Ebook Breast imaging - A core review: Part 1

BreastImaging
ACoreReview


BreastImaging
ACoreReview
EDITORS

BirenA.Shah,MD
SeniorStaffRadiologist,DivisionofBreastImaging
HenryFordHealthSystem
ClinicalAssociateProfessor
WayneStateUniversitySchoolofMedicine
Detroit,Michigan

SabalaR.Mandava,MD
SeniorStaffRadiologist,DivisionofBreastImaging
Director,BreastImagingFellowship
AssociateProgramDirector,Women’sImagingFellowship
HenryFordHealthSystem
ClinicalAssistantProfessor
WayneStateUniversitySchoolofMedicine
Detroit,Michigan


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Breastimaging(2013)
 Breastimaging:acorereview/editors,BirenA.Shah,SabalaR.Mandava.—Firstedition.
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 ISBN978-1-4511-7639-1
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2013018324
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Tomyparents,AshokandJyotiShah,towhomIoweeverythingIam.
Theyhaveguidedmebytheirlifeprinciplesandstrongworkethic.
Tomysister,BinitaAshar,forhersoundadviceandconstantencouragement.
Tomywife,DharmishthaShah,forherendlesssupportandlove.
Tomytwosons,ArenandDeven,whomakelifeworthwhile.
—BIRENA.SHAH

Tomyhusband,Rajesh,andmychildren,MilindandAriana,fortheirunwaveringloveandsupport.
—SABALAR.MANDAVA




CONTRIBUTORS

DonovanM.Bakalyar,PhD,FACR
SeniorStaffScientist
DepartmentofDiagnosticRadiology
HenryFordHealthSystem

Detroit,Michigan

HassanaBarazi,MD
StaffRadiologist
ValleyImagingConsultants,LLC.
MidwestCenterforAdvancedImaging
Rush-CopleyMedicalCenter
Aurora,Illinois

BrandonA.Behjatnia,DO,MPT
ClinicalInstructor
DepartmentofRadiology
MichiganStateUniversity
EastLansing,Michigan
Women’sImagingRadiologist
DiagnosticCenterforWomen
Miami,Florida

AmyS.Campbell,MD
AssistantProfessor
Co-Director,BreastImaging
DepartmentofRadiologyandRadiologicalScience
MedicalUniversityofSouthCarolina
Charleston,SouthCarolina

WalterHuda,PhD
ProfessorofRadiology
DepartmentofRadiologyandRadiologicalScience
MedicalUniversityofSouthCarolina
Charleston,SouthCarolina

SaumilR.Kadakia,MD
Radiologist
AssociatedRadiologists,Ltd.
Mesa,Arizona

MadeleneC.Lewis,MD
AssistantProfessor
AssistantProgramDirector,DiagnosticRadiologyResidencyProgram
DepartmentofRadiology
MedicalUniversityofSouthCarolina
Charleston,SouthCarolina

RalphP.Lieto,MSE,FAAPM,FACR
RadiationSafetyOfficer/MedicalPhysicist
RadiationSafetyOffice
St.JosephMercyHealthSystem
AnnArbor,Michigan

SabalaR.Mandava,MD
SeniorStaffRadiologist,DivisionofBreastImaging
Director,BreastImagingFellowship
AssociateProgramDirector,Women’sImagingFellowship


HenryFordHealthSystem
ClinicalAssistantProfessor
WayneStateUniversitySchoolofMedicine
Detroit,Michigan

ColleenH.Neal,MD
ClinicalAssistantProfessor
DepartmentofRadiology
UniversityofMichigan
AnnArbor,Michigan

JayPrakashPatel,MD
BreastandMusculoskeletalRadiologist
QuantumRadiology
Marietta,Georgia

ElizabethPopovski,MD,MSc
Radiologist
DepartmentofRadiology—ThePermanenteMedicalGroup
KaiserFoundationHospitals
RosevilleandSacramento,California

JaneG.Seto,DO
StaffRadiologist
DepartmentofRadiology
FreemanHealthSystem
Joplin,Missouri

