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215 Cards in this Set

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What is the reasoning behind performing a mammogram after lumpectomy, but before radiation therapy?
A. Reestablish baseline
B. Make sure calcification resected
C. Make sure mass is resected
D. To aid in selection of a radiation port
According to Cardenosa, a post-lumpectomy pre-irradiation mammogram should be obtained in patients who had calcifications in the cancer prior to lumpectomy to confirm that all calcifications have been removed surgically prior to beginning radiation therapy. If it has not been completely removed, then these patients benefit from re-excision prior to radiation therapy. Radiation therapy is intended to control microscopic disease, not to treat macroscopic disease. Any mass seen mammographically prior to lumpectomy would be obscured by post-surgical changes. The mammogram is unrelated to radiation port selection. After surgery, the post-surgical changes and scar will retract over months to years, so the immediate post-operative mammographic appearance of the breast will change with time and does not represent a baseline appearance.
Answer: B
Source: Breast Imaging: The Core Curriculum p. 325.
What causes the mammographic appearance of inflammatory carcinoma? a. Local dermal invasion by tumor cells. b. inflammatory cells within the breast c. obstruction of dermal lymphatics by tumor cells
C. Obstruction of dermal lymphatics by tumor cells
Thickened skin invariably accompanies inflammatory carcinoma, a highly aggressive manifestation of breast cancer with poor prognosis, in which tumor is found permeating the dermal lymphatics. By itself, however, the thickened skin is a nonspecific finding, and the diagnosis of inflammatory carcinoma is based on the clinical findings with erythema and increased skin temperature over 1/3 of the breast surface. Get peau d’orange appearance. Radiographically, have nonspecific skin thickening . The overall trabecular pattern of the breast appears thickened due to congestion in the intramammary lymphatics. On occasion, the underlying tumor mass that is not detectable on clinical examination, is visible mammographically. (Kopan’s page 341); Bassett p. 466.
Tubular CA most likely to show on mammography as: a.  Punctate microcalcs b.  Pleomorphic microcalcs c.  Circumscribed/well-defined mass d.  Spiculated mass
D. Spiculated mass
Tubular carcinoma (< 5% of all invasive breast CA):= well-differentiated form of ductal ca.assoc. with LCIS in 40%nonpalpablesee: high opacity nodule with spiculated margins < 17 mm diam.DDX: radial scar source Dähnert 4th p 460; Bassett p. 490.
1 cm, well defined, circumscribed, non-palpable mass, what is chance of malignancy?
a) <2%
b) 5%
c) 10%
d) 50%
e) 90%
A. < 2%
The likelihood of malignancy for probably benign lesions as reported by Sickles is low: 1.4% for solid, circumscribed masses 0.6% for focal asymmetric density 0.4% for localized microcalcifications 0.3% for multiple solid circumscribed masses see Cardenosa Breast Imaging Companion 2nd p. 151.** Dähnert 5th is contradictory: says 4% on p. 538, 2% in a Table on p. 551. Given this, ≤ 2% as specified by Cardeñosa is probably the best choice.
Which is highest grade DCIS?
a) comedo
b) medullary
c) micropapillary
d) mucinous
A. Comedo
The most aggressive subtype of ductal carcinoma is comedo Ref: Dänhert pg 458
Microcalcifications seen on CC not on MLO could be because all except
 Milk of calcium
 Increased noise
 Artifact
 Dermal calcifications
a. Milk of calcium –probably false
 Bassett p 433: on horizontal beam films [ML], milk of calcium is linear or crescent-shaped; whereas on vertical beam [CC], the calcification is rounded OR not visible [so they would show on ML/MLO not on CC- which is opposite the way it was recalled]
 Increased noise P 81 Noise, or radiographic mottle compromises the ability to discern small details, such as calcifications.
 Artifact p.83 shows fingerprints on screen mistaken for microcalcifications
 Dermal calc p.402 Depending on their location, dermal calcs may be projected peripherally on one or more views or they may appear to be in the parenchyma
 Milk of calcium
A 1 cm lesion in the superior aspect of MLO is not seen on CC and moves up on ML view. Where is it?
 upper inner
 upper outer
 lower inner
 lower outer
A 1 cm lesion in the superior aspect of MLO is not seen on CC and moves up on ML view. Where is it?
 upper inner
 upper outer
 lower inner
 lower outer
medial upper (A)
 Muffins Rise –medial lesions
 Lead Falls- lateral lesions
Lesion at 9:00 in right breast. Where do you insert needle for biopsy
 Lateral
 Superior
 Inferior
 Medial
Lesion at 9:00 in right breast. Where do you insert needle for biopsy
 Lateral
 Superior
 Inferior
 Medial
lateral
 For stereotactic, no reference found.
For U/S-guided, “by the shortest route with the needle parallel to the chest wall.” also shows need for “sufficient breast tissue to accommodate the throw of the needle” on the side opposite of insertion, i.e. on the other side of the lesion. p.286 bassett
So, I think lateral in this case
MQSA requirements
 Report with 30 days
 Follow positives
 Complaint management
 15 hours CME for physicians
 Physicist comes once a month
MQSA requirements
 Report with 30 days
 Follow positives
 Complaint management
 15 hours CME for physicians
 Physicist comes once a month

 True- p.104 report to pt’s health care provider within 30 days
 True p.104 “rules specify that each facility estab & maintain a mammo medical outcomes audit program to f/u positive mammos & correlate path”
 True p.105 – facility must have a written system for collecting & resolving consumer complaints
 ?true – p.89 initial qualification: 60 hrs CME in mammo [at least 15 in recent 3 yrs]; Continuing: 15 hrs/36 mo. At least 6 in ea modality used
 According to MQSA, physicist is required to survey the site once a year. I couldn’t finding anything in the guidelines that specifically addressed film sizes. The remainder of the choices are true.
Breast cyst
 Increased signal on T2
 Increased signal on T1
 Gd enhances
Breast cyst
 Increased signal on T2
 Increased signal on T1
 Gd enhances
• Increased on T2 p.238
 high signal intensity on T2
 .
 False- no enhancement on T1 post contrast
Breast saline implants rupture
 Mammo has to be extracapsular
 MRI needed for intracapsular rupture
 Pt’s asymptomatic
 Mammo shows collapsed capsule
Breast saline implants rupture
 Mammo has to be extracapsular
 MRI needed for intracapsular rupture
 Pt’s asymptomatic
 Mammo shows collapsed capsule
.
 F-Would be true for Silicone implant, but question says saline
 Ditto [MRI most accurate; U/S works]
 “Rupture of a saline implant is clinically obvious, because the implant deflates immediately. The saline is absorbed by the body…” so, ??? That’s probably technically a ‘symptom’
 True “saline is absorbed by the body, so that by the time a woman undergoes imaging only a collapsed outer membrane is visible on mammo.” [true if capsule & membrane are interchangeable OR if incorrectly recalled] …Also, mammo may show extracapsular silicone rupture
p.605 Bassett
Following breast biopsy…which is true
 Skin thickening may be present for years
 Mass at 2 years, indistinct is suspicious for CA
 Sutures commonly calcify
 scar associated with increased chance of malignancy
Following breast biopsy…which is true
 Skin thickening may be present for years
 Mass at 2 years, indistinct is suspicious for CA
 Sutures commonly calcify
 scar associated with increased chance of malignancy

 True
p.527 variety of causes of skin thickening: SVC obstruction, pemphigus, nephrotic syndrome, CHF, lymphoma, post-irradiation, inflam/inflam carcinoma.
p.409 most post-surgical or post-trauma skin scars are mammographically invisible OR manifest as localized skin thickening w/ or w/o retraction. [no time frame given]
 Mass @ 2 yrs susp for ca: ? True p.283 in a small percentage of pts, a small focal density may be seen on mammo 6 months or more after stereotactic bx w/ the 11-ga VAD…thought to represent post bx scar. [2 yrs is much more than 6 mo.]
 ? False? Only reference is regarding reduction mammoplasty not bx. P.618 suture material used in reduc. may calcify leading to small ring-like calcs.. Small knots occasionally
US guided Core biopsy of breast lesion
 Cheaper than stereotactic
 18 gauge needle usually used
 Not useful for superficial lesions
 Need specimen radiograph
 Post procedure mammogram is necessary to ensure successful biopsy
 It cannot be performed with a vacuum assisted device
 referring to U/S then Yes, it’s cheaper than stereotactic.
 F 14-ga automated push-button OR 11-ga vacuum-assisted needle [B&H p518]
 ? No reference found-so ? False. except if actually referring to skin lesions/calcs which may be true.
 ? T –p.288 Bassett “specimen radiography is often performed to confirm the presence of a lesion if it has been seen on mammo.”
Where should localization wire tip be relative to breast lesion?
 Within lesion
 1 to 1.5 cm past
 3 cm past
 Just before
Where should localization wire tip be relative to breast lesion?
 Within lesion
 1 to 1.5 cm past
 3 cm past
 Just before
b.

p.265 Bassett
“The goal is to have the hook approximately 1 cm beyond the lesion.”
Excisional biopsy with sclerosing adenosis and LCIS
 F/U at 1 year.
 Bilateral mastectomies
 Right-side mastectomy
 Lumpectomy and radiation
 6 month mammography
Excisional biopsy with sclerosing adenosis and LCIS
 F/U at 1 year.
 Bilateral mastectomies
 Right-side mastectomy
 Lumpectomy and radiation
 6 month mammography
a. Should be correct
 Sclerosing adenosis is benign. Imaging can mimic cancer, in which case it’s a histologic diagnosis, not an imaging diagnosis. p.439
 LCIS is a marker., not malignant or pre-malignant

 Source: Kopans, p. 548-551, p. 593.
Contraindication to conservative mastectomy
Which of the following is a contraindication to breast conservation therapy?
 A. Prior radiation
 B. Positive margins after lumpectomy
 C. Multifocal tumors
 D. Mass greater than 3 cm
 E. Positive palpable axillary nodes
A. Need to be able to radiate
 Breast conservation therapy involves wide local excision with axillary lymph node dissection and radiation therapy. The goal is to excise the cancer, treat the microscopic disease, and achieve an acceptable cosmetic result. The alternative is total mastectomy. In the proper clinical setting, breast conservation therapy has the same efficacy as total mastectomy. Prior radiation is an absolute contraindication to breast conservation therapy because additional radiation cannot be administered to the breast and local excision without radiation therapy is less effective than total mastectomy. Prior radiation to the breast may have been from either prior breast conservation therapy for breast cancer, or mantle therapy for Hodgkin’s disease or radiation therapy for lung cancer. Positive margins after lumpectomy may under go repeat excision and still be successful. Multifocal tumors may be successfully treated with breast conservation therapy if the tumors are close together, otherwise the cosmetic result may be unacceptable and total mastectomy may be a better choice. A mass greater than 3 cm may be treated with breast conservation therapy, up to 5cm traditionally, but even larger masses may be acceptably removed from large breasts. Positive palpable lymph nodes which are mobile and not fixed or matted are not a contraindication to breast conservation therapy.
 Answer: A
 Source: Diagnosis of Diseases of the Breast, Bassett et al. pp. 548-549.
Which of the following are characteristics of malignancy with dynamic breast MRI imaging?
 A. Enhances more slowly than glandular tissue
 B. Early washout
 C. Increasing enhancement with delayed images
 D. Early enhancement.
Early washout.
 Dynamic breast MR imaging is performed using gradient echo (fast) imaging techniques after administration of gadolinium. The pattern of enhancement is observed with studies showing the rapid uptake, early plateau, and early washout of contrast are signs of malignancy and slower progressive later enhancement are signs of benignancy. The most predictive sign of malignancy with dynamic breast MR imaging is early washout of contrast. Slow enhancement and increasing enhancement on delayed images are signs of benignancy, and early enhancement alone can be seen in both benign and malignant lesions.
 Answer: B
 Source: Orel SG, Schnall MD. MR Imaging of the Breast for Detection, Diagnosis, and Staging of Breast Cancer. Radiology 2001; 220:13-30
Motion artifact of the breast most likely to be seen on the:
 A. CC view medially
 B. CC view laterally
 C. CC view centrally
 D. MLO superiorly
 E. MLO inferiorly
 Breast tissue in the lateral and inferior quadrants of the breast is mobile and tissue in the upper and medial aspects is less mobile. Motion artifact, or motion unsharpness, is due to inadequate compression of the breast tissue. The inadequate compression is going to be a problem at the mobile edges of the breast and not at the fixed margins of the breast. Inferior margin of the breast on the MLO view will be the most mobile and most susceptible to inadequate compression with poor positioning technique on the part of the technologist.
 Answer: E
 Source: Diagnosis of Diseases of the Breast, Bassett et al. pp. 49-50.
A patient has a negative mammogram. 9 months later the patient has a palpable mass. The lesion is removed and is positive for intraductal carcinoma. The negative mammogram was:
 A. False positive
 B. False negative
 C. True positive
 D. True negative
B. False negative
 A false negative screening mammogram is defined in Dahnert’s as a pathologic diagnosis of breast cancer within 1 year after a negative mammogram with the following three types of misses. The lesion could not be seen in retrospect (25-33%). This is an “acute cancer” – cancer surfacing in the screening interval. The cancer was undetected by the first reader but correctly identified by a second reader (14%). Finally, the lesion was visible in retrospect on prior mammogram (61%). Mammographically missed cancers can be due to a large number of reasons, including technically inadequate films, failure to image region, observer error, benign appearance to a malignant lesion, and tumor biology (small size, failure to incite desmoplastic reaction or lack of calcifications). Malignant calcifications may not change for up to 63 months and a malignant mass may not change in size for up to 4.5 years.
 Answer: B
 Source: Dahnert’s Radiology Review Manual pp. 554-555.
What is the reasoning behind performing a mammogram after lumpectomy, but before radiation therapy?
 A. Reestablish baseline
 B. Make sure calcification resected
 C. Make sure mass is resected
 D. To aid in selection of a radiation port
According to Cardenosa, a post-lumpectomy pre-irradiation mammogram should be obtained in patients who had calcifications in the cancer prior to lumpectomy to confirm that all calcifications have been removed surgically prior to beginning radiation therapy. If it has not been completely removed, then these patients benefit from re-excision prior to radiation therapy. Radiation therapy is intended to control microscopic disease, not to treat macroscopic disease. Any mass seen mammographically prior to lumpectomy would be obscured by post-surgical changes. The mammogram is unrelated to radiation port selection. After surgery, the post-surgical changes and scar will retract over months to years, so the immediate post-operative mammographic appearance of the breast will change with time and does not represent a baseline appearance.
 Answer: B
 Source: Breast Imaging: The Core Curriculum p. 325.
 A woman is having her 1st screening mammogram, which shows a well-circumscribed ~2 cm lesion in the right breast. Spot compression views confirm that the lesion is well-marginated, and US can show no abnormality. Most appropriate follow-up?
a. BIRADS 0 (more imaging)
b. BIRADS 1
c. BIRADS 2
d. BIRADS 3 (6-month followup)
e. BIRADS 4 (surgical evaluation/biopsy)
I think birad 3, most well marginated benign.
E. BIRADS 4
 Discordant diagnostic work-up means the lesion needs to be biopsied, probably with needle loc in this case.
 The MLO view is not good for visualization of which part of the breast?
a. Lower
b. Inner
c. Upper
d. Outer
 B. Inner
 “On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 50.** repeat from ’01. Note that the ’03 version phrased it as “lower/inner/upper/outer”, not “upper inner, lower inner, etc.” as has been seen in some other years. **
Which H&D curve is most approprate for mammography?
E. The curve with the narrowest latitude
H & D curve: another term for characteristic curve for a film. The letters stand for Hurter and Driffield who investigated these characteristics and published a paper on such curves in 1890. A curve used to show the exposure properties of a film screen system. How the exposure of the film is related to the measurable signal (film blackening or density). Different for different film types. See figure provided. The shape tells the user the contrast properties (slope) and the useful exposure range (length of linear part) indicate the speed of the film which can be judged from the curve’s position along the horizontal axis. “Mammographic screen-film has higher resolution and higher film contrast than conventional radiographic screen-film, but also has less exposure latitude, which can be a problem when imaging thick, dense breasts”. Bushberg 2nd p. 214. ** repeat from ’99 **
Which of the following represents the best pre-fire position for a core needle biopsy?
