Lange Q&A: Mammography Examination, 2nd edition

SECOND EDITION LANGE Q&A ™ MAMMOGRAPHY EXAMINATION Olive Peart, MS, RT(R)(M) Clinical Coordinator Program in Radiogr...

Author: Olive Peart

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SECOND EDITION

LANGE Q&A

™

MAMMOGRAPHY EXAMINATION Olive Peart, MS, RT(R)(M) Clinical Coordinator Program in Radiography Stamford Hospital Stamford, Connecticut

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Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. 0-07-154838-6 The material in this eBook also appears in the print version of this title: 0-07-154835-1. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. For more information, please contact George Hoare, Special Sales, at [email protected] or (212) 904-4069. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. DOI: 10.1036/0071548351

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Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix

1. Patient Education and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2. Instrumentation and Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary of Important Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19 19 26 32

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

47 47 52 58

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

65 65 67 72

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

79 79 87 94

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iv

Contents

6. Practice Test 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 7. Practice Test 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Preface

This book is a review and self-assessment manual for radiologic technologists, its purpose being to help technologists who are considering the advanced level examination in mammography. The book follows the content category guidelines as speciﬁed in the examinee handbook published by the American Registry of Radiologic Technologists (ARRT). The ARRT does not review, evaluate, or endorse publications. Permission to reproduce ARRT copyrighted materials within this publication should not be construed as an endorsement of the publication by the ARRT. The first five chapters review the content category guidelines: (1) Patient Education and Assessment, (2) Instrumentation and Quality Assurance, (3) Anatomy, Physiology, and Pathology of the Breast, (4) Mammographic Technique and Image Evaluation, (5) Positioning and Interventional Procedures (© 2005 by The American Registry of Radiologic Technologists). Each chapter provides a brief summary of the material, followed by a question-and-answer section. The chapter summaries highlight the major points and important information in each content category; the questionand-answer sections are fully explained and referenced and cover all the information required by the ARRT for the mammography examination.

Chapters 6 and 7 each contain a complete practice mammography examination. The simulated examinations, also available on CD, have been designed to reduce examination jitters by providing a true simulation of the actual certiﬁcation examination. The CD will also allow the user to self-test in the subject area of choice. For the actual mammography examination, the ARRT allots 2 1/2 hours to complete 115 questions broken down as follows: category A, 18 questions; category B, 25 questions; category C, 25 questions; category D, 20 questions; and category E, 27 questions. Each examination will also include 20 unscored or pilot questions. For each of these examinations, the examinee should plan to spend up to 2 1/2 hours in a distraction-free environment to practice pacing and the economical use of time. Breast imaging is ﬁnally keeping pace with technology. Electronic imaging and image transfer will be the future of breast imaging but the transition may be bumpy. This text seeks to address both screen/ﬁlm and electronic/digital technology. One thing to note is that with the rapidly changing technology, the terminology being used in electronic imaging has not yet been standardized. This text has incorporated terms such as imaging receptor when referring to cassettes and imaging plate when referencing the

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Preface

object used to record the latent image: the ﬁlm in screen/ﬁlm imaging or the detector in electronic imaging. Chapter 2 details other terms in current use. It is my hope that users will reference this text as an invaluable resource when studying for the ARRT advanced level mammography examination. For questions or comments please visit my web site at http://www.opeart.com or email me at

[email protected]. Breast imaging can be a rewarding and meaningful profession. Good luck! Olive Peart, MS, RT(R)(M) Clinical Coordinator Program in Radiography Stamford Hospital Stamford, Connecticut

Acknowledgments

In preparing for this edition, I am indebted to the many users of my ﬁrst edition. Many readers gave me valuable insight and practical suggestions on the review questions. Indeed, your questions, suggestions, criticisms, corrections, comments, and compliments were greatly appreciated and many have been incorporated into this edition. I especially wish to thank technologist Sherry Van Helvoirt for her suggestions and ideas. Special thanks to Dorothy Saia, program director with the Radiography Program at Stamford Hospital. She was always available as a consultant but just as important was her role in encouraging me and keeping me on task. I am particularly grateful for the help that I received from the following technologists: Beth Siegelbaum, for her help in providing me with needed resource material; Elizabeth Dwyer and Iole Del Toro, who both reviewed digital quality control tests with me and spent a considerable amount of time cheerfully answering my numerous questions.

Thanks also to radiologist Karen Greenberg for her help and suggestions and physicist Jim Summers for his help with MQSA and related physics. Students played a very important role in making this book possible. I would like to thank the radiography students at Stamford Hospital (class of 2008), including Brandy M. Chassé, Marilyn P. DaSilva, Erica A. Guasco, Dawson C. Haffner, Kristiann Kalinski, Carl J. Laguzzi, Tanja M. AlbanerLall, Lewis R. Pierpoint, Claudia V. Tu, and John D. Velasco for their timely suggestions. This text would certainly not be possible without the care and commitment of my editors, Catherine Johnson and Robert Pancotti. The entire production team, including production supervisor Catherine Saggese, production manager Vastavikta Sharma, the copy editors, and other professionals at McGrawHill, deserves a special thanks for their attention to detail when preparing the ﬁnal manuscript. And ﬁnally, my heartfelt thanks to my husband and children for their patience and consideration.

