during compression techniques necessary?
1. to locate an abnormality visualized on
111. The superior inferior oblique (SIO) will best
one projection only
demonstrate the
2. during sterostatic breast biopsy
(A) OUQ and the LOQ of the breast 3. to perform spot magnication
(B) LIQ and the UIQ of the breast
(A) 1 and 2 only
(C) UIQ and LOQ of the breast
(B) 2 and 3 only
(D) LIQ and the OUQ of the breast
(C) 1 and 3 only
112. The basic premise of a medical audit is that (D) 1, 2, and 3

1. all positive mammograms should be 115. A dimpled skin condition seen in cases of
followed lymphatic edema of the breast is called
2. the pathology results of all biopsies per-
formed should be collected (A) inammatory carcinoma
3. all pathology results should be corre- (B) ductal ectasia
lated with the radiologists ndings (C) plasma cell mastitis
(D) peau do range
(A) 1 and 2 only
(B) 2 and 3 only
(C) 1 and 3 only
(D) 1, 2, and 3
 Answers and Explanations
1. (B) Many women are choosing conservation
therapy that removes the tumor with wide
margins (lumpectomy, quadrectomy, or seg-
mental mastectomy) and includes radiation
therapy (irradiation with high-energy
beams). Treatment starts 38 weeks after
surgery and includes about 56 weeks of
daily treatments. Nuclear medicine uses
radioactive tracer (also called radioactive iso-
topes or radiopharmaceutical). Drugs can be
hormonal therapy (estrogen therapy) such as
tamoxifen or chemotherapy (Andolina, 331330;
Peart, 220234).
2. (D) An annual mammogram is generally rec-
ommended for asymptomatic women above
age 40 who have not been identied as hav-
ing signicantly higher risk. The mammo-
gram is not an effective screening tool for
younger women (ACS, 116).
3. (B) Studies have suggested that synthetic
such as hormone replacement therapy (HRT)
or reproductive hormones inuence breast
cancer risk as well as promote cancer growth.
Early menarche (less than 12 years), late
menopause (equal to or more than 55 years),
oral contraceptive use, and fewer pregnan-
cies will all increase a womans risk by affect-
ing estrogen levels in the body. Hormones or
hormone use, however, are not known to
always cause breast cancer (ACS, 116).
4. (B) When exposed to radiation the intensify-
ing screen will emit light, which then exposes
the lm emulsion and forms a latent image.
However, photons can travel through the
intensifying screen interacting with the back
of the screen and also emitting light. Since
the light diverges as it travels, the image
formed at the back is not an exact replica of
the one formed in fronteffectively decreas-
ing the recorded detail of the image. In con-
ventional mammography imaging, the x-ray
beam should therefore travel through the
breast, through the lm, and then strike the
intensifying screen. This placement will
reduce screen blur. There is high x-ray absorp-
tion by the screen phosphors closest to the lm
emulsion reducing the diffusion of light emit-
ted from the screen. The result is less noise and
greater spatial resolution (Figure 6-14) (Bushong,
327340).
5. (D) If data seldom exceed the operating lim-
its by 0.1%, the medical physicist or radiolo-
gist may wish to narrow the control limits. If
the limits are consistently exceeded, it is nec-
essary to improve the QC procedures or
repair or replace the appropriate equipment.
Establishing new limits are allowed only
under specic circumstances, such as if the
lm is changed or there are changes in pro-
cessing method (equipment or solutions, for
example). Widening the control limits is never
allowed (ACR, 134135).
6. (B) Whenever a new box of lm is opened for
QC, a crossover must be carried out. Radi-
ographic lms are produced in batches,
which will have slight variations in charac-
teristics of the lm emulsion. This will affect
the sensitometric characteristics of the lm.
The crossover is carried out only with sea-
soned processor chemistry that is operating
within plus or minus 0.10 of the control limits.
149
150 7: Practice Test 2

Figure 76. The crossover worksheet is used to calculate the difference in the average values between the new and old boxes of lm and
thus determine new operating levels. If the new densities are so different from the old that the new steps will not be the best choice, then new
operating levels must be reestablished using the original method of establishing processor QC operating levels.

The crossover is used to compare the average

density difference (DD), mid-density (MD)
and base-plus-fog of ve lms from the old
box with ve lms from the new box. The new
operating level is established by adding the
difference (new minus old operating values)
Intensity relative IP
to the old operating level. If the difference is of the luminosity
positive, the new operating level is increased. Film/Screen
If the difference is negative, the new operating
level is decreased (Figure 7-6). If control limits
consistently exceed the normal values, the
equipment needs to be repaired or replaced.
Whenever new equipment is installed (proces-
sor, sensitometer, or densitometer), the proces- Log of relative exposure
sor QC operating levels must be reestablished
Figure 77. Characteristic curve for digital imaging. A graph of
(ACR, 161; Peart, 87112).
the optical density signal and the relative exposure for a digital
imaging plate (IP) will have a linear response to x-ray. This is
7. (C) Digital detectors have image characteris- unlike the curvilinear response of a lm-screen system.
tic similar to the response of screen-lm
except that the response in digital is linear
(Figure 7-7). This means that regardless of the

intensity of the x-ray beam, a small change in
the intensity is recorded as the same change
in the electronic image. In digital imaging,
this is possible because there are different
devices for acquisition and display, and each
can be separately optimized. Digital imaging
therefore has a much wider latitude than con-
ventional imaging. Digital imaging can
enhance the contrast resolution of the nal
image (Andolina, 437452; Peart, 179194).
8. (C) This is the total number in each group, but
the criteria for the number of objects to meet
accreditation requirements are a minimum
number of four bers, three speck groups, and
three masses (Figure 7-8). The only exceptions
to date are the Hologic and Siemens digital
units which require ve bers, four speck
groups, and four masses. When scoring, each
ber, speck group, or mass is counted as 1
point. Partial bers, speck groups, or masses
are counted as 0.5 point or not at all (ACR, 268).
Figure 78. Schematic diagram of the phantom showing the rel-
ative position of the different objects embedded within the phantom.
9. (B) The areola is the smooth, darkened area
that surrounds the nipple. Skin covers the
entire breast, and the Montgomery glands
are specialized sebaceous glands on the are-
ola. The ampulla is another name for the lac-
tiferous sinus, a part of the ductal system
in the internal breast anatomy (Peart, 3544;
Tortora, 1083).
Answers and Explanations: 7 through 13 151
10. (A) A keratosis forms on the skin surface of
the breast and gives a typical mammographic
appearance. They are multilobulated, with
sharply outlined borders. An example of a
mixed-density lesion with a radiolucent cen-
ter is a lymph node. Other mixed-density cir-
cular or oval lesions are hematomas, galacto-
celes, or broadenolipomas. Halos are narrow
radiolucent rings or ring segments typically
seen around the periphery of benign circular
or lesions (Peart, 4762; Tabr, 1792: Venes, 1171).
11. (A) Plasma cell mastitis, periductal mastitis, or
ductal ectasia is an inammatory reaction
characterized by the presence of plasma cells
surrounding a dilated duct. It is a benign con-
dition. Intra- and/or periductal calcications
are the nal results of this condition. The calci-
cation can be located around or inside the
dilated ducts. Most are elongated and sharply
outlined with smooth borders; some are
needlelike with high density or may have a
lucent central area. The broadenoma is an
oval lesion that may contain calcications. Ker-
atoses rarely calcify and mammographically
appear as lobulated lesions. Mammographi-
cally malignant calcications often appear in
clusters (Peart, 4762; Tabr, 1792; Venes, 1171).
12. (A) There are numerous advantages of com-
pression, but the immediate action of compres-
sion in reducing motion unsharpness is immo-
bilization. With the breast held still, the
possibility of motion blur is minimized.
Changes in the mAs mainly affect optical den-
sity and patient dose. The kVp has a direct effect
on subject contrast. There are only two focal
spot sizes in breast imagingthe routine larger
focal spot and the small focal spot for magni-
cation imaging (ACR, 2377; Bushong, 327340).
13. (C) The large air gap acts like a grid and
reduces scattered radiation, thus improving
contrast. Positioning the breast away from
the image receptor takes advantage of the
inverse square law: the intensity of the scat-
tered radiation is reduced because the dis-
tance between the image receptor and the
object is increased. The SID does not change
in magnication and, although a grid is not
152 7: Practice Test 2
used, there is no signicant reduction in
exposure because of reciprocity law failure.
Grid use in magnication increases exposure
times, increasing tube loading, thus increas-
ing motion artifact owing to long exposure
times. Patient radiation dose is also increased
(ACR, 5960; Peart, 6584).
14. (B) Quantum mottle refers to the mottled,
grainy appearance of a radiograph. In con-
ventional imaging it occurs when insufcient
x-rays interact with the intensifying screen to
form the image. The use of high mAs, low
kVp, and slower lm/screen combinations
reduce quantum mottle. Motion does not
affect quantum mottle (Bushong, 272273).
15. (C) The localization needle wire should be
positioned to pass just through the lesion.
Most surgeons feel for the tip of the wire
before making an incision in the patients
breast. Because the tip is being used as a loca-
tor, it should pass through the lesion, not
above, below, or beside it (Andolina, 313330;
Peart, 203220).
16. (A) The medial breast is the most important
aspect of the CC projection. The other routine
projection, the MLO, often does not image
medial breast clearly because of distance
from the image receptor and superimposition
of glandular structures. Eliminating the
medial breast on the CC would therefore
eliminate it from the study (Peart, 115145).
17. (D) In the TAN projection, the x-ray beam
just skims the area of interest. The beam is
always tangential or perpendicular to the
skin surface. This projection demonstrates
the area of interest free of superimposition.
The TAN is possible in any direction or pro-
jection (ACR, 65; Peart, 115145).
18. (A) In the RM position, the breast is position
for the CC. The top surface of the breast is
rolled medially and the bottom surface later-
ally (Andolina, 174245; Peart, 115145).
19. (D) Both saline and silicone implants are
radiopaque. The saline implant can be
inserted as an adjustable sac (similar to tissue
expanders) where the uid content is
adjusted as needed. The only radiolucent
implant available is the autologous myocuta-
neous aps. This involves transplanting tis-
sue from another area of the body to the
breast. The most popular is the transverse
rectus abdominis myocutaneous or TRAM
ap, using the rectus abdominis muscle, but
the procedure can also be done using the
latissimus dorsi or the gluteus maximus.
Mammographically, the breast has a fatty or
muscular appearance (Andolina, 306).
20. (B) After mastectomy, a three-projection series
including the CC, MLO, and ML is generally
recommended. Without the other breast for
comparison, this series gives the radiologist a
better opportunity to diagnose any new
malignancy. The AT images the axilla and the
TAN images skin lesions. The LMO is the true
reverse of the MLO (Peart, 115145).
21. (A) Even though men generally have a low
risk of developing breast cancer, they should
be aware of the risk factors, especially family
history which could be associated with
genetic changes. However, a family history of
breast does not mean breast cancer will
develop. Slightly over 1% of males in the
United States develop breast cancer each year
(ACR, 8; ACS, 116).
22. (A) The CBE is a clinical examination by a
trained health-care professional and should
be performed every 3 years for women below
40 and every year for women above 40. To be
effective, the CBE should be performed in
combination with a mammogram (ACS, 116).
23. (B) Because of the low x-ray energies used in
mammography, the dose to the skin may be
high, but dose falls off rapidly as the beam
penetrates the breast. The dose to the skin
may be as high as 8001000 mR/projection
(810 mGy/projection); the dose to the mid-
line of the breast (the average radiation dose
to the glandular tissue or glandular dose)
will be only 100 mrad (1.0 mGy). The nal
rules of mammography dictated by the

