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Mammography Questions

The following are True/False questions:

1994, 1992
Asymmetric breast tissue can be differentiated from a mass by:
1. convexity of borders
2. planar configuration
3. increased density at the periphery
4. sharp margins
5. inhomogenous tissue density
6. change in shape with compression
7. fades from the center to the periphery
8. stellate configuration
9. hypodensity
*
Answer: 1. True 2. True 3. True (?False, neither one usually does this) 4. True
5. True 6. True 7. True 8. True 9. True

This question has been on the test several times and apparently was poorly
worded.
(3, 5., and 7) Masses are denser in the center and are less dense in the periphery;
asymmetric glandular tissue will have nonpredictable density including a periphery which
appears more dense because of the superimposition of several nonrelated shadows.
(1 and 2) A mass will have convex margins (i.e., be a “ball” and not a “plane”)
(6) With compression, a mass should be better seen. Asymmetric breast tissue
should “compress out.”
(4) Asymmetric breast tissue will rarely if ever have sharp margins; masses often
(but not always) do. Be careful if this question is worded differently - not all masses have
sharp margins and not all masses with sharp margins are benign!!
(8) Stellate configuration is one of the most reliable indicators of malignancy.
However, occasionally, other lesions, like radial scar, postprocedure scar (not the same
thing!), and fat necrosis may have this appearance.
(9) If a mass definitely contains an area of hypodensity, it is benign.
*

1995
Ultrasound of the breast is useful in evaluating which of the following lesions?
10. solid nonpalpable well-circumscribed mass
11. spiculated breast mass
12. asymmetric breast tissue
13. microcalcifications in the breast
*
Answer: 10. true 11. true 12. true 13. false
Breast US should be used as a technique to help resove specific managment Q's.
If the lesion is not palpable, but ID by mammo, US can be used to analyze it's
composition., eg cyst and thus obviating surgery. US can help trangulate lsions that are
found in only one view. Us can be used to guide fine-needle aspiration.
Indications for breast sonography include: characterize mass as solid/cyst,
evaluate palpable mass in young/pregnant, evaluate non-palpable masses seen on
mammo, exclude a mass in an area of asymetric density, confirm or better visualize a
lesion seen incompletely or in one view on mammo, guide interventional procedures.
Microcalcifications are visualized inconsistently and are hard to distinguish from acoustic
interfaces. Can occationsaly see microcalcifications espicially when they are located w/in
a mass.
p 227-8 Kopans, p 541-2 , 553 Rumack

1995
Which of the following colors of nipple discharge can be seen in a woman with breast
carcinoma?
14. green
15. white
16. black
17. red
18. clear
*
Answer: 17, ?16-- old blood., 18

Nipple d/c is a unusual presentation of breast ca. Most nipple d/c whether serous or
serosanguinous, are caused by benign disorders, most commonly intraductal papilloma.
Nipple d/c w/ negative test for Hbg is almost always benign.. Breast ca is the cause of
sanguinous dc in less than 10%.
Galactorrhea is white. ?? infection may be green.
p 1615 Harrison's
According to Dr. Sullivan, clear breast d/c can also be associated with ca.

1995
Which of the following can cause gynecomastia?
19. marijuana
20. smoking
21. antihypertensive medications
22. hyperthyroidism
23. liver disease
*
Gynecomastia Answer: 19. true 20. false 21. true 22. true 23. true
may be physiologic as in the newborn, aging, adolescence. Pathologic etiologies include
deficient testerone production or action, increased estrogen-( liver disease,
thyrotoxicosis), drugs- marijuana, spironolactone- diuretic>antihypertensive, idiopathic.

ref: Harrison's p 1797

1994
Which of the following are characteristic findings of medullary carcinoma of the breast?
24. calcifications
25. well-circumscribed lesion
26. soft to palpation
27. fibrotic stroma
28. architectural distortion
29. extensive lymphocytic response
30. poorer prognosis than invasive ductal carcinoma
*
Answer: 24. False 25. True 26. True 27. False (this implies a desmoplastic
response) 28. False 29. True 30. False

Medullary carcinoma is relatively uncommon and can grow quite large before being
detected (Dahnert says it is the fastest growing breast carcinoma.). They are often round
or lobulated and are fairly distinct from surrounding tissue. They do not infiltrate
aggressively, are relatively soft on palpation, and tend to be freely movable. They must
have a syncytial growth pattern with pushing margins. They have an abundant infiltration
by lymphocytes and other inflammatory cells. Calcifications are not particularly
common. As long as they meet the strict histologic criteria that must be met, they have an
improved prognosis compared to invasive ductal carcinoma.
References: Kopans 1989, pp. 298-299; Dahnert 1993, p. 344
*
1994
Characteristic findings of infiltrating lobular carcinoma include:
31. ductal dilatation
32. calcifications only
33. spiculated mass
34. architectural distortion
35. dense circumscribed mass
36. asymmetric density
37. well-defined mass
*

Answer: 31 False (?True - see above) 32. False 33. True 34. True 35. False 36.
True 37. False
LCIS is different than DCIS.
However, infiltrating lobular and infiltrating ductal carcinoma are indistinguishable in
terms of physical exam, imaging characteristics, and prognosis. The only way to tell the
difference is histologically based on cytologic features. Therefore, all answers above
apply to infiltrating ductal carcinoma as well. (Kopans 1989, p. 302).
Ductal dilatation may be “True” because, even though infiltrating lobular
carcinoma does not arise in ducts, if it really is indistinguishable from invasive ductal
carcinoma, it must occasionally have linear and branching calcifications which implies
ductal dilatation. However, if by “characteristic” they mean “typical” the answer would
be false since this is not a typical finding of infiltrating carcinoma - it is a non-specific
finding, usually benign.
*

1995
Regarding ultrasound examination of the breast:
38. it is easier to identify a solid mass by ultrasound in a fatty breast (wording???)
39. it is easier to identify a cyst within a fibroglandular breast
40. fibroglandular tissue is hyperechoic with respect to fat in the breast
41. fibroadenomas can demonstrate enhanced through transmission
*
Answer: 38. ? true 39. ??false 40. true 41. true

Breast glandular parenchyma usually appears homogeneously echogenic caused


by fatty tissue. In general fibroglandular tissue appears echogenic whereas a mass
appears hypoechoic. In the breasts of the very young, extensively homogeneous
echogenic tissue often corresponds with dense breasts w/in which descrete masses ID
may be difficult.
Fat lobules are hypoechoic relative to the surrounding glandular tissue.
Fibroadenomas have a variable sonographic appearance. In general, they are
hypoechoic relative to the fibroglandular tissue and isoechoic to the fat. Most of the mass
is homogeneous, sharply marginated, oval, some posterior acoustic shadowing.