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Bibliography

This is a complete reference list of books, publications, and Internet sites used in compiling the text and 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 information was found. For example, (Shephard, p. 337) refers to page 337 in the book Radiographic Image Production and Manipulation by C. Shephard. Food and Drug Administration (FDA) Internet. Accreditation and Certiﬁcation Overview. September 2007. Available at http://www.fda.gov/cdrh/ mammography/robohelp/ﬁnalregs.htm. Accessed February 2007. American Cancer Society (ACS). Breast Cancer Facts & Figures 2005–2006. Atlanta, GA: American Cancer Society Inc. American Cancer Society. Detailed Guide: Breast Cancer. 2007. Available at http://www.cancer. org/docroot/CRI/CRI_2_3x.asp?dt=5. Accessed November 2007. American College of Radiology (ACR). Mammography Quality Control Manual. Reston, VA: The American College of Radiology; 1999. Andolina VF, Lille SL, Willison KM. Mammographic Imaging: A Practical Guide. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. Bontrager KL, Lampignano JP. Textbook of Radiographic Positioning and Related Anatomy. 6th ed. St. Louis, MO: Elsevier Mosby; 2005.

Burstein HJ. Aromatase inhibitor-associated arthralgia syndrome. 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 Radiographic Imaging: An Art and a Science. 4th ed. Albany, NY: Delmar; 2001. FDA Policy Guidance Help System. Available at http://www.fda.gov/cdrh/mammography/ robohelp/START.HTM. Accessed November 14, 2007. Harris JR, Lippman ME, Osborne CK. Diseases of the Breast. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. Herrmann VM, Borelli AJ. The role of MRI in breast imaging. 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 the Facts. New York, NY: McGraw-Hill; 2005. Sanders ME, Page DL. All radial scars/complex sclerosing lesions seen on breast screening mammograms should be excised. Breast Diseases: A Year Book Quarterly. 2007 Jan 1. Senior K. Beneﬁts of tamoxifen persist long after treatment ends. Lancet Oncol. 2007 Apr;8(4):288.

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

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Bibliography

Shephard C. Radiographic Image Production and Manipulation. New York, NY: McGraw-Hill; 2003. Steveb AT. Quality Management for Radiographic Imaging. 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 Cyclopedic Medical Dictionary. 18th ed. Philadelphia, PA: F.A. Davis; 2001. Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. 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 after stereotactic vacuum-assisted core biopsy of benign breast lesions. Clin Imaging. 2006;30(6):438. Zuley ML, Willison KM, Bonaccio E, et al. Full-ﬁeld digital mammography on LCD versus CRT monitors. AJR. 2006;187:1492–1498.

CHAPTER 1

Patient Education and Assessment Summary of Important Points BREAST EXAMINATION

The American Cancer Society (ACS) guidelines for breast examination and routine mammography screening are as follows: • Women aged 20 and older should perform breast self-examination (BSE) every month. • Women between ages 20 and 39 should have a clinical breast examination (CBE) every 3 years. • Women aged 40 and older should have a screening mammogram and a CBE every year. Breast Self-Examination

reduced with regular screening mammograms. Although the mammogram will not detect all cancers, its effectiveness and sensitivity increases with age. Risk from Radiation Exposure A mammogram delivers very low doses of radiation. In general, each projection in a screen-ﬁlm mammogram will give about 0.1–0.2 rad average glandular dose when a grid is used. RISK FACTORS FOR BREAST CANCER

A BSE is a check of your breast. It involves • Looking for changes in the breast • Feeling for changes in the breast Clinical Breast Examination

A CBE is a check of the breast by a qualiﬁed healthcare professional. A thorough clinical examination will locate any lumps or suspicious areas and any changes in the nipples or skin of the breast. The lymph nodes under the armpit and above the collarbone will also be checked for enlargement or ﬁrmness. Medical History and Documentation

Medical and family history will provide information about symptoms and risk factors for breast cancer and benign breast conditions. The history should also include questions about other health problems. Beneﬁts and Risks of Mammography

Mortality Reduction Breast cancer in its early stages is asymptomatic. Since the advent of modern mammography in the late 1960s, studies have conclusively proven that the mortality rate from breast cancer is signiﬁcantly

• Gender: The biggest risk factor for breast cancer is gender (female). Although men can also get breast cancer, the disease is about 100 times less common among men than among women. Other relatively high-risk factors (with a relative risk > 4.0) include: • Aging: A woman’s risk of developing breast cancer increases with age. Seventy-seven percent of women are above 50 when they are diagnosed with breast cancer. • Genetic risk factors: Genes known to be associated with breast cancer include the BRCA1 and BRCA2 genes, which carry a high risk but are rare in the general population. About 10% of breast cancer cases are hereditary. • Family history of breast cancer: Breast cancer risk is higher among women whose close blood relatives have this disease. The risk is greater if the breast cancer occurs in a relative before age 50. • Personal history of breast cancer: A woman with cancer in one breast has a greater risk of developing a new cancer in the other breast.

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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 previous cancer treatment are at increased risk • High bone density after menopause Minor risk factors (1.1–2.0 relative risk) are associated with hormonal changes in the woman’s body or hormonal use that may slightly increase a woman’s chance of developing breast cancer. These include: • Not having children or having the ﬁrst child after 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 replacement therapy (HRT) or oral contraceptive • Alcohol consumption • Obesity

BREAST DISEASE

Breast disease can be either benign or malignant. Benign Breast Diseases

Like malignant conditions, benign diseases of the breast can manifest themselves physically, such as in a painful cyst or nipple discharge. Some breast diseases, however, can be detected only on the mammogram. Such breast disease will be seen as asymmetric densities, calciﬁcations, circumscribed tumors, lesions, or skin thickening. Malignant Diseases

The two main classiﬁcations of breast cancer are ductal and lobular carcinoma. Ductal carcinoma is the most common, occurring in about 90% of all cases. The classiﬁcations of ductal carcinoma are as follows: • Ductal carcinoma in situ: The cancer is confined to the duct and does not invade the duct walls. This is commonly referred to as Stage 0 carcinoma. • Invasive or inﬁltrating ductal carcinoma: The cancer has spread from the ducts into the surrounding stromal tissue and may or may not extend into the pectoral fascia and muscle.