MQSA state that a single projection screen-
lm mammogram should not give more than
300 mrad/projection average glandular dose
when a grid is used and should not exceed
100 mrad/projection without a grid (Bushong,
327340; Peart, 6584).
24. (B) A compression force of a least 111 new-
tons (25 lb) and a maximum of 200 newtons
(20 decanewtons or 45 lb) is required for the
initial power drive. This is an MQSA require-
ment, necessary to avoid injury to patients
(ACR, 201).
25. (B) This is the MQSA requirement to avoid
excess radiation dose to the patient. All units
should have a beam-limiting device that
allows the entire chest wall edge of the x-ray
eld to extend to the chest wall edge of the
image receptor and should not extend
beyond any of the edges on the image recep-
tor by more than 2% (ACR, 109).
26. (A) The characteristic curve measures the
optical density or degree of blackness of the
lm to the log of the relative radiation expo-
sure. A single characteristic curve can be ana-
lyzed to determine the contrast (slope of the
straight-line portion of the curve) and the
lm latitude (the range of exposures over
which the lm responds with optical densi-
ties in the diagnostically useful range). Two
characteristic curves of different lms are
needed to compare lm speeds (Bushong,
272291; Peart, 6584).
27. (D) Establishing a new limit is allowed only
under specic circumstances, such as, if the
lm emulsion changes or there are changes in
processing or assessment methods (new
equipment or new solutions, new densitome-
ter or sensitometer, for example). If the limits
unexpectedly changed (up or down), it is
necessary to improve the QC procedures or
repair or replace the appropriate equipment.
Widening the control limits is never allowed
(ACR, 134135).
28. (B) To determine the density difference, DD,
the optical density inside the disk and density
Answers and Explanations: 14 through 33 153
directly adjacent to the disk (to the left or
right perpendicular to the anode-cathode
axis) is recorded. The DD is the difference
between these densities. The background
density is the density measured at the center
of the phantom image. The mid-density and
highest density are both obtained from the
sensitometric strip (ACR, 167).
29. (B) The breast can reach superiorly to the
clavicle (level of the second or third rib), infe-
riorly to meet the abdominal wall at the level
of the sixth or seventh rib (at the inframam-
mary fold or crease), laterally to the edge of
the latissimus dorsi muscle and medially to
the midsternum (Peart, 3544).
30. (B) The most prominent hormones active in
the breast are estrogen and progesterone.
Estrogen is mostly responsible for ductal pro-
liferation and progesterone is responsible for
lobular proliferation and growth. Studies
have shown the two actually work together
to produce full ductallobularalveolar (ter-
minal ductules) development. Prolactin is
present in the breast during initial breast
growth, pregnancy, and lactation (Peart, 3544).
31. (D) First-degree relatives are immediate rela-
tives such as mother, sister, or daughter (ACR, 8).
32. (A) The BSE involves looking and feeling for
changes in the breast. With routine BSE, a
woman will become familiar with both the
normal appearance and feel of her breasts so
that even small changes are noticeable. For
this reason BSE should be performed regu-
larly at the same time every month (about
510 days after the period begins, when the
breasts are least tender) (ACS, 116; American
Cancer Society).
33. (D) Unnecessary exposure should be avoided
with any radiographic examination. Some
studies have shown that the dense cellular
breast structure of women younger than 35 is
more susceptible to radiation. Dense breast
tissue will also need more radiation to pene-
trate, translating to increased dose (ACR, 79110;
Peart, 6584).
154 7: Practice Test 2
34. (A) For mammography tubes made with
molybdenum, the most prominent x-rays are
characteristic. Characteristic x-rays are pro-
duced after a photoelectric interaction. If the
target is ltered with molybdenum, the char-
acteristic energy of 19 keV from the K-shell
interaction will be prominent. This is within
the range of energies that are most effective
for mammographic imaging. Characteristic
radiation is produced when an outer shell
electron lls an inner shell void. If the outer
shell electron lls the void in the K-shell, the
x-ray emissions are termed K-characteristic
x-rays. Bremsstrahlung x-rays are produced
when an outer projectile electron is slowed by
the electric eld of the target atom nucleus.
This interaction is common in tungsten tar-
gets. Coherent or classical scattering describes
the interaction between low-energy electrons
and atoms. The x-ray loses no energy but
changes direction slightly. In Compton scatter-
ing, moderate-energy x-rays interact with an
outer-shell electron and eject the electron from
the atom. The ejected electron is the Compton
electron (Bushong, 117187; Peart, 6584).
35. (D) The QC testing for digital imaging has
most of the components of conventional
imaging plus additional tests on the display,
laser printer if used, and imaging system.
Repeat analysis is still needed for repeats
because of positioning, patient motion, noisy
images (underexposure), and equipment fail-
ure, to name just a few. Digital imaging can
correct for overexposure, although excessive
overexposure increases the patient dose. Digi-
tal imaging has a harder time correcting for
extreme underexposure, and creates a noisy
image (similar to quantum mottle). Digital
imaging can enhance the spatial display by
enhancing the edges of spiculation or calcica-
tions, making them more visible. Digital imag-
ing cannot correct unsharp images, especially
unsharpness caused by motion (Andolina,
437452; Peart, 87112, 179194; Stevens, 275370).
36. (A) Different individuals perceive different
numbers of test objects images or may count a
different number of objects in the same image.
For consistency, the same individual should
examine the images each time using the same
criteria (same time of day, same viewbox,
same magnier, and same viewing condi-
tions). The density calculations are mathe-
matical formulas that do not change. All
mammographers should be at least familiar
with the basic MQSA guideline (ACR, 184).
37. (A) The FB (from below) is the reverse CC
projection. The beam is directed caudocra-
nially to form an angle of 90 degrees with the
image receptor (Peart, 115145).
38. (D) After radiation therapy the breast may
appear red and swollen and may gradually
get tighter or harden. The breast may also get
smaller and be distorted from the surgical
technique. These changes are a result of the
radiation and although newer radiation treat-
ment has less effect on the breast, the mam-
mographer should still handle these patients
with care because the skin may be delicate
and the patient may have many tender or
painful areas (Andolina, 331402; Peart, 220234).
39. (D) Magnication is ideal for imaging small
areas such as the surgical site of a patient
with lumpectomy, specimen radiograph, or
microcalcications and masses. Magnica-
tion, however, should not be used for routine
imaging because the entire breast may not be
imaged completely and the patient dose is
increased (Bushong, 327340; Peart, 6584).
40. (B) The LMO provides a mirror image of the
MLO. The next best position is the LM pro-
jection, which is a true lateral projection use-
ful in imaging medially located lesions that
are high on the chest wall or extremely poste-
rior in the inferior half of the breast. The
image on the LM is very similar to the MLO,
the difference being that the MLO images the
lateral portion of the breast closer to the
image receptor. The ML, although also a true
lateral projection, cannot be used because it
does not image the posterior breast. The AT
best images the tail of Spence and the RL has
the breast positioned for the CC with the
upper surface rolled laterally while the lower
surface is rolled medially (Peart, 115145).

41. (B) Contrast resolution is the ability to distin-
guish anatomic structures with similar sub-
ject contrast. High-contrast resolution is
needed in mammography to distinguish sim-
ilar soft-tissue densities. Spatial resolution is
the ability to image high-contrast small
objects such as microcalcications. The spa-
tial resolution of the image is limited mainly
by the effective focal spot size. Spatial resolu-
tion is stated as the number of line pairs per
millimeter (lp/mm) that are imaged. The
higher the number, the smaller the object that
can be imaged and the better the spatial reso-
lution. High screen speed generally has
lower spatial resolution and spatial resolu-
tion can be improved by using smaller phos-
phor and thinner phosphor layers. The term
recorded detail is a less precise term referring
to the degree of sharpness of structural lines
on a radiograph, while the ability to visualize
recorded detail when image contrast and
optical density are optimized refers to visibil-
ity of detail (Bushong, 219227, 272).
42. (C) The best time to perform the BSE is 510
days after the start of the period when the
breast is least tender or swollen. If a patient is
not having regular periods, the BSE should
be done on the same day every month (American
Cancer Society).
43. (B) For the AEC to be effective, the thickest
portion of the compressed breast, regardless
of its size or tissue density, must be directly
over the AEC detector. If the AEC detector
does not cover the small breast tissue area,
the correct optical density will not be
recorded, resulting in an underpenetrated
nal image (Peart, 6584).
44. (D) Processing control makes sure the proces-
sor is working at optimal levels. The visual
checklist veries that the room equipment,
including the mammography unit, has all the
necessary accessories available and is safe for
patient and mammographer. Screen cleanliness
ensures clean screens, but to determine which
screen has the artifact all the screens would
have to be opened and cleaned. Standardized
image labeling identies the mammographic
Answers and Explanations: 34 through 48 155
unit (if there is more than one), the cassette or
image receptor by number, the mammogra-
pher performing the examination, the patient,
the facility name, and the projection. It is
important to be able to identify each
cassette/image receptor. Dirty cassettes/image
receptors are thus easily identied and cleaned
(ACR, 127).
45. (D) Phantom images are done weekly. The
repeat/reject analysis is made quarterly.
Compression check is tested semiannually,
and visual checks are done monthly (ACR,
119; Stevens, 275370).
46. (A) Ideally the rate should not exceed 2%, but a
rate of 5% is acceptable once a QC program has
been established. An analysis of the number of
repeated mammograms and rejected lms
identies ways to improve efciency and
reduce cost and patient exposure. Because the
main purpose of the reject/repeat analysis is to
determine problem areas within the depart-
ment, the one high-rate area should be targeted
for improvement (ACR, 202; Stevens, 275370).
47. (D) The linear-type grids used in mammogra-
phy typically have a very low ratio because
even with the common grid ratio of 4:1,
patient exposure doubles (grid ratio = the
height of the lead strips/the distance between
the strips; ratio = h/d). Most grids are focused
to the SID to increase contrast. Grids in mam-
mography typically have a frequency of 3050
lines per centimeter. The high-transmission
cellular (HTC) grid used in some units has the
characteristics of a crossed grid. It can reduce
scattered radiation in two directions rather
than the one direction of the linear or focused
grid. These grids use copper rather than lead
as the grid strip, and air rather than wood or
aluminum as the interspace material. When
compared to a similar ratio linear grid, the
HTC grids result in equal or less radiation
dose to the patient (Bushong, 327340; Peart,
6584).
48. (B) The staging of breast cancer is useful to
determine the extent of the spread of the can-
cer. In general, the higher the stage of the
156 7: Practice Test 2

cancer, the poorer the prognosis. The PET possible, resulting in increased resolution.
technique injects extremely short-lived The small focal spot sizes used in mammog-
nuclides into an arm vein. The technology raphy are therefore achieved using a combi-
works on the principle that because of the nation of 23 degrees target angle and 6 degrees
increase in metabolic activity, most cancerous tube tilt (Bushong, 327340; Peart, 6584).
tissue uses vast amounts of sugar (glucose)
and at a much higher rate than benign tissue.
The radioactive substance used is metabo-
lized in the body like sugar and will therefore
go to tissues that are most active. A gamma

t
targe
camera can then be used to measure the emit-
ted radiation signals making the cancers Horizontal
location visible. The extent of the cancer is
then known, which aids the oncologist in
determining treatment and monitoring ther-
apy. Currently, PET imaging is also used to
stage lymph node involvement, detect metas-
tases, and in staging and restaging cancerous
breast lesions and is becoming a useful tool
in molecular imaging (Peart, 179194, 220234).