A. diagram is nearly a perfect representation.1999 exam asked for “best position for FNA”
A 2 cm cluster of microcalcifications is seen on mammography. A stereotactic needle biopsy is performed. Calcifications are seen on radiographs of the core samples. The pathology report comes back as fibroadenoma and no calcifications were apparently seen on pathologic examination. The next appropriate step is
a. Excisional biopsy b. Repeat core biopsy c. 6 month follow up mammogram d. polarized light microscopy e. return to annual screening mammograms
In some cases, the initial histologic sections of breast specimens containing radiographic calcifications fail to reveal microscopic calcifications, even when the specimen radiograph clearly indicated that the calcifications are contained within the specimen. There are several possible explanations for this. First, the calcifications may be composed of calcium oxalate rather than the usual calcium phosphate. Both types of calcium deposits produce the mammographic appearance of microcalcifications but appear different histologically. The basophilic nature of calcium phosphate deposits is well known and easily recognized by pathologists. In contrast, calcium oxalate deposits, on hematoxylin-eosin sections, are pale and refractile and may be difficult to identify using routine microscopy. Examination of such specimens under polarized light, however, readily demonstrates this type of calcification. If, after examination under polarized light, there is still no microscopic evidence of calcifications, other possibilities must be considered. For example, the paraffin blocks may not have been cut deeply enough to provide histologic sections that demonstrate the calcifications. To investigate this possibility, the blocks may themselves be radiographed-, any blocks containing radiographic calcifications should be cut more deeply until the calcifications are microscopically identified. Finally, in some cases, larger calcifications may shatter out of the block during sectioning and will, therefore, not be demonstrable on histologic sections.
[I think this is from Kopans. Can’t remember.]
 A 2 cm cluster of microcalcifications is seen on mammography. A stereotactic needle biopsy is performed. Calcifications are seen on radiographs of the core samples. The pathology report comes back as fibroadenoma and no calcifications were apparently seen on pathologic examination. The next appropriate step is
 a. Excisional biopsy
b. Repeat core biopsy
c. 6 month follow up mammogram
d. polarized light microscopy
e. return to annual screening mammograms
D. Polarized light microscopy
 In some cases, the initial histologic sections of breast specimens containing radiographic calcifications fail to reveal microscopic calcifications, even when the specimen radiograph clearly indicated that the calcifications are contained within the specimen. There are several possible explanations for this. First, the calcifications may be composed of calcium oxalate rather than the usual calcium phosphate. Both types of calcium deposits produce the mammographic appearance of microcalcifications but appear different histologically. The basophilic nature of calcium phosphate deposits is well known and easily recognized by pathologists. In contrast, calcium oxalate deposits, on hematoxylin-eosin sections, are pale and refractile and may be difficult to identify using routine microscopy. Examination of such specimens under polarized light, however, readily demonstrates this type of calcification. If, after examination under polarized light, there is still no microscopic evidence of calcifications, other possibilities must be considered. For example, the paraffin blocks may not
 Regarding the mammographic appearance of reduction mammoplasty (multiple true/false):
1. Subareolar ducts may be disrupted
2. Superior skin thickening
3. The nipple may be moved inferiorly
4. Fibroglandular tissue may be moved inferiorly
5. Dystrophic calcifications
 1. True. subareolar ducts may be disrupted, particularly by a “transplantation type” of reduction mammoplasty.
 2. False. skin thickening is most commonly seen in the areolar region and the inferior aspect of the breast, in the areas of surgical anastamosis.
 3. False. the nipple moves superiorly, because there is less skin above the nipple and more below the nipple than in normal breasts. Bassett p. 583.
 4. True. Glandular tissue, which is normally most prominent in the upper-outer quadrant, moves inferiorly in the breast after reduction mammoplasty Source: Kopans, Breast Imaging 2nd p. 460-62; Bassett p. 583
 5. True. the most common findings are oil cysts, often with spherical lucent centered, eggshell, or dystrophic calcifications.
 70 yr. old woman not on HRT presents with bilateral extremely dense breasts. No masses or calcifications can be seen. Most likely cause:
a. inflammatory CA
b. SVC obstruction
c. normal variant
d. Mastitis
e. Breast edema
 B. SVC obstruction
 Most likely answer.
 Breast edema is 2nd to CHF. Also possible and more common.
A mass is seen at the medial aspect on the CC view but not visualized on the MLO view. Next step?
 lateral-medial view
 cleavage view
 spot compression
 Lateral medial view next.
 Which of the following findings on breast U/S would be least consistent with a malignancy?
a. taller than wide
b. shadowing
c. heterogeneous echogenicity
d. posterior acoustic enhancement
e. pseudocapsule
Answer E. pseudocapsule least consistent with malignancy.
pseudocapsule seen in 7% of malig, while post enhancement seen in 22%
 Which of the following is true regarding a biopsy that returns atypical ductal hyperplasia (ADH)?
a. more likely in a biopsy done for calcifications than for a mass
b. a woman’s risk of breast CA is increased by 20:1
AAAAAAAAAAAAAAAAAA A. More likely done for microcalcs
 ADH is often returned after a biopsy for microcalcs.
 Atypical ductal hyperplasia (OR = 2.4; 95% CI, 1.3-4.5) or atypical lobular hyperplasia (OR = 5.3; 95% CI, 2.7-10.4) in a prior biopsy were associated with increased breast cancer risk
 [OR = odds ratio]
 Cancer Epidemiol Biomarkers Prev. 1997 May;6(5):297-301.
 The most characteristic findings of Paget's carcinoma of the breast are secondary to:
a. Retraction of Cooper's ligaments
b. Cancerous invasion of the dermal lymphatics
c. Distortion of the breast normal architecture
d. Metastasis to the axillary lymph nodes
e. Infiltration of the nipple epidermis
E. Infiltration of the nipple epidermis
 Paget's carcinoma (PC) of the breast is characterized by neoplastic cells of "glandular" type located within the epidermis of the nipple-areolar complex, often associated with an underlying ductal carcinoma, either in situ or invasive.

At present the origin of PC cells is controversial, although there is a widespread opinion that PC cells are "foreign" elements to the epidermis resulting from an epidermotropic migration of neoplastic elements from an underlying ductal carcinoma. An alternative view is that some cases result from neoplastic transformation of preexisting, innocent intraepidermal clear cells of the nipple-areolar complex (Toker cells) that migrate from nonneoplastic ducts.
 Hum Pathol. Dec;34(12):1321-30 Abstract quote.
 Paget’s cells in the skin must be present for dx [AFIP 2004, p. 217]
Bx radial scar
 A biopsy of a breast lesion shows a radial scar. Most appropriate next step?
a. excisional biopsy
b. short-term followup
c. MIBI study
d. ultrasound
e. routine (yearly) followup
A. Excisional biopsy
 Radial scars are benign, but cause spiculations, mimicking a malignant lesion. The trouble with radial scars is that mammographically and histologically they are difficult to tell apart from cancer. The nidus has elastic tissue with fibrosis. The nidus is not a true “mass.” They must be removed to reliably distinguish them from cancer.
 Kopans, pp. 565-566
 In screening 1000 women, what is the number of breast cancers that are found yearly?
a. 0.1-0.3
b. 2-10
c. 15-20
d. 20-30
e. 90-100
B. 2-10
 The incidence of breast cancer is 2-5 per 1000 women, with 15% < 40yo and 85% > 30yo. One in 9 women will develop breast cancer during her life.
Source: Dähnert 5th ed. p.551
screen
 The 1997 American Cancer Society recommendation for screening mammograms is:
a. Annually after age 40
b. Annually after age 50
c. Every 2 years after age 40 and annually after age 50
d.
A. Annually after age 40
 Baseline mammogram between 35-40 yo; 30 yo for women with a first-degree relative with premenopausal breast cancer.
Source: Dähnert 5th ed. p.554; see also Bassett p. 342.“Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.” – ACS Website.
Mammo tech
 Which of the following is checked weekly in mammography?
a. processor temperature
b. phantom
c. darkroom cleanliness
d. repeat analysis
B. Phantom
 Although QC testing includes quarterly and semiannual testing, the daily processor and the weekly phantom tests are considered the most important http://www.fda.gov/cdrh/mammography/scorecard-article1.html
Where is the lesion located (see diagram)? a. upper inner quadrant b. upper outer quadrant c. lower inner quadrant d. lower outer quadrant
C. lower inner
Presumably the straight line in the MLO drawing represents the pectoralis muscle.The CC and MLO views are the standard screening views. The markers ‘MLO’ and ‘CC’ are placed near the axilla. The MLO (mediolateral oblique) view is taken parallel to the pectoralis major muscle. Drawing a line from the nipple to the pectoralis muscle divides the breast in upper and lower quadrants. The CC (craniocaudal) view is taken with the x-ray beam perpendicular to the floor. Drawing a line from the nipple to the back, divides the breast in outer and inner quadrants. The section close to the ‘CC’ marker is the outer quadrant.** Straight from ’00 Exam **
If the MLO view of the breast has 10 cm of breast tissue, the cc view should contain at least how much breast tissue? a. 8 cm b. 9 cm c. 10 cm d. 11 cm
The CC view should contain breast tissue at least within 1 cm of the MLO view (9 cm) see Bassett p. 50.
 The MLO view poorly visualizes the posterior portion of which part of the breast?
 a. Superior.
 b. Inferior.
 c. Medial.
 d. Lateral.
 e. Axillary tail.
 Answer: C Medial
 A 50 year old with dense breast. Her skin is normal clinically and mammographically. Her CXR shows cardiomegaly and increased pulmonary vasculature. Likely cause:
 a) CHF
 b) SVC compression
 c) others
 CHF
 Which is true regarding Phylloides tumor:
 a) peak incidence is in the early to mid 40’s
 b) malignant in 20-23%
 c) it is a small mass at the time of detection
 d) does not recur after resection
 A or b) malignant in 20-23%
 A biopsy of micro-calcifications shows lobular carcinoma in situ. How should this be counted in a medical audit?
a. true positive
b. false positive
c. false negative
d. true negative
 B. False positive
 “If this [LCIS] is the only diagnosis given in a biopsy done for clinical or mammographic findings, there is no explanation for what prompted the biopsy in the first place. Lobular neoplasia [=LCIS] is an incidental histologic diagnosis with no clinical or mammographic findings.”“Lobular neoplasia should not be counted as a positive biopsy in clinical or mammographic series. It is not a cancer and the abnormality that prompted the biopsy is usually something other than lobular neoplasia” Remember, LCIS is just a marker for increased risk. Cardeñosa Breast Imaging Companion 2nd p. 301.False Positive (* other definitions also, e.g., if no Bx performed)
- Biopsy with benign findings within 1 year of a biopsy
recommendation for an abnormal mammogram (BIRADS 4 or 5)
 A cluster of calcifications is seen on an initial screening mammogram. The proper birads classification is:
a. 0 (incomplete)
b. 2
c. 3
d. 4
e. 5
 A. 0 (incomplete)
 The patient needs repeat mag views. Indications--
”When there are calcifications, magnification views provide more detailed morphologic information, additional calcifications in a given cluster may become apparent, and additional unsuspected clusters of calcifications may be detected”.
Cardeñosa Breast Imaging Companion 2nd p. 129; ACR Breast Syl pp 212-3
 A patient has a palpable lesion on breast exam. The least likely diagnosis:
a. Mondor’s disease
b. Abscess
c. Inflammatory carcinoma
d. Lobular carcinoma in situ
 D. Lobular carcinoma in situ
 LCIS has been described as a serendipitous finding. It does not form palpable masses or lesions that are reproducible on mammography. Source Kopans 2nd p. 593; Dähnert 5th p. 549
 Mondor’s Disease: Also called Superficial venous thrombosis. A tender purplish cord extends over the surface of the breast. May see a prominent vein on mammo. Source: Kopans 2nd p. 566
 Abscess: May be palpable, as well as presenting with pain, erythema, and skin edema source: ACR Breast Syl pp 82-3
 Inflammatory carcinoma: Largely a clinical dx. Tenderness is a hallmark of the disease..See paplable tumor in 63%
source: Dähnert 5th p. 551
 A patient has a well-circicumscribed mass on screening mammography with fat and soft tissue density. What do you do?
a. core biopsy
b. excisional biopsy
c. routine follow-up
d. magnification views
e. 3 month follow-up
 C. routine follow-up
 Fat contained within a breast lesion proves benignity!
- lipoma
- galactocele
- traumatic lipid cyst = fat necrosis
- focal collection of nl breast fat
- hamartoma
- lymph node
source: Dähnert 4th p 450; AFIP / ACR Breast Module ‘03
 A patient with Hx of DVT on anticoagulation therapy and no history of trauma presents with a superficial 2 cm spiculated mass on mammography; the overlying skin is discolored. Most likely diagnosis:
a. inflammatory carcinoma
b. hematoma
c. abscess
d. ductal carcinoma
 B. Hematoma
 Hematoma of breast: causes—surgery, blunt trauma, coagulopathy, anticoagulant therapy. Can see well-defined ovoid mass, ill-defined mass with diffusely increased density, adjacent thickening. Can get fibrosis with spiculations. Hematomas can simulate a breast abscess or a carcinoma.Inflammatory carcinoma: char. mammographically by generalized skin thickening and increased radiographic densityAbscess: most infections of the breast are treated before they form an abscess. Furthermore, most breast abscesses occur in young women and are often assoc. with nursing. Source: Kopans p 287Other Sources: ACR Breast Syl 3rd pp 76, 91; Dähnert 5th p. 561
 After a breast needle localization, the specimen is sent for radiography. Review of the images shows that the calcifications are not seen in the specimen radiograph. The next step is:
a. repeat excisional biopsy
b. mammography of the biopsied breast
 B. mammography of the biopsied breast
 (* probably)You would want to ascertain whether the calcifications are really still in the breast, or were perhaps lost during the surgery, or in handling of the specimen post-biopsy. However, if the patient is kept “open” in surgery (as in some institutions), obtaining further tissue would be possible.
 All of the following are benefits of core biopsy over FNA except:
a. can better give specific benign diagnosis
b. can distinguish DCIS from invasive ducal carcinoma
c. more pathologists familiar with reading
d. can be ultrasound guided
 D. can be ultrasound guided
 Both FNAC and CNB can be performed with mammographic or ultrasonographic guidance, so neither would have an advantage in this respect. Bassett p. 259. See also ACR Breast Syl. P 215
 An older lady 5 years post breast conserving surgery for cancer has a new area of coarsened trabecula and thick skin. Most likely diagnosis:
a. Paget’s
b. recurrence
c. radiation changes
d. post surgical changes
 B. Recurrence
 “Postradiation findings usually consist of breast edema and are manifested as diffuse skin thickening, parenchymal density, and trabecular thickening., which are more pronounced 6 months after surgery. It is maximal at 6 months, and then decreases over time.”“Surgical changes consist of scar formation and contour deformity of the breast; in general, the radiation and surgical alterations of the mammogram should decrease or remain stable after 1 year”“Suspicious findings (for recurrence) include development of masses or densities or an increase in the size of the surgical scar after 1 year” source: ACR Breast Syl. 3rd Q 85. Bassett p. 557Paget’s disease of the nipple is an uncommon manifestation of breast cancer. Get eczema-like scaling + excoriation of the nipple and aerola, nipple discharge, and itching. Dähnert 5th p. 564
 Breast cancer reporting. BIRADS category. Screening mammo with well circumscribed mass (1-2cm) in breast (+- microcalcs)
a. 0
b. 1
c. 2
d. 3
e. 4
f. 5
 A. 0 (needs further imaging)
 This lesion needs ultrasound (see above question for rationale).
 Differences between plain film radiographs and mammography
a. Mammo has dual emulsions
b. Mammo is more susceptible to processor artifact
c. Mammo has increased film latitude
d. Mammo shows best on OD < 1.0
 B. Mammo is more susceptible to processor artifact
 Optimal film processing is critical to ensure high image quality, and dedicated film processors are recommended. Source Huda 2nd p 198For optical image contrast, the mean OD of mammograms should be in the range of 1.2-1.8. source Huda 2nd p. 199Mammography films generally have high gradients (approx. 3), resulting in low film latitude. Single emulsion film films are normally used to reduce receptor blur by eliminating crossover and parallax effects.
Source Huda 2nd p 198
 If a breast mass is located at the nipple line on the MLO view and in the far lateral aspect on the cc view of the left breast, at what clock position is the mass?
a. 2:00
b. 3:00
c. 4:00
d. 7:00
e. 9:00
 C. 4 O’Clock
 Using the triangulation method, place the MLO and CC views side-by-side, with the CC view to the right of the MLO (hopefully, the nipples at same level. An imaginary line is drawn from the lesion seen on the CC view through the lesion seen on the MLO view. This line is then extended to indicate the expected location of the lesion on the yet-to-be-obtained ML view.In this case the lesion is in the lateral half of the breast on the CC view, and projects at mid-breast level on MLO view. Thus, an imaginary line drawn through the lesion on these two views is inferior to nipple level when extended to the ML view. Hence, this is a lower outer quadrant lesion source: ACR Breast Syl pp 2-6
 In mammography, motion unsharpness is not improved by
 a. increased compression
b. automated phototimer
c. switching target/filter
d. increasing kVp
 C. Switching target / filter
 Motion unsharpness can be reduced by decreasing exposure time; this can be accomplished by increasing kVp, decreasing thickness with compression, decreasing density setting, or moving the photocell. Filtration does little to affect the number of photons reaching the imaging screen. Source ACR Breast Syl II #36
 In the diagram of a core needle breast biopsy, where is the needle located?
 a. too deep
b. too shallow
c. just right
d. right
e. left
 B. too shallow (* probably)
 “The needle is advanced through the skin nick to the predetermined depth. Prefire films are obtained to establish the relationship of needle to lesion (if needle is on target). The needle is withdrawn approximately 5 mm and fired…” Cardeñosa Breast Imaging Companion 2nd p. 453.Assuming the diagram is accurate, the question wants the position of the needle at the time the pre-fire film is taken. From the above description, the pre-fire film is taken before the needle is pulled back. The inner trocar has a “throw” of about 23 mm. Bassett p. 256.See also ACR Breast Syllabus pp 215-8 for very good discussion on core biopsy needle placement
 Mammography guided biopsy of 2 cm area of pleomorphic calcifications. The specimen radiograph shows multiple calcifications. Pathology shows fibroadenoma with no calcifications. The next best step is--
a. Excisional biopsy
b. Repeat core biopsy
c. 6 month follow up mammogram
d. polarized light microscopy
e. return to annual screening mammograms
 D. polarized light microscopy
 After a biopsy for microcalcifications, several possible explanations should be considered if the pathologist is unable to locate the calcifications… calcium oxalate calcifications (associated with fibrocystic lesions) require polarizing microscopy for visualization (malignant-type calcifications are usually calcium phosphate).The point is, by showing the calcifications (which fibroadenomas commonly have) are in the pathology specimen, you can be assured that the tissue of concern wasn’t missed.
