Mammography Answers

1.

1.T

2.T

3.T

4.???

5???

2.

1. T

2.F

3. F

4. F

Medullary carcinoma (2%)
=SOLID CIRCUMSCRIBED CARCINOMA
Fastest growing breast cancer!
Path:well-circumscribed mass with nodular architecture + lobulated contour; central necrosis is common in larger tumors; reminiscent of medullary cavity of bone
Histo:  intense lymphoplasmocytic reaction (reflecting host resistance); propensity for syncytial growth; no glands
Incidence: 11% of breast cancers in women <35 years of age; 40-50% of medullary cancers in women <50 years of age
Mean age:46-54 years
softer than average breast cancer
well-defined round / oval noncalcified uniformly dense mass (hemorrhage) with lobulated margin
may have partial / complete halo sign
US:  hypoechoic mass with some degree of through transmission
distinct / indistinct margins
large central cystic component
DDx:  fibroadenoma
Prognosis:  92% 10-year survival rate 

3.

1. F

2. F

3. T

4. T

5. T

RADIOGRAPHIC SHARPNESS
=subjective impression of distinctness / perceptibility of structure boundary / edge

1.Radiographic contrast

=magnitude of optical density difference between structure of interest + surroundings influenced by

(a)subject contrast
=ratio of x-ray intensity transmitted through one part of the breast to that transmitted through a more absorbing adjacent part affected by
-absorption differences in the breast (thickness, density, atomic number)
-radiation quality (target material, kilovoltage, filtration)
-scattered radiation (beam limitation, grid, compression)

(b)receptor contrast
=component of radiographic contrast that determines how the x-ray intensity pattern will be related to the optical density pattern in the mammogram
affected by
-film type
-processing (chemicals, temperature, time, agitation)
-photographic density
-fog (storage, safelight, light leaks)

2.Radiographic blurring

=lateral spreading of a structural boundary
(= distance over which the optical density between the structure and its surroundings changes)

(a) motion
reduced by compression + short exposure time

(b) geometric blurring
affected by
-focal spot: size, shape, intensity distribution
-focus-object distance (= cone length)
-object-image distance

(c) receptor blurring
=light diffusion (= spreading of the light emitted by the screen) affected by
-phosphor thickness + particle size
-light-absorbing dyes + pigments
-screen-film contact

4.

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.

5.

10. True

11. True

12. True

13. False

Breast US should be used as a technique to help resolve specific management 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 triangulate lesions 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 asymmetric 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 occasionasly see microcalcifications especially when they are located w/in a mass.

6.

14. false

15. false

16. ??true-- ?old blood

17. true

18 . true

Nipple d/c is an 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.

clear breast d/c can also be associated with ca.

7.

19. true

20. false

21. true

22. true

23. true

Gynecomastia may be physiologic as in the newborn, aging, adolescence. Pathologic etiologies include deficient testosterone production or action, increased estrogen-( liver disease, thyrotoxicosis), drugs- marijuana, spironolactone- diuretic>antihypertensive, idiopathic.

8.

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.

9.

31 False

32. False

33. ? false-- not a characteristic finding.

34. True

35. False

36. True

37. False

LCIS is different than DCIS. LCIS has a better px. Also, unlike DCIS, it doesn't lead to increase risk of breast ca in the same area. Usually dx incidentally on pathology when breast tissue is removed for another reason.

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.

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. Infiltrating lobular ca typically spreads " in line" and in one plane.

ductal dilatation is more characteristic of infiltrating ductal ca. not lobular.

10.

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.

11.

42. False

43. True (classically)

44. False

45. True rare

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.

punctate calcifications can occur but it is rare.-- <5%. ref:ACR

12.

49. False

50. True

51.  "probably False"

52. False

53. True

54. True

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.

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."

13.

55. False

56. True

57. True

58. False

59. True

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

To decrease dose several things are done:

To improve images several things are done:

14.

60. True

61. True

62. False

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:

15.

64. True

65. True (ACR syllabus)

66. True (DCIS will progress to carcinoma, LCIS is a marker for carcinoma in the future, usually ductal.)

67. False

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.