ref: Rumack p 544, 556

1995, 1992
Regarding radial scar:
42. dense center (92)
43. lucent center (95, 92)
44. spherical calcifications with hollow center (95, 92)
45. punctate calcifications (92)
46. skin thickening (95, 92)
47. radiating projections (95)
48. commonly occurs after incisional biopsy (95)
*
Answer: 42. False 43. True (classically) 44. False 45. True 46. False
47. true 48. false

DO NOT CONFUSE A RADIAL SCAR WITH A SCAR FROM PRIOR


SURGERY. Radial scar has a horrible name because it has nothing to do with anything
that causes a scar. Although on mammography it can look a lot like a carcinoma (can
form spiculations, can be palpable and firm, can have architectural distortion, can
occasionally have microcalcification (reason 45. is True)) it is entirely benign and does
not contain a mass at the center of the spiculations (reason for answers 42. and 43.). The
lesion is stellate with radiating fibrotic spicules.
Unfortunately, in Kopans (1989, p. 288) it is the last of the benign lesions listed so
it is on the same page as the word “malignant.” It can also be called elastosis, indurative
mastopathy, and sclerosing duct hyperplasia.
*

1994
Which of the following views will better clarify whether a suspected mass is a summation
of shadows or a true mass?:
49. tangential view
50. 90 degree ML view
51. reverse CC
52. exaggerated CC
53. tilting the tube 5-10 degrees off its normal axis
54. rotated craniocaudal
*
Answer: 49. False 50. True 51. Dr. Duckett -”True,” Dr. Sullivan - “probably
False” 52. True 53. True 54. True

The answers to this question really depend on how the question is worded. Let
me give you my reasoning:
49. is false because the tangential view is usually used to confirm that something
(usually calcification) is at the skin surface.
50., 52., 53., and 54. are true because one way to confirm a suspected mass is to
see it in another view. While the other view is preferentially perpendicular to the view
which shows the suspected mass, something as subtle as a 5-10 degree movement of the
tube may reveal that a suspected mass was merely perfect alignment of several glandular
shadows. Exaggerated CC can serve as a complementary view to an ML or MLO view
which shows a posterior mass which was not identified on the routine CC view.
Dr. Duckett adds that if you see something in only one view, you should go back
to the view in which it was originally seen and do some sort of exaggeration in that view.
“There was a question about that last year too.”
*

1994
Concerning the routine chest radiographs and routine mammography:
55. the screens are thicker in mammography
56. the screens are faster in mammography
57. chest films have wider latitude
58. chest film is faster
59. there is a single screen in mammography
*

Answer: 55. False 56. True 57. True 58. False 59. True

Mammography is a very demanding imaging technique for two main reasons:


1) Since it is a screening test that may be done yearly, the doses must be kept to an
absolute minimum
2) Since one of the hallmarks of breast carcinoma is microcalcifications, the technique
needs to be able to adequately image them
To decrease dose several things are done:
a) faster screens and films are used -therefore less photons are needed to form the image
b) compression is used - there is less tissue thickness
To improve images several things are done:
a) a small focal spot is used (0.3 mm, as small as 0.1 mm for magnification
mammography), thus making the source more like a point
b) a molybdenum target and filter system is used. This gives better soft tissue contrast.
c) high contrast film is used - of course, high contrast means narrow latitude
d) thin (and single) screens are used to decrease blurring at the surface
e) faster screens and films decrease time of exposure, thus reducing the amount of motion
artifact
f) there is close contact of the film and screen (see question regarding QC)
g) there is extended processing which increases the optical density and contrast of the
image (but also increases fog!)
Reference: Kopans 1989, pp. 38, 40
*

1995, 1994
Concerning radiography of the specimen block:
60. should be performed if calcifications are not seen on pathology (95, 94)
61. magnification technique should be used (95, 94)
62. does not have to be performed if a palpable lesion is in the specimen (95, 94)
63. does not need to be performed if the lesion is not palpable (95, 94)
*
Answer: 60. True 61. True 62. True 63. False

Breast lesions are either palpable or nonpalpable.


Palpable lesions do not require radiography of the specimen block. If the palpable
abnormality is included in the specimen, this is usually sufficient. However, radiography
may be performed if there were any radiographically distinctive characteristics in the
palpable mass which may help in diagnosis or assessment of whether or not the entire
mass has been excised.
Radiography of the specimen block in nonpalpable lesions is mandatory,
however. In almost every case, the lesion was first discovered on mammography and
mammography may be the only way to adequately localize the lesion and/or assess the
adequacy of excision. Radiography is usually performed on the fresh surgical specimen
while the patient is still in the OR to assess adequacy of excision. If the
mammographically detected calicifications are not seen on pathology, two things are
usually done:
1) the specimen block is reradiographed to guide the pathologists to the area of suspicious
calcifications. In rare instances, the area of suspicious calcifications is “lost” in transit.
In this case, part 2) becomes mandatory.
2) the breast which underwent the excisional biopsy is reradiographed to assure that there
are no residual suspicious calcifications within the breast.
*

1993
Concerning lobular carcinoma in situ:
64. also known as lobular neoplasia
65. more often bilateral
66. less aggressive than DCIS
67. can be distinguished from DCIS on mammography
*
Answer: 64. True 65. False 66. True (DCIS will progress to carcinoma, LCIS is a
marker for carcinoma in the future, usually ductal.) 67. True

While LCIS is typically not bilateral, its (unilateral presence) implies an increased
risk of later developing invasive carcinoma (usually ductal) with equal risk (15%) in each
breast.
I answered d. true but this could be taken either way. Since LCIS is usually a
serendipitous finding and since DCIS is often similar in appearance to invasive ductal
carcinoma, there is little overlap in visible appearance. However, both lesions may be
mammographically occult, so in this respect the may be indistinguishable.
Reference: Kopans 1989, pp. 301-302
*

1994, 1993
Concerning characteristics of invasive lobular carcinoma:
68. frequently is non-palpable
69. is more commonly bilateral than LCIS
70. has a characteristic mammographic appearance
71. it accounts for 30% of breast cancers

Answer: 68. True 69. False 70. False (looks just like invasive ductal) 71. False
Distribution of cancers is as follows:
A) Ductal (approximately 90%)
1) 60-75% invasive
2) 20-40% DCIS (greater percentage with more extensive mammographic screening)
B) Lobular (approximately 10%)
C) Other (few%, depending on series)

Reference: Dahnert 1993, p. 344


*

1993, 1991
A lesion which is located more cephalad on ML than on MLO can be in:
72. upper inner quadrant
73. upper outer quadrant
74. lower inner quadrant
75. lower outer quadrant
76. axillary tail
*
Answer: 72. True 73. False 74. True 75. False 76. False

