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Diagnostic In-Training Exam 2006 1

Section VIII – Breast Radiology

188. You are shown a CC view of the right breast (Figure 1A) following which a needle biopsy yielded fibroadenoma. A follow-up CC view of the right breast was obtained 6 months later(Figure 1B). What is the MOST LIKELY diagnosis?

A. Invasive lobular carcinoma

B. Ductal carcinoma in situ

C. Phyllodes tumor

D. Tubular carcinoma


Figure 1A Figure 1B

Question #188

Rationales:

A. Incorrect. The most common presentations of invasive lobular carcinoma are a spiculated mass, anill-defined or obscured mass and architectural distortion. Occasionally, lobular carcinomas are dif-fusely infiltrating and may show only subtle findings on mammography.

B. Incorrect. Ductal carcinoma in situ (DCIS) is usually detected on mammography with calcificationsbeing the mammographic hallmark. The calcifications are typically fine, linear, discontinuous, andbranching, often in a ductal distribution. In about 10% of cases, only a soft tissue mass can be seenon mammography.

C. Correct. Mammographically, most phyllodes tumors are large, circumscribed, noncalcified massesthat are round, oval, or lobulated. When small, the appearance may be identical to a fibroadenoma.When large, the size may suggest the diagnosis. The most common clinical presentation is a largerapidly growing mass.

D. Incorrect. Tubular carcinomas are usually small, irregularly shaped, and have spiculated margins.They are typically slow growing and small at the time of diagnosis. Due to the small size and slowgrowth, most tubular carcinomas are detected on mammography rather than on palpation.

American College of Radiology2




189. You are shown CC and MLO mammograms (Figures 2A through 2D). What is the MOST likely clinical presentation?

A. Peau d’orange skin in the left breast

B. No symptom; patient presented for routine screening mammography

C. Nipple discharge from the left breast

D. Pruritus in the left breast


Figure 2A Figure 2B


Section VIII – Breast RadiologySection VIII – Breast Radiology

Figure 2C Figure 2D

Question #189

Rationales:

A. Correct. The left mammogram is markedly dense compared with the right mammogram, andmalignant calcifications are present in the left mammogram. The ultrasound image of the left breastshows thickened skin and a solid mass containing malignant calcifications. This is a case of inflam-matory breast cancer. Hence, peau d’orange skin would be the most appropriate choice.

B. Incorrect. This is an incorrect choice because of all the reasons enumerated above.

C. Incorrect. Nipple discharge is not a usual presentation of inflammatory breast cancer.

D. Incorrect. Pruritus is not a usual presentation of inflammatory breast cancer.





190. You are shown a magnification ML mammogram (Figure 3). What is the MOST likelydiagnosis?

A. Lobular carcinoma in situ

B. Medullary carcinoma

C. Ductal carcinoma in situ

D. Colloid carcinoma


Figure 3

Question #190

Rationales:

A. Incorrect. LCIS has no definite radiographic findings on mammography and is usually an incidentalfinding. It is a high risk lesion which increases the risk of either invasive ductal or invasive lobularin either breast.

B. Incorrect. Medullary carcinoma presents as a mass, usually larger than with other subtypes of carci-noma.

C. Correct. Ductal carcinoma in situ presents with pleomorphic calcifications and can cause distortion.The most aggressive type is comedo which is usually a grade 2 or 3.

D. Incorrect. Colloid carcinoma unusually presents with a round mass often with indistinct margins.





191. You are shown a gadolinium-enhanced, fat-suppressed subtraction MR image of the left breast(Figure 4). Which is the BEST description?

A. Round mass, heterogeneous enhancement

B. Spiculated mass, rim enhancement

C. Irregular mass, homogeneous enhancement

D. Oval mass, central enhancement


Figure 4

Question #191

Rationales:

A. Incorrect. The mass has an uneven or irregular shape with spiculated margins and homogeneousenhancement.

B. Incorrect. The enhancement is not rim but homogeneous.

C. Correct.

D. Incorrect. The mass is not oval but irregular with some spiculated borders.





192. You are shown a screening mammogram (Figures 5A and 5B). What does the calcification inthe upper central breast MOST LIKELY represent?

A. Ductal carcinoma in-situ

B. Skin calcification

C. Milk-of-calcium

D. Dystrophic calcification


Figure 5A



Figure 5B

Question #192

Rationales:

A. Incorrect. The calcification shown is not clustered or of suspicious morphology (e.g. not amor-phous, linear, branching, or pleomorphic).