Cardeñosa Breast Imaging Companion 2nd p. 431; also http://www.digitalclinic.com/breastbio.htm
 The Mammography Quality Standards Act (MQSA) does not require which of the following?
a. two different film sizes
b. mechanical compression
c. two different screen sizes
d. kVp marker on compression paddle
 D. kVp marker on compression paddle
 The MQSA requires “size and positioning of detector indicated on the x-ray input surface of the compression paddle”. However, there are no requirements for the kVp marker to be on the compression paddle (they should be displayed, however). Cardeñosa Breast Imaging Companion 2nd p. 21Other requirements: dedicated mammo equipment; 2 receptors & matching grids; power-driven, hands-free compression devices; automatic exposure control; display of selected focal spot.
Source: Bushberg 2nd p. 207
 Tubular CA most likely to show on mammography as:
a. Punctate microcalcs
b. Pleomorphic microcalcs
c. Circumscribed/well-defined mass
d. Spiculated mass
 D. Spiculated mass
 Tubular carcinoma (< 5% of all invasive breast CA):= well-differentiated form of ductal ca.assoc. with LCIS in 40%nonpalpablesee: high opacity nodule with spiculated margins < 17 mm diam.DDX: radial scar source Dähnert 4th p 460; Bassett p. 490.
 What is the only way to diagnose intracystic breast cancer?
a. MR
b. pneumocystogram
 B. Pneumocystogram
 intracystic papillary carcinoma in situ
- rare variant of noncomedo DCIS
- aspiration may yield bloody fluid (cytology neg. in 80%)
- intracystic mass on pneumocystography
- solid intracystic mass on US
- round benign appearing mass on mammo
source: Dähnert 4th p 459
 What is the purpose of mammography?
a. reduce mortality from breast cancer
b. detect survival rate
c. detect interval cancer rate
 A. reduce mortality from breast cancer
 Value of screening mammography: decrease in cancer mortality through earlier detection + intervention when tumor size small + lymph nodes negative. Source Dähnert 4th p 463“It has been shown that screening can decrease breast cancer mortality by about 30% for women screened at age 50 and older…” Bassett p. 329.
 What to do in mammo when see well circumscribed mass 2 cm in UOQ on regular screening mammogram
a. Repeat screening in 6 mo
b. Repeat screening in 1 year
c. biopsy
d. US
e. Spot magnification views
 D. Ultrasound
 Most investigators have found that the probability of malignancy for round or oval masses with circumscribed margins is approx. 2%.Size does not predict malignancy.Kopans says: in his practice any solitary circumscribed lesion 8mm or larger gets US or FNA first to see if solid or cystic.
Source: Kopans 2nd pp281-2The medical literature supports follow-up mammography in 6 months as appropriate mgm. For a variety of lesions seen on mammograpgy, including the circumscribed, oval (noncalcifed) mass. The definition of a circumscribed mass as applied in these clinical studies is fairly uniform and requires that the lesion be (1) nonpalpable, (2) be solid rather than cystic on US, and (3) have well-defined margins over at least 75% on mammo.
Source: ACR Breast Syl.3rd p 46
 When aspirating a breast cyst what should be done if old blood is aspirated?
a. stop aspiration and refer for excisional biopsy
b. finish aspiration and schedule f/u mammo in 1 year
c. finish aspiration and schedule f/u mammo in 6 months
d. finish aspiration and schedule f/u ultrasound in 6 months
 A. Stop aspiration and refer for excisional biopsy
 Two undisputed indications for biopsy based on findings at cyst aspiration exist. The first is the presence of a residual mass; the second is the presence of old blood in the aspirate. Dark (old) blood may be due to an intracystic tumor (papilloma or carcinoma) or aspiration of the necrotic center of a solid tumor. Bassett p. 367-368., Kopans 2nd p 287 (*This question has been on many old tests)
 Which does not have ductal calfications?
a. adenosis
b. papillary carcinoma
c. intraductal CA
d. secretory disease
 A. Adenosis
 Sclerosing adenosis
- Diffusely scattered calcifications (seen in 50%)
- (calc. In cystically dilated acinar structures)
- calcification in “pure” adenosis even less common than in sclerosing adenosis Dähnert 5th p. 559.papillary carcinoma
- rare ductal carcinoma forming papillary structures
- assoc. microcalc. In 60%
- intraductal Ca = DCIS
calc, only on mammo in 72%secretory disease
- retained lactiferous secretions
- prolonged inspissation of secretion + intraductal debris, duct dilatation, linear calc. Several mm long
- galacocele
- plasma cell mastitis source Dähnert 4th pp 453, 469, 458, 460
 Which is the kVp typically used for Mammography?
a. 5 – 15 kVp
b. 24 – 28 kVp
c. 30 – 60 kVp
d. 75-85 kVp
e. 100 – 125 kVp
 B. 24-28 kVp
 Exposure without a grid is 25 kV, and with a grid is 26-27 kV.Source: Dähnert 5th p 545.
 Which of the following causes increased dose in mammography?
a. Increased compression
b. Something about phototimer
c. Decreasing kVP
d. change target to Tungsten (from Molybdenum)
 C. Decreasing kVp
 When kVp is reduced, the mean keV of the X-Ray photons is also reduced, which means more of them are attenenuated in the breast. Since the image is phototimed, this increases dose. Using a different anode (e.g., Tungsten or Rhodium) to produce a harder beam will decrease the dose. Bassett p. 31; Huda 1st p.205By reducing the breast thickness, proper compression reduces the dose needed for a proper exposure and improves contrast by decreasing scattered radiation. Bassett p. 46.; also Huda 1st p 197
 Which of the following is checked weekly in mammography?
a. processor temperature
b. phantom
c. darkroom cleanliness
d. repeat analysis
 B. Phantom
 Daily = processor, darkroom cleanliness
 Weekly = phantom, screen cleanliness, viewbox
 Monthly = visual check list, replenisment rates
 Quarterly = repeat analysis,fixer retention
 Semiannually = compression, film-screen contact, darkroom fog, viewbox luminance
 Source Primer 2nd p 659 (note: this edition of the Primer states phantom Q/monthly, which is no longer the case)
 Which of the following is false regarding reduction mammoplasty on mammography?
a. Nipple moves up
b. glandular tissue moves up
c. skin thickening may occur
d. fat necrosis calcifications
 B. Glandular tissue moves up
 This statement if False (thus the correct choice). Glandular tissue, which is normally most prominent in the upper-outer quadrant, moves inferiorly in the breast after reduction mammoplasty.
 The other choices are true.
 Other changes—Alteration of breast contour, architectural distortion, suture calcifications, retroareolar fibrotic band, and disruption of subareolar ducts.
Source: Kopans, Breast Imaging 2nd p. 460-62; Bassett p. 583.
 Which of the following is true regarding breast cysts?
a. associated increased risk of breast cancer
b. true negative
c. fluid should be sent for cytology after all aspirations
 B. True negative
 A true negative interpretation is one for which there is no known diagnosis of cancer within one year of a mammographic exam. With negative, benign, or probably benign findings (Birads 1,2, or 3).
 Source ACR Breast Syl p 137“Neither macro- nor microcysts increase a woman’s risk of breast cancer.” Source: ACR Breast Syl p 111; see also Bassett p. 267.“If non-bloody fluid is found, the cyst should be completely aspirated. The fluid can then be discarded.” Source ACR Breast Syl p 120
 20 yo female with palpable breast lump; which is the correct method of work-up?
a. 6 mo f/u
b. Excisional biopsy
c. Mammography
d. MRI
e. Ultrasound
 E. Ultrasound
 Fibroadenoma is the most common rounded breast mass in a woman 28 years or younger. Ultrasound is the most reasonable test to exam for the presence of a solid or cystic mass in this age group. The role of ultrasound is for a targeted exam of a palpable lump, suspected leaks form silicone implant; radiographically dense breast with strong family history or for an interventional procedure (cyst aspiration or core biopsy).
Source: Dähnert 5th ed. p.555
 A 50 yo female had a screening mammogram that was read as negative. Shortly thereafter, she developed breast cancer. The mammographic reading is considered to be:
a. False negative
b. False positive
c. True negative
d. True positive
 A. False negative
 False Negatives are negative test results in patients who have the disease.
Source: Huda 1st ed. p.209
 FN—Breast cancer diagnosis within 1 year of a normal mammogram (BI-RADS categories 1, 2, and 3).
Cardeñosa: Breast Imaging Companion 2nd ed. p. 275
 A 50 yo female has a circumscribed, non-calcified 1 cm breast mass on screening mammogram. Ultrasound demonstrates a solid mass. The chance of malignancy is:
a. 1-2%
b. 10-20%
c. 60-70%
d. 80-90%
 A. 1-2%
 Primer says, “Circumscribed masses with well-defined borders: uncommon sign of malignancy; only 2% of solitary masses with smooth margins are malignant.” Source: Primer 2nd ed. p.659, Kopans 2nd ed. p.397
 Sickles followed 589 round, well-defined lesions for 3 years and only 12 (2%) proved to be cancer. The likelihood of malignancy for probably benign lesions as reported by Sickles is low:
1.4% for solid, circumscribed masses
0.6% for focal asymmetric density
0.4% for localized microcalcifications
0.3% for multiple solid circumscribed masses
see Cardeñosa Breast Imaging Companion 2nd p. 151.
 A core biopsy of a non-calcified lesion reveals adenosis and lobular carcinoma in-situ. The most appropriate management is:
a. Annual f/u in 1 year
b. Short-term f/u in 6 months
c. Excisional biopsy
d. Mastectomy
e. Bilateral mastectomy
 A. Annual f/u in 1 year
 Lobular carcinoma in-situ is present in younger populations (40-50) and decreases with age. It has a high frequency of multicentricity (70%) and bilaterality (30%) and should be considered a systemic disease. Excisional biopsy is unlikely to be effective. 20-30% develop invasive ductal or lobular carcinoma within 20 years [in either breast]. Treatment is highly controversial, with 2 diametric treatments: close f/u or mastectomy. Kopans writes, “most now recommend careful follow-up with annual mammography and at least annual if not more frequent clinical breast examination.”
Source: Kopans 2nd ed. p.593“The most common method of treatment… is close clinical and mammographic surveillance…” Also, remember that adenosis has no increased risk of breast CA; sclerosing adenosis only slightly (~1.5x). Bassett p. 429, 308
 A patient has a 2 cm firm, palpable mass with no sonographic abnormalities seen. What is the BIRADS category?
a. 0
b. 1
c. 2
d. 3
e. 4
f. 5
 A. 0
 After the sonogram, we still don’t know what this mass is. Additional imaging evaluation is need for clarification. Therefore, this study should be labeled BIRADS 0: incomplete, need additional imaging evaluation.
Source: Primer 2nd ed. p.663* Also note that there is no accepted BI-RADS system for U/S.
 A patient has clear nipple discharge from a single duct. The most likely cause is:
a. Hyperfunctioning pituitary adenoma
b. Paget’s disease
c. Infiltrative carcinoma
d. Papilloma
 D. Papilloma
 A papilloma is the most common cause of bloody or serous nipple discharge. Ductal ectasia is the second most common cause. A pituitary cause should be bilateral.
Source: Primer 2nd ed. p. 676; Dähnert 5th p. 542
 A patient is 6 months s/p lumpectomy and radiation therapy. The mammogram demonstrates increased density and skin thickening. What is the most likely etiology?
a. Recurrent carcinoma
b. Inflammatory carcinoma
c. Post-radiation changes
d. Congestive heart failure
 C. Post-radiation changes
 The postradiation mammograms should be performed 6 months after initiation of therapy and followed annually. Radiographic features of postradiation breast include diffuse density of entire breast, unilateral (edema); most pronounced at 6 months, nearly gone at 24 months.Skin thickening is the most common change in the screening mammogram after breast conserving therapy and has been reported in up to 90% of cases. [normal in 2-3 yrs. in 46-60%]
Source: Primer 2nd ed. p.679; Bassett p. 554.
 A stereotactic biopsy is performed of a suspicious cluster of microcalcifications seen on mammography. Pathology reported no calcification seen. The most appropriate next step in management is:
a. Repeat stereotactic biopsy
b. Radiograph the paraffin specimen block
c. Excisional biopsy
d. Short term f/u in 6 months
 B. Radiograph the paraffin specimen block
 From http://www.digitalclinic.com/breastbio.htm:“In contrast, calcium oxalate deposits, on hematoxylin-eosin sections, are pale and refractile and may be difficult to identify using routine microscopy. Examination of such specimens under polarized light, however, readily demonstrates this type of calcification. If, after examination under polarized light, there is still no microscopic evidence of calcifications, other possibilities must be considered. For example, the paraffin blocks may not have been cut deeply enough to provide histologic sections that demonstrate the calcifications. To investigate this possibility, the blocks may themselves be radiographed, any blocks containing radiographic calcifications should be cut more deeply until the calcifications are microscopically identified…” see also Cardeñosa: Breast Imaging Companion 2nd p. 431 for a discussion.**There is a variant question concerning polarized light microscopy**
 A suspicious lesion is seen in the superior breast only on the MLO view (not seen on CC view). On the true lateral view, the lesion appears in a more cephalad (superior) position. Where is the lesion?
a. Upper inner quadrant
b. Upper outer quadrant
c. Lower inner quadrant
d. Lower outer quadrant
 A. Upper inner quadrant
 Any lesion within the superior portion on MLO view (or lateral view) must be within the upper quadrants. This PROBABLY puts it in the upper inner quadrant, unless the mass is not at significantly different levels on lateral and MLO views, which could still put it in the upper outer quadrants. One can use the PARALLEL SHIFT method to place the lesion.
Source: Kopans 2nd ed. p.734
 All of the following decrease motion unsharpness except:
a. Increasing mA
b. Increasing kVp
c. Changing the target material
d. Changing the screen material
e. Changing the filter material
 E. Changing the filter material
 Reducing the exposure time leads to a decrease in motion unsharpness. Increasing mA and faster screens reduce exposure time. Increasing kVp and changing the target material will increase the maximum energy and the number of higher energy photons, respectively. This will lead to better penetration through the imaged object resulting in shorter exposure time.
 Filtration increases the average x-ray energy, but decreases total x-ray output. It preferentially absorbs low-energy photons resulting in reduce dose to the patient. Put another way, changing the filter does little to affect the number of photons reaching the screen [and if anything may actually decrease photons reaching the screen, increasing exposure time and motion unsharpness]
Source: Huda 1st ed. p.39,40,70, Bushberg 2nd ed. p.114
 Core biopsy of a breast mass reveals atypical ductal hyperplasia. Appropriate management is:
a. Routine 12 month f/u
b. Short interval 6 month f/u
c. Excisional biopsy
d. MRI
 C. Excisional biopsy
 Atypical ductal hyperplasia is associated with 5x risk of breast cancer and should be excised. Atypical ductal hyperplasia has incomplete features of DCIS, which is premalignant.
Source: Primer 2nd ed. p.674, Dahnert 5th ed. p.560; Bassett p. 259
 Diagram of a breast biopsy of a spiculated mass. Which of the following needle positions is optimal before firing the biopsy needle?
 This depends on the sampling needle used. According to Kopans, the needle tip is initially placed at the center of the lesion. Before firing, the needle should be pulled back so that, when the needle is fired, the center of the sampling notch is centered in the lesion. The distance of “pull back” is calculated by subtracting the (distance from the stylet tip to the center of the notch) from the throw distance.
Source: Kopans 2nd ed. p.711-12
 How often is phantom imaging required?
a. Daily
b. Weekly
c. Monthly
d. Quarterly
 B. Weekly
 To maintain the quality and consistency of clinical images in practice, MQSA’s final regulations mandated that facilities conduct the phantom image test weekly (instead of monthly as under the interim regulations). Bushberg Table 8-8 p. 226.