BirenA.Shah,MD
SeniorStaffRadiologist,DivisionofBreastImaging
HenryFordHealthSystem
ClinicalAssociateProfessor
WayneStateUniversitySchoolofMedicine
Detroit,Michigan

EmilyC.Siegal,MD
SeniorStaffRadiologist
DivisionofBreastImagingHenryFordHealthSystem
ClinicalAssistantProfessor
WayneStateUniversitySchoolofMedicine
Detroit,Michigan

PaulJ.Spicer,MD
AssistantProfessor
DepartmentofRadiology
UniversityofKentucky
Lexington,Kentucky

AfuaY.Thompson,MD
AssistantProfessor
DepartmentofRadiology
MeharryMedicalCollege
StaffRadiologist
DepartmentofRadiology
NashvilleGeneralHospital
Nashville,Tennessee

SamanthaTunnecliffe,RT(R)(M)
MammographySupervisor
DepartmentofRadiology,DivisionofBreastImaging
HenryFordHealthSystem
Detroit,Michigan

JennyH.Wang,DO

DiagnosticRadiologist
DepartmentofRadiology
MercySt.VincentMedicalCenter
Toledo,Ohio




SERIESFOREWORD

Myideafortheseriesbeganwhensomeseniorresidentsaskedourattendingstafftohelpthemprepare
forthenewABRCoreExamination.Atthetime,Iknewverylittleaboutthenewformatfortheexam,
otherthanthatitwouldbeacomputer-basedexamwithmultiple-choicequestions.Istartedlookingfor
resourcesthatwouldhelpourresidentsprepareforthisexam.AsIresearched,Ifoundverylittleinthe
wayofreviewguides,banksofquestions,etc.thattheresidentscoulduse.Andsothegermofanidea
begantotakeshape.
Asmyareaofpracticeispredominantlybreastimaging,Ithoughtofputtingtogetherabankofquestions
in this subspecialty that would cover the curriculum tested on the ABR Core Exam. I discussed the
conceptwithmycolleague,SabalaMandava,whowasalsoofasimilarmind,andwedecidedtodoa
questionbookthatwouldbegearedtowardresidentspreparingfortheCoreExam,butcanalsobeuseful
toanyradiologistpracticingBreastImaging.
Wewerethenfortunatetobeabletoenlistmultiplecolleagueswhowereinterestedincontributingto
thebook.Asthisbookdeveloped,Istartedthinkingaboutsimilarbooksfortheothersubjectstestedon
theCoreExam.AfterseveralweeksofdiscussionwithJonathanPineandAmyDinkel,fromLippincott
William&Wilkins,theconceptofaseriesofbookswasborn.
I am very pleased that the Breast Imaging: A Core Review is the first in The Core Review Series.
TherearemultiplebookssuchasMusculoskeletalRadiology,Neuroradiology,andothersthatareeither
currentlybeingworkedonorinthenearfuturewillbeaddedtoseries.Thephilosophyforeachbookin
theseriesistoreviewtheimportantconceptstestedwithapproximately300questions,inaformatsimilar

tothenewABRCoreExam.
AsSeriesEditorofTheCoreReviewSeries,ithasbeenagreatsourceofpleasuretonotonlybean
author of one of the books, but also to work with many outstanding colleagues across the country who
contributedtotheseries.Thisseriesrepresentscountlesshoursofworkandinvolvementbymanyandit
wouldnothavecometogetherwithouttheirparticipation.
Myhopeforthisseriesisthatitwillprovetobeausefulandcomprehensiveguideforallresidentsas
wellasfellowsandpracticingradiologists.
BirenA.Shah
SeriesEditor




