(BQ) Part 2 book “Breast imaging - A core review” has contents: Diagnostic breast imaging, breast pathology, and breast imaging findings; breast intervention; physics related to breast imaging.
3 Diagnostic Breast Imaging, Breast Pathology, and Breast Imaging Findings QUESTIONS 1 Based on this image, what is the most likely diagnosis? A. Radial fold B. Capsular contracture C. Intracapsular rupture D. Extracapsular rupture 2 What is the most common location for an intramammary lymph node? A. Upper outer quadrant B. Upper inner quadrant C. Lower outer quadrant D. Lower inner quadrant 3a Based on the following images, the dominant finding is A. Subareolar region nonmass-like enhancement B. Enhancement of the pectoralis muscle C. Unilateral skin thickening D. Architectural distortion in the superior right breast 3b What would be an appropriate differential diagnosis for the previous finding? A. Related to phase of menstrual cycle B. Mastitis C. Hormone therapy D. Renal failure 4a A 16-year-old female presents with a palpable finding in her right breast What is the most appropriate imaging test? A. Unilateral right mammogram B. Bilateral mammogram C. Unilateral right ultrasound D. Bilateral ultrasound E. Unilateral right mammogram and ultrasound 4b Which of the following statements regarding fibroadenomas is correct? A. Giant fibroadenomas are more common in the Asian population B. Most fibroadenomas in teenagers are adult type C. Fibroadenomas are more common in postmenopausal women D. Fibroadenomas can be found equally in males and females 4c Based on the following image, what would be the most likely diagnosis? A. Fat necrosis B. Lymph node C. Hematoma D. Juvenile fibroadenoma 5 A 49-year-old female with no history of prior breast concerns or a family history of breast cancer presents with new onset right bloody nipple discharge Based on the ultrasound images below, what is the most likely diagnosis? A. Intraductal carcinoma B. Duct ectasia with debris C. Fibrocystic change D. Intraductal papilloma 6a Based on the following images, what would be the appropriate BI-RADS category? A. BI-RADS 2 B. BI-RADS 3 C. BI-RADS 4 D. BI-RADS 5 6b What is the appropriate recommendation? A. Annual screening mammography B. Short-term follow-up in 6 months C. Core needle biopsy D. Surgical excisional biopsy 7 A 45-year-old female presents with a palpable abnormality in the right breast Based on the ultrasound image below, what is the most appropriate BI-RADS assessment? A. BI-RADS 2 B. BI-RADS 3 C. BI-RADS 4 D. BI-RADS 5 8 A 35-year-old female with a history of a left lumpectomy, radiation therapy, and chemotherapy at age 29 presents for her annual diagnostic mammogram Based on the magnification images of the lumpectomy site, what is the most appropriate next step? A. 6-month follow-up B. MRI C. Stereotactic core biopsy D. Annual screening mammogram E. Annual diagnostic mammogram 9 A 40-year-old female was recalled from screening for calcifications in the right breast Based on the magnification views, what is the most appropriate BI-RADS lexicon description for the calcifications? A. Coarse heterogeneous B. Secretory C. Punctate D. Pleomorphic 10a A 50-year-old female was recalled from screening for a mass within the left breast Based on images A and B, what is the best description of the mass shape and margins using the BI-RADS lexicon? A. Round, obscured B. Irregular, microlobulated C. Irregular, spiculated D. Round, speculated 10b An ultrasound of mass was performed Based on images A and B, what is the best BI-RADS lexicon description of the shape and margins of the mass? A. Oval, spiculated B. Oval, angular C. Irregular, angular D. Irregular, speculated 10c The mass was also examined by elastography Given the image below, which statement is correct? A. The mass measures cystic or soft by elastography B. The mass measures hard or stiff by elastography C. The mass is indeterminate for stiffness by elastography D. The mass stiffness suggests malignancy by elastography 11a A 65-year-old female with a history of right mastectomy, contralateral prophylactic mastectomy, and bilateral TRAM flap reconstruction for right breast–invasive ductal carcinoma and DCIS presents for surveillance breast MRI Axial T1-weighted and axial postcontrast subtraction images are provided What is the most likely diagnosis? A. Recurrent invasive ductal carcinoma B. Fat necrosis C. Breast abscess D. Postsurgical seroma 11b The patient’s left mammogram is also shown No prior mammogram is available for comparison at this time What is the most appropriate BI-RADS classification? A. BI-RADS 2, benign B. BI-RADS 3, probably benign C. BI-RADS 4, suspicious D. BI-RADS 6, known malignancy 12 A 29-year-old female, who is 35 weeks pregnant, presents with a palpable lump in the right breast with associated pain She denies any fevers No skin erythema is seen on physical examination Ultrasound images of the palpable lump are provided No mammogram was performed due to patient’s age and pregnancy What is the most appropriate next step? A. Probable abscess, treat with antibiotics and short