Source: http://www.fda.gov/cdrh/mammography/scorecard-article1.html (under section B)
 If physical examination was not part of the evaluation, what percentage of cancers would be missed by mammography alone?
a. 5-10%
b. 10-15%
c. 15-20%
d. 20-25%
 A. 5-10%
 This data is taken from the Breast Cancer Detection Demonstration Project (BCDDP). BCDDP was NOT a randomized, controlled trial, but is quoted most often. According to Kopans, “Of the cancers found at screening, > 90% were detected by mammography.” This means that if PE was not performed, only 5-10% of detectable cancers would be missed. Please note that in this study 20% of cancers were NOT detectable by a combination of clinical breast examination and mammography.
Source: Kopans 2nd ed. p.72 [*this question appeared in 90,92, 94,99]
 In screening 1000 women, what is the number of breast cancers that are found yearly?
a. 0.1-0.3
b. 2-10
c. 15-20
d. 20-30
e. 90-100
 B. 2-10
 The incidence of breast cancer is 2-5 per 1000 women, with 15% < 40yo and 85% > 30yo. One in 9 women will develop breast cancer during her life.
Source: Dähnert 5th ed. p.551
 Regarding Paget’s disease, which of the following is true?
a. Benign eczematous reaction of the nipple
b. Always associated with invasive ductal carcinoma
c. Always associated with intraductal papilloma
d.
 B. Always associated with invasive ductal carcinoma
 Paget’s disease represents 5% of mammary carcinomas and typically occurs in older patients. It is a lesion of the nipple that is caused by epidermal infiltration of a ductal carcinoma. There are eczematoid nipple changes and occasionally serous or bloody nipple discharge. Because of the early clinical signs this cancer leads to early detection and thus has a good prognosis.
Source: Primer 2nd ed. p.672
 The 1997 American Cancer Society recommendation for screening mammograms is:
a. Annually after age 40
b. Annually after age 50
c. Every 2 years after age 40 and annually after age 50
d.
 A. Annually after age 40
 Baseline mammogram between 35-40 yo; 30 yo for women with a first-degree relative with premenopausal breast cancer.
Source: Dähnert 5th ed. p.554; see also Bassett p. 342.“Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.” – ACS Website.
 The MLO view is correctly described by which of the following?
a. should be performed at 45 degrees to horizontal
b. the tissue in the medial breast is the most sharp
c. is commonly associated with inadequate compression
d. Bill Clinton’s favorite view
 C. is commonly associated with inadequate compression
 Among other issues, the broad base of the breast on the MLO view may make adequate compression difficult. Bassett p. 47-50Although patients of average height and weight require an angle of 45 to 50 degrees, it is imperative that the angle utilized be adjusted to the body habitus of the individual patient (30 to 60 degrees). Bassett p. 47.If tissue is excluded from the MLO view, it is likely to be medial tissue. This is one advantage of the CC view. Bassett p. 50.
 The MLO view is not good for visualization of which part of the breast?
a. Lower
b. Inner
c. Upper
d. Outer
 B. Inner
 “On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 50.
 The usual range of kVp used in mammography is:
a. 19-24
b. 24-28
c. 28-34
d. 35-40
 B. 24-28
 The 24-28 kVp range is best suited for mammography. 25 kVp is optimal without a grid, 26-27 kVp with a grid, 22-24 kVp for specimens and 26-27 kVp for magnification views.
Source: Dähnert p.545; Bassett p. 31.
 Which is the most characteristic of a radial scar?
a. Skin thickening
b. Lucent center
 B. Lucent center
 A radial scar is a benign proliferative breast lesion (malignant potential is controversial) unrelated to prior surgery or trauma. In up to 50% it is associated with tubular carcinoma, comedocarcinoma, invasive lobular carcinoma and contralateral breast cancer. It typically has NO central mass and has oval/circular translucent areas at the center.
Source: Dähnert 5th ed. p. 565; Bassett p. 420.
 Which of the following is NOT a form of ductal carcinoma in situ?
a. Solid
b. Comedo
c. Medullary
d. Micropapillary
 C. Medullary
 The subgroups of DCIS are comedocarcinoma and non-comedocarcinoma (consisting of solid, micropapillary and cribriform subtypes). Medullary carcinoma is an uncommon, well-differentiated tumor that may get very large (5-10cm) before discovery. Typically there is a striking lymphocytic infiltration.
Source: Dahnert 5th ed. p.548, Primer 2nd ed. p.671
 A 1 cm circumscribed, benign appearing solid mass on ultrasound will be malignant what percent of the time?
a. 1-2%
b. 2-5%
c. 10-20%
d. 25-30%
 A. 1-2%
 The likelihood of malignancy for probably benign lesions as reported by Sickles is low:
1.4% for solid, circumscribed masses
0.6% for focal asymmetric density
0.4% for localized microcalcifications
0.3% for multiple solid circumscribed masses
see Cardenosa Breast Imaging Companion 2nd p. 151.** Dähnert 5th is contradictory: says 4% on p. 538, 2% in a Table on p. 551. Given this, ≤ 2% as specified by Cardeñosa is probably the best choice.
 A 40-year-old woman has a nonpalpable well-circumscribed mass seen in her right breast on her first screening mammogram. She is asymptomatic. Ultrasound in this area is unable to demonstrate this mass or any other abnormality. Which one of the following should be done next?
a. incisional biopsy
b. core biopsy
c. mastectomy
d. routine follow-up (BIRADS 2)
e. 6-month follow-up (BIRADS
 E. 6-month follow-up (BIRADS 3)
 The probability of malignancy for round or oval masses with well circumscribed margins is 2%. There should be no evidence of infiltration on magnification mammography. Most agree that it is reasonable to follow them at a short interval if they are found on a first mammogram and intervene only if they enlarge or demonstrate any other significant changes. (Kopan’s pages 280-281).“likelihood of malignancy… 1.4% for a solid, circumscribed mass. 6-month follow-up recommended” see Cardenosa Breast Imaging Companion 2nd p. 151.
 A core biopsy of a breast lesion shows a sclerosing adenosis. What is the next step?
a. Excisional biopsy
b. Close follow up
c. Annual screening mammogram
d.
 B. close follow upThere should be a 6 month follow-up mammogram if the biopsy results show sclerosing adenosis. Since there is small increase cancer risk, a follow-up mammogram could evaluate for recurrence of calcium. Sclerosing adenosis is adenosis with reactive fibrosis. Adenosis is hyperplasia of ducts, lobules, and acini. There is a 1.5-2 times increased risk of invasive breast cancer with sclerosing adenosis. (Dahnert, p.559, Basset 259-260)
 A density is seen in the upper portion of the breast on an MLO view. The density moves up on the true lateral view. Where is the lesion most likely located in the breast:
a. Upper inner quadrant
b. Upper outer quadrant
c. Lower inner quadrant
d. Lower outer quadrant
e. Retroareolar
 A. Upper inner quadrant
 Triangulation (see diagram p. 156 Cardenosa Breast Imaging Companion 2nd ed or Primer 3rd ed p. 719) Lateral High LowMLO High upper inner outer lower Low lower inner outer upperCC High upper inner outer lower Low lower inner outer upper
 Lesions in midportion of breast do not change position.Lateral lesions on CC move down on lateral and MLO.Medial lesions on CC move up on lateral and MLO.Medial lesions move up from MLO to lateral.Lateral lesions move down from MLO to lateral.
 Lesion that move down on lateral view are lateral.Lesions that move up on lateral are medial.

Muffins rise, lead falls.
 A lobulated, well-circumscribed mass on imaging is least likely to be which?
a. Invasive Lobular carcinoma
b. DCIS
c. Invasive ductal carcinoma
d. Medullary carcinoma
e. Fibroadenoma
 B. DCIS
 DCIS shows up as calcifications comedo type or as asymmetric density with architectural distortion noncomedo type.D and E present as circumscribed masses. Invasive ductal carcinoma shows up most commonly as a speculated and nodular growth but since it is the most common cancer (70% ) it is the most common circumscribed cancer (Diagnostic Breast Imaging 2nd ed. Pg 276) even though that is the typical appearance of Medullary and Colloid Ca. Invasive Lobular carcinoma (second most common type of breast Ca) has 1% of cases that will show as a round/ovoid mass with regular borders (Dähnert pg 460).The most common cancer that grows as a circumscribed mass is infiltrating ductal carcinoma NOS (Bassett p. 477). Lymphoma, colloid carcinoma, and papillary carcinoma can on occasion appear as round, smoothly marginated lesions. Papillary cancers are frequently intracystic, and the cyst accounts for the smoothness of the margin. (Kopan’s page 279)
 An excisional biopsy was performed for calcifications. Specimen radiograph contained two clusters of calcifications. The pathologist reported no malignancy and no calcifications. What is the next step?
a. repeat excisional biopsy
b. mammography follow up in 1 year
c. radiograph the paraffin block
d. immediate post-operative mammography
 C. radiograph the paraffin block
 From http://www.digitalclinic.com/breastbio.htm:
 “In contrast, calcium oxalate deposits, on hematoxylin-eosin sections, are pale and refractile and may be difficult to identify using routine microscopy. Examination of such specimens under polarized light, however, readily demonstrates this type of calcification. If, after examination under polarized light, there is still no microscopic evidence of calcifications, other possibilities must be considered. For example, the paraffin blocks may not have been cut deeply enough to provide histologic sections that demonstrate the calcifications. To investigate this possibility, the blocks may themselves be radiographed, any blocks containing radiographic calcifications should be cut more deeply until the calcifications are microscopically identified…” see also Cardeñosa: Breast Imaging Companion 2nd p. 431 for a discussion.
 An initial, screening mammogram demonstrates a 2 cm spiculated mass. The appropriate BiRADs category is:
I: normal
II: benign
III: probably benign, further imaging required
IV: suspicious, biopsy recommended
V: malignancy
 E. V: malignancy
 This fits the characteristics of a malignant lesion per Stavros -AFIP 2001.
 Mammographic findings after reduction mammoplasty include all of the following except--
a. skin thickening
b. fat necrosis
c. shift of glandular tissue superiorly
d. nipple moved to a higher position
 E. V: malignancy
 This fits the characteristics of a malignant lesion per Stavros -AFIP 2001.
 Mammographic findings after reduction mammoplasty include all of the following except--
a. skin thickening
b. fat necrosis
c. shift of glandular tissue superiorly
d. nipple moved to a higher position
 C. shift of glandular tissue superiorly
 The most common way of reduction mammoplasty, involves a long incision along the inframammary fold and incisions extending from it to the 6 o’clock edge of the areola and then around the areola. Tissue is removed from the bottom of the breast and between the vertical incisions. The nipple areolar complex is moved up into a keyhole extension of the vertical incisions, which are then brought together in the midline to reform the smaller breast. The fibroglandular tissues can appear redistributed from the usual upper breast location to the newly formed lower breast. There is often a swirling configuration to the remolded tissues, and isolated islands of breast tissue can be seen. Fat necrosis is relatively common with the extensive surgery involved, and oil cysts, as well as benign calcifications can be seen. (Kopan’s pages 460-462); Diagnostic Breast Imaging 2nd ed. Pg.371
 Most likely malignancy to arise in a cyst?
a. Medullary carcinoma
b. Tubular carcinoma
c. Ductal carcinoma
d. Papillary carcinoma
 D. Papillary carcinoma
 Carcinoma is rarely found in a cyst, however, when they occur, most intracystic cancers are papillary. When cyst fluid is maroon or brown, previous hemorrhage should be suspected. Hemorrhage into a cyst may be idiopathic, secondary to an intracystic papilloma, or due to a rare intracystic cancer. Cysts containing old hemorrhagic fluid should be excised because of the small possibility of intracystic carcinoma. The majority of focal intracystic lesions, prove to be benign papillomas. (Kopan’s pages 538-540)
 Most likely malignancy to escape mammographic detection?
a. Medullary carcinoma
b. Tubular carcinoma
c. Invasive lobular carcinoma
d. Colloid carcinoma
e. Infiltrating ductal carcinoma
 C. Invasive lobular carcinoma
 Most frequently missed breast cancer (difficult to detect mammographically + clinically) with 19-43% false-negative rate (occult in dense breast)
Dähnert p. 550. Invasive lobular carcinoma fails to incite a desmoplastic reaction.
 LCIS-CANCER MARKER NOT MALIGNANT OR PREMALIGNANT
 Most likely well-circumscribed breast malignancy?
a. Medullary carcinoma
b. Invasive ductal carcinoma
c. Colloid carcinoma
d. Tubular carcinoma
e. Papillary carcinoma
 B. Invasive ductal carcinoma
 Invasive ductal carcinoma shows up most commonly as a spiculated and nodular growth but since it is the most common cancer it is the most common circumscribed cancer (Diagnostic Breast Imaging 2nd ed. Pg 276) .“…in fact, due to its frequency, the usual ductal type of carcinoma (NOS) makes up the majority of carcinomas that have circumscribed margins…” Bassett p. 477.
 S/P lumpectomy for 2 years with new rim calcifications are most likely to be?
a. Fat necrosis
b. DCIS
c. Invasive ductal carcinoma
d. Atypical ductal hyperplasia
e. radial scar
 A. Fat necrosis
 “One common and characteristic finding is a radiolucent or mixed fat and soft-tissue density circumscribed mass with a calcified or noncalcified rim, known as a lipid or oil cyst… Fat necrosis is commonly seen after lumpectomy and radiation therapy for breast CA…” Bassett p. 375.
 Standard views are taken. What is the next step if a mammographic abnormality is seen on the CC view only?
a. Tangential view
b. Exagerrated CC
c. Repeat MLO
d. Medial-Lateral view
e. Eklund view
 D. Medial-Lateral view
 Medial-lateral. You can’t “triangulate” until you see it on two views. The exaggerated CC and valley view are variants on the CC that may help to characterize the lesion better, but do not help to localize it in conjunction with a CC view. The ML view is also helpful for localizing lesions seen only on MLO. The CC and ML views are perpendicular to each other, and the MLO is roughly 45 degrees off from the other two. Cardeñosa says to put the film closer to the side where the lesion is thought to be, in order to get slightly better resolution on the lesion (i.e., film is lateral for a lateral lesion, medial for a medial lesion). (Cardeñosa, p 81-82)
 Tangential-to determine the dermal location of lesions
 Two views of a mass with stereotactic core biopsy needle in it. Is the needle:
a. on target
b. too shallow
c. too deep
d. to the left
e. to the right
 E. to the right
 There were two views from a stereotactic biopsy. Usually, the views are taken 15 degrees to the right and 15 degrees to the left. The needle should be in the mass on both views. http://www.wfubmc.edu/imagelab/library/Carr_stereo_2001.pdf
 What causes the mammographic appearance of inflammatory carcinoma?
a. Local dermal invasion by tumor cells.
b. inflammatory cells within the breast
c. obstruction of dermal lymphatics by tumor cells
 C. Obstruction of dermal lymphatics by tumor cells
 Thickened skin invariably accompanies inflammatory carcinoma, a highly aggressive manifestation of breast cancer with poor prognosis, in which tumor is found permeating the dermal lymphatics. By itself, however, the thickened skin is a nonspecific finding, and the diagnosis of inflammatory carcinoma is based on the clinical findings with erythema and increased skin temperature over 1/3 of the breast surface. Get peau d’orange appearance. Radiographically, have nonspecific skin thickening . The overall trabecular pattern of the breast appears thickened due to congestion in the intramammary lymphatics. On occasion, the underlying tumor mass that is not detectable on clinical examination, is visible mammographically.
(Kopan’s page 341); Bassett p. 466.
 What is the BIRADS category for a 4mm cluster of microcalcifications seen on an initial mammogram?
a. 0
b. 1
c. 2
d. 3
e. 4
 A. BI-RADS 0.
 If microcalcifications are found on a screening mammogram, the patient should be called back for additional views. Ultrasound and/or biopsy may also be needed, depending on the results. (Cardeñosa, p.17)
 Microcalcifications are usually 100-300micrometer. They can be up to 2mm. 20% of clustered microcalcification represent malignancy. (Dähnert, p.540)
 Clustered heterogenous calcifications are secondary to adenosis (benign), peripheral ductal papilloma (benign), hyperplasia, and cancer.
 What is the goal of a randomized trial study on a screening mammography program?
a. To determine detection rate
b. To determine impact on mortality
c. To determine impact on survival
d. To determine incidence
e. To determine prevalence
 B. To determine impact on mortality.
 Early detection remains the only proven method for reducing the mortality from breast cancer, and the mammographic screening of asymptomatic women remains the only efficacious method for detecting earlier stage, clinically occult breast cancer.