49. (C) During the medical history documenta-

tion, the physician collects information on the
patients risk factors for benign or malignant
breast conditions and any other health prob-
lems. Information on past mammograms is
also collected because of the importance of
comparison. Although the medical history
does not prevent breast cancer, it is the rst
step in evaluating both symptomatic and
asymptomatic women and an important step
in evaluating treatment options (ACS, 116;
American Cancer Society).
50. (D) The smaller the focal spot size, the
greater the resolution. General radiography
uses target angles of 515 degrees but in con-
ventional mammography units the target is
angled about 23 degrees (line-focus princi-
ple). The large target angle would force the
use of larger focal spot sizes and result in the
heel effect (Figure 7-9). As a result of the heel
effect, some of the useful beam must travel
through the target material. This reduces the
intensity of the useful beam at the anode end
of the tube; however, with the cathode posi-
tioned to the chest wall and with the tube
tilted about 6 degree, the central rays parallel
the chest wall so no tissue is missed, the heel
effect is minimized, and small focal spots are
Compression plate
Breast
Breast
Image recorder
Figure 79. Mammography tube tilt. With the x-ray tube tilted
about 6 degrees off the horizontal, the central rays run parallel to
the chest wall so no breast tissue is missed. Tilting the tube allows
a smaller target angle and therefore a smaller effective focal spot
size while minimizing the heel effect. Tilting also allows greater
anode heat capacity because the actual focal spot size is not fur-
ther reduced.
51. (A) The retromammary space separates the
breast from the pectoral muscle. This space is
lled with a layer of adipose or fatty tissue
as opposed to the supporting and connective
tissue (stroma), blood vessels, and various
ductal structures that make up the glandular
and brous tissues of the breast (Peart, 3544).
52. (D) Cysts occur in the terminal ductal lobu-
lar units when the extralobular terminal duct
becomes blocked. Fluid accumulates faster
than it can be reabsorbed. Cysts vary in size
and respond to hormonal uctuations, but
the development of a cyst also depends on a
womans genetic predisposition. Younger

women, premenopausal women, and post-
menopausal women taking estrogen are
likely to have higher hormonal levels and
therefore have an increased possibility of
having cysts (Andolina, 155173; Peart, 3544).
53. (C) By the process of elimination, the best
choice is that the lesion is a cyst. Although
the broadenoma, hematoma, and lymph
node are all oval or circular lesions, all are of
mixed density (radiolucent and radiopaque)
(see Figure 3-2) (Tabr, 1792).
54. (B) Regardless of the kVp, as the kVp
increases, the relative number of x-rays
undergoing Compton interaction also
increases. With compression the part is thin-
ner, less kVp is needed to penetrate the part,
and therefore there is less Compton scatter
(Bushong, 117187).
55. (B) The CBE involves both a visual inspection
and palpation of the breast. A visual inspec-
tion involves looking for changes in the shape
and size and appearance of the breast and nip-
ple while noting any skin dimpling, redness,
or swelling (ACS, 116; American Cancer Society).
56. (D) The hypo estimator provides an estimate
of the amount of residual hypo in the lm in
units of grams per square meter. It should be
0.05 g/m2 or 5 g/cm2 or less. If the stain
indicates that the residual hypo has
increased, the test should rst be repeated. If
the result is the same then the rst check
should be the water wash tankit should be
full. Water wash ow rates should meet man-
ufacturers guidelines. The xer replenish-
ment rate must also be checked, because they
too should meet manufacturers guideline
(ACR, 211; Stevens, 275370).
57. (B) Fibrous and glandular tissues are
together described as broglandular densi-
ties. X-rays pass more easily through fatty tis-
sue than through brous or glandular tissues.
Fatty areas are more radiolucent and will
appear as high-density areas (black or less
dense) on the mammogram. The broglandu-
lar tissue is more radiopaque than fatty tissues
Answers and Explanations: 49 through 62 157
and results in areas of lower optical density
on the mammogram (white or denser areas)
(Peart, 3562).
58. (A) Estrogen and progesterone are two of the
many hormones responsible for many physio-
logical changes in the breast. Estrogen is respon-
sible for ductal proliferation and progesterone
for lobular proliferation. Once a woman starts
any of these hormones including HRT, the
changes can be spotty, causing lumps or
increased interstitial uids (cysts) but will gen-
erally result in an overall increase in glandular
tissue (Andolina, 155173; Peart, 4762).
59. (C) By process of elimination, the lesion is likely
to be a lymph node. Lymph nodes are lesions
with mixed density and generally have a radi-
olucent center corresponding to the hilus. The
broadenoma, hematoma, and the galactocele
are all mixed-density oval or circular lesions,
but none has the lucent center typical of the
lymph nodes (see Figure 3-2) (Tabr, 1792).
60. (C) When comparing the MLO projection to
the ML, a lateral abnormality will move down
on the lateral from its position on the MLO. A
medial abnormality will move up on the lat-
eral from its position on the MLO. A centrally
located lesion or a lesion at the areola will
show little or no movement (Peart, 115145).
61. (A) As the magnication factor increases, to
maintain a sharp image the focal spot must be
reduced or the thickness of the part has to
decrease. A greater magnication factor will
therefore need a smaller the focal spot. Small
focal spot is therefore used in magnication
mammography. Increasing OID increases the
magnication factor (Bushong, 117187; Peart, 6584).
62. (A) The actual focal spot size is the area on
the anode target that is exposed to electrons
from the tube current. Because the target is
angled, the effective area of the target is
made much smaller than the actual area of
electron interactions. The effective target is
the area projected onto the patient and the
image receptor. The nominal focal spot size is
a measure of the effective focal spot size and
158 7: Practice Test 2
is the value used when identifying large or
small focal spots (Peart, 6584).
63. (C) The MQSA governs nal assessment nd-
ing in the evaluation of mammographic
images. In an effort to guide referring physi-
cian and radiologist in the breast cancer deci-
sion making process, the ACR came up with
the BIRAD, which is a standardized mammo-
graphic reporting system that can be used as
a coding and assessment system. To ensure
recognition of the system the ACR collabo-
rated with the National Cancer Institute
(NCI), the Center for Disease Control and Pre-
vention (CDC), the FDA, the American Med-
ical Association (AMA), the American Col-
lege of Surgeon and the American College of
Pathologist. The BIRAD system is now well
recognized and used by radiologist, physi-
cians, and surgeons across the United States.
The MQSA also has a category assessment;
however the ACR assessment categories were
already in existence prior to the publication of
the nal regulations of MQSA. Because the
assessment categories developed by the ACR
are so widely recognized, the FDA accepts the
ACRs BIRAD categories; however to avoid
confusion in addition to the category name (eg,
BIRAD 1) the report must include the word
identier, for example, BIRAD 1: negative.
BREAST IMAGING REPORTING AND DATA
SYSTEM(BIRAD)
BIRAD 0: Need additional imaging
information and/or prior
mammograms for comparison
BIRAD 1: Negative
BIRAD 2: Benign nding
BIRAD 3: Probably benign ndingshort
interval follow-up suggested
BIRAD 4: Suspicious abnormalitybiopsy
should be considered
BIRAD 5: Highly suggestive of
malignancyappropriate
action should be taken
BIRAD 6: Known biopsy proven
malignancyappropriate
action should be taken
(Papp, 203; Peart, 246).
64. (D) The DD on the sensitometric control strip
is the difference between the average density
closest to 2.20 (high density, HD) and the
average density closest to but not less than
0.45 (low density, LD). Base plus fog is the
density over a clear area of the strip and the
mid-density is that closest to 1.20 (ACR, 151).
65. (C) Epithelial hyperplasia is also known as
proliferative breast disease and is an over-
growth of cells that line either the ducts or
the lobules. When hyperplasia involves the
duct, it is called ductal hyperplasia or duct
epithelial hyperplasia. When it affects the
lobules, it is referred to as lobular hyperpla-
sia. Depending on how it looks under the
microscope, it may be classied as usual or
atypical. An epidermoid cyst, often incor-
rectly referred to a sebaceous cyst, is a
pimple-like cyst that occurs in the oil glands
of the skin, and the hematoma is a pooling of
blood as a result of trauma. Over time a
hematoma may slowly calcify, resulting in the
formation of an oil cyst, and later a calcied
hematoma (American Cancer Society; Peart, 4762).
66. (A) A ruptured implant shows extracapsular
leakagesilicone may leak into the brous
capsule or may escape from the capsule leak-
ing into the surrounding breast tissues and
muscle causing pain or discomfort. In the
encapsulated implant, the implant hardens or
calcies but does not rupture. A herniated
implant shows the implant pushing out of
brous capsule, but does not indicate a sili-
cone leak. Patients with implant removal
may have traces of residual silicone in the
breast (Andolina, 246310; Peart, 115145).
67. (C) The rst step is to determine the location
of the lesion by applying the rules for lesion
movement. When comparing the MLO pro-
jection to the ML, a lateral abnormality will
move down from its position on the MLO. A
medial abnormality will move up from its
position on the MLO. A centrally located
lesion and lesions at the areola will show lit-
tle or no movement. Once the location of the
lesion is determined, an XCCL for a lateral
lesion or the CV for medial lesions will locate