Lobular carcinoma accounts for 5%–10% of all breast cancers • Lobular carcinoma in situ is not seen mammographically in 50% of cases; the abnormal cells grow within the lobules but do not penetrate through the lobule walls. • Invasive lobular carcinoma is difﬁcult to perceive on the radiographs; it may show as a spider web appearance or cause skin retraction. Other Breast Carcinomas Inﬁltrating medullary, colloid comedo, tubular, mucinous, papillary, and other carcinomas account for less than 10% of total breast cancer cases and most have a better prognosis than infiltrating ductal or lobular cancers. Appearance on Radiographs

Breast cancer may appear on the radiograph as asymmetric densities, calciﬁcations, circumscribed tumors or lesions, or skin thickening. • Malignant asymmetric densities are speculated or stellate lesions with a solid central tumor and radiating structures—the larger the central tumor, the longer the spicules. • Ductal calciﬁcations are granular or casting-type calciﬁcations and most often will appear in clusters. • Malignant circumscribed lesions are ill-deﬁned and high-density radiopaque lesions, except for a few rare carcinomas that are low-density radiopaque. • Skin thickening will appear in cases of advanced breast cancer, small cancers in the axillary tail or behind the nipple, breast carcinoma in a large area, invasive comedocarcinoma, diffusely invasive ductal carcinoma (ie, inﬂammatory carcinoma), secondary breast carcinoma, or metastasis from the opposite side. DIAGNOSTIC OPTIONS

The mammogram remains the single most-effective tool in the detection of breast cancer. There are two methods of mammography screening: conventional, which uses an analogy method of imaging, and digital, which can be cassette-based or cassette-less. • Digital imaging replaced the film with an electronic detector. The electronic system of the

Summary of Important Points

digital unit will collect a digital readout of the latent image. This image information can be electronically transmitted, manipulated, and efﬁciently stored using a variety of tools. Digital detectors are categorized as direct or indirect. Both the direct and indirect systems are considered cassette-less. Digital imaging also has a cassette-based system (computed radiography). The cassette-based system (computed radiography) has the detector loaded into a devise similar in shape and size of the conventional cassettes. The cassette-like device is called an image receptor (IR) and it holds a ﬂexible imaging plate (IP) instead of the conventional ﬁlm screen. The cassette-based system exposes the IR with a conventional unit, but after exposure the IR is placed in a computer reader where the IP is retrieved and the digital information analyzed. Other Imaging options • Computer-aided detection (CAD) uses a computer to analyze and in effect pre-read the mammograms by scanning every part of the radiograph and highlighting any suspicious areas. CAD can be used with conventional as well as digital images. • Ultrasound imaging utilizes high-frequency sound waves and is based on the principle of the piezoelectric effect. Piezoelectric crystals are capable of converting energy from one form to another. In conventional ultrasound, crystal in a transducer will vibrate to produce sounds that are sent through the tissues. Returning echoes that are reﬂected from the tissue again cause a vibration in the crystals, which is proportional to the strength of the returning echo. A computer will analyze the difference in returning signals to generate images of the area of interest. • Color doppler ultrasound can be used to provide an anatomic display of blood ﬂow and can therefore be used to outline the vascularity of a lesion. The technology is based on the fact that highly vascular lesions are often malignant. • Magnetic resonance imaging (MRI) technology uses a powerful magnetic ﬁeld, radio waves, and a computer to produce highly detailed images of the breast. The technology is highly sensitive and is based on the magnetic properties of hydrogen atoms in the body.

3

• Contrast digital mammography involves injecting a contrast while the breast is under compression. Pre- and post-contrast images are taken. Dual energy subtraction can be performed to assess the contrast in tumors. Dual-energy subtraction is used to subtract high- and lowenergy images to separate soft tissue from contrast or calcium deposits. The technology can also be used to enhance masses and eliminate obscuring structures. • Nuclear medicine uses artificially produced radioactive isotopes that can be introduced intravenously into the body. The isotopes generally have an afﬁnity to a speciﬁc organ or tissue type. Nuclear imaging studies are not used as screening tools but can complement the mammogram. They include Positron Emission Tomography or PET imaging, breast scintigraphy, and lymphoscintigraphy. • PET imaging, speciﬁcally using ﬂuorodeoxyglucose (FDG), utilizes the need that cancer cells have for sugar. Because FDG is structurally similar to glucose, positionemitting isotopes will attach to FDG molecules. The technique can be used to display an image of the tumor bed or to detect mediastinal lymph node metastases in breast cancer. • Breast scintigraphy, also called scintimammography and sometimes by the trade name Miraluma, uses the radioisotope Technetium Tc-99m sestamibi. The radioactive tracer is injected into an arm vein and will concentrate in malignant lesions in the breast. A gamma camera is then used to image the area. Technetium Tc-99m sestamibi is especially useful on patients with dense breasts, implants, diffuse calciﬁcations, and breast tissue scarred by radiation or surgery. The sensitivity of the technique is limited with lesions less than 1 cm. • Lymphoscintigraphy or sentinel node mapping involves the injection of a radioactive tracer in the area around the tumor to identify the path to the lymph nodes that cancer cells take. The idea behind lymphoscintigraphy is that the ﬁrst node, called the sentinel node that receives drainage from a tumor can be used to predict the presence or absence of tumor in the remaining nodes. After the injection of the radioactive isotope, the patient is sent to surgery. The surgeon will use