(Kopan’s pages 52-53)Value of screening mammography: decrease in cancer mortality through earlier detection + intervention when tumor size small + lymph nodes negative. Source Dähnert 4th p 463
 What is the most characteristic finding of an intramammary lymph node on ultrasound?
a. a notched border
b. echogenic mass
c. circumscribed mass
d. lobulated mass
e. oval
 A. a notched border
 Normal lymph nodes are reniform or oval, and have an echogenic fatty hilus. In depicting the fatty hilus within a lymph node, ultrasound is not reliable in excluding malignancy in a woman with breast cancer. Normal sized lymph nodes that are infiltrated with tumor may appear identical to normal nodes. A hypoechoic cortical focus or an irregular cortical margin may be found in a lymph node, suggesting a metastatic deposit. Normal intamammary lymph nodes are in the upper outer quadrant, and have a hilar notch. (Cardeñosa, p 135, Rumak pages 759-760)
 What is the treatment for a radial scar?
a. excision
b. short term followup
c. yearly screening mammogram
d. ultrasound
 A. Excision
 Radial scar has been reported to have coexistent carcinoma present in up to 25% of cases. Diagnostic Breast Imaging 2nd ed. Pg. 149; Bassett p. 420.The appearance of a radial scar can be indistinguishable from malignancy. Radial scars have dense radiating lines that are usually very long greater than or equal to 1cm, without a central mass. The radiating lines are interspersed with trapped fat, forming lucent zones near the center of the area. Radial scars should be biopsied to make a secure diagnosis. Needle biopsy has been found to be an unreliable method of diagnosing these lesions. Excisional biopsy is needed to to make the definitive diagnosis. Kopan’s page 380, 299.
 What is the treatment for atypical ductal hyperplasia?
a. Excisional biopsy
b. Short term followup
c. Yearly screening mammogram
d. ultrasound
 A. Excisional biopsy
 ADH may have DCIS or invasive ductal near this lesion . “surgical excision should be preformed to evaluate for possible coexistent carcinoma.” Diagnostic Breast Imaging 2nd ed. Pg. 149; also see Bassett p. 259.Several studies have demonstrated that if the histology of a core needle biopsy is read as atypical hyperplasia (a high risk, but benign lesion), excisional biopsy is warranted because may prove to be breast cancer at excision. (Kopan’s page 226)
 Where is the lesion located?
 a. axilla
b. upper outer
c. upper inner
d. lower outer
e. lower inner
 E. lower inner
 Presumably the straight line in the MLO drawing represents the pectoralis muscle.The CC and MLO views are the standard screening views. The markers ‘MLO’ and ‘CC’ are placed near the axilla. The MLO (mediolateral oblique) view is taken parallel to the pectoralis major muscle. Drawing a line from the nipple to the pectoralis muscle divides the breast in upper and lower quadrants. The CC (craniocaudal) view is taken with the x-ray beam perpendicular to the floor. Drawing a line from the nipple to the back, divides the breast in outer and inner quadrants. The section close to the ‘CC’ marker is the outer quadrant.
 Which is NOT an indication for cyst aspiration in the breast?
a. Symptomatic
b. Size
c. Low level internal echoes
d. Lobulated contours
e. Unclear if the mammo finding correlates with the ultrasound finding
 B. Size
 Unless the patient is bothered by it, there is no reason to aspirate a cyst based on size alone, provided it meets the criteria for a simple cyst: smooth walls, sharp anterior and posterior borders, no internal echoes, and posterior acoustical enhancement. Dahnert p.556 under breast cyst - "size changes over time" The size is also not a Stavros criteria for cysts. Most cysts get symptomatic with large size Lobulated contours do not meet strict criteria for a simple cyst. Bassett p. 400.; also Table 18-2 p. 266.
 Which is not associated with calcifications of the secretory ducts?
a. Paget's disease of the the nipple
b. Comedotype DCIS
c. Adenosis
d. Invasive ductal carcinoma
e. secretory disease
 C. Adenosis
 The mammographic findings [of adenosis] are usually non-specific and include diffuse ill-defined 3- to 5-mm nodular densities, multiple round or punctuate calcifications (often associated with radiographically dense breast tissue in sclerosing adenosis) and focal speculated masses with or without microcalcifications, mimicking breast CA. Bassett p. 406.
 Lesions that develop in the major ducts of the breast include Paget’s disease, duct ectasia, solitary large duct papillomas. Atypical ductal hyperplasia arises at the level of the terminal duct lobular unit (TDLU). Intraductal carcinoma (DCIS), and invasive or infiltrating ductal carcinoma arise at the level of the TDLU. (Kopan’s pages 513-516)
 Which of the following will not decrease the dose?
a. decreasing kVp
b. decreasing automated exposure time
c. fast screen-film combination
 A. decreasing kVp
 All other things being equal, decreasing kVp will increase the radiation dose. see Bassett p. 31.Increasing Kvp increase the number of photons that get through. Setting the phototimer to cut off earlier would decrease exposure to the patient. The processor is usually set for 3 min or in diagnostic 90 sec. Things that increase the density on the film would be increasing temperature which would also cause fog.
 Which of the following will not increase sharpness?
a. Decreasing kVp
b. Decreasing focal spot size
c. Decreasing exposure time
d. Adequate compression
 A. Decreasing kVp
 Sharpness aka detail is affected by motion; decreasing kVp will require a longer exposure, decreasing sharpness. Bassett p. 78.Decreased time and exposure (compression decreases thickness) decreases motion so these increase sharpness. Smaller focal spot sizes increases sharpness but causes problems with heat. Kopan’s pages 140-141
 Which portion of the breast is least visualized in a standard MLO image?
a. upper inner
b. upper outer
c. lower inner
d. lower outer
e. axillary tail
 A. upper Inner
 “On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 50.; also old questions & AFIP notes (Breast Module)Given that the superior/medial border of the breast is fixed (Bassett p. 44), this is the most difficult to image.
 Why is a specimen xray done?
a. To prove a non-palpable mass was appropriately biopsied
 A. To prove a non-palpable mass was appropriately biopsied“If the biopsy was performed for a nonpalpable abnormality, specimen radiographs should be performed to verify removal of the suspicious area.” Bassett p. 352
 If the MLO view of the breast has 10 cm of breast tissue, the cc view should contain at least how much breast tissue?
a. 8 cm
b. 9 cm
c. 10 cm
d. 11 cm
 B. 9 cm
 The CC view should contain breast tissue at least within 1 cm of the MLO view (9 cm) see Bassett p. 50.
 (T/F) Concerning medullary carcinoma of the breast:
1. soft on palpation
2. has a fibrous stroma
3. carries a worse prognosis than ductal carcinoma
4. is well circumscribed
5. calcifications
 1. True. SOFTER than average breast CA (Dähnert p. 550)
 2. False. “the fibrous stroma should be scant” Bassett p. 487.
 3. False. Despite its locally aggressince histologic features, the prognosis of pure medullary carcinomas is better than that seen with infiltrating ductal carcinomas. 92% 5 year survival rate. Dähnert 5th p. 550 and Breast Imaging Companion. Cardeñosa. 1997. pp. 218)
 4. True. Medullary carcinoma is a well‑circumscribed mass with nodular architecture and lobulated contour. (Radiology Review Manual , 3rd edition. Dahnert. 1996. pp. 407)
 5. False. It is described as well‑defined round/focal noncalcified uniformly dense mass. (Radiology Review Manual, 3rd edition. Dahnert. 1996. pp. 407)
 5 cm breast mass in a 20 year old is palpated. What is the most appropriate next step?
a. excisional biopsy
b. core needle biopsy
c. mammogram
d. U/S
e. gadolinium enhanced MRI.
 D. U/S
 “The proper means for evaluating a woman under age 30 with a palpable mass is controversial. The breasts of these women are more sensitive to radiation than are those of older women, and breast cancer in this age group is relatively rare. Thus it is desirable to limit the radiation exposure in young women. At our institution, we perform US as the initial imaging study. If the mass is a cyst, no further evaluation is required. However, if the mass is solid or not seen on US, we often obtain at least a single-view mammogram, primarily to look for microcalcifications.”
Source: Bassett, Diagnosis of Diseases of the Breast 1997 p 193.
 50 year old patient with increased density in the anterior breast seen only on the MLO view. The CC view is negative. What is the appropriate next step?
a. exaggerated CC view
b. cleavage view
c. 90 degree lateral
d. repeat CC view
e. Ultrasound
 C. 90 degree lateral
 “When an abnormality is seen on the MLO view but not on the standard CC view, it should first be determined whether it is a real abnormality, superimposed tissue, or an artifact on the film or in the skin. Sometimes repeating the oblique view with a slightly different angulation or obtaining a 90-degree lateral will provide this information.” Source: Bassett, Diagnosis of Diseases of the Breast, 1997, p. 52.
 5000 mammograms are performed and interpreted. 50 patients are recommended for a biopsy. Of the 50 biopsied, 15 are malignant. One year later, only one of the patients not recommended for a biopsy turns out to have a malignancy. What is the sensitivity of this study?
a. 3%
b. 10%
c. 50%
d. 78%
e. 94%
 E. 94%
 TP=15, FN=1Sensitivity = TP/(TP+FN) = TP / (all with disease)
= 15 / (15+1)
= 15 / 16
= 0.9375
= 94%
 5000 women undergo mammography, biopsy is recommended in 50. Of those 50, 40 undergo core biopsy (8 positive 32 negative), an additional 8 undergo excisional biopsy (5 positive, 3 negative), what is the true positive rate of biopsy
a. 10%
b. 13%
c. 27%
d. 48%
e. 88%
 C. 27%
 per biorads manual, positive predictive value (PPV3) can be based on the results of biopsy, otherwise known as the positive biopsy rate = how often biopsies done are cancer = tp/(tp +fp3)
 fp3= number of recommended core biopsies that were benign + the number of recommended surgical biopsies that were benign= 13/(13 +32+3)= 13/48 = 27% which is cPPV1 = how often abnormal screens are cancer =tp / total screening cases given a biorads 0, 4, or 5PPV2 = how often biopsy recommended are cancer = tp/ tp + number cat 4 and 5 that underwent core biopsy and were benign + number cat 4 or 5 that underwent surgical biopsy and were benign and total cases of cat 4 or 5 lesion that were lost to follow up, refused biopsy, or surgeon elected to follow rather than biopsyIn this question, = 13/13 + 32 + 3 + 2 =13/50 = .26or 26%Cancer detection rate = [tp/total screening cases] * 1000
 A 65 year old woman with nipple thickening and scaling for 6 months duration. The mammogram reveals fine linear calcifications in the subareolar region. What is the most likely diagnosis?
a. plasma cell mastitis
b. paget carcinoma
c. inflammatory carcinoma
d. seborrheic keratosis
e. ductal ectasia
 B Paget carcinoma
 Paget’s disease of the nipple is an uncommon manifestation of breast cancer. It presents with eczemalike scaling and excoriation of the nipple and areola and with nipple discharge and itching. Mammographic findings are negative in 50%, nipple/areolar thickening, dilated duct, linearly distributed microcalcifications and a retroareolar soft tissue mass.
Source: Dähnert, 4th ed p. 473
 A biopsy of a non-palpable lesion comes back LCIS. Further management would include:
a. Unilateral mastectomy
b. Bilateral mastectomy
c. Lumpectomy
d. annual Follow up
 D. annual follow up.
 LCIS is usually mammographically occult. It is usually an incidental microscopic finding on a biopsy performed for unrelated reasons or findings. 20%-30% develop invasive ductal or lobular carcinoma withing 20 years of initial diagnosis. LCIS serves as a marker of increased risk for developing invasive cancer in either breast. There is a range of recommendation for management of LCIS ranging from observation (examination every 3-6 months + annual mammograms) to unilateral / bilateral simple mastectomy. (Dähnert 5th, p.549)Kopans writes, “most now recommend careful follow-up with annual mammography and at least annual if not more frequent clinical breast examination.” Source: Kopans 2nd ed. p.593“The most common method of treatment… is close clinical and mammographic surveillance…” Bassett p. 429Lobular CIS tends to be multicentric and tends to be bilateral. Usually represents an incidental pathologic finding and should not be considered a positive biopsy. It is not a true cancer; lobular neoplasia is the preferred term. The risk of invasive cancer in the opposite and ipsilateral breasts is increased (30 %, 15 % for each breast). The cancer that develops may be either ductal or lobular. Has no mammographic correlate. Management is controversial and ranges from bilateral total mastectomies to complete excision with careful observation. (Cardeñosa pg 257)
 A cyst aspiration demonstrates old blood, the next step is:
a. stop the cyst aspiration and obtain a surgical consult
b. complete the aspiration and perform pneumocystography
c. f/u in 6 months with an ultrasound
d. f/u in 6 months with a mammogram
 A. stop the cyst aspiration and obtain a surgical consult
 Two undisputed indications for biopsy based on findings at cyst aspiration exist. The first is the presence of a residual mass; the second is the presence of old blood in the aspirate. Dark (old) blood may be due to an intracystic tumor (papilloma or carcinoma) or aspiration of the necrotic center of a solid tumor. Bassett p. 367-368., Kopans 2nd p 287 (*This question has been on many old tests)
 A lesion comes back sclerosing adenosis and LCIS. The next most appropriate step is:
a. excisional biopsy
b. f/u in 1 year
c. excise and radiation
d. mastestectomy
 B. f/u in 1 year
 LCIS is usually mammographically occult. It is usually an incidental microscopic finding on a biopsy performed for unrelated reasons or findings. 20%-30% develop invasive ductal or lobular carcinoma withing 20 years of initial diagnosis. LCIS serves as a marker of increased risk for developing invasive cancer in either breast. There is a range of recommendation for management of LCIS ranging from observation (examination every 3-6 months + annual mammograms) to unilateral / bilateral simple mastectomy.
(Dähnert 5th p. 549)
 There is NO increased risk of invasive breast cancer with sclerosing adenosis so I don’t think this would change follow up – note previous references have said there is a 1.5-2x increase in CA with Sclerosing adenosis. (Dähnert 5th , 559)
 A spiculated mass is core biopsied and reveals atypical ductal hyperplasia. What is the most appropriate next step?
a. repeat core-needle biopsy
b. MRI
c. u/s
d. excisional biopsy
e. f/u 6 month mammogram
 D. excisional biopsy
 Core biopsy results of atypical ductal hyperplasia (ADH) requires excisional biopsy since the lesion is understaged. 18-48% of biopsy with ADH, ultimately prove to be carcinomas. Atypical ductal hyperplasia is a precursor for DCIS.
(Brant & Helms, p. 518)This is a premalignant lesion. – 5x relative risk for breast ca, 10x risk if combined with family hx. Cardeñosa 2nd p. 239
 A suspected summation pseudomass is seen on routine mammography, the next best step is:
a. Tangential view
b. Ecklund view
c. 90 degree lateral
d. Reverse craniocaudal
e. spot compression
 Answer: E. spot compression view
 90 degree lateral is a true lateral view of the breast and used for trouble‑shooting (not routine screening). It is used for evaluating a medial or lateral lesion of the breast to improve resolution (put lesion closest to the film), preoperative localization, for triangulation of lesions seen on CC but not on the MLO view (or vice versa).Reverse CC is used to located superior lesions, for kyphotic patients, and for needle localization when the lesion is closest to the inferior portion of the breast. Tangential view is used to demonstrate dermal lesion, improve detection/evaluation of palpable masses in dense breasts, and separate skin changes from possible post‑lumpectomy changes in post‑op patients.
 After a succesful stereotactic needle biopsy of microcalcifications, the pathologist reports benign pathology without calcifications seen, what should be the next step:
a. Repeat mammogram in 6 mo
b. Repeat mammogram in one year
c. Repeat MLO/CC immediately
d. Repeat biopsy
e. Radiograph of the paraffin block
 E. Radiograph of the paraffin block
 Calcifications are biopsied since they may represent underlying malignancy. Calcification must be seen on the pathology slide to assure that the area that is most likely to have malignancy is examined by the pathologist. The biopsy cannot be considered benign if calcifications are not seen on the pathology slide since there may be a sampling error. A radiograph of the paraffin block should be performed. Slides should be made in from the area of the paraffin block that contains calcifications. If no calcifications are found on the paraffin block than a repeat biopsy should be performed.
see also Cardeñosa: Breast Imaging Companion 2nd p. 431.
 American College of Radiology recommends mammogram screening according to which of the following guidelines?
a. yearly at age 40
b. yearly at age 50
c. every other year at age 40
d. every 1-2 years starting at age 40, followed by yearly
starting at age 50
 A. yearly at age 40
 Screening of asymptomatic patients Guidelines of American Cancer Society, American College of Radiology, American Medical Association, National Cancer Institute:
1. Breast self-examination to begin at age 20
2. Breast examination by physician every 3 years between 20 - 40 years, in yearly intervals after age 40
3. Baseline mammogram between age 35 - 40; follow-up screening based upon parenchymal pattern + family history
4. Initial screening at 30 years if patient has first-degree relative with breast cancer in premenopausal years; follow-up screening based upon parenchymal pattern
5. Mammography at 1-year intervals for women between 40 - 49 years
6. Mammography at yearly intervals after age 50
7. All women who have had prior breast cancer require annual follow-upAdditional recommendations:
1. Baseline mammogram 10 years earlier than age of mother / sister when their cancer was diagnosed
Source: Dähnert, 4th ed, p. 463
 At least how often should the phantom for mammography be tested:
a. Daily
b. Weekly
c. Monthly
d. Quarterly
e. Semi-annually
 B. Weekly
 Quality assurance with the mammography phantom should be performed weekly. Other tests that should be performed weekly are screen cleanliness and viewboxes and viewing conditions. Visual checklist should be performed weekly- Darkroom cleanliness and processor quality control should be performed daily by a designated technologist.- Repeat analysis and fixer retention analysis should be performed quarterly. Darkroom fog test, screen-film contact test, and compression test should be performed semi-annually.