the lesion in the CC position. The AT images
the axilla of the breast only and is not needed
(Andolina, 155173; Peart, 115145).
68. (A) During ductography, a collecting duct
that ends at the nipple is cannulated and a
small amount of contrast agent is injected.
Generally, 15 cc is enough to ll the duct
(Andolina, 331402; Peart, 203220).
69. (C) The glandular dose is used in mammog-
raphy because the biological effects of radia-
tion are most likely to be related to the total
energy absorbed by glandular tissue. The
glandular dose is the average radiation dose
to the glandular tissue in the middle of the
breast. The other measure of dose is the ESE.
The ESE is most often referred to as the
patient dose. It is the exposure at the skins
surface. In mammography the ESE may be
very high because of low-energy x-rays but
the dose falls quickly as the x-rays penetrate
the breast (Bushong, 590591).
70. (C) Obtaining a magnied image requires that
the OID be increased while maintaining a con-
stant SID. Any change in OID will result in a
corresponding change in SOD. To maintain a
sharp image, a small focal spot must be used
in magnication (Bushong, 327340; Peart, 6584).
71. (D) QC testing should always be performed
by the dedicated QC personnel or the same
individual. Here the mammographer would
be the most obvious person (ACR, 90; Andolina,
4598; Peart, 87112).
72. (B) Galactoceles are small, milk-lled cysts
with a high fat content. These are associated
with lactation, may be mixed density, and are
circularoval with sharply dened contours.
A hematoma is associated with breast trauma
and the oil cyst appears mammographically
as eggshell-like calcications. Lymph nodes
typically have a central radiolucent area cor-
responding to the hilus (Tabr, 1792).
73. (A) During pregnancy and lactation, breast
density increases because of physiological
changes, milk production, and increased
Answers and Explanations: 63 through 77 159
blood supply. The changes are a result of the
action of estrogen, progesterone, and pro-
lactin, which cause a proliferation of the duc-
tal and lobular structure of the breast and an
increase in blood ow (American Cancer Society;
Peart, 3544).
74. (C) With the four quadrants terminology, the
breast can be described as: the upper outer
quadrant (UOQ), upper inner quadrant
(UIQ), lower outer quadrant (LOQ), and
lower inner quadrant (LIQ). The exact loca-
tions within the quadrant are represented by
viewing each breast separately as a clock
face. The upper outer quadrant, which
extends toward the axilla, is known as the
axillary tail, tail of the breast or tail of Spence.
Most glandular tissue is found centrally and
extends laterally toward the axilla in the
UOQ. This distribution increases or decreases
with hormonal uctuations, but generally
mirrors the opposite breast (Peart, 3544).
75. (C) Mammography uses very low-energy
kVp and it is very important that the x-ray
tube window not attenuate the low-energy
photons. Most mammography units have
either borosilicate or beryllium windows. The
low atomic number of these materials allows
an inherent ltration of approximately 0.1 mm
Al (aluminum). The material of the glass win-
dow has no effect of scattered radiation, nor
can it increase or decrease the output of the
x-ray tube (Bushong, 327340; Peart, 6584).
76. (C) Compression is important in mammogra-
phy to reduced breast thickness, radiation
dose, and motion unsharpness. Compression
also separates superimposed areas of the
breast tissue and brings abnormalities closer
to the image receptor. Unfortunately, compres-
sion is painful for some women. In general,
the breast should be compressed until taut to
ensure adequate compression. Compression,
however, should not be applied to cause the
patient severe pain (ACR, 2377; Peart, 115145).
77. (C) The greater the magnication factor, the
greater the skin dose to the patient. In magni-
cation the patient dose increases because
160 7: Practice Test 2
the breast is closer to the source and because
additional exposure is required because of
reciprocity law failure. The small focal spot
size used to maintain a sharp image requires
that the mA be reduced with a corresponding
increase in exposure time (Bushong, 197198;
Peart, 6584).
78. (B) The actual focal spot size is the area on
the anode target that is exposed to electrons
from the tube current. As the size of the focal
spot decreases, the heating of the target is
concentrated into a smaller area. In the
design known as the line focus principle, the
target is angled allowing a larger area for
heating while maintaining a small effective
focal spot. Because the target is angled, the
effective area of the target is made much
smaller than the actual area of electron inter-
actions. The effective target is the area pro-
jected onto the patient and the image recep-
tor. As the target angle is made smaller, the
effective focal spot decreases (Figure 7-10)
(Bushong, 137138; Peart, 6584).
Target angle
Electrons from cathode
Ac
tua
l fo
cal
spo
t si
ze
Effective focalspot size
Figure 710. Line focus principle. As the size of the focal spot
decreases, the heating of the target concentrates into a smaller
area. Angling the target makes the effective focal spot size much
smaller than the actual focal spot size. This line focus principle
allows a large area for heating while keeping the effective focal
spot small. Decreasing the target angle causes a corresponding
decrease in effective focal spot size.
79. (C) Radial scars are complex sclerosing
lesions and are often indistinguishable from
carcinoma. They are not truly scars and are
sometimes unrelated to prior surgery or
trauma. Some possible cause of the radial scar
is localized inammatory reaction or chronic
ischemia with slow infection. The radial scar is
a benign condition, but can be associated with
premalignantatypical ductal hyperplasia
and malignant condition. A benign radial scar
has no central tumor, although there may be
long spicules radiating from the center of the
lesion. Regardless of the size of the spicules in
the benign radial scar, there is no associated
skin thickening, dimpling, or nipple reaction.
The benign radial scar often resolves over
time, but because of the possible association
with malignancy radial scars should be moni-
tored carefully. In this case the lesion was the
result of surgery. As shown in Figure 7-3b, the
lesion is resolving. A galactocele is a benign,
milk-lled cyst with a high fat content. These
lesions are generally associated with lactation.
They are usually circular, with sharply
dened borders, and have densities that are a
combination of radiolucent and radiopaque.
They are often left alone, but if painful they
can be drained using needle puncture. Often
they yield a yellow uid. Oil cysts are gener-
ally seen mammographically as eggshell-like
calcications. Hematomas are generally asso-
ciated with trauma. They are mixed density
oval or circular calcication (American Cancer
Society; Peart, 4763; Tabr, 1792, 93147; Tucker,
125129).
80. (B) The patients face should be turned away
from the side under examination, curving the
neck and head around the face shield. This
ensures that medial tissue can be pulled onto
the image receptor. This is important because
eliminating medial breast tissue from the CC
projection may eliminate this tissue from the
study (Andolina, 174245; Peart, 115145).
81. (A) Using clock face terminology there are
four main clock positions (12-oclock, 3-oclock,
6-oclock, and 9-oclock). In the XCCL and
the CC, the central rays are directed superi-
orly to inferiorly; therefore, 12-oclock and
6-oclock lesions will be superimposed. The
AT images the axilla and would miss any
6-oclock lesion. In the MLO, the beam is
directed medially to laterally separating the

upper aspect of the breast (12-oclock position)
from the lower aspect (6-oclock position)
(Peart, 115145).
82. (C) This represents the standard terminology
adopted by the ACR. The Cleopatra view is
an old term given to a projection similar to
the current AT. All projections in mammogra-
phy are compression or compressed projec-
tions (ACR, 24; Peart, 115145).
83. (D) Casting calcications are produced when
carcinoma in situ lls the ducts and their
branches. The shape of the cast is determined
by the uneven production of calcication and
the irregular necrosis of the cellular debris. The
contours of the cast are always irregular in den-
sity, width, and length and the cast is always
fragmented. A calcication is seen as branching
when it extends into adjacent ducts. Addition-
ally, the width of the ducts determines the
width of the castings. Eggshell-like and needle-
like, sharply outlined, or elongated branching
calcications are typically benign mammo-
graphically. Granulated sugar or crushed stone
calcications are called granular-type calcica-
tions and are mammographically malignant
(Peart, 4762; Tabr, 149238).
84. (B) From the nipple orice, a connecting
duct immediately widens into the lactiferous
sinus or ampulla. The ampulla is a pouch-
like structure that holds milk (when it is
being produced). These ducts branch into
smaller and smaller ducts until becoming a
lobule. The lobule is also called the terminal
ductal lobular unit (TDLU) and holds the
milk-producing elements of the breast (Peart,
3544).
85. (D) The nipple cannot always be imaged in
prole because some women will not have a
centrally located nipple. (It will either be in
the top half or bottom half of the breast.) In
such situations imaging the nipple in prole
will actually lose posterior breast tissue. Addi-
tional projections of the nipple area are only
necessary if the nipple looks like a lesion, the
woman has a nipple or retroareolar abnormal-
ity (such as nipple discharge or a lesion), for
Answers and Explanations: 78 through 89 161
proper measurement in preoperative localiza-
tions, or if the patient is male. Male patients
have rudimentary breast buds lying directly
behind the nipple. Only by placing the nipple
in prole will this area be visualized clearly
(Andolina, 246310; Peart, 115145).
86. (C) The AT projection best demonstrates the
axillary tail of the breast. The medial and sub-
areolar areas are not visualized on the AT pro-
jection. With the four quadrants terminology,
the breast can be described as the upper outer
quadrant, upper inner quadrant, lower outer
quadrant, and lower inner quadrant. The
exact locations within the quadrant are repre-
sented by viewing each breast separately as a
clock face. The upper outer quadrant, which
extends toward the axilla, is known as the
axillary tail, tail of the breast, or tail of Spence.
The LIQ describes the medial portion of the
breast (Andolina, 174245; Peart, 115145).
87. (C) In this case the patients chin was not ele-
vated for the MLO projection. Pressure on the
lm after the exposure causes plus-density arti-
facts. This is inconsistent with malposition of
the mirror, which would cause a rectangular-
shaped artifact in the center of the lm. The
other alternative, the patients shoulder, would
only be imaged if the entire axilla were also
imaged (Peart, 115145).
88. (B) A hematoma is associated with breast
trauma. Generally, the trauma results in a pool-
ing of blood, which can show mammographi-
cally a low-density radiopaque lesion. If the
hematoma calcies, it slowly becomes a mixed-
density oil cyst with the typical eggshell-like cal-
cications and then eventually a high-density
radiopaque lesion. Galactoceles are small, milk-
lled cysts with a high fat content associated
with lactation. Fibroadenomas are benign
tumors common in women at any age and the
intramammary lymph nodes can be found in
any quadrant of the breast and are not related
to injury (Andolina, 155173; Peart, 4762; Tabr,
1792).
89. (D) Patients have breast tissue ranging
from fatty to thicker, more glandular tissue.
162 7: Practice Test 2
Adequate penetration of the glandular tissue
depends on the kVp selection. In mammogra-
phy, the use of single emulsion lms with
single-backed screens is necessary to enhance
contrast, but results in a relatively higher
patient dose. Dose in mammography is kept
low because of the inherent soft tissue struc-
ture of the breast. Viewing conditions should
not determine the exposure selection, but the
target material determines the energy of the
x-ray beam produced (Peart, 6584).
90. (B) Generally, when the shoulders are not
relaxed or if the height of the image receptor is
too high, most of the axilla and shoulders will
fall into the compression area. The thick area
of the axilla and shoulder will cause the com-
pression paddle to stop at maximum without
adequate compression being applied to the
lower breast (nipple area) (Peart, 115145).
91. (C) Ultrasound does not image microcalci-
cations well. The TAN projection is useful in
assessing skin calcication and the spot com-
pression increases compression over a spe-
cic area to eliminate pseudomasses. Magni-
cation, however, magnies the area of
interest allowing the number, distribution,
and type of calcications to be clearly seen.
Magnication can be used with and without
spot compression (ACR, 5960; Peart, 147162).
92. (D) In this case the circular lucency in the cen-
ter suggests a port-a-cath. A pacemaker gener-
ally presents with high-density wiring. A
hematoma is generally associated with trauma.
They are mixed-density oval or circular calci-
cation. The patients chin would present as a
uniform area of low density (Peart, 4763).
93. (A) The rolled positions are helpful when
dense breast tissue is superimposed on a
lesion. The dense tissue is rolled off the lesion
(ACR, 67; Peart, 115145).
94. (D) The specimen must be imaged after
biopsy to ensure that the lesion was com-
pletely removed. In imaging the specimen, it
should be compressed and magnied to pre-
vent the appearance of pseudomasses and to
assess calcications. The specimen should
also be compared to the initial mammograms.
Imaging the specimen before the surgery is
completed will allow the surgeon to take an
additional biopsy specimen if indicated
(Andolina, 313330; Peart, 203220).
95. (C) The LMO is useful for patients with prior
chest surgery or patients with pacemakers,
which prevent compression to the medial
breast. The LMO is an inferolateral to supero-
medial projection. The x-ray tube is angled
approximately 125 degrees (Figure 7-11). The
image receptor is positioned at the medial
aspect of the breast and compression is applied
from the lateral aspect. AT images the tail of
the breast (tail of Spence); LM and ML are both
90-degrees lateral projections (Peart, 115145).
Figure 711. ( 2000 The American Registry of Radiologic Tech-
nologists.)
96. (B) The actual focal spot size is the area on
the anode target that is exposed to electrons
from the tube current. Because the target is
angled, the effective area of the target is
made much smaller than the actual area of
electron interactions. The effective target is
the area projected onto the patient and the
image receptor. The nominal focal spot size is
a measure of the effective focal spot size and
is the value used when identifying large or
small focal spots (Peart, 6584).