interval follow-up ultrasound B. Probable abscess, recommend drainage/aspiration C. Probably benign, lactating adenoma, or fibroadenoma, recommend short interval follow-up ultrasound in 6 months D. Suspicious mass, recommend ultrasound-guided core biopsy 13 A 51-year-old female presents for a diagnostic mammogram, no prior studies are available for comparison Based on images, what is the most likely diagnosis? A. HIV B. Tuberculosis C. Metastases D. Sarcoidosis E. Rheumatoid arthritis 14a A 70-year-old female presents for breast MRI to assess for possible implant rupture Bilateral axial T1-weighted and left breast axial T2-weighted STIR water saturation images are provided What type of implant is present? A. Saline, prepectoral B. Saline, retropectoral C. Silicone, prepectoral D. Silicone, retropectoral 14b Which statement best describes the finding seen in the axial T2W STIR water-saturated image of the left implant? A. Intact implant with normal radial folds B. Intracapsular rupture only C. Intact implant with capsular contracture D. Intracapsular and extracapsular rupture 15 A 65-year-old male is diagnosed with breast cancer Regarding breast cancer in males, which statement is correct? A. Breast cancer in males in general has a better prognosis than in females due to the malignancy typically being in an earlier stage at the time of diagnosis B. Approximately 20% have axillary adenopathy at the time of diagnosis C. Approximately 15% have DCIS associated with their malignancy D. Infiltrating lobular carcinoma is less common in men than women 16 What is the protocol for performing rolled craniocaudal (CC) views? A. Always roll superior half of the breast medial and lateral B. Always roll inferior half of the breast medial and lateral C. Always roll medial half of the breast superior and inferior D. Always roll lateral half of the breast superior and inferior 17 A 50-year-old female presents with a right breast palpable abnormality at 9 o’clock Based on the ultrasound image below, what is the most likely diagnosis? relationship to their everyday English meanings Luminance is the perceived brightness of a display and can apply to both view boxes and the monitors used for digital display (Illuminance describes the outside light falling on the display and while illuminance is good when reading a book, it degrades the images from monitors used for mammographic displays by reducing the perceived contrast.) Now on to the question The answer choice A is wrong because there is a limit to the brightness range comfortable (and at extremes, safe) for the human vision system (That is why we have sunglasses, for example.) Answer choice B is somewhat better but again, as we go too high in the contrast ratio displayed, we again reach the limits of the adaption capabilities of the human visual system We also run into problems due to the contrast reduction processes of veiling glare and reflection The answer choice D is incorrect because even the best mammographic film cannot compete with the dynamic range in contrast of modern digital displays (Film still beats digital displays in resolution, however That is it can see tiny objects of high contrast better than digital displays.) Answer choice C is correct Modern digital displays can easily, as previously stated, exceed the contrast display capabilities of film so a good minimum contrast ratio is that of film on a standard view box However, it should not be too high for the reasons given above in discussing answer choice B Reference: Samei E Technological and psychophysical considerations for digital mammographic displays Radiographics 2005;25:491–501 7 Answer A. Imagine looking at a display with a uniform background of brightness L The display is divided into two sections but initially both are matched in brightness so that they appear as one Now imagine that one side (e.g., the left side) is very slowly made brighter while you are viewing the display At some point you perceive that there are two sections with the left half just barely brighter than the right half This difference in brightness ΔL is just noticeable and so it is called the just noticeable difference (JND) Dividing the JND by the luminance itself is called the contrast threshold In other words, the contrast threshold is the fractional change in luminance ΔL/L required to be just noticeable If the contrast threshold was a constant, independent of the luminance value, then Weber law would strictly hold for visual contrast perception It is not true but does provide us with a good starting point (Weber law is a rough approximation which can be applied to a number of sensory modalities, e.g., sound loudness perception.) The plot of the gray-scale standard display function taken from the DICOM 14 document (http://medical.nema.org/dicom/2004/04_14pu.pdf) shows that for dimly luminated displays, a larger contrast is required to be perceptible than for brighter displays and so Weber law does not hold For brighter screens (above 100 cd/m2), the curve flattens out to the right edge of the displayed range and beyond (A bright mammography