Download pdf - Olive Peart, MS, RT(R)(M) - sbmu.ac.irgynecology.sbmu.ac.ir/uploads/4_5974168447808963294.pdfOlive Peart, MS, RT(R)(M) Clinical Coordinator Program in Radiography Stamford Hospital

Olive Peart, MS, RT(R)(M)Clinical Coordinator

Program in RadiographyStamford Hospital

Stamford, Connecticut

MAMMOGRAPHYEXAMINATION

LANGE Q&A™

SECOND EDITION

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DOI: 10.1036/0071548351

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Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Patient Education and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2. Instrumentation and Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3. Anatomy, Physiology, and Pathology of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4. Mammographic Technique and Image Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

5. Positioning and Interventional Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

iii

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iv Contents

6. Practice Test 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

7. Practice Test 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

This book is a review and self-assessment manualfor radiologic technologists, its purpose being tohelp technologists who are considering the advancedlevel examination in mammography. The book fol-lows the content category guidelines as specified inthe examinee handbook published by the AmericanRegistry of Radiologic Technologists (ARRT).

The ARRT does not review, evaluate, or endorsepublications. Permission to reproduce ARRT copy-righted materials within this publication should notbe construed as an endorsement of the publication bythe ARRT.

The first five chapters review the contentcategory guidelines: (1) Patient Education andAssessment, (2) Instrumentation and QualityAssurance, (3) Anatomy, Physiology, and Patho-logy of the Breast, (4) Mammographic Techniqueand Image Evaluation, (5) Positioning and Inter-ventional Procedures (© 2005 by The AmericanRegistry of Radiologic Technologists). Each chapterprovides a brief summary of the material, followed bya question-and-answer section. The chapter sum-maries highlight the major points and importantinformation in each content category; the question-and-answer sections are fully explained and refer-enced and cover all the information required bythe ARRT for the mammography examination.

Chapters 6 and 7 each contain a complete prac-tice mammography examination. The simulatedexaminations, also available on CD, have been de-signed to reduce examination jitters by providing atrue simulation of the actual certification examina-tion. The CD will also allow the user to self-test inthe subject area of choice.

For the actual mammography examination, theARRT allots 21/2 hours to complete 115 questionsbroken down as follows: category A, 18 questions;category B, 25 questions; category C, 25 questions;category D, 20 questions; and category E, 27 ques-tions. Each examination will also include 20 unscoredor pilot questions. For each of these examinations,the examinee should plan to spend up to 21/2 hoursin a distraction-free environment to practice pacingand the economical use of time. Breast imaging isfinally keeping pace with technology. Electronicimaging and image transfer will be the future ofbreast imaging but the transition may be bumpy.This text seeks to address both screen/film andelectronic/digital technology. One thing to note isthat with the rapidly changing technology, the ter-minology being used in electronic imaging has notyet been standardized. This text has incorporatedterms such as imaging receptor when referring tocassettes and imaging plate when referencing the

Preface

v

Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.

object used to record the latent image: the film inscreen/film imaging or the detector in electronicimaging. Chapter 2 details other terms in current use.

It is my hope that users will reference this text asan invaluable resource when studying for theARRT advanced level mammography examination.For questions or comments please visit my website at http://www.opeart.com or email me at

[email protected]. Breast imaging can be a re-warding and meaningful profession. Good luck!

Olive Peart, MS, RT(R)(M)Clinical Coordinator

Program in RadiographyStamford Hospital

Stamford, Connecticut

vi Preface

http://www.opeart.com

In preparing for this edition, I am indebted to themany users of my first edition. Many readers gaveme valuable insight and practical suggestions onthe review questions. Indeed, your questions, sugges-tions, criticisms, corrections, comments, and com-pliments were greatly appreciated and many havebeen incorporated into this edition. I especiallywish to thank technologist Sherry Van Helvoirt forher suggestions and ideas.

Special thanks to Dorothy Saia, program directorwith the Radiography Program at Stamford Hospital.She was always available as a consultant but just asimportant was her role in encouraging me andkeeping me on task.

I am particularly grateful for the help that I receivedfrom the following technologists: Beth Siegelbaum,for her help in providing me with needed resourcematerial; Elizabeth Dwyer and Iole Del Toro, whoboth reviewed digital quality control tests with meand spent a considerable amount of time cheerfullyanswering my numerous questions.

Thanks also to radiologist Karen Greenberg forher help and suggestions and physicist Jim Sum-mers for his help with MQSA and related physics.

Students played a very important role in makingthis book possible. I would like to thank theradiography students at Stamford Hospital (classof 2008), including Brandy M. Chassé, Marilyn P.DaSilva, Erica A. Guasco, Dawson C. Haffner, Kris-tiann Kalinski, Carl J. Laguzzi, Tanja M. Albaner-Lall, Lewis R. Pierpoint, Claudia V. Tu, and John D.Velasco for their timely suggestions.

This text would certainly not be possible withoutthe care and commitment of my editors, CatherineJohnson and Robert Pancotti. The entire productionteam, including production supervisor CatherineSaggese, production manager Vastavikta Sharma,the copy editors, and other professionals at McGraw-Hill, deserves a special thanks for their attention todetail when preparing the final manuscript.

And finally, my heartfelt thanks to my husbandand children for their patience and consideration.

Acknowledgments

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This is a complete reference list of books, publica-tions, and Internet sites used in compiling the textand questions in this book. For your convenience,the last line of each answer refers back to the book,publication, or web site where the related informa-tion was found. For example, (Shephard, p. 337)refers to page 337 in the book Radiographic ImageProduction and Manipulation by C. Shephard.

Food and Drug Administration (FDA) Internet.Accreditation and Certification Overview. September2007. Available at http://www.fda.gov/cdrh/mammography/robohelp/finalregs.htm. AccessedFebruary 2007.

American Cancer Society (ACS). Breast Cancer Facts& Figures 2005–2006. Atlanta, GA: American CancerSociety Inc.

American Cancer Society. Detailed Guide: BreastCancer. 2007. Available at http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=5. AccessedNovember 2007.

American College of Radiology (ACR). MammographyQuality Control Manual. Reston, VA: The AmericanCollege of Radiology; 1999.

Andolina VF, Lille SL, Willison KM. MammographicImaging: A Practical Guide. 2nd ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2001.

Bontrager KL, Lampignano JP. Textbook of Radi-ographic Positioning and Related Anatomy. 6th ed.St. Louis, MO: Elsevier Mosby; 2005.

Burstein HJ. Aromatase inhibitor-associated arthralgiasyndrome. Breast. 2007 June 1;16(3):223–234.

Bushong SC. Radiologic Science for Technologists—Physics, Biology and Protection. 8th ed. St. Louis,MO: Mosby; 2004.

Carlton RR, Adler AM. Principles of RadiographicImaging: An Art and a Science. 4th ed. Albany, NY:Delmar; 2001.

FDA Policy Guidance Help System. Available athttp://www.fda.gov/cdrh/mammography/robohelp/START.HTM. Accessed November 14,2007.

Harris JR, Lippman ME, Osborne CK. Diseases of theBreast. 2nd ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2000.

Herrmann VM, Borelli AJ. The role of MRI in breastimaging. Commun Oncol. 2006 November 1;3(11):727–729.

Papp J. Quality Management in the Imaging Sciences.3rd ed. St. Louis, MO: Mosby; 2006.

Peart O. Mammography and Breast Imaging: Just theFacts. New York, NY: McGraw-Hill; 2005.

Sanders ME, Page DL. All radial scars/complexsclerosing lesions seen on breast screening mammogramsshould be excised. Breast Diseases: A Year BookQuarterly. 2007 Jan 1.

Senior K. Benefits of tamoxifen persist long aftertreatment ends. Lancet Oncol. 2007 Apr;8(4):288.

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http://www.fda.gov/cdrh/mammography/robohelp/START.HTM

http://www.fda.gov/cdrh/mammography/robohelp/START.HTM

http://www.fda.gov/cdrh/mammography/robohelp/finalregs.htm

http://www.fda.gov/cdrh/mammography/robohelp/finalregs.htm

http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=5

http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=5

x Bibliography

Shephard C. Radiographic Image Production andManipulation. New York, NY: McGraw-Hill; 2003.

Steveb AT. Quality Management for RadiographicImaging. New York, NY: McGraw-Hill; 2001.

Tabár L, Dean PB. Teaching Atlas of Mammography.3rd ed. New York, NY: Thieme; 2001.

Venes D, Biderman A, Adler E. Taber’s CyclopedicMedical Dictionary. 18th ed. Philadelphia, PA: F.A.Davis; 2001.

Tortora GJ, Derrickson B. Principles of Anatomy andPhysiology. 11th ed. New York, NY: John Wiley &Sons; 2006.

Tucker AK, Ng YY. Textbook of Mammography. 2nd ed.Edinburgh: Churchill Livingstone; 2001.

Yazici B, Sever AR, Mills P, et al. Scar formation afterstereotactic vacuum-assisted core biopsy of benignbreast lesions. Clin Imaging. 2006;30(6):438.

Zuley ML, Willison KM, Bonaccio E, et al. Full-fielddigital mammography on LCD versus CRT mon-itors. AJR. 2006;187:1492–1498.

1

CHAPTER 1

Patient Education and Assessment

Summary of Important Points

BREAST EXAMINATION

The American Cancer Society (ACS) guidelines forbreast examination and routine mammographyscreening are as follows:

• Women aged 20 and older should performbreast self-examination (BSE) every month.

• Women between ages 20 and 39 should have aclinical breast examination (CBE) every 3 years.

• Women aged 40 and older should have ascreening mammogram and a CBE every year.

Breast Self-ExaminationA BSE is a check of your breast. It involves

• Looking for changes in the breast• Feeling for changes in the breast

Clinical Breast ExaminationA CBE is a check of the breast by a qualified health-care professional. A thorough clinical examination willlocate any lumps or suspicious areas and any changesin the nipples or skin of the breast. The lymph nodesunder the armpit and above the collarbone will also bechecked for enlargement or firmness.

Medical History and DocumentationMedical and family history will provide informationabout symptoms and risk factors for breast cancerand benign breast conditions. The history shouldalso include questions about other health problems.

Benefits and Risks of Mammography

Mortality ReductionBreast cancer in its early stages is asymptomatic.Since the advent of modern mammography in thelate 1960s, studies have conclusively proven thatthe mortality rate from breast cancer is significantly

reduced with regular screening mammograms.Although the mammogram will not detect allcancers, its effectiveness and sensitivity increaseswith age.

Risk from Radiation ExposureA mammogram delivers very low doses of radia-tion. In general, each projection in a screen-filmmammogram will give about 0.1–0.2 rad averageglandular dose when a grid is used.

RISK FACTORS FOR BREAST CANCER

• Gender: The biggest risk factor for breast canceris gender (female). Although men can also getbreast cancer, the disease is about 100 timesless common among men than among women.

Other relatively high-risk factors (with a rela-tive risk > 4.0) include:

• Aging: A woman’s risk of developing breastcancer increases with age. Seventy-seven per-cent of women are above 50 when they arediagnosed with breast cancer.

• Genetic risk factors: Genes known to be associ-ated with breast cancer include the BRCA1 andBRCA2 genes, which carry a high risk but arerare in the general population. About 10% ofbreast cancer cases are hereditary.

• Family history of breast cancer: Breast cancer riskis higher among women whose close blood rel-atives have this disease. The risk is greater ifthe breast cancer occurs in a relative beforeage 50.

• Personal history of breast cancer: A woman withcancer in one breast has a greater risk of devel-oping a new cancer in the other breast.


2 1: Patient Education and Assessment

Moderate risk factors (relative risk 2.1–4.0) include:• Having one first-degree relative with breast

cancer• Atypical hyperplasia confirmed on biopsy• High-radiation dose to the chest area—women

who have had chest area radiation from a pre-vious cancer treatment are at increased risk

• High bone density after menopause

Minor risk factors (1.1–2.0 relative risk) are associ-ated with hormonal changes in the woman’s body orhormonal use that may slightly increase a woman’schance of developing breast cancer. These include:

• Not having children or having the first childafter age 30

• Not breast-feeding• Early menarche (before age 12) or late menopause

(after age 55)• Postmenopausal obesity• Recent and long-term use of hormone replace-

ment therapy (HRT) or oral contraceptive• Alcohol consumption• Obesity

BREAST DISEASE

Breast disease can be either benign or malignant.

Benign Breast DiseasesLike malignant conditions, benign diseases of thebreast can manifest themselves physically, such asin a painful cyst or nipple discharge. Some breastdiseases, however, can be detected only on themammogram. Such breast disease will be seen asasymmetric densities, calcifications, circumscribedtumors, lesions, or skin thickening.

Malignant DiseasesThe two main classifications of breast cancer are duc-tal and lobular carcinoma. Ductal carcinoma is themost common, occurring in about 90% of all cases.The classifications of ductal carcinoma are as follows:

• Ductal carcinoma in situ: The cancer is confinedto the duct and does not invade the ductwalls. This is commonly referred to as Stage 0carcinoma.

• Invasive or infiltrating ductal carcinoma: The can-cer has spread from the ducts into the sur-rounding stromal tissue and may or may notextend into the pectoral fascia and muscle.

Lobular carcinoma accounts for 5%–10% of allbreast cancers

• Lobular carcinoma in situ is not seen mammo-graphically in 50% of cases; the abnormal cellsgrow within the lobules but do not penetratethrough the lobule walls.

• Invasive lobular carcinoma is difficult to perceiveon the radiographs; it may show as a spiderweb appearance or cause skin retraction.

Other Breast CarcinomasInfiltrating medullary, colloid comedo, tubular,mucinous, papillary, and other carcinomas accountfor less than 10% of total breast cancer cases andmost have a better prognosis than infiltratingductal or lobular cancers.

Appearance on RadiographsBreast cancer may appear on the radiograph asasymmetric densities, calcifications, circumscribedtumors or lesions, or skin thickening.

• Malignant asymmetric densities are speculated orstellate lesions with a solid central tumor andradiating structures—the larger the centraltumor, the longer the spicules.

• Ductal calcifications are granular or casting-typecalcifications and most often will appear inclusters.

• Malignant circumscribed lesions are ill-definedand high-density radiopaque lesions, exceptfor a few rare carcinomas that are low-densityradiopaque.

• Skin thickening will appear in cases of advancedbreast cancer, small cancers in the axillary tailor behind the nipple, breast carcinoma in alarge area, invasive comedocarcinoma, dif-fusely invasive ductal carcinoma (ie, inflamma-tory carcinoma), secondary breast carcinoma,or metastasis from the opposite side.

DIAGNOSTIC OPTIONS

The mammogram remains the single most-effectivetool in the detection of breast cancer. There are twomethods of mammography screening: conventional,which uses an analogy method of imaging, and dig-ital, which can be cassette-based or cassette-less.

• Digital imaging replaced the film with an elec-tronic detector. The electronic system of the

Summary of Important Points 3

digital unit will collect a digital readout of thelatent image. This image information can beelectronically transmitted, manipulated, andefficiently stored using a variety of tools. Digi-tal detectors are categorized as direct or indi-rect. Both the direct and indirect systems areconsidered cassette-less. Digital imaging alsohas a cassette-based system (computed radiog-raphy). The cassette-based system (computedradiography) has the detector loaded into adevise similar in shape and size of the conven-tional cassettes. The cassette-like device iscalled an image receptor (IR) and it holds aflexible imaging plate (IP) instead of the con-ventional film screen. The cassette-based sys-tem exposes the IR with a conventional unit,but after exposure the IR is placed in a com-puter reader where the IP is retrieved and thedigital information analyzed.

Other Imaging options

• Computer-aided detection (CAD) uses a com-puter to analyze and in effect pre-read themammograms by scanning every part of theradiograph and highlighting any suspiciousareas. CAD can be used with conventional aswell as digital images.

• Ultrasound imaging utilizes high-frequencysound waves and is based on the principle ofthe piezoelectric effect. Piezoelectric crystalsare capable of converting energy from oneform to another. In conventional ultrasound,crystal in a transducer will vibrate to producesounds that are sent through the tissues.Returning echoes that are reflected from thetissue again cause a vibration in the crystals,which is proportional to the strength of thereturning echo. A computer will analyze thedifference in returning signals to generateimages of the area of interest.

• Color doppler ultrasound can be used to providean anatomic display of blood flow and cantherefore be used to outline the vascularity of alesion. The technology is based on the fact thathighly vascular lesions are often malignant.

• Magnetic resonance imaging (MRI) technologyuses a powerful magnetic field, radio waves,and a computer to produce highly detailedimages of the breast. The technology is highlysensitive and is based on the magnetic proper-ties of hydrogen atoms in the body.

• Contrast digital mammography involves injectinga contrast while the breast is under compres-sion. Pre- and post-contrast images are taken.Dual energy subtraction can be performed toassess the contrast in tumors. Dual-energy sub-traction is used to subtract high- and low-energy images to separate soft tissue from con-trast or calcium deposits. The technology canalso be used to enhance masses and eliminateobscuring structures.

• Nuclear medicine uses artificially producedradioactive isotopes that can be introducedintravenously into the body. The isotopes gen-erally have an affinity to a specific organ or tis-sue type. Nuclear imaging studies are not usedas screening tools but can complement themammogram. They include Positron EmissionTomography or PET imaging, breast scintigra-phy, and lymphoscintigraphy.• PET imaging, specifically using fluoro-

deoxyglucose (FDG), utilizes the need thatcancer cells have for sugar. Because FDG isstructurally similar to glucose, position-emitting isotopes will attach to FDG mole-cules. The technique can be used to display animage of the tumor bed or to detect mediasti-nal lymph node metastases in breast cancer.

• Breast scintigraphy, also called scintimam-mography and sometimes by the trade nameMiraluma, uses the radioisotope TechnetiumTc-99m sestamibi. The radioactive tracer is in-jected into an arm vein and will concentrate inmalignant lesions in the breast. A gamma cam-era is then used to image the area. TechnetiumTc-99m sestamibi is especially useful on patientswith dense breasts, implants, diffuse calcifica-tions, and breast tissue scarred by radiation orsurgery. The sensitivity of the technique islimited with lesions less than 1 cm.

• Lymphoscintigraphy or sentinel node mappinginvolves the injection of a radioactive tracerin the area around the tumor to identify thepath to the lymph nodes that cancer cellstake. The idea behind lymphoscintigraphy isthat the first node, called the sentinel nodethat receives drainage from a tumor can beused to predict the presence or absence oftumor in the remaining nodes. After theinjection of the radioactive isotope, the pa-tient is sent to surgery. The surgeon will use

a Geiger counter to locate and biopsy the radioac-tive lymph nodes. Lymphoscintigraphy can beused to reduce blind dissection of the axillarynodes and the resultant side effects.

• Computed tomographic (CT) laser mammography isan experimental technology that shows promisebecause no ionizing radiation is used. The tech-nique is based on the principle that malignanttumors develop numerous new vessels in aprocess called angiogenesis. By scanning thebreast with a low-wavelength laser, a three-dimensional image is generated that will showtemperature differences, indicating a growingtumor. The technique can be used to differenti-ate cystic versus solid lesions and to imagebreast implants.

• Digital tomosynthesis is a technology that maysoon achieve FDA approval. The x-ray tube ro-tates in a 50-degree arc around the breast, imag-ing it from 11 different angles with no movementof the patient. Eleven low-dose images taken dur-ing 7–11 seconds. The technology produces high-resolution three-dimensional, cross-section im-ages of the breast. It eliminates overlappingstructures and allows only one compression ofeach breast.

INTERVENTION OPTIONS

• Cyst aspiration involves the removal of thecontent of a cyst and is often performed underultrasound guidance.

• Fine needle aspiration (FNA) is ideal for cystevaluations and aspirations. The techniqueuses a small (22- to 25-gauge needle) and gen-erally requires cytotechnologist evaluation ofthe sample.

• Preoperative localization is a prelude to thesurgical biopsy. It is necessary if stereo local-ization is not available. The procedure can beperformed under mammographic or ultra-sound guidance.

• Fine needle biopsy (FNB) also uses small(22–25 gauge) needles to remove cell samplesfrom nonpalpable lesions for cytologicalanalysis. The technique is often used withstereo localization.

• Stereotactic breast localization or biopsy is amethod of locating nonpalpable lesions by

using a computer to calculate the precise loca-tion of the lesion within the breast. The lesionscan be biopsied after localization. Stereotacticbiopsy can be performed with an add-on ordedicated units.

• Core biopsy uses large-core needles (11–16gauge) to remove tissue samples. The corebiopsy needles have special cutting edges.Core biopsy can be performed using stereolocalization with mammography, or usingultrasound or MRI guidance.

• Open surgical biopsy is recommended with le-sions that are difficult to approach or close tobreast surface. The open biopsy is sometimesused to confirm the finding of FNA and FNB.

• Ductography is used to evaluate nipple dis-charge, duct expansion, defects, or irregularities.

TREATMENT OPTIONS

Breast cancer can be treated with surgery, radiation,and drugs (chemotherapy and hormonal therapy).Doctors can use one or more of these treatments,depending on the type and location of the cancer,whether the disease has spread, and the patient’soverall health status. Posttreatment can includebreast augmentation or reconstruction.

• Mastectomy is the removal of the entire breast.• A radical mastectomy removes the entire breast,

lymph nodes, and chest wall muscles underthe breast. It is rarely performed today becausethe modified mastectomy is just as effective. Themodified mastectomy is also less debilitatingand deforming.

• A modified radical mastectomy removes thebreast tissue and some of the underarm lymphnodes.

• Lumpectomy is the most breast-conservingsurgery. It removes only the cancerous tissueand the surrounding margins of normal tissue.Lumpectomy is generally followed by radia-tion treatment and or drug treatments.

• Radiation therapy is treatment with high-energyradiation to destroy cancer cells. External beamradiation is the more common form of treat-ment and can take 5–7 weeks, beginning about1 month after surgery. Newer techniques in-volve internal beam radiation that can beginthe day after surgery and last only for 7–9 days.



• Chemotherapy is a systemic treatment, affectingall the cells in the body. Many chemotherapydrugs work to kill actively reproducing cells;however, some drugs will work on cells in aparticular phase of the cell cycle.

• Hormonal treatment involves the use of drugscalled selective estrogen receptor modulators, orSERMs. These drugs are antiestrogen drugs toprevent estrogen from latching onto tumor cellreceptors. They are used to shrink or stop therecurrence of breast cancer or to lower the risksof breast cancer recurrence in postmenopausalwomen. Tamoxifen is a common antiestrogendrug, but there are now a number of similardrugs in the market with less toxic side effectssuch as raloxifene. Aromatase inhibitors are alsoantiestrogen drugs, but they work to block thegrowth of tumors by lowering the amount of es-trogen in the body. Another class of drugs suchas Herceptin can be used to treat HER2-positivemetastatic breast cancer.

• Pain medication is available for patients in se-vere pain from cancer. Newer pain medicationsare even more potent than morphine.

POSTTREATMENT OPTIONS

• Breast reconstruction aims to restore the appear-ance of the breast.

• Surgical reconstruction uses saline or siliconeimplants. Modern techniques (subpectoral orretropectoral placement) place the implantsbehind the pectoral muscle. Older techniques(subglandular or retromammary placement)placed the implants in front of the pectoralmuscle.

• Flap surgery removes skin, fat, and muscle fromthe abdomen, back, or buttock and uses it toform a new breast. Flap techniques can eitherleave the flap attached to its original blood sup-ply and tunnels the flap under the skin to thebreast area, or remove the flap completely,which would involve micro surgery to recreatea blood supply to the flap when it is in position.There are two common types of flap techniques:• TRAM flap (transverse rectus abdominis

muscle flap) using tissue from the abdomi-nal area

• Latissimus dorsi flap using tissue from theupper back

Newer flap techniques:

• DIEP (deep inferior epigastric artery perfora-tor flap—using skin and fat but no musclefrom the abdomen

• Gluteal-free flap—using the gluteal musclefrom the buttocks

1. The biggest risk factor for breast disease is

(A) a family history of breast cancer(B) a personal history of breast cancer(C) gender(D) not breast-feeding

2. One of the minor risk factors for breast can-cer could include

(A) gender(B) aging(C) genetic risk factors(D) not breast-feeding

3. What is the approximate risk of developingbreast cancer for a woman whose father’s sis-ter has the disease?

(A) higher than normal risk(B) no significant change in risk(C) lower than normal risk(D) none of the above

4. Seventy-seven percent of breast cancers arediscovered in women in which age group?

(A) age 30 or below(B) above age 50(C) between ages 30 and 40(D) above age 20 but below age 30

5. Symptoms of benign breast disease not seenmammographically can include

1. nipple discharge

2. skin thickening

3. circumscribed tumors(A) 1 only(B) 3 only(C) 2 and 3 only(D) 1 and 3 only

6. Symptoms of a malignant breast cancer caninclude

1. skin thickening2. nipple discharge3. calcifications

(A) 1 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3

7. Skin thickening can be malignant but couldalso be caused by

1. a breast abscess2. a calcified fibroadenoma3. postradiation

(A) 1 only(B) 2 only(C) 1 and 2 only(D) 1 and 3 only

Questions

6

Questions: 1 through 16 7

8. The two main classifications of breast cancer are

1. ductal2. lobular3. medullary


9. MRI could be used

1. as a primary breast cancer detection tool2. to image patients with breast implants to

evaluate ruptures3. to determine tumor margins and the

extent of tumor spread(A) 1 only(B) 1 and 2 only(C) 2 and 3 only(D) 1 and 3 only

10. Chemotherapy

(A) involves the use of drugs to treat cancerthat may have spread

(B) is the destruction of cancer cells usinghigh-energy radiation

(C) involves mapping the area around atumor with the injection of a radioactivetracer

(D) is the removal of only the cancerous tis-sue from the breast

11. The ACS recommends that

1. All women should have a screeningmammogram every year.

2. Women above 40 should have a screen-ing mammogram every year.

3. New masses or lumps in the breast shouldbe checked by a health-care provider.(A) 1 only(B) 2 only(C) 1 and 3 only(D) 2 and 3 only

12. A health-care provider should evaluate whichof the following breast changes?

1. lumps or swellings2. skin irritation or dimpling3. milky discharge from the nipple


13. A CBE should be performed every

1. year after age 402. 3 years between ages 20 and 393. month after age 50


14. A CBE can be performed by which of thefollowing?

1. the radiologist2. the patient3. a health-care professional


15. A BSE should be done regularly by

1. the radiologist2. the patient3. a health-care professional


16. All women above the age _______ shouldperform a BSE regularly.

(A) 20(B) 30(C) 40(D) 50

17. The two-step method of BSE is to

(A) look and feel for changes in the breast(B) examine your breasts and have a regular

mammogram(C) check for lumps in the breast and keep a

journal of changes in the breast(D) examine your breasts and nipples

18. When visually inspecting the breast, thechanges that should be recorded include

1. changes in size and shape2. changes in texture or color3. indentations

(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3

19. The patient’s medical history and documen-tation will

1. provide the radiologist with informationon the patient’s risk factors for breastcancer

2. give the radiologist information aboutgeneral symptoms of breast cancer

3. provide information about possiblebenign breast conditions of the patient(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3

20. The importance of BSE and a CBE is stressedbecause

1. both will detect benign breast diseases,which are very common

2. both will help in the detection of malig-nant breast conditions

3. a mammogram is not 100% effective(A) 1 only(B) 2 only(C) 2 and 3 only(D) 1 and 3 only

21. Which of the following are methods usedin BSE?

1. using the pads of the three middle fin-gers to palpate the entire breast

2. palpating around the breast in a verticalpattern

3. using up varying degrees of pressurewhile palpation of the breast(A) 1 only(B) 1 and 2 only(C) 1 and 3 only(D) 1, 2, and 3

22. For a menstruating woman, when is the besttime of the month to perform a BSE?

(A) 1 week before the start of menstruation(B) on the first day of the month(C) on the last day of the month(D) when the breast is least tender

23. Which of the following statements are true?

1. Breast cancer death rates in UnitedStates are going down.

2. Breast cancer is the leading cause of can-cer death in women in United States.

3. The second leading cause of cancerdeath in women in United States isbreast cancer.(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3

24. Postmenopausal obesity is associated with

(A) a relatively high risk of developingbreast cancer

(B) overall reduction in breast cancer risks(C) circulating estrogen that is produced in

fat tissue(D) a lower overall estrogen level



25. A process of removing tissue, muscle, and fatfrom the belly and transferring that tissue toreconstruct the breast is called

(A) TRAM flap(B) latissimus dorsi flap(C) implant placement(D) silicone implant

26. Antiestrogen drugs such as tamoxifen can beused to

1. slow or stop the cancer’s growth2. prevent breast cancer in high-risk

women3. prevent the recurrence of breast cancer


27. In routine mammography, the radiation doseper projection is generally about

(A) 0.1–0.2 rad(B) 1.0–2.0 rad(C) 0.01–0.02 rad(D) 2–3 mrad

28. Which age group is likely to get the mostradiation dose from a mammogram?

(A) between 20 and 35(B) between 40 and 50(C) between 55 and 60(D) above 70

29. The 5-year survival rate for a patient with astage 0 breast cancer is about

(A) 49%(B) 76%(C) 88%(D) 100%

30. During a mammogram, which of the follow-ing will affect the average glandular dose perbreast?

1. degree of breast compression2. the half-value layer (HVL) of the x-ray

beam3. breast size and composition

(A) 1 only(B) 2 only(C) 3 only(D) 1, 2, and 3

31. In general, the optimal duration of tamoxifentreatment is

(A) 2 years(B) 3 years(C) 4 years(D) 5 years

32. Lumpectomy describes the process of

(A) removing the entire breast including thenipple

(B) removal of the breast cancer tumor andsurrounding margins of normal breast

(C) making a small incision over or near thesite of breast lesion

(D) removing benign lumps from the breast

33. Radiation therapy can be used

1. combined with other treatment options2. to kill any remaining cancer cells in the

breast, or chest wall area3. to shrink the size of a tumor before

surgery



34. Chemotherapy is a class of drugs that can beused to

(A) stop the spread of cancer to other partsof the body

(B) block estrogen from cancer cells(C) reduce estrogen levels in the body(D) kill cancer cells by using high-energy

radiation

35. Breast reconstruction can involve the place-ment of small fluid-filled sacs behind thepectoral muscle. Two common types of suchimplants are

(A) saline and flap surgery(B) TRAM flap and silicone implant(C) silicone or saline implants(D) saline-filled implant and latissimus dorsi

flap implant

36. With its high sensitivity, MRI is ideal as

(A) a routine screen tool for breast cancer(B) a replacement for mammography

screening in detecting breast cancers(C) an adjunctive tool in detecting breast

cancer(D) a screening tool for older women

37. MRI imaging involves the use of

(A) radiation to detect breast lesions(B) sound waves in the imaging of the

breast(C) magnetic properties plus radio waves to

image the breast(D) strong sound and radio waves in

imaging the breast

38. Ultrasound uses

(A) high-frequency sound waves to imagethe breast

(B) low-frequency sound waves to imagethe breast

(C) longitudinal microwaves to image thebreast

(D) radiofrequency waves to image thebreast

39. MRI can be used to

1. map the extent of a tumor2. image patients with implants3. evaluate patients with dense breast


40. Conventional ultrasound imaging of thebreast is often used to

(A) map the extent of a breast tumor(B) verify that a lesion seen on the mammo-

gram is solid or fluid filled(C) verify the presence of microcalcifications(D) biopsy a lesion seen only on MRI

1. (C) Risk factors increase a woman’s risk forbreast cancer. These are divided into majorand minor. Major risks are those outside of awoman’s control, such as gender and age.Minor factors are linked to cancer-causingfactors in the environment or may be relatedto personal choices, such as using HRT. Sim-ply being a woman is the main risk factor fordeveloping breast cancer. Breast cancer canaffect men, but this disease is much morecommon among women than men (AmericanCancer Society: Causes, Risk Factors and Prevention;Peart, 28–29).

2. (D) A risk factor is anything that increases aperson’s chance of getting a disease. Majorrisk factors cannot be changed. Minor factorsare linked to cancer-causing factors in theenvironment or may be related to personalchoices, such as breast-feeding (AmericanCancer Society: Causes, Risk Factors and Prevention;Peart, 28–29).

3. (A) Higher than normal or major risk factorscarry a significantly higher risk for breast can-cer than minor risk factors. Breast cancer riskis higher among women whose close bloodrelatives have the disease. Blood relatives canbe either from the mother’s or father’s side ofthe family (American Cancer Society: Causes, RiskFactors and Prevention; Peart, 28–29).

4. (B) A woman’s risk of developing breast can-cer increases with age. Older women havethe greatest risk. Women younger than age30 years account for only 0.3% of breastcancer cases, and women in their thirtiesaccount for about 3.5% of cases.

• Below 30—0.3% of breast cancer cases• In thirties—3.5% of breast cancer cases• In forties—18% of breast cancer diagnosed• Above 50—77% of breast cancer diagnosed

(American Cancer Society: Causes, Risk Factors andPrevention; Peart, 28–29).

5. (A) Whereas skin thickening or tumors will beseen on a mammogram, nipple discharge isnot seen mammographically. Most nipple dis-charges or secretions are not cancerous. Ingeneral, if the secretion appears clear or milky,yellow or green, cancer is very unlikely. Fur-ther testing such as a ductogram or galac-togram helps in determining the cause of nip-ple discharge. The ducts can also be evaluatedusing ultrasound (American Cancer Society: Non-Cancerous Breast Conditions; Tabár, 16–20).

6. (D) Unfortunately, breast cancer in its earlystates is symptomless. As the cancer grows,some symptoms may appear. These symp-toms can include lumps in the breast, thick-ening of the breast skin, puckering or dim-pling of the breast, inverted nipples, or adischarge from the nipples (Peart, 15–23).

7. (D) Skin thickening or lymphedema of thebreast can indicate breast cancer, but may alsobe because of a breast abscess located behindthe nipple, severe infection involving the axil-lary nodes, mediastinal blockage owing to sar-coidosis (advanced stages), Hodgkin disease,lung cancer, bronchial cancer with mediastinalmetastases, esophageal cancer with mediastinalmetastases, right heart failure, advanced gyne-cologic malignancy, or postoperative or postra-diation lymphedema (Peart, 59–60; Tabár, 240–241).

Answers and Explanations

11


8. (C) Ductal carcinoma occurs in 90% of allwomen with breast cancer. Lobular carci-noma affects 5%–10% of women withbreast cancer. Other forms of breast carci-noma, including medullary carcinoma,account for less than 10% of the totalbreast cancer cases. (American Cancer Society:What is Breast Cancer).

9. (C) There is no evidence at this time thatMRI will be an effective screening tool forwomen at average risk for breast cancer. IfMRI is used, it should be in addition to, notinstead of a screening mammogram.Although MRI is more sensitive than mam-mograms, it also has a higher false-positiverate, which would result in unnecessarybiopsies, and it still misses some cancersthat a mammogram would detect. The ACSrecommends that women at high risk (>20%lifetime risk) should get an MRI and a mam-mogram every year. Women at moderatelyincreased risk (15%–20% lifetime risk)should talk with their doctors about the ben-efits and limitations of adding MRI screen-ing to their yearly mammogram. YearlyMRI screening is not recommended forwomen whose lifetime risk of breast canceris less than 15%. MRI, however, is useful forevaluating ruptures, leaks, free silicone inthe surrounding breast tissue, or the forma-tion of silicone granulomas. Also, the tumormargins and the extent of tumor spread areoften better defined on the MRI than onmammography (American Cancer Society: Mam-mograms and Other Breast Imaging Procedures;Herrmann, 727–729).

10. (A) Chemotherapy involves the use of drugsto treat cancer that may have spread beyondthe breast. The chemotherapy treatmentsmay last 3–6 months depending on the inten-sity of the chemotherapy drug and how farthe cancer has spread. Generally, chemother-apy treatment is given in cycles, with aperiod of treatment followed by a recoveryperiod (ACS 15; American Cancer Society: TreatingBreast Cancer; Peart, 35).

11. (D) The guidelines as suggested by the ACS are

• Women aged 40 and older should have ascreening mammogram and CBE everyyear.

• Women between ages 20 and 39 shouldhave a CBE every 3 years.

• Women aged 20 and older should performa BSE every month.

• All lumps or suspicious areas and anychanges in the nipple or skin of the breastshould be reported to a health-care provider(ACS, 13; American Cancer Society; Early Detection,Diagnosis, Staging).

12. (B) Changes such as a lump or swelling, ten-derness, skin irritation or dimpling, or nipplepain or retraction should be evaluated assoon as possible. In general, if the nipple dis-charge is clear or milky, yellow, or green acancer is unlikely. If the discharge is red orred-brown, suggesting blood, it could becaused by either a malignant or a benigncondition and should be evaluated (ACS,12–13; American Cancer Society; Early Detection,Diagnosis, Staging).

13. (C) A CBE is an examination of the breast bya health-care professional such as a physi-cian, nurse-practitioner, nurse, or physicianassistant. Between ages 20 and 39, womenshould have a CBE every 3 years. After age40, women should have a CBE every year(ACS, 15; American Cancer Society; Early Detection,Diagnosis, Staging).

14. (D) A CBE is an examination of the breast bya health-care professional such as a radiolo-gist, physician, nurse-practitioner, nurse, orphysician assistant. A similar examination,performed by the patient on herself, is referredto as the BSE (ACS, 15; American Cancer Society;Early Detection, Diagnosis, Staging).

15. (B) A BSE should be done by the patient,5–10 days after the start of the menstrualperiod, or when the breasts are not tender orswollen. For women not having regular men-struation, the BSE should be done on thesame day every month (ACS, 15–16; AmericanCancer Society; Early Detection, Diagnosis, Staging).

Answers and Explanations: 8 through 20 13

16. (A) The ACS recommends that the BSEshould be performed monthly beginning atage 20, but it is only one part of a three-partprogram: BSE, CBE, and mammogram. BSEis useful before age 40 to help woman learnboth the appearance and feel of their breast.After age 40 the BSE provides a safety net,detecting cancers that may not be seen on themammogram (ACS, 15–16; American Cancer Soci-ety; Early Detection, Diagnosis, Staging).

17. (A) For BSE, the first step is to look forchanges, either while standing or sitting. Acheck should be made for indentations,retracted nipples, dimpling, or prolonged skinconditions. The next step is to lie supine andfeel for changes using light, medium, and firmpressure with the pads of three fingers in anup-and-down pattern. The entire breast mustbe checked (Figure 1-1) (ACS, 15–16; AmericanCancer Society; Early Detection, Diagnosis, Staging).

18. (D) The visual stage of a BSE is a check forsigns of breast cancer. These signs caninclude changes in size, texture, or color ofthe breast; prolonged skin irritation; rednessor scaliness; dimpling; or nipple retraction(ACS, 15–16; American Cancer Society; Early Detec-tion, Diagnosis, Staging).

19. (C) The first step in evaluating a woman withsuspected breast cancer is a complete medicalhistory and physical or clinical examination.

The medical history will provide informationabout the patient’s symptoms and any otherhealth problems and risk factors for benignor malignant breast conditions. A clinicalexamination will be done to locate any lumpor suspicious areas and examine the texture,size, and shape of the breast. Any changes inthe nipples or skin of the breast will also benoted. Once the medical and clinical exami-nations are completed, biopsies or imagingtests such as mammography can be per-formed (ACS, 1–16; American Cancer Society; EarlyDetection, Diagnosis, Staging).

20. (C) Authors of the CMAJ article (164[13]:1837–1846) called for an end to routineteaching of BSE to women aged 40–69, say-ing that studies on the topic suggest BSEand BSE education do not reduce deaths,but increase unnecessary biopsies and anxi-ety. However, although the BSE and theCBE cannot detect all malignant breast con-ditions, they are primarily important ascomplimentary tests. The ACS suggests thatboth the BSE and CBE will compliment themammogram and help in the detection ofbreast cancers. Unfortunately, the mammo-gram is not foolproof. Even under idealconditions, the mammogram will not findall breast cancers 100% of the time (ACS,15–16; American Cancer Society; Early Detection,Diagnosis, Staging).

Figure 1–1. Breast self-examination (BSE) patterns showing (A) vertical, (B) circular, and(C) wedge patterns of BSE.

A CB


21. (D) The ACS suggests examining the breastwith three different levels of pressure: lightpressure to feel the tissues closest to the skin;medium pressure to feel a little deeper; andfirm pressure to feel the tissue closest to thechest and ribs. The up and down pattern(sometimes called the vertical pattern) is themost effective pattern for covering the entirebreast without missing any breast tissue, andthe pads of the three middle fingers (not thefinger-tips) are most sensitive to palpate forabnormalities. The patient should use smalldime-sized circular motion to examine theentire breast (ACS, 15–16; American Cancer Soci-ety; Early Detection, Diagnosis, Staging).

22. (D) The patient should perform a BSE 5–10days after the start of menstrual period, orwhen the breasts are not tender or swollen(ACS, 15–16; American Cancer Society; Early Detec-tion, Diagnosis, Staging).

23. (C) Although breast cancer is relatively com-mon, it is only the second leading cause ofcancer death in women, after lung cancer.About 178,480 women in the United Stateswill be found to have invasive breast cancerin 2007. About 40,460 women will die fromthe disease. In the United States, breastcancer death rates are going down, possi-bly because of finding cancers earlier andimproved treatment options (ACS, 3–7; Ameri-can Cancer Society: Early Detection, Diagnosis, Stag-ing; Tortora 1083).

24. (C) Circulating estrogen is mostly producedin fat tissue, therefore in postmenopausalwomen, having more fat tissue can lead toincreased estrogen levels. Weight gain istherefore associated with increased estrogenlevels and increased likelihood of developingbreast cancer (ACS, 11; American Cancer Society:Early Detection, Diagnosis, Staging).

25. (A) TRAM flap procedure uses tissue andmuscle from the lower abdominal wall to cre-ate a breast shape. There are two types ofTRAM flaps: the pedicle flap where the flap isleft with its original blood supply and tun-neled under the skin to the breast area; and

the free flap where the tissue from theabdomen is completely removed from itsoriginal location. This process requires micro-scopic surgery to reconnect a blood supply.Latissimus dorsi flap involves the removal ofmuscle and skin from the upper back to cre-ate a breast shape. Implants can be silicone orsaline (American Cancer Society: Treating BreastCancer; Peart, 232–234).

26. (D) Tamoxifen belongs to a class of drugscalled SERMs or selective estrogen receptormodulators. Normally, the estrogen receptormolecules in cancer cells will react withestrogen in the body, allowing the cells togrow. Antiestrogen drugs work by attachingto the estrogen receptor molecule in breastcancer cells that would normally react withestrogen. This prevents the estrogen receptorcancer cells from interacting with body estro-gen and will slow or stop the cancer’sgrowth and can also be used to preventbreast cancer and the recurrence of breastcancer at local, regional, and distal sites afterlumpectomy and radiation treatment (AmericanCancer Society: Treating Breast Cancer; Peart, 228;Senior; Tortora, 1096).

27. (A) The ACR recommends that the averageglandular dose on the mammogram be nogreater than 0.3 rads (300 mrad or 3 mGy)with a grid or 0.1 rad (100 mrad or 1 mGy)without a grid. With modern mammographyequipment, the patient will usually receiveonly about 0.1–0.2 rads per projection(Andolina, 124; Peart, 23–24; Bushong, 590–591).

28. (A) Although breast tissue composition isaffected by menarche, hormonal fluctuationboth normal and synthetic, pregnancy, lac-tation, menopause, and weight gain or loss,in general the breasts of young women aredenser than those of older women. Youngerbreasts will therefore require more radia-tion to penetrate and will absorb more radi-ation than those of older women. Fortu-nately, the incidence of breast cancer in thisage group is very low (American Cancer Society:Causes, Risk Factors and Prevention; Andolina, 124;Peart, 23–24).


29. (D) A stage 0 carcinoma refers carcinoma insitu, cancer that is still contained within theduct or lobule. The prognosis for this type ofcancer is 100% survival after 5 years. Five-year survival rate refers to the percent ofpatients who live at least 5 years after theircancer is diagnosed. Many of these patientslive much longer than 5 years after diagno-sis, but 5-year rates are used to produce astandard way of discussing prognosis. Five-year rates will exclude from the calculationspatients dying of other diseases and is con-sidered to be a more accurate way todescribe the prognosis for patients with aparticular type and stage of cancer (Table 1-1)(American Cancer Society: Causes, Risk Factors andPrevention; Peart, 23–24).

TABLE 1–1. BREAST CANCER SURVIVAL BY STAGE

5-Year RelativeSurvival

Stage Rate

0 Carcinoma in situ 100%

I Tumor = 2 cm; axillary node negative 98%

IIA, IIB Tumor 2–5 cm with or without 88%, 76%positive nodes or >5 cm without positive nodes

IIIA, IIIB >5 cm with positive nodes 56%, 49%

Any size if spread to breast skin, chest wall, or internal breast lymph nodes

IV Any size if there is distant metastasis 16% (eg, to bone, lungs)

30. (D) The major factors affecting dose are

• The imaging chain—the screen/film combi-nation and processing environment

• The x-ray beam energy—the higher the kVpand HVL, the lower the patient dose

• The compression—greater compression willresult in decreased exposure and thereforedecreased dose

• The patient’s breast tissue type (composition)and thickness—denser glandular breastrequires more exposure than fatter breast(Peart, 23–24)

31. (D) The optimal duration of tamoxifen inpostmenopausal women is 5 years. Studieshave confirmed that there is no benefit of

giving tamoxifen longer. Tamoxifen will reactwith the estrogen receptor in other areas ofthe body, such as bone and the lining of theuterus. With the cells in these areas, tamox-ifen acts like estrogen to promote growth,leading the increased bone density and ahigh risk of uterine cancer. Other side effectsof tamoxifen include endometrial cancer, pul-monary embolism, stroke, and deep vein andthrombosis (American Cancer Society: TreatingBreast Cancer; Peart, 228; Senior, 288; Tortora, 1096).

32. (B) Lumpectomy is a breast-conservingsurgery whereby the breast tumor and sur-rounding margin of normal tissue areremoved. Removing a benign lump does notdescribe lumpectomy. The main advantage ofa lumpectomy is that it preserves most of thebreast. A disadvantage is the need for adju-vant therapy such as radiation therapy. Fac-tors that can affect the choice of lumpectomyover mastectomy include tumor size, tumortype, and cancer stage (American Cancer Society:Treating Breast Cancer; Peart, 222; Tortora, 1096).

33. (D) Radiation will kill both normal and can-cerous cells. In any radiation treatment, thecell cycle is important because radiation usu-ally works best on cells that are actively orquickly dividing but does not work well oncells that are in the resting phase (G0) or aredividing slowly. Radiation is often used aftersurgery and in conjunction with other treat-ment options to remove any remaining can-cer cells in the breast, chest wall, and axillaarea but can be used before surgery to shrinkthe tumor and allow a better cosmetic surgi-cal result (Table 1-2) (American Cancer Society:Treating Breast Cancer; Peart, 224).

34. (A) Chemotherapy is an adjuvant therapyand involves the use of drugs to treat cancerthat may have spread beyond the breast. Thedrug is distributed throughout the entirebody via the blood stream and tends toattack cells that are rapidly dividing,whether they are cancerous or not. Drugsthat block estrogen from latching onto tocancer cells are antiestrogen drugs such astamoxifen and raloxifene. Another class of


drugs—aromatase inhibitors—that suppressblood levels of estrogen are also available inthe fight against breast cancer. Radiationtherapy uses high-energy radiation todestroy cancer cells (American Cancer Society:Treating Breast Cancer; Burstein; Peart, 228–229).

35. (C) Breast reconstruction can involve theplacement of saline or silicone-filled sac eitherin front of or behind the pectoral muscle.Implants placed behind the pectoral muscle(subpectoral or retropectoral placement) arebecoming more popular than the oldermethod of placing the implants in front of thepectoral muscle (subglandular or retromam-mary placement). Subpectoral placementallows easier imaging of the breast mammo-graphically and is less prone to encapsula-tion. Flap surgery uses skin, fat, or musclefrom other parts of the body to form anatural-looking breast mound. Two commonflap techniques are the TRAM flap—usingskin, fat, and muscle from the abdomen—and latissimus dorsi flap—using tissue fromthe upper back (American Cancer Society: TreatingBreast Cancer; Andolina, 298–307).

36. (C) MRI can find cancers that are missed onmammography, but cannot replace mam-mography because there are still some can-cers that are detected mammographically butnot with MRI. The ACS now recommendscontrast-enhanced MRI in conjunction with amammogram for women with approximately20%–25% or greater lifetime risk of breastcancer. The technology is not however rec-ommended as a screening tool because of the

high cost and the modality’s lack of speci-ficity, which often results in a high false-positive rate on biopsies (American Cancer Soci-ety: Early Detection, Diagnosis, Staging; Herrmann,727–729; Peart, 163–177).

37. (C) MRI technology uses a powerful mag-netic field, radio waves, and a computer toproduce highly detailed images of the breast.The technology is based on the magneticproperties of hydrogen atoms in the body.MRI technology is extremely sensitive and isnow recommended as an adjunctive screen-ing tool for high-risk women. Ultrasounduses high-frequency sound waves to imagethe breast and mammography uses x-radiationto image the breast (American Cancer Society: EarlyDetection, Diagnosis, Staging; Herrmann, 727–729;Peart, 163–177).

38. (A) Sound is a mechanical, longitudinal wavethat needs a medium to travel. Breast imag-ing with ultrasound uses high frequencies,above 20,000 Hz, which are beyond humanhearing. Microwaves are electromagneticwaves with a short radiofrequency (Andolina,322–323; Peart, 148–163; Tortora 1095).

39. (D) MRI is an imaging test that uses strongmagnets and radio waves to create verydetailed breast images. MRI is a promisingtool. Because of its sensitivity it can findtumors even in very dense breasts, and canfind very small tumors. It can be used tostage cancers, map the extent of the tumor,evaluate the effectiveness of chemotherapy,and distinguish postoperative or postradiation

TABLE 1–2. THE CELL CYCLE

G0 phase (resting stage): Cells have not yet started to divide. Cells spend much of their lives in thisphase. Depending on the type of cell, this step can last for a few hours to many years. When the cellis signaled to reproduce, it moves into the G1 phase.

G1 phase: During this phase, the cell starts making more proteins to get ready to divide. This phaselasts about 18–30 hours.

S phase: In the S phase, the chromosomes that contain the genetic code (DNA) are copied so thatboth of the new cells formed will have the right amount of DNA. This phase lasts about 18–20 hours.

G2 phase: The G2 phase is just before the cell starts splitting into two cells. It lasts from 2–10 hours.