 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 they may be indistinguishable.

16.

68. True

69. False

70. False (looks just like invasive ductal) ??true

71. False

Distribution of cancers is as follows:

Usually, invasive lobular ca has the appearance of asymmetric breast density with ill defined margins. It is frequently missed and difficult to detect on mammo. Can also appear round/ovoid or dense tissue with radiating spicules.

Reference: Dahnert 1993, p. 344

17.

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.

18.

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. True --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).

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.

19.

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.

20.

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 with a narrow exposure latitude. Vigorous compression is required to even out the thickness thru 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 of the low keV photons necessary for film/screen imaging. Tungsten imaging doesn't produce as high a contrast as molyb.

21.

92. True

93. True

94 False

95. False

96. False

22.

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 (SOD) difference is changed, since this is what creates the magnification (focus to film distance will not change). mag = SID/SOD. 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.

23.

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 proximity of the lesion to the chest wall and relatively long projections radiating from it that are thicker than those associated with ca. histologically , this lesion is hypocellular dense fibrous tissue that locally invades adjacent muscle.

24.

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.

25.

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.

26.

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.

Mammography

Select the single best answer

27.

Answer c

28.

Answer: c

29.

answer:  b

30.

Answer: c

31.

Answer: ??d

32.

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.

33.

Answer: b. nipple line

34.

Answer: c. at the inframammary fold

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.

35.

Answer: c. monthly

36.

Answer: a. assessment of implant rupture

37.

Answer: c. tangential

38.

Answer: c

39.

Answer: 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 ill defined mass with architectural distortion with calcification possible. It is usually a pathology incidental finding.

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. Lobulated shapes are more common, and the more undulating the border, the more suspicious. Infiltrating ductal carcinoma is so much more common than any other breast ca representing 75% and more likely to be a well circumscribed lesion just because of frequency.

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."

41.

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.

Answer: a or b

According to the mammo people, recall rate should be around 10%.

The double reading system necessitates the recall of approximately 3-7% of patients for more imaging of suspicious lesions.-- 5-15% of cancers are overlooked by a single reader system.

43.

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 While most masses with smooth margins are benign, up to 7% of malignant lesions can be well circumscribed . Other non-benign lesions which may be well-circumscribed:

44.

Answer: b. upper inner 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)".

45.

Answer: b. 5/cc

46.

Answer: a. 5-10%

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.)

47.

Answer: d- lobular

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 of 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. Also, Infiltrating lobular ca can be difficult to identify because they tend to grow in one plane. They may be only visible on one view of a mammo- mammo conf. 8/21/96

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.

48.

Answer: d

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, inflammatory ca.

49.

Answer: b. lymphoma

This is a tough one. The answer is NOT d, e. (which is unifocal and looks like a giant 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.

50.

Answer: a. need to use manual exposure

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.

51.

Answer: b. mortality reduction

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!)

52.

Answer: a.

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.

53.

Answer: b. invasive carcinoma

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)

54.

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.

55.

Answer: b linguini sign

56.

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.

57.

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).

58.

Answer:d. parasternal

In the Duke Review Manual, "peripheral location" is listed as characteristic for skin calcifications.

59.

Answer: a. microcyst

I assume they want you to think "milk of calcium!"

60.

Answer: e. Paget’s disease ( this one may be d. adenosis)

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 the 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.

61.

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.

62.

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.

63.

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.

64.

Answer: c. 3.5 mGy

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.

65.  

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.

66.  

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.

67. 

Answer; c. routine screening mammography in 1 year

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

68.

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).

69.

Answer: c. 140,000 and 34,000

70. 

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

71.  

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.

72.

a. focal spot size

Mammography Section

The following questions are matching:

73.

1??? 2??? 3??? 4??? 5???

74.

Answers:

1. d

2. a

3. b

4. c

5. a

75.

Answer:

6. c,a

7. d

8. b

9. a

10. e

76.

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 shaped hypoechoic structure that frequently has a triangular anterior margin. 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.

77. 

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)