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From MQSA:


* How many initial education category 1 CME hours are needed?


* How many exams for initial experience are needed?


* How many hours in a new modality are needed?


* Exams needed for continuing experience?





* 60 category 1 CME


* 240 exams in 6 months


* 8h training in new modality


* 960 exams in 24 mo

What are the BI-RADS categories?

0: Incomplete, need additional imaging or comparison to priors


1: Negative


2: Benign


3: Probably benign (<2% malignancy in 1 yr)


4: Suspicious (2-95% chance)


5: Highly suggestive of malignancy (>95%)


6: Biopsy-proven malignancy

BI-RADS shape? (3)


(same on mammo, US and MRI)

Oval


Round


Irregular

BI-RADS margins on mammo? (5)

Circumscribed


Obscured


Microlobulated


Indistinct


Spiculated

BI-RADS density? (4)

High, equal, low, or fat-containing

What are the "typically benign" BI-RADS calcifications? (9)

Skin

Vascular


Coarse or popcorn-like


Large rod-like


Round


Rim


Dystrophic


Milk of calcium


Suture


What are the "suspicious morphology" BI-RADS calcifications? (4)

Amorphous


Coarse heterogenous


Fine pleomorphic


Fine linear/branching

What are the BI-RADS "distributions" of calcifications? (5)

Diffuse


Regional


Grouped


Linear


Segmental

What are the BI-RADS "associated features?" (7)

Skin retraction


Nipple retraction


Skin thickening


Trabecular thickening


Axillary adenopathy


Architectural distortion


Calcification

How to describe the location of the lesion on BI-RADS?

Laterality


Quadrant and clock face


Depth


Distance from the nipple

BI-RADS orientation on US? (2)

Parallel


Not parallel

BI-RADS margins on US? (5)

Circumscribed



Indistinct


Angular


Microlobulated


Spiculated


BI-RADS echo pattern? (6)

Anechoic


Hyperechoic


Complex cystic and solid


Hypoechoic


Isoechoic


Heterogenous

BI-RADS posterior features on US? (4)

No posterior features


Enhancement


Shadowing


Combined pattern

BI-RADS associated features on US? (6)

Architectural distortion


Duct changes


Skin thickening/retraction


Edema


Absent/internal/rim vascularity


Soft/intermediate/hard elasticity



BI-RADS margins for MRI? (3)

Circumscribed




Irregular


Spiculated

BI-RADS mass internal enhancement characteristics for MRI? (4)

Homogeneous


Heterogeneous


Rim enhancement


Dark internal septations

BI-RADS non-mass enhancement distribution on MRI? (6)

Focal


Linear


Segmental


Regional


Multiple regions


Diffuse

BI-RADS non-mass internal enhancement patterns? (4)

Homogenous


Heterogenous


Clumped


Clustered ring

BI-RADS associated findings on MRI?

Nipple retraction/invasion


Skin retraction/thickening/invasion


Axillary adenopathy


Pectoralis invasion


Chest wall invasion


Architectural distortion

MRI fat-containing lesions? (4)

LNs (normal or abnormal)


Fat necrosis


Hamartoma


Post-op collection with fat

Kinetic curve description?

Initial: slow/med/fast




Delayed: persistent/plateau/washout

Expected number of cancers that should be found in 1,000 initial screening mammograms?

6-10


(Some say 3-8)

What is the accurate positioning of a breast on the MLO view?

Pulled up and out (football)


Open inframammary fold (neutral on CC)


Small amount of upper abdomen should be visible

The posterior nipple line on CC and MLO are permitted to be how different?

1 cm

Per MQSA, medical outcomes for interpreting physicians must be reviewed how often?

Every 12 months

How often should the nipple be in profile on a mammo study?

On at least one view

Positive mammo follow ups need to occur how often?

Within a year

How quickly do patients need to be informed of their results?

30 days

What causes ghosting artifact?

Cardiac or respiratory motion


(use the correct phase-encoding direction)

Tell me about BRCA:


Inheritance?


Chromosome?


Lifetime cancer risk?


Other cancer associations?

Tumor suppressor genes


Autosomal dominant


BRCA-1 on ch 17


BRCA-2 on ch 13


50-85% lifetime cancer risk


Ovarian and prostate cancer

What is the benchmark for the cancer detection rate?

2-10/1,000

What is the BI-RADS recall rate?

<10%

What are the standards of the mammography and compression plates?

Sizes are both 18 x 24 and 18 x 30


Force of 25-45 lbs


Moving grid


Collimate to receptor

What does correct film labeling entail?