PREFACE

With the changing of the Boards format, these are uncertain times for radiology residents. The days of
preparingfortheoralboardswithmultiplereviewsofimageinterpretationwilllikelychange.Instead,
the Boards are now geared to a more comprehensive understanding of disease processes, the physics
behindimageacquisition,qualitycontrol,andsafety.Thereisapaucityofstudyresourcesavailablefor
residents.
Withthisinmind,wewantedtoprovideaguideforresidentstobeabletoassesstheirknowledgeand
review the material in a format that would be similar to the Boards. The questions are divided into
differentsections,aspertheABRCoreExamStudyGuide,soastomakeiteasyforthereaderstowork
onparticulartopicsasneeded.Therearemostlymultiple-choicequestionswithsomeextendedmatching
questions. Each question has a corresponding answer with an explanation of not only why a particular
optioniscorrectbutalsowhytheotheroptionsareincorrect.Therearealsoreferencesprovidedforeach
questionforthosewhowanttodelvemoredeeplyintoaspecificsubject.Thisformatisalsousefulfor
radiologistspreparingforMaintenanceofCertification(MOC).
Therearemultiplecolleagues,someofwhomareourpastfellows,whocontributedtothispublication.
Thisbookcouldnothavebeenfinishedwithouttheeffortsofallthesepeoplewhotooktimefromtheir

busylivestoresearch,write,andsubmitmaterialinatimelymanner.Ourheartfeltthankstoallofthem.
ManythankstothestaffatLWW,JonathanPine,AmyDinkel,JeffGunning,SreeVidyaDhanvanthri,
andPriscillaCraterforgivingusthisopportunityandguidingusalongtheway.
Last,butcertainlynottheleast,wearegratefultoourfamilies,whohaveenduredourlonghoursof
workandkeptussmilingthroughouttheprocess.
We hope that this book will serve as a useful tool for residents on their road to becoming Boardcertifiedradiologistsandwillcontinuetobeareferenceintheirfuturecareers.
BirenA.Shah,MD
SabalaR.Mandava,MD




CONTENTS

Contributors
SeriesForeword
Preface

1  Regulatory/StandardsofCare
2  BreastCancerScreening
3  DiagnosticBreastImaging,BreastPathology,andBreastImagingFindings
4  BreastIntervention
5  PhysicsRelatedtoBreastImaging
Index


1

Regulatory/StandardsofCare

QUESTIONS
1 WhichofthefollowingisaMammographyQualityStandardsAct(MQSA)requirementfor
interpretingphysicians?
A. 15category1continuingmedicaleducation(CME)creditsperyear
B. 10hoursofinitialnewmodalitytraining(e.g.,digitalmammography)
C. Initialexperienceof240examsunderdirectsupervisioninthe6monthsbeforestartingto
interpretmammography
D. Continuingexperienceofinterpretationof960exams/12months
2 Foreachdiagnosticimage,below,assignthelikelyBI-RADSassessmentofeitherBI-RADS2
(answerchoice“A”)orBI-RADS4(answerchoice“B”).Eachoptionmaybeusedonce,more
thanonce,ornotatall:


3 Theapproximateexpectednumberofcancersthatshouldbefoundin1,000initialscreening
mammogramsis
A. 1to2


B. 6to10
C. 11to14
D. 15to19
E. 20to24
4 Overayear,100cancersareidentified;94ofthesewereidentifiedbasedonbiopsy
recommendationsfromascreeningmammogramandanadditional6cancersdevelopedaftera
negativemammogram.Whatisthesensitivityinthispopulation?
A. 6%
B. 88%
C. 90%
D. 94%
E. 96%

5 Whenassessingforaccuratepositioningonmediolateraloblique(MLO)view,whichofthe
followingiscorrect?
A. Alargeamountoftheupperabdomenshouldbevisible.
B. Thebreastshouldbepulledoutanddown.
C. Thepectoralmuscleshouldwidenattheaxillaandextendtothenipple,andtheanterior
marginshouldbeconvex.
D. Theinframammaryfoldshouldbeneutralinposition.
6 Apatienthasanegativescreeningmammogramstudyand8monthslaterdevelopsapalpablemass
thatisbiopsiedtorevealinvasiveductalcarcinoma.Thisistermeda
A. Falsenegative
B. Falsepositive
C. Truepositive
D. Truenegative
7 Whichofthefollowingqualitycontroltestsareperformedweeklyforfilmscreenmammography?
A. Darkroomcleanliness
B. Processorqualitycontrol
C. Screencleanliness
D. Viewboxcleanliness
E. Fixerretention
8a An85-year-oldfemalewithhistoryofleftmastectomy.Thepatientpresentedforascreening
mammogramoftherightbreast.Aradiopaquemarkerwasplacedonthenipple.Imagesare
providedbelow.