Position the 3 films (left to right) in this order: ML-MLO-CC. Make sure the nipple is at
the same level on all three films. Mark the mass in two views and use these two points to
draw a line. In the third view the mass will lie along that line. Therefore, if the mass is
moving down from ML to MLO, it will be even further “down” on CC, making it in the
inner half of the breast (therefore, b, d, and e are false). Now, the question didn’t say
specifically that the mass was in the upper half of the breast on either ML or MLO (it
could be in the inferior breast and just move further down on MLO) so a and c are true.
A quick and easy way to remember this is “Down and Out in Beverly Hills” and
“up and in.” (on the ML view) If it moves up on the ML view it is on the inner part of
the breast; if it moves down on the ML view it is in the outer (lateral) breast.
*

1992
True statements regarding ultrasonography of the breast include:
77. it is used to screen individuals under 30 years of age
78. it is the primary imaging modality in a 30 year old with a palpable mass
79. it should be used in cases of asymmetric tissue seen on mammography
80. it should be used to image palpable lesions not seen on mammography
81. it should be used to image nonpalpable lesions seen on mammography
*
Answer: 77. False (never used as screening tool) 78. True ( but this approaches the
age when mammography should be used as the screening modality (35 y/o)) 79. False
? This is an indication for US in Rumack 80. True 81. True
The use of ultrasound in mammography is very limited but very important - Is it a
simple cyst? For women less than 35 y/o cysts are much more common than cancer and
the younger the breast the more sensitive it is to radiation (However, if ultrasound is
negative mammography may be done). Ultrasound should be used to define a specific
lesion (reason why d. and e. are true) - do not use it for screening (reason why a and c. are
false). If a mass is anything but a simple cyst ultrasound is nonspecific.
That being said, ultrasound can also be used for guidance; therefore, a lesion
which appeared cystic (but was not a simple cyst) and ultrasound could be completely
drained with ultrasound guidance and then be evaluated as benign.
Ultrasound may also be used for needle localization, fine needle aspiration, and
core biopsy (although this is not commonly done at HUP but it is quite commonly done at
other medical centers).
*

1992
Regarding needle localization utilizing an alphanumeric grid:
82. needle path should be parallel to the x-ray beam
83. path should be from skin closest to the lesion
84. needle should be positioned just proximal to the lesion
85. one view is sufficient to confirm placement of the hook wire
86. compression should be released just prior to needle insertion
*
Answer: 82. True 83. True 84. False 85. False 86. False

Regarding needle localization - make sure you always have a CC and ML view
before starting (CC and MLO is not sufficient). The breast should be positioned so that
there is the least possible distance from the surface to the lesion - this may require the
breast to be “rolled” as compression is applied (since the needle is always inserted in
either vertical or horizontal orientation). With the breast in compression, a view with the
alphanumeric grid is obtained - the needle will be inserted with this view as the reference,
so the x-ray beam and needle path are parallel. The other view is used to calculate the
approximate distance that the wire should be placed - the needle length is usually chosen
so that the needle is “hubbed.” After the needle is inserted, a repeat view (and its
orthogonal companion) is obtained to confirm that the needle goes “through” the lesion
and that the patient has not moved or that the needle has not been inserted at an angle.
The wire is then hooked and compression can be released. Compression is then reapplied
in an orthogonal plane. An orthogonal view is then obtained to confirm that the wire is in
far enough and that the wire is through the lesion on two views.
Reference: Kopans 1989, pp. 320-330
*

1992
Which of the following would result in increased contrast in mammography?
87. use of longer processing times
88. compression of the breast
89. lowering developer temperature
90. use of tungsten anode
91. use of a glass window on the tube
*
Answer: 87. True (up to a limit of total time= 3 minutes) 88. True (less beam
hardening) 89. False (optimum contrast occurs in a narrow range around 95 degrees F)
90. False (low kV characteristic X-rays of molybdenum (17.9 and 19.6 kV) give the
greatest contrast for mammography) 91. False (glass window will filter out the
beneficial low kV X-rays so the contrast is worse. Beryllium is used)

high contrast film was developed which a narrow exposure latitude. Vigorous
compression is required to even out the thicness thu which the x-ray beam must pass.
Use high contrast molybdemun target/ molybdemun-filter system. Tungsten anode tubes
can be used but they need beryllium windows to permit the passage fot he low keV
photons necessary for film/screen imaging. Tungsten imaging doesn't produce as high a
contrast as molyb.
ref: Kopans p 40-1

1992
Which of the following are associated with a stellate lesion?
92. radial scar
93. carcinoma
94. lymph node
95. cyst
96. fibroadenoma
*
Answer: 92. True 93. True 94 False 95. False 96. False

1993
Regarding magnification mammography, which of the following demonstrate change
with magnification?
97. dose
98. noise
99. exposure time
100. focus to object distance
*
Answer: 97. True 98. True 99. True 100. True

Magnification requires higher dose (in proportion to the inverse square law). The
higher dose (# of photoelectrons) will result in less noise (noise is reduced by a factor
equal to the magnification). Of course, focus to object difference is changed, since this is
what creates the magnification (focus to film distance will not change). Remember, the
focal spot used in magnification mammography is even smaller than the focal spot used
in routine mammography (0.1-0.3 mm). The breast should still be compressed. Exposure
time will also increase during magnification mammography.
The best magnification ratio is approximately 1.5:1 to 2:1.
References: Kopans 1989, p. 56; Dahnert 1993, p. 342; ACR Syllabus #24, question 28
*

1993 c PreTest
Concerning extraabdominal desmoids:
101. they are usually related to striated muscle
102. they usually contain myoepithelial cells
103. the treatment of choice is radiation
104. they metastasize hematogenously
105. they represent an unusual form of infiltrating ductal cancer
*

Answer: 101. True 102. False 103. False 104. False 105. False

Extraabdominal desmoids are very rare lesions and are usually found in the breast
or axilla, adjacent to the pectoralis muscles. They may be related to prior trauma. They
are slow-growing lesions which do not metastasize, but rather infiltrate locally and have a
high rate of recurrence after removal. They have irregular, spiculated margins,
mimicking infiltrating ductal cancers. Histologically, they look like fibrous tissue which
is invading the striated muscle. Treatment is wide local excision.
Exta-abdominal desmoid tumor is extremely rare in the breast and usually arises
in the muscle and fascia of the abdominal wall. Truama is frequently a preceding event.
They are among the rare benign processes that can have spiculated margins on
mammography. None have been reported to demonstrate microcalcifications. Dx can be
suggested by the prximity ot the lesion to the chest wall and relatively long progections
radiating from it tht are thicker than those associated with ca. histologically , this lesion
is hypocellular dense fibrous tissue that locally invades adjacent muscle. ref: Kopans p
287
*