(ACR Mammography Module, p. 85)
 Chance Of Cancer In A Non-Palpable, well-circumscribed, Non-Calcified Mass:
a. < 2%
b. 2-5%
c. 10%
d. 15 %
e. 20%
 A. < 2%
 The likelihood of malignancy for probably benign lesions as reported by Sickles is low:
1.4% for solid, circumscribed masses
0.6% for focal asymmetric density
0.4% for localized microcalcifications
0.3% for multiple solid circumscribed masses
see Cardenosa Breast Imaging Companion 2nd p. 151.** Dähnert 5th is contradictory: says 4% on p. 538, 2% in a Table on p. 551. Given this, ≤ 2% as specified by Cardeñosa is probably the best choice.
 Concerning magnification mammography:
a. Requires a grid
b. 3X magnification is recommended
c. Dose is increased
d. Same focal spot size
 C. Dose is increased
 c = T. Using a smaller focal spot, longer exposure times thus increased dose are needed. (Review of Radiologic Physics. Huda. 1995. pp. 199)
 a = F. For spot magnification, no grid is used. Scatter radiation is dissipated by air gap and thus no degradation of the image. (Breast Imaging Companion. Cardenosa. 1997. pp. 72)
 b = F. The maximal magnification is approximately 1.8X. (Breast Imaging Companion. Cardenosa. 1997. pp. 72)
 d = F. To counter the effect of increased blurring at the edges related to the penumbra effect, a small focal spot is needed (0.1 mm). (Breast Imaging Companion. Cardenosa. 1997. pp. 72)
 Core biopsy of a spiculated lesion comes back radial scar, you recommend:
a. excisional bx
b. repeat core bx
c. F/U mammogram in 6 mo
d. routine mammographic screening
e. MRI
 A. excisional biopsy
 “If we do a core biopsy on a woman with a spiculated mass and the histologic diagnosis is that of radial scar or compelx sclerosing lesion, we recommend excisional biopsy following preoperative wire localization.” Reason: the pathologist may have a difficult time making a precise diagnosis (on histology differential diagnosis includes tubular carcinoma and sclerosing adenosis) and even if the pathologist can make a diagnosis on core bx, the high incidence of associated proliferative changes with add without atypia, lobular neoplasia, and tubular carcinoma is such that we believe these lesions are best excised.
Cardeñosa 2nd p235
AAAAAAAAAAAAA
 Core biopsy of a spiculated mass reveals fibroadenoma. What is the most appropriate next step?
a. excisional Biopsy
b. repeat core needle biopsy
c. 6 month f/u mammogram
d. return to screening mammogram
e. U/S
 A. excisional biopsy
 Radiographic findings of a spiculated mass and pathology findings of a fibroadenoma are not concordant. A excisional biopsy must be performed A fibroadenoma is a solid mass which is usually oval/round with smooth, discrete margins. When the fibroadenoma undergoes central myxoid degeneration , “popcorn” calcifications are present on mammogram. A fibroadenoma is benign. A spiculated mass usually suggests malignancy.When the tissue diagnosis from percutaneous biopsy is both benign and concordant with prebiopsy imaging features, surgery is avoided. The only lesions that require excision are those already found to be malignant or those for which pathologic results are inconclusive or discordant. This approach can substantially reduce the percentage of surgical biopsies performed for benign lesions, to 30% or even less, thereby considerably reducing morbidity and cost. Also, remember that U/S should never be used to “downgrade” a mammographically suspicious lesion.
Sickles, E. A. Breast Imaging: From 1965 to the Present. Radiology 215: 1-16.
Liberman, L. . Percutaneous Imaging-Guided Core Breast Biopsy: State of the Art at the Millennium. AJR 174: 1191-1199
 Diagram of CC and MLO views of the breast. Posterior nipple lines should be within how many cm of each other:
a. 0.5 cm
b. 1 cm
c. 2 cm
d. 3 cm
 B. 1 cm
 The posterior nipple line on the MLO is obtained by drawing a line perpendicular to the nipple and extending it back to the pectoralis muscle. If the MLO is positioned properly the pectoralis muscle should be seen to the level of the posterior nipple line. On the CC view, a line drawn perpendicular to the nipple and extended posteriorly to edge of the film should be measured. This distance on the CC should be within 1 cm of the posterior nipple line length on the MLO. This assures that the posterior tissue is seen. (Brant & Helms, p. 495)
 If out of 1000 mammograms are performed per year and 50 biopsies are recommended. Out of those, 40 under go needle biopsy and 13 come back positive. Over the next year, a breast cancer is found. The sensitivity of the test is
a. 10%
b. 20%
c. 45%
d. 90%
 D. 90%
 TP=13,
 FN=1
 Sensitivity= TP/(TP+FN)
= 13/(13+1)
= 0.93
= 93%
 Mammogram without physical examination would reduce the cancer detection rate by what percentage?
a. 5-10%
b. 15-20%
c. 25-30%
d. 35-40%
e. 45-50%
 A 5-10%
 This question is worded awkwardly. What they are trying to ask is what percentage of breast cancers are clinically palpable and mammographically negative. As per the Breast Cancer Detection Demonstration Project (BCCDP), that rate is 9%.
Source: Bassett, Diagnosis of Diseases of the Breast, 1997 p. 20.
 MLO view of a mass is at the nipple level. CC view it is far lateral in the left breast. Where is it located?
a. 12 o’clock
b. 2
c. 3
d. 4
e. 6
 D. 4:00
 Here is another one where you would line up the lateral > MLO > CC views left to right and with the nipple lines straight across and draw the line. This would put the lesion in the lower half of the breast on the lateral view thus somewhere between the 3 and 6 o’clock position.
Cardenosa 2nd p 154
 Most aggressive subtypes of ductal carcinoma
a. comedo
b. papillary
c. cribiform
d. medullary
 A. Comedo
 The most aggressive subtype of ductal carcinoma is comedo
Ref: Dänhert pg 458
 Most common well-circumscribed breast cancer?
a. invasive ductal ca
b. tubular
c. medullary
d. papilloma
e. mucinous
 A. Invasive ductal carcinoma
 All of these masses can present as a well-circumscribed mass. Infiltrating ductal carcinoma is the most frequent (65% of all breast cancers) therefore a well circumscribed mass is likely to be invasive ductal. Tubular carcinoma (a well differentiated form of ductal carcinoma presents as a high-opacity nodule with spiculated margins and makes up 6-8% of breast CA. Medullary carcinoma presents as a solid, well-circumscribed mass. However, medullary carcinoma makes up only 2% of all breast cancers. IPapillary carcinoma is 1-4% of all CA of breast. Mucinous is 1.5-2%. Invasive/infiltrating ductal carcinoma makes up 65% of all breast cancers. It usually presents as a spiculated mass or malignant calcifications. (Dähnert, p.459-460) “…in fact, due to its frequency, the usual ductal type of carcinoma (NOS) makes up the majority of carcinomas that have circumscribed margins…”
Bassett p. 477.
 Most reliable indicator of intramammary lymph node on US:
a. notch
b. well circumscribed
c. lobulated contour
d. acoustic shadowing
 A. Notch
 Both Bassett and Cardenosa talk about the fatty hilum being characteristic of a intramammary lymph node but to even be considered it has to first be well circumscribed. The well circumscribed nature you would see on mammo and then go to US where you could see the fatty hilum or “notch” .
 Not a subtype of intraductal carcinoma:
a. solid
b. micropapillary
c. cribiform
d. comedo
e. medullary
 E. Medullary
 Types of intraductal carcinoma = noninvasive ductal in my books: comedo, papillary, cribriform, solid, micropapillary, paget’s dz of the nipple per Robbin’s pathology. see Dähnert p. 550.Medullary: younger than average women, BRCA1 gene, lack desmoplastic rxn, well circumscribed, lymphoplasmyctic infiltrate, pushing (non infiltrating) border
 Pathological examination of an excisional biopsy of a breast mass reveals sclerosing adenosis as well as invasive lobular carcinoma. What is the most appropriate next step?
a. unilateral mastectomy
b. bilateral mastectomy
c. lumpectomy with radiation
d. 1 year f/u mammogram
e. 2 year f/u mammogram
 C. lumpectomy with radiation.
 Invasive lobular carcinoma (ILC) accounts for 5% to 10% of all invasive breast cancers. All patients underwent surgical resection and postoperative radiation therapy. The 5-year actuarial locoregional recurrence rate was 9.8%, and the median time to recurrence was 77 months (range 41 to 113 months).
 The 5-year disease-specific survival rate was 93.7%. CONCLUSIONS: Breast conservation therapy for ILC achieves locoregional control in the majority of patients.
Ann Surg Oncol 1997 Oct-Nov;4(7):545-50 see http://www.aboutcancer.com/bre6c.htm
 Pathology of a lumpectomy specimen demonstrates atypical ductal hyperplasia. What should be done next.
a. Excisional biopsy.
b. Unilateral mastectomy
c. Bilateral mastectomy
d. Short term follow up
e. Lumpectomy and radiation
 A. Excisional biopsy
 Atypical ductal hyperplasia is a low grade intraductal proliferation with partial/incomplete developed features of noncomedo DCIS
Ref: Dähnert pg 469
 Atypical ductal hyperplasia is associated with 5x risk of breast cancer and should be excised. Atypical ductal hyperplasia has incomplete features of DCIS, which is premalignant.
Source: Primer 2nd ed. p.674, Dahnert 5th ed. p.560; Bassett p. 259
 Patient presents with clear nipple discharge from a single duct, the cause is most likely
a. papilloma
b. carcinoma
c. abscess
d. Paget’s
 A. Papilloma
 A papilloma is the most common cause of bloody or serous nipple discharge. Ductal ectasia is the second most common cause. A pituitary cause should be bilateral.
Source: Primer 2nd ed. p. 676; Dähnert 5th p. 542
 Pt is 3 months status post excisional biopsy of the right breast and presents with new 3 cm nontender palpable mass in the region of the excision. Most likely:
a. Recurrent cancer
b. Radial scar
c. Seroma
d. oil cyst
e. Abscess
 D oil cyst
 Oil cyst (aka Traumatic Lipid cyst) is associated with history of trauma in 40% of cases (ie. previous sx, radiation,...) and most commonly occur in the biopsy site/surgical scar or areolar region). (Radiology Review Manual, 3rd edition, Dähnert. 1996. pp. 412)
 Refer to the next figure: If you see a lesion on an MLO view only within the outer breast, what will it position be in the breast if on a lateral view the lesion projects superiorly?
a. Upper/inner quadrant
b. Lower/inner quadrant
c. Upper/outer quadrant
d. Lower/outer quadrant
 A. Upper/inner quadrant.
 “A change in location of a lesion relative to its distance from the nipple on the oblique and 90-degree lateral views can be used to determine whether a the lesion is in the lateral, central or medial aspect of the breast. For example, if on the 90-degree lateral the lesion moves up relative to the nipple or is higher than on the MLO film, the lesion is in the medial aspect of the breast. If in the 90-degree lateral film , the lesion moves down relative to the nipple or is lower than in the oblique film, the lesion is in the lateral aspect of the breast. If the lesion does not significantly in MLO vs. 90-degree lateral films, it is located in the central aspect of the breast.”
Source: Bassett, Diagnosis of Diseases of the Breast, 1997 p. 52.A lateral lesion will move lower on the lateral view and a medial lesion will move higher on a lateral view. Central lesions will not move on the lateral view. The MLO view divides the breast in upper and lower quadrants. Since the density is in the upper breast on the MLO it is in the upper quadrant. Since the density moves up on the lateral image it is a medial lesion. Therefore, the density is the upper, inner quadrant.
 Muffins Rise, Lead Falls or Down and Out in Beverly Hills (ACR module)
 The most common occult breast lesion is:
a. invasive lobular
b. invasive ductal
c. medullary
d. tubular
e. papillary
 B invasive ductal
 Invasive Ductal Carcinoma (NOS) accounts for 65% of breast cancers. It can occur as either an occult or palpable lesion. (DCIS‑10%; Invasive Lobular‑ 10‑13%; Tubular Ca‑ 6‑8%; Medullary Ca‑ 2%; Mucinous Ca‑ 2%; Others (ie. papillary ca)‑ 2%). (Radiology Review Manual , 3rd edition. Dähnert. 1996. pp. 405)
 The outcomes for breast studies are used to evaluate:
a. increased survival
b. decreased mortality
c. increased early detection
d. increased late detection
 B. decreased mortality
 Value of screening mammography: decrease in cancer mortality through earlier detection + intervention when tumor size small + lymph nodes negative. Source Dähnert 4th p 463“It has been shown that screening can decrease breast cancer mortality by about 30% for women screened at age 50 and older…” Bassett p. 329.Survival by itself is insufficient to establish an alteration in the natural history (or mortality) of breast cancer… randomized controlled trials with mortality as the end point are needed to overcome biases. Cardeñosa Breast Imaging Companion 2nd p. 81.
 What is the best location for a pre-biopsy positioning during ultrasound guided FNA of a breast mass?
 C. (for an FNA)
 Answer is A for the pre-fire position for a core biopsy.
 Ed. Note: positions ‘A’ and ‘D’ look similar, but the difference is that the needle tip can be visualized by the US transducer in position A (which is desirable).
 What is the kVp of mammography with a molybdenum target?
a. 19-23
b. 24-28
c. 29-33
d. 34-38
e. 39-43
 B. 24-28 kVp
 A low KVp (24-28) is needed to obtain good tissue contrast
Ref: Weissleder, pg 900. The 24-28 kVp range is best suited for mammography. 25 kVp is optimal without a grid, 26-27 kVp with a grid, 22-24 kVp for specimens and 26-27 kVp for magnification views. Source: Dähnert p.545; Bassett p. 31.
 What is the mechanism of inflammatory carcinoma?
a. aggressive angioinvasion
b. multifocal and multicentric involvement
c. lymphatic invasion
 C. lymphatic invasion
 Due to tumor emboli within dermal lymphatics
Prognosis 2% at 5yr
Dähnert 5th p551
 What is the number of cancers expected to be present in 1000 screening mammograms?
a. 0.1-0.3
b. 2-3
c. 20-30
d. 30-40
e. 40-50
 B. 2 – 3
 If 1000 women are screened with mammography, about 80 women will be recalled for additional studies. Biopsy will be recommended to about 16 of these women and cancer will be found in about 6 for these women.
(Brant & Helms, p. 492)
 Where is the location of most breast carcinomas?
a. acinus
b. ductule
c. terminal ductal lobular unit
d. intralobular terminal duct
 C. terminal ductal lobular unit.
 The TDLU is the site of fibroadenomas, epithelial cysts, apocrine metaplasia, adenosis, epitheliosis, DCIS, LCIS and infiltrating ductal and lobular carcinoma.
Source: Dähnert, 4th ed, p 455.
 Which H&D curve is most approprate for mammography?
 E. The curve with the narrowest latitude
 H & D curve: another term for characteristic curve for a film. The letters stand for Hurter and Driffield who investigated these characteristics and published a paper on such curves in 1890. A curve used to show the exposure properties of a film screen system. How the exposure of the film is related to the measurable signal (film blackening or density). Different for different film types. See figure provided. The shape tells the user the contrast properties (slope) and the useful exposure range (length of linear part) indicate the speed of the film which can be judged from the curve’s position along the horizontal axis. “Mammographic screen-film has higher resolution and higher film contrast than conventional radiographic screen-film, but also has less exposure latitude, which can be a problem when imaging thick, dense breasts”. Bushberg 2nd p. 214.
 Which histology on DCIS carries the worst prognosis?
a. solid
b. papillary
c. cribriform
d. comedo
 D. Comedo
 “In reality, the histologic subtypes of DCIS are often intermediate and intermixed, and the prognosis is probably dependent on the nuclear grade”
Bassett 1st p 446“Higher recurrence rate than the non-comedo group…” Dähnert 5th p. 549.also, note that solid, cribriform, and papillary choices are noncomedo.
 Which of the following is associated with an increased risk of carcinoma?
a. Fibrosis
b. ductal ectasia
c. adenosis
d. benign cystic hyperplasia
e. fibrocystic disease
f. peripheral multiple papillomas
 F. Multiple papillomas
 Multiple Papillomas are usually peripheral within terminal ductal lobular unit. They may appear as a round/oval nodule. There is 5% frequency of carcinoma development. The increased risk of carcinoma is dependent on degree of cellular atypia. Adenosis, ductal ectasia, fibrosis, fibrocystic disease, and mild hyperplasia are not associated with increased risk of carcinoma.
(Dähnert, p. 473, 469)
 CENTRAL SOLITARY PAPILLOMA (more common)
Location: subareolar within major duct; NOT premalignant
• spontaneous bloody / serous / clear nipple discharge (52 - 100%); Most common cause of serous / sanguinous nipple discharge!