97. (D) Radiation and surgical treatment will
cause changes in the breast and can cause cal-
cium formation. Although the rate of recur-
rence after lumpectomy is relatively low,
magnication images are best to assess any
calcication at the tumor bed. These images
should be compared with radiographs taken
after surgery but before radiation treatment
(Peart, 203234).
98. (C) The ML is useful in determining whether
a lesion is medially or laterally located. If the
MLO projection is compared to the ML, a
medial lesion will move up from its position
on the MLO. A lateral lesion will move down
from its position on the MLO. A lesion that is
centrally located will show little or no move-
ment. The XCCL best images the lateral
breast from the CC position. The CV best
images the medial breast from the CC posi-
tion and the AT best images the tail of the
breast (Peart, 115145).
99. (D) Films should be processed promptly
because of latent image fading. If the time
between the creation of the latent image and
processing is 8 hours or more, the biggest
change will be in loss of lm speed. How-
ever, both density and contrast will also
decrease (ACR, 132; Peart, 87112).
100. (A) All three methods can be used to minimize
scattered radiation in general radiography. The
higher the kVp, the higher the level of scat-
tered radiation and reducing the thickness of
the part will allow a reduction in kVp, hence, a
reduction in scattered radiation. Scattered radi-
ation increases as the eld size increases; there-
fore, reducing the eld size will reduce the
amount of scattered radiation. Unfortunately,
reducing the eld size is not an option in mam-
mography. Mammography units have only
two available eld sizes, regardless of breast
size (Bushong, 117187, 327340).
101. (B) The MQSA was established on October 27,
1992, to establish minimum national standards
for mammography. Under the MQSA require-
ments, the FDA can authorize individual states
to certify mammography facilities, conduct
Answers and Explanations: 90 through 104 163
inspections, and enforce the MQSA quality
standards. After October 1994, the MQSA
required all legal providers of mammography
services to be accredited by an approved
accreditation body and certied by the FDA.
The FDA cannot ensure that all women have
access to a certied mammography facility
(Accreditation and Certication Overview).
102. (D) The MQSA nal regulations require facili-
ties to have a written and documented policy
of resolving consumer complaints. The facil-
ity may select its own format. Medical out-
come audit is required by MQSA to follow up
positive mammographic assessments and to
correlate pathology results with the radiolo-
gists ndings. Record keeping refers to the
section of MQSA standards dealing with the
maintenance of mammograms and reports in
a permanent le (for not less than 5 years, or
not less than 10 years if no additional mam-
mograms of the patient are performed at the
facility, or longer if required by state or local
laws). To satisfy the communication-of-results
section of the standards, all mammographic
facilities must send each patient a summary
of the report, written in lay terms, within
30 days of the mammographic examination.
If assessments are suspicious or highly suspi-
cious for malignancy, the facility should con-
tact the patient as soon as possible with the
results (Accreditation and Certication Overview).
103. (B) A harmartoma is a benign tumor. It is
considered self-limiting because the tumor
consists of an overgrowth of normal tissue
and the tumor cells do not reproduce. Breast
lesions associated with trauma and nursing
are hematoma and galactocele, respectively
(Tabr, 1792; Peart, 4762).
104. (B) Parturition is the process of giving birth.
In the immature breast, a two-layer epithe-
lium of cells lines the ducts and alveoli. After
puberty this epithelium proliferates, forming
three alveolar cell typessupercial (lumi-
nal) A cells, basal B cells (chief cells), and
myoepithelial cells forming the innermost
layer or basal surface of the epithelium. The
myoepithelial cells are arranged in a branching,
164 7: Practice Test 2
starlike fashion located around the alveoli
and excretory milk ducts. Contraction of the
myoepithelial cells helps to propel milk
toward the nipples. Beneath the epithelium is
connective tissue that helps to keep the
epithelium in place. Between the epithelium
and the connective tissue is a layer called the
basement membrane. The basement mem-
brane provides support and acts as a semi-
permeable lter under the epithelium (Peart,
3544; Tortora, 10831084).
105. (B) A benign nding means that although some-
thing was seen it is considered totally benign.
When using the BIRAD, the verbal identier
must be used to avoid confusion with the
MQSA assessment. The MQSA categories places
all mammographic ndings in categories similar
to the BIRAD system but is rarely used today.
BREAST IMAGING REPORTING AND DATA
SYSTEM (BIRAD)
BIRAD 0: Need additional imaging
information and/or prior
mammograms for comparison
BIRAD 1: Negative
BIRAD 2: Benign nding
BIRAD 3: Probably benign ndingshort-
108. (D) Noise on the mammogram is an undesir-
interval follow-up suggested
BIRAD 4: Suspicious abnormalitybiopsy
should be considered
BIRAD 5: Highly suggestive of
malignancyappropriate
action should be taken
BIRAD 6: Known biopsy proven
malignancyappropriate
action should be taken
(Accreditation and Certication Overview; Papp, 203;
Peart, 246).
106. (D) Erythema is a redness or inammation of
the skin. Although it can indicate inamma-
tory breast cancer, it can also be an indication
of breast abscess or other infectious changes.
Further evaluation and testing, including
mammography, would be necessary to deter-
mine the cause (Peart, 4762; Tabr, 1792).
109. (C) After puberty, the epithelium of the lob-
107. (C) Tamoxifen is a nonsteroidal antiestrogen
given to patients with breast cancer. It is
considered an antiestrogen drug because it
prevents estrogen from latching onto tumor
cell receptors and will shrink or stop the
recurrence of breast cancer. Tamoxifen will
also lower the risks of breast cancer recur-
rence in postmenopausal women. Tamoxifen
is considered a palliative treatment because it
will not cure the disease. The drug can cause
serious side effects including an increased
risk for endometrial cancer, uterine cancer,
pulmonary embolism, stroke, deep vein
thrombosis, blood clots, and increased
menopausal symptoms. Because of these
risks, tamoxifen should not be taken for more
than 5 years and there are now a number of
similar drugs on the market with less side
effects. Radiation therapy may be used to
destroy cancer cells remaining after surgery
or to reduce the size of a tumor before
surgery. Chemotherapy uses a combination
of drugs to kill undetected tumor cells that
may have migrated to other parts of the
body. Antibody therapy works by blocking
the effect of the protein HER-2important in
regulating the growth of breast cancer cells
(ACS, 116; Peart, 220234).
able uctuation in the optical density of the
image and will show on the radiographs sim-
ilar to snow on a monitor. The principal
cause of radiographic noise is scattered radia-
tion produced by Compton scattering, which
reduces contrast. Quantum mottles and lm
graininess also result in noise on the radiog-
raphy. Quantum mottle refers to the way x-rays
interact with the lm. If the image is pro-
duced with a few x-ray photons, the quan-
tum mottle will be higher than if the image is
produced with many x-ray photons. Film
graininess refers to the distribution in size
and space of the silver halide grains in the
emulsion and is a factor inherent in the image
receptor. This factor is not under the control of
the mammographer (Bushong, 272291; Peart,
6584).
ules proliferates, becoming multilayered and
forming three alveolar cell types, supercial

(luminal) A cells, basal B cells (chief cells),
and myoepithelial cells. The innermost layer
or basal surface of the epithelium consists of
myoepithelial cells. Beneath the epithelium is
connective tissue that helps to keep the
epithelium in place. Between the epithelium
and the connective tissue is a layer called the
basement membrane. The basement mem-
brane provides support and acts as a semiper-
meable lter under the epithelium (Peart,
3544; Tortora, 1083).
110. (C) The camels nose contour refers to the
sloping of the breast in the MLO projection
caused by insufcient compression. The
result is poor separation of the breast tissues.
Preventing camels nose involves pulling
the breast up and out and supporting it dur-
ing the initial stage of compression. The
mammographer should use one hand to
maintain support of the breast until enough
compression is in place to keep the breast in
position (Figure 7-12) (ACR, 3840).
Figure 712. Poor compression of the anterior breast in the MLO
projection results in drooping of the anterior breast camel nose.
Answers and Explanations: 105 through 113 165
111. (C) With the four quadrants terminology, the
breast can be described as UOQ, UIQ, LOQ,
and LIQ. The exact locations within the quad-
rant are represented by viewing each breast
separately as a clock face. The SIO best demon-
strates the UIQ and the LOQ of the breast, free
of superimposition. This projection can be used
to demonstrate these quadrants free of the
implant especially when using the implant-
displaced ID or Eklund compression techniques
(Figure 7-13) (Andolina, 174245; Peart, 115145).
Direction of x-rays
Image receptor
Figure 713. In the SIO position, the beam is directed from the
superior lateral aspect to the inferior medial aspect of the breast.
112. (D) The medical audit is used to check the
reliability of the mammographic image. The
interpreting physicians should evaluate all
mammographic results for clarity and accu-
racy at least once every 12 months. The med-
ical audit should also include any cases of
breast cancer found after a negative mam-
mography reading (Accreditation and Certica-
tion Overview: Medical Outcomes Audit Program).
113. (B) The MQSA requires facilities to maintain
records to the original mammograms and
report for a period of not less than 5 years
and not less than 10 years if no additional
mammograms of the patient are performed
166 7: Practice Test 2

at the facility. Some state and local laws may
require longer storage times. Facilities are also
allowed to permanently or temporarily trans-
fer a patients records to another medical
institution, physician, or health-care provider
if requested by the patient (Accreditation and
Certication Overview: Record Keeping).
high density, and have smooth borders. If
they are periductal, they have central lucencies.
Ductal ectasia involve the lactiferous ducts and
may or may not cause nipple discharge or
inversion. Both conditions are characterized by
the presence of plasma cells surrounding a
dilated duct (Peart, 3544; Tabr, 239243).