M phase (mitosis): In this phase, which lasts only 30–60 minutes, the cell actually splits into twonew cells.


scarring from recurrent cancer. MRI can alsobe used to image implants for leakage or rup-tures (American Cancer Society: Early Detection, Diag-nosis, Staging; Herrmann, 727–729; Peart, 163–177).

40. (B) Ultrasound is an adjunctive modality andis useful in determining whether the massseen on the mammogram is solid versuscystic (malignant vs. benign). Ultrasound isclose to 100% accurate in diagnosing cysts

(fluid-filled lesions), but the technology doesnot image calcifications well. Although ultra-sound can be used to image dense breast andto detect cancers missed on the mammogram,the technology is not sensitive enough to mapthe extent of a tumor. Lesions must be biopsiedin the modality in which they are visualized;therefore a lesion seen only on MRI can onlybe biopsied using MR technology (Andolina,322–323; Peart, 148–162; Tortora, 1095).


19

CHAPTER 2

Instrumentation and Quality Assurance


DESIGN CHARACTERISTICS OF FILM-SCREENMAMMOGRAPHY UNITS

All mammography units are designed to image thesoft tissue of the breast while displaying the neces-sary subtle contrast differences. Older mammogra-phy generators were three-phase generators; allmodern generators are high-frequency generators.Like the older units, these rectify the input to pro-duce a direct current (DC) voltage waveform, butthe modern high-frequency generators essentiallyprovide a constant potential with about 1% ripple.The high frequency allows more efficient x-ray pro-duction and therefore produces a higher effectiveenergy x-ray beam. The result is higher x-ray out-put for a given kVp (peak kilovoltage) and mA(milliamperes) setting.

kVp RangeThe kVp range will depend on the target/filtrationmaterial available. The kVp use will depend on anumber of factors (eg, radiologist preference, equip-ment calibration, manufacturer’s recommendations,equipment design, characteristic curve of the screen-film combination, processing, and patient breast sizeand thickness). The kVp selection can affect the radi-ographic contrast because contrast is highest in thin-ner breasts and lowest in thicker breasts. In thethicker breast, more radiation is needed (more kVp)and there is greater tissue absorption of the low-kVpradiation. Increased kVp will allow lower dose butwill reduce contrast. Decreased kVp will increasedose and increase subject contrast.

Mammography Tube (Anode, Filtration, Window)In mammography, special target materials and fil-trations are combined to provide the low-energy

beam needed. The target-filter combination will es-sentially shape the x-ray beam, providing the nec-essary kVp range to penetrate dense or fatty breast.Common combinations include:

• Molybdenum target with 0.03 mm (30 μm)molybdenum filtration or 0.05 mm rhodiumfiltration

• Rhodium target with 0.025 mm (25 μm) rhodiumfiltration (50 μm rhodium filtration is some-times recommended)

• Molybdenum and tungsten alloy target withmolybdenum or rhodium filtration

• Molybdenum and rhodium alloy target withmolybdenum or rhodium filtration

• Tungsten target and silver or rhodium filtra-tion (used on some digital units)

The material used for the exit port or window ofthe x-ray tube is borosilicate glass or beryllium (Be).A regular glass window would harden the emergingbeam by eliminating the soft characteristic radiation.

The intensity of the beam is less on the anodeside than on the cathode side because of the anodeheel effect. The cathode-side output of the x-raytube is always directed to the base; that is, thethickness area of the breast.

Compression DevicesCompression in mammography is provided by aflat-surfaced compression paddle. Importantdesign characteristics are:

• The flat surface must be parallel to imagereceptor (IR).

• The chest wall edge of the compression paddleshould not extend beyond the chest wall edgeof the IR by more than 2% of the source-to-image distance (SID).


20 2: Instrumentation and Quality Assurance

• A shadow of the vertical edge of the compres-sion paddle should not be visible on the image.

• The lip along the chest wall should be 2–4 cmin height.

• The lip should have a right angle at the chestwall.

Automatic Exposure ControlAutomatic exposure control (AEC) is used in mod-ern mammography units. AEC controls the lengthof the exposure and will therefore determine thedensity of the final image. The type of AEC devicefound in modern mammography units is:

• The ionization chamber• The phototimer is an AEC device used in older

x-ray units

Underexposure is still a common problem in con-ventional mammography and occurs when the AECcell is not placed over the densest area of the breast.

GridsGrids are used to improve radiographic contrast bydecreasing the amount of scattered radiation thatreaches the IR. The use of grids will always resultin increased dose to the patient. General character-istics of common mammography grids:

• Thinner than conventional radiography grids• Linear focused grid-movement in one direc-

tion only and focused to the SID• Carbon fiber or wood as the interspace material• Lead as the grid strip• 3:1 to 5:1 grid ratio• 30–50 lines per centimeter grid frequency

Characteristics of the high-transmission cellular(HTC) grid (specifically designed for mammogra-phy use)

• A crossed grid. It can reduce scatter in two direc-tions rather than the one direction of the linearfocused grid.

• Copper as the grid strip.• Air as the interspace material.• 3.8:1 grid ratio.

Beam Restriction DevicesBeam-restricting or -limiting devices are cones, col-limators, or diaphragms used to regulate the sizeand shape of the x-ray beam. There are three factsto consider when using beam-restricting devices inmammography.

• The entire film should be exposed (extraneouslight will compromise the perception of finedetail).

• Collimation should not extend beyond anyedge of the IR by more than 2% of the SID.

• Decreasing the x-ray field will require an increasein exposure to maintain constant density.

SYSTEM GEOMETRY (SID, OID, MAGNIFICATION)

Focal Spot SizeThe recommended focal spot sizes in mammogra-phy are:

• 0.4 mm or smaller for routine work (the mostcommonly used is 0.3 mm).

• 0.15 mm or smaller for magnification (themost common focal spot size in magnificationis 0.1 mm).

Size and shape of the focal spot are determinedby the

• Size and shape of electron beam hitting theanode

• Design and relationship of the filament coil tothe focusing cup.

• Angle of the anode.

Source-to-Image DistanceIn mammography the aim is to have the smallestfocal spot coupled with the longest SID. The SID inmammography is fixed—generally 50–80 cm.

Object-to-Image DistanceThe object-to-image distance (OID) should be assmall as possible. The only exception is micro focusmagnification.

• Magnification will reduce scatter, but thegreater the magnification factor the greater theskin dose to the patient.

• Magnification causes decrease in image resolu-tion. This is compensated by using a small focalspot size.

• A common magnification factor is 1.5 times.Other factors can be 1.6, 1.7, 1.85, or 2 times.

Other factors affecting image quality are

• Motion owing to long exposure times• Poor screen-film contact• Increase in the focal spot size• Increase in the OID• Decrease in the SID


• The relationship between the OID and the SID• Characteristics of the screen (faster screens have

a lower spatial resolution)

Imaging ComponentsThere are two imaging systems in current use:

• Screen-film system• Digital system

FilmThe film can be used to record the image, display theimage, and provide archival storage. Mammographyfilms are single emulsion and high contrast. High-contrast films generally have limited exposure lati-tude. Other film characteristics such as speed mustalso be taken into account to reduce patient dose.

ScreensSingle-screen cassette systems are used in mam-mography to provide the best spatial resolution.

Cassettes or Image ReceptorCassette or IR holds and stores the film duringexposure. Single-screen IRs are matched with thesingle emulsion mammography films. They can bedesigned for either daylight or darkroom use. AllIRs must have an identification system slot, capableof recording patient information on the image.

ProcessorsMammography images should be processed indedicated film processors. There are two commonoptions:

• Standard 90-second processing• Extended processing. This extends the devel-

oping time to improve image contrast and reducepatient dose.

Factors affecting film processing include: devel-oper time, developer temperature, and chemistrycomposition (developer and fixer).

DIGITAL MAMMOGRAPHY

Digital imaging offers the ability to manipulate orpost process the final image. There are two maindigital mammography systems in the market: acassette-less system and a cassette-based system;however, cassette-less systems can be considered tobe direct or indirect conversion systems.

In the direct system, x-rays are absorbed by thedetector and the electrical signal is created in onestep. Amorphous selenium is the flat-panel detec-tor often used. Thin-film transistor (TFT) arrays arethen used to transfer the electronic signals from theselenium photoconductor to a computer.

The indirect digital systems use a two-stepprocess. A scintillator such as cesium iodide dopedwith thallium absorbs x-rays and generates a lightscintillation that is then detected by an array ofthin-film diodes (TFDs) or charge-coupled devices(CCDs). Signals from the TDSs or CCDs are col-lected, converted to electronic signals, and trans-ferred to a computer.

The cassette-based system is similar to the com-puted radiography system used in general radiog-raphy. Here the same conventional mammographyunit is used but the cassettes are replaced by an IR,which holds an imaging plate during the exposure.The imaging plate has a photostimulable phosphorwith an active ingredient-europium-activated bar-ium fluorohalide—which is activated when exposedto x-rays. After exposure, the IR is transported to acomputer reader (CR), which uses laser light toread the emission from the image plate.

In all digital systems the spatial resolution willdepend on pixel size. A pixel is the smallest dis-crete picture element of an image, usually a singledot. Increased pixel size will increase resolution butwill also increase noises that can deteriorate imagequality.

Digital and Computer-Aided DetectorDigital signals are sent to a computer-aided detec-tor (CAD) reader. The computer prereads the mam-mograms, identifying areas of suspicion or areasneeding additional workup.

Digital and Picture-Achieving andCommunication SystemDigital signals are sent to a picture-achieving andcommunication system (PACS), enabling teleradi-ography and filmless libraries, which can be accessedvia telephone, the Internet, or any other off-sitelocation.

Digital systems approved by the Food and DrugAdministration (FDA):

GE Senographe 2000D (approval date: 1/28/00)Fischer Imaging SenoScan (approval date: 9/25/01)

Lorad Digital Breast Imager (approval date:3/15/02)

Hologic/Lorad Selenia FFDM System (approvaldate: 10/02/02)

GE Senographe DS (approval date: 02/19/04)Siemens Mammomat Novation DR (approval date:

08/20/04)GE Senographe Essentials (approval date:

04/11/2006)Fuji Computed Radiography Mammography Suite

(FCRMS) (approval date: 07/10/06)

QUALITY ASSURANCE

Quality assurance and processor quality control areabsolutely essential in producing quality images.Guidelines determined by the MammographyQuality Standards Act and the American College ofRadiology provide the standard criteria. These cri-teria exceed the criteria for processing of radi-ographic studies done in a diagnostic radiologydepartment. Mammographers must be aware of allperformance evaluations and quality control (QC)testings for film-screen or digital system.

FILM-SCREEN QUALITY CONTROL TEST FREQUENCY

Darkroom cleanliness DailyProcessor quality control DailyMobile unit quality control DailyScreen cleanliness WeeklyAnalysis of fixer retention in film QuarterlyDarkroom fog SemiannuallyScreen-film contact Semiannually

DIGITAL QUALITY CONTROL TEST

Monitor cleaning MonthlyCompression indicator WeeklyLaser imager test (including SMPTE Weekly

detector calibration/flat field) Weekly orSignal-to-noise measurement, biweekly

contrast-to-noise measurement Weeklymodulation transfer function (MTF)

Automatic optimization of Weekly orparameters (AOP) monthly

Monitor calibration and SMPTE Monthlypattern Weekly

Note: Digital quality controls can vary and aremanufacture dependent. Other tests can include aweekly artifact evaluation for the printer and elec-tronic detector.

QUALITY CONTROL TESTS FOR BOTH DIGITAL AND

FILM-SCREEN

View boxes and viewing conditions WeeklyPhantom images WeeklyVisual checklist MonthlyRepeat/reject analysis QuarterlyCompression SemiannuallyReview of medical physicist’s Yearly

annual survey report

ALL TESTS ARE

MEDICAL PHYSICIST TEST DONE ANNUALLY

Mammographic unit assemblyevaluation

Collimation assessment (field light and x-ray congruence)Evaluation of system resolutionAEC system performanceUniformity of screen speedArtifact evaluationImage quality evaluationkVp accuracy and reproducibilityBeam quality assessmentBreast exposure and AEC

reproducibilityAverage glandular doseRadiation output rateMeasure of view-box luminanceand room illuminance

The medical physicist must all perform all themanufacturer-recommended digital quality controltests. Some of these are similar to the digital testsperformed by mammographers.

Radiologist (Interpreting Physician)

• Primary responsibility—interpreting the mam-mography and ensuring that they are of opti-mal diagnostic quality.

• Responsible for a yearly review of the medical au-dit with the lead quality-control mammographer.

Testing Details

Darkroom CleanlinessPurpose: To minimize artifacts on radiographscaused by bits of dust, dirt, or food between thescreen and film.

This is extremely important when using singleemulsion film, as in mammography, not onlybecause they are more obvious, but because they



can look like microcalcifications and lead to misdi-agnosis or repeat examinations.

Processor Quality ControlPurpose: To confirm and verify that the processorchemical system is working properly according tospecifications.

Processor quality control should be carried outdaily, at the beginning of the day before processingany films.

Required: A 21-step sensitometer and adensitometer.

Processor quality control records should besaved for 1 year. Sensitometric images should besaved for the last full month.

Screen CleanlinessPurpose: To ensure the screens are free of dust orother potential artifacts.

Screens should be cleaned at least weekly, butalso anytime when dust or other artifacts are notedby the mammographer or radiologist.

Illuminators/Viewing ConditionsPurpose: To ensure optimal viewing conditions.

Viewing conditions can be extremely critical inmammography. High-luminance view boxes withproper masking of each image are essential. Typi-cally, view boxes should have a luminance level ofapproximately 1500 candela per square meter(cd/m2). For mammography, the luminance levelshould be at least 3500 cd/m2. (The unit candelaper meter is sometimes referred to as the “nit.” Theolder unit is the footlambert (fL). 1fL = 3.43 cd/m2.)

Phantom ImagesPurpose: To ensure that image density, contrast,uniformity, and image quality are maintained atoptimum levels.

Required: A mammographic phantom (4- to 4.5-cm-thick tissue equivalent breast phantom), with anacrylic disc 4-mm thick permanently fixed on thephantom, in a position that does not obscure anyphantom detail. (Digital phantom imaging does notalways use the acrylic disc.)

Note: The mammographic phantom shouldalways be viewed by the same person, on the sameview box, under the same viewing conditions,using the same type of magnifying glass at thesame time of day.

Visual ChecklistPurpose: To ensure the mechanical integrity andsafety of the mammographic equipment and acces-sory devices.

The system indicator lights, displays, mechani-cal locks, and detents are all checked.

Reject/Repeat AnalysisPurpose: To determine the number and cause ofrepeated mammograms and rejected films.

The overall repeat rate ideally should notexceed 2%, but a rate lower than 5% is acceptableonce the quality assurance program is operational.To be statistically meaningful, a volume of at least250 patients needs to be measured. The percentageof repeats from each category should be close. Ifone category is significantly higher than the others,it should be targeted for improvement.

Analysis of Fixer Retention in Film

Purpose: To determine the quantity of residual fixer(hypo) in the processed film.

The amount of fixer (hypo) retention in anyprocessed film is an indication of the length of timethat film will retain its archival quality (imagequality). Excess residual fixer can degrade thequality of the image.

Required: Residual hypo test solution, availablecommercially, or hypo estimator (eg, Kodak HypoEstimator, publication N-405, or equivalent). If thereis an excess of hypo retained on the film, the proces-sor wash tanks and water flow rates, in addition tofixer replenishment rates, need to be assessed.

Darkroom FogPurpose: To ensure that the film is not fogged as aresult of cracks in the safelight or other lightsources in and out of the darkroom.

Required: Mammographic or routine x-ray unit,densitometer, a radiopaque card, and a watch or timer.

Screen/Film Contact and IdentificationPurpose: To assure optimum contact betweenscreens and film in each cassette.

Screen-film contact will influence imagesharpness. Poor contact will impact image qual-ity. It is important to be able to identify eachscreen-cassette combination. If a problem occurswith one of the cassettes, for example, if an artifact

is detected in one of the cassettes, appropriate iden-tification will allow the mammographer to locatethe cassette and correct the problem. Each screenshould be marked with a unique identificationnumber near the left or right edge of the screen,using a marker approved by the screen manufac-turer. The same identification number should beplaced on the outside of each cassette.

Required: Mammographic film, a densitometer,and copper wire mesh screens with at least 40 wiresper inch grid density. These are commercially avail-able. The mesh can be placed between two thinsheets of acrylic to protect it.

The optical density of the final image must bemeasured using a densitometer with at least a 2-mm diameter aperture. The density should bebetween 0.70 and 0.80 when measured near thechest wall side of the film. A thin sheet of acryliccan be placed near the x-ray tube window to adjustthe density to the ideal level. Any cassette having alarge area (>1 cm in diameter) of poor contact thatcannot be eliminated should be replaced. Multiplesmall areas of poor contact (>1 cm) are consideredacceptable.

CompressionPurpose: To ensure that the mammographic systemcan provide adequate compression in both manualand automatic mode and that too much compres-sion cannot be applied. The compression should beadequate to separate glandular tissue without caus-ing injury to the patient or damage to the compres-sion device.

Required: Bathroom scale and several towels.Adequate compression ranges from 25–45 lb

in automatic mode (111–200 newton). The initialautomatic compression should not exceed 45 lb ofpressure.

Digital Quality AssuranceNote: Digital quality assurance is manufacturer spe-cific. Test can include:

• SMPTE tests—check communication betweenAWS (acquisition work station), detector, andprinter

• Automatic optimization of parameters (AOP)-checks auto-timing with auto kVp and/or auto-selection of target and filter

• Signal-to-noise ratio (SNR)/contrast-to-noiseratio (CNR)

• Checks consistency of the CNR• Ensures contrast is within acceptable range

• Phantom test on monitor and/or printer• Verifies consistent quality of images acquired

by the detector and displayed on the AWSmonitor and/or printer

• Artifact evaluation checks for artifacts onprinter and detector• Detector—confirms that there are no artifacts

resulting from the detector• Printer-confirms that there are no artifacts

resulting from the printer• Compression indicator—verifies the compres-

sion indicator is working• Flat field calibration for the detector—checks

the image quality of the detector including:• Brightness nonuniformity• High-frequency modulation (HFM)• SNR nonuniformity• Bad region of interest (ROI)• Bad pixel verification

MAMMOGRAPHY QUALITY STANDARDS ACT

Accreditation and CertificationThe Mammography Quality Standards Act(MQSA) was enacted on October 27, 1992 to estab-lish minimal national quality standards for mam-mography.

Agencies: The Food and Drug Administration(FDA) and the States as Certifiers (SAC) are theonly organizations authorized to issue MQSA certi-fication.

Process: Before a mammography facility canlegally perform mammograms, it must be certified.The facility must first contact an accreditation body.Provisional certification (valued for 6 months) isusually issued by the FDA as soon as the accredita-tion has been accepted. The accreditation body willthen accept clinical images and other data from thefacility to complete the accreditation process.

Key Components of the MQSAThe interpreting physician, the physicist, and themammographer must meet the education andtraining requirements of the MQSA. All are alsorequired to interpret/inspect/image a minimumnumber of mammograms or sites per year andobtain a minimum number of continuing education



units within a specific period. All mammographers(radiographer performing mammograms) mustmeet the training requirements of the MQSA.

Certificate placement—Must be prominentlydisplayed.

Consumer complaints mechanism—Facility musthave a system in place to collect and resolveserious consumer complaints.

Self-referrals—A facility can decide to accept ornot to accept self-referrals, but the policy mustbe stated.

Record keeping—Mammograms and medicalrecords of patients must be kept for a period ofnot less than 5 years, or not less than 10 years ifno additional mammograms of the patient areperformed at the facility (longer if mandatedby state or local law). Records must include:name of patient plus an additional patientidentifier, date of examination, name of radiol-ogist interpreting the mammogram, and a finalassessment finding.

Infection control—All facilities should have a pol-icy in place to prevent and control the spreadof infection to employees, patients, and visitorswithin the mammography facility.

Communication of results—All facilities must sendeach patient a summary of the mammographyreport written in lay terms within 30 days ofthe mammographic examination. Either verbalor written results are acceptable. Results must

be sent to the physician. Concerned findingsmust be sent within 3–5 days.

Assessment categories—All reports must have anassessment category. The most commonly usedis the Breast Imaging Reporting and Database(BIRAD) system.

Medical audit—All facilities must keep a medicaloutcomes audit to follow positive mammogra-phy results and to correlate pathology resultswith the interpreting physician’s findings.The Health Insurance Portability and Ac-countability Act (HIPAA) does not affectmedical audit because in MQSA documenta-tion patient information can be released with-out patient authorization.

Notes on Digital TerminologyUnfortunately the terminology being used in digi-tal imaging has not yet been standardized. The fol-lowing is a list of terms in current use.

The cassette in computed radiography (CR)has been replaced by a structure similar to thescreen-film cassette. It is sometimes called imagingplate (IP) or image receptor (IR). This text uses IR.

The film in CR and DR has been replaced by astorage phosphor screen. It is often called photo-stimulable phosphor (PSP), storage phosphorscreen (SPS), image recorder (IR) or image orimaging plate (IP). This text uses IP.

1. In mammography, selecting extremely lowkVp values

(A) reduces contrast and lowers patient dose(B) increases contrast but increases patient

dose(C) reduces contrast but increases patient

dose(D) increases contrast and reduces patient

dose

2. What target-filtration combination providesthe best penetration for dense or thick breast?

(A) molybdenum target with molybdenumfiltration

(B) rhodium target with rhodium filtration(C) tungsten target with tungsten filtration(D) molybdenum target with appropriate

K-edge filtration

3. The material used for the exit port of themammography tube is necessary because

(A) The intensity of the beam is less on theanode side than on the cathode side.

(B) Regular glass would harden the emerg-ing beam.

(C) The intensity of the beam is more on theanode side than the cathode side.

(D) Regular glass would soften the emerg-ing beam.

4. The intensity of the x-ray beam from thecathode side of the tube is generally higherbecause

(A) Soft characteristic radiation emergesfrom the anode side.

(B) The cathode side is directed to the thick-est part of the breast.

(C) The heel effect causes variation in theintensity of the x-ray beam.

(D) The heel effect increases the intensity ofthe beam at the anode side.

5. The design of the lip of the compression pad-dle (both height and angle along the chestwall) affects all of the following except that it

(A) prevents the posterior and axillary fatfrom overlapping the body of the breast

(B) allows uniform compression of the pos-terior breast tissue

(C) helps to increase structural strength ofthe compression paddle

(D) ensures greater compression of the ante-rior breast tissue

6. The primary goal of compression is to

(A) reduce the OID of the lesion(B) allow uniform penetration of structures

within the breast(C) reduce the possibility of motion during

the exposure(D) reduce the radiation dose to the breast

26

Questions


7. AEC failure, resulting in an underexposedradiograph, can be caused by

(A) processing deficiencies such as fluctuat-ing developer temperature

(B) improper placement of the dense breasttissue/size over the detector

(C) decreased radiographic contrast(D) inadequate breast compression

8. Most AEC circuitry in modern mammo-graphic imaging has at least three detectors.Three or more detectors are recommendedbecause

(A) Multiple detectors allow for maximumvariations in breast size and tissue den-sity.

(B) AEC detectors eliminate the guessworkin determining the proper exposure fac-tor for each patient.

(C) Detectors have the ability to terminatethe exposure by back-up timer when amaximum exposure time or maximummilliamperes (mA) per second isreached.

(D) All AEC detector systems provide con-sistent image densities because of thehigh-contrast mammography films.

9. The major difference between the generalradiography grid and the grid used in mam-mography is that the

(A) grid used in general radiography causesan increase in exposure

(B) grids used in general radiography havehigher ratios

(C) use of a grid in mammography increasespatient dose

(D) grids in mammography improve theradiographic image contrast

10. The grid ratio can vary in modern mammog-raphy units. A common grid ratio used is

(A) 8:1(B) 6:1(C) 4:1(D) 2:1

11. As the size of the x-ray field decreases, tomaintain a constant image density the expo-sure will

(A) increase(B) decrease(C) not change significantly(D) decrease inversely

12. The chest wall edge of the compression pad-dle should be aligned just beyond the chestwall edge of the IR to

(A) avoid pushing the patient’s chest awayand losing breast tissue

(B) properly position and compress thebreast

(C) permit uniform exposure and reducepatient discomfort

(D) avoid projecting the chest wall edge ofthe paddle on the mammogram

13. Which of the following affects focal spot size?

(A) angle of the anode(B) a decrease in the SID(C) decreasing the size of the collimated

beam(D) changing the relationship between the

OID and the SID

14. In mammography, the commonly used focalspot size for routine work is

(A) 3 mm(B) 0.3 mm(C) 1 mm(D) 0.1 mm

15. Which of the following characteristics areunique to mammography cassettes?

(A) must be easy to open(B) should be durable(C) generally have a single intensifying

screen(D) should have low absorption characteristics


16. Two main disadvantages of extended pro-cessing are

(A) decreased film speed and increasedfilm fog

(B) increased film speed and decreasedfilm fog

(C) increased processing artifact andincreased film fog

(D) decreased processing artifact andincreased film speed

17. In digital mammography, both the film andcassette can be replaced by

(A) a detector and electronic system(B) the CAD technology system(C) a flexible storage phosphor(D) photostimulable plates

18. The greatest difference between digital tech-nology and conventional mammographyimaging is

(A) The higher resolution system results inan increase in patient dose in digitaltechnology.

(B) There is no latent image formation whenusing digital technology.

(C) In digital technology, the final image canbe manipulated.

(D) The image can never be displayed on afilm in digital technology.

19. All of the following are characteristics ofdouble emulsion film/screens combination.Which characteristic makes these systemsundesirable in mammography use?

(A) They are less susceptible to imagingdust and dirt than the single emulsionsystems.

(B) They do not require extended processingtimes to develop optimum contrast andspeed.

(C) The screens are very efficient at convert-ing x-ray energy to visible or ultravioletlight.

(D) The system has a lower spatial resolu-tion than the single emulsion systems.

20. Film fog is best demonstrated on the charac-teristic curve as

(A) the straight-line portion of the graph(B) the toe of the graph(C) the shoulder of the graph(D) the shift of the graph to the left

21. The characteristic curve, obtained by plottingdensity values from a sensitometer, can beused to assess all of the following except

(A) to compare two different types of films(B) to compare the same film under differ-

ent processing conditions(C) to compare the x-ray beam quality with

different films(D) to monitor the daily processing conditions

22. The characteristic curve of two films is plot-ted. The curve of film A is positioned to theleft of the curve of film B.

1. film A is faster than film B2. film B is faster than film A3. at any optical density, film A will require

less exposure than film B(A) 1 only(B) 2 only(C) 2 and 3 only(D) 1 and 3 only

23. Which of the following mammographic qual-ity control tests is performed monthly?

(A) phantom images(B) visual checklist(C) repeat analysis(D) screen cleanliness

24. Adequate “air bleed time” refers to the

(A) elapsed time between film loading andexposure

(B) time taken to release air from the proces-sor drain tank

(C) time taken to remove air from the watertank

(D) time taken to empty or bleed the proces-sor chemistry

25. Which of the following quality control testsdoes not require a densitometer?

(A) darkroom fog(B) screen-film contact(C) screen cleanliness(D) phantom images

26. The criteria to pass the ACR MammographyAccreditation on conventional phantomimaging require a minimum of _______ masses.

(A) two(B) three(C) four(D) five

27. In establishing processing quality controloperating levels, the speed index is designatedas the density

(A) closest to but not less than 2.20(B) closest to but not less than 1.20(C) closest to but not less than 0.45(D) 2.20 or higher

28. For the daily quality control testing, the base-plus-fog level should remain within

(A) +0.15 of the established levels(B) +0.10 of the established levels(C) +0.30 of the established levels(D) +0.03 of the established levels

29. The screen-cleaning test should be carriedout whenever

(A) there is an upward drift in the operatingdata levels

(B) there is a change in the types of chemicalused

(C) there is a change in film brand or type(D) a mammographer notices dust artifacts

on the image

30. Before processing the sensitometric strip eachday, the mammographer should

(A) check the developer temperature(B) be sure the view boxes are clean

(C) clean the cassette screens with screencleaner

(D) check the cassettes for dirt or lint

31. The phantom image background optical den-sity should never be

(A) more than 1.20(B) less than 1.20(C) more than 1.40(D) less than 1.40

32. In the darkroom fog test, the optical densitydifference between fogged and unfoggedareas of the film should not exceed

(A) 1.20(B) 0.15(C) 0.05(D) 0.02

33. In viewing phantom image, which of the fol-lowing viewing conditions need not apply?

(A) on the same view box(B) using the same type magnifier(C) at the same time of day(D) using the same film emulsion batch

34. In the test for screen contact there were multi-ple points of small areas (<1 cm in diameter)of poor contact. The corrective action is to

(A) replace the cassettes; this result is notacceptable

(B) repeat the test(C) return the cassette to clinical use(D) clean the screens, wait 15 minutes, then

repeat the test

35. One of the two reasons towels are used in thecompression test is to

(A) protect the cassette holder(B) ensure that the compression is adequate(C) force slower application of compression(D) simulate 4 cm of compressed breast



36. For the repeat analysis to be meaningful, apatient volume of at least _______ patients isneeded.

(A) 50(B) 100(C) 250(D) 300

37. Daily processing control can involve all of thefollowing except

(A) cleaning the processor feed tray(B) using the sensitometer to measure the

densities on the strip(C) recording the temperature of the devel-

oper tank(D) mixing the chemicals

38. Proving that a darkroom fog failure is a resultof safelight problems involves

(A) moving the safelight at least 6 ft fromthe work surface

(B) repeating the test with the safelights off(C) checking for light leaks around the

doors and passbox(D) changing the filter on the safelight

39. The darkroom fog test is performed

(A) semiannually(B) monthly(C) weekly(D) daily

40. Daily processor control is used to

1. determine the film speed2. check the film contrast3. check the stability of the processor


41. If, after examining a phantom image, thenumber of visualized fibers or masses haschanged significantly, the next step is to(A) record the new values(B) call the medical physicist(C) call the equipment service personnel(D) check the mammography unit or the

image processor

42. Repeated films are

(A) films used for processor cleaning(B) films used for quality control(C) films that involve exposure to the

patient(D) all discarded films

43. If the patient volume at a mammography siteis 200 patients per week, the repeat/rejectanalysis should be done every

(A) week(B) 2 weeks(C) 2 months(D) 3 months

44. All the fluorescent tubes in the mammogra-phy view box should be replaced at the sametime because

(A) Fluorescent tubes decrease in brightnesswith age.

(B) Fluorescent tubes will only last about18–24 months.

(C) They have a higher luminescence thanconventional tubes.

(D) It saves time to replace them all at thesame time.

45. In imaging the phantom, the technical factorsused should be the same as those used clini-cally for a ______ -cm-thick breast of mediumglandularity.

(A) 6.0–6.5(B) 5.0–5.5(C) 4.0–4.5(D) 3.0–3.5


46. Mammography facilities can receive certifica-tion from

1. the ACR2. the FDA3. an SAC state

(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3 only

47. An MQSA certificate is issued when a mam-mography facility has been accredited. Thiscertification is valued for

(A) 1 year(B) 2 years(C) 3 years(D) 4 years

48. If any of the visual checks fail, the first stepis to

(A) correct or replace the item(B) call the medical physicist(C) call the processor service(D) call the equipment service representative

49. Digital images can be viewed on a computermonitor or printed using

(A) dry laser technology(B) single emulsion mammography film(C) single emulsion laser film(D) double emulsion film, sensitive to the

red-light spectrum emitted by lasers

50. Hardcopy viewing of the digital imagingdescribes

(A) displaying the image on the mammog-rapher’s workstation for furtherenhancement

(B) the only image viewed by the mammog-rapher

(C) the image that is sent for interpretation(D) the ability to reduce the cost associated

with repeats

1. (B) The kVp controls the wavelength or thepenetrating power of the beam. Increasingthe kVp will decrease the contrast. The kVpwill therefore ultimately control the subjectcontrast, exposure latitude, and image con-trast. Remember, however, that as the kVp isreduced, the penetrating ability of the beamis also reduced leading to the use of highermAs. Higher mAs use increases patient dose(Bushong, 327–340; Peart, 65–85).

2. (B) All mammography units are manufac-tured with tungsten, molybdenum, orrhodium targets matched with the appro-priate K-edge filters. These targets have dif-ferent atomic numbers and therefore differ-ent emission spectrums. The characteristicenergies of molybdenum are most effectivefor fatty breast tissue. The characteristicx-rays produced using rhodium targetswith rhodium filtration are similar to thosefrom molybdenum but, because rhodiumhas a slightly higher atomic number, morebremsstrahlung x-rays are produced. How-ever, the energy of the K-characteristicx-rays will be 2–3 keV higher, which pro-vides a better penetration of dense breastalthough it generally results in lower con-trast images. Tungsten targets with tung-sten filtration are not used in conventionalmammography units because here brems-strahlung x-rays will predominate atenergies above and below the 17- to 24-keVrange. The x-rays most useful in maximiz-ing contrast in breast tissue are in the 17- to24-keV range (Bushong, 327–340; Peart, 65–85).

3. (B) Mammography uses very low energyx-ray beams and it is important that the x-raytube window does not attenuate the low-energy photons therefore hardening thebeam. The proper filter shapes the emissionspectrum of the x-ray beam and makes itcompatible with the IR and breast character-istics of each patient. In general, mammogra-phy units either have borosilicate or beryl-lium as port windows (Bushong, 327–340).

4. (C) The heel of the anode will reduce theintensity of the x-ray beam on the anode sideonly. When comparing the beam intensity onthe cathode versus the anode side, the inten-sity on the cathode side will be higher. Tocompensate for this varying intensity, themammography tube is turned to position thethickest portion of the breast (posterior) atthe cathode end of the tube. In general, thesmaller the anode angle, the larger the heeleffect because there is increased absorptionof the rays (Figure 2-1) (Bushong, 327–340; Peart,65–85).

5. (D) Both the height and angle of the compres-sion paddle make a difference in the finalimage and the overall design is considered toincrease the structural strength of the compres-sion paddle. A compression device with arounded or gently sloping posterior edge doesnot allow uniform compression of the poste-rior area of the breast. The height of the com-pression reduces the chance of chest tissueoverlapping on the mammogram. The designof the lip has a lesser effect on the anterioraspect of the breast (ACR, 30–33; Peart, 65–85).


32


6. (B) Compression does all of these, but itsprimary goal is to reduce the breast thicknessuniformly-(separate breast structures) andallow uniform penetration by the x-ray beam(ACR, 30–33; Peart, 65–85).

7. (B) The most common cause of failure of theAEC is improper placement of the detector.Processing affects the mammographic imageafter exposure and mammographic qualitycontrol ensures correct processing conditions.Decreased radiographic contrast is a result ofunderexposure, not the cause, and inade-quate compression, although it causes unevendensities on the mammogram, does not resultfrom AEC failure (ACR, 92; Peart, 65–85).

8. (A) The multiple detector system of the AECallows the unit to respond to different breastcomposition and various breast sizes. If thedetector is placed over fatty breast tissue, theglandular tissue will be underexposed. Toproduce an adequate exposure, the detectormust be placed over the densest or mostglandular areas of the compressed breast(Bushong, 327–340; Peart, 65–85).

9. (B) All grids result in increased exposure andpatient dose, but improve contrast. The mam-mography grid, however, has a lower grid ratiothan general radiography grids. The grid ratioof mammography grids ranges from 3:1 to 5:1versus the 6:1 to 16:1 ratio of grids used in gen-eral radiography (Grid ratio = height of the leadstrips/the distance between the strips [h/d])(Bushong, 327–340; Peart, 65–85) (Figure 2-2).

10. (C) Higher grid ratios will require too largean increase in exposure. On an average, thegrids used in mammography range from 3:1to 5:1, with frequencies of 30–50 lines percentimeter. Typically, a mammography gridmay have a grid ratio of 4:1, and althoughsuch a grid will double the patient dosewhen compared to a nongrid exposure, theincreased contrast will be significant (Bushong,327–340; Peart, 65–85) (Figure 2-2).

11. (A) Collimating or decreasing field reducesscatter and therefore improves the contrast.However, because collimating reduces the scat-tered radiation density to the area, the exposuremust be increased (Bushong, 327–340; Peart, 65–85).

Target

Compression plate

x-ray tube tilted from the horizontal

Vertical beamparallel to the

chest wall

Breast

Image receptor

Horizontal

Figure 2–1. Heel effect. A portion of the beam is absorbed by theanode (target). This results in the lower energy beam at the anodeend of the tube. This effect is minimized in mammography by tiltingthe tube and placing the anode toward the nipple (lower density)area of the breast.

Grid height

Width of interspace material = d

Parallel grid line

A

Crossed grid lines

B

C

Cross-section of the grid showing the grid strips between theinterspace material

Grid ratio = h/d

Grid frequency = number of grid strips per inch or per centimeter

Figure 2–2. Schematic diagram showing (A) a parallel gridtypical of mammography grids and (B) the cross grid such asthe HTC grid. (C) Represents a cross-section of a typical grid.


12. (D) The compression plate is specificallydesigned to properly position and compressthe breast while reducing discomfort to thepatient. The placement of the lip, just beyondthe chest wall edge of the IR, prevents theprojection of an image of the chest wall edgeof the paddle on the mammogram (AEC, 30–33;Peart, 65–85).

13. (A) The focal spot size is the area that elec-trons strike on the target. In the designknown as the line-focus principle, the targetis angled allowing a larger area for the elec-trons to strike while maintaining a small,effective focal spot. The effective focal spotsize is the area projected onto the patient orIR. It is also the value quoted when identify-ing a small or large focal spot. The smallerthe target angle, the smaller the focal spotsize. Although the spatial resolution (the abil-ity to image small objects that have high con-trast) is directly related to the focal spot size,changes in the SID, OID, and size of the colli-mated field do not affect the focal spot size(Bushong, 327–340; Peart, 65–85).

14. (B) Mammography machines generally havetwo focal spot sizes. The large focal spot maybe 0.4 or below (generally 0.3 mm) and thesmall focal spot ranges from 0.15–0.1 (gener-ally 0.1 mm). Routine work utilizes the largefocal spot size (Bushong, 327–340; Peart, 65–85).

15. (C) All cassettes are easy to open, durable,and have low absorption characteristics rela-tive to the kVp. Mammography cassettes aredesigned for use with a single emulsion filmand are therefore matched with a singleintensifying screen (Bushong, 327–340; Peart,65–85).

16. (C) An increase in processing time generallyincreases the developer time with furtherincrease in contrast and film speed. The dis-advantage of this system is the increased riskof processing artifacts and the increase infilm fog (Bushong, 342–356; Peart, 87–111).

17. (A) Digital mammography systems utilizea detector and electronic system instead

of a cassette. CAD technology refers tocomputer-assisted diagnosis, a technologyused to preread mammograms. CAD can beused with both conventional and digitalmammography systems. Storage phosphorsare used with computed radiography sys-tems; the imaging plates or imaging detectorsare coated with storage phosphors or pho-tostimulable plates. X-rays will react withthe imaging plate to form the latent image(Figure 2-3) (Bushong, 327–340; Peart, 179–191).

18. (C) One of the greatest advantages of digitaltechnology is the ability to manipulate thefinal image. The image can be adjusted forcontrast or brightness or magnified to zoom-in on areas of interest. Digital mammogramsallow the same or lower patient dose andalthough the technology is digital, a digitallatent image will form in the digital detector.The image is converted to a manifest imageafter digital processing. Digital images can beviewed on a computer monitor or printedusing laser print technology (Figure 2-4)(Bushong, 327–340; Peart, 179–191).

19. (D) Despite the numerous advantages of thedouble emulsion system, these advantagesare outweighed by the single largest disad-vantage: the system has a lower spatial reso-lution than the single emulsion system. Indouble emulsion systems, the emulsions ofboth screens are activated by the x-rays andwill emit light. This crossover light compro-mises image quality (Peart, 79–83).

20. (B) The characteristic curve plots the relation-ship between the optical density of the filmand its exposure. The straight-line portion ofthe curve records the useful range of opticaldensities. The lowest exposure (base plusfog) is the reading recorded at the toe of thecurve, and the highest exposure level isrecorded at the shoulder of the curve. Agraph shift to the left or right indicates differ-ing film speeds (Figure 2-5) (Bushong, 272–283;Peart, 80–81).

21. (C) In conventional mammography, the char-acteristic curve is used in quality control to

B C

Figure 2–3. (A): A cross-section of an imaging plate. Computer radiography differs from conventional film-screen imaging in the acquisitionstage. Instead of a film-screen as the image detector, computer radiography uses a flexible imaging place (IP) coated with storage phosphorsor photostimulable plates. The imaging plates are less than 1 mm thick. They absorb x-ray energy and form a latent image in much the sameway a film does. The difference is the wide latitude of the storage phosphors. The higher sensitivity of the imaging plates demonstrates a lin-ear response (input to output) to the intensity of x-ray exposure over a broad range. The IP is constructed much like a conventional screen.Both have a protective laminate to protect the phosphor layer. The IP has a conductive layer to conduct away static; a flexible support layer,which allows IP flexibility; and a backing layer to prevent damage to the IP. The barcode reader on the IP allows for patient information andidentification. With such a similar structure, the IP can be placed in modified cassettes and exposed with standard x-ray equipment. The x-raypasses through the patient and reacts with the IP to form the latent image. (B): R2 ImageChecker DMax, a CAD device use to preread con-ventional mammogram. Images are fed into the CAD reader and a monitor will highlight suspicious areas of calcification or mass densities.(C): R2 CAD marks on Hologic SecurViewDX. (Figures 3B and 3C used with permission from Hologic R2.)

A

35

monitor processing conditions by recordingchanges in the density values. Because of thewide range of variables in x-ray-generatingequipment, the sensitometer and not the stepwedge is used to produce a uniform opticalstep wedge on a film, from which the charac-teristic curve can be plotted. This removesthe x-ray unit from the equation. The charac-teristic curve is then used to interpretcharacteristics of the film, such as contrast:the steeper the slope the higher the contrast.By plotting the characteristic curves of twofilms, the speeds of the different films can becompared. A characteristic curve obtainedby exposing a step wedge or penetrometer,however, is capable of monitoring both thex-ray equipment and film-screen combina-tion (Bushong, 272–283; Peart, 80–81).

22. (D) By plotting the characteristic curves oftwo films, the speed of the different films canbe compared: the curve of the faster film willbe positioned to the left of the curve of theslower film (Figure 2-6). The faster film willrequire less exposure than the slower film toproduce any optical density (Bushong, 272–283;Peart, 80–81).

A

B

Figure 2–4. (A): Actual computer reader. The IP is inserted into the reader, which converts the latent image to a manifest image. (B) Schematicdiagram of a computer reader. To read the latent image, the IP is inserted into an imaging plate reader or computer reader. The computerreader then scans the image with a laser beam to initiate the emission of light from the storage phosphors. This stored energy leaves the IP inthe form of ultraviolet light. The intensity of light emitted from the IP is proportional to the amount of radiation absorbed by the storage phosphor.During the reading process, the light emitted from the IP is collected and sent to a photomultiplier tube. The signal from the tube is amplifiedand sent to an analog-to-digital converter where it is converted to a digital or electrical signal. The resultant digital information can then beelectronically transmitted, manipulated, and stored. The IP can be erased and used again and again by exposing them to strong light.



23. (B) The visual checklist is performedmonthly, the phantom image check is takenweekly, the repeat/reject analysis is per-formed quarterly, and screen cleanliness isperformed weekly. The complete list of

mammography quality control tests and fre-quency are listed in the Summary of Impor-tant Points in the beginning of the chapter onpage 22 (ACR, 119; Peart, 92–112).

24. (A) The cassette should be loaded with a filmfor at least 15 minutes before testing torelease any trapped air. This is the air-bleedtime and refers to the time taken for the airtrapped in the cassette to dissipate (ACR, 141;Peart, 92–112).

25. (C) Screen cleanliness requires screen wipesand canned air or a screen cleaner. The den-sitometer is needed for darkroom fog test tomeasure the density of the fogged versus theunfogged area of the image. In assessing thescreen-film contact, the density at the chestwall area of the wire-mesh image should bebetween 0.7 and 0.8. In phantom image tests,the densitometer is needed to measure thebackground density and the density insidethe disk (ACR, 165–166; Peart, 92–112).

26. (B) The criteria for the number of objects onthe phantom necessary to pass the ACR area minimum of four largest fibers, threelargest speck groups, and three largestmasses (Figure 2-7). The only exceptions to

0

1.0

2.0

3.0

4.0

1.0 2.0 3.0 4.0

BF

Log relative exposure

Density y

x

D

SP

C =yx

Figure 2–5. Characteristic curve. Normal H & D curve showingbase-plus-fog (BF), speed (SP), contrast (C), and maximum density(D) for a single exposure.

0

1.0

2.0

3.0

4.0

1.0 2.0 3.0 4.0

A B


Density

Figure 2–6. H & D curve-film speed. Graph of H & D curves fortwo different types of radiographic films. Film A has a faster speedthan film B because its speed point is the left of film B. Film B hasa higher contrast than film A because the slope of its curve issteeper than that of film A.

0000 0000

Figure 2–7. Diagram of phantom. A schematic diagram of thephantom showing the relative position of the different objects embed-ded within the phantom.


date are the Hologic and Siemens digitalunits which require 5 fibers, 4 speck groups,and 4 masses. In addition, the number oftest objects of each group type (fibers,specks, and masses) visible in the phantomimage should not decrease by more thanone-half (ACR, 268; FDA; Peart, 92–112).

27. (B) In establishing processing controls,decide which sensitometer step has an aver-age density closest to but not less than 1.20(Figure 2-8). This is the mid-density (MD)step, sometimes recorded as the speed index.Decide which step has a density closest to2.20, and which step has a density closest tobut not less than 0.45. The difference indensities between these two is the density

difference (DD) or contrast index. Suggestedperformance criteria for the MD and DD are tobe within ±0.15 optical density units of the oper-ating level. If the MD or DD exceeds the operat-ing limits by ±0.15, corrective action needs to betaken. Changes in density can be because ofchemistry, temperature, replenishment, or dark-room fog (ACR, 149–164; Peart, 92–112).

28. (D) The base plus fog (B + F) should remainwithin +0.03 of the established levels. If B + Fexceed the normal level by 0.03, immediatecorrective action must be taken. Changes inB + F can be owing to chemistry, temperature,replenishment, or darkroom fog (ACR, 149–164;Peart, 92–112).

29. (D) Although recommended weekly, this testmust be carried out whenever dust or anyother artifact is seen on the image. Changesin the film brand, processing chemistry, orprocessing quality control will not affectscreen cleanliness (ACR, 165; Peart, 92–112).

30. (A) The sensitometer strip is used to verifythat the processor is operating within normallimits. Of all these answers, only a too highor too low developer temperature will havean impact on the density of the sensitometricstrip (ACR, 149–164; Peart, 92–112).

31. (B) The background optical density on thephantom should never be less than 1.2 andshould not vary by more than ±0.2 (Figure 2-9).The mAs should not vary by more than ±15%from test to test. Optical density should be atleast 1.4 (ACR, 268–269; Peart, 92–112).

32. (C) The optical density difference betweenthe fogged and unfogged areas of phantomin the darkroom fog test should not exceed0.05 (Figure 2-10) (ACR, 189–193; Peart, 92–112).

33. (D) Different individuals will always perceivean image differently. Because of this, the phan-tom should always be viewed by the sameindividual, using the same view box and view-ing conditions, such as magnification. In addi-tion, the criteria used for viewing the phantomimages should be the same as that used when

Figure 2–8. Sensitometer strip.In conventional imaging the sensit-ometer will produce a step-wedgepattern of 21 different optical densi-ties. A densitometer is then used torecord the base-plus-fog value andthe high-, medium-, and low-densitymeasurements. These results arethen plotted on the daily processorquality assurance chart.


reading mammograms. Because a box of filmswill not last forever, a new box, and therefore, adifferent film emulsion will eventually be nec-essary (ACR, 167–187; Peart, 92–112).

34. (C) Multiple small areas of poor contact (<1 cmin diameter) are acceptable (Figure 2-11).Large areas (>1 cm in diameter) of poor con-tact, which remain unchanged even after

cleaning the cassette, means the cassette hasfailed (ACR, 194–198; Peart, 92–112).

35. (A) The towels protect the cassette holderand prevent damage to the compressiondevice. The amount of automatic compres-sion applied is a function of the unit and willnot be altered by the presence or absence of atowel. However, the force of the compressiondevice hitting the cassette holder could dam-age both (ACR, 199–201; Peart, 92–112).

36. (C) The repeat analysis is used to identifyproblem areas within the department(Figure 2-12). However, for the analysis to be

B

Figure 2–9. (A): Radiograph of phantom. An actual radiograph ofa phantom with 1-cm diameter, 4-mm-thick disc. This disc is usedfor contrast measurement. Arrows indicate points where densitymeasurements should be made. The image is scored based onwhat is seen on the film. (B) Radiograph of a digital phantom. Indigital imaging the acrylic disc is not always needed.

Figure 2–11. Screen-film contact. A screen should be replacedif it has an area (>1 cm in diameter) of poor contact that cannot beeliminated. Multiple small areas are considered acceptable(sample area shown is 1 cm in diameter).

A

Figure 2–10. Darkroom fog test. Phantom images showing dark-room fog. A densitometer is used to measure close to the edgeseparating the fogged and unfogged portions of the phantomimage. The density should not be measured over any test object inthe phantom.


Figure 2–12. Repeat analysis. A sample of the repeat/reject chart used by mammographers to chart the reasons for rejected films. The finalpercentage of repeats and rejects is calculated as a percentage of the total films used. The percentage of each category of repeated film iscalculated as a percentage of the total repeat rate.


meaningful a sufficient patient volume isneeded. The MQSA recommends a meaningfulvolume of at least 250 patients (ACR, 202–203;Peart, 92–112; Stevens, 275–370).

37. (B) A sensitometer is designed to expose auniform optical step wedge onto a film; thedensitometer is an instrument that measuresthe degree of blackening (density) on a film.Daily processing control is a means of ensur-ing that the slight changes in film processingwill be corrected before they have an impacton the image quality. The developer tempera-ture and the chemistry of the solutions canboth impact image contrast. Keeping a cleanfeed tray reduces film artifacts (ACR, 339;Peart, 92–112).

38. (B) The simplest way to confirm that thedarkroom fog testing failed because of a safe-light problem is to repeat the test with thesafelight off. If the test passes, then the safe-light is the problem and the filter could bechanged or the light moved to a differentlocation. If the test with the safelight off fails,other areas to check include light leaksaround the doors and passbox (ACR, 192;Peart, 92–112).