4

1: Patient Education and Assessment

a Geiger counter to locate and biopsy the radioactive lymph nodes. Lymphoscintigraphy can be used to reduce blind dissection of the axillary nodes and the resultant side effects. • Computed tomographic (CT) laser mammography is an experimental technology that shows promise because no ionizing radiation is used. The technique is based on the principle that malignant tumors develop numerous new vessels in a process called angiogenesis. By scanning the breast with a low-wavelength laser, a threedimensional image is generated that will show temperature differences, indicating a growing tumor. The technique can be used to differentiate cystic versus solid lesions and to image breast implants. • Digital tomosynthesis is a technology that may soon achieve FDA approval. The x-ray tube rotates in a 50-degree arc around the breast, imaging it from 11 different angles with no movement of the patient. Eleven low-dose images taken during 7–11 seconds. The technology produces highresolution three-dimensional, cross-section images of the breast. It eliminates overlapping structures and allows only one compression of each breast.

INTERVENTION OPTIONS

• Cyst aspiration involves the removal of the content of a cyst and is often performed under ultrasound guidance. • Fine needle aspiration (FNA) is ideal for cyst evaluations and aspirations. The technique uses a small (22- to 25-gauge needle) and generally requires cytotechnologist evaluation of the sample. • Preoperative localization is a prelude to the surgical biopsy. It is necessary if stereo localization is not available. The procedure can be performed under mammographic or ultrasound guidance. • Fine needle biopsy (FNB) also uses small (22–25 gauge) needles to remove cell samples from nonpalpable lesions for cytological analysis. The technique is often used with stereo localization. • Stereotactic breast localization or biopsy is a method of locating nonpalpable lesions by

using a computer to calculate the precise location of the lesion within the breast. The lesions can be biopsied after localization. Stereotactic biopsy can be performed with an add-on or dedicated units. • Core biopsy uses large-core needles (11–16 gauge) to remove tissue samples. The core biopsy needles have special cutting edges. Core biopsy can be performed using stereo localization with mammography, or using ultrasound or MRI guidance. • Open surgical biopsy is recommended with lesions that are difﬁcult to approach or close to breast surface. The open biopsy is sometimes used to conﬁrm the ﬁnding of FNA and FNB. • Ductography is used to evaluate nipple discharge, 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’s overall health status. Posttreatment can include breast augmentation or reconstruction. • Mastectomy is the removal of the entire breast. • A radical mastectomy removes the entire breast, lymph nodes, and chest wall muscles under the breast. It is rarely performed today because the modiﬁed mastectomy is just as effective. The modiﬁed mastectomy is also less debilitating and deforming. • A modiﬁed radical mastectomy removes the breast tissue and some of the underarm lymph nodes. • Lumpectomy is the most breast-conserving surgery. It removes only the cancerous tissue and the surrounding margins of normal tissue. Lumpectomy is generally followed by radiation treatment and or drug treatments. • Radiation therapy is treatment with high-energy radiation to destroy cancer cells. External beam radiation is the more common form of treatment and can take 5–7 weeks, beginning about 1 month after surgery. Newer techniques involve internal beam radiation that can begin the day after surgery and last only for 7–9 days.

Summary of Important Points

• Chemotherapy is a systemic treatment, affecting all the cells in the body. Many chemotherapy drugs work to kill actively reproducing cells; however, some drugs will work on cells in a particular phase of the cell cycle. • Hormonal treatment involves the use of drugs called selective estrogen receptor modulators, or SERMs. These drugs are antiestrogen drugs to prevent estrogen from latching onto tumor cell receptors. They are used to shrink or stop the recurrence of breast cancer or to lower the risks of breast cancer recurrence in postmenopausal women. Tamoxifen is a common antiestrogen drug, but there are now a number of similar drugs in the market with less toxic side effects such as raloxifene. Aromatase inhibitors are also antiestrogen drugs, but they work to block the growth of tumors by lowering the amount of estrogen in the body. Another class of drugs such as Herceptin can be used to treat HER2-positive metastatic breast cancer. • Pain medication is available for patients in severe pain from cancer. Newer pain medications are even more potent than morphine.

POSTTREATMENT OPTIONS

• Breast reconstruction aims to restore the appearance of the breast.