B. Incorrect. The calcification shown is not lucent or geometric-shaped, and does not project near or inthe skin.

C. Incorrect. Milk-of-calcium calcifications are linear, meniscal, layering, or discoid in the lateral pro-jection, and smudgy, round, or amorphous in the craniocaudal projection. The calcification showndoes not meet the criteria for milk-of-calcium.

D. Correct. The calcification shown is coarse, chunky, distinct – it has the classic morphology of dys-trophic calcification.





Figure 6A



193. You are shown CC (Figure 6A) and magnification CC (Figure 6B) mammograms. Which of thefollowing malignant lesions is MOST LIKELY?

A. Tubular carcinoma

B. Lobular carcinoma

C. Papillary carcinoma

D. Paget’s disease


Figure 6B

Question #193

Rationales:

A. Incorrect. Tubular carcinoma typically presents as a spiculated mass, not a well-circumscribed massas seen here.

B. Incorrect. Lobular carcinoma is more typically an indistinct mass than a circumscribed mass.

C. Correct. Of the choices given, papillary carcinoma is most likely to present as a circumscribedmass, as shown here. It is a relatively well differentiated tumor with a better prognosis than ductalcarcinoma, not-otherwise-specified.

D. Incorrect. Paget's disease involves the nipple and can be associated with either DCIS or underlyinginvasive disease. While possible in this case, it is not the best answer.





194. What is the primary advantage of using an 11-gauge directional vacuum-assisted as compared toa 14-gauge automated core biopsy needle?

A. Less chance of bleeding

B. Less chance of infection

C. Less underestimation of disease

D. Less expensive needle

Question #194

Rationales:

A. Incorrect. The 11-gauge vacuum needle is not associated with less bleeding.

B. Incorrect. The 14-gauge automated needle is not associated with less chance of infection.

C. Correct. The larger samples obtained with the 11-gauge directional vacuum-assisted core biopsyneedle allow for a more accurate histologic diagnosis. For example, atypical ductal hyperplasia(ADH) diagnosed with 11-gauge vacuum is less likely to upgrade to DCIS or invasive cancer at sur-gical excision, when compared with ADH diagnosed with 14-gauge automated core needle.

D. Incorrect. The 11-gauge vacuum needle is more expensive than the 14-guage automated needle.


195. In mammography, adequate breast compression results in which of the following?

A. Elimination of grid

B. Increase in radiation dose

C. Increase in dynamic range

D. Decrease in scatter radiation

Question #195

Rationales:

A. Incorrect. A grid is needed for scatter rejection even when compression is used

B. Incorrect. Reducing tissue thickness with compression allows for use of a lower mAs which resultsin lower radiation dose

C. Incorrect. Compression results in reduced exposure dynamic range by spreading out tissue andachieving a more uniform thickness

D. Correct. Due to the decrease in tissue thickness, the scatter to primary ratio for a compressed breastis 0.4-0.5 while the scatter to primary ratio for an uncompressed breast is 0.8-1.0.



196. Concerning screening for breast cancer, which does the American Cancer Society recommend?

A. Annual mammogram beginning at age 50

B. Baseline mammogram at age 35

C. Screening before age 40 for women with high risk

D. Clinical breast exam every 3 years from age 20 to 49

Question #196

Rationales:

A. Incorrect. Should begin at age 40.

B. Incorrect. Baseline is no longer recommended at age 35 but rather start routine, yearly screening atage 40 and yearly thereafter.

C. Correct. Women in high-risk category should begin screening before age 40. It is recommended 10years prior to history of breast cancer in first degree relative.

D. Incorrect. Clinical exam should begin every 3 years 20-39 and annually at age 40.



197. Which is the MOST important view when evaluating calcifications that you think represent milkof calcium?

A. 90-degree lateral view

B. Rolled CC view

C. Medial lateral oblique view

D. Exaggerated lateral CC view

Question #197

Rationales:

A. Correct. In order to verify “tea-cups” or crescent shaped calcifications which are pathognomonicfor benign calcification, a true lateral film is required.

B. Incorrect.- Rolled CC view is mostly is best to evaluate a mass seen on CC view but not on MLOview. Milk of calcium would appear as “smudged” calcification on the CC view and “tea-cups” onthe true lateral. The appearance on the CC view is not pathonognomic.

C. Incorrect. MLO is one of the traditional views obtained but may not accurately demonstrate “tea-cups” or crescent appearance of milk of calcium.

D. Incorrect. Exaggerated lateral CC is for masses in the lateral breast that may not be completelyseen on routine CC view or for masses seen in axillary region on MLO, but not visible on routineCC.