viewing box is 3,000 cd/m2) This is the situation described in the correct answer choice A References: Samei E Technological and psychophysical considerations for digital mammographic displays Radiographics 2005;25:491–501 8 Answer D. Note that mean glandular dose (MGD) is the average dose throughout the breast The dose at the beam entrance surface of the breast would be the highest As the beam passes through the breast, it is attenuated and so the dose decreases as it passes through the breast Thus, the average dose is lower than the dose near the beam entrance The problem states that the entrance exposure has increased by 60% with a 16% increase in kVp In addition, the penetrability (range of x-rays in tissue) goes up with kVp (Bushong, p 140) (This is equivalent to saying that the x-ray attenuation is less at higher kVp.) What effect does this have? It means that as the radiation passes through the tissue, it does not get reduced as much as it would at lower kVp Thus, the mean (average) dose to the tissue is higher than it would have been had the penetrability remained constant Thus, the dose increases by more than 60% It is important to note that according to the problem, the mAs has been held constant Normally, if one chooses to increase the kVp, the system would automatically reduce the mAs Reference: Bushong SC Radiologic Science for Technologists 10th ed St Louis, MO: Elsevier; 2013 9 Answer B. CsI (indirect) is used by GE; Se (direct) is used by Hologics BaFBr is used by FUJI (photostimulable phosphor) NaI is used in gamma cameras, not mammography Reference: Huda W Review of Radiographic Physics 3rd ed Baltimore, MD: Lippincott Williams & Wilkins; 2010:53 10 Answer B. In conventional radiography (80 kV), about 2.5 to 3 cm of soft tissue attenuates half the x-ray beam; in mammography, about 1 cm of soft tissue will reduce the primary x-ray beam intensity to one half of its initial value Reference: Huda W Review of Radiographic Physics 3rd ed Baltimore, MD: Lippincott Williams & Wilkins; 2010:54 11 Answer C. Currently, in digital mammography, the typical x-ray tube voltage is 30 to 32 kV, with the higher value used in thicker breasts Twenty-five kV would be far too low, and 40 kV would be far too high Reference: Huda W Review of Radiographic Physics 3rd ed Baltimore, MD: Lippincott Williams & Wilkins; 2010:54 12 Answer C. Tube currents are 100 mA for the large (0.3-mm focal spot) and only 25 mA for the small focal spot (0.1 mm); as a result, to get a given mAs in magnification mammography, the exposure time must be increased (threefold) to get the correct exposure at the image receptor Reference: Huda W Review of Radiographic Physics 3rd ed Baltimore, MD: Lippincott Williams & Wilkins; 2010:54 13 Answer C. mAs is an abbreviation for milliampere second, the units of measure of x-ray tube current and exposure time (Bushong, p 593) Thus, at fixed mAs, if the exposure time goes up, the tube current must go down At constant kVp, the dose to the breast is proportional to the mAs, which has not changed (It has just been delivered to the breast over a longer period of time but at a lower rate.) Thus, answer choice A is incorrect There would also be no difference in the total amount of radiation impinging on the detector and so the viewing requirements should not change Thus, answer choice B is also incorrect Answer choice C is the correct answer since motion blur increases with exposure time (Bushong, pp 181, 182) A fixed mAs means that for a longer exposure time, the tube current is reduced Thus, answer choices D and E are both wrong If anything, since the tube current and radiation rate have both been reduced, the exposure is gentler on both the tube and the detector Reference: Bushong SC Radiologic Science for Technologists 10th ed St Louis, MO: Elsevier; 2013 14 Answer C. Calcium (Ca) has an atomic number of 20, whereas soft tissue has an effective atomic number of about 7.4 to 7.6 Though the attenuation coefficient drops with increasing keV for both calcifications (answer choice C) and normal breast tissue (answer choice D), the photoelectric effect for calcium is affected far more, and so the contrast between microcalcifications and normal breast tissue drops substantially as the photon energy increases (see Wolbarst, Fig 33.3) Thus, the correct answer is C Answer choice A is incorrect even though the large region of coverage for the chest radiograph might imply a decrease in resolution Even with high resolution, we still would probably not see calcium in a chest x-ray because of the high kV Answer choice B might be true except that the spine would generally not obfuscate the breasts in a chest radiograph and so this answer is easily eliminated The range of exposure times can substantially overlap for mammograms and chest x-rays Quite often, the exposure time will be shorter for a chest x-ray than for a mammogram and thus choice E is incorrect Reference: Wolbarst A Physics of Radiology 2nd ed Madison, WI: Medical Physics Publishing Corp.; 2000:355–356 15 Answer D. Because of the air gap in magnification mammography, much