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• Surgical reconstruction uses saline or silicone implants. Modern techniques (subpectoral or retropectoral placement) place the implants behind the pectoral muscle. Older techniques (subglandular or retromammary placement) placed the implants in front of the pectoral muscle. • Flap surgery removes skin, fat, and muscle from the abdomen, back, or buttock and uses it to form a new breast. Flap techniques can either leave the ﬂap attached to its original blood supply and tunnels the ﬂap under the skin to the breast area, or remove the ﬂap completely, which would involve micro surgery to recreate a 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 abdominal area • Latissimus dorsi ﬂap using tissue from the upper back Newer ﬂap techniques: • DIEP (deep inferior epigastric artery perfora-

tor ﬂap—using skin and fat but no muscle from the abdomen • Gluteal-free ﬂap—using the gluteal muscle from the buttocks

Questions

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 cancer could include (A) (B) (C) (D)

gender aging genetic risk factors not breast-feeding

3. What is the approximate risk of developing breast cancer for a woman whose father’s sister has the disease? (A) (B) (C) (D)

higher than normal risk no signiﬁcant change in risk lower than normal risk none of the above

4. Seventy-seven percent of breast cancers are discovered in women in which age group? (A) (B) (C) (D)

6

age 30 or below above age 50 between ages 30 and 40 above age 20 but below age 30

5. Symptoms of benign breast disease not seen mammographically 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 can include 1. skin thickening 2. nipple discharge 3. 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 could also be caused by 1. a breast abscess 2. a calciﬁed ﬁbroadenoma 3. postradiation (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1 and 3 only

Questions: 1 through 16

8. The two main classiﬁcations of breast cancer are 1. ductal 2. lobular 3. medullary (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1 and 3 only

7

12. A health-care provider should evaluate which of the following breast changes? 1. lumps or swellings 2. skin irritation or dimpling 3. milky discharge from the nipple (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

9. MRI could be used 1. as a primary breast cancer detection tool 2. to image patients with breast implants to evaluate ruptures 3. 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 cancer that may have spread (B) is the destruction of cancer cells using high-energy radiation (C) involves mapping the area around a tumor with the injection of a radioactive tracer (D) is the removal of only the cancerous tissue from the breast 11. The ACS recommends that 1. All women should have a screening mammogram every year. 2. Women above 40 should have a screening mammogram every year. 3. New masses or lumps in the breast should be checked by a health-care provider. (A) 1 only (B) 2 only (C) 1 and 3 only (D) 2 and 3 only

13. A CBE should be performed every 1. year after age 40 2. 3 years between ages 20 and 39 3. month after age 50 (A) 1 only (B) 2 only (C) 1 and 2 only (D) 2 and 3 only 14. A CBE can be performed by which of the following? 1. the radiologist 2. the patient 3. a health-care professional (A) 1 only (B) 2 only (C) 2 and 3 only (D) 1 and 3 only 15. A BSE should be done regularly by 1. the radiologist 2. the patient 3. a health-care professional (A) 1 only (B) 2 only (C) 2 and 3 only (D) 1 and 3 only 16. All women above the age _______ should perform a BSE regularly. (A) (B) (C) (D)

20 30 40 50

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1: Patient Education and Assessment

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, the changes that should be recorded include 1. changes in size and shape 2. changes in texture or color 3. 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 documentation will 1. provide the radiologist with information on the patient’s risk factors for breast cancer 2. give the radiologist information about general symptoms of breast cancer 3. provide information about possible benign 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 stressed because 1. both will detect benign breast diseases, which are very common 2. both will help in the detection of malignant 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 used in BSE? 1. using the pads of the three middle ﬁngers to palpate the entire breast 2. palpating around the breast in a vertical pattern 3. using up varying degrees of pressure while 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 best time of the month to perform a BSE? (A) (B) (C) (D)

1 week before the start of menstruation on the ﬁrst day of the month on the last day of the month when the breast is least tender

23. Which of the following statements are true? 1. Breast cancer death rates in United States are going down. 2. Breast cancer is the leading cause of cancer death in women in United States. 3. The second leading cause of cancer death in women in United States is breast 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 developing breast cancer (B) overall reduction in breast cancer risks (C) circulating estrogen that is produced in fat tissue (D) a lower overall estrogen level

Questions: 17 through 33

25. A process of removing tissue, muscle, and fat from the belly and transferring that tissue to reconstruct the breast is called (A) (B) (C) (D)

30. During a mammogram, which of the following will affect the average glandular dose per breast?

TRAM ﬂap latissimus dorsi ﬂap implant placement silicone implant

1. degree of breast compression 2. the half-value layer (HVL) of the x-ray beam 3. breast size and composition (A) 1 only (B) 2 only (C) 3 only (D) 1, 2, and 3

26. Antiestrogen drugs such as tamoxifen can be used to 1. slow or stop the cancer’s growth 2. prevent breast cancer in high-risk women 3. prevent the recurrence of breast cancer (A) 1 and 2 only (B) 2 and 3 only (C) 1 and 3 only (D) 1, 2, and 3 27. In routine mammography, the radiation dose per projection is generally about (A) (B) (C) (D)

0.1–0.2 rad 1.0–2.0 rad 0.01–0.02 rad 2–3 mrad

28. Which age group is likely to get the most radiation dose from a mammogram? (A) (B) (C) (D)

between 20 and 35 between 40 and 50 between 55 and 60 above 70

29. The 5-year survival rate for a patient with a stage 0 breast cancer is about (A) (B) (C) (D)

49% 76% 88% 100%

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31. In general, the optimal duration of tamoxifen treatment is (A) (B) (C) (D) 32.