Basedonthescreeningmammogramimages,whatisthemostappropriateBI-RADSassessment?
A. BI-RADS0
B. BI-RADS1
C. BI-RADS2
D. BI-RADS3
E. BI-RADS4

8b Thepatientiscalledbackforarepeatmediolateraloblique(MLO)imageoftherightbreast(see
below):

Thereasonthemediolateralobliqueviewwasrepeatedwasbecauseof
A. Hairartifact
B. Motionartifact
C. Chinartifact


D. Deodorantartifact
E. Skinartifact
9 Theposteriornipplelinemeasures13cmonthemediolateraloblique(MLO)view.Whatisan
acceptableposteriornipplelinemeasurementonthecraniocaudal(CC)view?
A. 8cm
B. 9cm
C. 10cm
D. 11cm
E. 12cm
10 InordertomeetMQSArequirements,allmammographyfacilitiesmustreviewmedicaloutcomes
auditdatafortheaggregateofinterpretingphysiciansaswellasdataforeachindividual
interpretingphysicianatthatfacility.Howoftenmustthemedicaloutcomesauditdatabe
reviewed?
A. 3months
B. 6months
C. 12months
D. 24months
11 Priortoindependentlyinterpretinganynewmammographicmodalitytheinterpretingphysician
mustfirstobtainanddocumentadditionaltraininginthismodality.Howmanyhoursoftrainingare
required?
A. 4hours

B. 6hours
C. 8hours
D. 12hours
12 Ascreeningmammogramcontainssignificantmotionartifactononeview.Whichmemberofthe
teamisresponsibleforassuringappropriatecorrectiveactionistaken?
A. Interpretingphysician
B. Radiologictechnologist
C. Medicalphysicist
D. Equipmentvendor
13a A41-year-oldfemalewithhistoryofapalpablelumpintherightbreast.Imagesareprovided
below.


Basedonthediagnosticmammogramimagesprovided,whatisthemostappropriatenextstep?
A. RepeatMLOviewduetopossibleartifact.
B. Proceedtoatargetedrightbreastultrasoundofareathatispalpable.
C. Requestrolledcraniocaudalviewsoftherightbreast.
D. Recommendreturntoannualscreeningmammography.
E. Referthepatienttoseeabreastsurgeon.
13b Thepatientiscalledbackforarepeatmediolateraloblique(MLO)imageoftherightbreast(see
below).

Thereasonthemediolateralobliqueviewwasrepeatedwasbecauseof
A. Hairartifact


B. Chinartifact
C. Deodorantartifact
D. Suboptimalpatientpositioning
E. Motionartifact

14 Whichofthefollowingiscorrectregardingscreeningmammographyguidelinesasrecommended
byAmericanCollegeofRadiology?
A. Annualmammogramsstartingatage40until80
B. Biannualmammogramsstartingatage35andannualafterage40
C. Annualmammogramsstartingatage50
D. Biannualmammogramsstartingatage40andannualafterage50
E. Annualmammogramsstartingatage40untiltheindividual’soverallhealthallows
15 Whichofthefollowingiscorrectregardingproperpositioningofbreastsinmammography?
A. Thecraniocaudal(CC)viewisaprojectionparalleltothepectoralismajormuscle.
B. OntheCCview,thepectoralismajormuscleisseenapproximately75%ofthetime.
C. Onthemediolateraloblique(MLO)view,thepectoralismajorshouldbeconcaveanteriorly.
D. OntheMLOview,thepectoralismajormuscleshouldbeseenabovetheleveloftheaxisof
thenipple.
E. Thenippleshouldbeinprofileonatleastoneview.
16 Federalregulationsrequirethatfollow-uponsurgicaland/orpathologyresultsbeperformedfor
patientswithpositivemammograms.Howfrequentlyarefacilitiesrequiredtoconductthis
follow-up?
A. Daily
B. Weekly
C. Monthly
D. Yearly
17 Failuretoinformpatientsoftheirresultsinatimelymannerisconsideredasignificantviolation.
WhatisthetimelimitsetbytheFDAtoprovidelaysummariestoallpatients?
A. 7days
B. 14days
C. 30days
D. 60days
18 WhichorganizationregulatesmammographyqualitystandardsintheUnitedStates?
A. FoodandDrugAdministration
B. AmericanCollegeofRadiology

