Download 3. This patient`s left CC projection shows a finding in the posterior

3.
This patient’s left CC projection shows a finding in the posterior breast. The left MLO projection
demonstrated no finding. The images (Figures 3-1 and 3-2) show a characteristic appearance of which
ONE of the following?
A. Sternalis muscle
B. Hair artifact
C. Invasive lobular carcinoma
D. A superimposed latent image from a prior exposure
Fig 3-2. Left breast. Mammogram. CC view.
Coned image of area of interest.
Fig 3-1. Left breast. Mammogram. CC view.
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CPI Breast Radiology Module 2014
4.
The patient depicted in Figure 4-1 has recently been diagnosed with right breast cancer. A
heterogeneous enhancing mass in the medial right breast correlates with the patient’s known
malignancy. Based on the imaging findings, which one of the following statements is TRUE?
A. The mass abuts the pectoralis muscle and, therefore, is concerning for muscle invasion.
B. There is loss of the fat plane, which is concerning for pectoralis muscle invasion.
C. There are no imaging findings suggestive of muscle invasion.
D. None of the above statements are true.
Fig 4-1. Bilateral breast. Magnetic resonance imaging (MRI). T1 weighted.
Delayed contrast enhancement. Axial plane.
CPI Breast Radiology Module 2014 5
5.
A 53-year-old woman presents with a newly palpable right breast mass. A conventional digital
mammogram right MLO view (Figure 5-1) and a single right MLO slice from her breast tomosynthesis
(Figure 5-2) are shown. Which one of the following BEST describes the findings?
A. Summation shadows of overlapping Cooper ligaments cause an artifactual appearance of a spiculated
mass seen on the tomosynthesis image.
B. A mass in the superior right breast is better assessed on the conventional mammogram because the
margins of the mass are better seen in their entirety on a single image.
C. Spiculated margins of a mass are better seen on the tomosynthesis image because the increased
compression of tomosynthesis disperses the overlapping tissues.
D. Spiculated margins of a mass are better seen on the tomosynthesis image because the breast is visualized
in thin slices.
Fig 5-1. Right breast. Mammogram.
MLO view. The circular marker is a mole
marker. The triangular marker indicates
the area of the palpable mass.
6
Fig 5-2. Right breast. Tomosynthesis
slice. MLO view. The circular marker is
a mole marker. The triangular marker
indicates the area of the palpable
mass.
CPI Breast Radiology Module 2014
46.Which one of the following statements regarding digital breast tomosynthesis is TRUE?
A. Tomosynthesis is less effective than mammography spot compression views in characterizing a
mass as benign or malignant.
B. Positioning the patient for tomosynthesis is more difficult than positioning for spot compression views.
C. Compared with conventional diagnostic mammography, tomosynthesis shows similar sensitivity
and specificity for noncalcified findings such as masses, asymmetries, and distortion.
D. Tomosynthesis obviates the need for the ultrasound evaluation of breast masses.
47. After targeting a superficial lesion using stereotactic guidance, the suction-needle biopsy device is fired
appropriately. If the biopsy notch is partially visible outside the skin, which one of the following is the
best NEXT step?
A. Discontinue the procedure.
B. Proceed with taking biopsy samples.
C. Advance the biopsy needle so the notch is completely covered by tissue.
D. Withdraw the needle and reattempt firing the needle.
48.Which one of the following statements regarding the assessment for breast cancer in a pregnant patient
is CORRECT?
A. Ultrasound should be the first-line modality in the imaging assessment of a palpable breast mass in
a pregnant patient.
B. The assessment of a palpable mass in a pregnant patient should begin with standard diagnostic
mammography.
C. Contrast-enhanced breast MRI is considered safe for the imaging assessment of extent of disease in
a pregnant patient.
D. Mammography is absolutely contraindicated during pregnancy and should not be used as part of the
imaging assessment of a pregnant patient with a biopsy-proven malignancy.
49.Which ONE of the following diagnoses obtained on stereotactic core biopsy would prompt a
recommendation for excisional biopsy of the area?