2 years 3 years 4 years 5 years

Lumpectomy describes the process of (A) removing the entire breast including the nipple (B) removal of the breast cancer tumor and surrounding margins of normal breast (C) making a small incision over or near the site of breast lesion (D) removing benign lumps from the breast

33. Radiation therapy can be used 1. combined with other treatment options 2. to kill any remaining cancer cells in the breast, or chest wall area 3. to shrink the size of a tumor before surgery (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

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1: Patient Education and Assessment

34. Chemotherapy is a class of drugs that can be used to (A) stop the spread of cancer to other parts of 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 placement of small ﬂuid-ﬁlled sacs behind the pectoral muscle. Two common types of such implants are (A) (B) (C) (D)

saline and ﬂap surgery TRAM ﬂap and silicone implant silicone or saline implants 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 image the breast (B) low-frequency sound waves to image the breast (C) longitudinal microwaves to image the breast (D) radiofrequency waves to image the breast 39. MRI can be used to 1. map the extent of a tumor 2. image patients with implants 3. evaluate patients with dense breast (A) 1 and 2 only (B) 2 and 3 only (C) 1 and 3 only (D) 1, 2, and 3 40. Conventional ultrasound imaging of the breast is often used to (A) map the extent of a breast tumor (B) verify that a lesion seen on the mammogram is solid or ﬂuid ﬁlled (C) verify the presence of microcalciﬁcations (D) biopsy a lesion seen only on MRI

Answers and Explanations

1. (C) Risk factors increase a woman’s risk for breast cancer. These are divided into major and minor. Major risks are those outside of a woman’s control, such as gender and age. Minor factors are linked to cancer-causing factors in the environment or may be related to personal choices, such as using HRT. Simply being a woman is the main risk factor for developing breast cancer. Breast cancer can affect men, but this disease is much more common among women than men (American Cancer Society: Causes, Risk Factors and Prevention; Peart, 28–29).

2. (D) A risk factor is anything that increases a person’s chance of getting a disease. Major risk factors cannot be changed. Minor factors are linked to cancer-causing factors in the environment or may be related to personal choices, such as breast-feeding (American Cancer Society: Causes, Risk Factors and Prevention; Peart, 28–29).

3. (A) Higher than normal or major risk factors carry a signiﬁcantly higher risk for breast cancer than minor risk factors. Breast cancer risk is higher among women whose close blood relatives have the disease. Blood relatives can be either from the mother’s or father’s side of the family (American Cancer Society: Causes, Risk Factors and Prevention; Peart, 28–29).

4. (B) A woman’s risk of developing breast cancer increases with age. Older women have the greatest risk. Women younger than age 30 years account for only 0.3% of breast cancer cases, and women in their thirties account 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 and Prevention; Peart, 28–29).

5. (A) Whereas skin thickening or tumors will be seen on a mammogram, nipple discharge is not seen mammographically. Most nipple discharges or secretions are not cancerous. In general, if the secretion appears clear or milky, yellow or green, cancer is very unlikely. Further testing such as a ductogram or galactogram helps in determining the cause of nipple discharge. The ducts can also be evaluated using ultrasound (American Cancer Society: NonCancerous Breast Conditions; Tabár, 16–20).

6. (D) Unfortunately, breast cancer in its early states is symptomless. As the cancer grows, some symptoms may appear. These symptoms can include lumps in the breast, thickening of the breast skin, puckering or dimpling of the breast, inverted nipples, or a discharge from the nipples (Peart, 15–23). 7. (D) Skin thickening or lymphedema of the breast can indicate breast cancer, but may also be because of a breast abscess located behind the nipple, severe infection involving the axillary nodes, mediastinal blockage owing to sarcoidosis (advanced stages), Hodgkin disease, lung cancer, bronchial cancer with mediastinal metastases, esophageal cancer with mediastinal metastases, right heart failure, advanced gynecologic malignancy, or postoperative or postradiation lymphedema (Peart, 59–60; Tabár, 240–241).

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1: Patient Education and Assessment

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

9. (C) There is no evidence at this time that MRI will be an effective screening tool for women at average risk for breast cancer. If MRI is used, it should be in addition to, not instead of a screening mammogram. Although MRI is more sensitive than mammograms, it also has a higher false-positive rate, which would result in unnecessary biopsies, and it still misses some cancers that a mammogram would detect. The ACS recommends that women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%. MRI, however, is useful for evaluating ruptures, leaks, free silicone in the surrounding breast tissue, or the formation of silicone granulomas. Also, the tumor margins and the extent of tumor spread are often better defined on the MRI than on mammography (American Cancer Society: Mammograms and Other Breast Imaging Procedures; Herrmann, 727–729).

10. (A) Chemotherapy involves the use of drugs to treat cancer that may have spread beyond the breast. The chemotherapy treatments may last 3–6 months depending on the intensity of the chemotherapy drug and how far the cancer has spread. Generally, chemotherapy treatment is given in cycles, with a period of treatment followed by a recovery period (ACS 15; American Cancer Society: Treating Breast Cancer; Peart, 35).

11. (D) The guidelines as suggested by the ACS are • Women aged 40 and older should have a screening mammogram and CBE every year. • Women between ages 20 and 39 should have a CBE every 3 years. • Women aged 20 and older should perform a BSE every month. • All lumps or suspicious areas and any changes in the nipple or skin of the breast should 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, tenderness, skin irritation or dimpling, or nipple pain or retraction should be evaluated as soon as possible. In general, if the nipple discharge is clear or milky, yellow, or green a cancer is unlikely. If the discharge is red or red-brown, suggesting blood, it could be caused by either a malignant or a benign condition and should be evaluated (ACS, 12–13; American Cancer Society; Early Detection, Diagnosis, Staging). 13. (C) A CBE is an examination of the breast by a health-care professional such as a physician, nurse-practitioner, nurse, or physician assistant. Between ages 20 and 39, women should have a CBE every 3 years. After age 40, 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 by a health-care professional such as a radiologist, physician, nurse-practitioner, nurse, or physician assistant. A similar examination, performed by the patient on herself, is referred to 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 menstrual period, or when the breasts are not tender or swollen. For women not having regular menstruation, the BSE should be done on the same day every month (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging).