C. DepartmentofHealthandHumanServices
D. Regulatedbyeachstateindependentlywithoutfederalinvolvement
19 GhostingartifactonMRIiscausedby:
A. Wrongfrequency-encodingdirection
B. Wrongphase-encodingdirection
C. Poorshimming


D. Patientmotion
20 Thedefinitionofpositivepredictivevalue1(PPV1)is:
A. Percentageofexaminationswithanabnormalfinalinterpretationthatresultinatissue
diagnosisofcancerwithin1year
B. Percentageofexaminationswithanormalinitialinterpretationthatresultinatissue
diagnosisofcancerwithin1year
C. Percentageofexaminationswithanabnormalinitialinterpretationthatresultinatissue
diagnosisofcancerwithin1year
D. Percentageofexaminationswithanabnormalfinalinterpretationwhereitisknownthata
biopsywasperformedasaresultoftheabnormaldiagnosticexaminationthatresultintissue
diagnosisofcancerwithin1year
21 WhichofthefollowingstatementsconcerningBRCA-1mutationcarrieriscorrect?
A. Itisautosomalrecessive.
B. Itisatumorsuppressorgeneonchromosome17.
C. Lifetimeriskofbreastcanceris25%to35%withthecarrier.
D. Itisalsoassociatedwithanincreasedriskoflungcancer.
22 WhatisthebenchmarkfortheCancerDetectionRate(CDR)accordingtothefourtheditionofBIRADS?
A. 1–5/1,000
B. 1–10/1,000
C. 2–10/1,000
D. >2.5/1,000
E. >5/1,000

23 Whatisthebenchmarkfortherecallrateinscreeningmammographyaccordingtothefourth
editionofBI-RADS?
A. <10%
B. <20%
C. 10%to15%
D. 5%to12%
E. 5%to15%
24 Whichofthefollowingisarequirementforcontinuingeducationinmammography?
A. Interpretationofatleast960mammogramsperyear
B. 15hoursofCMEthatarebreastspecificperyear
C. Performanceofatleast36breastbiopsiesin36months
D. Interpretationofatleast100breastultrasoundexaminationsin1year
25 WhichofthefollowingdescribestheappropriatepositioningfortheMLOandCCviewsona
screeningmammogram?
A. ThepectoralismusclemustalwaysbepresentonboththeMLOandCCprojections.
B. ThepectoralismusclemustonlybepresentontheCCprojection.
C. ThedifferencebetweenthelinefromthenippletothebackofthefilmonCCandtheline


fromthenippletothepectoralismuscleonMLOis2cm.
D. ThedifferencebetweenthelinefromthenippletothebackofthefilmonCCandtheline
fromthenippletothepectoralismuscleonMLOis1cm.
26 Regardingcompressionplateandimagingreceptor,whichofthefollowingisnecessary?
A. Both18×24cmand12×18cmsizesarerequired.
B. Collimationtothebreastcontour
C. Compressionforceof45to60pounds.
D. Afixedgridisrequiredforeachreceptorsize.
E. Paddleadvancedbyafootmotorwithhandcompressionadjustment
27 Thefollowingstudywasperformedtoevaluateforsiliconebreastimplantrupture.

Thisimagedepictswhichartifact?
A. Susceptibilityartifact
B. Wrap/aliasingartifact
C. Radiofrequency(RF)interferenceartifact
D. Siliconesaturationartifact
28 Thistabledemonstratesdataobtainedfromabreastcarecenterofacommunityhospitalina12monthperiod.

28a Whatisthescreeningabnormalinterpretationrateatthiscenter?
A. 4%
B. 5%
C. 6%


D. 8%
E. 12%
28b Whatisthecancerdetectionrate?
A. 4/1,000
B. 5/1,000
C. 6/1,000
D. 8/1,000
E. 12/1,000
29 Thefollowingimagefromacontrast-enhancedbreastMRexaminationdemonstrateswhich
artifact?