198. With magnification in mammography, what is the MOST LIKELY challenge to achieve goodimage quality compared to standard contact imaging?

A. Increased image noise

B. Increased scatter

C. Increased motion blur

D. Decreased contrast

Question #198

Rationales:

A. Incorrect. Quantum noise is decreased because the number of x-ray photons per unit object area isgreater in the magnified image

B. Incorrect. The air gap between the breast tissue and image receptor in magnification mammographyreduces the number scattered x-rays that reach the image receptor, so much so that a grid is nolonger needed

C. Correct. Use of the small focal spot limits the tube current resulting in longer exposure times andgreater opportunity for motion blur

D. Incorrect. Contrast is unchanged in magnification as compared to contact imaging



199. Concerning MR imaging of breast implants, which one is TRUE?

A. Breast MRI is the test of choice in evaluating saline implant integrity.

B. The linguine sign is diagnostic of extracapsular implant rupture.

C. Radial folds extend to the periphery, differentiating them from collapsed shell.

D. Pre- and post-contrast images are necessary for the diagnosis of implant rupture.

Question #199

Rationales:

A. Incorrect. Rupture of a saline implant is a clinically obvious finding, because the implant deflatesimmediately. The saline is absorbed by the body so that by the time the patient presents for imagingevaluation, only the collapsed outer membrane is visible on mammography. MRI is not necessaryfor the diagnosis of a saline implant rupture.

B. Incorrect. The most reliable sign of intracapsular rupture on MRI is the presence of multiple, curvi-linear low-signal intensity lines within the high intensity silicone. This is known as the “linguinesign.” The diagnosis of extracapsular rupture is made by noting the presence of free silicone in thebreast parenchyma.

C. Correct. Radial folds are a finding in normal implants and are a result of normal infolding of theSilastic elastomer membrane. These folds may be prominent enough to suggest an appearance ofimplant rupture. However, even prominent radial folds can be distinguished from a rupture becausethey are noted to extend to the periphery of the implant.

D. Incorrect. MRI for the detection of implant rupture is a distinct examination from the MRI exami-nation performed for the detection and diagnosis of breast cancer. Specifically, MRI examinationstailored to exclude implant rupture do not use intravenous contrast, while MRI studies performedfor the diagnosis of breast cancer rely on the use of intravenous contrast.



200. Concerning breast cancer recurrence after lumpectomy and radiation therapy, which is TRUE?

A. About 75% are in the same quadrant as the original tumor.

B. The long term risk is 3% of patients per year.

C. It usually occurs in the first two years post-treatment.

D. The risk is greater in post-menopausal women.

Question #200

Rationales:

A. Correct. Tumors that recur early, less than 3 years, typically recur within the original tumor bed,while those occurring later are more likely to be remote from the original tumor.

B. Incorrect. Long-term risk of recurrence is 1-2% in the first 5-10 years and falls to 1% per yearthereafter.

C. Incorrect. Mean time to recurrence is 3.5 years. Recurrence is most likely to occur 2-5 years postlumpectomy.

D. Incorrect. Risk of recurrence is greatest in premenopausal women, those with an extensive intraduc-tal component, tumors with vascular invasion, multicentric tumors, positive surgical margins orinadequate treatment of the original tumor.



201. The Mammography Quality Standard Act (MQSA) requirements state that a facility must sendeach patient a summary of the mammography report within how many days?

A. 7

B. 14

C. 30

D. 60

Question #201

Rationales:

A. Incorrect

B. Incorrect

C. Correct. Each patient must receive a written report in lay terms within 30 days of her visit.

D. Incorrect



202. Concerning the epidemiology of breast carcinoma, which one is CORRECT?

A. Black women have a greater 5-year survival rate than white women.

B. Mammographic density is a predictor of subsequent breast cancer risk.

C. Most women diagnosed have a family history of breast cancer.

D. Nonproliferative fibrocystic change is associated with a fivefold increase risk.

Question #202

Rationales:

A. Incorrect. The overall 5-year survival rates are lower in black women (73.5%) when compared towhite women (87.9%). The overall poor survival rate among black women is largely due to laterstage of diagnosis although poorer survival rates are seen at each stage of disease detection as well.

B. Correct. The mammographic appearance of the breast has been found to be a predictor of subse-quent breast cancer risk. Patients with denser breasts are at an increased risk of developing breastcancer when compared to patients with fatty breast tissue. In fact, patients with areas of density of75% or more had a nearly fivefold risk elevation.