114. (B) Triangulation is used to determine the

location of a nonpalpable lesion seen mammo-
graphically. One of the purposes of triangula-
tion is to spot compress the lesion for
improved separation of breast tissue. Triangu-
lation is also used to determine the shortest
skin-to-abnormality distance for the purpose
of sterostatic biopsy. To determine the location
of the lesion relative to the nipple, the mammo-
grapher should measure (1) the distance from
the nipple to the level of the lesion posteriorly
on the CC or MLO projection, (2) from that 3
level to the lesion in the superior-to-inferior
(as on the MLO) or medial-to-lateral direction
(as on the CC), and (3) from the lesion to the 2
skin surface (Figure 7-14) (ACR, 56). Lesion

115. (D) Peau do range describes the skin of the 1

breast wherein the breast skin thickens and
resembles an orange. The condition occurs
secondary to obstruction of the axillary lym-
phatic and may be a result of either benign or
malignant conditions such as inammatory
carcinoma. Plasma cell mastitis or ductal
ectasia are both inammatory conditions.
Plasma cell mastitis calcications follow the
course of the ducts. Some may be elongated Figure 714. The triangulation technique is used to determine the
shortest skin-to-abnormality distance in the MLO and CC projec-
and branching, some needlelike, and some tions. 1 = distance from nipple to the level of the lesion posteriorly, 2 =
ringlike or oval, but all are sharply outlined, distance from level to lesion, 3 = distance from lesion to skin surface.

A Axillary node dissection, 86
ABBI. See advanced breast biopsy
instrumentation
Acoustic enhancement, 93, 101
ACR. See American College of
Radiology
ACS. See American Cancer Society
Adipose tissue, 47, 53, 60
Advanced breast biopsy
instrumentation (ABBI), 86
AEC. See automatic exposure
control
American Cancer Society (ACS),
breast examination
guidelines of, 1, 7,
1214, 120
American College of Radiology
(ACR), 22, 37, 79, 116, 132,
136, 151
Amorphous selenium, 21
Anatomy, of breast, 4764, 110, 125
Angiogenesis, 4
Areola, 47, 136, 151
Artifacts, image quality relating to,
2324, 66, 107, 122, 140, 155
AT. See axillary tail
Atypical hyperplasia, 2
Augmentation, of breasts,
4, 92, 98
Automatic exposure control
(AEC), 106, 107, 111,
120121, 126
instrumentation and quality
assurance relating to, 20,
27, 33
mammographic technique and
image evaluation relating
to, 66, 69, 70, 7576
Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Index
Axillary tail (AT), 2, 8182, 8889,
89f, 9697, 145, 161
B posttreatment options for, 5
Backup timer, 70, 76
Barrel chest and pectus carinatum,
82, 89, 97
Basement membrane, 147, 164
Beam, x-ray, 19, 26, 32, 33f, 114, 130
Beam restriction devices, 20, 27, 33
Benign breast lesions. See breast,
lesions of
Benign cancer, of breast. See breast
Beryllium, 19, 143, 159
Biopsy. See also ABBI
core, 4, 8586, 93, 99101, 101f
large, 86
FNB, 4, 85, 93, 99, 102
lymph node, 86
MIBB, 86
MR, 86
open surgical, 4, 86, 93, 102,
146, 162
radio frequency, 86
VACB, 86
BIRAD. See breast imaging
reporting and database
system
Blood supply, to breast, 47
Breast
anatomy of, 4764, 110, 125
augmentation of, 4, 92, 98
blood supply to, 47
camels nose, 148, 165, 165f
cancer of
diagnostic options for, 24
ductal carcinoma, 7, 12
intervention options for, 4
lobular carcinoma, 2, 7
malignant, 2, 6, 11, 4849, 55,
55f, 6162
radiographs of, 2
risk factors for, 12, 6, 11,
107108, 110, 121125
survival rate of, 9, 15, 15t
symptoms of, 12, 6, 11
treatment options for, 45
changes in, 1, 7, 8
compression of. See compression
disease of
benign, 2, 6
malignant, 2, 6, 11
Paget, 107, 122
drooping, 79
examination of, 1, 135, 149.
See also BSE, CBE
ACS guidelines for, 1, 7,
1214, 120
fatty tissue of, 47, 49, 52, 59, 105,
120, 141, 157
histology of, 47
implants for, imaging of, 8182,
83f84f, 92, 99, 106, 121,
137, 152
involution of, 113, 129
irradiated, 82, 92, 99
large or wide, 82
lobes of, 47, 52, 58
lymphatic drainage of, 47, 48f,
53, 59
male, 82, 116, 132, 137, 152
malignant conditions and
mammographic
appearances of, 48
167
168 Index
Breast (Cont.):
masses in, 61f
medial and lateral aspects of, 79,
8182, 8790, 9497
pathology of, 4764
physiology of, 4764
postsurgical, 82
quadrants of, 47, 52, 58, 58f, 81
reconstruction of, 45, 10, 16
scintigraphy of, 3
skin folds or wrinkling of, 8285
small, 8182, 103, 118, 140, 147,
155, 163
tissue composition of, 4748,
138, 153
tumor of, 4849, 54, 54f, 56,
6162, 93
veins of, 47, 53, 60
Breast, lesions of, 50f51f
benign
calcification, 49, 81, 136, 136f,
151
circular/oval, 49
skin thickening syndrome, 2,
6, 11, 4849
spiculated/stellate, 49
malignant
calcifications, 48, 55, 55f,
6162, 111, 111f, 126,
144, 161
circular/oval, 48
circumscribed, 2
skin thickening syndrome, 2,
6, 11, 4849
spiculated/stellate, 48,
55, 62
visualized with compression,
65, 68, 73
Breast imaging reporting and
database system (BIRAD),
25, 142, 147, 158, 164
Breast self-examination (BSE), 1,
78, 1214, 103, 118,
139140, 153, 155
Bremsstrahlung radiation, 70, 76
BSE. See breast self-examination
C 1, 78, 12, 103, 105, 113, 118,
C-arm. See contralateral arm
CAD. See computer-aided detector
Calcifications
of breast lesions
benign, 49, 81, 136, 136f, 151
malignant, 48, 55, 55f, 6162,
111, 111f, 126, 144, 161
casting-type, 2, 48
ductal, 2
granular-type, 48
mammogram relating to, 81,
8889, 96
powderlike, 48
teacup-shaped, 81, 89, 96
Camels nose breast, 148, 165, 165f
Cancer, of breast. See breast
Cannulation, of lactiferous duct,
85, 93, 101
Carcinoma
ductal. See ductal carcinoma.
inflammatory, 56, 6263
lobular. See lobular carcinoma.
Cassette-based digital systems, 21
Cassette-less digital systems, 21
Cassettes or image receptor, 3, 21,
27, 34, 116, 132
Casting-type calcifications, 2, 48
Caudocranial or FB projection,
8182, 89, 97, 112, 112f, 114,
126, 130, 139, 154
CBE. See clinical breast
examination
CC projection. See craniocaudal
CCD. See charge-coupled devices
Cell stage, 16t
Cells, epithelial, 115, 131
Central venous access devices
(CVAD), 63
Certification process, 2425
Characteristic curve, 19, 28, 3436,
37f, 104, 119, 119f, 138, 153
Charge-coupled devices (CCD), 21
Chemotherapy, 5, 7, 10, 12, 1516
Circular/oval breast lesions,
malignant and benign,
4849
Cleavage (CV), 81, 90, 90f, 97, 106,
121, 144, 161
Clinical breast examination (CBE),
120, 128, 137, 141, 152, 157
Coherent scattering, 70, 76
Collimation, image quality relating
to, 20, 66, 104, 119, 138, 153
Color Doppler ultrasound, 3
Compression, 24, 33, 52, 58
considerations of, 65, 67,
72, 143, 159
devices for, 1920
image quality relating to, 66
lesions visualized with,
65, 68, 73
levels of, 108, 122
manual, 67, 72
MLO relating to, 66, 79, 8182,
85, 116, 133
patient knowledge of, 68, 73
QC tests for, 23, 29, 39
radiation relating to, 65, 67,
7273
reasons for, 65
spot, 57, 57f, 64, 8182, 92, 9899,
111112, 126127
Compression paddle, 1920, 2627,
32, 34, 81, 85
Compton effect, 70, 76, 141, 157
Computed tomography (CT), 4
Computer-aided detector (CAD),
21
Contaminated developer, 111, 126
Contralateral arm (C-arm), 79, 87,
94
Contrast, image quality relating to,
66, 7071, 77, 77f, 78
Contrast digital mammography, 3
Contrast resolution, 139, 155
Control film crossover, 135,
149150, 150f
Conventional mammogram/
mammography, 2, 21, 28,
3436, 103, 118
Cooper ligaments, 47, 52, 5859,
109, 109f, 123124, 124f
Core biopsy, 4, 8586, 93, 99101,
101f
Craniocaudal (CC), 66, 105106,
110, 113, 120121, 124, 129,
137, 144, 152, 160
positioning and interventional
procedures relating to, 79,
80f, 8182, 85, 8788, 88f, 91,
9495, 98