39. (A) Darkroom fog test is performed semian-nually to ensure that the darkroom safelightsor other source of light leaks are not foggingthe mammographic film. Film fog will resultin loss of contrast and therefore loss of diag-nostic information. This test should also beperformed whenever the safelight bulb or fil-ters are changed (ACR, 119; Bushong, 342–356;Peart, 92–112).

40. (D) The processor quality control test is usedto determine that the processor and processorchemistry are stable and consistent. At thebeginning of each day, a sensitometric strip isexposed and processed following MQSAguidelines. The medium density evaluatesfilm speed, the density difference evaluatesimage contrast, and the base-plus-fog valueevaluates the level of fog present in the pro-cessing chain. By checking and correctingany value that exceeds the normal limits,

mammography film will be processed onlyunder optimal conditions to enhance contrast(Figure 2-13) (ACR, 149; Bushong, 342–356; Peart,92–112).

41. (D) Because the purpose of quality controltesting is to ensure optimal conditions beforeclinical images are processed, significantchanges must first be corrected. Whenever atest fails, the first corrective action is to verifythat the equipment is operating correctly, andthen repeat the test to determine whether thechange is real or not. However, the phantomtest is a check of the mammography unit andthe processing. It will therefore assess theimage density, contrast, and uniformity. Thephantom test should therefore be performedonly after the daily processor quality check.Although this will not totally rule out theprocessor as the cause of the problem, it willdirect attention to the mammography unit.The medical physicist or the equipment ser-vice personnel should be called if the prob-lem cannot be isolated or corrected by themammographer (ACR, 186; Bushong, 342–356;Peart, 92–112).

42. (C) Repeated films are those that had to berepeated and resulted in additional exposureto the patient, for example, double exposedfilms or films with motion. Rejected films areall discarded films, including repeated films.Rejected films can include films used forquality control or processor cleaning (ACR,202; Peart, 92–112).

43. (D) Repeat analysis testing is carried outevery 3 months (quarterly), unless the patientvolume is less than 250 in the quarter (ACR,202; Peart, 92–112; Stevens, 275–370).

44. (A) Because fluorescent tubes decrease inbrightness with age, changing the tubes all atthe same time ensures that the mammogramsor phantom images are always viewed underidentical conditions—uniformity in color andluminance. In addition, it is advisable toreplace fluorescent tubes every 18–24 months.View boxes used for mammography shouldbe capable of producing a luminance of at


Figure 2–13. Sample processor control chart. The sensitometer strip is exposed and processed each day and the data evaluated and plot-ted. The result is the processor control chart. Data out of the control limits are circled and the test repeated. The cause of the problem andcorrective action is recorded in “remarks” section of the control chart.

Figure 2–14. Sample phantom control chart. The weekly phantom evaluation checks the film optical density, contrast (density difference),and number of fibers, speck groups, and masses. The results are plotted. Data out of the control limits are circled and the test repeated.The cause of the problem and corrective action is recorded in the remarks section of the control chart.



least 3000 cd/m2. The illumination levelsshould be 50 lux or less (equivalent to amoonlit room). Luminance is the amount oflight either scattered or emitted by a surfaceand is measured in cd/m2 (candela per metersquare). Illuminance is the intensity of lightstriking a surface and is measured in lux(1 lux = 1 lumen/m2; 1 lx = 1 lm/m2) (ACR,209; Peart, 92–112; Stevens, 275–370).

45. (C) The mammographic phantom is equiva-lent to a 4.2-cm-thick compressed breast con-sisting of 50% glandular and 50% adipose tis-sue. The technique used should be the sameas that used clinically and the film should beprocessed just like a clinical mammogram.Phantom images are taken to ensure that theoptical density contrast and image quality areat optimal levels (Figure 2-14) (ACR, 167;Bushong, 342–356; Peart, 92–112).

46. (B) Under MQSA rules, accreditation andcertification are two separate processes. Bothare required by the FDA. Effective on May2002, certification is permitted only by theFDA or certain states—States as Certifiers(SAC). The SAC permitted are Illinois, Iowaand South Carolina. States can certify onlyfacilities within their state. Accreditation is aprocess administered by an FDA-approvedaccreditation body, which can be a private,nonprofit organization or a state agencyapproved to accredit mammography facili-ties. The FDA has approved four accredita-tion bodies—the American College of Radiol-ogy (ACR) and the states of Arkansas, Iowa,and Texas. State accreditors can only accreditfacilities within their state. These four bodiesall have the authority to implement theMQSA standards through the accreditationprocess (FDA).

47. (C) After completing the accreditationprocess, the FDA or States as Certifiers, SACstate will issue a certification that is valid for3 years and can be renewed as long as thefacility remains properly accredited anddemonstrates that it meets the MQSA stan-dards during annual inspections (FDA).

48. (A) Examples of visual checklist items are acheck of mechanical locks or display lighting.Many items are for the mammographer’sconvenience; some, however, are essential forpatient safety and the production of qualityimages. If the technologist cannot replace orrepair missing or broken items, the equip-ment service personnel should be called(ACR, 213; Peart, 92–112; Stevens, 275–370).

49. (A) Most digital hard copy printing is doneusing a dry processing laser printer. This elim-inates the chemical solutions by using a heat-sensitive film that contains the processingchemicals. Also, this type of film can be han-dled in room light. In dry processing laserprinter, heating the film produces the manifestimage. These systems do not use chemicalsand need no water hook up. Disadvantages ofthe laser-printed film are: expense and thelower optical density and latitude. Film-screenmammography uses single emulsion films.Because of their lower spatial resolution, dou-ble emulsion films are not used in mammog-raphy. In the past, the laser printer used asingle emulsion film that is sensitive to thered light emitted by the laser, similar to howblue- and green-sensitive films are used inconventional systems. These laser films mustbe handled in total darkness and were usedmainly in computed tomography (CT) imag-ing (Bushong, 199; Peart, 187; Shephard, 359–362).

Figure 2–15. A soft copy viewer (digital LCD monitor) in the x-rayroom. The digital image can be viewed within seconds.


50 (C) In digital imaging, the image is availablefor viewing within seconds. This initial view-ing is often referred to as soft copy viewingby the mammographer. At the soft copyviewing station, the mammographer canenhance the image, modify patient demo-graphics, or accept/reject the image based onstandard positioning criteria, before sendingthe image to the radiologist workstation or to

the site of hardcopy viewing. Before theadvent of high-resolution monitors, the finalhard copy viewing of the digital images wasin printed form. Now, however, the hardcopy viewing can be on an LCD monitor atthe radiologist’s desk. Typically monochromemonitors, minimum 2,500 × 2,500 pixels(5-megapixel) are recommended (Peart, 181–182;Shephard, 335–340; Zuley, 1492–1498) (Figure 2–15).


47

CHAPTER 3

Anatomy, Physiology, and Pathology of the Breast


LOCALIZATION TERMINOLOGY

The breast is generally described in terms of theface of a clock, and can also be divided into fourquadrants.

External AnatomyIn the female, breasts are accessory glands of thereproductive system with the function of secretingmilk for nourishment of the newborn. The femalebreast is spherical in shape, and size varies withage, menstrual cycle, and lactation. Hormonal stim-ulation causes the breasts to grow. The breast isloosely attached to the fascia, covering the pec-toralis major muscle.

The skin of the breast, like the skin of the body,is filled with sweat glands, sebaceous glands (oilglands), and hair follicles that open to form the skinpores. The nipple lies at the center point of thebreast. The areola is the smooth, circular darkeningsurrounding the nipple that contains many smallprotrusions on its surface (Morgagni tubercles).The nipple itself contains multiple crevices, withinwhich are 15–20 orifices, or collecting ducts thattransfer milk from the lactiferous ducts.

LocationThe breasts lie anterior to the pectoralis major. Sep-arating the breast from the pectoral muscle is alayer of adipose tissue and connective fasciareferred to as the retromammary space.

Internal AnatomyThe breast is made up of a varying mixture of adi-pose or fatty tissue, glandular or secretory compo-nents, connective tissue, lymphatic vessels, and

blood vessels. Cooper ligaments are the supportivestructures of the breast. Fibrous and glandular tissuesare usually described together as fibroglandular. Thepattern and distribution of the glandular tissue is usu-ally the same bilaterally.

Blood Supply to the BreastThe breast receives its arterial supply frombranches of the internal mammary and lateral tho-racic arteries. Veins that drain the breast form avenous network under the nipple. This networkthen drains into the axillary and internal mammaryveins. Veins are usually larger than arteries and arelocated more peripherally.

Lymphatic Drainage of the BreastThe primary lymphatic drainage of the breast is tothe axilla. There is also cross-mediastinal drainagefrom the medial portion of the breast to the otherbreast. The majority of normal axillary lymphnodes is less than 2 cm in size and has a kidney-shaped appearance (Figure 3-1).

HistologyThe average female breast consists of 15–20 lobescontaining numerous glandular lobules heldtogether by connective tissue, blood vessels, andbranching ducts (lactiferous ducts). Each of the15–20 lobes in the breast contains a treelike pat-tern of ductal structures radiating out from thenipple.

Factors Affecting Tissue CompositionThe normal physiological changes that take placein the breast are related to the onset of menarche,the amount of hormone fluctuation whether normal


48 3: Anatomy, Physiology, and Pathology of the Breast

or synthetic, pregnancy, lactation, and menopause.Also, because the breast has a high fat content,weight gain or weight loss will affect breast tissuecomposition.

Malignant Conditions and MammographicAppearancesMammographically, the breast will be visualized asless dense areas of fat (which appear black on theradiograph) and denser glandular areas (whichappear white or gray on the radiograph). Oftenblood vessels can be seen, especially if they are cal-cified, and occasionally lymph nodes are visualizedwithin the breast as kidney-shaped oval densitieswith lucent centers.

The majority of breast diseases occur in the ter-minal duct lobular units (TDLUs); however, thefibrous or connective tissue can also be involved.Other lesions occur in the larger ducts.

Malignant and benign breast lesions can be placedin five categories:

• Circular/oval lesion may be poorly outlined: cir-cular, oval, or lobulated; and solitary or multiple.

• Spiculate/stellate lesions are radiating struc-tures with ill-defined borders.

• Calcifications may or may not be associatedwith a tumor.

• Thickened skin syndrome may present overthe entire breast and may or may not be associ-ated with an increased density.

• There may be any combination of two or moreof the above lesions.

Characteristics of Malignant Circular/Oval Lesions

• High density—structures such as veins andtrabeculae cannot be seen through the lesion

• Smooth or lobulated and randomly orientated—not aligned along the trabecular structure ofthe breast

Characteristics of Malignant Spiculated/Stellate Lesions

• Have a distinct central mass.• Sharp, dense, fine lines of variable length radi-

ating in all directions—the larger the centraltumor mass, the longer the spicules.

• If spicules reach the skin or muscle, it maycause localized skin thickening or skin dim-pling (retraction).

• Commonly associated with malignant-typecalcifications.

Characteristics of Malignant CalcificationThere are three basic forms of malignant calcifications:

• Casting-type calcifications—fine linear branch-ing calcifications seen on the mammogram aslinear, fragmented, or occasionally branchingcalcifications with irregular contours.

• Granular-type calcifications—irregular in form,size and density. They resemble granulated sugaror crushed stone. They are usually grouped veryclose together in single or multiple clusters.

• Powderlike calcifications—multiple clusters ofpowderlike calcifications

Skin Thickening SyndromeSkin thickening may be caused by either benign ormalignant conditions.

Lobule containing alveoli

Mammory duct (segmental ducts)

Lactiferous duct or connecting duct

Lactiferous sinus (ampulla)

Nipple

Figure 3–1. A schematic diagram of the breast showing thebranching distribution system of a collecting duct. The nomencla-ture of the duct system is varied.


• The skin will appear obviously thickened, gen-erally in the lower dependent portion of thebreast.

• The overall density of the breast is increasedowing to the high fluid content (seen as acoarse reticular pattern on the mammogram).

BENIGN CONDITIONS AND MAMMOGRAPHICAPPEARANCE

See Figure 3-2.

Characteristics of Benign Circular/OvalLesions

• Radiolucent, for example, lipoma, oil cyst,galactocele

• Radiolucent and radiopaque combined, forexample, lymph node, fibroadenolipoma,galactocele, and hematoma

• Low density, therefore the surrounding parenchy-mal structures can be seen through the lesion, forexample, fibroadenoma, cyst

• Spherical or ovoid with smooth borders gener-ally aligned in the direction of the nipple alongthe trabecular structure of the breast, for exam-ple, cyst

• A halo sign which is seen as a narrow radiolu-cent ring or ring segment around the circum-ference of the lesion, for example, cyst

• A capsule which is a thin curved radiopaqueline surrounding the lesion, for example,fibroadenoma

Some exceptions to these rules are abscess, cal-cified hematoma, and sebaceous cyst.

Characteristics of Benign Spiculated/StellateLesions

• No solid, dense, or distinct central mass, forexample, radial scar.

• May have translucent oval or circular area atthe center, for example, radial scar.

• Very fine linear densities or lower densityspicules, for example, radial scars or traumaticfat necrosis.

• Never associated with skin thickening or skinretraction. The exception is traumatic fat necrosis.

Characteristics of Benign Calcification

• Smooth contours, high uniform density, for ex-ample, plasma cell mastitis

• Evenly scattered homogenous, for example,calcified arteries

• Sharply outlined, spherical, or oval, for exam-ple, calcified hematoma

• Pear-like densities—resemble teacups or pearldrops on the lateral projection, for example,milk of calcium

• Bilateral and evenly scattered following thecourse of the ducts throughout much of theparenchyma, for example, plasma cell mastitis

• Ringlike, hollow, for example, sebaceous glandcalcifications

• Eggshell-like, for example, oil cyst, papilloma• Large size, bizarre shape, for example, heman-

giomas


A B C D

E F G

H

I J L

M N O P

Figure 3–2. Picture summary of breast lesions. (A) Benign-type calcifications. (B) Cyst. (C) Deodorant calcifications. (D) Benign calcifi-cations: developing oil cysts and calcified hematomas. (E) Fibroadenoma. (F) Epidermoid cyst in posterior breast. Lucency represents air, postbiopsy. (G) Calcified galactocele. (H) Lymph nodes. (I) Lymph nodes. (J) Calcified sebaceous glands. (K) Malignant-appearing stellatelesion. (L, M, N) Malignant-type calcifications. (O) Microhematoma. (P) Scar marker. (Q) Oil cyst—benign calcifications. (R) Plasma cellmastitis—benign calcifications. (S) Skin folds. (T) Skin mole. (U, V) Skin thickening. (W) Specimen. (X) Spot compression of an oval lesion.(Y) Stellate lesion. (Z) Stellate lesion. (AA) Sellate lesion. (BB) Veins, calcified. (CC) Keratosis.

K


Q

Figure 3–2. (continued)

R S T

U WVX

YZ AA BB CC

1. A lesion located in the upper outer quadrantof the right breast is located in the

(A) 5-o’clock position(B) 2-o’clock position(C) 10-o’clock position(D) 7-o’clock position

2. Morgagni tubercles are usually found

(A) on the nipple(B) on the lateral border of the breast(C) in the terminal duct lobular unit (TDLU)(D) on the skin of the areola

3. An inverted nipple

(A) always indicates breast cancer(B) sometimes indicates breast cancer(C) never indicates breast cancer(D) usually indicates breast cancer

4. Compression of the breast is most effective andmost comfortable when applied against the

(A) medial and lateral aspects(B) inferior and superior aspects(C) medial and superior aspects(D) inferior and lateral aspects

5. The normal breast may have

(A) 0–5 lobes(B) 15–20 lobes(C) 30–40 lobes(D) 340–350 lobes

6. The structure that gives the breast its supportand shape is called

(A) Montgomery ligament(B) Cooper ligament(C) fibroglandular tissue(D) fatty tissue

7. The breast extends vertically from the

(A) first through the ninth rib(B) second through the tenth rib(C) second through the sixth rib(D) third through the tenth rib

8. The thickest portion of the breast is the

(A) areola(B) nipple(C) tail of Spence(D) inframammary crease

9. Cooper ligaments attach anteriorly to the

(A) deep fascia of the lobes(B) fascia of the skin(C) posterior surface of the breast(D) connective and supporting stroma

10. Fatty tissue is generally _______ and on themammogram is seen as areas of _______ opti-cal density.

(A) radiolucent/lower(B) radiopaque/higher(C) radiolucent/higher(D) radiopaque/lower

52

Questions


11. Typically, a patient with dense fibrous andglandular tissue throughout the entire breaston a baseline mammogram is

(A) age 20 or younger(B) between age 50 and 60(C) above 70(D) below 45

12. Glandular tissue is usually found in the_______ of the breast.

(A) medial and lower inner quadrant(B) central and upper outer quadrant(C) medial and lower outer quadrant(D) central and upper inner quadrant

13. Lymph drainage from the medial half of thebreast is generally directed to the

(A) internal mammary lymph nodes(B) external mammary lymph nodes(C) axillary lymph nodes(D) axilla

14. Immediately behind the nipple, the connect-ing duct widens to form the

(A) lactiferous sinus(B) ampulla acinus(C) TDLU(D) segmental duct

15. The portion of the breast that holds the milk-producing element is the

(A) ampulla(B) segmental duct(C) lobule(D) lactiferous sinus

16. Veins are normally located

(A) in the periphery of the breast(B) central areas of the breast(C) in the axilla area of the breast(D) in the medial areas of the breast

17. The TDLU consists of the

(A) mammary ducts and the extralobularterminal ducts (ETDs)

(B) intralobular terminal duct (ITD) and thesegmental ducts

(C) the ETDs and the lactiferous ducts(D) both the ETDs and the ITDs

18. A patient began taking synthetic hormones 6 months prior to her current mammogram.The mammogram is most likely to

(A) be unchanged from the previous year(B) show increased glandular tissue com-

pared to her previous mammogram(C) show decreased glandular tissue com-

pared to her previous mammogram(D) show increased fatty tissue compared to

her previous mammogram

19. A baseline mammogram shows that thepatient’s breast consists primarily of adiposetissue. This patient is most likely to be

(A) on hormone therapy(B) above 60(C) below 20(D) above 35

20. A patient is to have a routine baseline mam-mogram, but it is determined that the womanis lactating. What should be done and why?

(A) Lactating breasts are extremely sensitiveto compression; the mammogramshould be postponed.

(B) The mammogram should be done; radiation has no effect on lactation.

(C) Although lactating breasts are extremelydense, the mammogram should not berescheduled.

(D) Lactation causes increased glandularity;the mammogram should be postponed.


21. The craniocaudad mammograms of the samewoman prior to menopause and 1 year afterthe onset of menopause are compared. Thewoman has never taken synthetic hormones.What is the most likely difference?

(A) The mammogram taken prior tomenopause shows signs of atrophy.

(B) The mammogram taken after the onsetof menopause shows signs of atrophy.

(C) There will be little or no change in theglandularity of the breast.

(D) The mammogram taken after menopausewill show increased glandularity.

22. Which of the following will affect the ratio ofglandular tissue to total breast tissue?

1. the woman’s genetic predisposition2. ratio of total body adipose tissue to total

body weight3. drastic weight gain or weight loss


23. Hormone replacement therapy could be rec-ommended to?

1. relieve insomnia symptoms2. prevent osteoporosis3. reduce weight gain


24. A woman is referred to as nullipara. Thismeans

(A) she has never given birth to a viable offspring

(B) the woman has had only one child(C) the woman has given birth to more than

one viable offspring(D) she carried a pregnancy past the point of

viability regardless of the outcome

25. An asymptomatic patient presents with anoval, lobulated tumor with unsharp margins.There is no evidence of a halo sign.

(A) If the lesion is also radiolucent it is likelyto be benign.

(B) The lesion could be malignant.(C) All oval lesions are benign.(D) The absence of a halo indicates

malignancy.

26. The tumor seen in Figure 3-3 is characteristic of

(A) invasive ductal breast carcinoma(B) a mammographically malignant tumor(C) a mammographically benign tumor(D) a low-density tumor typical of benign

lesions

Figure 3–3


27. The calcifications seen in Figure 3-4 have thetypical appearance of

(A) mammographically malignant-type calcifications

(B) mammographically benign-type calcifications

(C) calcifications typical of an oil cyst(D) calcified microhematomas

29. The calcifications seen in Figure 3-5 have thetypical appearance of

(A) an oil cyst(B) plasma cell mastitis calcification(C) a small calcified hematoma(D) a calcified sebaceous gland

Figure 3–4Figure 3–5

28. Characteristics of a malignant stellate tumorinclude which of the following?

1. The spicules are generally bunchedtogether.

2. The presence of a central tumor mass.3. The larger the tumor, the longer the

spicules.

(A) 1 only(B) 1 and 2 only(C) 2 and 3 only(D) 1 and 3 only

30. The radial scar or sclerosing duct hyperplasia

1. can sometimes be mistaken for carcinoma

2. sometimes has a solid dense centraltumor

3. is usually not associated with skin thick-ening or dimpling over the lesion



31. A mammogram shows a low-densityradiopaque tumor. It is oval, lobulated, and ahalo is seen along one border only. The nextstep should be

(A) pneumocystogram(B) ultrasound(C) biopsy(D) no further testing; the tumor is benign

32. A galactocele

(A) is always radiolucent(B) is usually associated with trauma(C) is associated with nursing(D) usually has irregular borders

33. A lipoma

(A) is generally seen as a high-densityradiopaque lesion on the mammogram

(B) can be a huge encapsulated lesion occu-pying the entire breast

(C) may have irregular borders typical ofmalignant lesions

(D) is usually difficult to image mammographically

34. A rare form of cancer that presents withswelling, warmth, or erythema and mammo-graphically with skin thickening is

(A) inflammatory carcinoma(B) invasive ductal carcinoma(C) lobular carcinoma in situ(D) papillary carcinoma

35. Sometimes described as an oil cyst, thislesion represents an encapsulated area on themammogram and can be caused by surgery,biopsy, trauma, or radiation therapy.

(A) stellate lesion(B) galactocele(C) fat necrosis(D) lipoma

36. A benign self-limiting breast tumor that is theresult of new disorganized cell growth

(A) sarcoma(B) radial scar(C) invasive lobular carcinoma(D) hamartoma

37. An infusa-port can be used to

(A) provide radiation therapy treatment(B) allow repeated access to the venous

system(C) infuse radioactive tracers directly into

the breast lesion(D) infuse drugs directly into the arterial

system

38. The low-density radiopaque lesions seen inFigure 3-6 suggests a

(A) benign fibroadenoma(B) skin mole(C) galectocele(D) keratosis

Figure 3–6


39. The right craniocaudal (RCC) of the routineimaging series showed a small, irregular-shaped lesion at the edge of the image plusscattered calcifications including calcificationclusters (Figure 3-7). The next immediate stepwould be

1. spot compression including magnifica-tion

2. additional imaging to include the mar-gins of the lesion

3. ultrasound

(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only

40. The circular mixed-density lesions seen inFigure 3-8 suggests a

(A) calcified microhematomas(B) galactocele, calcified(C) malignant calcification(D) epidermoid cyst

Figure 3–7

Figure 3–8

1. (C) Each breast can be divided into fourquadrants: the upper outer quadrant (UOQ),upper inner quadrant (UIQ), lower outerquadrant (LOQ), and lower inner quadrant(LIQ). The exact locations within the quad-rant are represented by viewing each breast(separately) as a clock face (Figure 3-9).Lesions can also be described in relation to thenipple (eg, subareolar or below the nipple)(Peart, 35–44).

at the very end of the ductal system (Peart,35–44; Tortora, 1083).

3. (B) The normal nipple can be either flattenedor inverted, both unilaterally and bilaterally.However, a nipple that suddenly becomesinverted or flattened can indicate malignancy(Peart, 35–44; Tortora, 1083).

4. (D) The breast is most secured at the superiorand medial aspects. The lateral borders of thebreast and the inferior aspect (inframammarycrease) are the most mobile portions. To max-imize compression of breast tissue, the com-pression should be applied against the mostmovable margins (Peart, 35–44; Tortora, 1083).

5. (B) On an average, a breast has 15 lobes. Thenumber can, however, be as low as 10 or ashigh as 20 (Peart, 35–44; Tortora, 1083, 13).

6. (B) Cooper ligaments are a network offibrous and elastic membranes. They incom-pletely sheath the lobes of the breast. The lig-aments start at the most posterior portion(base) of the breast and extend outward toattach to the anterior superficial fascia of theskin. Fibroglandular and fatty tissues makeup the breast parenchyma. Montgomery is agland, not a ligament. It is located on the are-ola (Peart, 35–44; Tortora, 1083).

7. (C) The breast extends vertically from theclavicle (the second or third rib) to meet theabdominal wall at the level of the sixth orseventh rib and horizontally from the mid-sternum to the midaxillary line (the latissimusdorsi muscle). However, breast tissue can


58

UOQ

LOQ LIQ

UIQ

12

Right Left

3

6

9

UOQ

LOQLIQ

UIQ

12

3

6

9

Figure 3–9. Breast localization pictures. The breast can beviewed in different ways: (1) As a clock with clock-time descriptionswithin the breast. (2) Using the four-quadrant method: the upper-outer quadrant (UOQ), the upper-inner quadrant (UIQ), the lower-outer quadrant (LOQ), and the lower-inner quadrant (LIQ). Notethat the 4-o’clock position on the right breast represents the lower-inner quadrant but on the left breast would indicate the lower-outerquadrant.

2. (D) Morgagni tubercles are elevationsformed by the opening of the ducts of theMontgomery glands, which are specializedsebaceous-type glands found on the areola,not the nipple. The terminal ductal lobularunit (TDLU), also called the lobule, is located


form anywhere along the milk ridge or line,also called the mammary line. This lineextends from the armpits in the axilla to thegroin region of the body (Figure 3-10)(Andolina, 139–154; Peart, 35–44; Tortora, 1083).

10. (C) Fatty tissue is radiolucent and will there-fore show as higher optical density areas onmammograms (black). Fibrous and glandulartissues are less radiolucent and will show aslower optical density on the mammograms(white or gray) (Andolina, 139–154; Peart, 35–44;Tortora, 1083).

11. (D) In general, the amount of fat and glandu-lar tissue varies with age. Glandular tissuepredominates in younger women, whereasfatty tissue predominates in older patients. Apatient below 20 is unlikely to have regularmammograms (Andolina, 139–154; Peart, 35–44;Tortora, 1083).

12. (B) The majority of glandular tissue is distrib-uted in the breast bilaterally and is locatedcentrally and laterally toward the upper outerquadrant, extending toward the axilla. Mostbreast cancer arises from the glandular tissue(Andolina, 139–154; Peart, 35–44; Tortora, 1083).

13. (A) The main direction of drainage from thelateral half of the breast tends to be into thepectoral group of axillary lymph nodes andfrom the medial half of the breast into the inter-nal mammary lymph nodes. However, therecan be cross-mediastinal drainage from themedial portion of one breast to the oppositebreast (Andolina, 139–154; Peart, 35–44; Tortora, 1083).

14. (A) From the nipple orifice a connecting or lac-tiferous duct immediately widens into the lac-tiferous sinus (or ampulla). The ampulla is apouch-like structure that holds milk (when itis being produced). The ampulla then narrowsto become the segmental or mammary ducts.These will branch into smaller ducts withdecreasing diameter until becoming a lobule(Andolina, 139–154; Peart, 35–44; Tortora, 1083).

15. (C) From the nipple, the mammary ductsbecome smaller and smaller until becoming alobule. The lobule is also called the TDLU.The TDLU is lined with a single layer ofepithelial cells and a peripheral layer ofmyoepithelial cells and can be furtherdivided into extralobular terminal ducts(ETD), which is a small duct leading into the

Milk lines

Figure 3–10. Picture showing the milk line; the milk ridge orline, also called the mammary line. This line extends from thearmpits in the axilla to the groin region of the body.

8. (C) The upper outer quadrant, whichextends toward the axilla, is known as theaxillary tail or the tail of Spence. It is thethickest portion of the breast. Thoroughknowledge of the anatomic extent of thebreast is critical in breast imaging. The nippleis the center point of the breast and it is sur-rounded by the areola. The inframammaryfold or crease (IMF) is the lowest extent of thebreast where it attaches to the chest wall(Andolina, 139–154; Peart, 35–44; Tortora, 1083).

9. (B) Cooper ligaments are strands of connec-tive tissue that run between the skin anddeep fascia to support the lobes of thebreast. They start at the most posterior por-tion (base) of the breast, extend outward,and attach to the anterior fascia of the skin(Andolina, 139–154; Peart, 35–44; Tortora, 1083).


terminal ductules, and the intralobular termi-nal ducts (ITD), located at the end of the ter-minal ductules. The ITDs hold the alveolarglands, which are the milk-producing elementsof the breast (Figure 3–11). (Andolina, 139–154;Peart, 35–44; Tortora, 1083).

16. (A) Veins are larger than arteries. Unlike arter-ies, they are normally located peripherally andeasily seen. Mammographically they appearas low-density, radiopaque vessels. Both arter-ies and veins can be outlined by calcifications(Andolina, 139–154; Peart, 35–44; Tortora, 1083).

17. (D) The TDLUs are further divided into theETD, which is a small duct leading into the ter-minal ductules, and the ITD, located at the endof the terminal ductules. The ETD is sur-rounded by elastic tissue and lined by colum-nar cells. The ITD has no surrounding elastictissue and contains cuboidal cells (Figure 3-11).

The ITD holds the milk-producing elementsof the breast, called the ductules or acinus(plural, acini). Each lobule can have 10–100terminal ductules (Andolina, 139–154; Peart,35–44; Tortora, 1083).

18. (B) Increased or decreased glandularity of thebreast is a part of the normal physiologicalchanges that take place. Glandularity can berelated to menarche, hormonal fluctuationwhether normal or synthetic, pregnancy, lac-tation, or menopause; however, increasingglandularity is usually related to an increasein any of the two most prominent hormonesactive in the breast. These are estrogen(responsible for ductal proliferation) andprogesterone (responsible for lobular prolif-eration and growth) (Andolina, 139–154; Peart,35–44; Tortora, 1083).

19. (B) As a person ages, there is a decline in hor-mones (perimenopause) eventually leadingto menopause after which the glandularbreast tissue will atrophy. The breast thenlooses its supportive and connective tissue tofat. Patients above 60 will most likely havefatty breast; glandular tissues predominate inyoung women and adipose tissue (fat) pre-dominate in older women. Patients below 20usually have dense breast, but are also lesslikely to have a mammogram. Hormone ther-apy is likely to increase the glandular natureof the breast (Andolina, 139–154; Peart, 35–44;Tortora, 1083).

20. (D) Ideally, a mammogram should not bescheduled during lactation unless the patientis symptomatic, has a personal history ofbreast cancer, or is very high risk. In suchcases, the total time of lactation may exceedthe recommended time interval for screening.If a mammogram must be done during lacta-tion, the patient should nurse just prior to themammogram to remove superimposed milkand improve visualization of breast tissue.Because this is a routine baseline mammo-gram on an asymptomatic patient, the mam-mogram should be postponed. During lacta-tion, the increased blood supply, milkproduction, and overall physiologic changes

Ductules (acinus)

Extralobularterminal duct

(ETD)

Intralobularterminal duct

(ITD)

Terminal ductallobular unit

(TDLU)

Figure 3–11. Picture of TDLU. The TDLU increase anddecrease in size and number, depending on menstrual cycle, preg-nancy, lactation, and hormone use. The TDLUs are responsible formilk production and it is here that most cancers originate. The duc-tal system ends at the TDLU. The unit is further divided into ETDand ITD.


cause increased glandularity that reduces theaccuracy of the mammogram, making it lesseffective as a diagnostic tool. Also, theincreased density results in increased radia-tion exposure to the patient (Andolina, 139–154;Peart, 35–44).

21. (B) Generally, atrophy of mammary struc-tures begins at menopause and ends 3–5years later. After menopause, the breast losesits supportive tissue to fat, producing asmaller breast, or a larger, more pendulousone. This process is called involution(Andolina, pp. 139-154; Peart, 35–44).

22. (D) The total amount of glandular tissueincreases and decreases with hormonal fluc-tuations, use of synthetic hormones, andmenopause. The amount of glandular tissueversus fatty tissue will also depend on awoman’s genetic predisposition and totalbody fat. It is therefore possible to find youngwomen with fatty breast and older womenwith extremely dense, glandular breast.Weight gain and loss also increase ordecrease the fat content of the breast tissue,thereby affecting the overall glandularity ofthe breast (Andolina, 139–154; Peart, 35–44).

23. (B) Hormone replacement therapy (HRT) willrelieve symptoms of menopause which caninclude hot flashes, sleep disturbance,fatigue, osteoporosis, and insomnia. HRT cancause increase in glandular tissue, increase infibroadenomas, and increase in developmentof breast cyst but it can inhibit involutionprocess. The negative effects of HRT can besevere and include breast and uterine cancer,asthma, dementia, heart attacks, strokes, andblood clots. Most women are now advised toconsult their doctors on long-term solutionsnot involving HRT (Andolina, 139–154; Peart,35–44).

24. (A) Nulliparous is the condition of not hav-ing given birth to a viable offspring. Nulli-para would then refer to a woman who hasnever produced a viable offspring. Parity isthe terminology used if a woman carries apregnancy to a point of viability (20 weeks of

gestation) regardless of the outcome. Otherterminology is multiparity, regarded as hav-ing carried one or more fetuses to viabilityregardless of the outcome, and primipara, awoman who has delivered a child of 500 g (orof 20 weeks’ gestation) regardless of its viabil-ity (Andolina, 139–154; Peart, 35–44; Venes, 1598).

25. (B) Although a halo is typically present inbenign lesions, absence of a halo does notnecessarily prove malignancy. However, anycircumscribed radiopaque tumor withunsharp borders and no demonstrable halosign should lead to suspicion of malignancy,regardless of density (Figure 3-12) (Peart,47–63; Tabár, 17–92).

Round Oval Lobulated Irregular Spiculatedarchitecturaldistortion

Figure 3–12. Breast masses. The borders or shape of breastmasses may be round, oval, lobulated, irregular, or spiculated. Aspiculated border is a strong indication for malignancy, whereas asmooth border is a strong indication for a benign abnormality.These, however, are indicators and will not necessarily determinethe presence or absence of carcinoma.

26. (B) The mammogram shows a stellate tumor.Although the mammogram can suggest car-cinoma and may be highly suspicious for car-cinoma, only a microscopic analysis (histo-logical or cytological analysis) will reveal theexact type. The presence of a central tumormass with associated spicules is typical ofmalignant stellate tumors. The spicules aredense and sharp, radiate from the tumor sur-face, and usually are not bunched together.When they extend to the skin or areolarregion, they cause retraction and local thick-ening. In general, the larger the tumor, thelonger the spicules (Peart, 47–63; Tabár, 93–147).

27. (A) These calcifications are typical of mam-mographically malignant-type casting orgranular microcalcifications. Casting calcifi-cations are produced when carcinoma in situ


fills the ducts and their branches. The shapeof the cast is determined by the uneven pro-duction of calcifications and the irregularnecrosis of the cellular content. (The cells arereproducing or growing at such a fast ratethat they outstrip their blood supply anddie—the results seen as calcifications.) Thecontours of the cast are always irregular indensity, size, and length and the casts arealways fragmented. A calcification is seen asbranching when it extends into adjacentducts. Also, the width of the ducts deter-mines the width of the castings. Granular-type calcifications are seen as mammographi-cally similar in appearance to granulatedsugar or crushed stones. These are alsomalignant-type calcifications. Oil cysts aregenerally seen mammographically aseggshell-like calcifications and a microhe-matoma or calcified microhematoma can behigh-density or a mixed-density oval or cir-cular calcification (Peart, 47–63; Tabár, 149–238).

28. (C) A typical malignant stellate tumor has acentral tumor with dense spicules radiatingin all directions. The spicules are separateand increase in length with increased tumorsize. If the spicules reach the skin, there islocalized dimpling or skin thickening (Peart,47–63; 93–147).

29. (A) This calcification has the typical appear-ance of an oil cyst. Oil cysts are generallyseen mammographically as eggshell-like cal-cifications. Plasma cell mastitis calcificationsfollow the course of the ducts. Some may beelongated and branching, some needlelike,and some ringlike or oval, but all are sharplyoutlined, high density, and have smooth bor-ders. If they are periductal, they have centrallucencies. Calcified sebaceous glands are typ-ically ringlike oval calcifications with lucentcenters; there are two types, depending onwhere the calcifications started. Calcificationswithin a sebaceous gland are hollow or ring-like calcifications; calcifications within thecavity are punctate calcifications. A microhe-matoma or calcified microhematoma can behigh-density or a mixed-density oval or cir-cular calcification (Peart, 47–63; Tabár, 149–238).

30. (D) Radial scar is benign and rarely palpable.It is often mistaken for carcinoma and itsexact nature is the subject of some contro-versy among pathologists. Recent studiessuggest that a radial scar may increase awoman’s risk of developing breast cancer.Generally, the radial scar has no centraltumor. There can be translucent, oval, or cir-cular areas at the center of the lesion and thelesion’s appearance varies from one mam-mography projection to another. Regardlessof the size of the lesion, there is generally noassociated skin thickening or dimpling andno discernible palpable mass (American CancerSociety; Peart, 47–63; Tabár, 93–147).

31. (B) Most highly suspicious lesion will be rec-ommended for biopsy, but if the lesion is sus-pected to be benign further test is done toprove the benign nature of the lesion. A par-tial halo around a lesion suggests a mammo-graphically benign tumor. An ultrasoundwould be the best next step to differentiatesolid versus a cyst. After the ultrasound, apneumocystogram could be used to assessthe inside margins of the tumor (Peart, 47–63;Tabár, 17–92).

32. (C) A galactocele is a benign, milk-filled cystwith high fat content. These lesions are gen-erally associated with lactation. They are usu-ally circular, with sharply defined bordersand have densities that are a combination ofradiolucent and radiopaque. They are oftenleft alone, but if painful they can be drainedusing needle puncture. Often they yield ayellow fluid. The galactocele can calcify to ahigh-density circular or oval radiopaquelesion (Peart, 47–63; Tabár, 17–92).

33. (B) A lipoma is a fatty tumor. It is radiolucentand may be huge, with smooth borders andoccupying the entire breast. It is easily seenmammographically and is not metastatic(Peart, 47–63; Tabár, 17–92, Venes, 1253).

34. (A) Inflammatory carcinoma is a rare formof invasive carcinoma accounting for 1%–4%of all breast cancers. It generally presentswith swelling, warmth, erythema, and skin


thickening. The symptoms result from vascu-lar or lymphatic invasion of the carcinoma butare unfortunately very similar to symptoms ofa severe infection. Invasive ductal carcinomaaccounts for more than 60% of all breast can-cers. It usually presents as a central tumorwith radiating spicules and often the associ-ated malignant microcalcifications. Invasiveductal carcinoma is the most common of allbreast cancers. This form of cancer is oftenassociated with a tumor and malignantappearing calcifications. Lobular carcinoma insitu is most often asymptomatic. The cellsgrow within the lobules but do not penetratethrough the lobule walls. This form of canceris not seen mammographically in all cases andis often an incidental finding on biopsies. Pap-illary carcinoma is frequently seen as a cir-cumscribed mass on older women. It is oftenindistinguishable from a cyst mammographi-cally, but on ultrasound is identified as a com-plex or solid mass. It is a slow-growing tumorwith good prognosis (Peart, 47–63).

35. (C) Fat necrosis can be caused by surgery,biopsy, trauma, or radiation therapy. At thesite of the injury there may be hemorrhage,then as the tissue dies, liquefied fat necroticmaterial and blood remains. The areabecomes encapsulated by a thin layer of calci-fication, which appears on the mammogramas eggshell-like calcification described as anoil cyst. Stellate lesions such as invasive duc-tal carcinoma have a distinct central massand sharp, dense fine lines of variable lengthradiating in all directions—the larger the cen-tral tumor mass, the longer the spicules. Agalactocele is a benign, milk-filled cyst withhigh fat content. These lesions are generallyassociated with lactation and can calcify to ahigh-density radiopaque circular or ovallesion. A lipoma is a fatty tumor. It is radiolu-cent and may be huge, occupying the entirebreast. It is easily seen mammographicallyand is not metastatic (Peart, 47–63; Venes, 1435).

36. (D) Hamartomas result from an abnormalformation of normal tissue. The cells of thetumor grow in a disorganized mass and arecomposed of tissue elements normally found

at the site. Unlike a cancerous tumor, thehamartoma rarely invade or compress sur-rounding structures. The cells grow sponta-neously, reach maturity, and then do notreproduce. This growth is self-limiting andbenign. Radial scars are complex sclerosinglesions. They are not truly scars and are some-times unrelated to prior surgery or trauma.Some possible cause of the radial scar is local-ized inflammatory reaction or chronicischemia with slow infection. The radial scaris a benign condition, but can be associatedwith premalignant—atypical ductal hyperpla-sia—and malignant condition. A benignradial scar has no central tumor, althoughthere may be long spicules radiating from thecenter of the lesion. Regardless of the size ofthe spicules in the benign radial scar, there isno associated skin thickening, dimpling, ornipple reaction. The benign radial scar oftenresolves over time, but because of the possibleassociation with malignancy it is recom-mended that all stellate lesions includingradial scars should be excised. A sarcoma is acancerous tumor from mesenchymal tissuesuch as muscle or bone. Lobular carcinomasare often difficult to diagnose. Invasive lobu-lar carcinoma is a malignant condition wherethe cancer has spread from the lobular intothe surrounding tissue. On the mammogramthis can show as a spiderweb appearance orcause skin retraction (Peart, 47–63; Sanders,358–359; Venes, 1943, 925; Yazici, 438).

37. (B) Infusa-ports are designed to permitrepeated access to the venous system for theparenteral delivery of medications, fluids,and nutritional solutions and for the sam-pling of venous blood. In the treatment ofbreast cancer the infusa-port or port-a-cathare often used to deliver chemotherapy treat-ment and are sometime referred to as centralvenous access devices (CVAD). They are sur-gically implanted completely under the skin.Patients with infusa-ports can leave the hos-pital and continue their treatment at home.The infusa-port must be inspected daily forsigns of infection. Radiation treatmentexposes a specific body area to various high-energy radiations to destroy cancer cells.


Radioactive tracers or radioactive isotopes areinjected directly into the breast tissue in atechnique known as lymphoscintigraphy orsentinel node mapping, the idea being totrack the path of metastatic cancer. Injectingmedication directly into the arterial system inrarely done. Intra-arterial chemotherapy canbe used to give very high doses of chemother-apy to the tumor. The drug is injected directlyinto the arteries that are close to the cancerthrough a tube inserted under local anesthetic(Peart, 223; Venes, 1104–1106).

38. (B) The skin markers suggests that these arevisible skin lesions. Epidermoid cysts, kerato-sis, moles, calcified sebaceous glands, andskin tags are the most common. These areskin moles. The epidermoid cyst appears asfirm, round, mobile lumps just below theskin surface. These cysts are often incorrectlyreferred to as sebaceous cysts but they are notof sebaceous origin. Mammographically, theyare seen as mixed-density circular or ovallesion and can be mistaken for an internallesion if not marked. The keratosis often pre-sents as a raised lesion on the skin surface.Unlike warts, which they resemble, they arenot caused by the human papilloma virus.They tend to have a very rough surface withbumps and crevices. Mammographically,they appear as oval mixed-density lesions,often radiolucent but the crevices willappear as higher density areas on the mam-mogram. Moles, known medically as nevi,can come in a range of colors, but are usuallydark brown spots. In rare cases, a mole canbecome cancerous, but usually they areharmless clusters of pigmented cells. Mam-mographically, the mole will can appear as aradiolucent circumscribed lesion and can bemistaken for an internal lesion if not identi-fied. Calcified sebaceous glands are typicallyringlike oval calcifications with lucent cen-ters. A skin tag is a benign skin growth thatlooks like a small piece of hanging skin.Mammographically, it is seen as a low-density circumscribed lesion and can be mis-taken for an internal lesion if not identified.The fibroadenoma is a benign radiolucentand radiopaque combined lesion within the

breast. The galactocele is often circular oroval with mixed density and is also locatedwithin breast tissue. It is associated with lac-tation (Peart, 47–63; Tabár, 149–238; Venes, 1171).

39. (A) Further imaging could include spot com-pression and magnification. Whenever possi-ble, imaging should demonstrate a lesion inits entirety. Before moving to another modal-ity, the radiologist is likely to recommendfurther imaging to demonstrate the marginsof the lesion and magnification to assess thecalcifications (Peart, 47–63; Tabár, 149–238).

40. (D) Epidermoid cysts are often incorrectlyreferred to a sebaceous cysts, but they are notof sebaceous origin. The epidermoid cystsappear as firm, round, mobile lumps justbelow the skin surface. Mammographically,they are seen as mixed-density circular oroval lesion and can be mistaken for an inter-nal lesion if not marked. A microhematomaor calcified microhematoma can be mixed-density or a high-density oval or circular cal-cification. A galactocele is a benign, milk-filled cyst with high fat content. These lesionsare generally associated with lactation. Theyare usually circular, with sharply definedborders and have densities that are a combi-nation of radiolucent and radiopaque. Thecalcified galactocele is usually seen mammo-graphically as a circular or oval high-densityradiopaque lesion. Malignant-type calcifica-tions are often seen in clusters and are typi-cally casting or granular in appearance. Cast-ing calcifications are produced whencarcinoma in situ fills the ducts and theirbranches. The shape of the cast is determinedby the uneven production of calcificationsand the irregular necrosis of the cellular con-tent. The contours of the cast are alwaysirregular in density, size, and length and thecasts are always fragmented. A calcificationis seen as branching when it extends intoadjacent ducts. Also, the width of the ductsdetermines the width of the castings. Granular-type calcifications are seen as mammographi-cally similar in appearance to granulatedsugar or crushed stones (Peart, 47–63; Tabár,149–238; Venes, 1171).

65

CHAPTER 4

Mammographic Technique and Image Evaluation


BREAST COMPRESSION

Before applying compression, the mammographershould consider the natural mobility of the breast.When applying compression, in order to optimizethe amount of tissue under the compression paddle,the compression should not push the breast tissueagainst its fixed margins. The most movable marginsare the lateral and inferior and the fixed margins arethe medial and superior. The initial automatic com-pression should never exceed 45 lb (200 newtons) ofpressure; the patient should not be in pain, but thebreast must be taut to fingertip contact.

Compression

• The main reason for breast compression is toallow a more uniform density by flattening thebase of the breast to the same degree as themore anterior regions, permitting optimalexposure of the entire breast in one image.

Other reasons for breast compression:

• Reduces dose to the breast by reducing tissuethickness

• Brings lesions closer to the image receptor formore accuracy when evaluating size

• Decreases motion unsharpness because thebreast is immobilized

• Increases subject contrast, reducing theamount of scattered radiation by decreasingthickness

• Separates superimposed areas of glandular tis-sue; compression spreads apart overlappingtissue, reducing confusion caused by superim-position shadows, and allowing visualizationof the borders of circumscribed lesions

MAGNIFICATION

Magnification is ideal in imaging small areas, suchas areas of suspicious microcalcifications or lesions,specimen radiographs, or at surgical sites. Unfortu-nately, the use of magnification increases patientdose because the breast is placed much closer to thesource of radiation.

• A grid is not necessary with magnification.• A small focal spot must be used with

magnification.

Selection of Technical Factors

• The kVp (peak kilovoltage) selection or pene-trating power of the beam will influence thesubject contrast and exposure latitude, andtherefore the image contrast. Considerationshould also be given to the patient’s breast tis-sue structure. Too high kVp will result in lossof contrast (image too dark or gray). Too lowkVp will be high subject contrast in themedium-density range, but result in loss ofdetail visibility in the dense breast tissue.

• For a given kVp, increasing the mAs (mil-liamperes per second) alters the optical densityof the final mammogram. In general, increas-ing the mAs increases the mA but not theexposure time.

• The reciprocity law states that the density pro-duced on the radiograph is equal to any com-bination of mA and exposure time as long asthe product of mAs is equal. However, the reci-procity law fails at long and short exposuresbecause the film is exposed to light from theintensifying screens. With long and short expo-sures, reduced film speed and an increase in


66 4: Mammographic Technique and Image Evaluation

exposure factors are required. Most modernautomatic exposure control (AEC) systemsprovide automatic correction for film reciproc-ity failure. If necessary, using a higher kVp,varying the target and/or filtration material, orusing a faster screen-film combination will cor-rect reciprocity failure. Also, the length of theexposure time must always be consideredbecause of the possibility of motion unsharp-ness.

• When using AEC, the position of the detectorvaries depending on breast size and tissuecomposition. AEC selection choices can be:Full automatic mode—all the parameter areautomatically selected.Semiautomatic mode—the operator sets thekVp and possibly the filter and target.Manual mode—the operator sets everythingincluding the kVp, filter, target, and mAs.

Evaluation of Image Quality

PositioningThe routine series for breast imaging is the cranio-caudal (CC) and the mediolateral oblique (MLO).The CC projection should always demonstrate asmuch medial tissue as possible because this area ismost likely to be distorted on the MLO. The MLOwill visualize the maximum amount of breast tissueif the angle used is parallel to the pectoral muscle.

CompressionCompression produces a uniform tissue thicknessand reduces the overall thickness of the breast.Improperly compressed breast tissue will result inoverlapping tissue structures, nonuniform expo-sure (especially of the denser breast tissue), over-penetration of the thinner breast tissue, poor pene-tration of the thicker portion, and motionunsharpness.

ExposureWith adequate exposure, it is difficult to see the skinand subcutaneous tissue until the images are maskedto block out extraneous view box light. Areas of theimage with optical densities less than 1.0 are gener-ally underexposed. The densest area on the image isthe area of pectoralis muscle and it is the only areathat should have an optical density less than 1.0.

ContrastRadiographic contrast is a product of the subjectcontrast and the film contrast. In breast tissue, con-trast is usually highest in thinner breast and lowestin thicker breast owing to more scattered radiationand greater tissue absorption of low-kVp radiationin the thicker breast. Without contrast, breastparenchyma with different tissue densities will havevery similar optical densities.

SharpnessThe ability of the mammographic system to capturefine details in the image is defined as sharpness. Ifthe image is not sharp, it is referred to as unsharp.Unsharpness may be the result of motion blur, poorscreen-film contrast, characteristics of the screen(faster screens and double emulsion systems resultsin more unsharpness), and geometric factors suchas larger focal spot size, increase in object-to-imagereceptor distance (OID), or decrease in source-to-image receptor distance (SID).

NoiseRadiographic noise is represented as nonuniformor nonhomogeneous appearances on the recordedimage (similar to “snow” on a television screen).There are four factors contributing to radiographicnoise: film graininess, structural mottle, quantummottle, and scatter radiation.