• “trigger point” = nipple discharge produced upon compression of area with papilloma; • intermittent mass disappearing with discharge
negative mammogram / intraductal nodules in subareolar area; asymmetrically dilated single duct; subareolar amorphous coarse calcifications; dilated duct with obstructing / distorting intraluminal filling defect on ductography (= galactography); Cx: 0 – 1
 4% frequency of carcinoma development (Dähnert); 1.5 – 2. times increased cancer risk (Kopans) PERIPHERAL MULTIPLE PAPILLOMAS
- Location: within terminal ductal lobular unit; bilateral in up to 14%
- In 10 - 38% associated with: atypical ductal hyperplasia, lobular carcinoma in situ, papillary + cribriform intraductal cancers, radial scar
- Nipple discharge (20%); Round / oval / slightly lobulated well-circumscribed nodules; Segmental distribution with dilated ducts extending from beneath the nipple (20%); May be associated with coarse microcalcifications; Cx: 5% frequency of carcinoma development; increased risk dependent on degree of cellular atypia
- Prognosis: in 24% recurrence after surgical treatment
- DDx: invasive papillary carcinoma (Dahnert)
- Increased risk of development of breast CA suggested but not proven (Kopans)
 Which one of the following is not an advantage of core biopsy versus fine needle aspiration:
a. can be performed under US
b. Special expertise by the pathologist is not required
c. Able to differentiate between infiltrating ductal
carcinoma and DCIS
d. Better false negative rate
 A can be performed under US
 Choice “A” is not an advantage for core biopsy, because either can be performed under U/SCNB superior to FNAC because:
1. the interpretation can be rendered by a pathologists who do not have special training in cytopathology
2. insufficient specimens are less frequent
3. it can usually differentiate in situ from invasive carcinoma
4.it can more completely characterize liesions
Basset 1st p. 252
 Which one of the following is not associated with ductal calcifications?
a. papillomatosis
b. Paget’s
c. secretory diseases
d. DCIS
e. adenosis
 E: adenosis
 Ductal calcifications occur with secretory disease, epithelial hyperplasia, atypical ductal hyperplasia, and intraductal carcinoma. It also states that lobular microcalcifications occur with adenosis. Paget’s is associated with DCIS and microcalcifications. Given all this I think adenosis is probably the correct choice
Dähnert 5th p. 540, 564
 Which type of cancer most likely to occur within a cyst:
a. Colloid
b. Papillary
c. Mucinous
d. Tubular
 B. Papillary
 Dark (old) blood may be due to an intracystic tumor (papilloma or carcinoma)… Intracystic papillomas are much more commonly the cause of bloody aspirated…” Bassett p. 267-268.
 A cyst aspiration demonstrates old blood, the next step is:
a. stop the cyst aspiration and obtain a surgical consult
b. complete the aspiration and perform pneumocystography
c. f/u in 6 months with an ultrasound
d. f/u in 6 months with a mammogram
e. routine f/u in 1 year
 A. stop the cyst aspiration and obtain a surgical consult
 Two undisputed indications for biopsy based on findings at cyst aspiration exist. The first is the presence of a residual mass; the second is the presence of old blood in the aspirate. Dark (old) blood may be due to an intracystic tumor (papilloma or carcinoma) or aspiration of the necrotic center of a solid tumor. Bassett p. 367-368., Kopans 2nd p 287
 A lesion is noted on the left MLO view a few centimeters deep to the nipple centrally. On the CC view it is located in the far lateral position. Where is the lesion located?
a. 2 o'clock
b. 3 o'clock
c. 4 o'clock
d. 7 o'clock
e. 8 o'clock
 B. 4 o’clock
 The best answer for the description given. For a discussion of triangulation, see Cardeñosa Breast Imaging Companion 2nd p. 154. a case of a 4 o’clock lesion is shown on p. 157.
 A suspected summation “pseudomass” is seen on routine mammography, the next best step is:
a. Tangential view
b. Ecklund view
c. 90 degree lateral
d. Reverse craniocaudal
 C. 90 degree lateral
 X-Ray beam enters breast laterally, bucky is placed medially. Indications:
- In the triangulation of a lesion seen on the CC view but not on the MLO view (or vice versa).
- Medial lesion evaluation
- needle localization see Cardeñosa p. 141.Reverse CC is used to located superior lesions, for kyphotic patients, and for needle localization when the lesion is closest to the inferior portion of the breast.Tangential view is used to demonstrate dermal lesion, improve detection/evaluation of palpable masses in dense breasts, and separate skin changes from possible post‑lumpectomy changes in post‑op patients.** Spot compression would be the best choice, but was not an option**
 Common associations with Medullary carcinoma of the breast include all of the following except:
a. Usually soft to palpation
b. Often presents as a well-defined lesion
c. Commonly calcify
d. Cause a marked desmoplastic response
 C. Commonly calcify
 (FALSE)Medullary CA
- soft on exam
- intense lymphoplasmocytic response
- well-defined round/oval noncalcified uniformly dense mass (hemorrhage) with lobulated margin
- fastest growing breast CA see Dähnert 5th p. 550.
 Concerning Gadolinium in MR in breast imaging of malignancy, which is true?
1. Requires fat suppression
2. Demonstrates very early enhancement
3. Does not wash out.
4. Demonstrates continued increased enhancement
after three minutes
5. Best seen on T1 Inverted Turbo Spin (TITS)
sequence
 1. True. see Bassett p. 228; also AFIP Breast Imaging Module p. 146.
 2. True. “the classic appearance of malignant breast tumors with contrast-enhanced MR imaging is a rapidly enhancing (within a few minutes) lesion …” Bassett p. 228.
 3. False. According to the AFIP Breast Imaging Module p. 151, lesions that wash out (Type III pattern) are 57% malignant. This seems to contradict some of the (older) information in Bassett & Jackson.
 4. True. “rapid increase in signal intensity after contrast injection reaching a markedly higher amplitude than parenchymal tissue, followed by a plateau and early washout.” Given the plateau phase, it seems likely that a malignant lesion will demonstrate greater enhancement than normal breast tissue for some amount of time after 3 minutes. Dähnert 5th p. 555.
 5. ? maybe—Bassett describes “FAST GRASS” sequences.
 Concerning magnification mammography:
1. Requires a grid
2. 3X magnification is recommended
3. Dose is increased
4. Same focal spot size
 1. False. For spot magnification, no grid is used. Scatter radiation is dissipated by air gap and thus no degradation of the image. Cardeñosa Breast Imaging Companion 2nd p. 129.
 2. False. The maximal magnification is approximately 1.8X
 3. True. Using a smaller focal spot, longer exposure times thus increased dose are needed. (Review of Radiologic Physics. Huda. 1995. pp. 199)
 4. False. To counter the effect of increased blurring at the edges related to the penumbra effect, a small focal spot is needed (0.1 mm).
 Concerning medullary carcinoma of the breast:
1. soft on palpation
2. has a fibrous stroma
3. carries a worse prognosis than ductal carcinoma
4. is well circumscribed
5. calcifications
 1. True. Well-defined, round, expansile lesion; soft in consistency
see Dähnert 5th p. 550.; Cardeñosa Breast Imaging Companion 2nd p. 258.
 2. False: “…the fibrous stroma should be scant…” Bassett p. 487.
 3. False: Despite its locally aggressince histologic features, the prognosis of pure medullary carcinomas is better than that seen with infiltrating ductal carcinomas. Bassett p. 488.
 4. True: Medullary carcinoma is a well‑circumscribed mass with nodular architecture and lobulated contour. (Radiology Review Manual , 3rd edition. Dahnert. 1996. pp. 407); Bassett p. 486.
 5. False: It is described as well‑defined round / local noncalcified uniformly dense mass. Dähnert 5th p. 550.
 In a patient where a core needle biopsy demonstrated atypical ductal hyperplasia (ADH), the next management choice is:
a. Excisional biopsy.
b. Repeat biopsy
c. Follow in 6 months
d. Follow in 1 year.
 A. Excisional biopsy
 ADH is a difficult histologic diagnosis that may be misinterpreted due to samplilng error on core needle biopsy. ADH may be confused with intraductal carcinoma histologically, and the two lesions can coexist. Therefore, it is our practice to recommend excisional biopsy following a core needle biopsy of ADH. Bassett 258-259.
 In a patient where a core needle biopsy produces a radial scar, the next management choice is:
a. Excisional biopsy.
b. Repeat biopsy
c. Follow in 6 months
d. Follow in 1 year.
e. mastectomy
 A. Excisional biopsy
 It is not possible to differentiate between radial scar and breast carcinoma by imaging, and biopsy should be performed. Excisional biopsy rather than needle biopsy is usually recommended as the definitive procedure because radial scar has been shown to be associated with invasive ductal carcinoma (NOS), tubular carcinoma, DCIS, LCIS, and atypical hyperplasia. In addition, it can be difficult for the pathologist to distinguish between radial scar and tubular carcinoma histologically, especially on small core needle biopsy specimens. Bassett p. 420.
 Matching with diagram of the breast:
1. adenosis
2. Infiltrating lobular
3. Infiltrating ductal
4. papilloma
a. acinus or terminal ductule
b. terminal ductal lobular unit
c. duct near the nipple
d. lymph node
I think 3 is in tdlu
 1. A: acinus or terminal ductule includes lactational change, sclerosing adenosis, lobular hyperplasia, and in situ and invasive lobular carcinomas. see also Bassett p. 409.
 2. A: acinus or terminal ductule (see above explanation)
 3. C: duct near the nipple includes epitheliosis, papillomatosis, ductal hyperplasia, intraductal carcinoma, and various types of invasive ductal carcinomas. see Bassett p. 348
 4. C: duct near the nipple. The Terminal Duct Lobular Unit (drawing at left) consists of an interlobular duct and associated lobule. The lobule itself is composed of terminal ducts and acini (sometimes called ductules and terminal ductules, respectively).
.
 Most reliable indicator of intramammary lymph node on US:
a. notch
b. well circumscribed
c. lobulated contour
d. acoustic shadowing
 A. Notch
 The notch is very specific for a lymph node. Cardeñosa (p. 312) writes:
”…a fatty hilum should be demonstrated before assuming a mass is a lymph node… demonstrating this may require spot compression views.”
 Of the following breast carcinomas, which is the most likely to present as a well defined lesion:
a. Colloid
b. Tubular
c. Medullary
d. Infiltrating ductal
e. Inflammatory
 D. Infiltrating ductal carcinoma
 “…in fact, due to its frequency, the usual ductal type of carcinoma (NOS) makes up the majority of carcinomas that have circumscribed margins…”
Bassett p. 477.Types of breast CA and their incidence: Infiltrating Ductal (NOS), 52.6%; mixed types that include NOS, 28.0%; Lobular invasive, 6.2%; Tubular, 1.2%; Mucinous, 4.9%. others—see Bassett p. 474.
 Patient presents with clear nipple discharge from a single duct, the cause is most likely
a. papilloma
b. carcinoma
c. abscess
d. Paget’s
 A. Papilloma
 A papilloma is the most common cause of bloody or serous nipple discharge. Ductal ectasia is the second most common cause. A pituitary cause should be bilateral.
Source: Primer 2nd ed. p. 676; Dähnert 5th p. 542
 Pt is 3 months status post excisional biopsy of the right breast and presents with new 3 cm nontender palpable mass in the region of the excision. Most likely:
a. Recurrent cancer
b. Radial scar
c. Seroma
d. Oil cyst
e. Abscess
 D. Oil cyst
 Aka Traumatic Lipid cyst--is associated with history of trauma in 40% of cases (ie. previous sx, radiation,...) and most commonly occur in the biopsy site/surgical scar or areolar region). 3 months out makes an abcess unlikely. (Dähnert, Radiology Review Manual, 5th edition p. 557)
 The least mammographically apparent breast cancer is:
a. Medullary.
b. Tubular
c. Lobular carcinoma in situ
d. Paget's disease of the breast.
e. DCIS.
 C. Lobular carcinoma in situ
 There are no mammographic or sonographic features of lobular neoplasia. It is an incidental finding for another mammographic or clinical abnormality. Associated with an approximate 8-11 times increased risk of carcinoma in either breast. Bassett p. 429.
 The most characteristic findings of Paget's carcinoma of the breast are secondary to:
a. Retraction of Cooper's ligaments
b. Cancerous invasion of the dermal lymphatics
c. Distortion of the breast normal architecture
d. Metastasis to the axillary lymph nodes
e. Infiltration of the nipple epidermis
 E. Infiltration of the nipple epidermis
 Paget’s disease of the nipple (described by Sir James Paget in 1874):
uncommon manifestation of breast cancer characterized by infiltration of the nipple epidermis by adenocarcinoma
- erythema, scaling, erosion, ulceration, retraction of nipple and areola
Dähnert 5th p. 564.
 The outcomes for breast studies are used to evaluate:
a. increased survival
b. decreased mortality
c. increased early detection
d. increased late detection
 B. decreased mortality
 Survival by itself is insufficient to establish an alteration in the natural history (or mortality) of breast cancer… randomized controlled trials with mortality as the end point are needed to overcome biases.
Cardeñosa Breast Imaging Companion 2nd p. 81.
 What is the mechanism of inflammatory carcinoma?
a. aggressive angioinvasion
b. multifocal and multicentric involvement
c. lymphatic invasion
 C. lymphatic invasion
 Dut to tumor emboli within dermal lymphatics
Prognosis 2% at 5yr
Dähnert 5th p 551
 Which histology on DCIS carries the worst prognosis?
a. solid
b. papillary
c. cribriform
d. comedo
 D. Comedo
 comedo type DCIS is high nuclear grade; it has a higher recurrence (worse prognosis) than the non-comedo group. Dähnert 5th p. 548.
 Which of the following is NOT an advantage of core needle biopsy (CNB) over fine needle aspiration (FNA):
a. More pathologists demonstrate expertise in reading the
samples.
b. More able to diagnose a benign condition
c. Can be performed by ultrasound
 C. Can be performed by ultrasound
 Both CNB and FNA can be ultrasound-guided see Bassett p. 263.“…barriers to acceptance of FNA for mammographically detected abnormalities in the United States have included inadequate numbers of skilled cytopathologists to promote and validate the procedure, variability in reported accuracy from one institution to another, high rates of insufficient samples, requirement for extremely accurate needle placement, and the medicolegal environment.” Bassett p. 252.A disadvantage of FNA is the large number of cytologies read as atypia, leading to excisional biopsies for benign conditions…” Bassett p. 255.
 Which one of the following is not associated with ductal calcifications?
a. papillomatosis
b. Paget’s
c. secretory diseases
d. DCIS
e. adenosis
 E. Adenosis
 The mammographic findings [of adenosis] are usually non-specific and include diffuse ill-defined 3- to 5-mm nodular densities, multiple round or punctuate calcifications (often associated with radiographically dense breast tissue in sclerosing adenosis) and focal speculated masses with or without microcalcifications, mimicking breast CA. Bassett p. 406.Lesions that develop in the major ducts of the breast include Paget’s disease, duct ectasia, solitary large duct papillomas. Atypical ductal hyperplasia arises at the level of the terminal duct lobular unit (TDLU). Intraductal carcinoma (DCIS), and invasive or infiltrating ductal carcinoma arise at the level of the TDLU. (Kopan’s pages 513-516)
 Which part of the breast if not well visualized on MLO view?
a. inner upper
b. inner lower
c. outer upper
d. outer lower
 A. inner upper
 “On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 44.; also old questions & AFIP notes (Breast Module)
 (T/F) 1.5 to 2 times increased risk of breast cancer:
1. cyst
2. fibrocystic disease
3. non-sclerosing adenosis
4. moderate hyperplasia
1.5-2X
 5. atypical ductal hyperplasia 5X
 1. False. Presumably refers to simple cysts. Some cysts, such as apocrine cysts, are at increased risk for breast CA. Dähnert p. 556.
 2. False*. Probably the best answer. Note that the term fibrocystic disease has fallen out of favor, and fibrocystic change is now recommended. Per Bassett p. 397, “Most of the benign histologic findings within the spectrum of fibrocystic change have no associated increased risk for breast carcinoma...”.
 3. False. this is just plain adenosis, which has no increased risk.
 4. True. also note that a papilloma with a fibrovascular core carries 1.5-2x risk.
 5. False. because it carries 5x increased risk.Other entities that carry no increased risk are fibroadenoma, fibrosis, adenosis, duct ectasia, mild hyperplasia (< 4 cell layers in depth), mastitis, and squamous or apocrine metaplasia
Table 25-1 on Bassett p. 397 correlates well with this question.
 (T/F) Concerning subpectoral implants as compared to subglandular implants:
1. There is less of chance of capsule contraction with subpectoral implants
2. Surgical placement of subpectoral is easier
3. It is easier to evaluate residual breast tissue with subpectoral implants
4. Subpectoral are less likely to rupture
5. There is more forward projection of the breast
 1. True. Subpectoral breast implants have less risk of capsular contracture (1-18%) than subglandular (18-50%).
 2. False. Makes sense, since they have to be placed under pectoralis muscles.
 3. True. Displacement (or Eklund) views are more difficult to perform in patients with subglandular implants, especially if they have associated capsular contracture. Brant & Helms, p.547.