1993 c PreTest
Mammographic patterns after reduction mammoplasty include:
106. skin thickening
107. transposition of breast tissue from a low to a high position
108. high nipple
109. retraction of the lower breast
110. fat necrosis
*

Answer: 106. True 107. False 108. True 109. True 110. True
The changes in the breast following mammoplasty are characteristic- they include
skin thickening and retraction of the lower portion of the breast. There is a linear vertical
scar inferiorly. The breast tissue is transposed from a high to a low position. The nipple
is moved to a position which is high relative to the relocated breast cone. Fat necrosis
may occur.
*

1993 c PreTest
Concerning the male breast:
111. gynecomastia may be accompanied by skin thickening
112. axillary node enlargement in a patient with gynecomastia is an ominous sign
113. approximately 5% of all breast cancers occur in males
114. male breast cancer differs histologically from female breast cancer
115. the most common location for breast tissue to appear in gynecomastia is the
subareolar region
*
Answer: 111. True 112. False 113. False 114. False 115. True

Gynecomastia is proliferation of normal breast tissue in the male; it may be


unilateral or bilateral. Skin thickening and axillary node enlargement may accompany it
as a benign phenomenon. The usual location is subareolar, though it may extend to the
upper outer quadrant. The ducts may hypertrophy.
Causes of gynecomastia include liver disease (cirrhosis), drugs (e.g., digoxin,
cimetidine, spironolactone, thiazides, and marijuana), testicular tumors, and hormonal
therapy, such as that for prostate carcinoma.
Male breast cancer accounts for less than 1% of all breast cancers. Risk factors
include radiation exposure and increased estrogen states. Histologically, it is
indistinguishable from female breast cancer. The poor prognosis associated with it may
be due to the fact that it is often diagnosed at a later stage.
Kopans p 342,
*

1995
Regarding compression of the breast during mammography:
116. motion is reduced
117. exposure time is reduced
118. radiation dose to the breast is decreased
*
Answer: 116. true 117. true 118. true

Firm compression has advantages including increased contrast, reduced dose,


shorter exposure time, image degradation from scatter is reduced, motion related blurring
is reduced.
p 40-1, Kopans
Mammography
Select the single best answer

1995, 1994
1. 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. 7 cm
b. 8 cm
c. 9 cm
d. 10 cm
*
Answer: c. 9 cm

If there is X cm of breast tissue from the anterior border of the pectoralis muscle
to the nipple on MLO projection, there should be at least X-1 cm of breast tissue from the
anterior chest wall to the nipple on CC projection.
*

1994, 1992
2. Where should the pectoralis major muscle be seen on MLO examination?
a. bottom of the breast inframammary fold
b. nipple line
c. axilla
d. 1/4 down breast
e. 7th rib
*
Answer: b. nipple line

1994
3. To see the most breast tissue (on CC view) where should the film cassette apparatus be
placed?
a. 2 cm above the inframammary fold
b. 1 cm above the inframammary fold
c. at the inframammary fold
d. 1 cm below the inframammary fold
e. 2 cm below the inframammary fold
*

Answer: c. at the inframammary fold


Quoting from Kopans 1989, p. 50, “The tissues are relatively fixed at the
inframammary fold, and the patient should be guided into the machine so that the edge of
the cassette is against the ribs at this level....”
*

1994
4. How often does the phantom test need to be done?
a. daily
b. weekly
c. monthly
d. quarterly
e. semiannually
*
Answer: c. monthly

1995
5. Which of the following is the most widely accepted reason for evaluating the breast by
MR examination?
a. assessment of implant rupture
b. assessment of postoperative scar vs. malignancy
c. evaluating cystic vs. solid mass
d. staging of a known lung carcinoma
*
Answer: a. assessment of implant rupture

1995
6. To prove calcifications are within the skin, which one of the following views would be
most useful?
a. ML
b. Cleopatra
c. tangential
d. CC
*
Answer: c. tangential

1995
7. A 40 y/o woman has a nonpalpable well-circumcribed mass seen in her right breast on
her first screening mammography. 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. 6 month followup
d. mastectomy
*
Answer: ???b,c

1995
8. The most common well-circumscribed carcinoma of the breast is:
a. infiltrating ductal carcinoma
b. mucinous carcinoma
c. papillary carcinoma
d. lobular carcinoma
e. colloid carcinoma
f. medullary carcinoma
*
Answer: prob a

Lobular ca in situ is generally a histologic dx and a tumor mass is rarely seen.


Infiltrating lobular ca and infiltrating ductal ca appear as illdefined mass with
architectural distortion with calcification possible.
Papillary ca is a intraductal neoplasm. These tumors do not tend to produe the
fibrotic proliferation assoicated with other forms of ductal ca. As they enlarge, they tend
to produce fairly well circumscribed masses. Papillary ca is relatively rare.
Colloid ca doesn't have typical mammo characteristics. The lesions tend to be
better circumscribed but may have ill-defined borders, spiculated margins, small
lobulations. When there is more mucin, these tumors tend to be less radiodense.
Medullary ca is also relatively rare. Often round, lobulated, and fairly distinct
from surrounding tissue.-- these are the same findings as on mammo.
Some Ductal ca reveal their presence early by calcium deposition. Can have a
tumor mass. Can get fibrosis and architectural distortion. The dx is virtually certain
when an ill defined mass with stellate margins is present. Lobulted shapes are more
common, and the more undulating the border, the more suspicious.
ref: Kopans, p 290-302

1994, 1993
9. What is the risk of carcinoma in a well-circumscribed mass which is less than 1 cm in
diameter?
a. 2%
b. 5%
c. 10%
d. 20%
e. 40%
*
Answer: a. 2%

Reference is Dr. Troupin (who says it depends on the age of the patient - younger patient
risk approaches zero; whereas risk in an older patient is about 2%) and the chart in
Dahnert. However, in Review of Radiology (Ravin, 1994), on page 33 it states that a
well-circumscribed mass has a 4.3% risk of malignancy. Kopans (1989) states on page
161 that “from 2-4% of circumscribed masses that are biopsied prove to be malignant.”
See also, Sickles, Aug 1994, AJR
*

1995, 1992, 1991


10. If a lesion is seen in the anterior breast on the MLO view but not on the CC view, the
next view should be:
a. axillary
b. true ML
c. cleavage
d. exaggerated CC
e. rolled ML
f. Cleopatra view
g. tangential
*
Answer: b. true ML

If the (potential) mass is in the anterior breast, it is unlikely to be in the axilla (a.).
A cleavage view is best at defining lesions at the medial portion of the breast which is not
very “anterior.” The exaggerated CC view rolls the breast so the far lateral (alternatively,
far medial) breast can be imaged better - again, not really the anterior portion of the
breast. A rolled ML may also be OK but this would usually occur after a true ML.
Further, if the mass is present on both the true ML and the MLO views, it has been seen
in two independent projections and all that remains is to further define it - with more
“specialized” views like compression or rolled views. (After the mass is seen on ML and
MLO, use triangulation to find the expected location in the CC view - it might be there in
retrospect and if not can be a guide for the region to compression on compression CC
view (needed if biopsy or needle localization is to be done).
An answer of last resort is to put the patient on the core biopsy table where the
computer will use the slight variations of a single projection to triangulate the location.
Very shaky.
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.
The tangential view is used to help prove that calcifications are within the skin.
*
????????
1995
11. In a mammographic screening program in asymptomatic women, a realistic (???) goal
for recall of patients should be no more than:
a. 5%
b. 10%
c. 20%
d. 25%
e. 40%
*
Answer: B. 10 percent is the recall rate that is quoted in Dahnert.