ArtifactsAny variation of density on the image that is not areflection of the attenuation differences in the sub-ject can be considered artifacts. Examples of arti-facts are pick-off, scratches, fingerprints, dirt, lint,or dust.

CollimationIn mammography, collimation is limited to the sizeof the image receptor and not to the breast.

LabelingStandardized labeling in mammography is impor-tant because mammograms can be legal documentsand it is important that the radiographs are notmisinterpreted. In the final rules of the Mammogra-phy Quality Standards Act (MQSA), labeling isdivided into required, highly recommended, andrecommended.

1. Which of the following statements is (are) true?

1. Compression increases image sharpnessby reducing the focal spot size.

2. Compression increases subject contrastby reducing the thickness of the pene-trated tissue.

3. Compression increases the uniformity ofthe image-making diagnosis easier.


2. The compression force should not exceed_______ on the initial power drive (auto-matic) mode.

(A) 25 lb(B) 35 lb(C) 40 lb(D) 45 lb

3. In assessing the degree of compression forany one patient, the mammographer shouldtake into consideration

1. the maximum to which the patient’sbreast can actually be compressed

2. the amount of compression the patientcan tolerate

3. compression that should be just suffi-cient to immobilize the breast


4. Manual compression in mammography

(A) must be between 25 and 45 lb(B) depends solely on breast size(C) depends on breast size and the patient’s

pain tolerance(D) generally depends on the patient’s pain

tolerance

5. Some considerations that could be given towomen with painful breasts include

1. having the patient take ibuprofen priorto the mammogram

2. scheduling the mammogram just afterthe menstrual cycle

3. explaining, before the examination, theimportance of compression

(A) 1 only(B) 1 and 2(C) 2 and 3(D) 1, 2, and 3

6. Compression will do all of the followingexcept

(A) bring tissue closer to the image receptor(B) reduce patient dose(C) improve image subject contrast(D) decrease spatial resolution

7. Compression reduces radiation to the breast by

(A) providing a uniform breast thickness(B) decreasing breast thickness(C) decreasing motion unsharpness(D) separating superimposed areas of glan-

dular tissue

67

Questions

8. What principle does compression use to visu-alize the borders of circumscribed lesions?

1. It brings the lesion closer to the imagereceptor.

2. It spreads apart overlapping tissue.3. It separates superimposed areas of glan-

dular tissue.


9. Ideally, breast compression is maximizedwhen

1. accompanied by a thorough explanationto increase patient cooperation

2. the exposure is made on arrested inspi-ration to reduce motion

3. the patient recognizes the advantage ofcompression in reducing radiation dose


10. Patients who are allowed to play an activerole in applying the compression are usually

1. less likely to tolerate the compression2. more likely to tolerate the compression3. more relaxed during the compression


11. Magnification can be used to assess the

(A) margins of a lesion(B) size of a lesion(C) location of a lesion(D) density of a lesion

12. With calcifications, magnification can be usedto assess

1. the number2. morphology3. distribution


13. In general, greater magnification will requirethe use of a

(A) larger focal spot size(B) smaller OID(C) smaller focal spot(D) larger SID

14. A grid is not necessary during magnificationbecause

(A) grid use decreases spatial resolution(B) the small focal spot used will compen-

sate for the loss of image detail(C) the large OID produces the same effect

as a grid(D) magnification will magnify the normally

invisible grid line

15. The air gap in magnification increases subjectcontrast by

(A) increasing scatter(B) reducing scatter(C) reducing motion(D) increasing motion

16. If the magnification mammography is per-formed without using a small focal spot, theresulting image will be magnified

(A) and blurred(B) and sharply outlined(C) with increased subject contrast(D) with increased detail



17. At higher magnification factors there is

1. higher skin dose2. increased scatter3. decrease source-to-object distance (SOD)


18. Magnification is beneficial in all of the fol-lowing situations except

(A) imaging the surgical site of a patientwith a lumpectomy

(B) imaging a specimen radiograph(C) evaluating microcalcifications in a lesion(D) routine imaging

19. Using a small focal spot size is recommendedfor magnification

(A) to reduce the resultant loss of imagedetail

(B) because of increased patient dose(C) to compensate for the small OID(D) to compensate for motion unsharpness

20. The greatest disadvantage of magnification is

(A) increased OID(B) increased patient dose(C) decreased subject contrast(D) increased risk of motion unsharpness

21. Optical densities less than 1.0 in the dense glan-dular tissue of the breast is considered a/an

(A) underexposure(B) overexposure(C) normal exposure(D) above average but not overexposure

22. In conventional imaging, some causes ofunderexposure include

1. processing deficiencies2. inadequate compression3. improper AEC setting


23. To select a 12% increase in mAs before expo-sure, the mammographer could

(A) use the density compensation circuit(B) double the selected mAs(C) activate the backup timer(D) readjust the AEC selector

24. In conventional imaging, the leading cause offalse-negative mammograms in dense breasttissue is

(A) motion(B) overexposure(C) underexposure(D) grid lines

25. In conventional imaging, overexposure issometimes called the recoverable errorbecause

(A) it can be corrected during developing(B) high illumination and masking can over-

come it(C) magnification can overcome it(D) the use of small focal spot sizes will

reduce it

26. Increased kVp during mammography issometimes necessary to penetrate densefibroglandular tissue. Increased kVp, however,generally causes

(A) increased subject contrast(B) decreased subject contrast(C) motion unsharpness(D) less scatter

27. Rhodium is not used as the primary anodematerial when imaging thinner breastbecause

(A) rhodium has an emission spectrum simi-lar to tungsten

(B) the higher energy of the rhodium beamis unsuitable for thinner breast

(C) the lower energy of the rhodium beam is unsuitable for thinner breast

(D) rhodium anodes are more expensive

28. If the backup time stops a breast exposure,the mammographer can repeat the radi-ograph using a

(A) higher kVp setting(B) greater density compensation(C) higher mAs setting(D) different AEC setting

29. The type of x-rays created from displacementof K-shell-binding electrons in the molybde-num atom are called

(A) coherent scattering(B) characteristic radiation(C) Compton effect(D) bremsstrahlung radiation

30. The function of the filter in mammography isto remove

1. low-energy x-rays not needed to pro-duce the breast image

2. high-energy x-rays that cause a reduc-tion of subject contrast

3. low-energy x-rays that increase patientdose


31. If the AEC cell is placed over an area of adi-pose tissue on a breast with a mixture of adi-pose and glandular tissue, the areas of glan-dular tissue will be

(A) underexposed(B) overexposed(C) normally exposed(D) the AEC cell position will not affect the

exposure

32. Causes of poor subject contrast include all ofthe following except

(A) inadequate exposure(B) lower kVp(C) inadequate compression(D) failure to use a grid

33. The use of low kVp and high mAs will serve to

(A) reduce radiographic noise and increasesubject contrast

(B) reduce subject contrast and reduce radi-ographic noise

(C) increase radiographic noise and reducesubject contrast

(D) increase subject contrast and increaseradiographic noise

34. A highly recommended labeling that is notrequired by the MQSA is

(A) technologist/mammographeridentification

(B) date stickers(C) technical factors(D) flash card identification system

35. Lack of breast compression is most likely tocause

(A) geometric unsharpness(B) screen unsharpness(C) motion unsharpness(D) parallax unsharpness



36. Increasing the kVp by two points will

(A) force a doubling of exposure time(B) reduce the exposure time by half(C) have no effect on the exposure time(D) increase the subject contrast

37. The mammographer can differentiate motionunsharpness from screen unsharpness because

(A) motion unsharpness is generally local-ized to a small area

(B) screen unsharpness is generally local-ized to a small area

(C) motion unsharpness will result in blurring(D) screen unsharpness is less likely at expo-

sures below 2 seconds

38. Increasing the kVp will influence the

1. optical density on the image2. penetrating power of the beam3. subject contrast and exposure latitude


39. The last degree of compression should beapplied

(A) using manual compression(B) after the breast is released from com-

pression(C) with the automatic compression device(D) with the mammographer’s hand

between the breast and the compressionpaddle

40. Anatomic parts with low subject contract willhave

(A) sharp difference in x-ray absorption(B) very little difference in x-ray absorption(C) the same x-ray absorption characteristics(D) similar x-ray absorption characteristics

1. (C) Compression makes the breast tissue moreuniform and reduces the thickness throughwhich the x-ray beam must pass. This pro-duces uniform densities that are easier to inter-pret. Although compression increases imagesharpness, compression has no impact on thefocal spot size (ACR, 199).

2. (D) According to the MQSA guidelines, thecompression force for the initial power drivemust be between 111 and 200 newtons (25and 45 lb). Manual compression should notexceed 45 lb. Too little compression will com-promise the image; too much can damagebreast tissue (ACR, 200–201).

3. (B) Ideally, compression should be applieduntil the breast tissue is taut. But if the patientis in pain at maximum compression, this willbe a disincentive to return for annual mammo-grams. The patient will generally be able to tol-erate more compression if they are prepared forit, and if it is applied slowly. Although com-pression immobilizes the breast and reducesmotion, compression just adequate to immobi-lize the breast is usually insufficient to separatebreast tissue (ACR, 30–33).

4. (C) The initial compression in mammographyshould be between 25 and 45 lb in the auto-matic mode. Manual compression should notexceed 45 lb. In general, the amount of man-ual compression depends on the patient’sbreast size and patient’s tolerance for com-pression. Some patients may require moremanual compression to adequately compressthe breast (ACR, 199; Peart, 65–85).

5. (D) Often the patient will be able to toleratemore compression if the need for compres-sion is explained to the patient. Patients withparticularly sensitive breasts will benefitfrom pain medication prior to the mammo-gram. (The patient must consult their physi-cian before taking any medication.) Also, thebreast is often more sensitive to pain justbefore or during the menstrual period and isleast sensitive 7–10 days after the start of theperiod (ACR, 33; Peart, 117).

6. (D) The spatial resolution is the ability toimage high-contrast small objects such as ofmicrocalcifications. The spatial resolution ofthe image is limited mainly by the effectivefocal spot size. Spatial resolution is stated asthe number of line pairs per millimeter(lp/mm) that are imaged. A high spatial res-olution means smaller objects can be imagedclearly. The compression increases spatialresolution by reducing patient thickness; thetissue is therefore closer to the image recep-tor. The tissue is thinner; there is thereforeless scatter and the subject contrast isimproved. Less radiation dose is used topenetrate the thinner breast tissue (Bushong,219–227, 327–340).

7. (B) Although the primary goal of compres-sion is to provide a uniform breast thickness,compression will also decrease motionunsharpness by immobilizing the breast andit will separate superimposed areas of glan-dular tissue. Compression also reduces radia-tion dose to the breast by decreasing thethickness through which the radiation must

72



pass, thus allowing less exposure (Andolina,184; Bushong, 334–335; Peart, 117).

8. (D) Compression separates overlapping andsuperimposed areas of glandular tissue andwill bring lesions closer to the image recep-tor. This action allows visualization of theborders of lesions (Andolina, 184; Bushong,334–335; Peart, 117).

9. (C) Often, the patient is able to tolerate morecompression if the need for compression isexplained. Knowledge of the procedure gen-erally alleviates fears, especially fears of theunknown. Any explanation should include astatement on how compression will reducethe radiation dose to help alleviate fears ofradiation dangers. Throughout the examina-tion, the patient should be encouraged torelax. Having the patient take a deep breathprior to holding the breath during the expo-sure is generally contraindicated. The patientmay alter her position as the lungs expand,and the expanding ribs and lungs generallycontract the pectoral muscles increasing dis-comfort during the mammogram. Thepatient should be simply advised to “stopbreathing” without moving her body or firsttaking a deep breath (Peart, 117–118).

10. (D) Studies have shown that if a patient playsan active role in applying the compressionthat patient will be able to tolerate the com-pression better and will be more relaxed dur-ing the compression. The more the patientknows about compression and understandsthe procedure, the more she will be relaxed. Togive the patient an active role in compression,the mammographer can allow the patient toapply the compression or constantly monitorthe patient, stopping the compression whenthe patient indicates (Peart, 117–118).

11. (A) Magnification cannot be used to assesslesion size because it gives a magnified imageof the area which will not be a true represen-tation of size. Location and density are alsonot easily assessed using magnificationbecause the magnified image does not

include the entire breast, and density compar-isons will be difficult if other densities are notpresent on the image. Magnification is, how-ever, capable of providing accurate assess-ment of the margins of a lesion (Figure 4-1)(ACR, 59–60).

X-ray tube

Object

SOD

SID

OID

Image receptor

Figure 4–1. Schematic diagrams showing the large OID used inmagnification mammography. Note the small SOD which places thebreast closer to the x-ray source.

12. (D) Morphology is the form or structure of thecalcification. By magnifying the area of inter-est, magnification provides images that can beused to assess the number, distribution, andmorphology of the calcifications (ACR, 59–60).

13. (C) To achieve magnification, the OID isincreased. As the magnification factorincreases, the focal spot must be reduced orthe thickness of the part decreased to main-tain sharp images. Both of these factors areused in breast magnification. The SID inmammography units is fixed and cannot beadjusted. Magnification factor = SID/SOD orimage size/object size (Figure 4-1) (Andolina,63–64; Bushong, 336; Peart, 118).

14. (C) Magnification mammography is neces-sary to enhance microcalcifications or theborders of a lesion. Grids are necessary inroutine mammography image to improvecontrast and spatial resolution; however, with


magnification a smaller effective focal spot isused to compensate for the loss of imagedetail and the air gap (large OID) acts like agrid in reducing the amount of scattered radi-ation reaching the film or electronic detector.The main disadvantage of magnificationmammography is the high patient dose(almost double the routine skin dose becausethe breast is closer to the radiation source).Grid use in magnification would furtherincrease exposure times, increasing tube load-ing, and thus increasing motion artifactowing to long exposure times. Radiation doseto the patient would also increase (Figure 4-2)(Andolina, 63–64; Bushong, 272, 336; Peart, 78–79).

magnification, there is an increase in focalspot blur. To keep focal spot blur at a mini-mum, to maintain subject contrast and imagedetail, and to compensate for the reducedresolution during magnification, a small focalspot must be used (Andolina, 63–64; Bushong,336; Peart, 78–79).

17. (C) The magnification factor equals thesource-to-image receptor distance divided bysource-to-object distance (SID/SOD). Radia-tion intensity is related to the square of thedistance; therefore, as the patient’s breast ismoved closer to the x-ray tube the SODdecreases and patient’s dose increases. With agreater magnification factor, there is a greaterskin dose because the SOD will be smaller.Also, as the magnification factor increases, asmall focal spot must be used to maintain asharp image. Scatter is insignificant duringmagnification because of the air gap (Bushong,321–322; Peart, 78–79).

18. (D) Magnification is ideal for imaging smallareas such as the surgical site of a patientwith a lumpectomy, specimen radiography,or microcalcifications. With magnification,microcalcifications that would otherwise bemissed can be seen. Magnification should notbe used in routine imaging because the entirebreast may not be imaged, and patient doseis increased (Bushong, 336; Peart, 78–79).

19. (A) The focal spot blur (penumbra or geometricunsharpness are the old terms) is caused by alarge effective focal spot. Whenever the rela-tionship between the source, object, andimage is altered, as in magnification, there isan increase in focal spot blur. To keep focalspot blur at a minimum, a small focal spot isused. The small focal spot necessitates alower mA output and thus results inincreased exposure time and risk of motion.Motion unsharpness is controlled by vigor-ous compression. The increase in patientdose is related to the smaller SOD used inmagnification (Bushong, 326–356).

20. (B) Unfortunately, magnification increasespatient skin dose. Using a magnification

Radiation source

X-ray traveling atan angle will be

absorbed

Grid

(Imagereceptor)

X-ray travelingstraight will be

transmitted

h

d

Grid ratio = height/distance between lead strips

Figure 4–2. Schematic diagram demonstrating the use of a grid.The grid strips will transmit x-rays traveling straight while absorbingany scattered rays.

15. (B) The large air gap acts like a grid andreduces scatter, thus improving subject con-trast. Positioning the breast away from theimage receptor takes advantage of the inversesquare law: the intensity of the scattered radi-ation is reduced because the distance betweenthe image receptor and the object is increased.In magnification, mammography motion iscontrolled by vigorous breast compression.Grid use in magnification would furtherincrease overall technical factors including theexposure times (Figure 4-1) (ACR, 59–60;Bushong, 336).

16. (A) Whenever the relationship between thesource, object, and image are altered, as in

factor of 1.4 may actually double the radia-tion dose to the patient because the breast isplaced closer to the radiation source. TheOID must be increased to achieve magnifica-tion. In magnification, subject contrast andmotion unsharpness are controlled by using asmall focal spot size with vigorous breastcompression (Bushong, 284, 336; Peart, 78–79).

21. (A) Normally, optical densities on the mam-mogram should never fall below 1.0–1.25 orgo above 2.50–3.0. The optimum is 1.60. Inconventional imaging, the trend clinically isto have higher optical densities to adequatelypenetrate the glandular tissue and producehigh-contrast images (ACR, 92; Peart, 74–77).

22. (D) All cause a reduction in the density of theimage, which can causes a radiograph toappear underexposed. If the developer tem-perature decreases, the film speed decreases,resulting in lower film density. Poor com-pression causes uneven densities, leading tounderpenetration of portions of the breast.Improper selection of the AEC results ininadequate x-ray penetration of the glandulartissue of the breast (ACR, 97; Peart, 116–117).

23. (A) Modern mammography machines are allequipped with a density compensation cir-cuit. The density compensation circuit allowsthe selection of at least two steps above andtwo steps below the normal setting. Eachstep translates to a 12%–15% increase ordecrease in the mAs or a 0.15 change in theoptical density. The AEC produces a diagnos-tic density determined by the tissue placeddirectly over the AEC cells. The backup timerwill prevent gross overexposure. In the oldermammography units the backup timer forgrid technique is preset at 600 mAs and fornongrid at 300 mAs. In the newer units, a testexposure is delivered to check for adequatepenetration. The backup timer is activatedand the unit will not complete the exposure ifthe mAs is inadequate. In both cases, if thebackup timer is reached during an exposurethen the selected mA is too low. To avoid get-ting the backup times, the kVp setting mustbe increased because the unit is already

exposing at the maximum mA (ACR, 97; Peart,116–117).

24. (C) Underexposure of dense breast tissue isthe leading cause of false-negative mammo-grams. If the area is slightly overexposed,high illumination and masking can be usedto visualize the image. If the area is underex-posed, calcifications or even subtle densitydifferences are not detected in the glandularbreast tissue. With the moving reciprocatinggrid systems of modern mammographyunits, grid lines are not a problem (ACR, 97;Peart, 65–86).

25. (B) Overexposure can sometimes be over-come by using high illumination and mask-ing. Modern automatic processing makes cor-recting techniques during developingunworkable and adjusting the focal spot sizeor magnification will not correct for overex-posure. Underexposure is an unrecoverableerror in which lost contrast cannot berestored in underexposed areas of the image.The radiograph has to be repeated withincreased technical factors. Note that extremeoverexposure decreases subject contrast (ACR,98; Peart, 65–86).

26. (B) The kilovoltage (kV) primarily influencesthe quality of the x-ray beam. As the kVpincreases, the penetrating quality of the beamincreases—more x-rays pass through thebreast and reach the film at higher kVp.There is, therefore, less differential absorp-tion and thus a reduction in subject contrast.Motion unsharpness is owing to movementof the patient during the exposure and scatterradiation increases at higher kVp levels(Bushong, 327–340; Peart, 65–86).

27. (B) Rhodium targets with rhodium filtershave an emission spectrum similar to molyb-denum, not tungsten. However, rhodium hasan atomic number of 45 compared to 42 formolybdenum. This means that the emissionspectrum for a molybdenum target filteredwith 30 μm of molybdenum will have anemission of characteristic x-rays with energiesof 19 keV (resulting from K-shell interactions)



and almost no bremsstrahlung x-rays. Theemission from rhodium will be slightlyhigher (23 keV) and there will be morebremsstrahlung x-rays. Bremsstrahlung x-raysare produced more easily in target atomswith a high atomic number. The significanceof this in mammography is that the keVenergy of the rhodium is designed to pene-trate thicker, more dense breast tissuewhereas molybdenum is used to image fattybreast. Bremsstrahlung x-rays will predomi-nate in the tungsten target (Bushong, 327–340;Peart, 65–84).

28. (A) In newer mammography units thebackup timer is activated if the initial testexposure, delivered to check for adequatepenetration, fails. The density compensationcircuit and the mAs should not be increased;because the primary reason for backup timeis that the beam has low-energy photons thatare unable to penetrate the breast. Increasingthe compensation circuit does not increasethe energy of the beam. Each step on thecompensation circuit generally results in a12%–15% change in mAs. Increasing the mAsincreases the overall film density, but similarto the compensation circuit, this does notincrease the penetrating power of the beam.Selecting another AEC setting may result inan underpenetrated image if the new AECsetting is placed over a less dense area of thebreast (Peart, 65–84).

29. (B) The molybdenum anode will produce x-rayphotons with energies in the range of 17–20 keV(kilo electron volt). The most prominent ofthese x-ray photons are characteristic and willaccount for 30% of the total x-rays in themolybdenum beam at 30 kVp. The emissionspectrum shows almost no bremsstrahlungx-rays because bremsstrahlung x-rays are pro-duced more easily in target atoms with highatomic numbers, such as tungsten. Coherent orclassical scattering describes the interaction ofvery low-energy x-rays with atoms in the tar-get. These energies are too low to impact breastimaging. Compton is the most common scat-tered radiation in imaging. The Compton effectoccurs when the incident x-ray interacts with

an outer-shell electron and ejects it from theatom, ionizing the atom. The ejected electron iscalled a Compton electron or secondary elec-tron. Compton-scattered x-rays can deflect inany direction and can retain up to two-thirds ofits original energy (Bushong, 327–340; Peart, 65–84).

30. (D) The most useful energy range for maxi-mizing breast tissue is 17–24 keV. To achievethis, added filtration must be used at the tubeport window on all mammography machines.It is important that the inherent filtration ofthe x-ray tube window does not filter out anyof the useful energy beam. Energies belowthe useful range will contribute to skin doseand energies above will reduce differentialabsorption in breast tissue. The x-ray tubeport is therefore made of beryllium or borosil-icate glass and not regular glass. Most mam-mography tubes have an inherent filtrationthe equivalent of 0.1 mm Al. The total inher-ent filtration cannot be less than the equiva-lent of 0.5 mm Al. The added filtration mustbe the same element as the x-ray tube targetto allow the K-characteristic x-rays to exposethe breast while stopping the lower or higherbremsstrahlung x-rays (Figure 4-3) (Bushong,327–340; Peart, 65–84) .

Unfiltered Mo beam

Filtered Mo beam

(mirror, breast, thickcompression device,or glass tube window)

keV (energy)

15 20 25

100%

Per

cent

pho

tons

in b

eam

30

Figure 4–3. Showing the emission spectrum of molybdenumbeam filtered and unfiltered. Note that the filter beam removes thelower energies (16 keV) that would contribute only to skin dose.


31. (A) The AEC detects the beam after the x-raypasses through the breast. Because the AECstops the exposure when it estimates that thecorrect exposure is reached, positioning theAEC over fatty breast tissue stops the expo-sure before there is sufficient exposure topenetrate the denser tissue. The result will bean underexposed radiograph (ACR, 97).

32. (B) Radiographic contrast is the product ofsubject contrast and film contrast. In general,lower kVp improves subject contrast,although some mammographic film nowallows significantly higher kVp without sacri-ficing image contrast. Subject contrast refersto the contrast of the radiograph when it isviewed on the illuminator. This is the differ-ence in quantity of radiation transmitted by aparticular structure or body part as a result ofthe difference in absorption characteristics ofthe tissues and structures making up thatpart. Subject contrast, often simply referred toas contrast, is most affected by the selectedkVp but body tissue thickness—dependenton breast compression—and the attenuatingcharacteristic of the part will also affect thecontrast. The impact of the mAs on contrast issmall. However, too low a mA setting willresult in low optical density (OD) and there-fore reduced radiographic contrast—straightline portion of the H & D curve (characteristiccurve) is flattened. Also, too high mAs resultin high OD and loss of radiographic contrast.Film contrast represents inherent propertiesof the film such as speed latitude and the dif-ferent quantities and qualities of radiationeffect on them. Low-contrast mammogramswill have a uniform appearance, making itdifficult to differentiate between differentbreast tissue thicknesses. Other causes of poorcontrast include processing deficiencies, lackof a grid (which will result in increased scat-tered radiation), improper target material,and/or filtration (ACR, 100–101; Bushong, 272–296;Peart, 115–118).

33. (A) Contrast (subject contrast) is the ability tosee subtle density differences and will behigher at lower kVp, where there is great tis-sue absorption and less scattered radiation.

Noise defines the ability to see minute struc-tures on the image and is reflected as randomfluctuations in optical density. Reducingnoise mostly involves reducing the scatteredradiation and quantum mottle. Noise istherefore lowest when using lower kVp andhigher mAs (ACR, 100; 105; Bushong, 272–273,290; Peart, 115–118) (Figure 4-4).

Figure 4–4. The increased graininess on this image demon-strates quantum mottle.

34. (D) The labeling guideline under MQSA rules isdivided into three areas: required, strongly rec-ommended, and recommended. The flashcard patient identification system is stronglyrecommended because it is the most perma-nent and will be reproduced on a copy,unlike the stick-on labels.

Required labeling includes:

• name of patient (first and last) and addi-tional patient identifier such as a uniquemedical record number

• date of examination• projection and laterality (right or left)

(placed near the axilla using the standard-ized codes approved by the FDA)

• facility name and location, including thecity, state, and zip code

• technologist/mammographer identification• cassette/screen identification


• mammography unit identification—if thereis more than one unit

Strongly recommended labels include:

• a flash card with a permanent patient iden-tification system

Recommended labeling includes:

• Date stickers—enable easy reading ofdates with overhead lights.

• Technical factors (including target filter,kVp, mAs and exposure time)

• Compression force• Compressed breast thickness• Degree of obliquity

(ACR, 26–27)

35. (C) Sharpness is the ability to see fine detailon the mammography image, and patientmotion is the most common form of unsharp-ness. Motion blurring is common with expo-sure above 2 seconds and can be preventedby proper communication. Good compres-sion will reduce breast thickness, thereforeallowing shorter exposure times. Screenunsharpness is a result of poor screen-filmcontact and can be caused by air trappedbetween the film and the screen during load-ing. Geometric unsharpness or focal spot bluris caused by increase in focal spot size or OIDor by a decrease in SID. Parallax unsharpnessresults from the use of double emulsion filmsand is generally not a factor in mammographyimaging (ACR, 102; Peart, 115–118).

36. (B) The kVp can have a major impact on theexposure time and dose. As the kVp isincreased, the exposure time decreasesrapidly—50% for every two-point drop inkVp. The dose will also decrease by 15%–20%for a two-point drop in kVp because a higherkVp setting will allow the use of lower mAsand therefore lower patient doses. As thekVp increases, however, there is less differen-tial absorption leading to a reduction in sub-ject contrast (ACR, 101; Bushong, 290).

37. (B) In screen unsharpness there is a furtherspread of light from the screen before itreaches the film. This type of unsharpness isindependent of the exposure time and unlike

motion unsharpness, which covers a widerarea, unsharpness because of poor screen con-tact is usually localized. All unsharp imagesare referred to as blurry (ACR, 104–105).

38. (B) The kVp controls the wavelength or pene-trating power of the beam. Increasing thekVp influences the subject contrast and expo-sure latitude, therefore also affecting theimage contrast. Latitude refers to the range ofexposures over which the film responds withoptical densities in the acceptable diagnosticrange. Wider latitude allows more variationin mAs while still producing an acceptableimage. Higher contrast generally results inlower latitudes. The main factor influencingthe optical density is the mA. Increasing themA will increase the quantity of the electronbeam (Bushong, 290; Peart, 116).

39. (A) In applying compression, the mammog-rapher needs to be as gentle as possible. Theautomatic compression should be appliedwith the mammographer’s hand between thebreast and the compression plate until theplate touches the back of the hand. Only thenshould the mammographer remove the hand,pulling the breast out, and applying the finaldegree of compression slowly. Always applythe last degree of compression using themanual rather than the automatic compres-sion paddle to avoid unnecessary pain to thepatient (Peart, 115–118).

40. (B) Subject contrast is a result of differencesin attenuation in body tissue and is greatlyaffected by the effective atomic number of thetissue being radiographed. Subject contrast isalso affected by the size, shape, and energy ofthe x-ray beam (kVp). Anatomic parts withhigh subject contrast will have sharp differ-ence in x-ray absorption, for example, boneand soft tissue. Anatomic parts with low sub-ject contrast will have very little difference inx-ray absorption, for example, breast (Bushong,290; Peart, 116).

79

CHAPTER 5

Positioning and Interventional Procedures


STANDARD PROJECTIONS

Craniocaudal

• Exposure made on suspended respiration.• Image receptor (IR) positioned at the level of

the raised inframammary crease.• The patient’s head is turned away from the

side being examined.• The patient’s feet are apart with weight

equally distributed, for stability.• The patient’s arm closest to breast being exam-

ined is placed by the patient’s side.• The contralateral arm is raised—holding the

bar on the unit will provide support.• Dense areas of the breast are well penetrated.• The nipple imaged in profile, centered on the IR.• The medial and lateral aspects of the breast

included in the collimated area. (The pectoralismajor muscle is seen approximately 20% of thetime.)

• The craniocaudal (CC) projection (Figure 5-1)should include, within 1 cm, the amount of tis-sue measured on the mediolateral oblique(MLO) image.

• Appropriate markers and labeling as requiredby the American College of Radiology (ACR).

Mediolateral Oblique (MLO)

• Exposure made on suspended respiration.• The tube angulation will vary between 30 and

60 degrees depending on patient size; thinpatients require steeper angulation than heavierpatients.

• Arm closest to the breast being imaged isdraped over the top of IR. The upper border ofthe IR fits in the armpit.

• Compression must adequately support theanterior breast tissue to prevent sagging anddistortion of the ductal architecture. Themammographer supports the anterior breastwith one hand during compression and uses theother hand to adjust the skin over the sternumand clavicle to reduce the “pulling sensation.”

• The convex-shaped pectoral muscles demon-strated to level of the nipple.

• Appropriate markers and labeling as requiredby the ACR.

Common Problems Associated with MLOImaging

• Drooping breast—anterior breast poorly com-pressed

• Abdominal tissue included on the mammogram• Posterior breast is not imaged or poorly

imaged—insufficient pectoral muscle

ADDITIONAL POSITIONS/PROJECTIONS

Supplemental projections become useful when thestandard projections or are difficult to obtain. Otherreasons include:

• A suspicious area is seen in one of the routineprojections but not on the second.

• Additional imaging allows the patient to avoidan invasive procedure such as needle localiza-tion (eg, a spot compression may prove an areaof suspicious density to be overlapping tissues).

Exaggerated Craniocaudal (XCCL)

• To image lesions in the lateral aspect of breastnot seen on the CC projection


80 5: Positioning and Interventional Procedures

A

C

B

D

Figure 5–1. Complete four-projection series mammogram. A routine mammogram showing the normal appearance of (A) RCC, (B) LCC,(C) RMLO, and (D) LMLO.


Mediolateral (ML) 90 degree

• To verify a finding or localize a lesion inanother dimension (necessary during needlelocalizations)

• To locate a lesion not seen on a CC projection iflesion is seen only on the MLO projection• medial lesions move up on the lateral from

their position on the MLO• lateral lesions move down on the lateral from

their position on the MLO• central lesions do not move significantly

from the MLO to the ML• To prove benign breast calcifications (eg,

“teacup”-shaped calcifications)

Caudocranial or From Below (FB)

• To image small breast• To image the kyphotic patient• To image patients with pacemakers• To better visualize lesions in the superior or

upper quadrants of the breast

Lateromedial (LM)

• To improve detail of a lesion located in themedial aspect of the breast

• To perform preoperative localization of aninferior and/or lateral lesion

• To image the nonconforming patient

Axillary Tail (AT)

• A 20-degree oblique projection used to visualizethe tail of the breast

Cleavage (CV) or “Valley View”

• To show deep medial lesions in the CC position

Tangential (TAN) Projection

• To demonstrate an area in question withoutsuperimposition of breast tissue

• To locate skin calcifications or lesions near the skin

Lateromedial Oblique (LMO)

• To image the nonconforming patient when thestandard MLO projection is difficult

• To image patients with a pacemaker• To image patients with chest surgery• To image patients with a prominent sternum• To evaluate the medial aspect of the breast

Superior-Inferior Oblique (SIO)The beam is directed from superior lateral aspect tothe inferior medial aspect.

• Demonstrates the upper-inner and the lower-outer quadrant

• Especially useful in imaging encapsulatedimplants

MODIFICATIONS

Magnification (M)

• To improve imaging of fine detail, especiallywhen analyzing calcifications

Rolled Lateral (RL) or Rolled Medial (RM)The breast is rolled laterally or medially from theCC position.

• This image removes superimposed tissuewhen imaging dense breast (the lesion is“rolled” off or away from the dense tissue).

Rolled Superior (RS) or Rolled Inferior (RI)The breast is rolled superiorly or inferiorly from thelateral position.

• This image removes superimposed tissue whenimaging dense breast (the lesion is “rolled” offor away from the dense tissue).

Spot Compression

• Applies more compression to a localized areaof interest using a smaller compression paddle• Localization of suspected abnormality• To evaluate a suspicious area

• Imaging performed in any projection, with orwithout magnification

Breast Implant Imaging

• The standard series include: the routine CCand MLO projection with modified compres-sion plus implant displaced (ID) projections.

• Standard imaging taken to demonstrate theposterior breast tissue surrounding the mar-gins of the implant. Compression is used forimmobilization only. Vigorous compressioncan rupture the implant.

• Implant-displaced imaging requires pulling thenatural breast tissue forward while simultane-ously pushing the implant back toward the chestwall. Compression is applied only to the breast

tissue. ID projections are taken in the CC,MLO, and sometimes the ML and SIO projec-tions (Figures 5-2a and b).

SPECIAL SITUATIONS

Imaging the Nonconforming Patients

Small Breast

• Manual technique—if the breast does not coverthe first photocell

• Use spatula if necessary• Roll/Tilt patient to affected side• MLO and or FB are generally easier to perform

Male Breast

• Similar to small female breast• FB an option• Chest hair and pectoral muscle can present

problems

Large or Wide Breast

• Use sectional imaging• The breast tissue must overlap.• Label all radiographs for proper evaluation

(eg, MLO upper or MLO lower)

Kyphotic Patients

• FB replaces CC imaging or two CC projections(medial and lateral imaging)

• LMO replace MLO imaging

Pectus Excavatum (Depressed Sternum)

• Two CC projections—to image medial and lat-eral portions of the breast

• CV can be used to image medial breast• LMO replace the MLO imaging

Pectus Carinatum (Pigeon Chest—ProminentSternum) and Barrel Chest (Prominent Ribsand Sternum)

• Routine CC imaging for medial breast plusXCCL for lateral breast tissue

• Routine MLO plus AT to image missed tissue

Elderly Patient

• Chair examination if necessary• Document limitations

Postsurgical Breast

• Postlumpectomy imaging can include CC andML or MLO of the surgical site.• May or may not include magnification

• Postmastectomy imaging or visual inspectionby oncologist.

• Other imaging may include a spot compres-sion of the area of concern, and/or an ATprojection

Irradiated Breast

• Mammograms can be performed 6–12 monthsafter completion of radiation treatment.• Infection control critical

Stretcher/Cart Patients

• CC imaging—patient supine on the stretcher• The x-ray tube is rotated 90 degrees.• CC imaging—patient lateral on the stretcher• Tube rotated 90 degrees. Image FB or CC

• MLO imaging with the tube is positioned at 0degree.• The patient is semiprone or lateral.

Wheelchair Patients

• Use FB or LM if possible• Bolster back of patient or have patient sit

upright• Support/Restrain patient if chair arm is

removed• Transfer patient or build up the patient in

case of nonremovable wheel chair arms

Solving Special Problems

Nipple Not in Profile

• Always image the entire breast first.• If necessary, image the nipple separately—

nipple in profile projections.• Use of nipple markers can prevent unneces-

sary imaging

Skin Folds or Wrinkling of the Breast

• Skin folds or wrinkling may be impossible toavoid in the elderly• Smooth folds or wrinkles using the index fin-

ger during compression.• Avoid pushing folds or wrinkle outside of the

compression field.



A B

C D

Figure 5–2. Complete implant series. Modified compression technique (Eklund method) (A–D) and implaced ID projections (E–H).


E F

G H

Figure 5–2. (continued)


• Eliminated breast tissue must be imaged separately.

Patients with Uneven Breast Thickness

• Reevaluate the patient.• Imaging for the MLO projection should place

the IR parallel to the pectoral muscle.• IR should be positioned in the axilla for MLO

imaging.• Two images for each routine projection—pos-

terior and anterior breast—may be necessary.• Flex paddle avoids overcompression of pos-

terior breast tissue to achieve adequate com-pression of anterior breast.

Patients with Protruding Abdomen

• CC imaging with patient standing away fromthe unit and leaning forward

• MLO imaging using reduce tube angulation

Patients with Frozen Shoulder

• Reverse LMO or LM replace the MLO

SPECIMEN RADIOGRAPHY

The specimen is the breast tissue sample removedduring a biopsy. A radiograph of the specimen isnecessary to ensure the area under suspicion istotally removed and the margins are clean. In imag-ing the specimen:

• Speed and efficiency are important because thepatient may be under anesthesia.

• Always use compression when imaging largerspecimens.

• Magnification may help to visualize microcal-cifications.

Interventional Procedures

Ductography

• Cannulation of the lactiferous ducts and theinjection of a contrast agent• Used to evaluate abnormal nipple discharge,

filling defects, or irregularities.• Radiographs are taken in the CC and ML

(90 degree) positions to determine the loca-tion and number of lesions.

• The examination cannot determine if thelesion is malignant or benign.

• Ultrasound can be used to image the ducts.

Cyst Aspiration

• Drainage or emptying of a cyst using a needle• Cyst aspiration/pneumocystography is per-

formed either under mammographic or ultra-sound guidance.

• A pneumocystograph can be performed afterthe aspiration.

Pneumocystography

• Injection of air in an aspirated cyst to evaluatethe cyst cavity for debris or inner wall of thecyst for abnormal growth.• Ultrasound or mammographic guidance

needed

Preoperative Needle Localization

• Localization of a nonpalpable abnormalities(lesions or microcalcifications) prior to a surgi-cal biopsy• Used if stereo localization is not available• Performed under mammographic or ultra-

sound guidance

Stereostatic Localization

• Use of computerized stereostatic equipment tolocalize a nonpalpable lesion.• Image taken at different angles to triangulate

the exact coordinates of the area.• Computer calculates the precise location of

lesions within the breast.• Stereotactic biopsy can be the prelude to an

FNA, FNB, or core biopsy.

Fine Needle Aspiration/Fine Needle Biopsy(FNA/FNB)

• Use of a small-gauge needle to remove cellularmaterial from the breast for cytological analy-sis, possibly reducing the necessity for a surgi-cal breast biopsy

Core Biopsy

• Use of a large-gauge needle to remove coresamples from the breast. Tissue samples areobtained with an 11- to 14-gauge needle andsent for histological analysis.


• Commercial modifications of the basic corebiopsy technique include minimally inva-sive breast biopsy (MIBB); vacuum-assistedcore biopsy (VACB); and advanced breastbiopsy instrumentation (ABBI).

Large-Core Biopsy

• Removal of 5–20 mm of breast tissue underlocal anesthesia• Not popular because of significant scaring

and complication that can result

Radio Frequency Biopsy

• Use of a radiofrequency (RF) device to removeareas of suspicion• Electrosurgical introducer with a stainless

steel cutting edge inserted into the breastafter local anesthesia

• Introducer positioned under ultrasoundguidance

Nipple Aspiration

• Removal of fluid from the nipple in a processcalled “ductal lavage.”

Open Surgical Biopsy

• Removal of lesion under general anesthesia• Use for difficult-to-approach lesions or lesions

close to the breast surface

Lymph Node Biopsy

• Method used to determine if cancer has spreadto the lymph nodes—axillary node dissection• Generally performed during a mastectomy or

lumpectomy

Ultrasound Biopsy

• The use of high-frequency sound waves toevaluate lesion in the breast• Used to determine if a mass is solid or fluid

filled• Commonly used with FNA/FNB or core biopsy

Magnetic Resonance (MR) Biopsy

• MR imaging takes advantage of the magneticproperties of hydrogen in the body. Imaging usesa strong magnetic and radiofrequency pulses.• MR-guided biopsy used to evaluate lesions

seen only on MR imaging• All equipment used must be MR compatible

1. Which projection is used to determine if alesion is medial or lateral to the nipple?

(A) CC(B) MLO(C) TAN(D) ML

2. If any breast tissue is poorly imaged ormissed on the MLO projection it is likely to be

(A) medial breast tissue(B) lateral breast tissue(C) inferior breast tissue(D) superior breast tissue

3. The posterior nipple line (PNL), visualizedon the ML, should be within how many cen-timeters of the PNL on the CC?

(A) 0.25(B) 0.50(C) 1.00(D) 1.50

4. Which of the following conditions must bemet when imaging the breast in the MLO?

1. The pectoral muscle should extend to orbelow the PNL.

2. Visualized fat should be posterior to allthe fibroglandular tissues.

3. The inframammary fold (IMF) should beopen.


5. In positioning for the CC projection, if the C-arm of the mammography unit is raised toohigh the IMF is overelevated, resulting inloss of

1. superior breast tissue2. inferior breast tissue3. posterior breast tissue


6. The single projection that will best visualizethe maximum amount of breast tissue is the

(A) CC(B) MLO(C) ML(D) XCCL

7. In general, when imaging tall, thin patientsthe angulation is adjusted to

(A) below 30 degrees(B) between 30 and 40 degrees(C) close to 60 degrees(D) almost 70 degrees

8. The position used to determine whether anabnormality is superior or inferior to thenipple is the

(A) CC(B) MLO(C) XCCL(D) TAN

87

Questions


9. The principle of mobile versus fixed tissue isused in mammography imaging to image themaximum

(A) medial breast on the MLO projection(B) inferior breast on the CC projection(C) superior breast on the MLO projection(D) medial tissue on the CC projection

10. In the CC projection of the breast, the IR ispositioned

(A) at the level of the raised inframammarycrease

(B) below the level of the raised inframam-mary crease

(C) at the level of the inframammary crease(D) just below the level of the inframam-

mary crease

11. In positioning for the MLO, the tube isalways angled

(A) 90 degree(B) 60 degree(C) 50 degree(D) none of the above

12. What projection/position is shown in Figure 5-3?

(A) CC(B) MLO(C) CV(D) XCCL

13. When positioning for the right CC, where isthe patient’s left arm placed?

(A) Brought back. This action rotates theshoulder to remove it from the imagingarea.

(B) Brought forward. The patient can holdthe handle bar of the unit.

(C) Brought forward. The patient can holdthe IR.

(D) Remains at the patient’s side.

14. Your patient has had recent chest surgeryand has a scarred and painful area runningalong the sternum. With the medial aspect ofthe breast immobile, which of the followingis an alternative to the RMLO?

(A) RLMO(B) LMLO(C) LLM(D) RML

15. Which projection is best used to visualize thetail of the breast?

(A) LMO(B) TAN(C) LM(D) AT

16. Calcifications seen on the mammogram aresuspected to be in the skin. The best projec-tion necessary to prove this theory is the

(A) LMO(B) TAN(C) LM(D) AT

17. The projection best used to demonstrate thetrue representation of medial breast struc-tures in relation to the nipple is the

(A) LM(B) AT(C) ML(D) TAN

Figure 5–3. (© 2000 The American Registry of Radiologic Technologists.)

18. A lesion on the lateral aspect of the breast isnot seen on the CC. An additional projectionused to image the lesion could be the

(A) CV(B) XCCL(C) FB(D) TAN

19. Which projection can be used instead of theCC to image patients with severe kyphosis?

(A) ML(B) TAN(C) FB(D) CV

20. A lesion moved up on the ML projectionfrom its original position on the MLO. Thelocation of the lesion within the breast is

(A) laterally(B) medially(C) inferiorly(D) superiorly

21. Which projection is used to prove breast cal-cifications are benign (teacup type)?

(A) CC(B) XCCL(C) FB(D) ML

22. Which projection is used to give a profileimage of the area in question without super-imposition of breast tissue?

(A) CV(B) TAN(C) LMO(D) AT

24. A barrel-chested patient whose chest wallprotrudes outward may have breast tissueextending laterally under the arm. What pro-jection, used to image the breast with thebeam directed superiorly to inferiorly, shouldbe taken in addition to the CC?

(A) AT(B) XCCL(C) CV(D) MLO

25. The FB projection can be useful in imaging

1. nonconforming patients2. abnormalities high on the chest wall or

superior aspect of breast3. inferior lesions or lesions near the IMF




23. Identify the position/projection shown inFigure 5-4.

(A) FB(B) XCCL(C) ML(D) AT


26. Identify the projection shown in Figure 5-5.

(A) MLO(B) CV(C) LM(D) ML

29. In which modified projection is the superioraspect of the breast rolled medially?

(A) RM(B) RL(C) M(D) LM

30. In the LMO projection, the beam is directedfrom the

(A) upper inner aspect to the lower outeraspect of the breast

(B) inner outer aspect to the upper outeraspect of the breast

(C) lower outer aspect to the upper inneraspect of the breast

(D) superolateral aspect to the inferomedialaspect of the breast


(A) MLO(B) CV(C) LM(D) ML

Figure 5–5. (© 2000 The American Registry of Radiologic Technologists).

27. Why is the MLO preferred to the ML as aroutine projection?

(A) The MLO visualizes the medial breast.(B) The ML does not visualize the medial

breast.(C) The ML poorly visualizes the posterior

and lateral breast.(D) The MLO does not distort the anterior

structure of the breast.

28. Which projection best shows the extrememedial aspect of the breast?

(A) CC(B) MLO(C) ML(D) CV



(A) RM(B) CV(C) RL(D) MLO


33. Which projection is especially useful whenanalyzing calcifications?

(A) RM(B) M(C) LM(D) ML


(A) RM(B) CV(C) RL(D) MLO

35. All of the following statements about magni-fication are true except

(A) With magnification, patient doseincreases.

(B) Magnification can be used to imagespecimen radiographs.

(C) Magnification can be used to assess sus-picious lesions.

(D) Magnification images the entire breastwith one exposure.

36. In the RS position, the surface __________ theIR is rolled _______.

(A) furthest from/inferiorly(B) closest to/superiorly(C) furthest from/superiorly(D) closest to/inferiorly

37. Which technique accurately describes howthe breast is rolled for the RM?

(A) The superior surface is rolled mediallyand the inferior surface does not move.

(B) The superior surface is rolled laterallyand the inferior surface is rolled medially.

(C) The inferior surface is rolled mediallyand the superior surface does not move.

(D) The inferior surface is rolled laterally andthe superior surface is rolled medially.

38. A patient with pectus excavatum may pre-sent a positioning problem because thepatient has

(A) extensive pectoral muscle(B) barrel chest(C) kyphosis(D) depressed sternum

39. In imaging the augmented breast in the CCposition, using the modified implant-displaced technique, the breast tissue ispulled/pushed

(A) anteriorly(B) posteriorly(C) inferiorly(D) superiorly

Rolled Lateral(RL)




40. A routine series on patients with encapsu-lated implants could include an additionalprojection such as the

(A) AT(B) CC(C) MLO(D) ML

41. Which of the following is used to spread outthe tissue and improve resolution on a local-ized area of interest?

(A) CV(B) AT(C) TAN(D) spot compression

42. How many projections are routinely requiredto image a patient with implant augmentedbreasts?

(A) 5(B) 6(C) 7(D) 8

43. When is imaging of the irradiated breast recommended?

(A) immediately after treatment(B) 1–2 months after treatment(C) 6–12 months after treatment(D) 1–2 years after treatment

44. Which of the following can be used with anyprojection with or without magnification?

(A) spot compression(B) XCCL(C) AT(D) CV

45. In addition to the routine series, many post-mastectomy patients will also need a

(A) CC(B) MLO(C) ML(D) CV

46. The standard projection taken on patientswith breast implants requires compression

1. for immobilization only2. to separate the breast tissue3. to assess areas of lumps


47. The specimen is radiographed to

(A) confirm that the lesion was removed(B) compare various needle localization

techniques(C) magnify the lesion to assess any possible

microcalcifications(D) check the position of the lesion

48. The specimen is compressed to

(A) reduce motion unsharpness(B) reduce radiation exposure(C) reduce tissue thickness(D) reduce the magnification factor

49. Which procedure is performed to obtain cel-lular material from a suspicious area for cyto-logical analysis?

(A) Ductography(B) Needle localization(C) Pneumocystogram(D) Fine needle aspiration (FNA)

50. Preoperative localization will

1. direct the surgeon to the area requiringbiopsy

2. help the surgeon to excise a smallerspecimen

3. ensure that the correct area wasremoved



51. Core biopsy techniques developed as an alter-native to surgical biopsy because this tech-nique provided a larger sample of the area ofsuspicion and thus more information than

(A) ductography(B) needle localization(C) pneumocystogram(D) FNB

52. An ultrasound of a lesion showed a sphericalmass with smooth regular borders, anechoicinterior, and acoustic enhancement. Thelesion is likely to be a

(A) fibroadenoma(B) abscess(C) simple cyst(D) ductal carcinoma

53. In ultrasound, the term acoustic enhancementrefers to

(A) a structure without internal echoes(B) a structure with internal echoes(C) the amount of sound passing through a

structure(D) few echoes within a structure

54. A procedure whereby the lactiferous duct iscannulated and a small amount of contrastagent is injected into the duct is termed

(A) ductography(B) needle localization(C) pneumocystogram(D) FNA

55. A patient had an ultrasound, which con-firmed the presence of a cyst in the breast.The radiologist wished to rule out intracystictumor. What additional study could be recommended?