 4. True. better protected, less chance of capsular contraction.
 5. True. Because the pectoralis muscle tends not to sag, placement of the implant behind the muscle means that the implant is likely in these women to be higher on the chest than sagging breast tissue, which will tend to look like separate tissue hanging from the firmer, higher mound of the implant. Because of this, in cases where subpectoral or submuscular placement is desired (read on for the reasons this might be so), many surgeons will recommend a mastopexy (breast lift) in conjunction with a subpectoral or submuscular augmentation when there is significant droop
 (T/F) Invasive lobular carcinoma can have the following appearance:
1. Calcifications
2. Spiculation
3. Rounded mass
4. Architectural distortion
5. Ductal dilatation
 1. True. but, read the exact wording of the question carefully—“…calcifications are uncommonly seen in invasive lobular carcinoma…” Bassett p. 483.
 2. True. “…the most common presentation of invasive lobular carcinoma is a spiculated mass…” Bassett p. 480.
 3. True. “Rarely, lobular carcinoma presents as a circumscribed mass…” Bassett p. 481.
 4. True. “architectural distortion may accompany the asymmetric density”
 5. False. no references describe ductal dilatation. Dähnert 5th p. 550.
 (T/F) The following occur in the terminal duct lobular unit (TDLU):
1. papilloma
2. DCIS
3. invasive ductal carcinoma
4. fibroadenoma
 1. False. The ’96 recall specified solitary papilloma, which is probably what is meant here—this occurs in the duct. However, peripheral multiple papillomas do occur within the TDLU Dähnert 5th p. 564.
 2. True. see Dähnert 5th p. 544, 559 for the remaining choices.
 3. True.
 4. True.
 Increasing the processor time or temperature, increases:
a. Subject contrast
b. Noise
c. Patient dose
d. Film latitude
 B. Noise“
 …for very fast film, a reduction in temperature may reduce noise… when the developer temperature is slightly higher than the manufacturer’s recommendations, film speed and contrast increase but so do radiographic noise and film fog.” Bassett p. 37.It works like this—hotter/longer processing makes the film more sensitive (= decreased radiation dose and decreased film latitude). But, less radiation (i.e., photons) means more noise. (recall SNR = ; see Bushberg 2nd p. 278).Subject contrast is intrinsic to the breast—completely independent of processing.
 Most common cancer in a cyst:
a. medullary
b. papillary
c. tubular
d. colloid
e. invasive ductal
 B. Papillary
 Dark (old) blood may be due to an intracystic tumor (papilloma or carcinoma)… Intracystic papillomas are much more commonly the cause of bloody aspirated…” Bassett p. 267-268.
 Phantom QI evaluation is done:
a. daily
b. weekly
c. monthly
d. quarterly
e. semiannually
 B. Weekly
 To maintain the quality and consistency of clinical images in practice, MQSA’s final regulations mandated that facilities conduct the phantom image test weekly (instead of monthly as under the interim regulations). Bushberg Table 8-8 p. 226.
Source: http://www.fda.gov/cdrh/mammography/scorecard-article1.html (under section B)
 Regarding the mammographic appearance of reduction mammoplasty (multiple true/false):
1. Subareolar ducts may be disrupted
2. Superior skin thickening
3. The nipple may be moved inferiorly
4. Fibroglandular tissue may be moved inferiorly
5. Dystrophic calcifications
 1. True. subareolar ducts may be disrupted, particularly by a “transplantation type” of reduction mammoplasty.
 2. False. skin thickening is most commonly seen in the areolar region and the inferior aspect of the breast, in the areas of surgical anastamosis.
 3. False. the nipple moves superiorly, because there is less skin above the nipple and more below the nipple than in normal breasts. Bassett p. 583.
 4. True. Glandular tissue, which is normally most prominent in the upper-outer quadrant, moves inferiorly in the breast after reduction mammoplasty Source: Kopans, Breast Imaging 2nd p. 460-62; Bassett p. 583
 5. True. the most common findings are oil cysts, often with spherical lucent centered, eggshell, or dystrophic calcifications.
Deltoid
shoulder
 Sonographic features favoring the diagnosis of malignancy include:
1. Mass taller than it is wide
2. Thin capsule
3. Lesion more echogenic than surrounding fatty tissue
4. Increased through transmission
 1. True. This is a result of the fact that malignancies tend to cross normal tissue planes, resulting in a “taller than wide” appearance. Cardeñosa p. 178.
 2. False. Benign characteristic. Cardeñosa p. 174.
 3. False. Benign characteristic.
 4. False. Cardeñosa classifies enhanced transmission as an “intermediate” characteristic.Note that the Negative predictive value of a sonographically benign mass is 99.5%.
 The likelihood of malignancy in a smooth, round, nonpalpable, < 1 cm mass is approximately:
a. 2%
b. 5%
c. 10%
d. 20%
e. 50%
 A. 2%
 The likelihood of malignancy for probably benign lesions as reported by Sickles is low:
1.4% for solid, circumscribed masses
0.6% for focal asymmetric density
0.4% for localized microcalcifications
0.3% for multiple solid circumscribed masses
see Cardeñosa Breast Imaging Companion 2nd p. 151.
 The MLO view may exclude the posterior tissues of which region of the breast:
a. Inner?
 b. outer
c. medial
d. lateral
e. axillary
 C. Medial
 “On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 50.; also old questions & AFIP notes (Breast Module)
 The most common well-circumscribed breast cancer is:
a. colloid
b. medullary
c. invasive ductal cancer NOS
d. papillary
e. tubular
 C. invasive ductal cancer NOS
 Invasive ductal carcinoma shows up most commonly as a spiculated and nodular growth but since it is the most common cancer it is the most common circumscribed cancer (Diagnostic Breast Imaging 2nd ed. Pg 276) .“…in fact, due to its frequency, the usual ductal type of carcinoma (NOS) makes up the majority of carcinomas that have circumscribed margins…” Bassett p. 477.
 What is the most appropriate follow-up for a 2 cm spiculated mass with a core biopsy path result of fibroadenoma:
a. 6 month follow-up mammogram
b. excisional biopsy – most conservative answer
c. repeat core
d. mastectomy
 B. excisional biopsy
 Whenever there is discordance with the diagnostic procedure (mammogram, US) or clinical findings and the core-specimen pathology findings then the analyses is ignored and it is recommended that the patient undergo excisional biopsy. In this case the mammogram demonstrated a worrisome finding (spiculated mass) and the pathology did not correlate. Due to the chance of sample error (although low) and the suggestive X-ray findings the patient should undergo open surgical BX. Bassett p. 255 Fig,. 17-4.If the lesion is borderline radiographically then some recommend mammogram q 4 months for one year. If the patient is very close to your threshold for possible cancer then an alternative is to repeat the core BX at the first 4 month follow up.
 What is the most appropriate follow-up for a patient s/p core needle biopsy with the path finding of atypical ductal hyperplasia?
a. follow-up mammography in 6 months
b. excisional biopsy
c. mastectomy
d. repeat core biopsy
 B. excisional biopsy.
 Atypical ductal hyperplasia is associated with 5x risk of breast cancer and should be excised. Atypical ductal hyperplasia has incomplete features of DCIS, which is premalignant. Source: Primer 2nd ed. p.674, Dahnert 5th ed. p.560; Bassett p. 259
 Which cancer has the best prognosis:
a. invasive lobular
b. medullary
c. tubular
d. colloid
e. DCIS
 C. Tubular
 Tubular carcinoma is highly differentiated and has a favorable prognosis. Most benign of all breast Ca. Diagnostic Breast Imaging, p.227.
 Pure mucinous carcinoma has a good prognosis. Diagnostic Breast Imaging, p.312.
 Medullary Ca has a significantly better survival than invasive ductal NOS.
 Papillary Ca 90% 5 yr survival after mastectomy, better prognosis than infiltrating ductal. Dahnert, p. 407.
 DCIS is generally treated with mastectomy with cure rates approaching 100%. Approximately 2% of DCIS is found to be metastatic. Bassett p. 490.
 Woman with bilateral increased density of the breasts. Breasts tender, no skin thickening on mammogram. CXR shows mild cardiomegaly and prominence of the brachiocephalic vessels. What is the most likely etiology of the increased breast density:
a. estrogen replacement therapy
b. CHF
c. inflammatory carcinoma
d. mastitis
e. SVC sydrome
CHF
 65 yo woman with scaling and erythema around the nipple for the last 6 months. On mammo, there are fine linear calicifications.
a. duct ectasia
b. keratosis
c. inflammatory carcinoma
d. Paget's
 D. Paget’s
 Paget’s disease of the nipple (described by Sir James Paget in 1874):
uncommon (1-5%) manifestation of breast cancer characterized by infiltration of the nipple epidermis by adenocarcinoma
- erythema, scaling, erosion, ulceration, retraction of nipple and areola
Dähnert 5th p. 564.Mammography may be normal, or may show nipple calcifications. Cardeñosa Breast Imaging Companion 2nd p. 212.
 A 60 y/o woman is currently being treated for DVT’s. She has an ill-defined 1 cm density on mammogram with a 2 cm area of discoloration in the skin overlying the mammographic finding. The breast exam is otherwise normal and she has no history of trauma. The most likely cause is:
a. Mondor’s disease
b. inflammatory carcinoma of the breast
c. hematoma
d. fat necrosis
e. hemorrhagic cyst
 C. Hematoma
 Hematoma of breast: causes—surgery, blunt trauma, coagulopathy, anticoagulant therapy. Can see well-defined ovoid mass, ill-defined mass with diffusely increased density, adjacent thickening. Can get fibrosis with spiculations. Hematomas can simulate a breast abscess or a carcinoma.Inflammatory carcinoma: char. mammographically by generalized skin thickening and increased radiographic densityAbscess: most infections of the breast are treated before they form an abscess. Furthermore, most breast abscesses occur in young women and are often assoc. with nursing. Source: Kopans p 287Other Sources: ACR Breast Syl 3rd pp 76, 91; Dähnert 5th p. 561
 Benign breast calcifications include (T/F):
1. dystrophic
2. rim
3. coarse
4. amorphous
5. casting
 1. True.
 2. True.
 3. True. Benign calcifications: skin, vascular, coarse (popcorn), rod-like, spherical ± lucent center, rim / eggshell, milk of calcium, suture calcifications, dystrophic, punctate.
 4. False. Intermediate concern: indistinct or amorphous BI-RADS 3rd p. 43.
 5. False. Higher probability of malignancy: pleomorphic or heterogeneous, fine and/or branching (casting). Remember, casting suggests a duct filled with cancer.
AFIP Breast Module 2003 p. 90; BI-RADS 3rd p. 48.
 Characteristics of medullary carcinoma of the breast include (T/F):
1. soft to palpation
2. worse prognosis than intraductal carcinoma
3. calcification
4. fibrotic stroma
 1. True.
 2. False
 3. False.
 4. False. Medullary CA (2-4% of breast CA, typically < 50 yo women)
- soft on exam
- intense lymphoplasmocytic response
- well-defined round/oval noncalcified uniformly dense mass (hemorrhage) with lobulated margin
- fastest growing breast CA see Dähnert 5th p. 550
- fibrous stroma should be scant Bassett p. 487.
- typical medullary carcinomas have better outcome than do the NOS type of invasive carcinoma (92% 10-year survival).
 Choose the single false answer among the following choices concerning advantages of core needle biopsy versus fine needle aspiration:
a. core biopsy can be performed with ultrasound guidance
b. pathologists are more comfortable reading core biopsy specimens
c. samples are more likely adequate with core biopsy
d. invasive vs. intraductal carcinoma can be distinguished
e. a benign finding may be confidently diagnosed with core biopsy
 A. core biopsy can be performed with ultrasound guidance
 Both CNB and FNA can be ultrasound-guided see Bassett p. 263.“…barriers to acceptance of FNA for mammographically detected abnormalities in the United States have included inadequate numbers of skilled cytopathologists to promote and validate the procedure, variability in reported accuracy from one institution to another, high rates of insufficient samples, requirement for extremely accurate needle placement, and the medicolegal environment.” Bassett p. 252.A disadvantage of FNA is the large number of cytologies read as atypia, leading to excisional biopsies for benign conditions…” Bassett p. 255
 Concerning the routine chest radiographs and routine mammography:
1. the screens are thicker in mammography
2. the screens are faster in mammography
3. chest films have wider latitude
4. there is a single screen in mammography
 1. False. Screens are thinner, to allow the light photons to diffuse less before interacting with the film.
 2. False. This is a departure from past answers, but here’s why:
”The absolute speed of a screen-film combination is simply the inverse of the exposure (measured in roentgens) required to achieve an OD of 1.0 + base +fog…” Bushberg 2nd p. 161. Then, ”…the 100-speed system [in mammography] requires 12 to 15 mR radiation exposure to achieve the desired film optical density. For comparison, a conventional “100-speed” screen film cassette requires about 2 mR.” Bushberg 2nd p. 212.
 3. True. Mammographic screen-film has higher resolution and higher film contrast than conventional radiographic screen-film, but also has less exposure latitude, which can be a problem when imaging thick, dense breasts. Bushberg p. 214.
 4. True. Bushberg p. 212.
 In mammography , unsharpness is directly related to:
1. compression
2. kVp
3. focal spot size
4. film-screen contact
5. exposure time
 1. True. Compression #1 immobilizes the breast (reduces motion unsharpness), #2 brings structures closer to the receptor (geometric unsharpness), and #3 decreases scattered radiation, among other things see Bassett p. 45-46.
 2. True. higher-energy photons have a higher probability of penetrating the breast, reducing exposure time (& motion).
 3. True. focal spot size affects geometric unsharpness. Bassett p. 32.
 4. True. for geometric reasons. In fact, it is recommended to wait 15 minutes after loading the cassette so air can escape from between the film and the screen. Bassett p. 78.
 5. True. longer exposure time = more motion unsharpness
 The anode most frequently used in mammo is:
a. tungsten
b. molybdenum
c. rhodium
d.
 B. Molybdenum
 Molybdenum is the most common anode material [in mammography], although rhodium and tungsten targets are also used. Characteristic X-rays at 17.5 and 19.6 keV. Bushberg 2nd p. 194.
 The goal of a study evaluating screening mammography is to evaluate:
a. increased survival rate
b. mortality reduction
c. interval carcinoma
d. the increase in early detection of cancers
e. the increase in late detection of cancers
 B. mortality reduction
 Survival by itself is insufficient to establish an alteration in the natural history (or mortality) of breast cancer… randomized controlled trials with mortality as the end point are needed to overcome biases.
Cardeñosa Breast Imaging Companion 2nd p. 81.
 The most characteristic feature of a lymph node on US--
a. well circumscribed
b. oval
c. ill defined margins
d. lobulated mass
e. notching
 E. Notching
 Normal lymph nodes are reniform or oval, and have an echogenic fatty hilus. In depicting the fatty hilus within a lymph node, ultrasound is not reliable in excluding malignancy in a woman with breast cancer. Normal sized lymph nodes that are infiltrated with tumor may appear identical to normal nodes. A hypoechoic cortical focus or an irregular cortical margin may be found in a lymph node, suggesting a metastatic deposit. Normal intamammary lymph nodes are in the upper outer quadrant, and have a hilar notch. (Cardeñosa, p 135, Rumak pages 759-760)
 The worst type of histology for DCIS is--
a. cribiform
b. solid.
c. comedo
d. micropapillary
 C. Comedo
 Comedo type DCIS is high nuclear grade; it has a higher recurrence (worse prognosis) than the non-comedo group. Dähnert 5th p. 548
 There is a lesion seen anteriorly on the MLO view of the breast and not on the CC view. What is the next step?
a. valley view
b. exaggerated CC
c. 90o ML view
d. axillary tail view
e. Cleopatra view
 C. 90o ML view
 “When an abnormality is seen on the MLO view but not on the standard CC view, it should first be determined whether it is a real abnormality, superimposed tissue, or an artifact on the film or in the skin. Sometimes repeating the oblique view with a slightly different angulation or obtaining a 90-degree lateral will provide this information.”
Source: Bassett, Diagnosis of Diseases of the Breast, 1997, p. 52.The Cleopatra view is a modification of a rotated CC view which allows even better visualization of the lateral breast. The reason for the name is that the patient must be positioned in a semi-reclining posture to permit positioning the cassette.
 What region is most excluded from view on an MLO film?
a. axillary tail
b. upper inner quadrant
c. lower inner quadrant
d. upper outer quadrant
e. lower outer quadrant
 B. upper inner quadrant
 If tissue is excluded on the MLO view, it is likely to be medial tissue. Bassett p. 50.Given that the superior/medial border of the breast is fixed (Bassett p. 44), this is the most difficult to image.
 Which of the following is the best way to detect an intracapsular rupture of a silicone implant:
a. silicone in the axilla
b. linguine sign
c. abnormal contour of the implant
 B. linguine sign
 “The most reliable sign of intracapsular rupture on MR imaging is the presence of multiple curvilinear low-signal intensity lines within the high-signal intensity silicone gel, the so-called linguine sign.” Bassett p. 572-573.Silicone in the axilla would suggest an extracapsular rupture.