A. Fibroadenoma
B. Calcified fat necrosis
C. Fibrocystic change with hyperplasia
D. Intraductal papilloma
CPI Breast Radiology Module 2014 35
ANSWER KEY
CPI Breast Radiology 2014
1.B
27.A
2.B
28.A
3.B
29.A
4.C
30.C
5.D
31.D
6.B
32.D
7.A
33.B
8.C
34.C
9.D
35.B
10.B
36.B
11.C
37.E
12.B
38.B
13.D
39.B
14.C
40.A
15.C
41.B
16.A
42.C
17.D
43.E
18.D
44.B
19.D
45.B
20.D
46.C
21.C
47.C
22.C
48.A
23.B
49.D
24.C
50.C
25.B
51.C
26.B
52.D
CPI Breast Radiology Module 2014 37
Answer 3 is B.
Figures 3-1 and 3-2 show a wispy curvilinear asymmetry extending posterior to the field-of-view centrally on
the CC view only. This is a characteristic appearance of the patient’s hair inadvertently included on the
image. This is also a common location for inadvertent inclusion of the patient’s gown. If there is any question
as to the etiology of such an asymmetry, a repeat film with careful attention to exclude the patient’s hair from
the field-of-view would be appropriate.
Fig 3-2. Curvilinear asymmetry from hair
artifact. Annotated. Left breast. Mammogram. CC view. Coned image of area of
interest. Arrows point to hair artifact.
Option A is not correct.
The sternalis muscle is an uncommon anatomic variant of chest wall musculature found adjacent to the
medial edge of the pectoralis major. When present, the sternalis muscle is also seen in the posterior aspect of
the breast and characteristically appears medially on the CC view only. Classically, it has a triangular-shaped
appearance but may also be wispy or feathery. Because it runs longitudinally anterior to the pectoralis
muscle, it should not be present on orthogonal imaging. If there is any question as to the etiology, ultrasound
would be appropriate to exclude a true lesion.
Option C is not correct.
Invasive lobular carcinoma has a propensity to appear on the CC view only and may be a consideration for
that reason. It may present as a vague asymmetry; however, this image shows the characteristic wispy
curvilinear appearance of hair artifact.
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CPI Breast Radiology Module 2014
Option D is not correct.
A superimposed latent image from a prior exposure is known as a “ghosting artifact.” It is an artifact
associated with the first generation of selenium digital detectors that occurs when a latent image from a prior
exposure is superimposed on a newly acquired image. Although ghost artifacts may have a variety of
appearances, the wispy asymmetry demonstrated would not be expected. The main reason for ghosting was
low detector temperature.
Reference(s):
Ayyala RS, Chorlton M, Behrman RH, Kornguth PJ, Slanetz PJ. Digital mammographic artifacts on full-field systems: what
are they and how do I fix them? RadioGraphics. 2008;28:1999-2008.
Hogge JP, Palmer CH, Muller CC, et al. Quality assurance in mammography: artifact analysis. RadioGraphics. 1999;19:503-522.
Answer 4 is C.
Tumors located posteriorly in the breast may invade the pectoral muscle and/or chest wall. Although tumor
invasion of only the pectoralis muscle does not change disease stage, it does alter surgical treatment. With
only superficial invasion a portion of the muscle will be resected; however, with deep muscle invasion, a
radical mastectomy with removal of the entire muscle may be required. Mammography and ultrasound are
limited in making the diagnosis of muscle invasion, and breast MRI is used to provide the most accurate
assessment of disease extent. It has been shown that contrast enhancement of the pectoral muscle is the only
reliable finding to predict invasion. Close proximity of the tumor mass to the muscle and loss of fat planes
alone do not indicate muscle invasion. In this case, the fat plane is preserved and there is no enhancement of
the muscle; thus, there are no imaging findings suggestive of muscle invasion.
Option A is not correct.
Although the mass is posterior in location, the fat plane is preserved and there is no contrast enhancement of
the muscle to suggest invasion.
Option B is not correct.
Figure 4-1 shows no effacement of the fat plane and, more importantly, no contrast enhancement of the
muscle to suggest muscle invasion.
Option D is not correct.
Option C is the best option; therefore, this choice is incorrect.
Reference(s):
Morris EA, Schwartz LH, Drotman MB, et al. Evaluation of pectoralis major muscle in patients with posterior breast tumors
on breast MR images: early experience. Radiology. 2000;214:67-72.
CPI Breast Radiology Module 2014 41
Answer 5 is D.