CT. See computed tomography
CT laser mammography, 4
CV. See cleavage
CVAD. See central venous access
devices
Cyst, 141142, 156157
aspiration of, 4, 85, 93, 102
epidermoid, 49, 57, 57f, 64
oil, 49, 55, 55f, 62, 115, 130131
Cytological analysis, 92, 99
D Epithelial cells, 115, 131
Darkroom cleanliness, QC tests
for, 2223
Darkroom fog, QC tests for, 23,
2830, 38, 41
Deep inferior epigastric artery
perforator flap (DIEP), 5
Densitometer, 24
Depressed sternum. See pectus
excavatum
Developer temperature, 21, 110,
112, 125, 128, 128f
DIEP flap. See deep inferior
epigastric artery perforator
flap
Digital imaging, 23, 31, 44, 136,
150, 150f
Digital mammogram/
mammography, 2, 21, 28,
34, 35f
contrast, 3
Digital quality assurance, 24
Digital systems, 2122
cassette-based, 21
cassette-less, 21
Digital technology, 28, 34, 36f
Digital tomosynthesis, 4
Disease, of breast. See breast
Documentation and medical
history, 1, 8, 140, 156
Doppler ultrasound, color, 3
Drooping breast, 79
Ductal calcifications, 2
Ductal carcinoma, 7, 12
invasive or infiltrating, 2
in situ, 2
Ductal ectasia, 103, 115
Ductal lavage, 86
Ductal papilloma, 103, 118
Ductography, 4, 85, 93, 101, 109,
124, 143, 159
E 93, 99, 102
Eklund method, implants relating
to, 100f
Elderly patients, 82
Electrosurgical introducer, 86
Encapsulated implants, 81, 92, 98
Entrance skin exposure, 138, 152
Epidermoid cyst, 49, 57, 57f, 64
Epithelial hyperplasia, 142, 158
Erythema, 147, 164
ETD. See extralobular terminal
duct
Exaggerated craniocaudal (XCCL),
79, 82, 89, 96, 97, 105106,
107f, 120121
Exposure. See also AEC
image quality relating to, 66
log relative, 37f
radiation dose relating to, 1, 9,
1415, 65, 69, 7475
Extended processing, 21, 112, 128
Extralobular terminal duct (ETD),
53, 60, 60f
F
False-negative mammograms,
69, 75
Fat necrosis, 49, 56, 63
Fatty tissue, of breast, 47, 49, 52,
59, 105, 120, 141, 157
FB. See from below
FB or caudocranial projections,
8182, 89, 97, 112, 112f, 114,
126, 130, 139, 154
FDA. See Food and Drug
Administration
FDG. See fluorodeoxyglucose
Fibroadenolipoma, 49
Fibroadenoma, 49, 56, 56f, 64, 93,
100
Fibroglandular tissue, 47, 105, 113,
120, 128
Film, analyses of fixer retention in,
23
Film fog, 23, 28, 34
Filtration, 109, 123
Index 169
Fine needle aspiration (FNA), 4,
85, 92, 99, 101, 113, 128129
Fine needle biopsy (FNB), 4, 85,
Fixer retention in film, 23
Flap surgery
DIEP, 5
gluteal-free, 5
latissimus dorsi, 5
TRAM, 5
Fluorescent tube, 30, 4144
Fluorodeoxyglucose (FDG), 3
FNA. See fine needle aspiration
FNB. See fine needle biopsy
Focal spot size, 110, 114, 125, 130,
142143, 146, 157, 160, 160f,
162
mammographic technique and
image evaluation relating
to, 65, 69, 74
patient education and
assessment relating to, 20,
27, 34
Food and Drug Administration
(FDA), 4, 21, 24, 112, 116,
131, 147, 163
From below (FB), 8182
Frozen shoulder, patients with, 85
G
Galactocele, 49, 56, 62, 143, 159
Geiger counter, 4
Glandibular dose, 1, 143, 159
Glandular tissue, 47, 5354, 59, 61,
143, 159
Gluteal-free flap surgery, 5
Granular-type calcifications, 48
Grid ratio, 20, 140, 155
Grids
HTC, 20
mammography, 20, 27, 33,
110, 125
parallel, 114, 130
radiography, 20, 27, 33
use of, 114, 130
Gynecomastia, 108, 112, 123, 128
H
Halo sign, 49, 54, 61, 61f
Hamartomas, 56, 63, 147, 163
170 Index
Health Insurance Portability and
Accountability Act
(HIPAA), 25
Hemangiomas, 49
Hematoma, 49, 145, 161
Herceptin, 5
High-transmission cellular grid
(HTC), 20
HIPAA. See Health Insurance
Portability and
Accountability Act
Histology, of breast, 47
Hormone replacement therapy
(HRT), 2, 5, 54, 61, 107, 122,
141, 157
Hormones
synthetic, 4748, 5354, 6061
use of, 47, 104, 119, 135, 138,
149, 153
HRT. See hormone replacement
therapy
HTC. See high-transmission
cellular grid
Hyperplasia
atypical, 2
epithelial, 142, 158
Hypo estimator, 23, 141, 157
Hypo-retention test, 23, 116, 132
I chest, 82, 89, 97
ID projections. See implant
displaced projections
Image evaluation. See
mammographic technique
and image evaluation
Image quality
artifacts relating to, 2324, 66,
107, 122, 140, 155
collimation relating to, 20, 66,
104, 119, 138, 153
compression relating to, 66
contrast relating to, 66, 7071,
7778, 77f
exposure relating to, 66
labeling relating to, 66, 70, 72,
7779, 82
noise relating to, 66, 116, 132,
147, 164
overexposure relating to, 69, 75
positioning relating to, 66
sharpness relating to, 66, 70, 78
underexposure relating to, 66,
69, 75, 112, 127, 127f
unsharpness relating to, 65, 66,
7178, 137, 151
Image receptor (IR), 3, 21, 79, 85,
88, 95
cassettes or, 3, 21, 27, 34, 116, 132
Image viewing environment,
115, 131
Images, phantom, QC tests for. See
phantom images, QC tests
for
Imaging
components of
digital system, 2122
screen-film system, 21
digital, 23, 31, 44, 136, 150, 150f
of implants. See implants,
imaging of.
Miraluma, 3
of nonconforming patients
elderly, 82
irradiated breast, 82, 92, 99
kyphotic, 8182, 89, 96
large or wide breast, 82
male breast, 82, 116, 132,
137, 152
pectus carinatum and barrel
pectus excavatum, 82, 91, 98
postsurgical breast, 82
small breast, 8182, 103, 118,
140, 147, 155, 163
stretcher/cart, 82
wheelchair, 82
postlumpectomy, 82
ultrasound, 3, 10, 17
Imaging plate, 3, 21
IMF. See inframammary fold
Implant displaced (ID) projections,
8182, 110, 115, 125, 131
Implants
Eklund method relating to, 100f
encapsulated, 81, 92, 98
imaging of, 8182, 83f84f, 92,
99, 106, 121, 137, 152
ruptured, 142, 142f, 158
Inflammatory carcinoma, 56,
6263
Inframammary fold (IMF), 79,
8788, 9495, 109, 123
Infusa-port, 56, 63
Instrumentation and quality
assurance, 1946
Intensifying screen, 104, 113, 120,
129, 129f, 135, 149
Intracystic tumor, 93
Intraductal papilloma, 118
Intralobular terminal duct (ITD),
53, 60, 60f
Involution, of breast, 113, 129
IR. See image receptor
Irradiated breast, 82, 92, 99
ITD. See intralobular terminal duct
K
Keratosis, 136, 151
kVp (peak kilovoltage) range
of mammography units, 19, 26,
32, 108, 123
technique and image evaluation
relating to, 6566, 69, 7071,
75, 77, 78
Kyphotic patient, 8182, 89, 96
L
Labeling, image quality relating to,
66, 70, 72, 7779, 82
Lactation, 47, 53, 6061, 143, 159
Lactiferous duct, 4748, 48f
cannulation of, 85, 93, 101
Lactiferous sinus, 48f, 109, 109f,
124, 124f
Large core biopsy, 86
Lateromedial (LM), 8182, 85, 88,
90, 90f, 9697
Lateromedial oblique (LMO),
8182, 85, 90, 97, 139, 146,
154, 162
Latissimus dorsi flap surgery, 5
Lesions, of breast. See breast,
lesions of
Lesions visualized with
compression, 65, 68, 73
Lipoma, 49, 56, 62, 111, 126
LM. See lateromedial
LMO. See lateromedial oblique
Lobes, of breast, 47, 52, 58
Lobular carcinoma, 7

invasive, 2
in situ, 2
Lobules, 2, 47
Localization
needle, 79, 117, 133, 137, 152
preoperative, 4, 81, 85, 92, 99
stereostatic breast, 4, 85, 93, 102
Log relative exposure, 37f
Lumpectomy, 4, 9, 15, 86, 146, 163
Lymph node, 1, 49, 142, 157
biopsy of, 86
Lymphatic drainage, of breast, 47,
48f, 53, 59
Lymphedema, 11
Lymphoscintigraphy, 34
M design characteristics of,
Magnetic resonance imaging
(MRI), 3, 7, 10, 12, 1617
Magnetic resonance (MR) biopsy,
86
Magnification, 103, 105, 108, 110,
112, 118, 120, 122, 124, 127,
139, 154
disadvantage of, 65
mammographic technique and
image evaluation, 6566,
6869, 7374, 73f, 74f
positioning and interventional
procedures relating to, 81,
85, 91, 98
spot, 145, 162
Male breast, 82, 116, 132, 137, 152
Malignant asymmetric densities, 2
Malignant breast lesions. See
breast, lesions of
Malignant cancer, of breast, 2, 6,
11, 4849, 55, 55f, 6162
Malignant circumscribed lesions, 2
Mammogram/mammography
accuracy of, 104, 119
benefits and risks of, 1
calcifications relating to, 81,
8889, 96
conventional, 2, 21, 28, 3436,
103, 118
CT laser, 4
digital, 2, 21, 28, 34, 35f
contrast, 3
false-negative, 69, 75
filter used in, 66, 70, 76
grids relating to, 20, 27, 33, 110,
125
mortality reduction, 1, 111, 126
optical densities relating to, 66,
69, 75
radiation dose, exposure relating
to, 1, 9, 14, 15, 65, 69, 7475
screening, routine, 1
tube relating to, 19, 26, 32, 141,
156, 156f
units relating to
AEC, 20, 27, 33, 66, 69, 70,
7576, 106107, 111,
120121, 126
compression devices, 1920
1920
kVp range, 19, 26, 32, 108, 123
Mammographers, 143, 159
requirements of, 22, 24, 115, 131
Mammographic appearances, of
breast, 48
Mammographic technique and
image evaluation, 6578
AEC relating to, 66, 69, 70, 7576
breast compression, 65
focal spot size relating to, 65,
69, 74
kVp relating to, 6566, 69, 7071,
75, 7778
magnification, 6566, 6869,
7374, 73f, 74f, 103, 105,
118, 120
MLO relating to, 66
Mammography Quality Standards
Act (MQSA), 107, 109, 117,
121123, 133, 138, 147148,
153, 163, 165
labeling relating to, 66, 70, 72,
7779, 82
quality assurance relating to, 22,
2425, 29, 31, 3738
Mammoplasty, 116, 132
mAs (milliamperes), 19, 6566, 69,
7475
Mass
in breast, 61f
painless, 104, 119
palpable, 110, 125
Index 171
Mastectomy, 86
modified radical, 4
radical, 4
Medical audit, 25, 148, 165
Medical history and
documentation, 1, 8,
140, 156
Medication, for pain, 5
Mediolateral (ML) 90 degree, 114,
114f, 130, 143, 146, 158, 163
positioning and intervention
procedures relating to,
8182, 85, 8890, 9697
Mediolateral oblique (MLO)
projection, 106, 106f, 108,
112113, 115116, 121,
122123, 126, 129, 131, 133,
144, 145, 160, 162
mammographic technique and
image evaluation relating
to, 66
positioning and interventional
procedures relating to, 79,
8182, 85, 87, 8990, 9497
Menarche, 2, 47
Menopause, 2, 48
MIBB. See minimally invasive
breast biopsy
Milk lines, 59f
Minimally invasive breast biopsy
(MIBB), 86
Miraluma imaging, 3
ML. See mediolateral (ML)
90 degree
MLO. See mediolateral oblique
projection
Mobile v. fixed tissue, 88, 95
Modifications, to imaging. See
positioning and
interventional procedures
Modified radical mastectomy, 4
Molybdenum, 19, 70, 7576, 76f,
139, 153
Montgomery glands, 107, 112,
122, 128
Morgagni tubercles, 47, 52, 58
Morphine, 5
Mortality reduction,
mammography relating to,
1, 111, 126
172 Index
MQSA. See Mammography
Quality Standards Act
MR biopsy. See magnetic
resonance biopsy
MRI. See magnetic resonance
imaging
N 137, 152
Needle localization, 79, 117, 133,
137, 152
Nipple, 4748, 48f, 5253, 5859,
79, 87, 95
aspiration of, 86
markers for, 82
Nipple not in profile, 82, 106, 121,
145, 161
Noise, image quality relating to,
66, 116, 132, 147, 164
Nuclear medicine, 3
Nullipara/nulliparous, 54, 61
O 30, 3739, 37f, 39f, 41, 44
Obesity, postmenopausal, 2, 8, 14
Object-to-image receptor distance
(OID), 2021, 66, 69, 75, 78,
136, 142, 151, 157
OID. See object-to-image receptor
distance
Oil cyst, 49, 55, 55f, 62, 115,
130131
Open surgical biopsy, 4, 86, 93,
102, 146, 162
Overexposure, image quality
relating to, 69, 75
P procedures
Pacemaker, 81, 146, 146f, 162
PACS. See picture-achieving and
communication system
Paget disease, of breast, 107, 122
Pain medication, 5
Painless mass, 104, 119
Palpable mass, 110, 125
Papilloma, 49
ductal, 103, 118
intraductal, 118
Parallel grid, 114, 130
Parturition, 147, 163
Pathology, of breast, 4764
Patient. See also imaging
compression knowledge of,
68, 73
education and assessment of,
focal spot size relating to,
20, 27, 34
with frozen shoulder, 85
postmastectomy, 82, 92, 99,
with protruding abdomen, 85
with uneven breast thickness, 85
Peau dorange, 148, 166
Pectus carinatum and barrel chest,
82, 89, 97
Pectus excavatum, 82, 91, 98
PET. See positron emission
tomography
Phantom images, QC tests for, 107,
122, 136, 139, 140, 151, 151f,
154155
instrumentation and quality
assurance relating to, 23, 29,
Physiology, of breast, 4764
Picture-achieving and
communication system
(PACS), 2122
Piezoelectric effect, principle of, 3
Pigeon chest-prominent sternum.
See pectus carinatum and
barrel chest
Pneumocystography, 85
PNL. See posterior nipple line
Positioning, image quality relating
to, 66
Positioning and interventional
additional positions/projections
AT, 8182, 8889, 89f, 9697
caudocranial or FB, 8182, 89,
97, 112, 112f, 114, 126, 130,
139, 154
CV or valley view, 81, 90, 90f,
97, 106, 121, 144, 161
LM, 8182, 85, 88, 90, 90f,
9697
LMO, 8182, 85, 90, 97, 139,
146, 154, 162
ML, 8182, 85, 8890, 9697,
114, 114f, 130, 143, 146,
158, 163
SIO, 8182
TAN projection, 81, 8889,
9596, 104, 118119, 119f,
137, 152
XCCL, 79, 82, 89, 9697,
105106, 107f, 120121
modifications
breast implant imaging,
8182, 83f84f, 92, 99
magnification, 81, 85, 91, 98,
110, 112, 124, 127
RL or RM, 81, 90, 91f, 9798
RS or RI, 81
spot compression, 8182, 92,
9899
special situations
imaging nonconforming
patients, 8182, 89, 92,
9699
solving special problems,
8285
specimen radiography
core biopsy, 4, 8586, 93,
99100, 101, 101f
cyst aspiration, 4, 85,
93, 102
ductography, 4, 85, 93, 101,
109, 124, 143, 159
FNA, 4, 85, 92, 99, 101, 113,
128129
FNB, 4, 85, 93, 99, 102
large core biopsy, 86
lymph node biopsy, 86
MR biopsy, 86
nipple aspiration, 86
open surgical biopsy, 4, 86, 93,
102, 146, 162
pneumocystography, 85
preoperative needle
localization, 4, 81, 85,
92, 99
radio frequency biopsy, 86
stereostatic localization, 4, 85,
93, 102
ultrasound, 8586, 93, 100101
standard projections
CC, 66, 79, 80f, 8182, 85,
8788, 88f, 91, 9495, 98,
105106, 110, 113, 120, 121,
124, 129, 137, 144, 152, 160