of the scatter from the breast does not reach the detector Thus, there is little scatter reduction that can be accomplished by using a grid Yet the grid, if present, would still attenuate a significant fraction of the primary beam, requiring an increase in breast dose for the same exposure to the detector Thus, in magnification mammography, the grid is left out since it does little good and requires more dose to the breast (None of this is unique to mammography.) Grids are used in contact (nonmagnification) mammography and so answer choice A is wrong If the grids were present, it would be moving just as it does in contact mammography and so would be just as invisible as it would be in contact mammography Thus, answer choice B is wrong The contrast really should not be affected by magnification and so answer choice C is wrong Answer choice E is more or less hogwash Reference: Bushberg JT, Seibert JA, Leidholdt EM, et al The Essential Physics of Medical Imaging 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2001:207–212 16 Answer B. Consider the geometry used for magnification mammography compared to imaging with the breast in contact with the detector Start with the contact mammography depicted in Figure 5.1 The breast is compressed and in close contact with the detector X-rays must penetrate through the compressed breast As they pass through the breast, a fraction is absorbed (resulting in radiation dose to the breast.) After a sufficient amount of time, the detector receives enough radiation for an image and the automatic exposure control (AEC) turns the radiation off Now for the magnification mammography shown in Figure 5.2, note that the breast is still compressed (eliminating answer choice D) and the x-rays must still penetrate the same thickness of breast tissue The same area of the detector is irradiated, and thus, the total amount of radiation received by the detector to make an image has not changed However, the air gap in Figure 5.2 substantially reduces the amount of scatter reaching the detector while allowing all of the primary radiation to reach the detector However, in Figure 5.1, a great deal of scatter is generated near the detector For the geometry of Figure 5.1, this scatter would reach the detector and degrade the image and so here, a grid is used Unfortunately, this grid also reduces the primary radiation; to make up for this, more radiation is required and thus a large focal spot is used so that this larger amount can be delivered in a comparable period of time Thus, answer choice B is the correct answer Answer choice A is wrong Magnification enhances the effect of motion, not reduces it The geometry shows that answer choice C is wrong because the density of radiation reaching the detector is what matters for making images (If this is puzzling, think of film The radiation density reaching the film must be the same in both cases to cause the same amount of exposure Similar considerations apply to digital detectors.) The image of the magnified portion of the breast in Figure 5.2 will be about the same size as the image of the whole breast in Figure 5.1 and so the total radiation required by the detector should be about the same for both configurations Finally, answer choice E is wrong because the overall image quality needs to be the same for both situations (Thought question? What are the implications for radiation dose to the breast for both 1 and 2? What are the implications for total amount of radiation absorbed by the breast for both 1 and 2?) Reference: Bushberg JT, Seibert JA, Leidholdt EM, et al The Essential Physics of Medical Imaging 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2001:207–212 17 Answer A. First consider answer choices C, D, and E Answer choice C is wrong because tissue contrast decreases with increased kV (Wolbarst, Fig 33.3, p 356) In considering answer choice D, the spatial resolution can actually improve some at moderate and higher kV because at low kV, a phenomenon called “blooming” can become significant (Wolbarst, p 290) This occurs because at lower kV, the electrons traveling from the cathode to anode have a little more time to repel each other and spread apart more, slightly increasing the effective size of the focal spot Increasing the kV beyond 26 or so does not improve things much and so this is generally not an important effect (and has nothing to do with breast thickness) Scatter itself generally increases with kV, not decreases (Wolbarst, p 314) and so choice E is wrong This leaves answer choices A and B The correct answer is A Higher penetration allows for a shorter exposure time (If possible, the exposure time should be kept below 2 seconds Discuss this with mammography radiologists for more insight.) Though answer choice B is also true the most important reason is to keep the exposure time down to reduce motion artifacts Reference: Wolbarst A Physics of Radiology 2nd ed Madison, WI: Medical Physics Publishing Corp.; 2000 18 Answer C. Xeroradiography is no longer available but had breast doses greater than filmscreen Both CR and digital mammogram are