A mass is present in the superior right breast at middle depth. The spiculated margin along the superior
aspect of the mass (arrow) is better seen on the tomosynthesis image (Figure 5-2) and is partially obscured on
the conventional mammogram (Figure 5-1). Overlapping tissues can obscure important features of a mass on
conventional mammography. Breast tomosynthesis is a digital mammography technique that reduces the
obscuring effect of overlapping tissues. A conventional mammographic view is a single exposure x-ray of a
compressed 3-dimensional volume of breast tissue which provides a 2-dimensional image. In comparison,
breast tomosynthesis images are created from multiple x-ray exposures of the compressed breast acquired in
an arc or linear fashion. Those acquisitions are then reconstructed to allow the breast to be visualized in thin
slices (1-mm slices in the test case), which minimizes the obscuring effect of overlapping tissues. A targeted
ultrasound was performed (not shown) confirming the presence of a mass with spiculated margins.
Ultrasound-guided core biopsy yielded invasive ductal carcinoma.
Fig 5-2. Mass with spiculated margin. Annotated.
Right breast. Tomosynthesis slice. MLO view. Arrow
points to the spiculated margin of the mass, which is
better seen on the tomosynthesis image compared
to the conventional mammogram (Figure 5-1).
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CPI Breast Radiology Module 2014
Option A is not correct.
A mass with spiculated margins in the upper right breast is a true finding. Overlapping Cooper ligaments are
less of a problem with breast tomosynthesis because the breast can be visualized in thin slices, reducing
summation shadows.
Option B is not correct.
The mass is not better assessed on conventional mammography in this example. The spiculated margins, a key
feature of this mass, are mostly obscured by overlapping fibroglandular tissue on the conventional mammogram.
Option C is not correct.
The degree of compression used with tomosynthesis is similar to conventional mammography. Tomosynthesis
technique does not rely on mechanical separation of overlapping tissues to improve visualization of breast
lesions.
Reference(s):
Brandt KR, Craig DA, Hoskins TL, et al. Can digital breast tomosynthesis replace conventional diagnostic mammography
views for screening recalls without calcifications? A comparison study in a simulated clinical setting. AJR Am J
Roentgenol. 2013;200:291-298.
Zuley ML, Bandos AI, Ganott MA, et al. Digital breast tomosynthesis versus supplemental diagnostic mammographic
views for evaluation of noncalcified breast lesions. Radiology. 2013;266:89-95.
Answer 6 is B.
The mammogram images (Figures 6-1 and 6-2) show a round, hyperdense mass with irregular margins. The
mass is eccentric (in reference to the nipple) and contains pleomorphic calcifications. Ultrasound of the right
breast (Figure 6-3) shows an irregular hypoechoic solid mass with internal vascularity. The most likely
diagnosis for this hyperdense mass with irregular margins containing pleomorphic calcifications is invasive
ductal carcinoma of the breast.
Option A is not correct.
While an abscess may have heterogeneous echogenicity on ultrasound, it should not show internal vascularity.
Also, the test patient did not have any clinical signs or symptoms of infection.
Option C is not correct.
Nodular gynecomastia usually appears as a nodular, mass-like lesion in the subareolar region. It would not
have associated suspicious calcifications.
Option D is not correct.
On mammography, breast lymphoma may present as a mass with circumscribed or indistinct margins but
without calcifications.
Reference(s):
Lattin GE Jr, Jesinger RA, Mattu R, Glassman LM. From the radiologic pathology archives: diseases of the male breast:
radiologic-pathologic correlation. RadioGraphics. 2013;33:461-489.
Nguyen C, Kettler MD, Swirsky ME, et al. Male breast disease: pictorial review with radiologic-pathologic correlation.
RadioGraphics. 2013;33:763-779.
CPI Breast Radiology Module 2014 43
Answer 47 is C.
For a suction biopsy device to work appropriately and to prevent a skin defect, the biopsy notch must be
completely covered by tissue. Therefore, the operator may have to advance the biopsy device such that only
the proximal portion of the notch is positioned at the lesion, just under the skin.
Option A is not correct.
The procedure can be continued and appropriate diagnosis made, if the biopsy needle notch is advanced so
that it is completely covered by tissue.
Option B is not correct.
Proceeding with the biopsy without needle advancement is not recommended, as the suction biopsy device
will not work appropriately and the patient will be at risk for a skin defect and healing complications.
Option D is not correct.
If the biopsy device was initially fired appropriately, then withdrawing the needle and refiring it will not
likely be of benefit in performing a biopsy on a superficial lesion.