1994
12. The “halo sign” indicates:
A. benign lesion
B. malignant lesion
C. fibroadenoma
D. well circumscribed nodule
E. cyst
*
Answer: d. well circumscribed nodule

In the past, some felt that the “halo sign” was diagnostic for a benign lesion.
However, all it really means is that there is an abrupt transition in density associated with
a smooth margin (Kopans 1989, p. 297 and p. 73). While most masses with smooth
margins are benign, up to 7% of malignant lesions can be well circumscribed (Kopans
1989, p. 76). Other non-benign lesions which may be well-circumscribed:
1) lymphoma
2) papillary carcinoma
3) invasive carcinoma (NOS)
4) colloid carcinoma
5) intracystic carcinoma
6) medullary carcinoma
*

1995, 1994, 1992


13. 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
*
In 1995, the question was “Which part of the posterior breast is not well seen on
MLO examination (choices were medial, lateral, axillary, inferior)”.
Reference: Kopans, 1989, p. 51
*
Answer: b. upper inner quadrant

1995, 1993
14. The concentration of microcalcifications which is concerning for malignancy:
a. 2/cc
b. 5/cc
c. 10/cc
d. 15/cc
e. 20/cc
*
Reference: Kopans 1989, p. 137
*
Answer: b. 5/cc

1994, 1992, 1990


15. What percentage of breast cancer would be missed if mammography was performed
without physical exam?
a. 5-10%
b. 15-20%
c. 25%
d. 38%
*
BCDDP states that almost 9% of cancers were detectable on physical exam only.
Also in BCDDP, almost 42% of cancers were detected only by mammography (this
percentage was greater than 50% for cancers less than 1 cm in diameter.)

Reference: Review of Radiology (Duke-Ravin) 1994, p. 30


*
Answer: a. 5-10%

1995
16. Which of the following is the most common type of intraductal breast carcinoma
missed on mammography?
a. colloid
b. mucinous
c. medullary
d. lobular
e. tubular
*
Colloid ca is relatively uncommon. Colloid ca or mucinous ca is the same thing
according to Robbins. The presence of abundant mucin production is characteristic. As
the tumor enlarges, it forms a firm but not particularly hard mass to palpation. On
mammo there are no particular features that distinguish it from other ca. The lesions tend
to be better circumscribed but may have ill-defined, spiculated margins. When mucin is
profuse, these tumors tend to be less dense. Good survival rate.
Medullary ca is also relatively uncommon. They are dinstincive in that they are
quite large before being detected. They are relatively soft on physical exam. They are
often round or lobulated and fairly distinct from surrounding tissue. Medullary ca is fairly
well circumscribed. BUT, most well circumscribed tumors are infiltrating ductal lesions
NOS>
Lobular tumors in situ arise form the epithelial lining fo the blunt ending ducts
within the lobule. The lesions are almost always discovered by serendipity rarely forming
a palpable mass or producing a mammo distinctive appearance. Infiltrating lobular ca
looks like infiltrating ductal ca-- ill defined margins and architectural distortion.
Tubular ca is a well differentiated form of ductal ca. The lesions are frequently ID
on mammo and slowly growing. They are usually small on presentation. Looks like
other breast ca w/o distinguishing features.
ref: Kopans 292-302

Answer: d?-- if in situ form.

1995
17. Which one of the following is not a subtype of intraductal breast carcinoma?
a. comedocarcinoma
b. micropapillary
c. medullary
d. solid
e. mucinous
*
Tumors of ductal orgin include: ductal ca in situ, invasive duct ca, Paget's, tubular
ca, comedoca, papillary ca, colloid ca(aka mucinous) , medullary ca, inflmmatory ca.
ref : Kopans p 289

Answer: d

1994, 1992
18. Films show bilateral dense axillary lymphadenopathy. What is the most likely
diagnosis?
a. melanoma
b. lymphoma
c. bilateral breast carcinoma
d. Mondor’s disease
e. cystosarcoma phylloides
f. adenosis
*
This is a tough one. The answer is NOT d. (see question 8), e. (which is unifocal
and looks like a fibroadenoma), or f. (which give microcalcifications which may be
diffuse)
C. is possible. Bilateral breast cancer may have bilateral axillary metastases
which may be bulky - but no mention is made of a breast lesion. This combination makes
C. less likely.
A. is probable. Melanoma is the most common tumor to metastasize to the breast.
Since melanoma may metastasize anywhere and since a malignant lesion to the breast
drains via axillary nodes, widely metastatic melanoma may have this appearance.
B. is the most likely. Quoting Kopans (1989, p. 307) “...the presence of large
axillary nodes should raise the possibility of lymphoma...” Since no mention was made
of a breast mass, lymphoma is probably the best answer. Sometimes the only sign of
lymphoma in the breast is diffuse increased density.
Dr. Duckett remembers this one from last year. She says that there are only
benign calcifications in the breasts and huge dense lymph nodes; therefore, the answer is
lymphoma.
*
Answer: b. lymphoma

1994, 1992
19. Choose the one incorrect answer among the following concerning Eklund views:
a. need to use manual exposure
b. presence of fibrous capsule may limit exam
c. the implant is better seen on standard views
d. more normal breast tissue is seen on the Eklund view
e. can be magnified
*
The Eklund view attempts to push the implant back against the chest wall, leaving
only breast tissue between the paddle and the cassette. Therefore, the implant is not as
well seen, but the normal breast tissue is. As you might imagine, a fibrous capsule may
make it more difficult to push the implant back (but the view is still useful).
With the implant out of the way, the phototimer can be used, provided it measures
x-rays penetrating breast tissue. Manual exposure must be done on “routine” views
because the phototimer will be “behind” the implant and therefore not count as many X-
ray and the exposure will be way too long - thus “blacking out” normal breast tissue.
The December 1993 issue of Applied Radiology has a short but good article on
Imaging the Augmented Breast (Hayes-Macaluso et. al, pp. 21-26.)
*
Answer: a. need to use manual exposure

1994
20. 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
*
Survival statistics may merely reflect the detection of a lesion earlier in its growth
and not necessarily indicate a benefit from a particular detection/treatment strategy (lead
time bias).
Mortality indicates who actually lived longer. For instance, in the study, a woman
who had her cancer found 10 years earlier would still have to outlive (in total
chronological age) her matched cohort. As a group, the study patients would live longer
than the control patients and thus have a lower mortality rate. (Not merely live longer
after their tumors were found!)
Reference: Kopans 1989, pp. 9-10.
*
Answer: b. mortality reduction

An expert is a man who has made all the mistakes which can be made in a very narrow
field.
Niels Bohr (1885–1962), Danish physicist. Quoted in: Alan Mackay, The Harvest of a
Quiet Eye (1977).

