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Breast imaging - A core review prepares you for the updated exam with a focus on understanding disease processes, the physics behind image acquisition, quality control, and safety. More than 300 questions, answers, and explanations accompany hundreds of high-quality images, in a format that mimics the Core Exam.
Breast Imaging A Core Review Breast Imaging A Core Review EDITORS Biren A Shah, MD Senior Staff Radiologist, Division of Breast Imaging Henry Ford Health System Clinical Associate Professor Wayne State University School of Medicine Detroit, Michigan Sabala R Mandava, MD Senior Staff Radiologist, Division of Breast Imaging Director, Breast Imaging Fellowship Associate Program Director, Women’s Imaging Fellowship Henry Ford Health System Clinical Assistant Professor Wayne State University School of Medicine Detroit, Michigan Senior Executive Editor: Jonathan W Pine, Jr Product Manager: Amy G Dinkel Production Product Manager: Priscilla Crater Senior Manufacturing Coordinator: Beth Welsh Senior Designer: Stephen Druding Production Service: SPi Global © 2014 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Breast imaging (2013) Breast imaging : a core review / editors, Biren A Shah, Sabala R Mandava — First edition p ; cm Includes bibliographical references ISBN 978-1-4511-7639-1 I Shah, Biren A., editor II Mandava, Sabala, editor III Title [DNLM: 1 Mammography—methods Breast Neoplasms—radiography WP 815] RG493.5.R33 618.1'907572—dc23 2013018324 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638–3030 or fax orders to (301) 223–2320 International customers should call (301) 223–2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST 10 9 8 7 6 5 4 3 2 1 To my parents, Ashok and Jyoti Shah, to whom I owe everything I am They have guided me by their life principles and strong work ethic To my sister, Binita Ashar, for her sound advice and constant encouragement To my wife, Dharmishtha Shah, for her endless support and love To my two sons, Aren and Deven, who make life worthwhile —BIREN A SHAH To my husband, Rajesh, and my children, Milind and Ariana, for their unwavering love and support —SABALA R MANDAVA CONTRIBUTORS Donovan M Bakalyar, PhD, FACR Senior Staff Scientist Department of Diagnostic Radiology Henry Ford Health System Detroit, Michigan Hassana Barazi, MD Staff Radiologist Valley Imaging Consultants, LLC Midwest Center for Advanced Imaging Rush-Copley Medical Center Aurora, Illinois Brandon A Behjatnia, DO, MPT Clinical Instructor Department of Radiology Michigan State University East Lansing, Michigan Women’s Imaging Radiologist Diagnostic Center for Women Miami, Florida Amy S Campbell, MD Assistant Professor Co-Director, Breast Imaging Department of Radiology and Radiological Science Medical University of South Carolina Charleston, South Carolina Walter Huda, PhD Professor of Radiology Department of Radiology and Radiological Science Medical University of South Carolina Charleston, South Carolina Saumil R Kadakia, MD Radiologist Associated Radiologists, Ltd Mesa, Arizona Madelene C Lewis, MD Assistant Professor Assistant Program Director, Diagnostic Radiology Residency Program Department of Radiology Medical University of South Carolina Charleston, South Carolina Ralph P Lieto, MSE, FAAPM, FACR Radiation Safety Officer/Medical Physicist Radiation Safety Office St Joseph Mercy Health System Ann Arbor, Michigan Sabala R Mandava, MD Senior Staff Radiologist, Division of Breast Imaging Director, Breast Imaging Fellowship Associate Program Director, Women’s Imaging Fellowship Henry Ford Health System Clinical Assistant Professor Wayne State University School of Medicine Detroit, Michigan Colleen H Neal, MD Clinical Assistant Professor Department of Radiology University of Michigan Ann Arbor, Michigan Jay Prakash Patel, MD Breast and Musculoskeletal Radiologist Quantum Radiology Marietta, Georgia Elizabeth Popovski, MD, MSc Radiologist Department of Radiology—The Permanente Medical Group Kaiser Foundation Hospitals Roseville and Sacramento, California Jane G Seto, DO Staff Radiologist Department of Radiology Freeman Health System Joplin, Missouri Biren A Shah, MD Senior Staff Radiologist, Division of Breast Imaging Henry Ford Health System Clinical Associate Professor Wayne State University School of Medicine Detroit, Michigan Emily C Siegal, MD Senior Staff Radiologist Division of Breast Imaging Henry Ford Health System Clinical Assistant Professor Wayne State University School of Medicine Detroit, Michigan Paul J Spicer, MD Assistant Professor Department of Radiology University of Kentucky Lexington, Kentucky Afua Y Thompson, MD Assistant Professor Department of Radiology Meharry Medical College Staff Radiologist Department of Radiology Nashville General Hospital Nashville, Tennessee Samantha Tunnecliffe, RT(R)(M) Mammography Supervisor Department of Radiology, Division of Breast Imaging Henry Ford Health System Detroit, Michigan Jenny H Wang, DO Diagnostic Radiologist Department of Radiology Mercy St Vincent Medical Center Toledo, Ohio SERIES FOREWORD My idea for the series began when some senior residents asked our attending staff to help them prepare for the new ABR Core Examination At the time, I knew very little about the new format for the exam, other than that it would be a computer-based exam with multiple-choice questions I started looking for resources that would help our residents prepare for this exam As I researched, I found very little in the way of review guides, banks of questions, etc that the residents could use And so the germ of an idea began to take shape As my area of practice is predominantly breast imaging, I thought of putting together a bank of questions in this subspecialty that would cover the curriculum tested on the ABR Core Exam I discussed the concept with my colleague, Sabala Mandava, who was also of a similar mind, and we decided to do a question book that would be geared toward residents preparing for the Core Exam, but can also be useful to any radiologist practicing Breast Imaging We were then fortunate to be able to enlist multiple colleagues who were interested in contributing to the book As this book developed, I started thinking about similar books for the other subjects tested on the Core Exam After several weeks of discussion with Jonathan Pine and Amy Dinkel, from Lippincott William & Wilkins, the concept of a series of books was born I am very pleased that the Breast Imaging: A Core Review is the first in The Core Review Series There are multiple books such as Musculoskeletal Radiology, Neuroradiology, and others that are either currently being worked on or in the near future will be added to series The philosophy for each book in the series is to review the important concepts tested with approximately 300 questions, in a format similar to the new ABR Core Exam As Series Editor of The Core Review Series, it has been a great source of pleasure to not only be an author of one of the books, but also to work with many outstanding colleagues across the country who contributed to the series This series represents countless hours of work and involvement by many and it would not have come together without their participation My hope for this series is that it will prove to be a useful and comprehensive guide for all residents as well as fellows and practicing radiologists Biren A Shah Series Editor PREFACE With the changing of the Boards format, these are uncertain times for radiology residents The days of preparing for the oral boards with multiple reviews of image interpretation will likely change Instead, the Boards are now geared to a more comprehensive understanding of disease processes, the physics behind image acquisition, quality control, and safety There is a paucity of study resources available for residents With this in mind, we wanted to provide a guide for residents to be able to assess their knowledge and review the material in a format that would be similar to the Boards The questions are divided into different sections, as per the ABR Core Exam Study Guide, so as to make it easy for the readers to work on particular topics as needed There are mostly multiple-choice questions with some extended matching questions Each question has a corresponding answer with an explanation of not only why a particular option is correct but also why the other options are incorrect There are also references provided for each question for those who want to delve more deeply into a specific subject This format is also useful for radiologists preparing for Maintenance of Certification (MOC) There are multiple colleagues, some of whom are our past fellows, who contributed to this publication This book could not have been finished without the efforts of all these people who took time from their busy lives to research, write, and submit material in a timely manner Our heartfelt thanks to all of them Many thanks to the staff at LWW, Jonathan Pine, Amy Dinkel, Jeff Gunning, Sree Vidya Dhanvanthri, and Priscilla Crater for giving us this opportunity and guiding us along the way Last, but certainly not the least, we are grateful to our families, who have endured our long hours of work and kept us smiling throughout the process We hope that this book will serve as a useful tool for residents on their road to becoming Boardcertified radiologists and will continue to be a reference in their future careers Biren A Shah, MD Sabala R Mandava, MD What BI-RADS assessment would you give? A. BI-RADS 0 B. BI-RADS 2 C. BI-RADS 3 D. BI-RADS 4 26 Based on the location of the lesion in the left breast shown below, how do you expect the lesion to shift on a mediolateral (ML) view? A. Inferior B. Lateral C. Medial D. Superior 27 Which of the following is correct about human epidermal growth factor receptor 2 (HER2)? A. HER2 positive breast cancers usually demonstrate rapid growth and spread B. HER2 negative breast cancers are more aggressive than HER2 positive cancers C. Approximately 60% of newly diagnosed breast cancer is HER2 positive D. ER negative, PR negative, and HER2 negative cancers have a better prognosis E. HER2 positive breast cancers are more responsive to hormonal treatment 28a Screening breast MRI was performed on a high-risk patient with history of right breast cancer and mastectomy Based on the following images, what is the best BI-RADS assessment to assign this patient’s breast MRI? A. 0 B. 2 C. 3 D. 4 E. 5 28b What is the best follow-up recommendation for this patient? A. Focused ultrasound B. Surgical referral C. MRI-guided biopsy D. 6-month follow-up MRI E. Annual follow-up MRI 29 A 52-year-old female presents with a painless, swollen, and erythematous left breast Based on the images above, what is the most appropriate next step? A. Recommend follow-up imaging after antibiotic treatment B. Biopsy C. Breast MRI D. Annual screening mammography 30 Which of the following is true regarding breast-specific gamma imaging (BSGI)? A. BSGI is less sensitive in women with dense breasts B. BSGI cannot distinguish and differentiate between scar tissue and recurrence in a patient with a history of breast cancer with lumpectomy C. BSGI uses technetium-99m-sestamibi D. BSGI has lower lifetime attributable risk of mortality when compared to radiation exposure from a four-view screening digital mammogram E. BSGI does not involve whole body radiation exposure 31 Match the anatomic structure to the appropriate numerical location on the sonographic image of a normal breast A. Cooper’s ligament B. Subcutaneous fat C. Pectoralis muscle D. Skin 32 Based on the images below, what is the most likely location on the craniocaudal (CC) view for the lesion shown? A. Lateral and posterior B. Medial and posterior C. Lateral and anterior D. Medial and anterior 33 What is the initial imaging modality for evaluation of a palpable breast lesion in a 29-year-old male patient? A. Ultrasound B. Mammography C. Contrast-enhanced MRI D. Contrast-enhanced CT E. Breast-specific gamma imaging 34 Which of the following is considered a second-degree relative? A. Father B. Daughter C. Aunt D. Sister 35 Which of the following is true of surveillance and treatment for breast cancer in treated Hodgkin’s survivors? A. Peak incidence of breast cancer is 25 to 30 years after treatment B. No significant increased risk of breast cancer if treated before the age of 30 C. Preferred treatment in these patients is mastectomy in conjunction with radiation D. If treated for Hodgkin’s before the age of 30, begin annual screening mammography 8 years after radiation exposure 36 Which of the following is a risk factor for breast cancer? A. Family history of breast cancer in cousin B. Late menarche C. First childbirth after age 30 D. Prior history of chemotherapy 37 Which of the following concerning interval cancers is correct? A. Breast cancer found during regular interval mammographic examinations with prior mammogram prospectively having been interpreted as negative B. Increases ductal histology C. Incidence of interval cancers has no relation to density of breast tissue D. Interval cancers can be mammographically occult or a new mammographic finding 38 With regards to the nipple on screening mammographic views, which of the following statements is correct? A. Nipple should be in profile on both MLO and CC projections of both breasts B. Nipple should be in profile on either CC or MLO projection of both breasts C. Nipple does not need to be in profile on either CC or MLO projections D. Nipple should be in profile for one breast but need not be in profile for the other breast 39 Regarding the use of compression while obtaining mammographic images, which of the following statements is correct? A. It helps maintain the nipple in the midline on the images B. It is less painful during the second half of the menstrual cycle C. It reduces the amount of radiation needed D. It helps reduce the number of technical recalls ANSWERS AND EXPLANATIONS 1 Answer D Reference: Saslow D, Boetes D, Burke W, et al American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography CA Cancer J Clin 2007;57:75–89 Recommendations for Breast MRI Screening as an Adjunct to Mammography a Evidence from nonrandomized screening trials and observational studies Based on evidence of lifetime risk for breast cancer 2 Answer B Sternalis muscle is a normal variant of an anatomic chest wall musculature It is located medially adjacent to the sternum and is seen only on the CC mammogram medially It is present in both males and females Reference: Berg A, Birdwell R, Gombos E Diagnostic Imaging Breast 1st ed Salt Lake City, UT: Amirsys; 2008:IV:3:40–41 3a Answer A 3b Answer B Although these calcifications appear suspicious on the provided screening mammogram, it is important to remember the steps required in the workup of an abnormality seen at screening BI-RADS 0, incomplete, is the appropriate first step in diagnosis The patient can then return for additional views These calcifications are highly suspicious; thus, the term “pleomorphic fine linear branching” is the best answer for description Stereotactic or surgical biopsy should be recommended Reference: Kopans D Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006:530–543 4 Answer B The important findings to detect in this case include a bilateral increase in breast density, loss of fat, and decrease of breast size The differential diagnosis for increased breast density includes hormone replacement therapy, endogenous hormonal stimulation such as in pregnancy and lactation, bilateral breast edema such as from congestive heart failure, bilateral breast trauma, weight loss, and bilateral inflammatory breast cancer Of these, bilateral inflammatory breast cancer Of these, bilateral inflammatory breast cancer is the rarest In this case, the decreased breast size and loss of fat combined with the increased breast density are most consistent with weight loss The patient in this case reported a 90-pound weight loss between the two studies Hormone replacement therapy and endogenous hormonal stimulation are typically associated with increased breast size Reference: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:5-48–IV:5–49 5 Answer B This is an example of a mammogram in a woman who has had a previous bilateral reduction mammoplasty The nipple is elevated because there is more skin inferior to the nipple than superior to the nipple In these cases, the residual fibroglandular breast tissue is redistributed from the upper outer quadrant to the inferior inner quadrant to replace the tissue that was removed This creates a swirled fibroglandular tissue pattern in the inferior inner quadrant The calcifications associated with fat necrosis are visible mammographically; later, they are seen in only 50% of cases by 2 years after the surgery Reference: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:4-32–IV:4–35 6 Answer A Carriers of the BRCA1 or BRCA2 mutation should begin annual routine screening mammography at age 30 years Women with mothers or sisters with breast cancer should begin annual routine screening at age 30 (but not before age 25) or 10 years earlier than the age of their relatives’ diagnosis, whichever is later In this case, if the patient was not a BRCA2 mutation carrier she would have begun screening at age 35 based on her mother’s history and at age 32 based on her sister’s history Forty is the age when women who do not have an increased risk of breast cancer to begin screening Reference: Lee CH, Dershaw DD, Kopans D, et al Breast cancer screening with imaging: Recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer J Am Coll Radiol 2010;7:18–27 7 Answer A B. MRI is recommended in women with >20% lifetime risk for breast cancer on the basis of family history C. Women with a history of chest irradiation should begin screening MRI 8 years after the completion of radiation therapy, not necessary at age 30 D. Women with a history of biopsy-proven ADH should be considered for screening MRI only if other factors make their overall lifetime risk between 15% and 20% Reference: Lee CH, Dershaw D, Kopans D, et al Breast cancer screening with imaging: Recommendations from the society of breast imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer J Am Coll Radiol 2010;7:18–27 8 Answer E The positive predictive value (PPV) of biopsy will be increased because of a substantial reduction in the number of interventional procedures that produce benign results A. Periodic mammographic surveillance does not affect call-back rates B. Operating costs will decrease substantially because (1) the cost of diagnostic examinations usually is much lower than that of imaging-guided interventional procedures and (2) surveillance adds cost only to the extent that it requires examinations in between those performed for routine screening, which for most follow-up protocols involves only one additional examination C. False-positive results will be reduced, similar to increase in PPV, due to reduction of the number of interventions that produce benign results D. Surveillance is associated with reduced morbidity, especially when compared to open surgical biopsy but also when compared to percutaneous imaging-guided tissue sampling Reference: Sickles EA Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up protocol? Radiology 1999;213:11–14 9 Answer A According to BI-RADS manual, lesions appropriately placed in BI-RADS category 3 include a nonpalpable, circumscribed mass on a baseline mammogram (unless it can be shown to be a cyst, an intramammary lymph node, or another benign finding), a focal asymmetry that partially thins on spot compression, and a cluster of round punctate calcifications Answer choices B, D, and E should be given a BI-RADS 0 category assessment and be called back for additional imaging, and if persist, undergo biopsy Answer choice C is a benign lesion Reference: American College of Radiology (ACR) BI-RADS Mammography: Guidance Chapter Reston, VA: American College of Radiology; 2012:254–255 10 Answer B Computer-aided detection (CAD) mammography increases breast cancer detection rate ~7% to 20% A. CAD sensitivity is greater for calcifications than masses C. Use of CAD increases the recall rate by about 8.2% D. CAD is to provide “spell check” while looking at screening mammograms, after independent or unaided case assessment by radiologist It is not a primary tool in reading mammograms E. CAD makes about 2.0 false marks per every four-view negative mammogram However, with experience, overwhelming majority of false CAD marks are readily dismissed Reference: Birdwell RL, Bandodkar P, Ikeda DM Computer-aided detection with screening mammography in a university hospital setting Radiology 2005;236:451–457 11 Answer E Known risk factors of male breast cancer include advance age, Klinefelter syndrome, BRCA2, family history, obesity, treatment with estrogen for prostate cancer, excess alcohol consumption, head trauma resulting in increased prolactin production, and testicular diseases such as undescended testes, orchiectomy, mumps orchitis, and testicular injury A. Gynecomastia is not considered a risk factor for male breast cancer by most authorities B. Male breast cancer is 2%) Category 4 can be subdivided into 4A-low suspicion, 4B-intermediate suspicion, or 4C-high suspicion, which can guide the decision for plan of action BI-RADS 6 is used when there is an imaging finding that is already biopsy proven to be a malignancy but prior to definitive therapy Reference: American College of Radiology (ACR) ACR BI RADS—Mammography In: ACR Breast Imaging Reporting and Data System, Breast Imaging Atlas 4th ed Reston, VA: American College of Radiology; 2003:194–197 14 Answer D. There are multiple neurofibromas consistent for neurofibromatosis type 1 (NF1) NF1 is associated with Lisch nodules (hamartomas of iris), freckling in the iris NF2 is associated with bilateral acoustic neuromas, increased risk for meningiomas, and ependymomas Reference: Brant WE, Helms CA Fundamentals of Diagnostic Radiology 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:233–237 15 Answer D Neurofibromatosis, breast cysts, melanoma, and fibroadenomas are all in the differential for multiple bilateral breast masses It is the diffuse shadowing or “snowstorm” appearance on ultrasound that is classic for free silicone Free silicone injection into the breasts is not approved in the United States, but is still practiced in other parts of the world, such as Asia and South America Free silicone injection can present as large high density masses, some with curvilinear calcification Masses demonstrate foci of low signal intensity on fat-suppressed T1weighted images and high signal intensity on water-suppressed T2-weighted images, and MRI may be essential in evaluating for malignancy References: Caskey CI, Berg WA, Hamper UM, et al Imaging spectrum of extracapsular silicone: correlation with US, MR imaging, mammographic, and histopathologic findings Radiographics 1999;19:S39–S51 Cheung YC, Su MY, Ng SH, et al Lumpy silicone-injected breasts: enhanced MRI and microscopic correlation Clin Imaging 2002;26:397–404 Leibman AJ, Misra M Spectrum of imaging findings in the silicone-injected breast Plast Reconstr Surg 2011;128:28e–29e 16a Answer C The test is indicated in this patient Due to increased parenchymal enhancement during the secretory phase, there is increased risk of false-positive MRI results Optimal timing of an MRI study of the breasts is during the 2nd week of the menstrual cycle Reference: Morris EA, Bassett LW, Berg WA, et al ACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast Reston, VA: American College of Radiology (ACR); 2008:7 www.acr.org/secondarymainmenucategories/quality_safety/guidelines/breast/mri_breast.aspx 16b Answer D The patients history of treated non-Hodgkin lymphoma places the patient at a >20% lifetime risk of breast cancer, due to exposure to mantle radiation Although breast augmentation can also be an indication, it is typically performed without contrast Reference: Morris EA, Bassett LW, Berg WA, et al ACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast Reston, VA: American College of Radiology (ACR); 2008:7 www.acr.org/secondarymainmenucategories/quality_safety/guidelines/breast/mri_breast.aspx 17 Answer D Yearly mammograms are recommended starting at age 40 and continue as long as the woman is in good health Reference: http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-theearly-detection-of-cancer 18 Answer D Breast cancers in the subareolar region are subject to the rich lymphatics of the Sappey plexus; therefore, they are at risk of earlier metastatic spread compared to other breast cancers Breast cancers in this location are more common in the male population than in females In females, breast cancer in the subareolar region constitutes ~1% of all breast cancers Breast cancers in this location are often difficult to detect due to breast tissue summation artifact, particularly due to retroareolar fibrosis Reference: Tabar L, Tot T, Dean P Breast Cancer the Art of and Science of Early Detection with Mammography New York, NY: Thieme; 2005:259, 346 19 Answer B The mass is located in the upper inner quadrant, which is the second most common location for breast cancers after the upper outer quadrant Approximately 17% of all breast cancer in women occurs in the upper inner quadrant The retroglandular clear space, the space between the posterior border of the glandular tissue and the anterior border of the pectoralis major muscle, and the medial breast are important locations to evaluate for an abnormality on the CC view, which is the location of the finding on the CC view in this case Reference: Tabar L, Tot T, Dean P Breast Cancer the Art of and Science of Early Detection with Mammography New York, NY: Thieme; 2005:259 20 Answer C Sixty-one percent of all breast cancers in females occur in the upper outer quadrant, making this the most common location for breast cancer It is important to evaluate the retroglandular clear space on the MLO view for a potential finding The retroglandular clear space is the predominately fatty tissue between the posterior border of the glandular tissue and the anterior border of the pectoralis major muscle on the MLO view, which is the location of the mass in this case Reference: Tabar L, Tot T, Dean P Breast Cancer the Art of and Science of Early Detection with Mammography New York, NY: Thieme; 2005:259 21 Answer C On ultrasound, hamartomas present as an encapsulated heterogeneous masses with both fibroglandular tissue and fat This is easily distinguished from the other fat-containing masses provided as possible answers The most appropriate BI-RADS classification for this lesion is BIRADS 2, benign This is considered a “don’t touch” lesion, and further intervention is unnecessary unless the patient is bothered by the mass and desires surgical resection Reference: Appleton CM, Wiele KN Breast Imaging Cases (Cases in Radiology) New York, NY: Oxford University Press; 2012:21–22 22 Answer B These are classic secretory calcifications and are benign No additional evaluation is needed They develop from the calcification of debris within dilated ducts Secretory calcifications typically present as coarse rod-like branching calcifications in a ductal distribution It is important to understand that these are not the calcifications of DCIS, which are more likely to present as fine, pleomorphic calcifications Reference: Evans AJ Breast Calcifications: A Diagnostic Manual San Francisco, CA: Cambridge University Press; 2002:16–18 23a Answer B 23b Answer B These are bilateral secretory calcifications They have a classic thick rod-shaped appearance and often, but not always bilateral They can be seen converging toward the nipple They are always benign and do not need any further evaluation Reference: Shah BA, Fundaro GM, Mandava S Breast Imaging Review: A Quick Guide to Essential Diagnoses 1st ed New York, NY: Springer; 2010:6–7 24a Answer D 24b Answer C The tattoo sign is a finding seen on mammograms It appears as calcifications that maintain a fixed and reproducible relationship to one another on mammograms obtained with similar projections at different times In addition to the tattoo sign, there is another similar unnamed mammographic sign that also indicates the presence of dermal calcifications, and it should be applied in all cases of peripheral calcifications The tattoo sign is made up of calcifications that maintain a fixed and reproducible relationship to one another on mammograms obtained with similar projections at different times The unnamed sign is made up of microcalcifications that maintain a fixed relationship to one another on mammograms obtained with different projections during the same examination Reference: Loffman Felman RL Signs in imaging Radiology 2002;223:481–482 25 Answer B Multiple partially circumscribed masses are a relatively common occurrence, with studies estimating a rate close to 2% for every 100 screening mammograms The vast majority of these masses represent cysts or fibroadenomas There is no increased risk of cancer in women with multiple partially circumscribed breast masses if management was limited to annual mammography follow-up Reference: Leung JW, Sickles EA Multiple bilateral masses detected on screening mammography: assessment of need for recall imaging Am J Roentgenol 2000;175(1):23–29 26 Answer A Lesions laterally in the breast project higher on the mediolateral oblique (MLO) view than they are actually located in the breast and lesions in the medial breast project lower on the MLO view than they are actually located Lateral lesions shift lower in position on the ML view Lesions in the medial breast shift higher on the ML view “Lead (lateral) sinks, muffins (medial) rise.” Of note, lesions located more centrally in the breast shift little or not at all between the MLO and ML views Reference: Harvey JA, Nicholson BT, Cohen MA Findings early invasive breast cancers: A practical approach Radiology 2008;248:61–76 27 Answer A HER2 positive breast cancers usually demonstrate rapid growth and spread Approximately 20% of newly diagnosed breast cancer is HER2 positive HER2 breast cancers are more aggressive than HER2 negative cancer and are less responsive to hormonal treatment Triple negative breast cancers do not have a good prognosis Reference: Lakhani SR, Van De Vijver MJ, Jacquemier J, et al The pathology of familial breast cancer: Predictive value of immunohistochemical markers estrogen receptor, progesterone receptor, HER-2, and p53 in patients with mutations in BRCA1 and BRCA2 J Clin Oncol 2002;20:2310–2318 28a Answer B This breast MRI demonstrates left duct ectasia, which is a benign finding, BI-RADS category 2 Duct ectasia is a common, benign finding seen on breast MRI It may be seen unilateral or bilateral, focal or diffuse Duct ectasia is ductal dilatation with internal proteinaceous content or debris; it is characterized by high T1 signal in a ductal distribution on the precontrast T1 sequence Because the proteinaceous content has inherent high T1 signal, it will also be high signal on the postcontrast T1 However, since the finding is due to precontrast signal and not truly enhancing, high signal will not be seen in the area on the subtraction sequence It is important to examine the subtraction sequence closely to ensure that no actual enhancement is present Answer choice A is incorrect because the finding is not incomplete (BI-RADS category 0); no additional imaging is necessary Answer choices C, D, and E are not correct; short-term follow-up or biopsy is not indicated 28b Answer E The correct follow-up recommendation for this patient based on the included images is an annual screening breast MRI in addition to her annual left mammogram Answer choice A is incorrect as additional ultrasound evaluation is not needed to further characterize the finding Surgical referral is not necessary for this finding As long as the patient is stable and asymptomatic, she can continue with her standard clinical follow-up Therefore, answer choice B is incorrect Answer choice C is not correct because MRI biopsy is not necessary Duct ectasia alone is not a suspicious finding on MRI Again, it is important to examine the area closely for enhancement on the subtraction sequence DCIS may also present with high T1 signal on the precontrast sequence with possible blood/debris in the duct However, it would be seen as high T1 signal on both pre- and postcontrast T1 as well as concomitant high signal/enhancement on the subtraction sequence Answer choice D is incorrect; this is a benign finding Annual, rather than 6month follow-up breast MRI is indicated Reference: Morris EA, Liberman L, eds Breast MRI Diagnosis and Intervention New York, NY: Springer; 2005:25–26, 437–440 29 Answer B This patient has inflammatory carcinoma The findings of a dominant mass in the upper outer quadrant of the breast in the presence of skin and trabecular thickening confirm the diagnosis This patient requires a core biopsy of the mass to confirm the diagnosis In the absence of a dominant mass, mastitis may be considered as the working diagnosis If, however, the findings persist on follow-up mammogram after antibiotic treatment, the diagnosis is inflammatory carcinoma unless proven otherwise At that point the patient should have a punch biopsy Punch biopsy will often demonstrate tumor cells invading the dermal lymphatics and will confirm the diagnosis of inflammatory carcinoma Although breast MRI may reveal the dominant mass, it is not the most cost-effective step in diagnosis Returning the patient to annual screening mammography is only appropriate when a mammogram is clearly negative or benign and should not be recommended in this setting Even if a dominant mass were not present and one suspects a benign entity like mastitis, follow-up should be recommended after treatment to exclude an underlying malignancy References: Gunhan-Bilgen I, et al Inflammatory breast carcinoma: Mammographic, ultrasonographic, clinical and pathologic findings in 142 cases Radiology 2002;223:829–838 Kushwaha AC, et al Primary inflammatory carcinoma of the breast Retrospective review of radiological findings AJR Am J Roentgenol 2000;174:535–538 30 Answer C There is whole-body radiation exposure from BSGI, with greatest effect on the bowel wall BSGI has a lifetime attributable risk of mortality that is ~20 to 30 times greater than that of a complete screening digital mammogram The density of breast tissue does not affect sensitivity, and BSGI is equally sensitive in dense and fatty breasts References: Brem RF, Rechtman LR Nuclear medicine imaging of the breast: A novel, physiologic approach to breast cancer detection and diagnosis Radiol Clin North Am 2010;48:1055–1074 Hendrick RE Radiation does and cancer risks from breast imaging studies Radiology 2010;257:246–253 31 Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:151 32 Answer B If a lesion is visible only on mediolateral oblique (MLO) and true lateral views, the triangulation method is used to locate the lesion on the craniocaudal (CC) view With the MLO view in the middle, a line drawn through the lesion in the MLO and true lateral views and extending through to the CC view will intersect lesion location on the CC view Reference: Berg WA, Birdwell R, Gombos EC, et al Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2006;II:0–13 33 Answer B Mammography is the first imaging test of choice for a clinically suspicious mass in a male A palpable mass that is occult or incompletely imaged on mammography warrants a targeted ultrasound Reference: Nguyen C, Kettler MD, Swirsky ME, et al Male breast disease: Pictorial review with radiologic-pathologic correlation Radiographics 2013;33(3):763 34 Answer C First-degree relatives include mother, father, sister, and daughter Second-degree relatives include grandmother, aunt, and niece Reference: Berg WA, Birdwell R, Gombos EC, et al Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2006;II:0–24 35 Answer D Peak incidence of breast cancer in these patients is at 15 years after treatment They have an increased risk if radiation exposure is before 30 years of age Preferred treatment is mastectomy with chemotherapy Radiation is contraindicated References: Alm El-Din MA, Hughes KS, Raad RA, et al Clinical outcome of breast cancer occurring after treatment for Hodgkin’s lymphoma: case control analysis Radiat Oncol 2009;4:19 Berg WA, Birdwell R, Gombos EC, et al Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2006;IV:4-58 36 Answer C Risk factors for breast cancer include early menarche, late menopause, nulliparous, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), personal history of breast cancer, first-degree relative with breast cancer, first birth after age 30, BRCA1 and BRCA2, radiation exposure at a young age Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:24–25 37 Answer D Interval cancers are defined as breast cancers presenting with chemical findings during the interval between recommended screenings They can be mammographically occult or missed on prior mammography Usually presenting as a new palpable lump compared to screen- detected cancers, there is an increased incidence of lobular and mucinous histology There is a lower rate of ductal carcinoma in situ (DCIS) Women with very dense breasts have a higher incidence than those with fatty breasts Prognosis for interval cancers is similar to symptomatic, unscreened breast cancers References: Berg WA, Birdwell R, Gombos EC, et al Diagnostic Imaging: Breast Salt Lake City, UT: Amirysis Inc; 2006;IV:2:140–143 Buist DS, et al Factors contributing to mammography failure in women aged 40–49 years J Natl Cancer Inst 2004;96:1432–1440 Ikeda DM, et al Analysis of 172 subtle findings on prior normal mammograms in women with breast cancer detected at follow up screening Radiology 2003;226:494–503 38 Answer B The nipple should be seen on profile in at least one view to assess the subareolar area Reference: Bassett L, Hirbawi I, DeBruhl N, et al Mammographic positioning: Evaluation from the viewbox Radiology 1993;188:803–806 39 Answer C Adequate compression when obtaining mammograms is important for a number of reasons It prevents motion, reduces scatter and spreads out the tissues better It reduces the amount of radiation needed Compression is usually less painful during the first half of the menstrual cycle and if the compression is applied gradually Reference: Berg WA, Birdwell R, Gombos EC, et al Diagnostic Imaging: Breast Salt Lake City, UT: Amirsis Inc.; 2006:I1:0-2– I1:0-3 ... 14 Which of the following is correct regarding screening mammography guidelines as recommended by American College of Radiology? A. Annual mammograms starting at age 40 until 80 B. Biannual mammograms starting at age 35 and annual after age 40 C. Annual mammograms starting at age 50... Includes bibliographical references ISBN 97 8 -1 -4 51 1-7 63 9 -1 I Shah, Biren A. , editor II Mandava, Sabala, editor III Title [DNLM: 1 Mammography—methods Breast Neoplasms—radiography WP 815 ] RG493.5.R33 618 .1' 907572—dc23... government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Breast imaging (2 013 ) Breast imaging : a core review / editors, Biren A Shah, Sabala R Mandava — First edition