(A) ductography(B) needle localization(C) pneumocystogram(D) FNA

56. Biopsy performed using a 14-gauge needle toremove tissue samples from the breast istermed

(A) core biopsy(B) cytology(C) ductography(D) aspiration

57. Which of the following techniques use asmall-gauge needle to obtain cellular samplesfrom a lesion?

(A) core biopsy(B) FNB(C) ductography(D) ductal lavage

58. Stereotactic breast localization is used to

(A) obtain two-dimensional information onpalpable breast lesions

(B) calculate the vertical position of nonpal-pable lesions

(C) obtain a three-dimensional image of thebreast

(D) calculate the horizontal, vertical, anddepth position of nonpalpable lesions

59. A cyst aspiration can only be performed

(A) under ultrasound guidance(B) using mammographic imaging(C) using MRI guidance(D) none of the above

60. Which of the following biopsy techniques ismost accurate?

(A) FNB(B) open surgical biopsy(C) core biopsy(D) MRI core biopsy

1. (A) CC projection determines whether thelesion is medial or lateral and how far it isfrom the nipple. The MLO or ML determinesif the abnormality is superior or inferior tothe nipple and how far posterior it is. TheTAN projection skims the area of interest andis best used to determine if a suspectedabnormality is located in the breast or theskin of the breast (ACR, 43–49; Peart, 115–146).

2. (A) The MLO best demonstrates the posteriorand upper-outer quadrants of the breast. Agood MLO must include both the superiorand inferior portions of the breast. However,it may not be possible to image the medialarea on all patients in the MLO projection.Often, the medial breast is distorted. The CCprojection will cover this portion of medialtissue that is most likely to be missed on theMLO (ACR, 43; Peart, 115–146).

3. (C) The PNL measures the perpendicular dis-tance from the nipple to the visualized pectoralmuscle on the MLO or from the nipple to theedge of the image on the CC (Figure 5-9). Thismeasurement on the MLO should be within1 cm of the measurement on the CC projec-tion. In 10% of cases, the PNL will be greateron the CC (ACR, 43–49; Peart, 115–146).

4. (D) In general, guidelines for the MLO includeall of these statements. Additionally, the breastshould not droop on the image. It may not bepossible to meet all these guidelines on allpatients. If one or more of these guideline ele-ments are missing, the mammographer or radi-ologist must determine whether a third projec-tion is necessary (ACR, 34–42; Peart, 115–146).

5. (B) If the C-arm is raised too high, IR will ele-vate the patient’s inframammary fold orcrease and the patient will be unable to leanforward and relax. This results in loss of the


94

PNL PNL

PNL PNL

Figure 5–9. Showing the PNL. Measurement of the posterior nip-ple line (PNL) on the MLO projection should be within 1 cm of thePNL measurement on the CC projection. In about 10% of cases,the PNL will be greater on the CC projection.


posterior and inferior breast tissue. If the IRis too low, the breast droops and superiorand posterior tissue is lost (Peart, 115–146).

6. (B) The MLO best visualizes the posteriorand upper-outer quadrants of the breastwhile allowing distortion and overlap of theanterior structures. However, it is the singlebest projection to visualize a maximumamount of breast tissue. The CC does notimage the lateral breast while the ML doesnot image the posterior breast. The XCCLwill miss the medial breast (ACR, 34; Peart,115–146).

7. (C) In imaging the MLO, the edge of the IR isplaced parallel to the oblique line formed bypectoral muscle. This oblique line varies inindividuals; tall, thin patients require steeperangulations (50–60 degrees), average patientsrequire 40–50 degrees and short, heavypatients 30–40 degrees. The angle is usuallythe same for both breasts. Male breast mayrequire even steeper angulations (ACR, 60–62;Peart, 115–146).

8. (B) The MLO or ML determines if the abnor-mality is superior or inferior to the nipple andhow far posterior it is. The CC or XCCL pro-jections determine whether the lesion ismedial or lateral and how far it is from thenipple. The TAN projection skims the area ofinterest and is best used to determine if a sus-pected abnormality is located in the breast orthe skin of the breast (ACR, 43–49; Peart, 115–146).

9. (A) The breast is least mobile at the medialand superior aspects and most mobile at thelateral and inferior aspects. To image the max-imum amount of breast tissue, the mostmobile parts of the breast must be placedadjacent to the IR while applying compres-sion from the least mobile aspect of the breast.In most cases, compression is applied fromthe superior aspect for the CC projections—(to image the maximum amount of superiorand posterior breast) and from the medialaspect for the MLO projections (to image themaximum amount of medial and posteriorbreast) (ACR, 34; Peart, 115–146).

10. (A) The IR must be placed at the level of theelevated IMF or crease. If the IR is raised toohigh, the patient will be unable to lean for-ward and relax. This results in loss of poste-rior and inferior breast tissue. If the IR is atthe IMF or is too low, the breast droops andsuperior and posterior tissues will be lost(Peart, 115–146).

11. (D) In imaging for the MLO, the edge of theIR is placed parallel to the oblique lineformed by pectoral muscle. This oblique linevaries in individuals; tall, thin patientsrequire steeper angulations (50–60 degrees),average patients require 40–50 degrees andshort, heavy patients 30–40 degrees. Theangle is usually the same for both breasts(ACR, 60–62; Peart, 115–146).

12. (A) In the (CC) projection, the beam isdirected superiorly to inferiorly, withoutangulation. The MLO uses tube angulation.The CV shows the medial breast from the CCposition and the XCCL images the lateralportions of the breast in the CC position (CR,43–49; Peart, 115–146).

13. (B) Having the patient hold the supportingbars with the contralateral hand stabilizes thepatient and helps to bring medial breast tis-sue closer to the IR. This is important becauseeliminating medial breast tissue from the CCprojection may eliminate this tissue from thestudy. The patient holding the IR can projectbody parts in the image (Peart, 115–146).

14. (A) The right lateromedial oblique (RLMO) isa useful alternative to the right mediolateraloblique (RMLO) in patient with prior pace-maker surgery, open-heart surgery, or anyother painful scarring along the sternumwhere the compression paddle would causediscomfort by pulling on scar tissue. The lat-eromedial oblique (LMO) projection is a truereverse of the MLO and will demonstrate thesame anatomical structures. The ML will notdemonstrate adequate posterior breast. TheLM can often be used to replace the MLO inthe nonconforming patient but in this examplea right LM would be needed (Peart, 115–146).


15. (D) The AT or axilla projection demonstratesthe axillary contents or tail of the breast. It isalso called the tail of Spence. This projection isespecially useful in demonstrating swollenlymph nodes (lymphadenopathy). The studymay be unilateral or bilateral. LMO is thereverse of the MLO with an oblique beam trav-eling from inferiolateral to superior-medial.The TAN is used to image lesions in the skinand the LM is a 90-degree lateral, which can beused to image the medial breast (Peart, 115–146).

16. (B) The TAN projection is used to skim thearea of interest. The projection demonstratesskin calcifications or areas free of superimpo-sition. The TAN projection also brings thearea closer to the IR. Before obtaining a TANprojection, the abnormality must be palpableor visualized on another projection to deter-mine its approximate location. In the LM,the beam travels from lateral to medial at90 degrees and best images the medial breast.LMO is the reverse of the MLO with anoblique beam traveling from inferiolateral tosuperior-medial. The AT or axilla projectiondemonstrates the axillary contents or tail ofthe breast (Peart, 115–146).

17. (A) With the nipple in profile, both the MLand the LM are lateral projections that willshow the breast structures in relation to thenipple. With the medial breast closest to theIR, the LM projection is best suited to imagemedially located abnormalities and will givethe best image detail; the ML images lateralabnormalities best. In addition, unlike theimage produced with the ML, the resultantimage from the LM is similar to the MLO.The AT images the tail of the breast and theTAN best images skin lesion and calcifica-tions (Peart, 115–146).

18. (B) The XCCL will best image the posterolat-eral tissue of the breast, which may not bevisualized on the CC. The FB is the reverse ofthe CC with the beam traveling from inferiorto superior (caudocranial). The TAN gives atangential projection of the area of interestand the CV images the medial breast in theCC position (Peart, 115–146).

19. (C) A patient with kyphosis may also havepectus excavatum (sunken chest), barrel-chest or pectus carinatum (pigeon breast).With these patients, it is rarely possible toimage the entire breast with the standard twoprojections. An FB projection in such a situa-tion is often useful. For the FB, the entiremammography unit is rotated 180 degreesand the IR is placed at the superior aspect ofthe breast. If the FB is not possible because oflimitations of the mammography unit, theCC should be performed to image as muchmedial tissue as possible. Alternatively, theCV can be used to image both medial breastswith a right and left CC for the lateral por-tion of the breast. In addition, the MLO,LMO, or LM will complete the series (Peart,115–146; Venes, 1610).

20. (B) When comparing the MLO to the ML insearch for an abnormality, medial lesionsmove up on the lateral from their position onthe MLO; lateral lesions move down on thelateral from their position on the MLO. Cen-trally located lesions show little or no move-ment (Peart, 115–146).

21. (D) Milk of calcium deposits are benign calci-fications that occur in microcysts asradiopaque particles mixed with fluid. On theCC, XCCL, or FB projections, they will appearas ill-defined calcifications. On a true lateralprojection, such as the ML, the radiopaqueparticles settle to the dependent portion ofthe cyst, forming crescent- or teacup-shapedcalcifications. These may be clustered, scattered,or occur bilaterally (Peart, 115–146).

22. (B) The TAN projection is used to skim thearea of interest. The projection demonstratesskin calcification or any area free of superim-position. The TAN projection also brings thearea closer to the IR. The CV images themedial breast, and both the LMO and the ATare oblique projections (Peart, 115–146).

23. (D) The AT projection is a 20-degree obliqueanterior-posterior projection used to visualizethe axillary area or tail of the breast. Gener-ally, the degree of angulation can depend on


the patient’s body habitus. In the ML, the beamtravels from lateral to medial at 90 degreesand best images the lateral breast. The XCCLimages the lateral portions of the breast inthe CC position, and the FB is a caudocranialprojection that best images the superiorbreast tissue (Peart, 115–146).

24. (B) The XCCL can be used to image theextreme posterolateral tissue missed on theCC. As with the CC projection, the beam isdirected superiorly to inferiorly. The CVimages the medial breast and the MLO andAT are oblique projections (Peart, 115–146).

25. (A) The caudal-cranial, FB, projection is thereverse of the CC and can be used to imagenonconforming patients, such as those withextreme kyphosis. The FB also places supe-rior lesions that are high on the chest wallcloser to the IR, providing more detail of thelesion. Inferior lesions are imaged furthestfrom the IR (Peart, 115–146).

26. (C) The LM projection gives a true representa-tion of breast structure in relation to the nipple.The LM places medially located lesions closeto the IR. For the LM, the beam is directed lat-erally to medially. The CV shows the medialbreast from the CC position. In the ML, thebeam travels from lateral to medial at 90 degreesand best images the lateral breast. The MLO isa routine projection with the beam travelingfrom superior-medial to inferiolateral (Peart,115–146).

27. (C) The MLO projection gives a distorted andoverlapping image of the anterior and medialstructures of the breast because it is anoblique project. However, it is the single bestprojection used to image the breast in itsentirety. The MLO is also best at visualizingthe posterior and upper-outer quadrants ofthe breast. The ML is poor at visualizing themost posterior and lateral parts of the breastand is not useful in visualizing areas of thebreast missed on the MLO (Peart, 115–146).

28. (D) The CV projection is the best at imagingthe extreme medial aspect of the breast with

the beam directed craniocaudal. The CC is aroutine projection and will image medialbreast tissue, but not extreme medial tissue.The MLO distorts the medal breast and theML often misses the medial breast (Peart,115–146).

29. (A) The rolled image helps to move superim-posed breast tissue away from a suspectedlesion. The breast is rolled in equal and oppo-site directions through physical manipulationof the patient’s breast. The rolled projectionscan be performed in any direction. For theRM, the breast is first positioned for the CCprojection. The upper surface is then rolledmedially and the lower surface is rolled later-ally. For the RL, the upper surface is rolledlaterally and the lower surface is rolled medi-ally. “M” indicates magnification and ML is a90-degree lateral projection (Peart, 115–146).

30. (C) The LMO is a reverse of the MLO andresults in a similar image. For the LMO, thebeam is directed from the inferolateral (lowerouter) aspect of the breast to the superome-dial (upper inner) aspect In the LM, the beamtravels from lateral to medial at 90 degreesand best images the medial breast. The ML isalso a true lateral, with the beam travelingfrom lateral to medial. The MLO is a routineprojection with the beam traveling fromsuperior-medial to inferiolateral (ACR, 71;Peart, 115–146).

31. (B) The CV is a cranial–caudal projectionused to image the extreme medial aspect ofthe breast (Peart, 115–146).

32. (C) In the rolled image, the breast is rolled inequal and opposite directions via physicalmanipulation of the patient’s breast. For theRM, the patient is position for the CC projec-tion. The upper surface of the breast is thenrolled medially and the lower surface isrolled laterally. For the RL, the patient is alsopositioned for the CC projection. The uppersurface of the breast is rolled laterally and thelower surface is rolled medially. The MLO isa routine projection with the beam travelingfrom superior-medial to inferiolateral. The


CV shows the medial breast from the CCposition (Peart, 115–146).

33. (B) Magnification mammography (M) isespecially useful in assessing or findingbreast calcifications, or to better outline theborders of masses. The other projection willimage the calcification but do not provide amagnified image of the area of concern. TheMLO is a routine projection with the beamtraveling from superior-medial to inferiolat-eral. The CV shows the medial breast fromthe CC position (Peart, 115–146).

34. (A) In the rolled image, the breast is rolled inequal and opposite directions via physicalmanipulation of the patient’s breast. For theRM, the patient is positioned for the CC pro-jection. The upper surface of the breast isthen rolled medially and the lower surface isrolled laterally. For the RL, the patient is alsopositioned for the CC projection. The uppersurface is rolled laterally and the lower sur-face is rolled medially (Peart, 115–146).

35. (D) With magnification, the breast may bemagnified up to twice its original size; there-fore, the entire breast is rarely imaged. Thepatient’s skin dose increases because thebreast is closer to the source plus additionalexposure is required because of reciprocitylaw failure. Magnification can be used toimage specimens and lesions and to assessthe borders or the presence of calcifications(Bushong, 327–340; Peart, 115–146).

36. (C) For the RS, the patient is positioned for theML. The surface of the breast away from the IRis rolled superiorly and the lower surface isrolled inferiorly. For the RI, the patient is posi-tioned for the ML. The surface of the breastaway from the IR is rolled inferiorly and thelower surface is rolled superiorly (Peart, 115–146).

37. (D) For the RM, the patient is positioned forthe CC projection. The upper (superior) sur-face of the breast is rolled medially and thelower (inferior) surface is rolled laterally. Forthe RL, the patient is positioned for the CCprojection. The upper (superior) surface is

rolled laterally and the lower (inferior) sur-face is rolled medially (Peart, 115–146).

38. (D) A patient with pectus excavatum has asunken or depressed sternum and rib cage,which make imaging the medial and lateralbreast tissue difficult on the routine CC projec-tion. Extensive pectoral muscle is mainly aproblem when imaging males in the MLO pro-jection. In barrel chest, the chest protrudes andthe kyphotic patient has exaggerated thoraciccurvature or rounded shoulders (Peart, 115–146).

39. (A) In the modified ID projections, the pros-thesis is displaced posteriorly and superiorlyagainst the chest wall while gently pullingthe breast tissue anterior away from the pros-thesis, onto the IR. The implant or prosthesisis held in place with the compression device(ACR, 73; Peart, 115–146).

40. (D) The routine series for an implant patientincludes the routine CC, routine MLO, CCwith ID, and MLO with ID. It may be difficultto displace the implant on some patients,especially if the implant is encapsulated. If itcannot be adequately displaced, another pro-jection (such as the 90-degree lateral with theimplant included) should be added to the rou-tine CC and MLO projections of the implant.Imaging the patient in three projectionsensures visualization of some parts of all fourquadrants of the breast. The AT could be usedto evaluate silicone spread into the lymphnodes. Another useful projection to imageencapsulation is the SIO (ACR, 73; Peart, 115–146).

41. (D) The spot compression projection focusesthe compression on a single area to improveresolution and evenly spread out the breast tis-sues. This is sometimes useful in eliminatingpseudomasses. The TAN images skin lesion.The CV images the medial breast and the ATimages the axillary tail (ACR, 54; Peart, 115–146).

42. (D) The routine series for an implant patientincludes the routine CC, routine MLO, CCwith ID, and MLO with ID. The total projec-tions per patient would therefore be eight(ACR, 73; Peart, 115–146).


43. (C) Radiation-induced changes in the breastusually peak at 6 months after treatment, butmay continue for up to 1 year. Initially, thebreast may exhibit erythema and edema, or itmay harden. The breast may also be extremelysensitive and distorted because of surgery.Although the mammography examinationmust be adapted for each patient, a mammo-gram is not recommended earlier than 6 monthsafter radiation treatment (Peart, 115–146).

44. (A) Spot compression focuses compression ona single area to improve resolution and evenlyspread out the breast tissues. This is sometimesuseful in eliminating pseudomasses. Spot com-pression can be taken with or without magnifi-cation and in any projection. XCCL, AT, andCV are all specific supplementary projectionswith set central ray directions and tube orien-tations (ACR, 54; Peart, 115–146).

45. (C) With postmastectomy imaging, it is nolonger possible to make a comparison betweentwo “mirror-image” breasts. Therefore, anadditional projection will give the radiologist abetter opportunity to diagnose cancer. The MLor LM is often the preferred additional projec-tion. The CC and the MLO are routine projec-tions and the CV shows the medial breast fromthe CC position (Peart, 115–146).

46. (A) Caution should be used when compress-ing implants to avoid implant rupture. Com-pression should therefore be used for immo-bilization only and not to separate breasttissue structures. TAN projections and mag-nification could be used to evaluate lumpsand calcifications, respectively. The implantdisplaced (ID) compression technique is usedto image portions of the breast that wouldnot be visualized because of superimpositionof the implant (Figure 5-10) (Peart, 115–146).

47. (A) The specimen is radiographed to ensurethat the lesion was removed. The lesionshould be circled on the radiograph and allthe borders checked to confirm that the entirelesion was removed. The specimen can be mag-nified, especially if calcifications are present tocount and confirm that all the calcifications

have been removed (Andolina, 313–400; Peart,115–146).

48. (C) Compression of the specimen reduces tis-sue thickness, thus improving subject con-trast. Structures are spread out, and tissuedensity is uniform with less superimpositionof structures. The specimen can also be mag-nified to image calcifications. The overalleffect is improved visualization and a moreuniform density. Motion unsharpness andradiation reduction is not an issue in speci-men imaging. Compression will improvevisualization of structures in the magnifiedspecimen but will not alter the magnificationfactor (Andolina, 313–400; Peart, 115–146).

49. (D) FNA obtains cellular material for cyto-logical analysis. FNA uses small-gauge nee-dles (23 gauge), which limits the amount ofcells that can be aspirated. The accuracy ofthe procedure depends on the radiologistperforming the examination and the cytolo-gist interpreting the results. Ductographycannulates a duct to introduce a contrastagent. Needle localization positions a guidewire in a nonpalpable lesion for surgicalremoval. Pneumocstogram injects air in acyst for analysis of the inner lining of the cyst(Andolina, 313–400; Peart, 203–217).

50. (D) Preoperative localization is performed onnonpalpable lesions or suspicious areas thatare identified only mammographically. Theradiologist assists the surgeon by placing awire in the suspected tissue as a guide for thesurgeon. The surgeon is then able to exciseonly the lesion and surrounding marginsrather than a larger area of the breast. Onceexcised, the wire in the area of suspicion con-firms that the correct area was removed(Andolina, 313–400; Peart, 203–217).

51. (D) Core biopsy provides a larger sample ofbreast tissue for histological study. The largersample (generally an 11- to 14-gauge needleis used) offers a more definitive diagnosiswhen compared with FNB. Ductography can-nulates a duct to introduce a contrast agent.Needle localization positions a guide wire in


a nonpalpable lesion for surgical removal.Pneumocstogram injects air in a cyst foranalysis of the inner lining of the cyst(Andolina, 313–400; Peart, 203–217).

52. (C) A fibroadenoma usually has low-levelinternal echoes and the borders may besmooth, round, or lobulated. An abscess willbe fluid filled and usually has some internalechoes. Their borders are generally welldefined, but irregular. Ductal carcinomas typ-ically are taller than they are wide—benign

masses spread out horizontally. Cancers havea spiculated outline with alternatingechopenic and echogenic straight lines radiat-ing from the surface of the mass (echopenicmeans there are few echoes within a struc-ture; echogenic describes a structure that pro-duces echoes; anechoic means no internalechoes). A cyst is usually fluid filled withsmooth walls that allow transmission ofsound. Sound traveling through a fluid-filledstructure is barely attenuated; the structuresdistal to a cystic lesion appear to have more

Figure 5–10. Diagram of the Eklund method (ID technique). The ID or implant-displaced technique or Eklund method for implants displacesthe implant posteriorly and superiorly to image the breast tissue free of the implant. (A) Normal compression. (B and C) Displacing the implantposteriorly and superiorly prior to compression. (D) Compression of the breast tissue free of implant.


echoes than neighboring areas. This process isalso referred to as distal echo enhancement. Itis rare for calcifications in a cyst wall ordebris within the cyst to present throughtransmission (Peart, 147–162).

53. (C) If the sound traveling through a cyst isbarely attenuated then the structure distal tothe cyst appears to have more echoes thanneighboring areas. The phenomenon isreferred to as acoustic enhancement orthrough transmission (Peart, 147–162).

54. (A) Ductography or galactography can beperformed on patients with nipple discharge.A small amount of contrast agent is injectedinto the duct and radiographs are taken in theCC and lateral positions. The contrast agentoutlines these structures to visualize anypathology. Needle localization positions aguide wire in a nonpalpable lesion for surgi-cal removal. Pneumocstogram injects air in acyst for analysis of the inner lining of the cyst.FNA removes fluid from a cystic lesion forcytologic analysis (Andolina, 313–400; Peart,203–217).

55. (C) A pneumocystogram may be performedin conjunction with cyst aspiration. Air isinjected into the cyst, which has been emp-tied. The inner walls of the cyst can then beassessed. In general, the air is reabsorbed bythe body within a week. Ductography exam-ines the ducts; needle localization is used tolocate nonpalpable lesions, and FNA can beused to remove the content of a cyst (Andolina,313–400; Peart, 203–217; Tabár, 89).

56. (A) Breast biopsy is the taking of a samplespecimen of breast cells or tissue for cytologi-cal or histological analysis. In a core biopsy, alarge-gauge needle (11–16 gauge) is used toremove tissue samples. The core biopsy nee-dles can be mechanical or automatic core“guns” with an inner needle. These needlegun combinations are designed to move acutting needle rapidly through the breast toobtain a tissue sample. Core biopsies can beperformed under mammography, ultra-sound, or MRI guidance. Cytology refers to

the study of cells. Ductography is used toevaluate patients with abnormal nipple dis-charge. The lactiferous duct is cannulatedand a small amount of contrast agent isinjected before the area is imaged. Aspirationis a method of removing fluid from a cystusing a needle (Figure 5-11) (Andolina, 313–400;Peart, 48, 203–212).

A

B

C

D

Figure 5–11. Core biopsy gun (A) prefire; (B) trough without theneedle; (C) postfire into the lesion—the needle moves forward, fill-ing the trough with breast tissue; and (D) postfire the outer sheathmoves forward to cut the tissue and keep it in the trough.

57. (B) FNA is a technique used to obtain cellularmaterial from a lesion for cytological analy-sis. FNA can reduce the need for a surgicalbreast biopsy. Because the technique is per-formed using a small-gauge needle (20–25),the accuracy of the procedure is dependenton the skills of the radiologist or surgeon per-forming the procedure. During the proce-dure, the presence of a cytotechnologist orcytopathologist is recommended to verify theadequacy of the cell samples and to preparethe slides. Core biopsies can be performedunder mammography, ultrasound, or MRIguidance. Cytology refers to the study ofcells. Ductography is used to evaluatepatients with abnormal nipple discharge. Thelactiferous duct is cannulated and a smallamount of contrast agent is injected beforethe area is imaged. Ductal lavage is a tech-nique used to collect cells from the lining ofthe milk duct (Andolina, 332; Peart, 209–215).


58. (D) Stereology is the science of determiningthe three-dimensional location of an objectbased on two-dimensional images. Stereotac-tic breast localizations can be used to locatethe horizontal, vertical, and depth positionof nonpalpable lesions. A computer performsthe necessary calculations therefore if theinput information is inaccurate, errors inlocalization will result (Andolina, 334; Peart, 204).

59. (D) Cyst aspiration removes the contents of acyst for analysis. Although the technique isoften done with ultrasound guidance, aspira-tions can be performed under mammo-graphic guidance for nonpalpable lesions orclinical guidance for large palpable cyst. MRIaspirations are not common because oftencysts, if not visualized on mammography, arevisualized on ultrasound. The needle sizeused depends on the viscosity and thicknessof the fluid content of the cyst but generally a

small gauge (eg, 21 gauge) is used to reducepatient discomfort (Andolina, 322; Peart, 204).

60. (B) The open surgical biopsy is the most inva-sive procedure, but it has the lowest false-negative rates. Open surgical biopsies willneed more hospital time, require anesthesia,and will leave visible scars on the breast.These factors all contribute to a higher compli-cation rate with open biopsy than with theother minimal invasive procedure. FNB is thecheapest but least accurate biopsy method.The main cause is insufficient samples becauseof the small-needle gauge used. Core biopsy ishas a lower false-negative rate than FNB, butagain insufficient samples can reduce theaccuracy. MRI-guided biopsy is usually usedfor lesions seen only on MR imaging. Thetechnique involves the removal of core sam-ples and is considered a minimally invasiveprocedure (Andolina, 313–400; Peart, 203–217).

103

CHAPTER 6

Practice Test 1Questions

1. A clinical breast examination (CBE) andbreast self-examination (BSE) are similar inthat both

(A) involve looking and feeling for changesin the breast

(B) are done by a trained medical profes-sional

(C) are done monthly(D) are done yearly

2. The most common cause of undercompres-sion is

(A) a faulty compression paddle(B) inadequate compression by the

mammographer(C) patient pain tolerance level(D) broken automatic compression device

3. In establishing processor quality control(QC), the high average density is generallythe density closest to

(A) but not less than 2.20(B) but not less than 1.20(C) but not less than 0.45(D) 2.20

4. Ductal papilloma is

(A) a benign proliferation of tissue in themale breast

(B) a malignant tumor involving the ducts(C) a collection of blood in the breast, which

can occur after surgery(D) benign growths involving the milk ducts

5. The large air gap used in magnification func-tions to

1. increase scatter 2. improve contrast3. reduce scatter


6. In high-contrast imaging or conventionalimaging

(A) skin detail is easily seen(B) bright light is needed to see skin detail(C) glandular tissue and skin detail are seen

equally(D) glandular tissue and skin detail are seen

poorly

7. Which of the following could be used whenimaging extremely small breasts in the cran-iocaudal (CC) position?

(A) spatula(B) ML(C) cleavage (CV)(D) exaggerated craniocaudal (XCCL)


104 6: Practice Test 1

8. In the tangential (TAN) projection, any tubeangulation will depend on

(A) the size of the patient’s breast(B) the location of the abnormality(C) the location of the nipple in relation to

the abnormality(D) whether the abnormality is palpable or

nonpalpable

9. A small but growing cancer is often not obvi-ous to the individual because it often pre-sents as

(A) skin irritation(B) inverted nipples(C) a painless mass(D) a painful mass

10. Mammography is more accurate in

(A) premenopausal women(B) postmenopausal women(C) women with fibrocystic breast(D) women with dense breast tissue

11. In taking medical history, hormones use(both natural and artificial) are taken intoaccount because

1. hormones cause breast cancer2. early menarche can increase breast

cancer risks3. contraceptive use can increase breast

cancer risk


12. One major difference between collimation inmammography and collimation in generalradiography is that

(A) in mammography the entire imagereceptor area is exposed

(B) decreasing collimation increases expo-sure in mammography

(C) mammography uses a variety of beam-limiting devices

(D) in radiography the entire image receptorarea is always exposed

13. Two film emulsions are compared on a char-acteristic curve. The higher contrast film will

(A) have the steeper slope(B) have a longer toe(C) shift to the right of the lower contrast

film(D) shift to the left of the lower contrast film

14. When cleaning the intensifying screens, theloaded cassette is unloaded under safelightconditions in the darkroom. The film in thecassette is

(A) stored in the film bin during the clean-ing process

(B) removed from the cassette and dis-carded

(C) returned to the cassette after cleaning(D) returned to the film bin

15. The retromammary space is filled with

(A) supportive and connecting tissue(B) adipose tissue(C) fibroglandular tissue(D) blood vessels


16. The fatty versus fibroglandular nature ofbreast tissue is affected by which of the following?

1. age2. hormone use3. number of pregnancies


17. In compression on the XCCL projection, theaffected arm should

(A) not be raised, but rest along the top ofthe image receptor

(B) be raised, with hand resting/holding onbar of unit

(C) be place on the patient’s hips(D) be placed according to the wishes and

comfort of the patient

18. In the CC position the pectoral muscle is seen

(A) all the time(B) rarely if ever(C) about 30%–40% of the time(D) about 50% of the time

19. Between ages 20 and 39, a woman shouldhave a CBE every

(A) year(B) 2 years(C) 3 years(D) 4 years

20. The lesion seen in Figure 6-1 is not palpableand is not associated with nipple or skinchanges. It is likely to be

(A) invasive ductal breast carcinoma(B) a mammographically malignant tumor(C) a mammographically benign tumor(D) nonspecific; further testing is indicated

21. Regardless of the reason, if the properamount of compression cannot be appliedwhich of the following must apply?

(A) the patient must be told(B) the patient’s doctor must be told(C) the radiologist must be told(D) it must be noted on the patient’s

history form

22. Magnification is contraindicated

1. when imaging the mastectomy site2. in specimen radiography3. as a normal/routine screening tool


Figure 6–1


23. If no previous mammograms are availablefor comparison, the automatic exposure con-trol (AEC) detector should be placed

(A) in the central aspect of the compressedarea of the breast

(B) as close to the chest wall as possible(C) toward the medial aspect of the breast(D) anywhere—placement will not affect the

exposure

24. Which section of the breast is poorly visual-ized on the CC projection?

(A) medial(B) axial(C) lateral(D) superior

25. Identify the projection in Figure 6-2.

(A) rolled medial (RM)(B) mediolateral (ML)(C) XCCL(D) mediolateral oblique (MLO)

26. Manual technique is sometimes necessarywhen imaging implants because

(A) the implant covers the AEC detector(B) patients with implants have small

breasts(C) patients with implants have large breasts(D) the implant does not cover the AEC

detector

27. Which projection could be used to demon-strate a deep medial lesion not seen on the CC?

(A) axillary tail (AT)(B) XCCL(C) CV(D) MLO

28. After a routine four-projection mammo-graphic series, the nipple is not seen in pro-file on any of the images. Additional projec-tions are done if

1. the nipple is indistinguishable from amass

2. a subareolar abnormality is suspected3. the nipple is not marked with a BB

(lead shot)



(A) TAN(B) from below (FB)(C) XCCL(D) ML



30. Your patient’s sister had breast cancer. Yourpatient is considered to have

(A) a greater risk for breast cancer(B) a lower risk for breast cancer(C) no significantly increased risk for

breast cancer(D) a personal history of breast cancer

31. The Mammography Quality Standards Act(MQSA) mandates that the average glandulardose received per projection/position duringroutine screen-film mammography cannotexceed

(A) 100 mrad(B) 200 mrad(C) 300 mrad(D) 400 mrad

32. When imaging an extremely dense breastusing AEC, the exposure sometimes termi-nates, resulting in an underexposed imagebecause of the action of the

(A) exposure timer(B) backup timer(C) phototimer(D) device timer

33. The operating level density difference (DD)for the phantom should be at least

(A) 0.40(B) 0.80(C) 0.02(D) 1.20

34. A film was accidentally bent prior to loadinginto the mammography cassette. If this filmis used in mammography screening, an arti-fact would appear as

(A) a minus-density artifact(B) a plus-density artifact(C) static(D) lines parallel to the direction of film

travel

35. Montgomery glands are specialized

(A) sweat glands(B) sebaceous gland(C) Cooper ligaments(D) hair follicles

36. A woman taking estrogen replacement ther-apy may notice changes in the breast such as

1. breast enlargement2. lumpy breast3. cysts


37. Paget disease of the breast is a(an)

(A) infiltrating carcinoma generally limitedto the breast

(B) form of carcinoma associated withchanges of the nipple

(C) benign breast condition that is relativelycommon

(D) malignant form of breast carcinomainvolving the lobules



38. Variation in compression levels causes

1. inadequate exposure on one portion ofthe breast

2. over- or underexposure in other portionsof the breast

3. adequate exposure throughout thebreast

(A) 1 and 2 only(B) 2 and 3 only(C) 1 and 3 only(D) 1, 2, and 3 only

39. What is the major disadvantage of magnifi-cation?

(A) reduced resolution of the image(B) increased patient dose(C) increased scattered radiation(D) none of the above

40. Selection of rhodium anode/filter combina-tion for a fatty breast

1. overpenetrates the fatty breast2. alters the penetrating power of the beam3. results in loss of subject contrast


41. When imaging the breast using the MLO pro-jection, drooping breast can be a result ofwhich of the following?

1. too much compression of the anteriorbreast

2. too little compression of the anteriorbreast

3. too much axilla included in the compres-sion field


42. In which of the following modified projectionis the superior surface of the breast rolledmedially?

(A) RM(B) RL(C) M(D) lateral medial (LM)

43. Factors that lower breast cancer risk include

1. having your first child after age 302. breast-feeding your child3. late menarche


44. The minimum and maximum kilovoltagepeak (kVp) of a mammography unit dependson which main factor(s)?

(A) Radiologist preference or recommendations

(B) Characteristics of the screen-film combination

(C) Processing and the patient’s breast size(D) Target and filtration material selected

45. For the daily processor QC, the mid-densityshould remain within

(A) ±0.15 of the established levels(B) ±0.10 of the established levels(C) +0.30 of the established levels(D) +0.03 of the established levels

46. Gynecomastia defines

(A) a localized abscess(B) increased breast tissue in the male breast(C) decreased breast tissue in the female

breast(D) a risk of carcinoma for the male patient


47. Total filtration with a rhodium target filtra-tion combination is

(A) the added filtration plus the inherent fil-tration

(B) equal to the added filtration(C) equal to the inherent filtration(D) the added filtration minus the inherent

filtration

48. According to MQSA regulations, which ofthe following is not required on the finalmammographic image?

(A) date of the examination(B) technical factors used(C) mammographer/technologist identifica-

tion(D) cassette/screen identification

49. The inframammary crease is located atapproximately the level of the

(A) second to third rib(B) third to fourth rib(C) fourth to fifth rib(D) sixth to seventh rib

50. Identify Cooper ligament in Figure 6-4.

(A) site A(B) site B(C) site C(D) site D

51. Identify the lactiferous sinus in Figure 6-4.

(A) site A(B) site B(C) site C(D) site D

52. Scattered radiation is reduced during magni-fication mammography by

(A) using a small focal spot size(B) using a grid(C) using the air-gap technique(D) increasing the source-to-image receptor

distance (SID)

53. Ductography can be used to determine

1. the location of the lesions in the ducts2. if a lesion is benign or malignant3. changes or abnormalities associated

with the ducts


Artery

Connective tissueand adipose tissue

Glandular tissuelobules

Areola

BC

D

ASubcutaneous adipose tissue

Retromammary adipose tissueVein

Pectoral muscle

Rib

Figure 6–4


54. In the CC projection, a technique especiallyuseful in maximizing the amount of lateralbreast tissue imaged on the small-breastedpatient with rounded shoulders is

(A) 5-degree lateral tube angulation(B) 5-degree medial angulation(C) using a straight tube(D) the ML projection

55. During magnification, positioning the breastaway from the image receptor utilizes whichlaw/principle in scatter reduction?

(A) inverse-square law(B) reciprocity law(C) heel effect(D) line focus principle

56. A woman with one first-degree relative withbreast cancer has a higher risk for breast cancerthan a woman with

1. early menarche, taking oral contraceptives2. a personal history of breast cancer3. late menopause


57. The primary purpose of the grid in mam-mography is to

(A) improve image sharpness(B) reduce the production of scatter(C) reduce patient dose(D) increase the subject contrast

58. The implant-displaced (ID) projection is pos-sible on all of the following cases except

(A) implants placed posterior to the pectoralmuscle

(B) implants placed anterior to the pectoralmuscle

(C) soft implants(D) encapsulated implants

59. A palpable mass that is not seen on a diag-nostic mammogram generally means

(A) breast cancer is ruled out; the mass isprobably benign

(B) other diagnostic testing must be considered(C) the mass is likely breast cancer(D) the mass is likely caused by fluctuating

hormones

60. Which of the following patients has the great-est risk for breast cancer?

(A) A nulliparous woman at age 40(B) A never married woman(C) A woman, age 70(D) A woman, age 30

61. A mammographer using a 0.1-mm focal spotsize is most likely performing

(A) routine mammography work(B) magnification imaging(C) spot compression imaging(D) stereotactic work

62. The developer temperature should always be

(A) 95°C(B) 95°F(C) ±0.5°F (±0.3°C) of the manufacturer’s

recommendation(D) ±5.0°F (±3.0°C) of the manufacturer’s

recommendation

63. One box of film should be dedicated to pro-cessing QC because

(A) it is easier to track the repeat rate(B) multiple boxes introduce multiple

variables(C) overall film density may cause fogging(D) films need consistent handling

64. The base of the breast refers to the

(A) the nipple area of the areola(B) area adjacent to the chest wall(C) axilla area of the breast(D) lower outer quadrant of the breast


65. Fibrous tissues are presented radiographi-cally as

(A) black or radiolucent areas(B) gray and less dense areas(C) white or denser areas(D) black and less dense areas

66. Figure 6-5 shows

(A) invasive ductal breast carcinoma(B) mammographically malignant

calcifications(C) mammographically benign calcifications(D) numerous oil cysts

68. In mammography, the AEC detector is placeddirectly

(A) above the image receptor(B) below the grid(C) above the grid(D) below the image receptor

69. Since 1989, the death rate from breast cancerhas declined because

(A) more cancers are discovered at a laterstage

(B) more cancers are discovered at an earlierstage

(C) the long-term survival rate for breastcancer patients is stable

(D) patients who survive 5 years will survive an additional 10 years

70. Contaminated developer will likely result in

1. decreased film speed2. increased image receptor contrast3. increased film base density


71. Spot compression

1. applies more compression to a localizedarea

2. can be performed with magnification3. employs a coned collimated field to limit

the area of interest


Figure 6–5

67. The MLO projection demonstrates a largeencapsulated lesion occupying almost theentire breast. The contour is sharp and thelesion is radiolucent. This lesion is mostlikely to be a(an)

(A) oil cyst(B) hematoma(C) fibroadenoma(D) lipoma



(A) TAN(B) FB(C) XCCL(D) RM

75. Why is the specimen magnified?

(A) to ensure that the lesion has been com-pletely removed

(B) to visualize the calcifications within thespecimen

(C) to compare the magnified and nonmag-nified images

(D) to check the number and placement ofcalcifications

76. In digital mammography, a grossly underex-posed image

(A) appears excessively noisy(B) is too light(C) is too dark(D) appears correctly exposed

77. Which of the following patients is likely to bediagnosed with pathological gynecomastia?

(A) lactating woman(B) elderly man(C) premenopausal woman(D) young man

78. Montgomery glands are located on thebreasts

(A) skin(B) nipple(C) areola(D) muscle

79. Extended processing increases the amount oftime the film is immersed in the

(A) developer solution(B) fixer solution(C) dryer(D) both the developer and fixer solutions

80. If the humidity in the dark room drops lowerthan 30%, the result is

(A) an increase in base fog(B) film scratches(C) static patterns on film(D) reduced film speed


73. To reduce the possibility of imaging theabdomen in the MLO position, the mammo-grapher could

(A) have the patient stand just at the imagereceptor and bend back

(B) have the patient stand away from theimage receptor and bend forward

(C) have the patient turn medially to imagethe lateral breast on the CC

(D) discard the MLO and image the breastin the lateral position instead

74. A four-projection mammography seriesshows a solitary tumor without calcificationin the upper outer quadrant (UOQ) of theleft breast. Only the anterior margins areseen. The next recommended step is

(A) biopsy(B) spot compression(C) stereotactic localization(D) aspiration


81. Over age 40, it is recommended that womenhave a CBE every

(A) year(B) 2 years(C) 3 years(D) 4 years

82. Fibrous and glandular tissues are more_______ than fatty tissue and result in areasof _______ optical density on the radiograph.

(A) radiolucent/lower(B) radiolucent/higher(C) radiopaque/higher(D) radiopaque/lower

83. Good compression results in

1. increased spatial resolution2. decreased spatial resolution3. improved subject contrast


84. Which of the following involves the use of athin needle to remove cell samples from asuspected cancerous lesion in the breast forcytological analysis?

(A) core biopsy(B) excisional biopsy(C) needle localization(D) fine needle aspiration (FNA)

85. A lesion is superimposed by breast tissue inthe CC projection. A projection used todemonstrate the lesion in the same projectionand free of superimposition is the

(A) MLO(B) ID(C) XCCL(D) RM

86. In imaging the breast in the MLO projection,compression to the lower portion of thebreast is compromised if

1. the image receptor is too high2. the patient has a protruding abdomen3. too much axilla and shoulder are under

compression


87. Involution of the breast describes a processby which

(A) milk is removed from the breast by suckling

(B) breast epithelium proliferates duringmenstruation

(C) breast epithelium decreases because ofpostmenopausal changes

(D) estrogen causes an overall densitydecrease in the breast

88. In imaging the breast for the CC projection,what technique is used to minimize skinfolds in the lateral aspect of the breast?

(A) lift the posterior lateral aspect of thebreast onto the image receptor

(B) drape the contralateral breast over thecorners of the image receptor

(C) have the patient’s head turned awayfrom the breast being imaged

(D) on the side being imaged, the patient’sarm hangs relaxed with humerus exter-nally rotated

89. In the dedicated mammography unit, the sin-gle intensifying screen is positioned in con-tact with the film emulsion on

(A) the side of the IR away from the x-raysource

(B) the side of the film facing the x-ray source(C) the side of the IR facing the x-ray source(D) either side—the placement does not

matter


90. Grid use in magnification mammography iscontraindicated because

1. grid use increases subject contrast2. scatter is already minimized3. the grid results in increased patient dose


91. The breast can be imaged in the FB projection

1. to improve visualization of lesions inuppermost aspect of breast by reducingobject-to-image receptor distance (OID)

2. during needle localization to provide ashorter route to inferior lesions

3. to maximize the amount of tissue visual-ized in patients with kyphosis



(A) TAN(B) FB(C) XCCL(D) ML

93. Which statement best describes a parallel orlinear grid?

(A) Lead strips are aligned adjacent to oneanother and placed lengthwise in thesame direction within the structure ofthe grid.

(B) Lead strips are aligned at right angles toeach other.

(C) Lead strips are designed to take advan-tage of the divergence of the x-ray beamas it leaves the x-ray tube.

(D) Lead strips are designed to move duringthe exposure.

94. Mercury in a glass-type thermometer is notrecommended for use in QC testing because

1. Mercury is potentially inaccurate.2. Mercury is a potential source of

contamination.3. Glass-type thermometers may break.


95. What factors are used to maintain a sharpimage during magnification?

1. adjustable focal spot sizes2. decreasing the thickness of the body part3. decreasing the resolution


96. The half-value layer (HVL) of the x-ray beamis measured with a

(A) star pattern (B) slit camera(C) pinhole camera(D) quality-control dosimeter Figure 6–7. (© 2000 The American Registry of Radiologic

Technologists.)


97. The repeat rate should be analyzed if the ratechanges from the previous measure rate bymore than

(A) ±2%(B) ±3%(C) ±4%(D) ±5%

98. A magnification image of breast shows sev-eral oval-shaped radiolucent lesions witheggshell-like calcifications. These are mostlikely to be

(A) ductal papilloma(B) fibroadenomas(C) oil cysts(D) hematomas

99. The image viewing environment

1. has no effect on the detection of cancer-ous lesions

2. can obliterate the advantages of opti-mum image quality

3. should eliminate extraneous viewboxlight


100. In general, ID series are taken in

(A) AT and MLO projections(B) CC and ML projections(C) CC and MLO projections(D) CC and LM projections

101. Today all mammographers (radiographerperforming mammograms independently)must have

1. satisfied the interim requirements of theFDA

2. completed at least 40 contact hours ofdocumented training in mammography

3. performed at least 25 examinationsunder direct supervision of a qualifiedmammographer


102. The criteria for a properly positioned MLOincludes

1. a concave pectoral muscle on the ante-rior border

2. fat visualized posterior to the fibroglan-dular tissues

3. an open inframammary fold (IMF)


103. A benign inflammatory condition of the lact-iferous ducts leading to nipple discharge,nipple inversion, or periareolar sepsis iscalled

(A) ductal ectasia(B) Paget disease of the breast(C) peau d’o range(D) ductal papilloma

104. The cells lining the alveoli in the lobules arecalled

(A) epithelial cells(B) myoepithelial cells(C) basement cells(D) superficial cells


105. Using a cassette with poor film screen contactwill result in

(A) a noisy image(B) localized unsharpness(C) motion unsharpness(D) a lower subject contrast

106. A technique describing reshaping of thebreast is called

(A) reduction mammoplasty(B) mammoplasty(C) breast augmentation(D) breast biopsy

107. A major cause of radiographic noise is

(A) image graininess(B) quantum mottle(C) poor contrast resolution(D) motion

108. Failure of the hyporetention test will result inwhat type of long-term artifact marks on theimage?

(A) streaks of increased optical density(B) areas of reduced density(C) yellow brown stains(D) round spots of increased density

109. In positioning for the superior-inferioroblique (SIO), the _________ of the breast willrest on the image receptor.

(A) lateral surface(B) superior surface(C) medial surface(D) inferior aspect

110. Imaging males will present the same diffi-culty as imaging small, firm-breasted females.An added problem may be that

(A) males have more problems with thecompression

(B) the male breast is smaller than the smallest female breast

(C) males have more muscular breast tissue(D) hair on the chest of males makes com-

pression difficult

111. For the SIO projection, the central ray (CR) isdirected

(A) inferolateral to superomedial(B) superomedial to inferolateral(C) inferomedial to superolateral(D) superolateral to inferomedial

112. Which of the following are considered agen-cies granting accreditation under the FDAregulation?

1. ACR2. ARRT3. NY State Department of Health


113. Which alternative projection could be used,in addition to the CC, in imaging a patientwith a prominent pacemaker?

(A) ML(B) lateromedial oblique (LMO)(C) XCCL(D) MLO


114. During needle localization, breast positioningshould provide the shortest skin-to-abnormality distance in order to

1. minimize trauma to the breast2. ensure minimal excursion of the biopsy

needle into the breast3. reduce the possibility of needle

deflection


115. In addition to the patient’s name, all mam-mographic reports should have the

1. final assessment of findings2. hospital number or additional patient

identifier3. name of the radiologist


1. (A) Both the CBE and the BSE are examina-tions of the breast where changes in theshape, contour, and texture of the breast areassessed and the breast is checked for lumps.The CBE is done by a health professional,whereas the BSE is done by the woman onherself. The BSE should always be donemonthly after age 20. The CBE is recom-mended every 3 years for those below 40 andevery year for those over 40 (ACR, 10).

2. (B) Studies have shown that although thereare many reasons for undercompression, themain reason is a lack of communicationbetween the mammographer and the patient.The mammographer undercompresses thebreast either because the patient refuses fur-ther compression, is unable to tolerate morecompression, or the mammographer wants to“protect” the patient from further pain.Patients generally tolerate more compressionif they fully understand the reason for thecompression. Faulty or broken compressiondevices are generally easily repaired (ACR, 90;Andolina, 184; Peart, 116–117).

3. (D) In calculating the density difference, DD,two average densities are used. The highaverage density is the density closest to 2.20.The low average density is the density closestto but not less than 0.45. The differencebetween these two densities is the DD (ACR,151; Peart, 87–112).

4. (D) An intraductal papilloma generallyoccurs near the nipple within the larger ducts,but can also occur deep within the breast. Thepapilloma may produce spontaneous discharge

from the nipple or if deep within the breastmay appear radiographically as a mass. Duc-tal papillomas are benign and can be visual-ized with ductography or ultrasound (Andolina,155–173; Peart, 47–62; Venes, 1584).

5. (C) The large air gap acts like a grid andreduces scatter, thus improving subject con-trast. Positioning the breast away from theimage receptor takes advantage of the inverse-square law: the intensity of the scattered radia-tion is reduced because the distance betweenthe image receptor and the object is increased(ACR, 59–60; Bushong, 327–340; Peart, 65–84).

6. (B) To visualize minimal changes in glandu-lar structures, high-contrast conventionalmammography provides detail of glandulartissue, but does not show skin detail. Theskin is only seen under “bright light.” If theskin is seen normally, the image is underex-posed, especially in the glandular regions;detail is lost and lesions may be missed (ACR,79–110; Peart, 65–84).

7. (A) The spatula can be used instead of themammographer’s fingers to pull extremelysmall breasts into position for compression.The ML is a lateral projection. CV images theextreme medial breast in the CC projectionand XCCL images the extreme lateral breastin the CC projection (Peart, 115–145).

8. (B) In the TAN projection, the technique is totake a skimming projection of the area ofinterest. Because the TAN can be taken in anyprojection, the degree of obliquity and theprojection depends on the location of the


118


abnormality. The TAN can be taken in anyprojection (Figure 6-8) (Peart, 115–145).

devices. However, unlike general radiogra-phy where the beam should be limited to thesize of the part, in mammography the entirefield (not just the breast) is exposed. This isnecessary to reduce extraneous light whenviewing the image (Peart, 65–84).

13. (A) In conventional imaging, the characteristiccurves (also called D log E, sensitometric, orHurter and Driffield [H&D] curve) describethe relationship between the radiation expo-sure and the optical density produced on animage. At the toe and shoulder of the curve,large variations in exposure result in little orno change in density. In the straight-line por-tion of the curve (the useful region), smallchanges in exposure cause large changes indensity. Calculations of film contrast use theaverage gradient or slope between two points ofthe curve. Films that have a steeper slope have ahigher contrast. Two characteristic curves canalso be used to compare film speeds (Figure 6-9).The curve that lies to the left (closer to thedensity axis) is faster (Bushong, 272–281).

Figure 6–8. ((© 2000 The American Registry of Radiologic Technologists.)

Figure 6–9. Characteristic curve (also called sensitometric curveor Hurter and Driffield [H & D] curve) from two different types of radi-ographic films. Film A has a faster speed than film B because itsspeed point is the left of film B. Film B has a higher contrast thanfilm A because the slope of its curve is steeper than that of film A.