1994
21. Choose the single false answer among the following choices concerning 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
*
Is the difference that FNA can only give a cytologic diagnosis; whereas core can
give a histologic diagnosis?
This questions assumes that the lesion was successfully biopsied.
*
Answer: a. Dr. Duckett - “True,” Dr. Sullivan - “? False, why not FNA with ultrasound?”
b. True c. True d. True e. True

1994, 1992
22. A woman with a history a melanoma metastatic to the inguinal lymph nodes develops
a new spiculated mass in the breast. It is most likely to be:
a. metastatic melanoma
b. invasive carcinoma
c. lobular carcinoma
d. carcinoma in situ
*
Metastases are usually not spiculated and are usually multiple. A lesion has
associated spiculations only after it is invasive and incites a desmoplastic response (c. and
d. not invasive)
*
Answer: b. invasive carcinoma

1994
23. The worst histology of DCIS would be:
a. comedocarcinoma
b. papillary
c. cribriform
d. mucinous
e. tubular
*
Answer: a. comedocarcinoma

The comedocarcinoma variety of DCIS has 5% incidence of positive axillary


lymph nodes at diagnosis. Comedocarcinoma is a descriptive term for a ductal carcinoma
that is characterized by the abundant cell necrosis that fills the ducts of the involved lobe
and frequently calcifies. When cut in cross section, this necrotic debris is extruded from
the duct like a comedome, and hence the name.
References: Review of Radiology (Ravin) 1994, p. 29; Kopans 1989, pp. 292, 296
*

1994
24. Which of the following is the best way to detect an intracapsular rupture of a silicone
implant:
a. silicone in the axilla
b. linguini sign
c. abnormal contour of the implant
*
Answer: b linguini sign

1994
25. 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
f. pituitary carcinoma
*
Answer: probably c. hematoma

Mondor’s disease is also called superficial venous thrombosis. A tender


purplish cord extends over the surface of the breast. A prominent vein may be seen on
mammography - this gives a long shadow. Mondor’s disease is not usually associated
with discoloration. A stimulating article on this is by Grow and Lewison in SGO 53:180-
182, 1963.
Hematoma is also a possibility. However, hematomas are usually well-defined
(but may become ill-defined as the blood dissects) and associated with trauma. I am not
sure about the risk of spontaneous breast hematoma formation in a woman on
anticoagulation. If I saw this I would be very suspicious of an underlying malignancy.
Inflammatory carcinoma of the breast is largely a clinical diagnosis - tenderness is
a hallmark of this disease, so this would be very unlikely in this case (remembering of
course that persons with carcinoma may be hypercoagulable so if the question was
changed such that the woman had a tender, erythematous mass with “orange peel” skin
that this is much more likely.)
Hemorrhagic cyst is (almost) always well-defined.
Fat necrosis has a variety of appearances. Regardless of the appearance, it is
usually secondary to some sort of traumatic insult.

1994
26. The best initial workup of a 5 cm mass in a 20 year old would be:
a. mammogram
b. ultrasound
c. follow-up
d. excisional biopsy
e. gadolinium enhanced MR
*
Answer: b. ultrasound

A mass in a young women (defined as less than 35 y/o) is most commonly a cyst
(or fibroadenoma). Since the breast of a young woman is more sensitive to radiation,
mammography should be withheld initially (it may be necessary in the complete workup
of a mass which is indeterminate on ultrasound).
If ultrasound shows a simple cyst, the workup is complete. If the mass appears
cystic but it is not “simple,” ultrasound can be used to guide aspiration or “biopsy.”
Biopsy should not be the initial workup, however.
MR may be an excellent choice in the complete workup of an indeterminate mass
but in 1995 should never be used as the initial diagnostic examination.
Follow-up makes no sense. You would be saying “I don’t know what this mass is
but I am going to wait and see if it grows.” If it doesn’t grow you still don’t know what it
is and it still could be cancer. If it grows, it is more likely cancer (although the risk in a
20-year-old is still small). The reality is that no matter what size the mass is it is unlikely
to be cancer in a 20-year-old - but you don’t know until you look (and you would feel
rotten - the patient wouldn’t be too happy either - if you chose to follow-up an obvious
mass and on the follow-up it was cancer). ‘Nuff said.
*

1994
27. Where is the most likely location for skin calcifications in the breast?
a. axillary
b. inframammary
c. lower outer quadrant
d. parasternal
e. periareolar
*
Answer: Dr Duckett: e. periareolar, Dr. Sullivan: d. parasternal (answer is probably d.)

In the Duke Review Manual, “peripheral location” is listed as characteristic for


skin calcifications.
Reference: Review of Radiology (Duke-Ravin) 1994, p. 38
*

1994, 1992
28. The diagnosis in a film showing multiple “tea cup” like calcifications:
(In 1992, this was worded as “innumerable calcifications throughout, arguably with fluid
levels”)
a. microcyst
b. adenosis
c. DCIS
d. intraductal carcinoma
e. fat necrosis
*
Answer: a. microcyst

1994, 1992
29. Which of the following is least likely to produce intraductal calcification?
a. secretory disease
b. intraductal carcinoma (=comedocarcinoma?)
c. papillomatosis
d. adenosis
e. Paget’s disease
*
Answer: e. Paget’s disease
Secretory disease is a benign condition with a typical pattern of diffuse rod-like
calcifications within the ducts.
Comedocarcinoma is an indolent form of intraductal carcinoma which grows
along ducts with no or minimal invasion. It is classically associated with linear casting
microcalcifications.
Multiple peripheral papillomas, or papillomatosis, are hyperplastic lesions that
project into the lumen of the distal ductal epithelium just proximal to the lobule. These
lesions lack the fibrovascular core that distinguishes the large-duct papilloma. They may
produce mammographically detectable clustered microcalcifications. Haagensen and
others have described a 25-30% risk of carcinoma in these patients.
Adenosis is a relatively common benign lesion of the breast. It represents an
enlargement of the lobule secondary to a benign proliferation of the blunt-ending
intralobular ducts. On occasion, it may be they cause of isolated clustered
microcalcifications
Paget’s disease is a form of ductal carcinoma that involves the epidermal layers of
the nipple. It is merely a ductal malignancy that presents itself at an early stage owing to
its spread to the nipple. The prognosis generally is favorable because of the early
presentation. It is not unusual for Paget’s disease to be clinically apparent with no
mammographic abnormality; however, microcalcifications may be seen within the ducts
in the subareolar region directed toward the nipple.
References: Review of Radiology (Duke-Ravin) 1994, p. 39; Kopans 1989, pp. 89-90,
271-272, 274, 290-292; Haagensen ed. 3, pp. 136-191
*