A. Chemicalshiftartifact
B. Wrap/Aliasingartifact
C. Susceptibilityartifact
D. Motionartifact
30 Regardingstandardizedfilmlabelingformammogramimages,whichofthefollowingiscorrect?
A. Eitherthepatient’sfullnameorauniquepatientidentificationnumberneedstobeonthe

film.
B. Thenameandaddressofthefacilityisneededwhenapatientrequestsfilmsforother
facilities.
C. Arabicnumberindicatingthecassetteshouldbeoneveryimage.
D. Viewandlateralityplacednearthenipple
E. Thetechnologist’semployeenumbershouldbeincluded.
31 A55-year-oldwomanisplacedintoaBI-RADS3categoryafteradiagnosticworkup.According
totheBI-RADSlexicon,aBI-RADS3findinghaslessthanwhatpercentchanceofmalignancy?
A. 1%
B. 2%
C. 3%
D. 4%
E. 5%
32 A60-year-oldfemalepresentswithafindingwhichisplacedintoaBI-RADS5category.
AccordingtotheBI-RADSlexicon,aBI-RADS5lesionhasgreaterthanorequaltowhatpercent
chanceofmalignancy?
A. 90%


B. 93%
C. 95%
D. 97%
E. 99%
33 Whatartifactisnotedonthisstudy?

A. Hairartifact
B. Deodorant
C. VPshuntcatheter
D. Jewelry
34 Whatartifactisnotedonthisstudy?

A. Hairartifact
B. Deodorant
C. VPshuntcatheter
D. Jewelry
35 AccordingtotheAmericanCollegeofRadiologyandtheAmericanCancerSociety,contrastenhancedscreeningbreastMRIisrecommendedforwomenatwhatpercentagelifetimeriskof
developingbreastcancer?
A. >10%
B. >20%
C. >50%
D. >75%
36 Whatartifactisnotedonthisstudy?


A. Staticartifact
B. Gridlinesartifact
C. Hairartifact
D. Rollerartifact
37 ApremenopausalwomanrequiresabreastMRIwithcontrast.Whichweekofthemenstrualcycle
isthebestchoicetoperformtheMRI?
A. Days1to6
B. Days7to14
C. Days15to21
D. Days22to28
38 Whichofthefollowingisaclinicalindicatorofbreastcancerriskaccordingtothe2007
AmericanCancerSociety(ACS)recommendationsforperformingascreeningbreastMRIasan
adjuncttomammography?
A. Hodgkindiseasewithmantlefieldradiation
B. Historyofneurofibromatosistype1

C. Lifetimeriskofbreastcancerof10%ormoreusingstandardriskassessmentmodels
D. Breastdensity>50%
39 Aphantomimageobtainedduringaweeklycheckshouldshowwhichofthefollowingtomeet
minimumacceptablecriteria?
A. Twofibers,twomicrocalcificationclusters,andtwomasses
B. Onefiber,twomicrocalcificationclusters,andonemass
C. Threefibers,threecalcificationclusters,andthreemasses
D. Fourfibers,threecalcificationclusters,andthreemasses
40 Theviewshownintheimagebelowissuboptimalforevaluatingwhichportionofthebreast?


A. Inferior
B. Lateral
C. Medial
D. Superior
41 Regardingcontrast-enhancedbreastMRIforthedetectionofbreastcancer,whichoneofthe
followingstatementsiscorrect?
A. Cancerisexcludedifamasshashyperintense/fluidsignalontheT2-weightedsequence.
B. BreastMRIisoptimallyperformedinweek4ofapatient’smenstrualcycle.
C. T1-weightednon–fatsaturationisthebestsequenceforidentificationofafat-containing
mass.
D. Abodycoilistheoptimalradiofrequencyreceivercoilfortheexam.
E. Anequivalentdoseofagadolinium-basedcontrastagentisusedforbreastMRpatients.
42a Thefollowingimagefromacontrast-enhancedbreastMRexaminationdemonstrateswhich
artifact?