Patient's first and last name


Unique patient identifier


Name and address of facility


Mammography unit


Date of exam


View and L/R near axilla


Arabic cassette number


Techs initials

When should screening MRI be performed?

When lifetime cancer risk is >20% (on Fm Hx)


BRCA mutation


8 yrs after chest irradiation (or at 25 yo)

What minimum critera must a phantom meet?

Four fibers


Three calcifications


Three masses

The MLO is suboptimal for what part of the breast?

Medial part

How much gadolinium contrast is used in breast MRI?

0.1 mmol/kg

What variant muscle can be seen in both men and women medially only on the CC view?

Sternalis muscle

BI-RADS?


1. A nonpalpable, circumscribed mass on a baseline mammogram.




2. A nonpalpable, circumscribed mass, new since the last mammogram.




3. A nonpalpable, circumscribed mass, unchanged for 2 years.




4. A nonpalpable, noncircumscribed mass on a baseline mammogram.




5. A palpable, noncircumscribed mass, new since last mammogram.

1. BI-RADS 3


2. BI-RADS 0


3. BI-RADS 2


4. BI-RADS 0


5. BI-RADS 0

Which breast lesions tend to have earlier lymphatic spread via Sappey plexus?

Subareolar lesions

What are the top two most common locations for breast cancer?

Upper outer (61%)


Upper inner (17%)

When is a targeted ultrasound recommended as the initial exam?

<30 yrs of age, lactating, pregnant

What is the "snowstorm" or dirty shadowing on US classic for?

Extracapsular silicone implant rupture

Most common malignancy, other than primary breast cancer, to metastasize to the breast?

Melanoma

Lesion on MRI with multiple small fluid intensity components within a heterogenous mass?

Phyllodes tumor

What percent of type 3 curves with rapid uptake and washout correspond to cancer?

87%

What type of breast cancer is most likely to present as a small spiculated mass on mammogram?

Tubular carcinoma

What are the high risk lesions?

Atypical ductal hyperplasia (ADH)


Atypical lobular hyperplasia (ALH)


Lobular carcinoma in situ (LCIS)


Peripheral duct papilloma


Phyllodes tumor


Radial scar

You see a mass that looks like cancer in a woman with type I diabetes. Pathology comes back as fibrous stromal proliferation. What is the diagnosis?

Diabetic mastopathy

What type of breast cancer may coexist with a radial scar?

Tubular carcinoma

77yo F with a new microlobulated hypoechoic mass on US is most likely what?

Mucinous carcinoma

What is the BI-RADS and most common diagnosis for an abrupt filling defect on a ductogram?

BI-RADS 4


Intraductal papilloma

Are radial scars benign?

Yes, but association with ADH and carcinoma is seen in 50% of cases




(occurrence 0.1 to 2 per 1,000)

What BI-RADS is a hematoma?

BI-RADS 3 because it can often mimic a malignancy

ADH is found on needle biopsy. Whats the next step in management?

Surgical excision. Concomitant DCIS is found in 25-50% of cases.

What is fibrocystic change?

More common in >30 yo


Cysts originate from terminal lobules


Cysts fluctuate

On stereostatic breast biopsy radial scar is diagnosed, what is the best next step?

Surgical excision b/c it may contain DCIS or ADH

Is phyllodes tumor benign?

It is a spectrum of benign to malignant


Typically no calcifications


21% risk recurrence


XRT helps



Diagnosis?

Diagnosis?

Invasive lobular carcinoma

What modality is best at assessing response to neoadjuvant chemotherapy?

MRI

What is the only reliable criteria for pectoralis muscle cancer involvement on MRI?

Muscle enhancement

What are some stats on recurrent breast cancer after breast conservation therapy?

Local recurrence rate is 1-4% (or 6-8%)


Most occur 4-6 years after treatment


MRI is advantageous for assessment


Enhancement can be seen 18-24 months at the surgical site on MRI

What is the difference between multifocal and multicentric disease?

Multifocal: >1 lesion in the same quadrant




Multicentric: >1 lesion in different quadrants

Patient has a palpable cord like mass associated with pain and erythema. What is the diagnosis?

Mondor's disease


(Superficial thrombophlebitis)




Tx is NSAIDs and warm compress


(no anticoagulation)

Poland syndrome is associated with increased risk of which cancers?

Non-Hodgkin lymphoma


Leukemia


Breast


Lung




(Autosomal recessive)

Focal fibrosis typically occurs in which type of women?

Premenopausal or


postmenopausal on hormone replacement

Mass on MRI with dark internal septations?