about 30% less than that for film-screen with direct digital almost one-half of film-screen References: Hendick RE, et al Comparison of acquisition parameters and breast dose in digital mammography and screen-film mammography in the American College of Radiology Imaging Network digital mammographic imaging screening trial AJR Am J Roentgenol 2010;194(2):362–369 Michigan Department of Licensing and Regulatory Affairs MGD results from 427 mammography machines January 2012 Available at: http://www.michigan.gov/images/mdch/bhs_mammo_dose_220795_7.gif 19 Answer C. When compared to routine screening, magnification views have longer exposure time They are also associated with more motion blur, less scatter, less noise, decreased sourceto-object distance and have no significant change in contrast References: Bushberg JY, Seibert JA, Leidholt EM, et al The Essential Physics of Medical Imaging 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2001:210 Huda W Review of Radiographic Physics 3rd ed Baltimore, MD: Lippincott Williams & Wilkins; 2010:54–55 20 Answer D. Breast compression obviously reduces object thickness, which reduces scatter Lower scatter lowers image noise improving image contrast Reference: Barnes G RSNA Categorical Course in Diagnostic Radiology Physics: Technical Aspects Haus A, Yaffe M, eds Oak Brook, IL: RSNA; December 1992:59–68 21 Answer C. This limit is specified in the NRC regulations for radioactive materials and adopted into CRCPD Suggested State Regulations, which are adopted by states with regulations over radiation machines Is also the current standard of the National Council on Radiation Protection and Measurements (NCRP) Reference: Conference of Radiation Control Program Directors, Suggested State Regulations for Control of Radiation, Standards for Protection Against Radiation, Part D; 2003 http://www.crcpd.org/SSRCRs/dpart.pdf 22 Answer D. Since 2002, it has been shown that the thyroid dose is insignificant compared to the breast dose Most importantly, they are neither necessary nor helpful, and their use can result in inadequate or repeat studies References: Kopans DB Mammograms and thyroid cancer: the facts about breast-cancer screening Available at: http://www.massgeneral.org/imaging/about/newsarticle.aspx?id=2720 Whelan C, McLean D, Poulos A Investigation of thyroid dose due to mammography Australas Radiol 1999;43(3):307–310 23 Answer D. The W target with Rh filter provides the highest effective energy to maximize penetrability while minimizing the reduction in image contrast, which is critical breast imaging Reference: Pizzutiello R RSNA Categorical Course in Diagnostic Radiology Physics: From Invisible to Visible The Science and Practice of X-ray Imaging and Radiation Dose Optimization Frush D, Huda Q, eds Oak Brook, IL: RSNA; December 2006:219–234 24 Answer C. Film is the capture, display, and storage medium Its spatial resolution is limited by the phosphor particle size and screen characteristics, which is about 15 to 20 lp/mm This exceeds the pixel resolution characteristics of the image recording and display of the digital imaging chain References: Bushberg JT The Essential Physics of Medical Imaging 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2001:293–316 Williams MB, Fajardo LL Digital mammography: Performance considerations and current detector designs Acad Radiol 1996;3:429–437 25 Answer C Reference: Ranger NT, Lo JY, Samei E A technique optimization protocol and the potential for dose reduction in digital mammography Med Phys 2010;37:962–969 26 Answer C. The question tests knowledge of units and clinical absorbed dose from current digital mammogram for an average breast 100 millirad = 1 milligray = 1 millisievert; 300 millirads is the ACR limit for accreditation and represents a limit for an average breast that must not be exceeded 100 millisieverts is not a measure of absorbed dose and is a huge dose in worker dose limit range Clinical techniques for digital imaging are lower than filmscreen for the same breast thickness While film is in the 200- to 300-millirad range, digital is in the 150- to 200millirad or 1.5- to 2.0-milligray range Reference: Hendrick RE, Pisano E, Averbukh A, et al Comparison of acquisition parameters and breast dose in digital mammography and screen-film mammography in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial AJR Am J Roentgenol 2010;194:362–369 27 Answer A. All factors affect the acquisition side of the imaging chain Image quality is maximizing signal-to-noise ratio (SNR) per unit of dose Based on maximizing a figure of merit, which is the ratio of SNR to MGD, very gradually decreases with kVp Field size and mAs are constant for a fixed breast thickness but increase MGD causing a decreased figure of merit (FOM) For the same thickness, target/filter combo strongly affected the FOM as kVp increased References: Ranger NT, Lo JY, Samei E A technique optimization protocol and the potential for dose reduction in digital mammography Med Phys 2010;37:962–969 Williams, et al Optimization of exposure factors in full field digital mammography Med