C. Incorrect. Most women diagnosed with breast cancer have no family history of breast cancer. Theproportion of women in the general population with a family history of breast cancer in a firstdegree relative has been estimated at 8%. Of those patients with breast cancer, 14% have a firstdegree relative with a history of breast cancer.

D. Incorrect. Nonproliferative fibrocystic change has not been shown to be associated with anincreased risk of breast cancer. The risk increases in women with proliferative fibrocystic changewithout atypia (risk of 1.9) and further increases for women with atypical hyperplasia (risk of 5.3).



203. Concerning the diagnosis of Paget’s disease, which one is TRUE?

A. Ultrasound is more sensitive than mammography.

B. Breast conservation is contraindicated.

C. It is most commonly bilateral.

D. A palpable mass indicates a worse prognosis.

Question #203

Rationales:

A. Incorrect. Clinical exam and mammography are the main tools in the diagnosis of Paget's disease.

B. Incorrect. Treatment depends on the underlying extent of disease and breast conservation is possiblein some cases.

C. Incorrect. It is most commonly unilateral.

D. Correct. A palpable mass worsens the prognosis, probably due to the increased likelihood of axil-lary and distant metastasis in these patients.



204. Concerning invasive lobular carcinoma of the breast, which one is TRUE?

A. There is a higher rate of bilaterality than with ductal carcinoma.

B. It is the most common histologic subtype of breast carcinoma.

C. Pleomorphic calcifications are typically seen in association.

D. Pathologically there is a proliferation of angulated and elongated tubules.

Question #204

Rationales:

A. Correct. Up to one third of invasive lobular carcinomas are bilateral, with a higher rate of bilaterali-ty and multicentricity than ductal carcinoma. Therefore, special attention should be given to thecontralateral breast when a diagnosis of lobular carcinoma is made.

B. Incorrect. Invasive ductal carcinoma is the most common histologic subtype of breast carcinoma.Invasive lobular carcinoma accounts for less than 10% of all invasive breast carcinomas.

C. Incorrect. Associated calcifications are seen in only 20% of invasive lobular carcinomas. The mostcommon presentations are a speculated mass, an ill-defined or obscured mass and architectural dis-tortion. Many invasive lobular carcinomas are diffusely infiltrating and may show only subtle find-ings on mammography.

D. Incorrect. Histologically, invasive lobular carcinoma is characterized by small, monomorphic cellsinfiltrating the stroma in single file. A proliferation of angulated, oval and elongated tubules linedby a single epithelial layer is characteristic of tubular carcinoma.



205. Concerning gynecomastia, which one is TRUE?

A. It carries an increased risk of malignancy.

B. It is typically echogenic on ultrasound.

C. The pathology is similar to adenosis in females.

D. It can be unilateral or bilateral.

Question #205

Rationales:

A. Incorrect. There is no increased risk of malignancy.

B. Incorrect. Sonographically the breast is either normal or hypoechoic.

C. Incorrect. The pathology is mostly ductal proliferation. Adenosis is a lobular process.

D. Correct. Gynecomastia can be unilateral or bilateral.



206. Which quality control test must be performed on a WEEKLY basis?

A. Processor quality control

B. Phantom images

C. Screen film contact

D. Visual checklist

Question #206

Rationales:

A. Incorrect. Processor QC should be performed daily

B. Correct. Phantom images must be performed weekly

C. Incorrect. Screen film contact must be performed semiannual

D. Incorrect. Visual checklist must be done monthly.



207. What is the correct stage for a patient with a 2.5-cm invasive ductal carcinoma with negativelymph nodes and no evidence of metastatic disease?

A. Stage I

B. Stage II A

C. Stage II B

D. Stage III A

Question #207

Rationales:

A. Incorrect. Stage I tumor size is less than 2 cm with no lymph node involvement.

B. Correct. Stage II A is less 5 cm but larger than 2 cm with negative nodes.

C. Incorrect. Stage II B is greater than 2 cam but less than 5 ca with mets to ipsilateral moveable axil-lar lymph nodes or tumor greater than 5 cam with negative lymph nodes.

D. Incorrect. Stage III B is tumor of any size extending to chest wall or skin with or without positiveaxillary nodes.



208. Concerning BI-RADS® coding, which one is TRUE?

A. Category 3 lesions should be followed at 3 month intervals for 1 year.

B. Category 0 indicates that the patient requires a breast ultrasound examination.

C. Category 3 lesions have a 10% probably of carcinoma.

D. Category 5 lesions have a 95% chance of malignancy.

Question #208

Rationales:

A. Incorrect. The vast majority of findings placed into this category are managed with an initial short-term follow up of 6 months, followed by a bilateral examination after a second 6-month interval,and then additional examinations until longer term stability is demonstrated. On occasion (patientwishes or clinical concerns), biopsy may be done.