1994
30. Contraindications to lumpectomy with radiation include all of the following except:
a. 5 cm mass
b. positive axillary lymph nodes
c. multiple multi-centric calcifications
d. multi-centric carcinoma
e. pregnant patient with breast cancer
*
Answer: b. positive axillary lymph nodes

A 5 cm mass is a relative contraindication to conservative therapy. The incidence


of recurrence in the treated breast for a tumor less than or equal to 2 cm (T1) is 5-10%.
However, for tumors greater than 5 cm, it is greater than 15%.
There is no increased risk of breast recurrence in patients with positive axillary
nodes undergoing conservative surgery and radiation. In fact, patients with positive
axillary nodes who undergo conservative surgery and radiation with adjuvant systemic
chemotherapy have a decreased risk of breast recurrence.
Gross multifocal or multicentric disease is characterized by the clinical and/or
mammographic appearance of more than one malignant area of disease in the same
breast. In general, multifocal disease refers to more than one malignant area in the same
quadrant, and multicentric disease refers to more than one malignant area in separate
quadrants. The presence of gross multicentric or multifocal disease has been associated
with a relatively high risk (30%-40%) of breast recurrence in patients undergoing
conservative surgery and radiation. The presence of diffuse or widespread malignant-
appearing microcalcifications is also a contraindication to conservative surgery and
radiation.
The specific contraindication to pregnancy is that scattered radiation to the fetus
should be kept to an absolute minimum. On the other hand, pregnancy does not
contraindicate anything that is medically necessary.
Reference: Fowble, BL, Orel, SG, and Jardines, L, “Conservative Surgery and Radiation
for Early-Stage Breast Cancer,” Seminars in Roentgenology, Vol 28, No. 3 (July), 1993,
pp. 279-288.
*

1993
31. Which of the following does not present as a well circumscribed mass on
mammography?
a. colloid carcinoma
b. cystosarcoma phylloides
c. metastasis from melanoma
d. lobular carcinoma in situ
*
Answer: d. lobular carcinoma in situ - LCIS is not visible on mammogram

Phylloides tumor (formerly called cystosarcoma phylloides) is rare and similar in


mammographic appearance to that of a large fibroadenoma. Most are benign, but there is
malignant potential. Phylloides tumor metastasis are via the blood rather than the
lymphatics.
Reference: Review of Radiology (Duke-Ravin) 1994, p. 33
*

1993
32. Lobular calcifications in the breast are most likely due to:
a. papillomatosis
b. sclerosing adenosis
c. secretory calcification
d. comedocarcinoma
*
Answer: b. sclerosing adenosis (c. and d. give ductal calcification, a. refers to a
histologic diagnosis (Dr. Troupin))
Sclerosing adenosis is adenosis plus reactive fibrosis with the proliferating acinar
structure maintaining a lobular configuration. Calcifications are usually in cystically
dilated acinar structures.
Also, see the answer to question 26
Reference: Dahnert 1993, p. 350
*

1993
33. According to ACR guidelines, the average dose for a two-view per breast
mammogram is approximately:
a. 1.0 mGy
b. 2.5 mGy
c. 3.5 mGy
d. 5.0 mGy
*
Answer: c. 3.5 mGy (see above)

Maximum acceptable dose limits are (ACR accreditation guidelines) 400 mrad (4
mGy) per film (e.g., 800 mrad (8 mGy) for a 2 projection study) for a typical breast
thickness of 4.5 cm and a breast composition of 50% glandular and 50% adipose tissue.
With current state-of-the-art mammography units and film-screen combinations,
the average glandular dose is 100-200 mrad (1-2 mGy) per view or 200-400 mrad (2-4
mGy) for two views
Average glandular dose per breast is used because skin exposure is misleading -
there is rapid absorption of the low kV spectrum used, even though exit dose may be as
high as 90% of the entrance (skin) dose.
A grid will increase the mean gladular dose to the breast threefold. Molybdenum
filtration (a 30 micrometer thickness = 3-4 mm Al) significantly reduces the dose to the
breast, and careful collimation further reduces the dose by decreasing scatter.
*

1992, 1990
34. Mammography shows a well-circumscribed ovoid lesion in the upper anterior breast.
The next step should be:
a. excisional biopsy
b. ultrasound
c. follow up in 6 months
e. additional compression films
*
Answer: b. ultrasound

This answer may depend on the way the question is worded. See question 36 for
ultrasound discussion. If the “ovoid lesion” is in the upper outer quadrant it could be a
lymph node - in this case a benign lymph node has a typical appearance (“notch” of fat)
and an ultrasound may be misleading (“solid mass”) The savvy ultrasonographer,
however, will look for the characteristic notch on ultrasound! If the ovoid lesion is old
(for example, it has been there for 10 years) and stable, no further workup is needed
(mass is most likely fibroadenoma or cyst). Characteristic calcifications of fibroadenoma
may be present and further workup then is not needed.
Additional compression films are only needed if the lesion needs to be further
defined mammographically - the lesion in this question has already been defined.
Be very careful about recommending six months follow-up - remember we biopsy
a lot of stuff that isn’t cancer, so have a low threshold.
*

1991
35. What is the % risk of excess mortality per 1 rad to the breast?
*
Answer: 0.42% excess mortality for women 20 and over. This is a very age-related
number which is extrapolated from women with high exposures (i.e., atomic bomb
survivors). Another figure used is that 6 excess cancers per million women per rad per
year (after a “latent” period of 10 years) will be caused by mammography.