Phys 2008;35:2414–2423 28 Answer B. Electronic magnification is a postacquisition processing technique that is analogous to enlarging an already acquired picture It does not affect the dose employed for the image or affect the image resolution Noise is increased with electronic magnification Geometric magnification is the actual image magnification based on imaging technique and will affect image resolution Reference: Niklason L RSNA Categorical Course in Diagnostic Radiology Physics: From Invisible to Visible The Science and Practice of X-ray Imaging and Radiation Dose Optimization Frush D, Huda Q, eds Oak Brook, IL: RSNA; December 2006:235–241 29 Answer E. Honeycomb-type grids (HTC) 4:1 are used in mammography Exposure doubles even with a grid ratio of 4:1 compared to a nongrid exposure References: Huda W, Greene-Donnelly K RT X-Ray Physics Review Madison, WI: Medical Physics Publishing; 2011:180 Bushong SC Radiologic Science for Technologists—Physics, Biology and Protection St Louis, MO: Mosby; 2001:315 Carlton RR, Adler AM Principles of Radiographic Imaging An Art and a Science Albany, NY: Delmar; 2001:583 30 Answer C. Mammography uses two focal spot sizes: a large and a small For the standard CC and MLO, the large focal spot size is used, which is generally 0.3 mm Reference: Bushong SC Radiologic Science for Technologists—Physics, Biology and Protection St Louis, MO: Mosby; 2001:311 31 Answer E. The recommended SID for mammography should be from 50 to 80 cm It is best to have a long SID and a small focal spot size for optimal sharpness and resolution Reference: Wentz G, Parsons WC Mammography for the Radiologic Technologist 2nd ed New York, NY: McGraw-Hill; 1992:17 32 Answer A. The most common focal spot size used for magnification imaging in mammography is 0.1 mm Reference: Valerie F, Andolina RT, Shelly LL, et al Mammographic Imaging: A Practical Guide 2nd ed Baltimore, MD: Lippincott Williams & Wilkins; 2001:64 33 Answer B. High-resolution monitors should be used for reading digital mammography to appreciate fine detail A 5-megapixel monitor (2,048 × 2,560 pixel samples in the horizontal and vertical directions for portrait orientation) is recommended by the ACR Reference: ACR–AAPM–SIIM Practice Guideline for Determinants of Image Quality in Digital Mammography; 2012:6 section 4a resolution 36 http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Image_Quality_Digital_Mammo.pdf 34 Answer C. The x-ray field should not extend beyond the image receptor by more than 2% of the SID Reference: Hendrick RE, Bassett L, Botsco MA, et al ACR Committee on Quality Assurance in Mammography Reston, VA: Mammography Quality Control Manual; 1999:236 35 Answer D. Slit camera with a 10-μm slit width Reference: Hendrick RE, Bassett L, Botsco MA, et al ACR Committee on Quality Assurance in Mammography Reston, VA: Mammography Quality Control Manual; 1999:321–322 36 Answer D. Weekly imaging of the ACR phantom is done to verify whether all aspects of the imaging system are functioning properly: image quality, contrast, optical density, uniformity, and scores of the detection limits of the phantom, which are required by the ACR: four fibers, three speck groups, and three masses Reference: Bushong SC Radiologic Science for Technologists: Physics and Protection 10th ed St Louis, MO: Elsevier Mosby; 2013:391–393 37 Answer A. Beryllium is a very low attenuating material that is used in the mammography tube window Reference: Huda W, Greene-Donnelly K RT X-Ray Physics Review Madison, WI: Medical Physics Publishing; 2011:178 38 Answer B. Due to the anode heel effect, the cathode is placed at the chest wall Reference: Huda W, Greene-Donnelly K RT X-Ray Physics Review Madison, WI: Medical Physics Publishing; 2011:178 39 Answer B. The size of the large focal spot used in mammography is 0.3 mm; 0.1 mm is incorrect This smaller focal spot would typically be used for magnification mammography; 0.7 and 1.0 are entirely too large a focal spot for standard mammography Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:3 40 Answer A. In mammography, the goal is to improve soft tissue contrast in order to distinguish smaller, more dense lesions (such as tiny microcalcifications) from the surrounding fibroglandular tissue This is done by lowering the kVp (peak kilovoltage) Reference: Ikeda D Breast Imaging: The Requisites 2nd ed St Louis, MO: Elsevier Mosby; 2011:2–4 41 Answer D. Breast compression allows lower kVp values to be used, due to decrease in the thickness of the breast Motion blur is decreased since the breast is less likely to move There is decreased scattered radiation which leads to improved contrast The compression allows the spread of overlying tissue, which reduces superimposition and decreases structural mottle Reference: Nickoloff EL Radiology Review: Radiological Physics New York, NY: Elsevier Saunders; 2005:156 42 Answer D. This image has a poor contrast because of the exposure factors (high kvP and low mAs) for the thickness of the breast Answer choice D is correct because of the decrease in kVp, there is increase in contrast The