Answers and Explanations: 8 through 20

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

17. (A) For BSE, the ﬁrst step is to look for changes, either while standing or sitting. A check should be made for indentations, retracted nipples, dimpling, or prolonged skin conditions. The next step is to lie supine and feel for changes using light, medium, and ﬁrm pressure with the pads of three ﬁngers in an up-and-down pattern. The entire breast must be checked (Figure 1-1) (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging). 18. (D) The visual stage of a BSE is a check for signs of breast cancer. These signs can include changes in size, texture, or color of the breast; prolonged skin irritation; redness or scaliness; dimpling; or nipple retraction (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging).

19. (C) The ﬁrst step in evaluating a woman with suspected breast cancer is a complete medical history and physical or clinical examination.

A

B

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The medical history will provide information about the patient’s symptoms and any other health problems and risk factors for benign or malignant breast conditions. A clinical examination will be done to locate any lump or suspicious areas and examine the texture, size, and shape of the breast. Any changes in the nipples or skin of the breast will also be noted. Once the medical and clinical examinations are completed, biopsies or imaging tests such as mammography can be performed (ACS, 1–16; American Cancer Society; Early Detection, Diagnosis, Staging).

20. (C) Authors of the CMAJ article (164[13]: 1837–1846) called for an end to routine teaching of BSE to women aged 40–69, saying that studies on the topic suggest BSE and BSE education do not reduce deaths, but increase unnecessary biopsies and anxiety. However, although the BSE and the CBE cannot detect all malignant breast conditions, they are primarily important as complimentary tests. The ACS suggests that both the BSE and CBE will compliment the mammogram and help in the detection of breast cancers. Unfortunately, the mammogram is not foolproof. Even under ideal conditions, the mammogram will not find all breast cancers 100% of the time (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging).

C

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

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1: Patient Education and Assessment

21. (D) The ACS suggests examining the breast with three different levels of pressure: light pressure to feel the tissues closest to the skin; medium pressure to feel a little deeper; and ﬁrm pressure to feel the tissue closest to the chest and ribs. The up and down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast without missing any breast tissue, and the pads of the three middle ﬁngers (not the ﬁnger-tips) are most sensitive to palpate for abnormalities. The patient should use small dime-sized circular motion to examine the entire breast (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging). 22. (D) The patient should perform a BSE 5–10 days after the start of menstrual period, or when the breasts are not tender or swollen (ACS, 15–16; American Cancer Society; Early Detection, Diagnosis, Staging).

23. (C) Although breast cancer is relatively common, it is only the second leading cause of cancer death in women, after lung cancer. About 178,480 women in the United States will be found to have invasive breast cancer in 2007. About 40,460 women will die from the disease. In the United States, breast cancer death rates are going down, possibly because of finding cancers earlier and improved treatment options (ACS, 3–7; American Cancer Society: Early Detection, Diagnosis, Staging; Tortora 1083).

24. (C) Circulating estrogen is mostly produced in fat tissue, therefore in postmenopausal women, having more fat tissue can lead to increased estrogen levels. Weight gain is therefore associated with increased estrogen levels and increased likelihood of developing breast cancer (ACS, 11; American Cancer Society: Early Detection, Diagnosis, Staging).

25. (A) TRAM ﬂap procedure uses tissue and muscle from the lower abdominal wall to create a breast shape. There are two types of TRAM ﬂaps: the pedicle ﬂap where the ﬂap is left with its original blood supply and tunneled under the skin to the breast area; and

the free ﬂap where the tissue from the abdomen is completely removed from its original location. This process requires microscopic surgery to reconnect a blood supply. Latissimus dorsi ﬂap involves the removal of muscle and skin from the upper back to create a breast shape. Implants can be silicone or saline (American Cancer Society: Treating Breast Cancer; Peart, 232–234).

26. (D) Tamoxifen belongs to a class of drugs called SERMs or selective estrogen receptor modulators. Normally, the estrogen receptor molecules in cancer cells will react with estrogen in the body, allowing the cells to grow. Antiestrogen drugs work by attaching to the estrogen receptor molecule in breast cancer cells that would normally react with estrogen. This prevents the estrogen receptor cancer cells from interacting with body estrogen and will slow or stop the cancer’s growth and can also be used to prevent breast cancer and the recurrence of breast cancer at local, regional, and distal sites after lumpectomy and radiation treatment (American Cancer Society: Treating Breast Cancer; Peart, 228; Senior; Tortora, 1096).

27. (A) The ACR recommends that the average glandular dose on the mammogram be no greater 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 mammography equipment, the patient will usually receive only about 0.1–0.2 rads per projection (Andolina, 124; Peart, 23–24; Bushong, 590–591).

28. (A) Although breast tissue composition is affected by menarche, hormonal fluctuation both normal and synthetic, pregnancy, lactation, menopause, and weight gain or loss, in general the breasts of young women are denser than those of older women. Younger breasts will therefore require more radiation to penetrate and will absorb more radiation than those of older women. Fortunately, the incidence of breast cancer in this age group is very low (American Cancer Society: Causes, Risk Factors and Prevention; Andolina, 124; Peart, 23–24).