9. (C) Although pain can be associated withbreast cancer; a painless mass is the more com-mon symptom of breast cancer. Painful massesare associated with cysts. Less common symp-toms of advanced breast cancer include skinthickening; skin irritation or distortion; andsudden nipple inversion, discharge, erosion,or tenderness (ACS, 1–17; Peart, 47–62).

10. (B) On an average, a mammogram willdetect 90% of breast cancers in women with-out symptoms and is more accurate in post-menopausal compared to premenopausalwomen. Some cancers are not detected mam-mographically because of increased breastdensity, as in the fibrocystic breast, fastergrowth rate, or failure to recognize the earlysigns of an abnormality (ACS, 1–17).

11. (B) Hormone use influences breast cancerrisk, but does not actually cause breast can-cer. All factors that affect the reproductivehormones in a woman’s body increase riskfor breast cancer (ACS, 1–17).

12. (A) In general, the use of any beam-limitingdevice in radiography or mammographyrequires increased exposure. Both imagingmethods use varying sized beam-limiting

0

1.0

2.0

3.0

4.0

1.0 2.0 3.0 4.0

A B


Density


14. (B) The film in the cassette should be dis-carded because any attached dirt from the cas-sette will be carried into the film bin orreturned to the cassette (ACR, 149; Peart, 87–112).

15. (B) The retromammary space separates thebreast from the pectoral muscle. It is filledwith a layer of adipose or fatty tissue asopposed to the supporting and connectivetissue (stroma), blood vessels, and variousductal structures that make up the glandularand fibrous tissues of the breast (Peart, 35–44).

16. (D) Generally, glandular tissues predominatein younger women and adipose or fatty tis-sues in older patients. This ratio is not fixed,and depends on the woman’s age and geneticpredisposition. It fluctuates with hormonelevels, whether the hormonal changes arecaused by medication use or pregnancy, lac-tation, or menopause (Peart, 35–44).

17. (B) The purpose of the XCCL projection is toimage the lateral aspect of the breast. Raisingthe patient’s arm on the ipsilateral side forcesmore axilla under the compression paddle.Keeping the ipsilateral arm down or placingthe hand at the patient’s hip does not allowadequate compression of the lateral and ante-rior aspects of the breast. The ipsilateral shoul-der should be relaxed and down with the armraised (Andolina, 174–245; Peart, 115–145).

18. (C) Depending on patient body habitus, thepectoral muscle is imaged on the medialaspect of the breast in about 30%–40% of allCC projections. It may be visualized unilater-ally or bilaterally. Routine CC imaging thatincludes the pectoral muscle can indicatefaulty positioning with loss of medial or lat-eral breast tissue (ACR, 79-110-310).

19. (C) The American Cancer Society (ACS)guidelines for early detection of breast cancerincludes having a CBE every 3 years betweenages 20 and 39 and every year after age 40(ACS, 1–17).

20. (D) Whenever a large radiating structure orarea of architectural distortion (even when

superficial) is not associated with skinchanges or nipple retraction, the mammo-gram is considered nonspecific, and furthertesting is indicated. If the lesion is palpable,malignancy cannot be ruled out. However,the lesion must be biopsied for a definitivediagnosis. This lesion is a radial scar (seeFigure 6-1). Radial scars are rarely palpableand never involve skin changes. Generallythe radial scar has no central tumor and itsappearance varies from one mammogramprojection to another. Some studies suggestthat a radial scar may increase a woman’srisk of developing breast cancer (Peart, 47–62;Tabár, 93–147; Tucker, 241–280).

21. (D) Although the mammographer shouldinform the radiologist and can also inform thepatient, anything unusual must be charted onthe patient’s medical or history form. Thepatient’s records are a means of communica-tion between the mammographer and theradiologist and can be important legal docu-ments used to define what was or was notdone to a patient. Records can also be used asevidence in court cases (Peart, 13–31).

22. (B) Magnification techniques are useful inmammography to assess microcalcificationsor the border of a lesion, or to image a speci-men to check for calcifications. However,magnification does not image the entirebreast and cannot be used as a screening tool.Magnification can be used to image the rela-tively small area of a mastectomy site. (Thesite can also be imaged without magnifica-tion.) For a woman with thick, dense breasttissue, magnification is sometimes con-traindicated because long exposure times andhigh kVp degrades the image. The patientalso receives an unnecessarily high radiationdose (Bushong, 327–340; Peart, 115–145).

23. (A) If the detector is placed in a single regionof adipose tissue in an otherwise glandularbreast, the adipose area will be correctlyexposed but the glandular area will be under-exposed resulting in an increased chance ofmissed breast cancer. In imaging adipose andglandular tissue, the detector must be under


glandular breast to obtain proper image den-sity. Glandular tissue is distributed centrallyand laterally within the breast; therefore, theAEC should be centrally placed behind thenipple, making sure it is under an area ofcompressed breast (Peart, 65–84).

24. (C) All effort should be made to image themedial breast tissue on the CC mammogram;eliminating it could eliminate this area of thebreast from the study. The CC best demon-strates the anterior, central, medial, and pos-teromedial portions of the breast but is poor atvisualizing the lateral breast tissue. The patientshould be rotated slightly medially, even if thismeans loosing some lateral breast tissue.Although the medial breast is imaged on theMLO, superimposition of glandular structuresand increased OID often causes distortion ofthat area (Andolina, 174–245; Peart, 115–145).

25. (D) The MLO projection best demonstratesthe posterior and UOQ of the breast. Thisprojection images the breast entirely, but dis-torts the anterior structures. The ML is a90-degree lateral, the XCCL images the lat-eral aspect of the breast in the CC position,and the roll medial rolls the superior surfaceof the breast, from the CC position (Andolina,174–245; Peart, 115–145).

26. (A) If breast tissue is over the AEC detector,automatic exposure is possible. AEC works onthe principle of terminating the exposure whensufficient x-ray reaches the film to produce apreset optical density. Because implants arebasically radiopaque, if the implant is posi-tioned over the AEC the tube will try to pro-vide sufficient output to penetrate the implantand also provide optimal density with thisaction stopped only by the backup timer. Thisgenerally leads to an excessive radiation doseto the patient (Peart, 65–84).

27. (C) The CV best images the medial breast.The MLO will best demonstrate the posteriorand UOQ of the breast. The XCCL and ATwill demonstrate the lateral and axilla por-tion of the breast, respectively (Andolina,174–245; Peart, 115–145).

28. (D) Putting the nipple in profile is sometimescounterproductive. Breast tissue is lost eithersuperiorly, inferiorly, laterally, or medially,depending on the projection and the locationof the nipple on the breast. Missed tissue canthen lead to undetected breast cancer. If thenipple is not in profile, additional images areneeded for the above reasons, but should notbe done solely to place the nipple in profile,even if the nipple is not marked with a BB-marker (small radiopaque marker) (Andolina,246–310; Peart, 115–145).

29. (C) The XCCL projection best images the pos-terolateral parts of the breast. The beam isdirected superiorly to inferiorly, similar to astandard CC projection. The TAN gives a tan-gential image of the area in question, the FBimage directs the beam caudocranially andthe ML is a 90-degree lateral projection(Andolina, 174–245; Peart, 115–145).

30. (A) Although the biggest risk factor of breastcancer is gender (female), having a sisterwith breast cancer can significantly increase aperson’s risks for the disease. A personal his-tory applies only if the patient has had breastcancer (ACR, 8–9).

31. (C) The final rule of mammography, dictatedby the MQSA, states that a single projection/position screen-film mammogram should notgive more that 300 mrad (3 mGy) per projec-tion/position average glandular dose when agrid is used and should not exceed 100 mrad(1 mGy) per projection/position without agrid (Bushong, 342–356; Peart, 237–256).

32. (B) Newer mammogram generators have abackup timer that works with the conven-tional AEC systems. The mammographyexposure timer selects the actual time of theexposure which affect patient dose andimage optical density, while the AEC cuts theexposure when the correct density isachieved. The phototimer was a type of AECdevice used in older x-ray units. Currentlymost AEC devices are ionization chambertype. The backup timer stops the exposurebefore the optimal density is reached if the


energy of the beam is too low. If the backuptime is reached during a breast exposure, themammographer should select a higher kVpsetting for the repeat radiograph. Only byselecting a higher kVp is the mammographerable to increase the beam’s energy. The back-up timer is preset at 600 mAs for grid workand 300 mAs for nongrid (magnification)imaging (Peart, 65–84).

33. (A) The MQSA requires that the density dif-ference, DD, created by using the 4.0-mmacrylic disk, should be at least 0.40, andshould not vary by more than ±0.05 from theoperating level. Also, the phantom imagebackground optical density should be at least1.40 and should not vary by more than ±0.20from the operating level (ACR, 186).

34. (A) White (minus-density) artifacts indicatepressure on the emulsion before exposureand dark (plus-density) artifacts indicatepressure after exposure. Static is caused byfilm handling in low humidity. Improperlycleaned or worn rollers cause repeating arti-facts that run parallel to the direction of filmtravel (Andolina, 44–94; Peart, 87–112).

35. (B) The Montgomery glands (glands of Mont-gomery) are seen as protrusions on the sur-face of the areola and are actually specializedsebaceous glands. (The openings to the pro-trusions are called Morgagni tubercles.) Theyusually become more prominent duringpregnancy and lactation and secrete a fluidwhich helps lubricate the nipple and areola(Peart, 35–44).

36. (D) Estrogen and progesterone are two of themany hormones responsible for many physio-logical changes in the breast. Estrogen isresponsible for ductal proliferation and proges-terone for lobular proliferation. Once a womanstarts estrogen, the changes can be spotty, caus-ing lumps or increased interstitial fluids (cysts),but will generally result in an overall increasein glandular tissue (Peart, 35–44).

37. (B) Paget disease of the breast (first describedby Jean Paget in 1874) is a special form of

ductal carcinoma associated with eczematouschanges of the nipple. Generally it presentsas a malignant nipple lesion. Infiltrating car-cinoma implies that the cancer has left thepoint of origin and is spreading into the sur-rounding tissues (Venes, 1566; Peart, 47–62).

38. (A) Compression should be applied evenlyover the breast by using a flat paddle parallelto the image receptor. Uneven compressionleads to false-negative or false-positive resultsbecause comparison between relative massdensities is not possible (Andolina, 174–245;Peart, 87–112).

39. (B) The principle disadvantage of magnifica-tion is that the increased OID places thepatient’s breast very close to the x-ray tube.Because the radiation intensity is related tothe square of the distance, magnification usu-ally results in about twice the normal patientdose. The small focal spot used in magnifica-tion compensates for the reduced resolution.Magnification therefore does not decrease res-olution. The air-gap technique reduces, ratherthan increases, the amount of scattered radia-tion reaching the image receptor (Bushong,327–340).

40. (D) Conventional mammography usually useseither molybdenum or rhodium as targetmaterials. Molybdenum has an atomic numberof 42 versus rhodium with a slightly higheratomic number of 45. The emission spectrumfrom a molybdenum target tube has a slightlylower K-edge and less bremsstrahlung x-raysthan that of rhodium. This difference in emis-sion spectra allows for slightly higher kVpselections when using rhodium targets. The tar-get material then determines the kVp range andthus the quality of the beam. Rhodium pro-duces better images for thick, dense breast with-out loss of contrast and with decreased patientdose. However, if used on fatty breast, the con-trast will be significantly reduced with only aminimal reduction in dose (Peart, 65–84; Bushong,327–340).

41. (B) The breast droops in the MLO if adequatecompression is not applied to the anterior


breast. Compression should be appliedevenly throughout the anterior, posterior, andlateral parts of the breast. If too much axilla isincluded in the compression field, the poste-rior breast is adequately compressed, butcompression is inadequate for the anteriorbreast (Andolina, 174–245; Peart, 115–145).

42. (A) In the rolled positions, the top half of thebreast is rolled in one direction and the bottomhalf in the other direction. With the medialroll, the top is rolled medially. In the lateralroll, the top is rolled laterally. The medial andlateral roll (RM and RL) are both useful in sep-arating glandular structures of the breast toclear questions of superimposition. The LM isa lateral projection, with the x-rays travelingfrom lateral to medial and magnification (M)producing a magnified image of an area(Andolina, 174–245; Peart, 115–145).

43. (B) Breast cancer risk decreases amongwomen who have a first child prior to age 30,breast-feed, and experience late menarche orearly menopause. Studies have suggestedthat reproductive hormones influence breastcancer; therefore, factors that affect reproduc-tive hormones (early menarche [before 12],late menopause [after 55], late age at firstfull-term pregnancy [after 30], use of oralcontraceptives, and estrogen replacementtherapy) affect breast cancer risk (ACR, 8–9).

44. (D) All mammographic x-ray tubes are man-ufactured with a tungsten, molybdenum, orrhodium target. These targets have differentatomic numbers and therefore different emis-sion spectrums. The emission spectrum of thebeam is shaped by altering a combination ofthe target material and the filtration. How-ever, these designs are built into the mam-mography unit. Although the mammogra-pher can select different targets, the he/she isunable to alter the built-in target materialand therefore the emission spectrum of thebeam (Bushong, 327–340; Peart, 65–84).

45. (A) The MQSA requires that the mid-densityand density difference, DD be within ±0.15 ofthe established operating level. The base plus

fog must remain within +0.03 of the estab-lished operating level (ACR, 159).

46. (B) Gynecomastia is a benign increase of tissuein the male breast. It can occur bilaterally orunilaterally. Gynecomastia does not increasethe risk of breast cancer for male patients(Peart, 47–62).

47. (A) The total filtration is a combination ofthe inherent and any added filtration. In anymammography unit, the inherent filtrationmay fall in the region of 0.1 mm Al or equiv-alent, but the total filtration should never belower than 0.5 mm Al or equivalent (Bushong,327–340).

48. (B) Although the MQSA recommends thattechnical factors appear on the image, this isnot an MQSA requirement. Other recommen-dations are

• flash card ID versus stick-on labels becausethe flash ID is more permanent

• separate date stickers because they are easyto read and can be color-coded by year

The requirements are

• name of patient and additional patientidentifier

• date of examination• projection and laterality (right or left

marker)—placed near the axilla using thestandardized codes

• facility name and location (must includecity, state, and zip code)

• mammographer identification• cassette/screen identification• mammography unit identification (if more

than one unit per site) (ACR, 26–27).

49. (D) The breast can reach superiorly from theclavicle (second or third rib), and inferiorly tomeet the abdominal wall at the level of thesixth or seventh rib. This lowest point of thebreast is called the inframammary crease orfold (Peart, 35–44).

50. (A) The Cooper ligaments are fibrous mem-branes that support the lobes of the breast.The ligaments attach to the base of the breast


and extend outward attaching to the anteriorsuperficial fascia of the skin (Figure 6-10)(Peart, 35–44).

the amount of scattered radiation reachingthe film (Bushong, 327–340).

53. (C) Ductography will not determine if alesion is malignant or benign, but it candetermine the location and number of lesionsor changes associated with the ducts. Only acytological or histological analysis can accu-rately determine the true nature of the lesion(Andolina, 313–330; Peart, 203–220).

54. (A) A 5-degree lateral tube angulation allowsthe compression paddle to clear the humeralhead. The tube angled medially further pro-jects the humeral head in the area of interest.Using a straight tube is a routine CC projec-tion and does not alter the imaging. Otheralternatives XCCL image the lateral breast orML change the orientation of any abnormalityin relation to the nipple (ACR, 60; Peart, 115–145).

55. (A) Positioning the breast away from theimage receptor takes advantage of theinverse-square law: the intensity of the scat-tered radiation is reduced because the dis-tance between the image receptor and theobject is increased. The heel effect describesthe process that causes the radiation intensityat the cathode side of the x-ray field to behigher than that on the anode side. The linefocus principle is an angled design of thetube target that allows a large area for heat-ing while maintaining a small focal spot. Thereciprocity law states that the density pro-duced on a radiograph is equal for any com-bination of mA and exposure time as long asthe product of mA and the ms is equal (ACR,59–60; Bushong, 327–340).

56. (C) Risk factors increases a woman’s risk forbreast cancer. Risks factors are divided intorelatively high risk, moderate risks, andminor risks. High-risks factors include gen-der (female), age, genetic factors, and familyor personal history of breast cancer. Moder-ate risk factors include having one first-degree relative with breast cancer, havingatypical hyperplasia confirmed on biopsy,high radiation dose to the chest area, highbone density after menopause. Minor risk

ArteryConnective tissueand adipose tissue

Glandular tissuelobules

Areola

Mammary ducts or segmental ductsAmpulla orlactiferous sinusNipple

Cooper ligamentsSubcutaneous adipose tissue

Retromammary adipose tissueVein

Pectoral muscle

Rib

Figure 6–10. Diagram of the breast.

51. (C) Starting at the nipple, the collecting ductalsystem immediately widens into an ampullacalled the lactiferous sinus. This is a pouch-like structure that again narrows and joinsone or more segmental ducts, eventuallybranching further until it ends at the terminalductal lobular unit (TDLU) (Peart, 35–44).

52. (C) Scattered radiation is produced when-ever the useful beam intercepts any objectcausing it to diverge. There are two methodsof reducing the amount of scattered radia-tion reaching the image receptor: limiting thex-ray field size (not an option in mammogra-phy) and the use of grids. In magnificationmammography the large air gap acts as agrid in reducing scattered radiation. Grid usein magnification will therefore unnecessarilyincrease the exposure dose to the patient.Increasing the SID reduces magnification butdoes not reduce the amount of scatter pro-duction. It is not used in magnification mam-mography. The small focal spot is necessaryto increase resolution, but this does not affect


factors are associated with hormonal use orchanges in the body and include not havingchildren or having the first child after age 30,not breast-feeding, early menarche (beforeage 12) or late menopause (after age 55),postmenopausal obesity, recent and long-term use of hormone replacement therapy(HRT) or oral contraceptive, alcohol con-sumption, and obesity (ACS, 1–17).

57. (D) Grids do not improve image sharpness;the sharpness of an image is affected by thefocal-spot size, SID, OID, type of intensifyingscreens, and motion. Grids increase patientdose and reduce the amount of scatteredradiation striking the film, but do not affectthe production of scatter radiation. Grid usewill, however, result in increased subject con-trast (Bushong, 327–340; Peart, 65–84).

58. (D) As long as the implant is soft andremains free of encapsulation, the ID projec-tions are possible. Once the implant is encap-sulated, it is difficult if not impossible to dis-place. Most modern implants are placedbehind the pectoral muscle (subpectoral orretropectoral placement) versus placement infront of the pectoral muscle (subglandular orretromammary placement) that was done inthe past. The placement of the implantbehind the pectoral muscle allows betterimaging and better displacement of theimplants for the ID projections (Andolina,174–245; Peart, 115–145).

59. (B) On an average, a mammogram detects90% of breast cancers in women withoutsymptoms, and is more accurate in post-menopausal than premenopausal women.Some cancers are not detected mammograph-ically because of high breast density, fastergrowth rate, or failure to recognize the earlysigns of an abnormality. If the mammogram isnormal and the patient feels a palpable mass,the mass could be normal or abnormal. Thepatient must contact her doctor immediatelyfor further testing (ACS, 1–17; Peart, 47–62).

60. (C) Risk factors increases a woman’s risk forbreast cancer. Risks factors are divided into

relatively high risk, moderate risks, andminor risks. High-risk factors include gender(female), age, genetic factors, and family orpersonal history of breast cancer. Moderaterisk factors include having one first-degreerelative with breast cancer, having atypicalhyperplasia confirmed on biopsy, high radia-tion dose to the chest area, high bone densityafter menopause. Minor risk factors are asso-ciated with hormonal use or changes in thebody and include not having children or hav-ing the first child after age 30, not breast-feeding, early menarche (before age 12) or latemenopause (after age 55), postmenopausalobesity, recent and long-term use of HRT ororal contraceptive, alcohol consumption, andobesity (ACR, 8–9; ACS, 1–16).

61. (B) The focal spot size is important in mam-mography and many x-ray tubes have twofocal spot sizes—one for routine and one formagnification work. In routine work, thefocal spot size can be 0.4 or smaller. In mag-nification work, the focal spot may be 0.15 orsmaller. Any work done with a 0.1-mm focalspot size would be for magnification (Bushong,327–340; Peart, 65–84).

62. (C) Although the majority of processing unitsoperate at a developer temperature of 95°F,some may not. The actual temperature is sug-gested by the manufacturer and should bewithin ±0.5°F of the value specified by themanufacturer (ACR, 130, 215).

63. (B) Daily QC is used to assess consistency offilm and film processing. Introducing multipleprocessing variables such as variations in filmemulsion (by using a film from a different boxeach time) will muddle the results (ACR, 149).

64. (B) The breast includes the nipple, infra-mammary fold, and tail of Spence. The tail ofSpence (tail, axilla, or axillary tail are othernames used) describes the area of the breaststretching up into the axilla. The basedescribes the region where the inframam-mary fold is located, closest to the chest wall.The apex is the nipple region, and the mostdistal point of the breast (Peart, 35–44).


65. (C) Fibrous tissue is usually described withglandular tissue together as fibroglandulardensities. X-rays pass more easily throughfatty tissue than through fibrous or glandu-lar tissue. Fatty areas appear radiolucent(black or less dense area on the mammo-gram). The fibroglandular or fibrous tissueis more radiopaque than fatty tissue, andshows as areas of lower optical density(white or dense) on the mammogram (Peart,35–44).

66. (B) Figure 6-5 shows casting-type calcificationswhich are often malignant. The shape of thecast is determined by the uneven productionof calcification and the irregular necrosis of thecellular debris. The contours of the cast arealways irregular in density, width, and length,and the cast is always fragmented. A calcifica-tion is seen as branching when it extends intoadjacent ducts. Also, the width of the ductswill determine the width of the castings. Adiagnosis of invasive ductal carcinoma is onlymade on cytological or histological analysis(Tabár, 149–238).

67. (D) The only huge radiolucent breast lesionhere is a lipoma, which is a common benigntumor composed of fatty tissue. Another largelesion is the fibroadenolipoma or hamartoma.It is a benign proliferation of fibrous, glandu-lar, and fatty tissue surrounded by a thin cap-sule of connective tissue. The oil cyst isbenign and appears mammographically aseggshell-like calcifications. Both the fibroade-noma and the hematoma are seen as circular-oval lesions with mixed densities and gener-ally will not occupy the entire breast (Tabár,17–92).

68. (D) The AEC detector is placed directlybelow the image receptor or cassette in mam-mography to minimize OID (in x-ray imag-ing, the AEC detector is most often placedabove the image receptor). Because radiationhas to pass through the breast before reach-ing the detector, the primary reason forbackup time and inadequate exposure is theinability of low-energy photons to penetratethe breast (Peart, 65–84).

69. (B) The decline in breast cancer mortality is aresult of improvement in breast cancer treat-ment and the benefits of mammographyscreening. Although there is no guaranteethat all patients will survive, the long-termsurvival rates are actually improving becausecancers discovered at an earlier stage have abetter prognosis, giving women a better long-term survival rate (ACS, 1–16).

70. (C) Contaminated developer can cause wetfilms, an increase in the base fog, or decreasedfilm speed. Increased film contrast representsinherent properties of the film speed latitudeand the different quantities and qualities ofradiating effect on them. Processing conditionsuch as the developer temperature being toohigh, the replenishment rates being too high,or improper mixing of the developer solu-tion and overall radiographic quality willalso affect film contrast (Bushong, 204–217;Peart, 65–84).

71. (B) Spot compression increases compressionto the area of suspected abnormality, allowingthe tissue to spread more evenly and elimi-nating pseudomasses. Because of the need toreduce extraneous light (increase visualiza-tion of breast tissue), coned collimated imagesare no longer taken when imaging with spotcompression (Peart, 115–145).

72. (B) The FB or caudal-cranial projection maybe useful in nonconforming patients or find-ing lesions high on the chest wall. In per-forming the FB, the image receptor is abovethe breast and compression is applied at theinframammary fold. The TAN is used toimage skin lesions. The XCCL images the farlateral breast in the CC position and RM isthe roll medial where the upper surface ofthe breast is rolled medially (from the CCposition) (Peart, 115–1457).

73. (B) If the patient stands away from the imagereceptor and bends forward, her chest will bebrought forward and derriere back, removingthe abdomen from the imaging area. If thisdoes not achieve the desired results and theabdomen still protrudes, the mammographer


cannot sacrifice posterior and lateral tissue toimage the anterior breast. Two projectionsmay be required—a lateral of the anteriorbreast and the MLO for the posterior andUOQ of the breast (Andolina, 246–310; Peart,115–145).

74. (B) Spot compression increases compressionover the area of interest, spreading out the tis-sue more evenly and allowing visualization ofthe margins or borders of lesions. Biopsy is asurgical procedure. Aspiration is generallydone to remove the content of a cyst, andstereotactic localization is used to localizenonpalpable lesions. Mammography is thefirst line of defense against breast cancer.Before further testing is undertaken, as muchinformation on the lesion should be gatheredfrom mammography (Andolina, 174–245; Peart,115–145; Tucker, 241–280).

75. (B) The specimen should always be com-pressed and radiographed to ensure that thelesion was completely removed. If there arecalcifications present, the lesion should bemagnified to ensure that all the calcificationswere removed (Andolina, 331–402; Peart, 203–220;Tucker, 241–280).

76. (A) Digital images generally will not appeartoo light or dark because digital imaging hasthe advantage of being able to manipulatethe final image. In digital imaging, if a graphof the optical density (called the signal) andthe relative exposure is plotted the relation-ship is not the characteristic curve (alsocalled Hurter and Driffield [H & D] or sensit-ometric curve); rather, it is a straight line(Figure 6-11). The digital image therefore hasmuch wider latitude than conventional mam-mography. This ability to adjust the finalimage (thus reducing the need for repeats) isone of the greatest advantages of digitalimaging. The problem is that, although over-exposure can be corrected, the patient dose ishigh. The mammographer can encounterproblems with underexposed images, how-ever. If the digital signal is not enough toproduce a “good” image, the image appearsexcessively noisy (appearance similar to

quantum mottle) (Figure 6-12) (Andolina, 437–452;Peart, 179–194).

Film/Screen

IPIntensity relativeof the luminosity

Log of relative exposure

Figure 6–11. Characteristic curve (also called sensitometric curveor Hurter and Driffield [H & D] curve) from film-screen versus digitalimaging. A graph of the optical density signal and the relative expo-sure for a digital imaging plate (IP) has a linear response to x-ray.This is unlike the curvilinear response of a film-screen system.

Figure 6–12. In conventional imaging, quantum mottle occurswhen there are not sufficient incident photons reaching the intensi-fying screen. The effect is similar in digital imaging.

77. (B) Gynecomastia is a benign proliferation oftissue in the male breast. The condition usu-ally has a high rate of spontaneous regres-sion and can occur at birth, during teenageyears (can last up to 18 months), or in malesabove age 50. It is often seen bilaterally butcan be unilateral. Gynecomastia is not asso-ciated with increased risk for breast cancer inmales (Peart, 47–62; Venes, 918).


78. (C) The Montgomery glands (glands ofMontgomery) are seen as protrusions on thesurface of the areola. They are actually spe-cialized sebaceous glands that usuallybecome more prominent during pregnancyand lactation (Peart, 35–44).

79. (A) Extended processing extends the time thefilm spends in the developer solution. It mayalso raise the temperature of the developersolution. The overall effect of extended pro-cessing is to increase the speed and contrastof some single emulsion films. The filmrequires less exposure; therefore, the radia-tion dose to the patient can be lowered(Andolina, 45–98; Peart, 65–84).

80. (C) The humidity level in the darkroomshould be between 30% and 50%. Lowhumidity (less than 30%) causes static andhigh humidity (more than 50%) causesclumping of the film emulsion from watervapor clinging to the film. Dirty rollers maycause scratches on the films. Changes indeveloper temperature, improperly mixeddeveloper, or contaminated developer cancause reduced film speed or increased basefog (Figure 6-13) (Andolina, 45–98; Peart, 65–84).

81. (A) Above 40, it is recommended that awoman have a CBE at about the same time asthe annual mammogram, even if the womanhas no symptoms and no significantly higherrisk for breast cancer (ACR, 10).

82. (D) Fibrous and glandular tissue together aredescribed as fibroglandular densities. X-rayswill more easily penetrate through fatty tis-sue than through fibrous or glandular tissue.Fatty areas appear as radiolucent (black orless dense) areas on the mammogram. Thefibroglandular tissue is more radiopaquethan fatty tissues and results in areas of loweroptical density on the mammogram (white ordenser areas) (Peart, 35–44).

83. (C) Compression decreases the thickness ofthe breast, bringing the breast closer to theimage receptor and increasing subject con-trast. Spatial resolution (sometimes calledimage detail) is the ability to image smallobjects that have a high subject contrast, forexample, microcalcifications in breast tissue,and is most affected by focal-spot blur butalso improved with decrease geometric blurand motion blur. Contrast resolution (some-times called visibility of detail) is the abilityto distinguish anatomic structures of similarsubject contrast and is most affected by scat-ter radiation and radiographic noise. Resolu-tion affects the image appearance by demon-strating fine detail of structures. Becauseresolution improves when the OID decreases,compression also increases spatial resolution(ACR, 23–77; Peart, 115–145).

84. (D) A core biopsy removes a cylinder of tis-sue using a 14- or higher gauge needle. Thesample from a core biopsy is larger than thatfrom FNA. Tissue samples from a core biopsyare assessed histologically. FNA or fine nee-dle aspiration cytology (FNAC) is more diffi-cult to perform. A 20- to 23-gauge needle isused to remove cellular material for cytologi-cal analysis. Excisional biopsy is a surgicalbiopsy where the entire lesion as well as sur-rounding margins of normal-appearing tis-sue is removed. Wire localization is a proce-dure during which nonpalpable lesions orFigure 6–13. Static is often the result of low humidity in the

darkroom.


calcifications in the breast are identified byplacing a thin needle into the breast. The nee-dle is guided using mammograms or ultra-sound, and a small hook wire is placed tomark the site of the lesion before surgery(Andolina, 313–330; Peart, 203–220).

85. (D) The rolled medial or the rolled lateral(RM or RL) are both useful in separating glan-dular structures of the breast to clear ques-tions of superimposition. The ID projection isused in imaging augmented breast clear ofthe implants. The MLO is a routine projectionand would not be used as an additional pro-jection. The XCCL is best for imaging the pos-terolateral parts of the breast with the x-raytraveling craniocaudal (Peart, 115–145).

86. (C) The high placement of the image receptorunnecessarily elevates the shoulder, pullingbreast tissue from the compression field.There will be poor pectoral muscle and possi-ble missed posterior breast but compressionof the lower breast will not be compromised.If, however, the patient has a protrudingabdomen the compression paddle hits theabdomen, compressing the abdomen and notthe lower breast. If too much shoulder mus-cle and axilla are allowed in the compressionfield, the axilla will be compressed but thethickness of the axilla will not allow for com-pression of the lower breast (Peart, 115–145).

87. (C) As a woman ages, declining hormonelevels affect both the breast stroma andepithelium. The breast loses its supportingstructure to fat, producing a smaller breast ora larger, more pendulous breast because ofthe loss of the epithelial structures andstroma and gain of fat. The duct systemremains but the lobules shrink and collapse.This process generally speeds up atmenopause and may continue for 3–5 years.It is referred to as atrophy or involution.Increased estrogen or hormone levels, whichoccur during menstruation, result in anincrease in breast stroma and epitheliumleading to denser breast tissue (Peart, 13–44).

88. (D) The arm position will help to minimizeskin folds. Sliding your finger under the com-pression device to roll the folds laterally willalso help. (A) will maximize visualization ofthe posterior lateral tissue. (B) and (C) willimprove visualization of the medial breast(ACR, 34–50).

89. (A) In conventional mammography imagingthe x-rays interacts primarily with theentrance surface of the screen. If the screen isbetween the x-ray tube and the film, theexcess screen blur will cause increased spatialresolution or image detail. This refers to theability to image small objects that have a highsubject contrast, for example, microcalcifica-tions in the breast. With the film between thex-ray tube and the screen (the film is placedwith the emulsion side to the screen), screenbloom is reduced and spatial resolution isimproved (Figure 6-14) (Bushong, 327–340;Peart, 65–84).

90. (B) Although grids increase contrast, in mag-nification mammography the large OID or airgap acts like a grid in reducing scatter radia-tion from reaching the film. Grid use in mag-nification would increase exposure times,increase tube loading, and thus increasemotion artifact because of long exposuretimes. Patient radiation dose is also increased(ACR, 59; Peart, 65–84).

X-ray tube X-ray tube

Film(base andemulsion)

Incorrect screen positionCorrect screen position

Screen

Screenbloom

Film

Screenbloom

Figure 6–14. Position of the film and intensifying screen is impor-tant in mammography. In the incorrect position, the intensifyingscreen is placed between the primary beam and the film resultingin excessive screen blur. Spatial resolution will improve if the film isplaced between the primary beam and the intensifying screen.


91. (D) The FB best visualizes the central andmedial abnormalities high on the chest walland can be done for all these reasons. Thebeam is directed inferiorly to superiorly(ACR, 68; Peart, 115–145).

92. (D) The ML provides a true representation ofthe breast structures in relation to the nipple,but should not be used as a routine projectionbecause it is poor at visualizing the posteriorand lateral aspects of the breast. TAN projec-tion can be used to locate skin lesions. The FBcan replace the CC in the nonconformingpatient and the XCCL images the far lateralbreast tissue in the CC position (Peart, 115–145).

93. (A) Parallel grid designs are common inmammography. Here the lead strips arealigned adjacent and parallel to each otherand placed lengthwise in grid structure. Par-allel grids allow CR angulation in the direc-tion of the lead strips only and will removescatter in one direction. Option (B) describesthe crossed (crosshatch or crisscross) griddesign. This is similar to having two lineargrids with their linear patterns at right anglesto each other. Crossed grids do not permitany CR angulation and will clean up scatterin both directions. Option (C) describes thefocused grid where the lead strips are virtu-ally parallel in the midsection but at theperiphery they incline slightly toward thecenter of the grid. The focused grid must beused at its designed SID to avoid grid cutoffand work will with mammography unitswhich are designed to operate at fixed a SID.Grid cutoff is the unwanted absorption of theprimary bema by the lead strips of the grid.Option (D) describes the moving grid. Gridscan be stationary or moving. The stationarygrid will produce observable images of thegrid lines. The moving grid “moves” duringthe exposure. In breast imaging, the grid is areciprocating grid that moves to and fro ver-sus the oscillating grid that moves in the cir-cular pattern (Bushong, 248–261; Peart, 77).

94. (B) If the processor does not have an internaldigital thermometer, any regular digital ther-mometer can be used. The mercury-in-glass

thermometers are easily broken and can dam-age or contaminate the processor. Even smallamounts of mercury can permanently conta-minate the processor (ACR, 130; Peart, 65–84).

95. (A) Mammography units generally have twosets of focal spot sizes, one for routine imagingand the other for magnification. To maintain asharp image during magnification, a smallfocal spot size is used. The small focal spotsize increases spatial resolution. Resolution isalso increased by decreasing the thickness ofthe part under compression, thereby lesseninggeometric unsharpness (Bushong, 327–340; Peart,65–84).

96. (D) The half-value-layer (HVL) of the x-raybeam is the thickness of absorbing materialneeded to reduce the intensity of the beam tohalf of its original value. Dosimeter equipmentand an ionization chamber are just two of anumber of methods that can be used to mea-sure the radiation intensity for successivelythicker sections of filters. The slit camera is aneffective measuring tool used to determine thefocal spot size. The star pattern and the pin-hole camera can also be used to measure focalspot size (Bushong, 327–340; Peart, 237–256).

97. (A) The overall repeat rate should be approx-imately 2% or less, but a rate of 5% is proba-bly adequate. If the repeat rate exceeds theacceptable level (2% or 5%) or if repeat orreject rates change from the previously mea-sured rate by more than ±2%, the changeshould be investigated and corrective actiontaken (ACR, 207).

98. (C) Oil cysts show mammographically ashigh-density tumors with lucent centers andeggshell-like calcifications. They usually formas a result of fat necrosis or are calcifiedhematomas. Fat necrosis is death of fatty tis-sue in the breast that can occur spontaneously,but is usually the result of a biopsy or injury.When the fat tissue dies, it changes to oil. Thebody then forms a capsule around the oil toprotect itself. The capsule generally has a thinlayer of calcifications, which give an eggshell-like appearance on the mammogram. Oil cysts


are benign. Ductal papillomas are benignmasses associated with the ducts and are notseen mammographically. A fibroadenoma is abenign radiolucent mass that may or may notcontain calcifications. A hematoma is seen as acircular-oval lesion with mixed density. It is abenign mass associated with injury or surgery(Peart, 47–63; Tabár, 17–92).

99. (C) The final mammographic image should beevaluated under ideal viewing conditions.Excellent viewing conditions include lowambient room light to minimize light reflectedoff the surface of the image. The view-boxesshould be cleaned and checked regularlybecause they can become dirty or the lumi-nance of the bulbs can fade. Masking theimage eliminates extraneous viewbox light,which has not passed through the exposedarea of the film, from reaching the eye. If theextraneous viewbox light is blocked, it is oftenpossible to see the skin and subcutaneous tis-sues (ACR, 92; Peart, 87–112).

100. (C) The implant displaced (ID) projection isa method of imaging the augmented breast.The method displaces the implant posteri-orly to exclude it from the compressionarea. ID projections are taken in addition tothe routine projections. In general, the rou-tine series of projection for a patient withbreast augmentation would be routine CCof both breasts, routine MLO of bothbreasts, CC with ID of both breasts, andMLO with ID of both breasts (Peart, 115–145).

101. (D) Under the final regulations of the US Foodand Drug Administration (FDA), all mammo-graphers satisfying the interim regulationscan still perform mammograms. All newmammographers must:

• complete at least 40 contact hours of docu-mented training in mammography underthe supervision of a qualified instructor or,before April 28, 1999, have satisfied therequirements of the interim regulation ofthe FDA

• perform a minimum of 25 examinationsunder direct supervision of a qualifiedmammographer

• have at least 8 hours of training in eachmammography modality in which thetechnologist intends to practice (eg, digital-vs. conventional screen–film systems) if themammographer started working in thenew modality after April 28, 1999

(Accreditation and Certification Overview: Technolo-gist Training)

102. (B) For proper positioning of the MLO, thepectoral muscle is wide superiorly with aconvex anterior border, extending to orbelow the posterior nipple line. Other criteriainclude that there is no evidence of motionand deep and superficial tissues are well sep-arated (ACR, 42).

103. (A) Ductal ectasia is a benign inflammatorycondition of the ducts, which leads to nippledischarge, nipple inversion, or periareolarsepsis. The condition may resemble breastcarcinoma. Paget disease of the breast is aspecial form of ductal carcinoma associatedwith changes of the nipple. Peau d’o range isa condition where the skin of the breastbecomes thickened and dimpled, resemblingan orange; this may be the result of eitherbenign or malignant conditions. Ductal papil-lomas are benign masses associated with theducts and are not usually seen mammo-graphically (Andolina, 155–173; Peart, 35–44).

104. (A) In the immature breast the ducts andalveoli in the lobule are lined by a two-layerepithelium of cells. After puberty this epithe-lium proliferates, forming three alveolar celltypes: superficial (luminal) A cells, basal Bcells (chief cells), and myoepithelial cellsforming the innermost layer or basal surfaceof the epithelium. Beneath the epithelium isconnective tissue that helps to keep theepithelium in place. Between the epitheliumand the connective tissue is a layer called thebasement membrane. The basement mem-brane provides support and acts as a semi-permeable filter under the epithelium (Peart,35–44; Tortora, 1083).


105. (B) In this form of unsharpness there is a fur-ther spread of light from the screen before itreaches the film. Unlike motion unsharpness,which covers a wider area, unsharpnessbecause of poor screen contact is usuallylocalized. Noisy images are mainly becauseof scatter or quantum mottle. Scatter radia-tion provides no useful information on theimage and will also reduce subject contrast.Most scatter in imaging is the result ofCompton effect, where an incident electroninteracts with an outer-shell electron andejects it from the atom, ionizing the atom.The ejected electron is called the Comptonelectron. When not enough photons are usedto form the image, the result is a greateramount of quantum mottle. Subject contrastrefers to the variations of tissue density seenon the image (ACR, 104–105).

106. (B) Mammoplasty is the general term usedwhen describing reshaping of the breast. Thebreast can be lifted to reduce a sagging breast,enlarged (augmented), or reconstructed afterthe removal of a tumor. Reduction mammo-plasty is the term used to describe the reduc-tion of the size of the breast by removingexcess breast tissue. A breast biopsy is theremoval of breast tissue for histological test-ing (Peart, 220–234; Tortora, 1096).

107. (B) Quantum mottle is one of the principalcauses of radiographic noise. Radiographicnoise is the undesirable fluctuation in the den-sity of the image because of fluctuations in thenumber of x-ray photons interacting with thefilm. The quantum mottle will be higher ifthe x-rays are produced with few x-ray pho-tons. Image graininess (film graininess) isthe distribution in size and space of the sil-ver halide grains in the emulsion, and contrastresolution refers to the ability to visuallydetect separate objects distinct from eachother. Contrast resolution is best improvedby using collimation. Motion results in blur-ring unsharpness of the image (ACR, 102–105;Bushong, 272–291).

108. (C) Yellow-brown stains on the film arecaused by thiosulfate from the fixer, left on

the film because of improper washing. Thisgenerally indicates a problem with hypo-retention from the fixer. The silver sulfideslowly builds up and appears as yellow inthe stored radiograph. Streaks on the film canresult from light leaks in the cassette; a roundspot of increased density may be caused bylow humidity (static). Areas of reduced den-sity could be caused by pressure on the filmbefore exposure (Bushong, 204–217).

109. (C) In the SIO projection, the beam is directedfrom the superolateral to the inferomedial sur-face of the breast; therefore, the medial breastis closest to the image receptor (Peart, 115–145).

110. (D) In general, male breast imaging will pre-sent the same difficulty as imaging a small,dense female breast and the breast size ofmales is sometimes no different than that offemales. However, because of chest hair onmales, the breast tends to slip from under thecompression (Andolina, 246–310; Peart, 115–145).

111. (D) In the SIO, the rays are directed from thelateral portion of the upper axilla to thelower medial portion of the breast, that is,superiolateral to inferomedial. The supero-medial to inferolateral is the routine MLOand the inferolateral to superomedial is theLMO. The inferomedial to superolateral hasno American College or Radiology (ACR)label (Peart, 115–145).

112. (B) Under current regulations, an accredita-tion body can be a private, nonprofit organi-zation or state agency. Currently, the US Foodand Drug Administration (FDA)-approvedaccreditation bodies are the American Col-lege of Radiology (ACR) and the states ofArkansas, Iowa, and Texas. Accreditationbodies can accredit only those facilitieslocated within their respective states (Accredi-tation and Certification Overview).

113. (B) The MLO is one of the routine imagingprojections. The reverse of this is the LMO.This projection will give a mirror image ofthe MLO and is useful in imaging patientswith pacemakers. The LMO and also the LM


are good alternatives to the routine imagesand both can also be used for patients withinfusa-port (port-a-caths inserted for long-term chemotherapy treatment), the kyphoticpatient, and patients with recent open-heartsurgery. The ML is not a good replacementbecause it is poor at imaging the posteriorand lateral aspects of the breast. The XCCLonly images the posterolateral breast tissue(Peart, 115–145).

114. (D) In breast localization, the shortest skin-to-abnormality distance should always be usedunless that projection will not demonstrate

the abnormality. In addition to these reasons,the greater the distance the needle travels inthe breast, the greater the risk of deflection(Andolina, 313–330; Peart, 203–220).

115. (D) These are the MQSA requirements. Theassessment of findings refers to the final result(eg, benign). Additional patient identifierscould be the patient’s age, date of birth, ormedical record number (Accreditation and Certifi-cation Overview: Record Keeping).


135

CHAPTER 7

Practice Test 2Questions

1. Radiation therapy is a treatment that utilizes

(A) drugs to treat cancer that may havespread

(B) high-energy radiation to destroy cancercells

(C) radioactive tracers to track the path ofcancer to the lymph nodes

(D) potent pain medication to treat thesevere pain from cancer

2. Between ages 20 and 30 an asymptomaticwoman should be having a mammogramevery

(A) year(B) 2 years(C) 3 years(D) none of the above

3. Medical history may include questions onhormone use because

(A) synthetic hormones such as hormonereplacement therapy (HRT) will alwayscause breast cancer

(B) reproductive hormones are a factor inbreast cancer risks

(C) family history of hormone use predis-poses a woman to cancer

(D) personal history of hormone use decreasesa woman’s risk for breast cancer

4. X-ray photons leaving the breast enter thetop of the cassette/image receptor

1. to go through the intensifying screenbefore reaching the film

2. then go through the film before reachingthe intensifying screen

3. interact with the single intensifyingscreen of the cassette/image receptor

(A) 1 and 2(B) 2 and 3 (C) 1 and 3(D) 1, 2, and 3

5. In quality control (QC), if the data consis-tently exceed the operating level the recom-mendation is

(A) establish new operating limits(B) narrow the control limits(C) widen the control limits(D) improve QC procedures

6. A control film crossover should be carried out

(A) whenever the processing chemistry ischanged

(B) when a new box of film is opened(C) if a new processor is installed(D) if the control limits consistently exceed

the normal values



7. In digital imaging, a graph of the densityrange to the log of relative exposure (the char-acteristic curve or Hurter and Driffield (H&D)curve used in conventional imaging) shows a

(A) shallow sloping curve(B) steep sloping curve(C) linear response(D) curve similar to conventional imaging

8. On the American College of Radiology(ACR)-approved accreditation phantom, thetotal number of fibers, speck groups, andmasses are

(A) five fibers, five speck groups, and fivemasses

(B) five fibers, six speck groups, and fivemasses

(C) six fibers, five speck groups, and fivemasses

(D) five fibers, five speck groups, and sixmasses

9. The circular pigmented area around the nippleis called the

(A) skin(B) areola(C) Montgomery gland(D) ampulla

10. A keratosis is demonstrated mammographi-cally as a

(A) sharply outlined multilobulated lesion(B) sharply outlined lesion with a halo(C) mixed-density circular lesion with a

radiolucent center(D) mixed-density oval lesion

11. Figure 7-1 indicates

(A) mammographically benign calcifications(B) malignant calcifications(C) keratosis (D) fibroadenomas

12. What immediate action is used to reducemotion unsharpness in mammography?

(A) compression (B) low mAs (milliamperes per second)(C) low kVp (kilovoltage peak)(D) small focal spot size

13. In magnification, what immediate role doesthe large object-to-image receptor distance(OID) play in reducing scattered radiation?

(A) The compressed breast allows lowerkVp values.

(B) Exposure is reduced because a grid isnot needed.

(C) Most of the scattered radiation missesthe image receptor.

(D) The larger source-to-image receptor distance (SID) utilizes the inverse square law.

Figure 7–1


14. Quantum mottle on the image is reduced by

(A) high kVp(B) high mAs(C) motion(D) fast intensifying screens

15. What is the best placement for the needlewire during needle localization?

(A) The needle wire should pass immedi-ately below the lesion.

(B) The needle wire should pass immedi-ately above the lesion.

(C) The needle wire should pass through thelesion.

(D) The needle wire should pass immedi-ately beside the lesion.

16. Although it often means losing some of thelateral breast tissue, in imaging for the cran-iocaudal (CC) projection, most experts advisea slight rotation of the patient’s body to max-imize imaging of the medial breast tissue.Why?

(A) Medial breast is imaged best on the CC.(B) Medial breast is imaged only on the CC.(C) Slight rotation avoids distorting the

medial breast.(D) The slight rotation enables ease in

positioning.

17. Which is true for all tangential (TAN) projec-tion positioning?

(A) The patient is always in the CC position.(B) The central ray is always directed

vertically.(C) The central ray is always parallel to the

plane of the breast.(D) The central ray is always perpendicular

to the skin surface.

18. In the rolled medial (RM) position, thelower surface of the breast is rolled in whichdirection?

(A) laterally(B) medially(C) inferiorly(D) superiorly

19. A radiopaque implant used in breast recon-struction that easily adjusts for cup size afterplacement is the

(A) silicone gel implant (B) transverse rectus abdominis muscle

(TRAM) flap implant(C) silicone liquid implant(D) saline implant

20. In addition to the routine CC and mediolateraloblique (MLO), a routine series for a postmas-tectomy patient could also include the

(A) axillary tail (AT)(B) mediolateral (ML)(C) TAN(D) lateromedial oblique (LMO)

21. Men with a family history of breast cancerwill

(A) have a greater risk for breast cancer(B) have a minor risk for breast cancer(C) have no significantly increased risk for

breast cancer(D) always get breast cancer

22. The clinical breast examination (CBE) shouldbe performed

(A) at or near the time of the annual mammogram

(B) only by the radiologist(C) monthly, preferable at the same time of

the month(D) at least twice a year


23. The absorbed dose in mammography is gen-erally _______ the entrance skin exposure(ESE).

(A) significantly higher than(B) significantly lower than(C) about the same as(D) slighter higher than

24. The Mammography Quality Standards Act(MQSA) requires that the maximum com-pression for the initial power drive notexceed

(A) 100 newtons(B) 200 newtons(C) 400 newtons(D) 500 newtons

25. Collimation should not extend beyond anyedge of the image receptor by more than

(A) 1% of the SID(B) 2% of the SID(C) 3% of the SID(D) 4% of the SID

26. In conventional imaging, the characteristiccurve of a particular film describes the rela-tionship between the

(A) exposure the film receives and the den-sity after processing

(B) x-ray beam quality of the mammo-graphic unit and film speed

(C) speed of the film and the density at dif-ferent exposure levels

(D) screen-film combination as it relates tothe selected mAs

27. Under which of the following circumstancesis it necessary to reestablish processor QCoperating levels?

(A) a change in film volume(B) a change in mammographer(C) an unexplained upward change in

the data(D) using a different sensitometer

28. Densities on the sensitometric strip andphantom image were recorded as follows:density inside the disk = 1.23, the mid-density = 1.25, the background density =1.68, the density adjacent to the disk = 1.66,and the highest density = 1.69. What is thedensity difference (DD) on the phantomimage?