radiographic contrast is also dependent on the patient as well as the image contrast Contrast is affected by the breast thickness, density, and atomic differences of the patient, kVp, contrast material, and scatter radiation Answer choice A is incorrect because the MAs is a combination of the mA tube current and exposure time Increasing the mAs increases the exposure time Decreasing the kVp from 28 to 26 indirectly affects the exposure time in cases where phototiming is used With a decrease in kVp, there is a compensatory increase in mAs Answer choice B is incorrect because of the longer exposure time, the likelihood of motion artifact increases An exposure of 90 mAs is usually acceptable for most patients A desired exposure time is usually between 0.5 and 2 seconds Shorter the exposure time, the greater the production of noise artifacts and grid lines The longer the exposure time, the increased risk of motion and overexposure Answer choice C is incorrect because increasing mAs increases the radiation dose Answer choice E is incorrect because density refers to the blackness of an image The degree of image blackness is directly related to the intensity of the radiation reaching the film or intensifying screen Increasing mAs results in increase in density Reference: Curry TS III, Dowdey JE, Murry RC Jr Christensen’s Physics of Diagnostic Radiology 4th ed Philadelphia, PA: Lea & Febiger; 1990:149, 153 INDEX A Abscess Apocrine cyst cluster Atypical ductal hyperplasia (ADH) B Bilateral breast edema Bilateral diagnostic mammography Breast cancer abnormal interpretation rate breast conservation surgery calcific particles detection rate fat necrosis fibrocystic change histopathologic subtype interval cancers local recurrence, breast conservation therapy lymph nodes draining male metastasis, contralateral breast primary neoadjuvant chemotherapy pleural effusion pregnancy-associated prevalence of risk factor for screening for American Cancer Society (ACS) recommendations anatomic structure, normal breast BRCA1/BRCA2 mutation carriers breast-specific gamma imaging CC view, lesion location decrease in breast density differential diagnosis HER2 positive initial imaging modality keyhole sign linguine sign milk of calcium MRI (see Magnetic resonance imaging) nipple elevation pleomorphic calcifications shape and margins of mass simple cysts sternalis muscle subcapsular line sign triangulation method ultrasound unilateral right breast skin thickening unilateral/bilateral patchy isotope uptake second-degree relative surveillance and treatment for TNM staging classification Breast hamartoma Breast intervention antiplatelet/anticoagulation therapy bracketing technique, wire placement breast-conserving therapy, contraindications calcium oxalate crystals chest wall lesion collagen vascular decrease fluid aspiration galactography lidocaine with epinephrine dosage percutaneous biopsy sentinel lymph node biopsy seroma stereotactic biopsy acetaminophen atypical ductal hyperplasia (ADH) device florid epithelial hyperplasia needle retraction parallax shift patient positioning postwire localization spinal needle use stroke margin surgical biopsy x and y coordinates x-ray tube angling topical lidocaine ultrasound-guided wire localization Breast-conserving therapy Breast-specific gamma imaging C Calcifications calcium phosphate dermal fine pleomorphic linear linear branching lucent centered milk of calcium pleomorphic polarized light microscopy popcorn-like round secretory tangential view tissue sampling D Diabetic fibrous mastopathy (DFM) Diabetic mastopathy Duct ectasia Ductal carcinoma, invasive retroglandular clear space upper inner quadrant Ductography E Elastography F Fat necrosis Fibroadenolipoma Fibroadenomas Filariasis Florid epithelial hyperplasia Focal fibrosis G Galactocele Galactography Giant fibroadenoma Gynecomastia H Hematoma I Infiltrating lobular carcinoma Inflammatory carcinoma Intracapsular rupture keyhole sign linguine sign subcapsular line sign Intramammary lymph node J Juvenile fibroadenoma L Lipoma Lisch nodules Lobular carcinoma, invasive M Magnetic resonance imaging (MRI) BI-RADS category breast cancer age considerations duct ectasia Hodgkin disease, clinical indicator indication for lifetime risk percentage optimal timing of T1 without fat saturation fat necrosis flap edema ghosting artifact inhomogeneous fat saturation artifact intramammary lymph node intravenous gadolinium use invasive lobular carcinoma irregular breast mass, spiculated margins mass-like enhancement multicentric disease multifocal disease nonmass-like enhancement, kinetic interrogation patient motion/ghosting artifact phase wrap/aliasing artifact postoperative cavity site premenopausal prepectoral implant rim enhancement silicone implant susceptibility artifact tumor muscle invasion, muscle enhancement Mammography accurate positioning, MLO views American Cancer Society (ACS) recommendations American College of Radiology guidelines bilateral secretory calcifications bilateral subpectoral saline breast implants BI-RADS 2 assessment BI-RADS 5 category BI-RADS category