B. Incorrect. BI-RADS™ category 0 (assessment incomplete) is usually reserved for screening studiesin which additional imaging evaluation is suggested. The additional imaging may include specialmammographic views and/or ultrasound.

C. Incorrect. A finding placed in the BI-RADS category 3 should have less than a 2% risk of malig-nancy. It is not expected to change over the follow-up interval but the radiologist would prefer toestablish its stability. A complete diagnostic imaging evaluation should be made before making aBI-RADS™ category 3 assessment.

D. Correct. BI-RADS™ category 5 lesions have a > 95% probability of being cancer. This categorycontains lesions for which one-stage surgical treatment could be considered without preliminarybiopsy.



209. Concerning galactoceles, which one is TRUE?

A. Generally seen in women over 60

B. Horizontal x-ray beam may show a fat-fluid level

C. Mammographically seen as an a spiculated mass

D. Biopsy is usually required for diagnosis

Question #209

Rationales:

A. Incorrect. Galactoceles are seen in younger pregnant or lactating patients and although they may beseen for up to several years, they would not commonly be seen in women over 60.

B. Correct. Since the milk has a high fat content, a fat fluid level can be found with the separation ofthe milk fat and protein.

C. Incorrect. Mammograms generally show a well circumscribed rounded mass.

D. Incorrect. As with other radiolucent lesions of the breast, galactoceles are always benign and in theappropriate clinically setting requires no further work up.



210. Concerning the evaluation of possible dermal calcifications, what is the BEST additional view toperform for confirmation?

A. Tangential view

B. Cleopatra view

C. Cleavage view

D. Rolled view

Question #210

Rationales:

A. Correct. Tangential views are performed for the evaluation of skin lesions. This is accomplished byplacing a skin marker over the area of mammographic concern. An x-ray is then obtained with thebeam tangential to the marker.

B. Incorrect. This is also known as an axillary tail view and is performed to confirm lesions are locatedwithin this section of the breast. The view includes only the lateral aspect of the breast and axilla.

C. Incorrect. The cleavage view is used to evaluate lesions in the medial posterior aspect closest to thesternum. The medial aspect of both breasts is placed on the cassette with the detector placed underthe side in question.

D. Correct. Rolled views are used to evaluate lesions seen only on the CC view. This can be used tolocate lesion in the MLO projection or to demonstrate parenchymal summation. The view isacquired by “rolling” the upper half of the breast either medial or later. Knowing which way thebreast is rolled and which direction the lesion moves on CC helps determine whether it is in theupper or lower half of the breast. Spurious “lesions” will disappear.



211. A mass with indistinct margins on mammography is evaluated with ultrasound. Which sonographic finding is MOST supportive of malignancy?

A. Angular margins

B. Posterior enhancement

C. Heterogeneous echotexture

D. Horizontal orientation

Question #211

Rationales:

A. Correct. Angular margins occur with abrupt transition between tumor and normal breast tissue andare more common with malignancy due to the desmoplastic response elicited by some carcinomas.

B. Incorrect. Posterior acoustic enhancement can be seen with carcinomas but is more commonly seenwith fluid-filled cysts and benign masses.

C. Incorrect. Both benign and malignant lesions may be heterogeneous.

D. Incorrect. Horizontal orientation is a characteristic of benign masses, that grow along tissue planes.Malignant masses are more likely to have a vertical orientation because of their ability to disrupt tis-sue planes.



212. The Mammography Quality Standards Act (MQSA) requires which use of the BI-RADS® terminology?

A. Use in mammography, breast ultrasound, and breast MRI reports

B. Reporting breast density in mammography reports

C. Assigning assessment category in mammography reports

D. Use in letters that describe results to patients

Question #200

Rationales:

A. Incorrect: This is an incorrect choice because MQSA does not extend to breast ultrasound or breastMRI exams.

B. Incorrect: This is an incorrect choice because MQSA does not require the reporting of breast density.

C. Correct. This is the correct choice because MQSA requires the assignment of BI-RADS assessmentcategories (0, 1, 2, 3, 4, or 5) in mammography reports.

D. Incorrect. This is an incorrect choice because letters should be in lay terms.



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