Fibroadenoma

How are calcium phosphate and calcium oxalate different on pathology?

Calcium oxalate is only seen with polarized light

What is a grape-like anechoic area with internal septations?

Apocrine cyst cluster


BI-RADS 2 unless not well seen, then BI-RADS 3



Can biopsy if a solid component is preset

Axillary lymph node levels?

level I - below/lateral to pec minor




level II - lies underneath/posterior to pec minor




level III - above/medial to pec minor

Most common site of mets for a malignant phyllodes tumor?

Lung and bone




10% are malignant


Uncommon

Which type of calcifications have lucent centers?

Oil cysts and dermal calcifications

What anticoagulation medications are safe for breast biopsy?

All expect clopidogrel



Counsel for hematoma/hemorrhage


What is the most common breast surgery-related complication?

Seroma

What are the contraindications to radiation therapy?

Multicentric disease


Pregnancy


Prior radiation therapy


Collagen vascular disease


Poor cosmetic outcome

What type of needle should be used for microcalcifications?

11-gauge or larger vacuum assisted

Best indication for galactography?

Single duct spontaneous bloody, serous or clear nipple discharge (not green or white)

What is the maximum dose of 1% lidocaine w/epinephrine for deep local anesthesia?

7 mg/kg body weight, no more than 500 mg

What is the primary purpose of mammo grids?

Increase contrast

What is the typical kV range used in mammography?

30-32 kV

What are the typical tube currents for each focal spot?

0.3 mm uses 100 mA for ~1 sec




0.1 mm uses 25 mA for ~3 sec

How does kVp affect tissue contrast?

Higher kVp decreases contrast

What target/filter combos are good for thick, dense breasts?

Tungsten/Rhodium (W/Rh)


Moly/Aluminum (Mo/Al)

What type of dose is mean glandular dose (MGD)?

Absorbed dose




150-200 mrads (1.5 to 2 mGy is typical)

What technique factor has the strongest impact on image quality?

Target/filter combo

What grid ratio is used in full-field mammography?

4:1

What focal spot size is used for standard CC and MLO views?

0.3 mm

What is the recommended source to image distance in mammography?

50 to 80 cm

What is used to determine focal spot size?

10 um slit camera

Progressive unilateral shrinking breast?

Invasive lobular breast cancer



Sternalis muscle

What is the peak time in a woman's life for breast pain and cyst formation?

Perimenopause

Which true lateral view do you get if you only see the lesion on the lateral aspect of the CC view? Medial aspect? What if you only see it on the MLO view?

Medial: LM




Lateral: ML




MLO: ML

What things can be BI-RADS 3?

Baseline study:


-Fibroadenoma


-Focal asymmetry that becomes less dense on compression (i.e. normal breast tissue)


-Grouped or clustered round calcifications

What's the difference between a mass and focal asymmetry according to the BI-RADS lexicon?

Mass: space occupying lesion seen in two views




Focal asymmetry: A density only seen on one view

List distribution of calcifications in order of increasing suspicion

Scattered


Regional


Grouped/clustered


Linear


Segmental (most worrisome)

What demographic do you see secretory calcifications in?

10-20 years postmenopause

What is a large area of fat necrosis called?

Liponecrosis macrosystica

Ddx for amorphous calcifications?

Fibrocystic change


Sclerosing adenosis


ADH


DCIS

Ddx for coarse heterogenous calcifications?

Fibroadenoma


Papilloma


Fibrocystic change


DCIS (low to intermediate nuclear grade)

Ddx for fine pleomorphic calcifications?

(Most suspicious for cancer)




Fibroadenoma


Papilloma


Fibrocystic change


DCIS (high nuclear grade)

What are the 5 fat-containing breast lesions?

Hamartoma (breast with a breast)


Galactocele (only during lactation)


Oil cyst/Fat necrosis (eggshall calcs)


Lipoma


Intramammary LN

Water density on mammo. Diagnosis?

Water density on mammo. Diagnosis?

PASH

Young woman. Diagnosis?

Young woman. Diagnosis?

Fibroadenoma

DCIS trivia:


% Invasive on biopsy?


% Invasive on excision?


% present with mass and no calcs?

10%

25%


8%


Ddx for architectural distortion without a mass?

Radial scar (spiculated, lucent center)


Surgical scar


Lobular carcinoma


Invasive ductal carcinoma

Contraindications for breast conservation treatment?

Inflammatory cancer


Large cancer relative to breast


Multicentric disease


Prior XRT


Unable to get XRT (collagen vascular disease)

What 2 cancers can be T2 bright?

Mucinous


Colloid