Reference(s):
Kopans DB. Breast Imaging. 3rd ed. Philadelphia, PA: Lippincott Williams & Williams; 2007:960-967.
Answer 48 is A.
Ultrasound is a safe imaging modality with no risk of exposing the fetus to ionizing radiation or gadolinium
contrast. Additionally, the breast parenchyma of a pregnant patient is usually dense and physiologically
activated due to hormonal stimulation. As a result, mammography and MRI are less sensitive. For evaluating
women aged <30 years and women who are pregnant or lactating, ultrasound is used for the initial evaluation.
Option B is not correct.
Although the exposure of the fetus to ionizing radiation with mammography is relatively low, it is still a
consideration, and the use of mammography during pregnancy requires a risk-benefit analysis. The dense
breast parenchyma associated with pregnancy also decreases the sensitivity of mammography. Therefore, the
assessment of a palpable mass in a pregnant female should begin with sonography, not mammography.
Option C is not correct.
Gadolinium is categorized as a “Pregnancy Category C” by the FDA and is not recommended for use
during pregnancy. Although there have been no reports of teratogenic effects of gadolinium, there are no
controlled-prospective studies evaluating gadolinium’s effect on fetal development in humans. For this
reason, contrast-enhanced breast MRI is not considered safe for use in a pregnant patient.
Option D is not correct.
Although the fetus is exposed to a low level of ionizing radiation during mammography, the benefit of
mammography is generally considered to outweigh the low risk to the fetus, if used as part of the imaging
assessment of a breast cancer which has been confirmed by ultrasound-guided biopsy. Mammography may be
able to identify features of the malignancy which might be sonographically occult, such as extensive
calcifications associated with ductal carcinoma in situ. The combined use of sonography and mammography
for imaging staging of a pregnant patient with breast cancer is important for surgical planning.
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CPI Breast Radiology Module 2014
Reference(s):
Harvey JA, Mahoney MC, Newell MS, et al. ACR Appropriateness Criteria® palpable breast masses. J Am Coll Radiol.
2013;10:742-749.
Vashi R, Hooley R, Butler R, Geisel J, Philpotts L. Breast imaging of the pregnant and lactating patient: imaging modalities
and pregnancy-associated breast cancer. AJR Am J Roentgenol. 2013;200:321-328.
Answer 49 is D.
Intraductal papilloma is a solid mass arising from the lumen of a duct. These typically have a benign 2-cell
epithelial layer. These cells may undergo hyperplasia and evolve to ADH, ductal carcinoma in situ, or
invasive carcinoma. Diagnosis may prove challenging with the small samples that are provided at core biopsy.
Given the uncertainties of accurate diagnosis, these are generally considered high-risk lesions, and excisional
biopsy is suggested.
Option A is not correct.
Fibroadenomas are benign lesions for which excision is not usually suggested. As with all core biopsies,
concordance between the radiologic and pathologic diagnoses must be determined.
Option B is not correct.
Calcified fat necrosis is a benign lesion for which surgical excision is not indicated. While many cases of fat
necrosis can be diagnosed based on the typical imaging appearance, occasionally biopsy will be necessary to
differentiate the calcifications of early fat necrosis from carcinoma. As with all core biopsies, concordance
between the radiologic and pathologic diagnoses must be determined.
Option C is not correct.
Fibrocystic change with hyperplasia is a benign, generally nonspecific finding that may be encountered when
sampling breast calcifications. Excisional biopsy is not recommended. If there is atypia along with the
hyperplasia, excisional biopsy would be recommended. As with all core biopsies, concordance between the
radiologic and pathologic diagnoses must be determined.
Reference(s):
Georgian-Smith D, Lawton TJ. Variations in physician recommendations for surgery after diagnosis of a high-risk lesion on
breast core needle biopsy. AJR Am J Roentgenol. 2012;198:256-263.
Answer 50 is C.
Ductal was a term previously used in the BI-RADS® lexicon as a descriptor of nonmass enhancement. This
terminology has been removed from the lexicon.
Option A is not correct.
The term linear, indicating that nonmass enhancement follows the distribution of a duct, is still included as
part of the lexicon.
Option B is not correct.
A focal area of enhancement pertains to lesions that are 5 mm or less in size. The term is still utilized as a
descriptor.
CPI Breast Radiology Module 2014 71