MLO, 66, 79, 8182, 87, 89, 90,
9497, 106, 106f, 108,
112113, 115116, 121123,
126, 129, 131, 133, 144, 145,
160, 162
Positron emission tomography
(PET), 3, 140, 155
Posterior nipple line (PNL), 87,
94, 94f
Postlumpectomy imaging, 82
Postmastectomy patient, 82, 92, 99,
137, 152
Postmenopausal obesity, 2,
8, 14
Postsurgical breast, 82
Posttreatment options, for breast
cancer, 5
Powderlike calcifications, 48
Preoperative needle localization, 4,
81, 85, 92, 99
Processors, 21, 28, 34
quality control of, QC tests for,
23, 30, 41, 42f, 43f, 103, 108,
118, 123
Projections. See implant displaced
projections; positioning and
interventional procedures
Prominent ribs and sternum. See
pectus carinatum and barrel
chest
Protruding abdomen, patients
with, 85
Q 139, 149, 154
QC tests. See quality assurance
Quadrants, of breast, 47, 52, 58,
58f, 81
Quality assurance. See also
Mammography Quality
Standards Act
digital, 24
instrumentation and, 1946
QC tests
for analyses of fixer retention
in film, 23
for compression, 23, 29, 39
for darkroom cleanliness,
2223
for darkroom fog, 23, 2830,
38, 41
for phantom images, 23,
2930, 3739, 37f, 39f, 41, 44,
107, 122, 136, 139, 140, 151,
151f, 154155
for processor quality control,
23, 30, 41, 42f, 43f, 103, 108,
118, 123
for reject/repeat analysis, 23,
30, 3941, 40f, 115, 130,
139140, 154, 155
for screen cleanliness, 23, 29,
37, 38
for screen/film contact and
identification, 23, 29, 39, 39f,
110, 125
for visual checklist, 23, 28, 31,
37, 44
radiologist relating to, 22
Quality control (QC) tests. See
quality assurance
Quantum mottle, 66, 137, 152
R RLMO. See right lateromedial
Radial scar, 49, 55, 62, 105, 105f,
120, 144, 144f, 160
Radiation
bremsstrahlung, 70, 76
compression relating to, 65, 67,
7273
dose of, exposure relating to, 1,
9, 1415, 65, 69, 7475
scattered, 20, 65, 109, 124
Radiation therapy, 4, 9, 15, 82, 135,
Radical mastectomy, 4
Radio frequency biopsy, 86
Radiographs, of breast cancer,
2 RS. See rolled superior
Radiography. See positioning
and interventional
procedures
Radiography grid, 20, 27,
33
Radiologist, 22
Radiopaque tumor, 49, 56, 62
Raloxifene, 5
Receptor. See image receptor
Reciprocity law, 65
Reconstruction, of breast, 45,
10, 16
Index 173
Reject/repeat analysis, QC tests
for, 23, 30, 3941, 40f, 115,
130, 139, 140, 154155
Repeat/reject analysis, QC tests
for, 23, 30, 3941, 40f, 115,
130, 139, 140, 154155
Resolution
contrast, 139, 155
spatial, 21, 67, 72
Retromammary space, 47, 104, 120,
141, 156
Rhodium, 19, 70, 7576,
108, 122
RI. See rolled inferior
Right lateromedial oblique
(RLMO), 88, 95
Right mediolateral oblique
(RMLO), 88, 95
Risk factors, associated with breast
cancer, 12, 6, 11, 107108,
110, 121, 123125
RL. See rolled lateral
oblique
RM. See rolled medial
RMLO. See right mediolateral
oblique
Rolled inferior (RI), 81
Rolled lateral (RL), 81, 90, 91f,
9798
Rolled medial (RM), 81, 9091, 91f,
9798, 108, 113, 123, 129,
137, 152
Rolled projections, 81, 146, 162
Rolled superior (RS), 81, 91, 98
Routine mammography
screening, 1
Ruptured implant, 142, 142f, 158
S
SAC. See States as Certifiers
Scar, radial, 49, 55, 62, 105, 105f,
120, 144, 144f, 160
Scar tissue, 86, 88, 95
Scattered radiation, 20, 65,
109, 124
Scattering, coherent, 70, 76
Scintigraphy, of breast, 3
Scintillator, 21
174 Index
Screen
cleanliness of, QC tests for, 23,
29, 37, 38
intensifying, 104, 113, 120, 129,
129f, 135, 149
Screen/film contact and
identification, QC tests for,
23, 29, 39, 39f, 110, 125
Screen-film system, 21
Selective estrogen receptor
modulators (SERMs), 5, 14
Sensitometer, 23, 2930, 38, 38f, 41,
138, 142, 153, 158
Sentinel node mapping, 34
SERMs. See selective estrogen
receptor modulators
Sharpness, image quality relating
to, 66, 70, 78
SID. See source-to-image receptor
distance
SIO. See superior-inferior oblique
projection
Skin folds or wrinkling, of breast,
8285
Skin thickening syndrome, 2, 6, 11,
4849
Small breast, 8182, 103, 118, 140,
147, 155, 163
SMPTE tests, 24
SOD. See source-to-object distance
Soft copy viewer, 44f
Source-to-image receptor device
(SID), 2021, 66, 68, 74, 78,
143, 159
Source-to-object distance (SOD),
69, 74
Spatial resolution, 21, 67, 72
Spatula, 82, 103, 118
Specimen radiography. See
positioning and
interventional procedures
Spiculated/stellate breast lesions
benign, 49
malignant, 48, 55, 62
Spot compression, 57, 57f, 64, 111,
112, 126127
positioning and interventional
procedures relating to,
8182, 92, 9899
Spot magnification, 145, 162
States as Certifiers (SAC), 24
Stereostatic localization, 4, 85, 93,
102
Stretcher/cart, patient in, 82
Superior-inferior oblique (SIO)
projection, 8182, 116, 132,
148, 165, 165f
Surgery. See flap surgery
Surgical reconstruction, 5
Survival rate, of breast cancer, 9,
15, 15t
Synthetic hormones, 4748, 53, 54,
60, 61
System geometry, 2021, 28, 34
T Ultrasound imaging, 3, 10, 17
Tail of Spence, 52, 59
Tamoxifen, 5, 9, 1415, 147, 164
TAN. See tangential projection
Tangential (TAN) projection, 81,
8889, 9596, 104, 118119,
119f, 137, 152
TDLUs. See terminal duct lobular
units
Teacup-shaped calcification, 49, 81,
89, 96
Technetium, 3
Terminal duct lobular units
(TDLUs), 48, 5253, 5860,
60f
TFD. See thin-film diodes
TFT. See thin-film transistors
Thin-film diodes (TFD), 21
Thin-film transistors (TFT), 21
Tissue
adipose, 47, 53, 60
composition of, 4748, 138, 153
fatty, 47, 49, 52, 59, 105, 120, 141,
157
fibroglandular, 47, 105, 113, 120,
128
glandular, 47, 5354, 59, 61, 143,
159
mobile v. fixed, 88, 95
scar, 86, 88, 95
TRAM flap. See transverse rectus
abdominus muscle flap
Transverse rectus abdominus
muscle flap (TRAM), 5, 9,
14
Triangulation techniques, 85, 148,
166, 166f
Tubes
angle of, 79, 82, 85, 88, 95
fluorescent, 30, 4144
mammography, 19, 26, 32, 141,
156, 156f
Tumors, of breast, 48, 54, 54f, 61
intracystic, 93
radiopaque, 49, 56, 62
Tungsten, 19
U
Ultrasound, 85, 86, 93, 100101
color Doppler, 3
Undercompression, 103, 118
Underexposure, image quality
relating to, 66, 69, 75, 112,
127, 127f
Uneven breast thickness, patients
with, 85
Unsharpness, image quality
relating to, 6566, 71, 78,
137, 151
UOQ. See upper outer quadrant
Upper outer quadrant (UOQ), 112,
127
V
VACB. See vacuum-assisted core
biopsy
Vacuum-assisted core biopsy
(VACB), 86
Valley view, 81
Veins, of breast, 47, 53, 60
Visual checklist, QC tests for, 23,
28, 31, 37, 44
W
Wheelchair, patient in, 82
Wide or large breast, 82
X
X-ray beam, 19, 26, 32, 33f,
114, 130
X-ray photons, 135, 149
XCCL. See exaggerated
craniocaudal
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