(A) 0.42(B) 0.43(C) 0.44(D) 0.45

29. Breast tissue can extend medially to the

(A) latissimus dorsi muscle(B) midsternum(C) retromammary space(D) inframammary crease

30. Which of the following hormones has themost influence on the normal physiologicalchanges of the breast?

1. prolactin2. estrogen3. progesterone


31. Which of the following is (are) considered afirst-degree relative?

1. mother2. aunt3. sister



32. A woman should perform breast self-examination (BSE) monthly to

(A) become familiar with both of her breasts(B) localize cancerous lumps(C) recognize breast dimpling(D) discover nipple discharge

33. The breast of a woman below age 35 is

(A) not related to radiation sensitivity(B) less sensitive to radiation(C) less sensitive to low-dose radiation(D) more sensitive to radiation

34. In the low kVp range using a molybdenumtarget tube, what type of photon interactionpredominates?

(A) photoelectric interaction(B) Compton interactions(C) Bremsstrahlung interaction(D) Coherent interaction

35. In digital imaging a repeat analysis test is

(A) unnecessary—digital imaging automati-cally corrects exposure mistakes

(B) necessary—digital imaging cannot cor-rect for overexposure

(C) unnecessary—digital imaging correctsunsharpness by altering the spatial dis-play

(D) necessary—digital imaging cannot cor-rect factors such as motion unsharpness

36. The same mammographer should view thephantom images because

(A) subjective judgment about images isalways difficult

(B) it is not wise to have different individu-als handling the phantom

(C) not all mammographers know theMQSA regulations

(D) given set values, different mammogra-phers will calculate the densities differently

37. The from below (FB) projection utilizes abeam directed

(A) perpendicular to the image receptor(B) horizontally(C) tangentially(D) parallel to the image receptor

38. Radiation changes that the breast may exhibitinclude

1. erythema2. edema3. hardening

(A) 1 and 2(B) 2 and 3(C) 1 and 3(D) 1, 2, and 3

39. Magnification in mammography can be usefulin all of the following except

(A) specimen radiographs(B) to define borders of masses(C) to assess calcification(D) routine screening

40. Which of the following projections could beused to replace the MLO in patients wherethe MLO is not possible?

(A) ML(B) lateromedial (LM)(C) rolled lateral (RL)(D) AT

41. Contrast resolution in conventional imagingrefers to the ability to

(A) image high-contrast small objects suchas microcalcifications

(B) distinguish anatomic structures withsimilar subject contrast

(C) visualize recorded detail when imagecontrast and optical density are optimized

(D) visualize recorded detail


42. The best time for a woman to perform a BSE is

(A) before the start of the monthly period(B) just after the period starts(C) within 5–10 days after the start of the

period(D) anytime

43. It may be necessary to use manual techniquewith small breast because the

(A) multiple detectors can be moved accord-ing to breast size

(B) automatic exposure control (AEC) detec-tor may not cover the small breast tissuearea

(C) AEC detector cannot compensate forbreast size

(D) AEC cannot compensate for varyingbreast tissue types

44. If an artifact is noted on some mammo-graphic images, which appropriate MQSAregulation will identify the dirty cassette/image receptor quickly and easily?

(A) processor QC test(B) screen cleanliness(C) visual checklist(D) standardized image labeling

45. Which of the following tests are performedmonthly?

(A) phantom images(B) repeat/reject analysis(C) compression check(D) visual checklist

46. On a reject/repeat analysis, the rate waslower than 5% but one category of thereject/repeat analysis is significantly higherthan others. What should be done?

(A) Although the overall rate is less than 5%,that one area should be targeted forimprovement.

(B) If the other categories are within normallimits, that area can be disregarded.

(C) Because the rate was more than 2%, the entire department needs to bereassessed.

(D) With an overall rate lower than 5%, onehigh rate is statistically meaningless.

47. Typically, grid ratios in mammography rangefrom

(A) 7:1 to 8:1(B) 6:1 to 7:1(C) 4:1 to 6:1(D) 3:1 to 5:1

48. Positron emission tomography (PET) imag-ing is useful in staging tumors because

(A) the positron emitting isotopes areradioactive

(B) PET imaging can display an image of thetumor bed

(C) the positron emitting isotopes destroythe tumor bed

(D) PET imaging tracks the increased bloodflow from the cancerous tumor

49. Medical history is important in

1. assessing risk factors for breast cancer2. preventing breast cancer3. evaluating treatment options



50. Unlike conventional x-ray tubes, somemammography tubes are tilted 7.5–12 degreesfrom the horizontal. The effect of this is to

1. allow the use of smaller focal spot size2. minimize the heel effect3. increase resolution


51. The retromammary space describes the area

(A) between the breast and pectoral muscle(B) separating the skin of the breast from the

deep fascia(C) separating the skin from the superficial

fascia(D) between the glandular tissue and the

inframammary fold

52. In which of the following are breast cystsmore common?

1. young women in their early 20s2. premenopausal woman3. postmenopausal woman on estrogen

therapy


53. The CC shows a circumscribed oval radiolu-cent lesion. There was a definite halo sur-rounding the lesion. It is most likely to be a

(A) fibroadenoma(B) lymph nodes(C) cyst(D) hematoma

54. What effect does compression have on Comp-ton interactions?

(A) The absolute number of Compton inter-actions increases.

(B) The absolute number of Compton inter-actions decreases.

(C) Compression has no affect on Comptoninteractions.

(D) Compression affects Compton interac-tion only above 70 kVp.

55. Visual inspection done during CBE involves

(A) feeling for changes in the breast(B) looking for changes in the breast(C) palpating the breast(D) examining areas under the armpit

56. If the residual hypo in the mammography filmexceeds 0.05 g/m2 or 5 μg/cm2, this can indicate

1. improper washing of the film2. improper fixer replenishment3. the film will have poor archival quality


57. Fatty tissue is generally radiolucent and willshow on the mammogram as

(A) glandular areas(B) high-density areas(C) low-density areas(D) medium-density areas

58. The mammogram of a woman age 50 whohas recently started estrogen replacementtherapy is likely to be

(A) more fibroglandular than her past mam-mographic study

(B) more fatty that her previous mammogram(C) less fibrous and less glandular than her

previous studies(D) unchanged from her previous

mammograms


59. The mammogram shows an oval-shapedlesion with mixed density. The lesion has acentral radiolucent area and is freely mov-able. This lesion is most likely to be a

(A) fibroadenoma(B) hematoma(C) lymph node(D) galactocele

60. If a cyst moves down on the ML from itsposition on the MLO, the cyst is located

(A) centrally(B) medially(C) laterally(D) at the areola

61. Increased OID causes loss of image detail inmagnification mammography. What factorshelp to compensate for this loss of imagedetail?

1. compression of the part2. decreased focal spot size3. increased OID


62. What does the actual focal spot size measure?

(A) the area on the anode exposed to electrons

(B) the area projected on the patient(C) the area projected on the image receptor(D) the nominal focal spot size

63. The mammography report has an assessmentfinding of Breast Imaging Reporting andData System (BIRAD) 0. This means that

(A) the mammogram is negative(B) there is a high probability of a benign

finding(C) additional imaging is needed(D) the findings are suspicious

64. The density difference, DD on the sensito-metric strip is the difference between

(A) the average density closest to 2.20 andthe mid-density

(B) the mid-density and the base plus fog(C) the average density closest to 0.45 and

the mid-density(D) the high and low average densities

65. What is epithelial hyperplasia?

(A) A calcified hematoma resulting fromtrauma

(B) An oil cyst within the breast(C) An overgrowth of cells in the ducts or

lobules(D) An epidermoid cyst on the skin of the

breast

66. Figure 7-2 shows a (an)

(A) ruptured implant(B) encapsulated implant(C) herniated implant(D) implant removal

Figure 7–2


67. After a four-projection mammogram, calcifi-cations are visualized superior to the nipplebut only on the MLO projection. What addi-tional projection would best be used to locatethe position of the lesion?

(A) exaggerated craniocaudal (XCCL)(B) cleavage (CV)(C) ML(D) AT

68. Approximately how much contrast agent isinjected into the breast during ductography?

(A) 1–5 cc(B) 15–25 cc(C) 30–40 cc(D) 50–100 cc

69. What does the glandular dose measure?

(A) the average dose to the patient’s skin(B) the absorbed dose to the skin(C) the absorbed dose at the tissue level(D) the same as the entrance skin dose

70. Which of the following relationships does notchange when moving from routine to magni-fication mammography?

(A) OID(B) focal spot size(C) SID(D) source-to-object distance (SOD)

71. Who performs the compression device checkfor mammography QC?

(A) physicist(B) staff technologist(C) radiologist(D) mammographer

72. A galactocele is

(A) a lesion associated with trauma to thebreast

(B) a benign milk-filled cyst(C) associated with eggshell-like calcification(D) associated with a central radiolucent hilus

73. During pregnancy and lactation, the breast

(A) shows increased density(B) increases in fatty content(C) atrophy of glandular structures(D) shows decreased density

74. Most of the glandular tissue is arranged inthe breast around the

(A) medial and upper inner quadrants (B) lateral and lower inner quadrants(C) central and upper outer quadrants (D) medial and upper outer quadrants

75. A beryllium (Be) window enhances contrast by

(A) increasing the output of the x-ray tube(B) reducing production of scattered

radiation(C) transmitting more low-energy photons(D) transmitting more high-energy photons

76. Proper compression of the breast is indicatedwhen the

(A) patient is in pain(B) compression paddle stops(C) breast is taut(D) breast feels soft

77. Which factors cause increased skin dose inmagnification?

1. larger OID2. smaller focal spot size3. increased mAs


78. In radiology, according to the line focus prin-ciple, the effective focal spot is

(A) larger than the actual focal spot(B) smaller than the actual focal spot(C) the same as the actual focal spot(D) decreased as the target angle increases


79. Figures 7-3A and 7-3B are mammograms ofthe same patient. Figure 7-3B was taken 6months after Figure 7-3A. These mammo-grams demonstrate a

(A) resolving oil cyst(B) galactocele(C) radial scar(D) hematoma

80. In the optimum position of the patient for theCC projection, the patient’s head is turned

(A) toward the side under examination(B) away from the side under examination(C) depending on the preference of the

mammographer(D) to the patient’s right

81. Which of the following projections wouldbest separate superimposed 12-o’clock and 6-o’clock masses?

(A) MLO(B) XCCL(C) CC(D) AT

82. In positioning terminology, CV means

(A) compressed position(B) Cleopatra view(C) cleavage view(D) compression view

83. Malignant casting-type calcifications appearon the mammogram as

(A) granulated sugar or crushed stone calcifications

(B) eggshell-like calcifications(C) elongated, branching, and needlelike

calcifications(D) fragmented, linear branching

calcifications

84. The functional milk-producing units of thebreast are contained within the

(A) lactiferous sinuses(B) lobules(C) ampulla(D) areola

Figure 7–3A

Figure 7–3B

A

B


85. If the nipple is not imaged in profile on the four-projection series, indications to take additionalprojections with the nipple in profile include

1. the nipple cannot be differentiated froma mass

2. the patient has a possible retroareolar mass3. the patient is male


86. The AT projection best demonstrates the

(A) subareolar area(B) medial aspect of the breast(C) axillary aspect of the breast(D) lower inner quadrant of the breast

87. The area of minus density in the upper partof Figure 7-4 best represents

(A) the patient’s shoulder(B) a pressure artifact occurring after the

exposure(C) the patient’s chin(D) malposition of the mirror supplying

illumination

88. The patient had trauma to the breast 1 monthago and has developed a lump. Such aninjury may show mammographically as a

(A) galactocele(B) hematoma(C) lymph node(D) fibroadenoma

89. In mammography imaging, exposure factorsused depends on all of the following except

(A) the patient(B) target material(C) screen/film combination(D) viewing conditions

90. If too much upper axilla and shoulder areunder the compression paddle when imagingfor the MLO, the effect is to

(A) inhibit proper compression of the upperbreast

(B) inhibit proper compression of the lowerbreast

(C) ensure equal compression of the upperand lower breast

(D) ensure proper compression of the lowerbreast

91. Of these four, which would best demonstratemicrocalcifications within the breast?

(A) ultrasound(B) spot compression(C) spot magnification(D) TAN projection

Figure 7–4


92. The area of minus density in the upper partof Figure 7-5 best represents

(A) a pacemaker(B) the patient’s chin(C) a hematoma(D) port-a-cath

95. Which projection gives a mirror image of theMLO?

(A) ML(B) LM(C) LMO(D) AT

96. The nominal focal spot size of the mammog-raphy unit is 0.3. This means that the

(A) actual focal spot size is 0.3(B) effective focal spot size is 0.3(C) both effective and actual focal

spot size is 0.3(D) actual focal spot is smaller than 0.3

97. Women with lumpectomy should have mag-nified images taken of the tumor bed to

1. confirm the removal of the cancer2. check calcium deposits that may result

from radiation and surgical changes3. check for recurrence of the cancer

(A) 1 and 2(B) 2 and 3(C) 1 and 3(D) 1, 2, and 3

98. A lesion is present on the MLO but is notseen on the CC projection. What projectioncould best be used to determine whether thelesion is laterally or medially located?

(A) XCCL(B) CV(C) ML(D) AX

99. Delaying the processing of films will affect the

1. speed of the film2. film contrast3. density of the film


Figure 7–5

93. A rolled projection can be performed to

1. remove superimposed tissues2. separate superimposed breast tissue3. determine the location of a finding seen

only on one of the standard projection


94. Ideally, in an open surgical biopsy, whenshould a breast tissue specimen be imaged?

(A) immediately after surgery(B) within 24 hours of the surgery(C) while the patient is still in the recovery

room(D) before the surgery is terminated


100. When imaging a small breast, scattered radi-ation can be minimized by

1. increasing compression2. reducing kVp3. reducing field size


101. The purpose of the certification and accredi-tation process is to

(A) provide legal mammography services(B) establish minimum national quality

standards for mammography(C) ensure that all women have access to a

certified mammography facility(D) authorize certain states to certify mam-

mography facilities and conduct inspections

102. A facility has a sign posted advising patientsto contact a designated person within theorganization with comments. This facility ismeeting the U.S. Food and Drug Administra-tion (FDA)’s

(A) medical outcome audit program(B) record-keeping program(C) patient communication of results

program(D) customer complaint program

103. A hamartoma is

(A) a malignant tumor of the breast(B) a benign tumor of the breast(C) associated with trauma of the breast(D) associated with nursing

104. After parturition, contraction of which cellshelp to eject milk from the alveoli?

(A) epithelial cells(B) myoepithelial cells(C) basement cells(D) superficial cells

105. A finding of BIRAD 1 on the mammogrammeans that the mammogram

(A) cannot accurately evaluate the breast(B) showed benign findings(C) showed suspicious findings(D) is suggestive for malignancy

106. Erythema of the breast generally indicates

(A) inflammatory breast cancer(B) breast abscess(C) breast infections(D) further testing of the breast is necessary

107. Which of the following is used as a treatmentfor estrogen-dependent tumors in post- andpremenopausal women?

(A) radiation therapy(B) chemotherapy(C) tamoxifen(D) antibody therapy

108. Causes of radiographic noise include

1. quantum mottle on the image2. scattered radiation3. film graininess


109. A thin supportive layer located between thebasal surface of the epithelium and the con-nective tissue layer of the lobule is called

(A) chief cells(B) myoepithelial(C) basement membrane(D) superficial A cells


110. A “camel’s nose” breast contour can be pre-vented in the MLO projection by

(A) including all of the breast under thecompression paddle

(B) angling the image receptor parallel tothe pectoralis muscle

(C) properly supporting the breast duringcompression

(D) ensuring that the nipple remains in pro-file during compression

111. The superior inferior oblique (SIO) will bestdemonstrate the

(A) OUQ and the LOQ of the breast(B) LIQ and the UIQ of the breast(C) UIQ and LOQ of the breast(D) LIQ and the OUQ of the breast

112. The basic premise of a medical audit is that

1. all positive mammograms should be followed

2. the pathology results of all biopsies per-formed should be collected

3. all pathology results should be corre-lated with the radiologist’s findings


113. Under the MQSA, how long are facilitiesrequired to maintain the records of a patientwho died shortly after her first mammogram?

(A) 5 years(B) 10 years(C) 20 years(D) permanently

114. Under what circumstances are triangulationtechniques necessary?

1. to locate an abnormality visualized onone projection only

2. during sterostatic breast biopsy3. to perform spot magnification


115. A dimpled skin condition seen in cases oflymphatic edema of the breast is called

(A) inflammatory carcinoma(B) ductal ectasia(C) plasma cell mastitis(D) peau d’o range

1. (B) Many women are choosing conservationtherapy that removes the tumor with widemargins (lumpectomy, quadrectomy, or seg-mental mastectomy) and includes radiationtherapy (irradiation with high-energybeams). Treatment starts 3–8 weeks aftersurgery and includes about 5–6 weeks ofdaily treatments. Nuclear medicine usesradioactive tracer (also called radioactive iso-topes or radiopharmaceutical). Drugs can behormonal therapy (estrogen therapy) such astamoxifen or chemotherapy (Andolina, 331–330;Peart, 220–234).

2. (D) An annual mammogram is generally rec-ommended for asymptomatic women aboveage 40 who have not been identified as hav-ing significantly higher risk. The mammo-gram is not an effective screening tool foryounger women (ACS, 1–16).

3. (B) Studies have suggested that syntheticsuch as hormone replacement therapy (HRT)or reproductive hormones influence breastcancer risk as well as promote cancer growth.Early menarche (less than 12 years), latemenopause (equal to or more than 55 years),oral contraceptive use, and fewer pregnan-cies will all increase a woman’s risk by affect-ing estrogen levels in the body. Hormones orhormone use, however, are not known toalways cause breast cancer (ACS, 1–16).

4. (B) When exposed to radiation the intensify-ing screen will emit light, which then exposesthe film emulsion and forms a latent image.However, photons can travel through theintensifying screen interacting with the back

of the screen and also emitting light. Sincethe light diverges as it travels, the imageformed at the back is not an exact replica ofthe one formed in front—effectively decreas-ing the recorded detail of the image. In con-ventional mammography imaging, the x-raybeam should therefore travel through thebreast, through the film, and then strike theintensifying screen. This placement willreduce screen blur. There is high x-ray absorp-tion by the screen phosphors closest to the filmemulsion reducing the diffusion of light emit-ted from the screen. The result is less noise andgreater spatial resolution (Figure 6-14) (Bushong,327–340).

5. (D) If data seldom exceed the operating lim-its by ±0.1%, the medical physicist or radiolo-gist may wish to narrow the control limits. Ifthe limits are consistently exceeded, it is nec-essary to improve the QC procedures orrepair or replace the appropriate equipment.Establishing new limits are allowed onlyunder specific circumstances, such as if thefilm is changed or there are changes in pro-cessing method (equipment or solutions, forexample). Widening the control limits is neverallowed (ACR, 134–135).

6. (B) Whenever a new box of film is opened forQC, a crossover must be carried out. Radi-ographic films are produced in batches,which will have slight variations in charac-teristics of the film emulsion. This will affectthe sensitometric characteristics of the film.The crossover is carried out only with sea-soned processor chemistry that is operatingwithin plus or minus 0.10 of the control limits.

149



The crossover is used to compare the averagedensity difference (DD), mid-density (MD)and base-plus-fog of five films from the oldbox with five films from the new box. The newoperating level is established by adding thedifference (new minus old operating values)to the old operating level. If the difference ispositive, the new operating level is increased.If the difference is negative, the new operatinglevel is decreased (Figure 7-6). If control limitsconsistently exceed the normal values, theequipment needs to be repaired or replaced.Whenever new equipment is installed (proces-sor, sensitometer, or densitometer), the proces-sor QC operating levels must be reestablished(ACR, 161; Peart, 87–112).

7. (C) Digital detectors have image characteris-tic similar to the response of screen-filmexcept that the response in digital is linear(Figure 7-7). This means that regardless of the

Figure 7–6. The crossover worksheet is used to calculate the difference in the average values between the new and old boxes of film andthus determine new operating levels. If the new densities are so different from the old that the new steps will not be the best choice, then newoperating levels must be reestablished using the original method of establishing processor QC operating levels.

Film/Screen

IPIntensity relativeof the luminosity

Log of relative exposure

Figure 7–7. Characteristic curve for digital imaging. A graph ofthe optical density signal and the relative exposure for a digitalimaging plate (IP) will have a linear response to x-ray. This isunlike the curvilinear response of a film-screen system.


intensity of the x-ray beam, a small change inthe intensity is recorded as the same changein the electronic image. In digital imaging,this is possible because there are differentdevices for acquisition and display, and eachcan be separately optimized. Digital imagingtherefore has a much wider latitude than con-ventional imaging. Digital imaging canenhance the contrast resolution of the finalimage (Andolina, 437–452; Peart, 179–194).

8. (C) This is the total number in each group, butthe criteria for the number of objects to meetaccreditation requirements are a minimumnumber of four fibers, three speck groups, andthree masses (Figure 7-8). The only exceptionsto date are the Hologic and Siemens digitalunits which require five fibers, four speckgroups, and four masses. When scoring, eachfiber, speck group, or mass is counted as 1point. Partial fibers, speck groups, or massesare counted as 0.5 point or not at all (ACR, 268).

10. (A) A keratosis forms on the skin surface ofthe breast and gives a typical mammographicappearance. They are multilobulated, withsharply outlined borders. An example of amixed-density lesion with a radiolucent cen-ter is a lymph node. Other mixed-density cir-cular or oval lesions are hematomas, galacto-celes, or fibroadenolipomas. Halos are narrowradiolucent rings or ring segments typicallyseen around the periphery of benign circularor lesions (Peart, 47–62; Tabár, 17–92: Venes, 1171).

11. (A) Plasma cell mastitis, periductal mastitis, orductal ectasia is an inflammatory reactioncharacterized by the presence of plasma cellssurrounding a dilated duct. It is a benign con-dition. Intra- and/or periductal calcificationsare the final results of this condition. The calci-fication can be located around or inside thedilated ducts. Most are elongated and sharplyoutlined with smooth borders; some areneedlelike with high density or may have alucent central area. The fibroadenoma is anoval lesion that may contain calcifications. Ker-atoses rarely calcify and mammographicallyappear as lobulated lesions. Mammographi-cally malignant calcifications often appear inclusters (Peart, 47–62; Tabár, 17–92; Venes, 1171).

12. (A) There are numerous advantages of com-pression, but the immediate action of compres-sion in reducing motion unsharpness is immo-bilization. With the breast held still, thepossibility of motion blur is minimized.Changes in the mAs mainly affect optical den-sity and patient dose. The kVp has a direct effecton subject contrast. There are only two focalspot sizes in breast imaging—the routine largerfocal spot and the small focal spot for magnifi-cation imaging (ACR, 23–77; Bushong, 327–340).

13. (C) The large air gap acts like a grid andreduces scattered radiation, thus improvingcontrast. Positioning the breast away fromthe image receptor takes advantage of theinverse square law: the intensity of the scat-tered radiation is reduced because the dis-tance between the image receptor and theobject is increased. The SID does not changein magnification and, although a grid is not

Figure 7–8. Schematic diagram of the phantom showing the rel-ative position of the different objects embedded within the phantom.

9. (B) The areola is the smooth, darkened areathat surrounds the nipple. Skin covers theentire breast, and the Montgomery glandsare specialized sebaceous glands on the are-ola. The ampulla is another name for the lac-tiferous sinus, a part of the ductal systemin the internal breast anatomy (Peart, 35–44;Tortora, 1083).


used, there is no significant reduction inexposure because of reciprocity law failure.Grid use in magnification increases exposuretimes, increasing tube loading, thus increas-ing motion artifact owing to long exposuretimes. Patient radiation dose is also increased(ACR, 59–60; Peart, 65–84).

14. (B) Quantum mottle refers to the mottled,grainy appearance of a radiograph. In con-ventional imaging it occurs when insufficientx-rays interact with the intensifying screen toform the image. The use of high mAs, lowkVp, and slower film/screen combinationsreduce quantum mottle. Motion does notaffect quantum mottle (Bushong, 272–273).

15. (C) The localization needle wire should bepositioned to pass just through the lesion.Most surgeons feel for the tip of the wirebefore making an incision in the patient’sbreast. Because the tip is being used as a loca-tor, it should pass through the lesion, notabove, below, or beside it (Andolina, 313–330;Peart, 203–220).

16. (A) The medial breast is the most importantaspect of the CC projection. The other routineprojection, the MLO, often does not imagemedial breast clearly because of distancefrom the image receptor and superimpositionof glandular structures. Eliminating themedial breast on the CC would thereforeeliminate it from the study (Peart, 115–145).

17. (D) In the TAN projection, the x-ray beamjust skims the area of interest. The beam isalways tangential or perpendicular to theskin surface. This projection demonstratesthe area of interest free of superimposition.The TAN is possible in any direction or pro-jection (ACR, 65; Peart, 115–145).

18. (A) In the RM position, the breast is positionfor the CC. The top surface of the breast isrolled medially and the bottom surface later-ally (Andolina, 174–245; Peart, 115–145).

19. (D) Both saline and silicone implants areradiopaque. The saline implant can be

inserted as an adjustable sac (similar to tissueexpanders) where the fluid content isadjusted as needed. The only radiolucentimplant available is the autologous myocuta-neous flaps. This involves transplanting tis-sue from another area of the body to thebreast. The most popular is the transverserectus abdominis myocutaneous or TRAMflap, using the rectus abdominis muscle, butthe procedure can also be done using thelatissimus dorsi or the gluteus maximus.Mammographically, the breast has a fatty ormuscular appearance (Andolina, 306).

20. (B) After mastectomy, a three-projection seriesincluding the CC, MLO, and ML is generallyrecommended. Without the other breast forcomparison, this series gives the radiologist abetter opportunity to diagnose any newmalignancy. The AT images the axilla and theTAN images skin lesions. The LMO is the truereverse of the MLO (Peart, 115–145).

21. (A) Even though men generally have a lowrisk of developing breast cancer, they shouldbe aware of the risk factors, especially familyhistory which could be associated withgenetic changes. However, a family history ofbreast does not mean breast cancer willdevelop. Slightly over 1% of males in theUnited States develop breast cancer each year(ACR, 8; ACS, 1–16).

22. (A) The CBE is a clinical examination by atrained health-care professional and shouldbe performed every 3 years for women below40 and every year for women above 40. To beeffective, the CBE should be performed incombination with a mammogram (ACS, 1–16).

23. (B) Because of the low x-ray energies used inmammography, the dose to the skin may behigh, but dose falls off rapidly as the beampenetrates the breast. The dose to the skinmay be as high as 800–1000 mR/projection(8–10 mGy/projection); the dose to the mid-line of the breast (the average radiation doseto the glandular tissue or glandular dose)will be only 100 mrad (1.0 mGy). The finalrules of mammography dictated by the


MQSA state that a single projection screen-film mammogram should not give more than300 mrad/projection average glandular dosewhen a grid is used and should not exceed100 mrad/projection without a grid (Bushong,327–340; Peart, 65–84).

24. (B) A compression force of a least 111 new-tons (25 lb) and a maximum of 200 newtons(20 decanewtons or 45 lb) is required for theinitial power drive. This is an MQSA require-ment, necessary to avoid injury to patients(ACR, 201).

25. (B) This is the MQSA requirement to avoidexcess radiation dose to the patient. All unitsshould have a beam-limiting device thatallows the entire chest wall edge of the x-rayfield to extend to the chest wall edge of theimage receptor and should not extendbeyond any of the edges on the image recep-tor by more than 2% (ACR, 109).

26. (A) The characteristic curve measures theoptical density or degree of blackness of thefilm to the log of the relative radiation expo-sure. A single characteristic curve can be ana-lyzed to determine the contrast (slope of thestraight-line portion of the curve) and thefilm latitude (the range of exposures overwhich the film responds with optical densi-ties in the diagnostically useful range). Twocharacteristic curves of different films areneeded to compare film speeds (Bushong,272–291; Peart, 65–84).

27. (D) Establishing a new limit is allowed onlyunder specific circumstances, such as, if thefilm emulsion changes or there are changes inprocessing or assessment methods (newequipment or new solutions, new densitome-ter or sensitometer, for example). If the limitsunexpectedly changed (up or down), it isnecessary to improve the QC procedures orrepair or replace the appropriate equipment.Widening the control limits is never allowed(ACR, 134–135).

28. (B) To determine the density difference, DD,the optical density inside the disk and density

directly adjacent to the disk (to the left orright perpendicular to the anode-cathodeaxis) is recorded. The DD is the differencebetween these densities. The backgrounddensity is the density measured at the centerof the phantom image. The mid-density andhighest density are both obtained from thesensitometric strip (ACR, 167).

29. (B) The breast can reach superiorly to theclavicle (level of the second or third rib), infe-riorly to meet the abdominal wall at the levelof the sixth or seventh rib (at the inframam-mary fold or crease), laterally to the edge ofthe latissimus dorsi muscle and medially tothe midsternum (Peart, 35–44).

30. (B) The most prominent hormones active inthe breast are estrogen and progesterone.Estrogen is mostly responsible for ductal pro-liferation and progesterone is responsible forlobular proliferation and growth. Studieshave shown the two actually work togetherto produce full ductal–lobular–alveolar (ter-minal ductules) development. Prolactin ispresent in the breast during initial breastgrowth, pregnancy, and lactation (Peart, 35–44).

31. (D) First-degree relatives are immediate rela-tives such as mother, sister, or daughter (ACR, 8).

32. (A) The BSE involves looking and feeling forchanges in the breast. With routine BSE, awoman will become familiar with both thenormal appearance and feel of her breasts sothat even small changes are noticeable. Forthis reason BSE should be performed regu-larly at the same time every month (about5–10 days after the period begins, when thebreasts are least tender) (ACS, 1–16; AmericanCancer Society).

33. (D) Unnecessary exposure should be avoidedwith any radiographic examination. Somestudies have shown that the dense cellularbreast structure of women younger than 35 ismore susceptible to radiation. Dense breasttissue will also need more radiation to pene-trate, translating to increased dose (ACR, 79–110;Peart, 65–84).


34. (A) For mammography tubes made withmolybdenum, the most prominent x-rays arecharacteristic. Characteristic x-rays are pro-duced after a photoelectric interaction. If thetarget is filtered with molybdenum, the char-acteristic energy of 19 keV from the K-shellinteraction will be prominent. This is withinthe range of energies that are most effectivefor mammographic imaging. Characteristicradiation is produced when an outer shellelectron fills an inner shell void. If the outershell electron fills the void in the K-shell, thex-ray emissions are termed K-characteristicx-rays. Bremsstrahlung x-rays are producedwhen an outer projectile electron is slowed bythe electric field of the target atom nucleus.This interaction is common in tungsten tar-gets. Coherent or classical scattering describesthe interaction between low-energy electronsand atoms. The x-ray loses no energy butchanges direction slightly. In Compton scatter-ing, moderate-energy x-rays interact with anouter-shell electron and eject the electron fromthe atom. The ejected electron is the Comptonelectron (Bushong, 117–187; Peart, 65–84).

35. (D) The QC testing for digital imaging hasmost of the components of conventionalimaging plus additional tests on the display,laser printer if used, and imaging system.Repeat analysis is still needed for repeatsbecause of positioning, patient motion, noisyimages (underexposure), and equipment fail-ure, to name just a few. Digital imaging cancorrect for overexposure, although excessiveoverexposure increases the patient dose. Digi-tal imaging has a harder time correcting forextreme underexposure, and creates a noisyimage (similar to quantum mottle). Digitalimaging can enhance the spatial display byenhancing the edges of spiculation or calcifica-tions, making them more visible. Digital imag-ing cannot correct unsharp images, especiallyunsharpness caused by motion (Andolina,437–452; Peart, 87–112, 179–194; Stevens, 275–370).

36. (A) Different individuals perceive differentnumbers of test objects images or may count adifferent number of objects in the same image.For consistency, the same individual should

examine the images each time using the samecriteria (same time of day, same viewbox,same magnifier, and same viewing condi-tions). The density calculations are mathe-matical formulas that do not change. Allmammographers should be at least familiarwith the basic MQSA guideline (ACR, 184).

37. (A) The FB (from below) is the reverse CCprojection. The beam is directed caudocra-nially to form an angle of 90 degrees with theimage receptor (Peart, 115–145).

38. (D) After radiation therapy the breast mayappear red and swollen and may graduallyget tighter or harden. The breast may also getsmaller and be distorted from the surgicaltechnique. These changes are a result of theradiation and although newer radiation treat-ment has less effect on the breast, the mam-mographer should still handle these patientswith care because the skin may be delicateand the patient may have many tender orpainful areas (Andolina, 331–402; Peart, 220–234).

39. (D) Magnification is ideal for imaging smallareas such as the surgical site of a patientwith lumpectomy, specimen radiograph, ormicrocalcifications and masses. Magnifica-tion, however, should not be used for routineimaging because the entire breast may not beimaged completely and the patient dose isincreased (Bushong, 327–340; Peart, 65–84).

40. (B) The LMO provides a mirror image of theMLO. The next best position is the LM pro-jection, which is a true lateral projection use-ful in imaging medially located lesions thatare high on the chest wall or extremely poste-rior in the inferior half of the breast. Theimage on the LM is very similar to the MLO,the difference being that the MLO images thelateral portion of the breast closer to theimage receptor. The ML, although also a truelateral projection, cannot be used because itdoes not image the posterior breast. The ATbest images the tail of Spence and the RL hasthe breast positioned for the CC with theupper surface rolled laterally while the lowersurface is rolled medially (Peart, 115–145).


41. (B) Contrast resolution is the ability to distin-guish anatomic structures with similar sub-ject contrast. High-contrast resolution isneeded in mammography to distinguish sim-ilar soft-tissue densities. Spatial resolution isthe ability to image high-contrast smallobjects such as microcalcifications. The spa-tial resolution of the image is limited mainlyby the effective focal spot size. Spatial resolu-tion is stated as the number of line pairs permillimeter (lp/mm) that are imaged. Thehigher the number, the smaller the object thatcan be imaged and the better the spatial reso-lution. High screen speed generally haslower spatial resolution and spatial resolu-tion can be improved by using smaller phos-phor and thinner phosphor layers. The termrecorded detail is a less precise term referringto the degree of sharpness of structural lineson a radiograph, while the ability to visualizerecorded detail when image contrast andoptical density are optimized refers to visibil-ity of detail (Bushong, 219–227, 272).

42. (C) The best time to perform the BSE is 5–10days after the start of the period when thebreast is least tender or swollen. If a patient isnot having regular periods, the BSE shouldbe done on the same day every month (AmericanCancer Society).

43. (B) For the AEC to be effective, the thickestportion of the compressed breast, regardlessof its size or tissue density, must be directlyover the AEC detector. If the AEC detectordoes not cover the small breast tissue area,the correct optical density will not berecorded, resulting in an underpenetratedfinal image (Peart, 65–84).

44. (D) Processing control makes sure the proces-sor is working at optimal levels. The visualchecklist verifies that the room equipment,including the mammography unit, has all thenecessary accessories available and is safe forpatient and mammographer. Screen cleanlinessensures clean screens, but to determine whichscreen has the artifact all the screens wouldhave to be opened and cleaned. Standardizedimage labeling identifies the mammographic

unit (if there is more than one), the cassette orimage receptor by number, the mammogra-pher performing the examination, the patient,the facility name, and the projection. It isimportant to be able to identify eachcassette/image receptor. Dirty cassettes/imagereceptors are thus easily identified and cleaned(ACR, 127).

45. (D) Phantom images are done weekly. Therepeat/reject analysis is made quarterly.Compression check is tested semiannually,and visual checks are done monthly (ACR,119; Stevens, 275–370).

46. (A) Ideally the rate should not exceed 2%, but arate of 5% is acceptable once a QC program hasbeen established. An analysis of the number ofrepeated mammograms and rejected filmsidentifies ways to improve efficiency andreduce cost and patient exposure. Because themain purpose of the reject/repeat analysis is todetermine problem areas within the depart-ment, the one high-rate area should be targetedfor improvement (ACR, 202; Stevens, 275–370).

47. (D) The linear-type grids used in mammogra-phy typically have a very low ratio becauseeven with the common grid ratio of 4:1,patient exposure doubles (grid ratio = theheight of the lead strips/the distance betweenthe strips; ratio = h/d). Most grids are focusedto the SID to increase contrast. Grids in mam-mography typically have a frequency of 30–50lines per centimeter. The high-transmissioncellular (HTC) grid used in some units has thecharacteristics of a crossed grid. It can reducescattered radiation in two directions ratherthan the one direction of the linear or focusedgrid. These grids use copper rather than leadas the grid strip, and air rather than wood oraluminum as the interspace material. Whencompared to a similar ratio linear grid, theHTC grids result in equal or less radiationdose to the patient (Bushong, 327–340; Peart,65–84).

48. (B) The staging of breast cancer is useful todetermine the extent of the spread of the can-cer. In general, the higher the stage of the


cancer, the poorer the prognosis. The PETtechnique injects extremely short-livednuclides into an arm vein. The technologyworks on the principle that because of theincrease in metabolic activity, most canceroustissue uses vast amounts of sugar (glucose)and at a much higher rate than benign tissue.The radioactive substance used is metabo-lized in the body like sugar and will thereforego to tissues that are most active. A gammacamera can then be used to measure the emit-ted radiation signals making the cancer’slocation visible. The extent of the cancer isthen known, which aids the oncologist indetermining treatment and monitoring ther-apy. Currently, PET imaging is also used tostage lymph node involvement, detect metas-tases, and in staging and restaging cancerousbreast lesions and is becoming a useful toolin molecular imaging (Peart, 179–194, 220–234).

49. (C) During the medical history documenta-tion, the physician collects information on thepatient’s risk factors for benign or malignantbreast conditions and any other health prob-lems. Information on past mammograms isalso collected because of the importance ofcomparison. Although the medical historydoes not prevent breast cancer, it is the firststep in evaluating both symptomatic andasymptomatic women and an important stepin evaluating treatment options (ACS, 1–16;American Cancer Society).

50. (D) The smaller the focal spot size, thegreater the resolution. General radiographyuses target angles of 5–15 degrees but in con-ventional mammography units the target isangled about 23 degrees (line-focus princi-ple). The large target angle would force theuse of larger focal spot sizes and result in theheel effect (Figure 7-9). As a result of the heeleffect, some of the useful beam must travelthrough the target material. This reduces theintensity of the useful beam at the anode endof the tube; however, with the cathode posi-tioned to the chest wall and with the tubetilted about 6 degree, the central rays parallelthe chest wall so no tissue is missed, the heeleffect is minimized, and small focal spots are

possible, resulting in increased resolution.The small focal spot sizes used in mammog-raphy are therefore achieved using a combi-nation of 23 degrees target angle and 6 degreestube tilt (Bushong, 327–340; Peart, 65–84).

Horizontal

targ

et

Compression plate

Image recorder

BreastBreast

Figure 7–9. Mammography tube tilt. With the x-ray tube tiltedabout 6 degrees off the horizontal, the central rays run parallel tothe chest wall so no breast tissue is missed. Tilting the tube allowsa smaller target angle and therefore a smaller effective focal spotsize while minimizing the heel effect. Tilting also allows greateranode heat capacity because the actual focal spot size is not fur-ther reduced.

51. (A) The retromammary space separates thebreast from the pectoral muscle. This space isfilled with a layer of adipose or fatty tissueas opposed to the supporting and connectivetissue (stroma), blood vessels, and variousductal structures that make up the glandularand fibrous tissues of the breast (Peart, 35–44).

52. (D) Cysts occur in the terminal ductal lobu-lar units when the extralobular terminal ductbecomes blocked. Fluid accumulates fasterthan it can be reabsorbed. Cysts vary in sizeand respond to hormonal fluctuations, butthe development of a cyst also depends on awoman’s genetic predisposition. Younger


women, premenopausal women, and post-menopausal women taking estrogen arelikely to have higher hormonal levels andtherefore have an increased possibility ofhaving cysts (Andolina, 155–173; Peart, 35–44).

53. (C) By the process of elimination, the bestchoice is that the lesion is a cyst. Althoughthe fibroadenoma, hematoma, and lymphnode are all oval or circular lesions, all are ofmixed density (radiolucent and radiopaque)(see Figure 3-2) (Tabár, 17–92).

54. (B) Regardless of the kVp, as the kVpincreases, the relative number of x-raysundergoing Compton interaction alsoincreases. With compression the part is thin-ner, less kVp is needed to penetrate the part,and therefore there is less Compton scatter(Bushong, 117–187).

55. (B) The CBE involves both a visual inspectionand palpation of the breast. A visual inspec-tion involves looking for changes in the shapeand size and appearance of the breast and nip-ple while noting any skin dimpling, redness,or swelling (ACS, 1–16; American Cancer Society).

56. (D) The hypo estimator provides an estimateof the amount of residual hypo in the film inunits of grams per square meter. It should be0.05 g/m2 or 5 μg/cm2 or less. If the stainindicates that the residual hypo hasincreased, the test should first be repeated. Ifthe result is the same then the first checkshould be the water wash tank—it should befull. Water wash flow rates should meet man-ufacturer’s guidelines. The fixer replenish-ment rate must also be checked, because theytoo should meet manufacturer’s guideline(ACR, 211; Stevens, 275–370).

57. (B) Fibrous and glandular tissues aretogether described as fibroglandular densi-ties. X-rays pass more easily through fatty tis-sue than through fibrous or glandular tissues.Fatty areas are more radiolucent and willappear as high-density areas (black or lessdense) on the mammogram. The fibroglandu-lar tissue is more radiopaque than fatty tissues

and results in areas of lower optical densityon the mammogram (white or denser areas)(Peart, 35–62).

58. (A) Estrogen and progesterone are two of themany hormones responsible for many physio-logical changes in the breast. Estrogen is respon-sible for ductal proliferation and progesteronefor lobular proliferation. Once a woman startsany of these hormones including HRT, thechanges can be spotty, causing lumps orincreased interstitial fluids (cysts) but will gen-erally result in an overall increase in glandulartissue (Andolina, 155–173; Peart, 47–62).

59. (C) By process of elimination, the lesion is likelyto be a lymph node. Lymph nodes are lesionswith mixed density and generally have a radi-olucent center corresponding to the hilus. Thefibroadenoma, hematoma, and the galactoceleare all mixed-density oval or circular lesions,but none has the lucent center typical of thelymph nodes (see Figure 3-2) (Tabár, 17–92).

60. (C) When comparing the MLO projection tothe ML, a lateral abnormality will move downon the lateral from its position on the MLO. Amedial abnormality will move up on the lat-eral from its position on the MLO. A centrallylocated lesion or a lesion at the areola willshow little or no movement (Peart, 115–145).

61. (A) As the magnification factor increases, tomaintain a sharp image the focal spot must bereduced or the thickness of the part has todecrease. A greater magnification factor willtherefore need a smaller the focal spot. Smallfocal spot is therefore used in magnificationmammography. Increasing OID increases themagnification factor (Bushong, 117–187; Peart, 65–84).

62. (A) The actual focal spot size is the area onthe anode target that is exposed to electronsfrom the tube current. Because the target isangled, the effective area of the target ismade much smaller than the actual area ofelectron interactions. The effective target isthe area projected onto the patient and theimage receptor. The nominal focal spot size isa measure of the effective focal spot size and


is the value used when identifying large orsmall focal spots (Peart, 65–84).

63. (C) The MQSA governs final assessment find-ing in the evaluation of mammographicimages. In an effort to guide referring physi-cian and radiologist in the breast cancer deci-sion making process, the ACR came up withthe BIRAD, which is a standardized mammo-graphic reporting system that can be used asa coding and assessment system. To ensurerecognition of the system the ACR collabo-rated with the National Cancer Institute(NCI), the Center for Disease Control and Pre-vention (CDC), the FDA, the American Med-ical Association (AMA), the American Col-lege of Surgeon and the American College ofPathologist. The BIRAD system is now wellrecognized and used by radiologist, physi-cians, and surgeons across the United States.

The MQSA also has a category assessment;however the ACR assessment categories werealready in existence prior to the publication ofthe final regulations of MQSA. Because theassessment categories developed by the ACRare so widely recognized, the FDA accepts theACR’s BIRAD categories; however to avoidconfusion in addition to the category name (eg,BIRAD 1) the report must include the wordidentifier, for example, BIRAD 1: negative.

BREAST IMAGING REPORTING AND DATA

SYSTEM (BIRAD)BIRAD 0: Need additional imaging

information and/or prior mammograms for comparison

BIRAD 1: NegativeBIRAD 2: Benign findingBIRAD 3: Probably benign finding—short

interval follow-up suggestedBIRAD 4: Suspicious abnormality—biopsy

should be consideredBIRAD 5: Highly suggestive of

malignancy—appropriate action should be taken

BIRAD 6: Known biopsy proven malignancy—appropriate action should be taken

(Papp, 203; Peart, 246).

64. (D) The DD on the sensitometric control stripis the difference between the average densityclosest to 2.20 (high density, HD) and theaverage density closest to but not less than0.45 (low density, LD). Base plus fog is thedensity over a clear area of the strip and themid-density is that closest to 1.20 (ACR, 151).

65. (C) Epithelial hyperplasia is also known asproliferative breast disease and is an over-growth of cells that line either the ducts orthe lobules. When hyperplasia involves theduct, it is called ductal hyperplasia or ductepithelial hyperplasia. When it affects thelobules, it is referred to as lobular hyperpla-sia. Depending on how it looks under themicroscope, it may be classified as usual oratypical. An epidermoid cyst, often incor-rectly referred to a sebaceous cyst, is apimple-like cyst that occurs in the oil glandsof the skin, and the hematoma is a pooling ofblood as a result of trauma. Over time ahematoma may slowly calcify, resulting in theformation of an oil cyst, and later a calcifiedhematoma (American Cancer Society; Peart, 47–62).

66. (A) A ruptured implant shows extracapsularleakage—silicone may leak into the fibrouscapsule or may escape from the capsule leak-ing into the surrounding breast tissues andmuscle causing pain or discomfort. In theencapsulated implant, the implant hardens orcalcifies but does not rupture. A herniatedimplant shows the implant pushing out offibrous capsule, but does not indicate a sili-cone leak. Patients with implant removalmay have traces of residual silicone in thebreast (Andolina, 246–310; Peart, 115–145).

67. (C) The first step is to determine the locationof the lesion by applying the rules for lesionmovement. When comparing the MLO pro-jection to the ML, a lateral abnormality willmove down from its position on the MLO. Amedial abnormality will move up from itsposition on the MLO. A centrally locatedlesion and lesions at the areola will show lit-tle or no movement. Once the location of thelesion is determined, an XCCL for a laterallesion or the CV for medial lesions will locate


the lesion in the CC position. The AT imagesthe axilla of the breast only and is not needed(Andolina, 155–173; Peart, 115–145).

68. (A) During ductography, a collecting ductthat ends at the nipple is cannulated and asmall amount of contrast agent is injected.Generally, 1–5 cc is enough to fill the duct(Andolina, 331–402; Peart, 203–220).

69. (C) The glandular dose is used in mammog-raphy because the biological effects of radia-tion are most likely to be related to the totalenergy absorbed by glandular tissue. Theglandular dose is the average radiation doseto the glandular tissue in the middle of thebreast. The other measure of dose is the ESE.The ESE is most often referred to as thepatient dose. It is the exposure at the skin’ssurface. In mammography the ESE may bevery high because of low-energy x-rays butthe dose falls quickly as the x-rays penetratethe breast (Bushong, 590–591).

70. (C) Obtaining a magnified image requires thatthe OID be increased while maintaining a con-stant SID. Any change in OID will result in acorresponding change in SOD. To maintain asharp image, a small focal spot must be usedin magnification (Bushong, 327–340; Peart, 65–84).

71. (D) QC testing should always be performedby the dedicated QC personnel or the sameindividual. Here the mammographer wouldbe the most obvious person (ACR, 90; Andolina,45–98; Peart, 87–112).

72. (B) Galactoceles are small, milk-filled cystswith a high fat content. These are associatedwith lactation, may be mixed density, and arecircular–oval with sharply defined contours.A hematoma is associated with breast traumaand the oil cyst appears mammographicallyas eggshell-like calcifications. Lymph nodestypically have a central radiolucent area cor-responding to the hilus (Tabár, 17–92).

73. (A) During pregnancy and lactation, breastdensity increases because of physiologicalchanges, milk production, and increased

blood supply. The changes are a result of theaction of estrogen, progesterone, and pro-lactin, which cause a proliferation of the duc-tal and lobular structure of the breast and anincrease in blood flow (American Cancer Society;Peart, 35–44).

74. (C) With the four quadrants terminology, thebreast can be described as: the upper outerquadrant (UOQ), upper inner quadrant(UIQ), lower outer quadrant (LOQ), andlower inner quadrant (LIQ). The exact loca-tions within the quadrant are represented byviewing each breast separately as a clockface. The upper outer quadrant, whichextends toward the axilla, is known as theaxillary tail, tail of the breast or tail of Spence.Most glandular tissue is found centrally andextends laterally toward the axilla in theUOQ. This distribution increases or decreaseswith hormonal fluctuations, but generallymirrors the opposite breast (Peart, 35–44).

75. (C) Mammography uses very low-energykVp and it is very important that the x-raytube window not attenuate the low-energyphotons. Most mammography units haveeither borosilicate or beryllium windows. Thelow atomic number of these materials allowsan inherent filtration of approximately 0.1 mmAl (aluminum). The material of the glass win-dow has no effect of scattered radiation, norcan it increase or decrease the output of thex-ray tube (Bushong, 327–340; Peart, 65–84).

76. (C) Compression is important in mammogra-phy to reduced breast thickness, radiationdose, and motion unsharpness. Compressionalso separates superimposed areas of thebreast tissue and brings abnormalities closerto the image receptor. Unfortunately, compres-sion is painful for some women. In general,the breast should be compressed until taut toensure adequate compression. Compression,however, should not be applied to cause thepatient severe pain (ACR, 23–77; Peart, 115–145).

77. (C) The greater the magnification factor, thegreater the skin dose to the patient. In magni-fication the patient dose increases because


the breast is closer to the source and becauseadditional exposure is required because ofreciprocity law failure. The small focal spotsize used to maintain a sharp image requiresthat the mA be reduced with a correspondingincrease in exposure time (Bushong, 197–198;Peart, 65–84).

78. (B) The actual focal spot size is the area onthe anode target that is exposed to electronsfrom the tube current. As the size of the focalspot decreases, the heating of the target isconcentrated into a smaller area. In thedesign known as the line focus principle, thetarget is angled allowing a larger area forheating while maintaining a small effectivefocal spot. Because the target is angled, theeffective area of the target is made muchsmaller than the actual area of electron inter-actions. The effective target is the area pro-jected onto the patient and the image recep-tor. As the target angle is made smaller, theeffective focal spot decreases (Figure 7-10)(Bushong, 137–138; Peart, 65–84).

trauma. Some possible cause of the radial scaris localized inflammatory reaction or chronicischemia with slow infection. The radial scar isa benign condition, but can be associated withpremalignant—atypical ductal hyperplasia—and malignant condition. A benign radial scarhas no central tumor, although there may belong spicules radiating from the center of thelesion. Regardless of the size of the spicules inthe benign radial scar, there is no associatedskin thickening, dimpling, or nipple reaction.The benign radial scar often resolves overtime, but because of the possible associationwith malignancy radial scars should be moni-tored carefully. In this case the lesion was theresult of surgery. As shown in Figure 7-3b, thelesion is resolving. A galactocele is a benign,milk-filled cyst with a high fat content. Theselesions are generally associated with lactation.They are usually circular, with sharplydefined borders, and have densities that are acombination of radiolucent and radiopaque.They are often left alone, but if painful theycan be drained using needle puncture. Oftenthey yield a yellow fluid. Oil cysts are gener-ally seen mammographically as eggshell-likecalcifications. Hematomas are generally asso-ciated with trauma. They are mixed densityoval or circular calcification (American CancerSociety; Peart, 47–63; Tabár, 17–92, 93–147; Tucker,125–129).

80. (B) The patient’s face should be turned awayfrom the side under examination, curving theneck and head around the face shield. Thisensures that medial tissue can be pulled ontothe image receptor. This is important becauseeliminating medial breast tissue from the CCprojection may eliminate this tissue from thestudy (Andolina, 174–245; Peart, 115–145).

81. (A) Using clock face terminology there arefour main clock positions (12-o’clock, 3-o’clock,6-o’clock, and 9-o’clock). In the XCCL andthe CC, the central rays are directed superi-orly to inferiorly; therefore, 12-o’clock and6-o’clock lesions will be superimposed. TheAT images the axilla and would miss any6-o’clock lesion. In the MLO, the beam isdirected medially to laterally separating the

Electrons from cathode

Actual focalspot sizeEffective focalspot size

Target angle

Figure 7–10. Line focus principle. As the size of the focal spotdecreases, the heating of the target concentrates into a smallerarea. Angling the target makes the effective focal spot size muchsmaller than the actual focal spot size. This line focus principleallows a large area for heating while keeping the effective focalspot small. Decreasing the target angle causes a correspondingdecrease in effective focal spot size.

79. (C) Radial scars are complex sclerosinglesions and are often indistinguishable fromcarcinoma. They are not truly scars and aresometimes unrelated to prior surgery or


upper aspect of the breast (12-o’clock position)from the lower aspect (6-o’clock position)(Peart, 115–145).

82. (C) This represents the standard terminologyadopted by the ACR. The Cleopatra view isan old term given to a projection similar tothe current AT. All projections in mammogra-phy are compression or compressed projec-tions (ACR, 24; Peart, 115–145).

83. (D) Casting calcifications are produced whencarcinoma in situ fills the ducts and theirbranches. The shape of the cast is determinedby the uneven production of calcification andthe irregular necrosis of the cellular debris. Thecontours of the cast are always irregular in den-sity, width, and length and the cast is alwaysfragmented. A calcification is seen as branchingwhen it extends into adjacent ducts. Addition-ally, the width of the ducts determines thewidth of the castings. Eggshell-like and needle-like, sharply outlined, or elongated branchingcalcifications are typically benign mammo-graphically. Granulated sugar or crushed stonecalcifications are called granular-type calcifica-tions and are mammographically malignant(Peart, 47–62; Tabár, 149–238).

84. (B) From the nipple orifice, a connectingduct immediately widens into the lactiferoussinus or ampulla. The ampulla is a pouch-like structure that holds milk (when it isbeing produced). These ducts branch intosmaller and smaller ducts until becoming alobule. The lobule is also called the terminalductal lobular unit (TDLU) and holds themilk-producing elements of the breast (Peart,35–44).

85. (D) The nipple cannot always be imaged inprofile because some women will not have acentrally located nipple. (It will either be inthe top half or bottom half of the breast.) Insuch situations imaging the nipple in profilewill actually lose posterior breast tissue. Addi-tional projections of the nipple area are onlynecessary if the nipple looks like a lesion, thewoman has a nipple or retroareolar abnormal-ity (such as nipple discharge or a lesion), for

proper measurement in preoperative localiza-tions, or if the patient is male. Male patientshave rudimentary breast buds lying directlybehind the nipple. Only by placing the nipplein profile will this area be visualized clearly(Andolina, 246–310; Peart, 115–145).

86. (C) The AT projection best demonstrates theaxillary tail of the breast. The medial and sub-areolar areas are not visualized on the AT pro-jection. With the four quadrants terminology,the breast can be described as the upper outerquadrant, upper inner quadrant, lower outerquadrant, and lower inner quadrant. Theexact locations within the quadrant are repre-sented by viewing each breast separately as aclock face. The upper outer quadrant, whichextends toward the axilla, is known as theaxillary tail, tail of the breast, or tail of Spence.The LIQ describes the medial portion of thebreast (Andolina, 174–245; Peart, 115–145).

87. (C) In this case the patient’s chin was not ele-vated for the MLO projection. Pressure on thefilm after the exposure causes plus-density arti-facts. This is inconsistent with malposition ofthe mirror, which would cause a rectangular-shaped artifact in the center of the film. Theother alternative, the patient’s shoulder, wouldonly be imaged if the entire axilla were alsoimaged (Peart, 115–145).

88. (B) A hematoma is associated with breasttrauma. Generally, the trauma results in a pool-ing of blood, which can show mammographi-cally a low-density radiopaque lesion. If thehematoma calcifies, it slowly becomes a mixed-density oil cyst with the typical eggshell-like cal-cifications and then eventually a high-densityradiopaque lesion. Galactoceles are small, milk-filled cysts with a high fat content associatedwith lactation. Fibroadenomas are benigntumors common in women at any age and theintramammary lymph nodes can be found inany quadrant of the breast and are not relatedto injury (Andolina, 155–173; Peart, 47–62; Tabár,17–92).

89. (D) Patients have breast tissue rangingfrom fatty to thicker, more glandular tissue.


Adequate penetration of the glandular tissuedepends on the kVp selection. In mammogra-phy, the use of single emulsion films withsingle-backed screens is necessary to enhancecontrast, but results in a relatively higherpatient dose. Dose in mammography is keptlow because of the inherent soft tissue struc-ture of the breast. Viewing conditions shouldnot determine the exposure selection, but thetarget material determines the energy of thex-ray beam produced (Peart, 65–84).

90. (B) Generally, when the shoulders are notrelaxed or if the height of the image receptor istoo high, most of the axilla and shoulders willfall into the compression area. The thick areaof the axilla and shoulder will cause the com-pression paddle to stop at maximum withoutadequate compression being applied to thelower breast (nipple area) (Peart, 115–145).

91. (C) Ultrasound does not image microcalcifi-cations well. The TAN projection is useful inassessing skin calcification and the spot com-pression increases compression over a spe-cific area to eliminate pseudomasses. Magni-fication, however, magnifies the area ofinterest allowing the number, distribution,and type of calcifications to be clearly seen.Magnification can be used with and withoutspot compression (ACR, 59–60; Peart, 147–162).

92. (D) In this case the circular lucency in the cen-ter suggests a port-a-cath. A pacemaker gener-ally presents with high-density wiring. Ahematoma is generally associated with trauma.They are mixed-density oval or circular calcifi-cation. The patient’s chin would present as auniform area of low density (Peart, 47–63).

93. (A) The rolled positions are helpful whendense breast tissue is superimposed on alesion. The dense tissue is rolled off the lesion(ACR, 67; Peart, 115–145).

94. (D) The specimen must be imaged afterbiopsy to ensure that the lesion was com-pletely removed. In imaging the specimen, itshould be compressed and magnified to pre-vent the appearance of pseudomasses and to

assess calcifications. The specimen shouldalso be compared to the initial mammograms.Imaging the specimen before the surgery iscompleted will allow the surgeon to take anadditional biopsy specimen if indicated(Andolina, 313–330; Peart, 203–220).

95. (C) The LMO is useful for patients with priorchest surgery or patients with pacemakers,which prevent compression to the medialbreast. The LMO is an inferolateral to supero-medial projection. The x-ray tube is angledapproximately 125 degrees (Figure 7-11). Theimage receptor is positioned at the medialaspect of the breast and compression is appliedfrom the lateral aspect. AT images the tail ofthe breast (tail of Spence); LM and ML are both90-degrees lateral projections (Peart, 115–145).

Figure 7–11. (© 2000 The American Registry of Radiologic Tech-nologists.)

96. (B) The actual focal spot size is the area onthe anode target that is exposed to electronsfrom the tube current. Because the target isangled, the effective area of the target ismade much smaller than the actual area ofelectron interactions. The effective target isthe area projected onto the patient and theimage receptor. The nominal focal spot size isa measure of the effective focal spot size andis the value used when identifying large orsmall focal spots (Peart, 65–84).


97. (D) Radiation and surgical treatment willcause changes in the breast and can cause cal-cium formation. Although the rate of recur-rence after lumpectomy is relatively low,magnification images are best to assess anycalcification at the tumor bed. These imagesshould be compared with radiographs takenafter surgery but before radiation treatment(Peart, 203–234).

98. (C) The ML is useful in determining whethera lesion is medially or laterally located. If theMLO projection is compared to the ML, amedial lesion will move up from its positionon the MLO. A lateral lesion will move downfrom its position on the MLO. A lesion that iscentrally located will show little or no move-ment. The XCCL best images the lateralbreast from the CC position. The CV bestimages the medial breast from the CC posi-tion and the AT best images the tail of thebreast (Peart, 115–145).

99. (D) Films should be processed promptlybecause of latent image fading. If the timebetween the creation of the latent image andprocessing is 8 hours or more, the biggestchange will be in loss of film speed. How-ever, both density and contrast will alsodecrease (ACR, 132; Peart, 87–112).

100. (A) All three methods can be used to minimizescattered radiation in general radiography. Thehigher the kVp, the higher the level of scat-tered radiation and reducing the thickness ofthe part will allow a reduction in kVp, hence, areduction in scattered radiation. Scattered radi-ation increases as the field size increases; there-fore, reducing the field size will reduce theamount of scattered radiation. Unfortunately,reducing the field size is not an option in mam-mography. Mammography units have onlytwo available field sizes, regardless of breastsize (Bushong, 117–187, 327–340).

101. (B) The MQSA was established on October 27,1992, to establish minimum national standardsfor mammography. Under the MQSA require-ments, the FDA can authorize individual statesto certify mammography facilities, conduct

inspections, and enforce the MQSA qualitystandards. After October 1994, the MQSArequired all legal providers of mammographyservices to be accredited by an approvedaccreditation body and certified by the FDA.The FDA cannot ensure that all women haveaccess to a certified mammography facility(Accreditation and Certification Overview).

102. (D) The MQSA final regulations require facili-ties to have a written and documented policyof resolving consumer complaints. The facil-ity may select its own format. Medical out-come audit is required by MQSA to follow uppositive mammographic assessments and tocorrelate pathology results with the radiolo-gist’s findings. Record keeping refers to thesection of MQSA standards dealing with themaintenance of mammograms and reports ina permanent file (for not less than 5 years, ornot less than 10 years if no additional mam-mograms of the patient are performed at thefacility, or longer if required by state or locallaws). To satisfy the communication-of-resultssection of the standards, all mammographicfacilities must send each patient a summaryof the report, written in lay terms, within30 days of the mammographic examination.If assessments are suspicious or highly suspi-cious for malignancy, the facility should con-tact the patient as soon as possible with theresults (Accreditation and Certification Overview).

103. (B) A harmartoma is a benign tumor. It isconsidered self-limiting because the tumorconsists of an overgrowth of normal tissueand the tumor cells do not reproduce. Breastlesions associated with trauma and nursingare hematoma and galactocele, respectively(Tabár, 17–92; Peart, 47–62).

104. (B) Parturition is the process of giving birth.In the immature breast, a two-layer epithe-lium of cells lines the ducts and alveoli. Afterpuberty this epithelium proliferates, formingthree alveolar cell types—superficial (lumi-nal) A cells, basal B cells (chief cells), andmyoepithelial cells forming the innermostlayer or basal surface of the epithelium. Themyoepithelial cells are arranged in a branching,


starlike fashion located around the alveoliand excretory milk ducts. Contraction of themyoepithelial cells helps to propel milktoward the nipples. Beneath the epithelium isconnective tissue that helps to keep theepithelium in place. Between the epitheliumand the connective tissue is a layer called thebasement membrane. The basement mem-brane provides support and acts as a semi-permeable filter under the epithelium (Peart,35–44; Tortora, 1083–1084).

105. (B) A benign finding means that although some-thing was seen it is considered totally benign.When using the BIRAD, the verbal identifiermust be used to avoid confusion with theMQSA assessment. The MQSA categories placesall mammographic findings in categories similarto the BIRAD system but is rarely used today.

BREAST IMAGING REPORTING AND DATA

SYSTEM (BIRAD)BIRAD 0: Need additional imaging

information and/or prior mammograms for comparison

BIRAD 1: NegativeBIRAD 2: Benign findingBIRAD 3: Probably benign finding—short-

interval follow-up suggestedBIRAD 4: Suspicious abnormality—biopsy

should be consideredBIRAD 5: Highly suggestive of

malignancy—appropriate action should be taken

BIRAD 6: Known biopsy proven malignancy—appropriate action should be taken

(Accreditation and Certification Overview; Papp, 203;Peart, 246).

106. (D) Erythema is a redness or inflammation ofthe skin. Although it can indicate inflamma-tory breast cancer, it can also be an indicationof breast abscess or other infectious changes.Further evaluation and testing, includingmammography, would be necessary to deter-mine the cause (Peart, 47–62; Tabár, 17–92).

107. (C) Tamoxifen is a nonsteroidal antiestrogengiven to patients with breast cancer. It is

considered an antiestrogen drug because itprevents estrogen from latching onto tumorcell receptors and will shrink or stop therecurrence of breast cancer. Tamoxifen willalso lower the risks of breast cancer recur-rence in postmenopausal women. Tamoxifenis considered a palliative treatment because itwill not cure the disease. The drug can causeserious side effects including an increasedrisk for endometrial cancer, uterine cancer,pulmonary embolism, stroke, deep veinthrombosis, blood clots, and increasedmenopausal symptoms. Because of theserisks, tamoxifen should not be taken for morethan 5 years and there are now a number ofsimilar drugs on the market with less sideeffects. Radiation therapy may be used todestroy cancer cells remaining after surgeryor to reduce the size of a tumor beforesurgery. Chemotherapy uses a combinationof drugs to kill undetected tumor cells thatmay have migrated to other parts of thebody. Antibody therapy works by blockingthe effect of the protein HER-2—important inregulating the growth of breast cancer cells(ACS, 1–16; Peart, 220–234).

108. (D) Noise on the mammogram is an undesir-able fluctuation in the optical density of theimage and will show on the radiographs sim-ilar to “snow” on a monitor. The principalcause of radiographic noise is scattered radia-tion produced by Compton scattering, whichreduces contrast. Quantum mottles and filmgraininess also result in noise on the radiog-raphy. Quantum mottle refers to the way x-raysinteract with the film. If the image is pro-duced with a few x-ray photons, the quan-tum mottle will be higher than if the image isproduced with many x-ray photons. Filmgraininess refers to the distribution in sizeand space of the silver halide grains in theemulsion and is a factor inherent in the imagereceptor. This factor is not under the control ofthe mammographer (Bushong, 272–291; Peart,65–84).

109. (C) After puberty, the epithelium of the lob-ules proliferates, becoming multilayered andforming three alveolar cell types, superficial


(luminal) A cells, basal B cells (chief cells),and myoepithelial cells. The innermost layeror basal surface of the epithelium consists ofmyoepithelial cells. Beneath the epithelium isconnective tissue that helps to keep theepithelium in place. Between the epitheliumand the connective tissue is a layer called thebasement membrane. The basement mem-brane provides support and acts as a semiper-meable filter under the epithelium (Peart,35–44; Tortora, 1083).

110. (C) The “camel’s nose” contour refers to thesloping of the breast in the MLO projectioncaused by insufficient compression. Theresult is poor separation of the breast tissues.Preventing “camel’s nose” involves pullingthe breast up and out and supporting it dur-ing the initial stage of compression. Themammographer should use one hand tomaintain support of the breast until enoughcompression is in place to keep the breast inposition (Figure 7-12) (ACR, 38–40).

111. (C) With the four quadrants terminology, thebreast can be described as UOQ, UIQ, LOQ,and LIQ. The exact locations within the quad-rant are represented by viewing each breastseparately as a clock face. The SIO best demon-strates the UIQ and the LOQ of the breast, freeof superimposition. This projection can be usedto demonstrate these quadrants free of theimplant especially when using the implant-displaced ID or Eklund compression techniques(Figure 7-13) (Andolina, 174–245; Peart, 115–145).

Figure 7–12. Poor compression of the anterior breast in the MLOprojection results in drooping of the anterior breast “camel nose.”

Figure 7–13. In the SIO position, the beam is directed from thesuperior lateral aspect to the inferior medial aspect of the breast.

Image receptor

Direction of x-rays

112. (D) The medical audit is used to check thereliability of the mammographic image. Theinterpreting physicians should evaluate allmammographic results for clarity and accu-racy at least once every 12 months. The med-ical audit should also include any cases ofbreast cancer found after a negative mam-mography reading (Accreditation and Certifica-tion Overview: Medical Outcomes Audit Program).

113. (B) The MQSA requires facilities to maintainrecords to the original mammograms andreport for a period of not less than 5 yearsand not less than 10 years if no additionalmammograms of the patient are performed


at the facility. Some state and local laws mayrequire longer storage times. Facilities are alsoallowed to permanently or temporarily trans-fer a patient’s records to another medicalinstitution, physician, or health-care providerif requested by the patient (Accreditation andCertification Overview: Record Keeping).

114. (B) Triangulation is used to determine thelocation of a nonpalpable lesion seen mammo-graphically. One of the purposes of triangula-tion is to spot compress the lesion forimproved separation of breast tissue. Triangu-lation is also used to determine the shortestskin-to-abnormality distance for the purposeof sterostatic biopsy. To determine the locationof the lesion relative to the nipple, the mammo-grapher should measure (1) the distance fromthe nipple to the level of the lesion posteriorlyon the CC or MLO projection, (2) from thatlevel to the lesion in the superior-to-inferior(as on the MLO) or medial-to-lateral direction(as on the CC), and (3) from the lesion to theskin surface (Figure 7-14) (ACR, 56).

115. (D) Peau d’o range describes the skin of thebreast wherein the breast skin thickens andresembles an orange. The condition occurssecondary to obstruction of the axillary lym-phatic and may be a result of either benign ormalignant conditions such as inflammatorycarcinoma. Plasma cell mastitis or ductalectasia are both inflammatory conditions.Plasma cell mastitis calcifications follow thecourse of the ducts. Some may be elongatedand branching, some needlelike, and someringlike or oval, but all are sharply outlined,

high density, and have smooth borders. Ifthey are periductal, they have central lucencies.Ductal ectasia involve the lactiferous ducts andmay or may not cause nipple discharge orinversion. Both conditions are characterized bythe presence of plasma cells surrounding adilated duct (Peart, 35–44; Tabár, 239–243).

Lesion2

1

3

Figure 7–14. The triangulation technique is used to determine theshortest skin-to-abnormality distance in the MLO and CC projec-tions. 1 = distance from nipple to the level of the lesion posteriorly, 2 =distance from level to lesion, 3 = distance from lesion to skin surface.

167

Index

AABBI. See advanced breast biopsy

instrumentationAcoustic enhancement, 93, 101ACR. See American College of

RadiologyACS. See American Cancer SocietyAdipose tissue, 47, 53, 60Advanced breast biopsy

instrumentation (ABBI), 86AEC. See automatic exposure

controlAmerican Cancer Society (ACS),

breast examinationguidelines of, 1, 7,12–14, 120

American College of Radiology(ACR), 22, 37, 79, 116, 132,136, 151

Amorphous selenium, 21Anatomy, of breast, 47–64, 110, 125Angiogenesis, 4Areola, 47, 136, 151Artifacts, image quality relating to,

23–24, 66, 107, 122, 140, 155AT. See axillary tailAtypical hyperplasia, 2Augmentation, of breasts,

4, 92, 98Automatic exposure control

(AEC), 106, 107, 111,120–121, 126

instrumentation and qualityassurance relating to, 20,27, 33

mammographic technique andimage evaluation relatingto, 66, 69, 70, 75–76

Axillary node dissection, 86Axillary tail (AT), 2, 81–82, 88–89,

89f, 96–97, 145, 161

BBackup timer, 70, 76Barrel chest and pectus carinatum,

82, 89, 97Basement membrane, 147, 164Beam, x-ray, 19, 26, 32, 33f, 114, 130Beam restriction devices, 20, 27, 33Benign breast lesions. See breast,

lesions ofBenign cancer, of breast. See breastBeryllium, 19, 143, 159Biopsy. See also ABBI

core, 4, 85–86, 93, 99–101, 101flarge, 86

FNB, 4, 85, 93, 99, 102lymph node, 86MIBB, 86MR, 86open surgical, 4, 86, 93, 102,

146, 162radio frequency, 86VACB, 86

BIRAD. See breast imagingreporting and databasesystem

Blood supply, to breast, 47Breast

anatomy of, 47–64, 110, 125augmentation of, 4, 92, 98blood supply to, 47camel’s nose, 148, 165, 165fcancer of

diagnostic options for, 2–4ductal carcinoma, 7, 12

intervention options for, 4lobular carcinoma, 2, 7malignant, 2, 6, 11, 48–49, 55,

55f, 61–62posttreatment options for, 5radiographs of, 2risk factors for, 1–2, 6, 11,

107–108, 110, 121–125survival rate of, 9, 15, 15tsymptoms of, 1–2, 6, 11treatment options for, 4–5

changes in, 1, 7, 8compression of. See compression disease of

benign, 2, 6malignant, 2, 6, 11Paget, 107, 122

drooping, 79examination of, 1, 135, 149.

See also BSE, CBE ACS guidelines for, 1, 7,

12–14, 120fatty tissue of, 47, 49, 52, 59, 105,

120, 141, 157histology of, 47implants for, imaging of, 81–82,

83f–84f, 92, 99, 106, 121,137, 152

involution of, 113, 129irradiated, 82, 92, 99large or wide, 82lobes of, 47, 52, 58lymphatic drainage of, 47, 48f,

53, 59male, 82, 116, 132, 137, 152malignant conditions and

mammographicappearances of, 48


Breast (Cont.):masses in, 61fmedial and lateral aspects of, 79,

81–82, 87–90, 94–97pathology of, 47–64physiology of, 47–64postsurgical, 82quadrants of, 47, 52, 58, 58f, 81reconstruction of, 4–5, 10, 16scintigraphy of, 3skin folds or wrinkling of, 82–85small, 81–82, 103, 118, 140, 147,

155, 163tissue composition of, 47–48,

138, 153tumor of, 48–49, 54, 54f, 56,

61–62, 93veins of, 47, 53, 60

Breast, lesions of, 50f–51fbenign

calcification, 49, 81, 136, 136f,151

circular/oval, 49skin thickening syndrome, 2,

6, 11, 48–49spiculated/stellate, 49

malignantcalcifications, 48, 55, 55f,

61–62, 111, 111f, 126,144, 161

circular/oval, 48circumscribed, 2skin thickening syndrome, 2,

6, 11, 48–49spiculated/stellate, 48,

55, 62visualized with compression,

65, 68, 73Breast imaging reporting and

database system (BIRAD),25, 142, 147, 158, 164

Breast self-examination (BSE), 1,7–8, 12–14, 103, 118,139–140, 153, 155

Bremsstrahlung radiation, 70, 76BSE. See breast self-examination

CC-arm. See contralateral armCAD. See computer-aided detector

Calcificationsof breast lesions

benign, 49, 81, 136, 136f, 151malignant, 48, 55, 55f, 61–62,

111, 111f, 126, 144, 161casting-type, 2, 48ductal, 2granular-type, 48mammogram relating to, 81,

88–89, 96powderlike, 48teacup-shaped, 81, 89, 96

Camel’s nose breast, 148, 165, 165fCancer, of breast. See breastCannulation, of lactiferous duct,

85, 93, 101Carcinoma

ductal. See ductal carcinoma. inflammatory, 56, 62–63lobular. See lobular carcinoma.

Cassette-based digital systems, 21Cassette-less digital systems, 21Cassettes or image receptor, 3, 21,

27, 34, 116, 132Casting-type calcifications, 2, 48Caudocranial or FB projection,

81–82, 89, 97, 112, 112f, 114,126, 130, 139, 154

CBE. See clinical breastexamination

CC projection. See craniocaudalCCD. See charge-coupled devicesCell stage, 16tCells, epithelial, 115, 131Central venous access devices

(CVAD), 63Certification process, 24–25Characteristic curve, 19, 28, 34–36,

37f, 104, 119, 119f, 138, 153Charge-coupled devices (CCD), 21Chemotherapy, 5, 7, 10, 12, 15–16Circular/oval breast lesions,

malignant and benign,48–49

Cleavage (CV), 81, 90, 90f, 97, 106,121, 144, 161

Clinical breast examination (CBE),1, 7–8, 12, 103, 105, 113, 118,120, 128, 137, 141, 152, 157

Coherent scattering, 70, 76

Collimation, image quality relatingto, 20, 66, 104, 119, 138, 153

Color Doppler ultrasound, 3Compression, 24, 33, 52, 58

considerations of, 65, 67,72, 143, 159

devices for, 19–20image quality relating to, 66lesions visualized with,

65, 68, 73levels of, 108, 122manual, 67, 72MLO relating to, 66, 79, 81–82,

85, 116, 133patient knowledge of, 68, 73QC tests for, 23, 29, 39radiation relating to, 65, 67,

72–73reasons for, 65spot, 57, 57f, 64, 81–82, 92, 98–99,

111–112, 126–127Compression paddle, 19–20, 26–27,

32, 34, 81, 85Compton effect, 70, 76, 141, 157Computed tomography (CT), 4Computer-aided detector (CAD),

21Contaminated developer, 111, 126Contralateral arm (C-arm), 79, 87,

94Contrast, image quality relating to,

66, 70–71, 77, 77f, 78Contrast digital mammography, 3Contrast resolution, 139, 155Control film crossover, 135,

149–150, 150fConventional mammogram/

mammography, 2, 21, 28,34–36, 103, 118

Cooper ligaments, 47, 52, 58–59,109, 109f, 123–124, 124f

Core biopsy, 4, 85–86, 93, 99–101,101f

Craniocaudal (CC), 66, 105–106,110, 113, 120–121, 124, 129,137, 144, 152, 160

positioning and interventionalprocedures relating to, 79,80f, 81–82, 85, 87–88, 88f, 91,94–95, 98

168 Index

CT. See computed tomographyCT laser mammography, 4CV. See cleavageCVAD. See central venous access

devicesCyst, 141–142, 156–157

aspiration of, 4, 85, 93, 102epidermoid, 49, 57, 57f, 64oil, 49, 55, 55f, 62, 115, 130–131

Cytological analysis, 92, 99

DDarkroom cleanliness, QC tests

for, 22–23Darkroom fog, QC tests for, 23,

28–30, 38, 41Deep inferior epigastric artery

perforator flap (DIEP), 5Densitometer, 24Depressed sternum. See pectus

excavatumDeveloper temperature, 21, 110,

112, 125, 128, 128fDIEP flap. See deep inferior

epigastric artery perforatorflap

Digital imaging, 2–3, 31, 44, 136,150, 150f

Digital mammogram/mammography, 2, 21, 28,34, 35f

contrast, 3Digital quality assurance, 24Digital systems, 21–22

cassette-based, 21cassette-less, 21

Digital technology, 28, 34, 36fDigital tomosynthesis, 4Disease, of breast. See breastDocumentation and medical

history, 1, 8, 140, 156Doppler ultrasound, color, 3Drooping breast, 79Ductal calcifications, 2Ductal carcinoma, 7, 12

invasive or infiltrating, 2in situ, 2

Ductal ectasia, 103, 115Ductal lavage, 86Ductal papilloma, 103, 118

Ductography, 4, 85, 93, 101, 109,124, 143, 159

EEklund method, implants relating

to, 100fElderly patients, 82Electrosurgical introducer, 86Encapsulated implants, 81, 92, 98Entrance skin exposure, 138, 152Epidermoid cyst, 49, 57, 57f, 64Epithelial cells, 115, 131Epithelial hyperplasia, 142, 158Erythema, 147, 164ETD. See extralobular terminal

ductExaggerated craniocaudal (XCCL),

79, 82, 89, 96, 97, 105–106,107f, 120–121

Exposure. See also AECimage quality relating to, 66log relative, 37fradiation dose relating to, 1, 9,

14–15, 65, 69, 74–75Extended processing, 21, 112, 128Extralobular terminal duct (ETD),

53, 60, 60f

FFalse-negative mammograms,

69, 75Fat necrosis, 49, 56, 63Fatty tissue, of breast, 47, 49, 52,

59, 105, 120, 141, 157FB. See from belowFB or caudocranial projections,

81–82, 89, 97, 112, 112f, 114,126, 130, 139, 154

FDA. See Food and DrugAdministration

FDG. See fluorodeoxyglucoseFibroadenolipoma, 49Fibroadenoma, 49, 56, 56f, 64, 93,

100Fibroglandular tissue, 47, 105, 113,

120, 128Film, analyses of fixer retention in,

23Film fog, 23, 28, 34Filtration, 109, 123

Fine needle aspiration (FNA), 4,85, 92, 99, 101, 113, 128–129

Fine needle biopsy (FNB), 4, 85,93, 99, 102

Fixer retention in film, 23Flap surgery

DIEP, 5gluteal-free, 5latissimus dorsi, 5TRAM, 5

Fluorescent tube, 30, 41–44Fluorodeoxyglucose (FDG), 3FNA. See fine needle aspirationFNB. See fine needle biopsyFocal spot size, 110, 114, 125, 130,

142–143, 146, 157, 160, 160f,162

mammographic technique andimage evaluation relatingto, 65, 69, 74

patient education andassessment relating to, 20,27, 34

Food and Drug Administration(FDA), 4, 21, 24, 112, 116,131, 147, 163

From below (FB), 81–82Frozen shoulder, patients with, 85

GGalactocele, 49, 56, 62, 143, 159Geiger counter, 4Glandibular dose, 1, 143, 159Glandular tissue, 47, 53–54, 59, 61,

143, 159Gluteal-free flap surgery, 5Granular-type calcifications, 48Grid ratio, 20, 140, 155Grids

HTC, 20mammography, 20, 27, 33,

110, 125parallel, 114, 130radiography, 20, 27, 33use of, 114, 130

Gynecomastia, 108, 112, 123, 128

HHalo sign, 49, 54, 61, 61fHamartomas, 56, 63, 147, 163

Index 169

Health Insurance Portability andAccountability Act(HIPAA), 25

Hemangiomas, 49Hematoma, 49, 145, 161Herceptin, 5High-transmission cellular grid

(HTC), 20HIPAA. See Health Insurance

Portability andAccountability Act

Histology, of breast, 47Hormone replacement therapy

(HRT), 2, 5, 54, 61, 107, 122,141, 157

Hormonessynthetic, 47–48, 53–54, 60–61use of, 47, 104, 119, 135, 138,

149, 153HRT. See hormone replacement

therapyHTC. See high-transmission

cellular gridHyperplasia

atypical, 2epithelial, 142, 158

Hypo estimator, 23, 141, 157Hypo-retention test, 23, 116, 132

IID projections. See implant

displaced projectionsImage evaluation. See

mammographic techniqueand image evaluation

Image qualityartifacts relating to, 23–24, 66,

107, 122, 140, 155collimation relating to, 20, 66,

104, 119, 138, 153compression relating to, 66contrast relating to, 66, 70–71,

77–78, 77fexposure relating to, 66labeling relating to, 66, 70, 72,

77–79, 82noise relating to, 66, 116, 132,

147, 164overexposure relating to, 69, 75positioning relating to, 66

sharpness relating to, 66, 70, 78underexposure relating to, 66,

69, 75, 112, 127, 127funsharpness relating to, 65, 66,

71–78, 137, 151Image receptor (IR), 3, 21, 79, 85,

88, 95cassettes or, 3, 21, 27, 34, 116, 132

Image viewing environment,115, 131

Images, phantom, QC tests for. Seephantom images, QC testsfor

Imagingcomponents of

digital system, 21–22screen-film system, 21

digital, 2–3, 31, 44, 136, 150, 150fof implants. See implants,

imaging of. Miraluma, 3of nonconforming patients

elderly, 82irradiated breast, 82, 92, 99kyphotic, 81–82, 89, 96large or wide breast, 82male breast, 82, 116, 132,

137, 152pectus carinatum and barrel

chest, 82, 89, 97pectus excavatum, 82, 91, 98postsurgical breast, 82small breast, 81–82, 103, 118,

140, 147, 155, 163stretcher/cart, 82wheelchair, 82

postlumpectomy, 82ultrasound, 3, 10, 17

Imaging plate, 3, 21IMF. See inframammary foldImplant displaced (ID) projections,

81–82, 110, 115, 125, 131Implants

Eklund method relating to, 100fencapsulated, 81, 92, 98imaging of, 81–82, 83f–84f, 92,

99, 106, 121, 137, 152ruptured, 142, 142f, 158

Inflammatory carcinoma, 56,62–63

Inframammary fold (IMF), 79,87–88, 94–95, 109, 123

Infusa-port, 56, 63Instrumentation and quality

assurance, 19–46Intensifying screen, 104, 113, 120,

129, 129f, 135, 149Intracystic tumor, 93Intraductal papilloma, 118Intralobular terminal duct (ITD),

53, 60, 60fInvolution, of breast, 113, 129IR. See image receptorIrradiated breast, 82, 92, 99ITD. See intralobular terminal duct

KKeratosis, 136, 151kVp (peak kilovoltage) range

of mammography units, 19, 26,32, 108, 123

technique and image evaluationrelating to, 65–66, 69, 70–71,75, 77, 78

Kyphotic patient, 81–82, 89, 96

LLabeling, image quality relating to,

66, 70, 72, 77–79, 82Lactation, 47, 53, 60–61, 143, 159Lactiferous duct, 47–48, 48f

cannulation of, 85, 93, 101Lactiferous sinus, 48f, 109, 109f,

124, 124fLarge core biopsy, 86Lateromedial (LM), 81–82, 85, 88,

90, 90f, 96–97Lateromedial oblique (LMO),

81–82, 85, 90, 97, 139, 146,154, 162

Latissimus dorsi flap surgery, 5Lesions, of breast. See breast,

lesions ofLesions visualized with

compression, 65, 68, 73Lipoma, 49, 56, 62, 111, 126LM. See lateromedialLMO. See lateromedial obliqueLobes, of breast, 47, 52, 58Lobular carcinoma, 7

170 Index

invasive, 2in situ, 2

Lobules, 2, 47Localization

needle, 79, 117, 133, 137, 152preoperative, 4, 81, 85, 92, 99stereostatic breast, 4, 85, 93, 102

Log relative exposure, 37fLumpectomy, 4, 9, 15, 86, 146, 163Lymph node, 1, 49, 142, 157

biopsy of, 86Lymphatic drainage, of breast, 47,

48f, 53, 59Lymphedema, 11Lymphoscintigraphy, 3–4

MMagnetic resonance imaging

(MRI), 3, 7, 10, 12, 16–17Magnetic resonance (MR) biopsy,

86Magnification, 103, 105, 108, 110,

112, 118, 120, 122, 124, 127,139, 154

disadvantage of, 65mammographic technique and

image evaluation, 65–66,68–69, 73–74, 73f, 74f

positioning and interventionalprocedures relating to, 81,85, 91, 98

spot, 145, 162Male breast, 82, 116, 132, 137, 152Malignant asymmetric densities, 2Malignant breast lesions. See

breast, lesions ofMalignant cancer, of breast, 2, 6,

11, 48–49, 55, 55f, 61–62Malignant circumscribed lesions, 2Mammogram/mammography

accuracy of, 104, 119benefits and risks of, 1calcifications relating to, 81,

88–89, 96conventional, 2, 21, 28, 34–36,

103, 118CT laser, 4digital, 2, 21, 28, 34, 35f

contrast, 3false-negative, 69, 75

filter used in, 66, 70, 76grids relating to, 20, 27, 33, 110,

125mortality reduction, 1, 111, 126optical densities relating to, 66,

69, 75radiation dose, exposure relating

to, 1, 9, 14, 15, 65, 69, 74–75screening, routine, 1tube relating to, 19, 26, 32, 141,

156, 156funits relating to

AEC, 20, 27, 33, 66, 69, 70,75–76, 106–107, 111,120–121, 126

compression devices, 19–20design characteristics of,

19–20kVp range, 19, 26, 32, 108, 123

Mammographers, 143, 159requirements of, 22, 24, 115, 131

Mammographic appearances, ofbreast, 48

Mammographic technique andimage evaluation, 65–78

AEC relating to, 66, 69, 70, 75–76breast compression, 65focal spot size relating to, 65,

69, 74kVp relating to, 65–66, 69, 70–71,

75, 77–78magnification, 65–66, 68–69,

73–74, 73f, 74f, 103, 105,118, 120

MLO relating to, 66Mammography Quality Standards

Act (MQSA), 107, 109, 117,121–123, 133, 138, 147–148,153, 163, 165

labeling relating to, 66, 70, 72,77–79, 82

quality assurance relating to, 22,24–25, 29, 31, 37–38

Mammoplasty, 116, 132mAs (milliamperes), 19, 65–66, 69,

74–75Mass

in breast, 61fpainless, 104, 119palpable, 110, 125

Mastectomy, 86modified radical, 4radical, 4

Medical audit, 25, 148, 165Medical history and

documentation, 1, 8,140, 156

Medication, for pain, 5Mediolateral (ML) 90 degree, 114,

114f, 130, 143, 146, 158, 163positioning and intervention

procedures relating to,81–82, 85, 88–90, 96–97

Mediolateral oblique (MLO)projection, 106, 106f, 108,112–113, 115–116, 121,122–123, 126, 129, 131, 133,144, 145, 160, 162

mammographic technique andimage evaluation relatingto, 66

positioning and interventionalprocedures relating to, 79,81–82, 85, 87, 89–90, 94–97

Menarche, 2, 47Menopause, 2, 48MIBB. See minimally invasive

breast biopsyMilk lines, 59fMinimally invasive breast biopsy

(MIBB), 86Miraluma imaging, 3ML. See mediolateral (ML)

90 degreeMLO. See mediolateral oblique

projectionMobile v. fixed tissue, 88, 95Modifications, to imaging. See

positioning andinterventional procedures

Modified radical mastectomy, 4Molybdenum, 19, 70, 75–76, 76f,

139, 153Montgomery glands, 107, 112,

122, 128Morgagni tubercles, 47, 52, 58Morphine, 5Mortality reduction,

mammography relating to,1, 111, 126

Index 171

MQSA. See MammographyQuality Standards Act

MR biopsy. See magneticresonance biopsy

MRI. See magnetic resonanceimaging

NNeedle localization, 79, 117, 133,

137, 152Nipple, 47–48, 48f, 52–53, 58–59,

79, 87, 95aspiration of, 86markers for, 82

Nipple not in profile, 82, 106, 121,145, 161

Noise, image quality relating to,66, 116, 132, 147, 164

Nuclear medicine, 3Nullipara/nulliparous, 54, 61

OObesity, postmenopausal, 2, 8, 14Object-to-image receptor distance

(OID), 20–21, 66, 69, 75, 78,136, 142, 151, 157

OID. See object-to-image receptordistance

Oil cyst, 49, 55, 55f, 62, 115,130–131

Open surgical biopsy, 4, 86, 93,102, 146, 162

Overexposure, image qualityrelating to, 69, 75

PPacemaker, 81, 146, 146f, 162PACS. See picture-achieving and

communication systemPaget disease, of breast, 107, 122Pain medication, 5Painless mass, 104, 119Palpable mass, 110, 125Papilloma, 49

ductal, 103, 118intraductal, 118

Parallel grid, 114, 130Parturition, 147, 163Pathology, of breast, 47–64Patient. See also imaging

compression knowledge of,68, 73

education and assessment of,focal spot size relating to,20, 27, 34

with frozen shoulder, 85postmastectomy, 82, 92, 99,

137, 152with protruding abdomen, 85with uneven breast thickness, 85

Peau d’orange, 148, 166Pectus carinatum and barrel chest,

82, 89, 97Pectus excavatum, 82, 91, 98PET. See positron emission

tomographyPhantom images, QC tests for, 107,

122, 136, 139, 140, 151, 151f,154–155

instrumentation and qualityassurance relating to, 23, 29,30, 37–39, 37f, 39f, 41, 44

Physiology, of breast, 47–64Picture-achieving and

communication system(PACS), 21–22

Piezoelectric effect, principle of, 3Pigeon chest-prominent sternum.

See pectus carinatum andbarrel chest

Pneumocystography, 85PNL. See posterior nipple linePositioning, image quality relating

to, 66Positioning and interventional

proceduresadditional positions/projections

AT, 81–82, 88–89, 89f, 96–97caudocranial or FB, 81–82, 89,

97, 112, 112f, 114, 126, 130,139, 154

CV or valley view, 81, 90, 90f,97, 106, 121, 144, 161

LM, 81–82, 85, 88, 90, 90f,96–97

LMO, 81–82, 85, 90, 97, 139,146, 154, 162

ML, 81–82, 85, 88–90, 96–97,114, 114f, 130, 143, 146,158, 163

SIO, 81–82TAN projection, 81, 88–89,

95–96, 104, 118–119, 119f,137, 152

XCCL, 79, 82, 89, 96–97,105–106, 107f, 120–121

modificationsbreast implant imaging,

81–82, 83f–84f, 92, 99magnification, 81, 85, 91, 98,

110, 112, 124, 127RL or RM, 81, 90, 91f, 97–98RS or RI, 81spot compression, 81–82, 92,

98–99special situations

imaging nonconformingpatients, 81–82, 89, 92,96–99

solving special problems,82–85

specimen radiographycore biopsy, 4, 85–86, 93,

99–100, 101, 101fcyst aspiration, 4, 85,

93, 102ductography, 4, 85, 93, 101,

109, 124, 143, 159FNA, 4, 85, 92, 99, 101, 113,

128–129FNB, 4, 85, 93, 99, 102large core biopsy, 86lymph node biopsy, 86MR biopsy, 86nipple aspiration, 86open surgical biopsy, 4, 86, 93,

102, 146, 162pneumocystography, 85preoperative needle

localization, 4, 81, 85,92, 99

radio frequency biopsy, 86stereostatic localization, 4, 85,

93, 102ultrasound, 85–86, 93, 100–101

standard projectionsCC, 66, 79, 80f, 81–82, 85,

87–88, 88f, 91, 94–95, 98,105–106, 110, 113, 120, 121,124, 129, 137, 144, 152, 160

172 Index

MLO, 66, 79, 81–82, 87, 89, 90,94–97, 106, 106f, 108,112–113, 115–116, 121–123,126, 129, 131, 133, 144, 145,160, 162

Positron emission tomography(PET), 3, 140, 155

Posterior nipple line (PNL), 87,94, 94f

Postlumpectomy imaging, 82Postmastectomy patient, 82, 92, 99,

137, 152Postmenopausal obesity, 2,

8, 14Postsurgical breast, 82Posttreatment options, for breast

cancer, 5Powderlike calcifications, 48Preoperative needle localization, 4,

81, 85, 92, 99Processors, 21, 28, 34

quality control of, QC tests for,23, 30, 41, 42f, 43f, 103, 108,118, 123

Projections. See implant displacedprojections; positioning andinterventional procedures

Prominent ribs and sternum. Seepectus carinatum and barrelchest

Protruding abdomen, patientswith, 85

QQC tests. See quality assuranceQuadrants, of breast, 47, 52, 58,

58f, 81Quality assurance. See also

Mammography QualityStandards Act

digital, 24instrumentation and, 19–46QC tests

for analyses of fixer retentionin film, 23

for compression, 23, 29, 39for darkroom cleanliness,

22–23for darkroom fog, 23, 28–30,

38, 41

for phantom images, 23,29–30, 37–39, 37f, 39f, 41, 44,107, 122, 136, 139, 140, 151,151f, 154–155

for processor quality control,23, 30, 41, 42f, 43f, 103, 108,118, 123

for reject/repeat analysis, 23,30, 39–41, 40f, 115, 130,139–140, 154, 155

for screen cleanliness, 23, 29,37, 38

for screen/film contact andidentification, 23, 29, 39, 39f,110, 125

for visual checklist, 23, 28, 31,37, 44

radiologist relating to, 22Quality control (QC) tests. See

quality assuranceQuantum mottle, 66, 137, 152

RRadial scar, 49, 55, 62, 105, 105f,

120, 144, 144f, 160Radiation

bremsstrahlung, 70, 76compression relating to, 65, 67,

72–73dose of, exposure relating to, 1,

9, 14–15, 65, 69, 74–75scattered, 20, 65, 109, 124

Radiation therapy, 4, 9, 15, 82, 135,139, 149, 154

Radical mastectomy, 4Radio frequency biopsy, 86Radiographs, of breast cancer,

2Radiography. See positioning

and interventionalprocedures

Radiography grid, 20, 27,33

Radiologist, 22Radiopaque tumor, 49, 56, 62Raloxifene, 5Receptor. See image receptorReciprocity law, 65Reconstruction, of breast, 4–5,

10, 16

Reject/repeat analysis, QC testsfor, 23, 30, 39–41, 40f, 115,130, 139, 140, 154–155

Repeat/reject analysis, QC testsfor, 23, 30, 39–41, 40f, 115,130, 139, 140, 154–155

Resolutioncontrast, 139, 155spatial, 21, 67, 72

Retromammary space, 47, 104, 120,141, 156

Rhodium, 19, 70, 75–76,108, 122

RI. See rolled inferiorRight lateromedial oblique

(RLMO), 88, 95Right mediolateral oblique

(RMLO), 88, 95Risk factors, associated with breast

cancer, 1–2, 6, 11, 107–108,110, 121, 123–125

RL. See rolled lateralRLMO. See right lateromedial

obliqueRM. See rolled medialRMLO. See right mediolateral

obliqueRolled inferior (RI), 81Rolled lateral (RL), 81, 90, 91f,

97–98Rolled medial (RM), 81, 90–91, 91f,

97–98, 108, 113, 123, 129,137, 152

Rolled projections, 81, 146, 162Rolled superior (RS), 81, 91, 98Routine mammography

screening, 1RS. See rolled superiorRuptured implant, 142, 142f, 158

SSAC. See States as CertifiersScar, radial, 49, 55, 62, 105, 105f,

120, 144, 144f, 160Scar tissue, 86, 88, 95Scattered radiation, 20, 65,

109, 124Scattering, coherent, 70, 76Scintigraphy, of breast, 3Scintillator, 21

Index 173

Screencleanliness of, QC tests for, 23,

29, 37, 38intensifying, 104, 113, 120, 129,

129f, 135, 149Screen/film contact and

identification, QC tests for,23, 29, 39, 39f, 110, 125

Screen-film system, 21Selective estrogen receptor

modulators (SERMs), 5, 14Sensitometer, 23, 29–30, 38, 38f, 41,

138, 142, 153, 158Sentinel node mapping, 3–4SERMs. See selective estrogen

receptor modulatorsSharpness, image quality relating

to, 66, 70, 78SID. See source-to-image receptor

distanceSIO. See superior-inferior oblique

projectionSkin folds or wrinkling, of breast,

82–85Skin thickening syndrome, 2, 6, 11,

48–49Small breast, 81–82, 103, 118, 140,

147, 155, 163SMPTE tests, 24SOD. See source-to-object distanceSoft copy viewer, 44fSource-to-image receptor device

(SID), 20–21, 66, 68, 74, 78,143, 159

Source-to-object distance (SOD),69, 74

Spatial resolution, 21, 67, 72Spatula, 82, 103, 118Specimen radiography. See

positioning andinterventional procedures

Spiculated/stellate breast lesionsbenign, 49malignant, 48, 55, 62

Spot compression, 57, 57f, 64, 111,112, 126–127

positioning and interventionalprocedures relating to,81–82, 92, 98–99

Spot magnification, 145, 162

States as Certifiers (SAC), 24Stereostatic localization, 4, 85, 93,

102Stretcher/cart, patient in, 82Superior-inferior oblique (SIO)

projection, 81–82, 116, 132,148, 165, 165f

Surgery. See flap surgerySurgical reconstruction, 5Survival rate, of breast cancer, 9,

15, 15tSynthetic hormones, 47–48, 53, 54,

60, 61System geometry, 20–21, 28, 34

TTail of Spence, 52, 59Tamoxifen, 5, 9, 14–15, 147, 164TAN. See tangential projectionTangential (TAN) projection, 81,

88–89, 95–96, 104, 118–119,119f, 137, 152

TDLUs. See terminal duct lobularunits

Teacup-shaped calcification, 49, 81,89, 96

Technetium, 3Terminal duct lobular units

(TDLUs), 48, 52–53, 58–60,60f

TFD. See thin-film diodesTFT. See thin-film transistorsThin-film diodes (TFD), 21Thin-film transistors (TFT), 21Tissue

adipose, 47, 53, 60composition of, 47–48, 138, 153fatty, 47, 49, 52, 59, 105, 120, 141,

157fibroglandular, 47, 105, 113, 120,

128glandular, 47, 53–54, 59, 61, 143,

159mobile v. fixed, 88, 95scar, 86, 88, 95

TRAM flap. See transverse rectusabdominus muscle flap

Transverse rectus abdominusmuscle flap (TRAM), 5, 9,14

Triangulation techniques, 85, 148,166, 166f

Tubesangle of, 79, 82, 85, 88, 95fluorescent, 30, 41–44mammography, 19, 26, 32, 141,

156, 156fTumors, of breast, 48, 54, 54f, 61

intracystic, 93radiopaque, 49, 56, 62

Tungsten, 19

UUltrasound, 85, 86, 93, 100–101

color Doppler, 3Ultrasound imaging, 3, 10, 17Undercompression, 103, 118Underexposure, image quality

relating to, 66, 69, 75, 112,127, 127f

Uneven breast thickness, patientswith, 85

Unsharpness, image qualityrelating to, 65–66, 71, 78,137, 151

UOQ. See upper outer quadrantUpper outer quadrant (UOQ), 112,

127

VVACB. See vacuum-assisted core

biopsyVacuum-assisted core biopsy

(VACB), 86Valley view, 81Veins, of breast, 47, 53, 60Visual checklist, QC tests for, 23,

28, 31, 37, 44

WWheelchair, patient in, 82Wide or large breast, 82

XX-ray beam, 19, 26, 32, 33f,

114, 130X-ray photons, 135, 149XCCL. See exaggerated

craniocaudal

174 Index

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