1995 ITE (q. 458)


36. Utilizing figure 30 (shows tubular calcifications with lucent centers), which of the
following is the MOST appropriate management for a screening mammogram in a 50-
year-old patient?
a. excisional biopsy
b. needle biopsy
c. routine screening mammography in 1 year
d. magnification mammography
e. short-interval (6-month follow-up mammography
*
Answer; c. routine screening mammography in 1 year

The calcifications are benign (always) and patient can continue with regular
screening.
*

1995 ITE (q. 459)


37. Utilizing Figure 31 (shows clustered microcalcifications and some fine linear and
branching calcifications along with a spiculated mass) which one of the following is the
MOST likely diagnosis?
a. sclerosing adenosis
b. fat necrosis
c. secretory disease
d. intraductal and invasive breast cancer
e. microcystic hyperplasia (milk of calcium)
*
Answer: d. intraductal and invasive breast cancer

The description above is classic for breast cancer. In its evolution fat necrosis
may resemble invasive breast cancer. Sclerosing adenosis may have isolated clustered
microcalcifications which are indistinguishable from invasive breast cancer. However,
adenosis usually doesn’t have an associated spiculated mass or linear and branching
calcifications. Also, adenosis may be diffuse (cancer occurs in a cluster).
*

1993 c PreTest
38. In 1991, how many new cases of breast cancer and breast cancer deaths were there?
a. 24,000 and 20,000
b. 80,000 and 67,000
c. 140,000 and 34,000
d. 210,000 and 98,000
*
Reference: American Cancer Society 1991, pp. 19-36
*
Answer: c. 140,000 and 34,000

1993 c PreTest
39. The percent reduction in mortality from screening mammography, based on several
studies, is approximately:
a. 2%
b. 6%
c. 10%
d. 30%
e. 41%
*
Answer: d. 30%

Two large studies are cited in discussions of reduction in mortality from breast
cancer by screening mammography. The first is the HIP (Health Insurance Plan of New
York) study, begun in 1963, which included 64,000 healthy women. It demonstrated a
significant reduction in mortality (approximately 30%), even in the much-debated 40- to
49-year-old group. The later study was begun in Sweden in the late 1970s, and is
ongoing. At the point at which 134,000 women were enrolled, there was a 31% reduction
in deaths when screening was done by film-screen mammography
Reference: Tabas, Radiology 174:655-656, 1990
*

1993 c PreTest
40. If a focal cluster of microcalcifications is biopsied, the chances of malignancy are:
a. 5%
b. 10%
c. 20%
d. 50%
e. 80%
*
Answer: c. 20%

When all lesions with microcalcifications are biopsied, the proportion which is
cancerous is 20-30%. Certain characteristics suggest malignancy such as pleomorphism,
casting , and multiplicity. Some calcifications are obviously benign, such as the coarse
rim type (eggshell) or the amorphous, large and rounded, or layered types. Analysis of
these features helps decrease the false positive rate to an acceptable level. Unfortunately,
it is often not possible for mammography to differentiate benign from malignant
microcalcifications, and needle localization and specimen radiography are necessary. The
radiologist’s role is not complete even after documentation of removal of
microcalcification, since the follow-up mammography must be done according to
accepted guidelines.
*

1994
41. Resolution in magnification mammography is limited by:
a. focal spot size

Mammography Section
The following questions are matching:

1995v, 1993
Matching regarding mammo quality assurance:
1. cassette film contact
2. processor temperature
3. cleaning screens
4. phantom study
5. QC of processor control

a. daily
b. weekly
c. monthly
d. semi-annually
e. annually
*
Answers: 1. d 2. a 3. b 4. c 5. a
Responsibilities of the radiologist:
1. ensuring that the technologists are appropriately trained in mammography and perform
required quality assurance measurements
2. provide feedback to the technologist regarding aspects of clinical performance and
quality control issues.
3. having a qualified medical physicist perform the necessary tests and administer the QC
program
4. keeping and maintaining records concerning employee qualifications, quality assurance
and safety records, and protocol manuals
Frequency of quality assurance (responsibility of the technologist):
daily - darkroom cleanliness, processor QC (including temperature)
weekly - screen cleanliness, view box QC
monthly - phantom images, visual checklist
quarterly - film repeat analyses (how many exams need to be repeated), fixer retention
analysis
semi-annual - darkroom fog, screen-film contact, compression
Physicist responsibilities (done on an annual basis)
1. mammographic unit assembly evaluation
2. collimation assessment
3. focal spot size measurement
4. kVp accuracy and reproducibility
5. beam quality assessment and half value layer (HVL) determination
6. automatic exposure control (AEC) performance assessment
7. screen speed uniformity
8. breast entrance exposure and average glandular dose measurement
9. phantom evaluation of image quality
10. artifact assessment

Reference: AFIP notes, July 1994


*

1995
Matching regarding the postoperative breast:
6. curvilinear soft tissue calcification in the inferior breast
7. surgical clips in the axilla
8. capsular calcifications
9. periareolar calcifications
10. dystrophic calcifications

a. breast reduction mammoplasty


b. breast augmentation mammoplasty
c. breast reconstruction with a rectus femoris flap
d. lumpectomy with radiation therapy
e. incisional biopsy
*
Answer: 6. c 7. d 8. b 9. a 10. e

1995
11. phylloides tumor
12. infiltrating ductal carcinoma
13. lymph node

a. homogeneous medium echotexture well-circumscribed mass in the breast


b. well-circumscribed mass with a notch
c. lobulated, primarily hypoechoic well-circumscribed mass
d. ill-defined mass
*
Answer: 11.c 12. d 13. b

The mammo appearance of infiltrating ductal ca is varied. The dx with an ill


defined mass with spiculated or stellate margins is virtually certain. Lobulated shapes are
more common. The classic appearance on US is usually an irregularly shpaed hypoechoic
structure that fequently has a triangular anterior margin with posterior shadowing.
Virtually every other shape and pattern have been seen on US.
Phylloides tumor are indistinguishable from other well circumscribed breast
lesions. Spiculation does not occur and microcalcifications are not a feature. ON US the
appearance is identical to that of a fibroadenoma which is typically hypoechoic, well
circumscribed.
ref 302, 290, 265, Kopans

1994, 1992
14. low sensitivity
15. high sensitivity
16. low specificity
17. high specificity

a. low positive predictive value


b. interval development of cancer
c. low false positive rate
d. high detection rate
*
Answers: 14. b 15. d 16. a 17. c

Basically, sensitivity means “can you find it when it’s there?” An exam with low
sensitivity will not find the cancer that is there - and there will be interval development
(actually “presentation,” the cancer has been developing for a long time). Conversely, an
exam with high sensitivity will find more of the cancers that are there (high detection
rate).
Specificity means - “if I see it can I be sure it is a cancer?” An exam with low
specificity will be wrong a lot and therefore have a low positive predictive value. An
exam with high specificity won’t be wrong very often and therefore will have a low false
positive rate.
For all you math weenies:

Test + | Test - |
------------------------------------|-----------------| TP = true positive
Diagnosis + TP | FN | FP = false positive
-------------------------------------|-----------------| FN = false negative
Diagnosis - FP | TN | TN = true negative
------------------------------------|-----------------|

Sensitivity = TP / (FN + TP) Specificity = TN / (TN + FP)


PPV = TP / (FP + TP)
*