BRCA1/BRCA2 mutation carriers breast hamartoma breast positioning cancer detection rate cancer sensitivity chin artifact, MLO view compression compression plate and imaging receptor computer-aided detection (CAD) continuing education requirements decrease in breast density deodorant artifact detector interface line diffuse increased trabecular thickening document interpretation, additional training epidermal inclusion cyst false negative fibroadenolipoma film labeling follow-up, positive mammograms free silicone injection free silicone, intracapsular and extracapsular rupture galactocele grid artifacts gynecomastia hair artifact hematoma image blurring increased positive predictive value (PPV) increasing asymmetry inferior lesions inflammatory carcinoma irregular mass margins lateral-medial (LM) view, calcifications linear calcification lipoma Lisch nodules lucent centered calcification malignancy percentage mass location mass with calcifications medial breast tissue medical outcomes audit data metaplastic carcinoma milk of calcium Mondor disease motion artifact neurofibromatosis type 1(NF1) nipple elevation oil cyst organ malformations, fetus dose palpable abnormality, upper outer quadrant partially circumscribed masses phyllodes tumors physics related to Albert Xthona beryllium tube window cathode side placement contrast threshold direct digital radiography displays electronic magnification focal spot sizes grids purpose high-resolution monitors honeycomb-type grids (HTC) increase in contrast lower peak kilovoltage mA, exposure time magnification values mean glandular dose (MGD) microcalcification moving grids Nal x-ray detector occupational dose limit phantom routine screening vs magnification views screen-film vs digital mammography slit camera soft tissue thickness source to image distance (SID) target/filter combination thyroid shielding tube voltage voltage (kV) used W target with Rh filter pleomorphic calcification Poland syndrome posterior nipple line (PNL) pseudocalcifications quality control tests quality standards in United states radial scar, tubular carcinoma readout failure recall rate rolled CC views rolled views roller artifact scar screening ratio secretory calcifications shrinking breast silicone injection granulomata silicone saturation artifact spot compression magnification views spot magnification steatocystoma multiplex stereotactic core biopsy sternalis muscle subareolar area, nipple tattoo sign time limit, lay summaries tubular carcinoma unilateral axillary adenopathy unilateral gynecomastia VP shunt catheter Mammography Quality Standards Act (MQSA) continuing education continuing experience credentials initial experience initial medical education new modality training Mastectomy Melanoma Mondor disease Multicentric disease Multifocal disease N Nephrogenic systemic fibrosis (NSF) Nipple retraction P Papilloma, intraductal Peripheral duct papilloma Phyllodes tumors Pleural effusion Poland syndrome incidence of inheritance pattern Postprocedural skin thickening Pseudoangiomatous stromal hyperplasia (PASH) Psoriasis R Radial scar mammographic prevalence surgical excision, stereotactic breast biopsy tubular carcinoma Regulatory/standards of care BI-RADS assessment BI-RADS ultrasound lexicon descriptors BRCA-1 mutation carrier breast tomosynthesis cancer detection rate (CDR) cancer sensitivity Mammography Quality Standards Act (MQSA) phantom images PPV1 definition screening ratio S Sentinel lymph node biopsy Seroma Silicone injection granulomata Steatocystoma multiplex Stereotactic biopsy, breast intervention acetaminophen device florid epithelial hyperplasia needle retraction parallax shift patient positioning postwire localization prone table spinal needle use stroke margin surgical biopsy topical lidocaine upright add-on unit x and y coordinates x-ray tube angling T Trauma Tubular carcinoma U Ultrasound axillary lymph nodes calcifications BI-RADS 2 category breast abscess breast cancer diffuse shadowing and hamartomas juvenile fibroadenoma lymph nodes chest wall lesion core biopsy focal asymmetry lump with pain diabetic mastopathy duct ectasia extracapsular silicone rupture fibroadenoma galactocele guided wire localization increasing asymmetry intraductal papilloma lipoma metaplastic carcinoma mucinous carcinoma oil cyst painful, erythematous mass, right breast scar simple cyst ... ultrasound image below, what is the most appropriate BI-RADS assessment? A. BI-RADS 2 B. BI-RADS 3 C. BI-RADS 4 D. BI-RADS 5 8 A 35-year-old female with a history of a left lumpectomy, radiation therapy, and chemotherapy at age 29 presents for her annual diagnostic mammogram... 31 Which of the following would you expect to present as a spiculated mass on mammogram? A. Medullary carcinoma B. Papillary carcinoma C. Phyllodes tumor D. Tubular carcinoma 32 A 6 2- year-old female presents for additional views for a mammographic finding... E. Intra- and extracapsular rupture 5 0a A 55-year-old high-risk patient presents for screening breast MRI No comparison available The following contrast-enhanced breast MR images are available: