Ebook Breast imaging - A core review: Part 1

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.

A Core Review

Wayne State University School of Medicine

Detroit, Michigan

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.

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10 9 8 7 6 5 4 3 2 1

Jenny H Wang, DO

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 preparefor 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 forresources that would help our residents prepare for this exam As I researched, I found very little in theway of review guides, banks of questions, etc that the residents could use And so the germ of an ideabegan 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 theconcept with my colleague, Sabala Mandava, who was also of a similar mind, and we decided to do aquestion 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 tothe book As this book developed, I started thinking about similar books for the other subjects tested onthe Core Exam After several weeks of discussion with Jonathan Pine and Amy Dinkel, from LippincottWilliam & 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 eithercurrently being worked on or in the near future will be added to series The philosophy for each book inthe 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 whocontributed to the series This series represents countless hours of work and involvement by many and itwould 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 aswell 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 ofpreparing 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 physicsbehind image acquisition, quality control, and safety There is a paucity of study resources available forresidents

With this in mind, we wanted to provide a guide for residents to be able to assess their knowledge andreview the material in a format that would be similar to the Boards The questions are divided intodifferent 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 matchingquestions Each question has a corresponding answer with an explanation of not only why a particularoption is correct but also why the other options are incorrect There are also references provided for eachquestion for those who want to delve more deeply into a specific subject This format is also useful forradiologists 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 theirbusy 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 ofwork 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 certified radiologists and will continue to be a reference in their future careers

Board-Biren A Shah, MD Sabala R Mandava, MD

1 Regulatory/Standards of Care

QUESTIONS

1 Which of the following is a Mammography Quality Standards Act (MQSA) requirement forinterpreting physicians?

A. 15 category 1 continuing medical education (CME) credits per year

B. 10 hours of initial new modality training (e.g., digital mammography)

C. Initial experience of 240 exams under direct supervision in the 6 months before starting tointerpret mammography

D. Continuing experience of interpretation of 960 exams/12 months

2 For each diagnostic image, below, assign the likely BI-RADS assessment of either BI-RADS 2(answer choice “A”) or BI-RADS 4 (answer choice “B”) Each option may be used once, morethan once, or not at all:

A. 1 to 2

6 A patient has a negative screening mammogram study and 8 months later develops a palpable massthat is biopsied to reveal invasive ductal carcinoma This is termed a

A. Hair artifact

B. Motion artifact

C. Chin artifact

E. Skin artifact

9 The posterior nipple line measures 13 cm on the mediolateral oblique (MLO) view What is anacceptable posterior nipple line measurement on the craniocaudal (CC) view?

A. Hair artifact

16 Federal regulations require that follow-up on surgical and/or pathology results be performed forpatients with positive mammograms How frequently are facilities required to conduct this

A. The pectoralis muscle must always be present on both the MLO and CC projections

B. The pectoralis muscle must only be present on the CC projection

C. The difference between the line from the nipple to the back of the film on CC and the line

D. The difference between the line from the nipple to the back of the film on CC and the linefrom the nipple to the pectoralis muscle on MLO is 1 cm

A. 90%

B. Breast MRI is optimally performed in week 4 of a patient’s menstrual cycle

C. T1-weighted non–fat saturation is the best sequence for identification of a fat-containingmass

D. A body coil is the optimal radiofrequency receiver coil for the exam

E. An equivalent dose of a gadolinium-based contrast agent is used for breast MR patients

42a The following image from a contrast-enhanced breast MR examination demonstrates whichartifact?

demonstrates which type of digital mammogram artifact?

B. Reconstruction of the projections into the mediolateral oblique (MLO) and craniocaudal(CC) views

C. Digital acquisition technique

D. Multiple exposures of the breast at different angles

E. Increased breast compression

55 The above mediolateral oblique (MLO) image taken during a screening mammogram examinationdemonstrates which type of digital mammogram artifact?

Reference: American College of Radiology (ACR) BI-RADS-Mammography The ACR Breast Imaging Reporting and Data System (BI-RADS) Reston, VA: American College of Radiology; 2003:61–107.

Reference: Shah BA, Fundaro GM, Mandava S Breast Imaging Review: A Quick Guide to Essential Diagnoses 1st ed New

11 Answer C.

Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand Program/Guidance/PolicyGuidanceHelpSystem/ucm052165.htm

12 Answer A.

Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand Program/Guidance/PolicyGuidanceHelpSystem/ucm052779.htm

mammogram It is unclear at what age, if any, women cease to benefit from screening

mammography Because this age is likely to vary depending on the individual’s overall health, thedecision as to when to stop routine mammography screening should be made on an individualbasis by each woman and her physician

Reference: American College of Radiology (ACR) ACR Practice Guidelines for the Performance of Screening and Diagnostic Mammography American College of Radiology; May 2013, http://amclc.acr.org/LinkClick.aspx? fileticket=dQDASxSIrJ4%3D&tabid=61

17 Answer C.

Reference: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActand Program/FacilityScorecard/ucm113812.htm

18 Answer A. The U.S Congress appointed the Food and Drug Administration (FDA) to develop

guidelines to oversee the quality of mammography equipment and facilities after the enactment ofthe Mammography Quality Standards Act (MQSA) in 1992 Various states have also been

certified to accredit mammography facilities; these are approved by the FDA

Radiation-Emitting Products www.fda.gov/radiation-emittingproducts/mammographyqualitystanda rdsactand program/default.htm

19 Answer B. Ghosting from cardiac or respiratory motion occurs in the phase-encoding direction.

encoding directions Patient motion causes blurring of the poor shimming results in poor fat

Reference: Berg WA, Birdwell RL, Gombos EC, et al Diagnostic Imaging Breast 1st ed Salt Lake City, UT: Amirsys;

Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:5.

silicone is selected for saturation rather than fat Fat and silicone resonate closely at 1.5 T Notethat silicone was saturated in this image, but fat was not correctly saturated As a result of siliconesaturation, a silicone breast implant will have dark signal and the examination will be renderednondiagnostic for evaluation of implant rupture The inversion recovery (IR) sequence with watersaturation is a silicone-specific sequence (water and fat will be saturated) that is the most

important sequence of the examination Silicone should appear white on this sequence, enablingthe detection of intracapsular and/or extracapsular rupture Answer A is wrong because

susceptibility artifact is a signal void or field inhomogeneity caused by metal in or on the patient’sbody Answer B is wrong because wrap or aliasing artifact occurs when tissue extends beyond thefield of view (FOV), causing signal from tissues outside the FOV to be superimposed on

structures within the FOV It occurs in the phase encoding direction This artifact can be seen withpatients’ arms in breast MRI practice Answer C is not correct because RF interference is anartifact that occurs due to incomplete shielding of the MRI suite (e.g., door ajar) or radiofrequencydisturbance within the MR suite (e.g., patient monitoring equipment) This artifact manifests asrepetitive lines extending across the image at a fixed interval

Reference: Hendrick RE Breast MRI: Fundamentals and Technical Aspects New York, NY: Springer; 2008:187–207.

28a Answer D. Abnormal interpretation rate, also known as recall rate, in screening mammography

is the percentage of examinations interpreted as positive For screening mammography, positiveexams include BI-RADS category 0, 4, and 5 assessments given based on screening mammograms.Screening abnormal interpretation rate = (Category 0, 4, and 5 cases based on screening

mammograms)/(Total number of screening mammograms) = 400 + 0 + 0/5,000 = 400/5,000 = 0.08

= 8%

For diagnostic mammography, abnormal interpretation rate or biopsy recommended rate is thepercentage of examinations interpreted as positive For diagnostic mammography, positive examsinclude BI-RADS category 4 and 5 assessments based on diagnostic workup

significant motion on this image Motion artifact is one of the most commonly encountered artifactsaffecting breast MRI Motion can arise from patient motion or cardiac, respiratory, or great vesselmotion All motions propagate in the phase encoding direction despite the direction of the motion.Phase encoding direction should be left to right for axial sequences and superior to inferior forsagittal sequences to reduce the effect of cardiac and respiratory motion on the breasts

Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:7, 12.

31 Answer B. A BI-RADS 3 category finding should have a less than 2% chance of malignancy.

RADS 3 findings include the noncalcified circumscribed solid mass, the focal asymmetry, and thecluster of round and punctate calcifications

The finding is not expected to change over the time interval of the BI-RADS 3 follow-up BI-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.

32 Answer C. BI-RADS 5 lesions have a > 95% chance of malignancy The level of suspicion is

high enough in these lesions that they could be taken to surgery without preoperative biopsy;

however, current oncologic evaluation may require a tissue biopsy to adequately plan the patient’streatment course before surgery

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.

lobular neoplasia, or more limited family histories

References: 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

premenopausal females This enhancement is greatest in weeks 1 and 4 of the cycle, assuming a 4-Reference: Morris EA, Liberman L, eds Breast MRI: Diagnosis and Intervention New York, NY: Springer; 2005:36–38.

38 Answer A. The 2007 American Cancer Society Guidelines recommend the use of screening

MRI in patients with a history of Hodgkin disease, particularly those with a prior history of mantlefield radiation Neurofibromatosis is an incorrect answer Although there has been a recognizedlink between neurofibromatosis type 1 and breast carcinoma, current guidelines do not recommendthe use of screening MRI in this patient population The ACS guidelines also recommended theuse of screening breast MRI in patients with a 20% to 25% or greater lifetime risk of breast

cancer As such, C would also be an incorrect choice Heterogeneously dense breasts (>50%breast density) has not been shown to be a clinical indicator of breast cancer risk Multiple

studies have shown, however, that women with >75% breast density have a fivefold increasedrisk of breast cancer

a minimum score with visibility of at least four fibers, three microcalcifications, and three masses

Reference: Kopans DB Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:275–277.

40 Answer C. The MLO view provides the greatest amount of coverage for a single projection In

positioning the patient, care must be taken to make sure the medial breast tissue is not pulled out ofthe field of view The medial breast tissue is tethered along the sternum, which can easily slide out