Answers and Explanations: 21 through 34

29. (D) A stage 0 carcinoma refers carcinoma in situ, cancer that is still contained within the duct or lobule. The prognosis for this type of cancer is 100% survival after 5 years. Fiveyear survival rate refers to the percent of patients who live at least 5 years after their cancer is diagnosed. Many of these patients live much longer than 5 years after diagnosis, but 5-year rates are used to produce a standard way of discussing prognosis. Fiveyear rates will exclude from the calculations patients dying of other diseases and is considered to be a more accurate way to describe the prognosis for patients with a particular type and stage of cancer (Table 1-1) (American Cancer Society: Causes, Risk Factors and Prevention; Peart, 23–24). TABLE 1–1. BREAST CANCER SURVIVAL BY STAGE 5-Year Relative Survival Rate

Stage 0 I IIA, IIB

IIIA, IIIB

IV

Carcinoma in situ Tumor = 2 cm; axillary node negative Tumor 2–5 cm with or without positive nodes or >5 cm without positive nodes >5 cm with positive nodes Any size if spread to breast skin, chest wall, or internal breast lymph nodes Any size if there is distant metastasis (eg, to bone, lungs)

100% 98% 88%, 76%

56%, 49%

16%

30. (D) The major factors affecting dose are • The imaging chain—the screen/ﬁlm combination and processing environment • The x-ray beam energy—the higher the kVp and HVL, the lower the patient dose • The compression—greater compression will result in decreased exposure and therefore decreased dose • The patient’s breast tissue type (composition) and thickness—denser glandular breast requires more exposure than fatter breast (Peart, 23–24)

31. (D) The optimal duration of tamoxifen in postmenopausal women is 5 years. Studies have conﬁrmed that there is no beneﬁt of

15

giving tamoxifen longer. Tamoxifen will react with the estrogen receptor in other areas of the body, such as bone and the lining of the uterus. With the cells in these areas, tamoxifen acts like estrogen to promote growth, leading the increased bone density and a high risk of uterine cancer. Other side effects of tamoxifen include endometrial cancer, pulmonary embolism, stroke, and deep vein and thrombosis (American Cancer Society: Treating Breast Cancer; Peart, 228; Senior, 288; Tortora, 1096).

32. (B) Lumpectomy is a breast-conserving surgery whereby the breast tumor and surrounding margin of normal tissue are removed. Removing a benign lump does not describe lumpectomy. The main advantage of a lumpectomy is that it preserves most of the breast. A disadvantage is the need for adjuvant therapy such as radiation therapy. Factors that can affect the choice of lumpectomy over mastectomy include tumor size, tumor type, and cancer stage (American Cancer Society: Treating Breast Cancer; Peart, 222; Tortora, 1096).

33. (D) Radiation will kill both normal and cancerous cells. In any radiation treatment, the cell cycle is important because radiation usually works best on cells that are actively or quickly dividing but does not work well on cells that are in the resting phase (G0) or are dividing slowly. Radiation is often used after surgery and in conjunction with other treatment options to remove any remaining cancer cells in the breast, chest wall, and axilla area but can be used before surgery to shrink the tumor and allow a better cosmetic surgical result (Table 1-2) (American Cancer Society: Treating Breast Cancer; Peart, 224).

34. (A) Chemotherapy is an adjuvant therapy and involves the use of drugs to treat cancer that may have spread beyond the breast. The drug is distributed throughout the entire body via the blood stream and tends to attack cells that are rapidly dividing, whether they are cancerous or not. Drugs that block estrogen from latching onto to cancer cells are antiestrogen drugs such as tamoxifen and raloxifene. Another class of

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TABLE 1–2. THE CELL CYCLE G0 phase (resting stage): Cells have not yet started to divide. Cells spend much of their lives in this phase. Depending on the type of cell, this step can last for a few hours to many years. When the cell is 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 phase lasts about 18–30 hours. S phase: In the S phase, the chromosomes that contain the genetic code (DNA) are copied so that both 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 two new cells.

drugs—aromatase inhibitors—that suppress blood levels of estrogen are also available in the ﬁght against breast cancer. Radiation therapy uses high-energy radiation to destroy cancer cells (American Cancer Society:

high cost and the modality’s lack of speciﬁcity, which often results in a high falsepositive rate on biopsies (American Cancer Society: Early Detection, Diagnosis, Staging; Herrmann, 727–729; Peart, 163–177).

Treating Breast Cancer; Burstein; Peart, 228–229).

35. (C) Breast reconstruction can involve the placement of saline or silicone-ﬁlled sac either in front of or behind the pectoral muscle. Implants placed behind the pectoral muscle (subpectoral or retropectoral placement) are becoming more popular than the older method of placing the implants in front of the pectoral muscle (subglandular or retromammary placement). Subpectoral placement allows easier imaging of the breast mammographically and is less prone to encapsulation. Flap surgery uses skin, fat, or muscle from other parts of the body to form a natural-looking breast mound. Two common ﬂap techniques are the TRAM ﬂap—using skin, fat, and muscle from the abdomen— and latissimus dorsi ﬂap—using tissue from the upper back (American Cancer Society: Treating Breast Cancer; Andolina, 298–307).

36. (C) MRI can ﬁnd cancers that are missed on mammography, but cannot replace mammography because there are still some cancers that are detected mammographically but not with MRI. The ACS now recommends contrast-enhanced MRI in conjunction with a mammogram for women with approximately 20%–25% or greater lifetime risk of breast cancer. The technology is not however recommended as a screening tool because of the

37. (C) MRI technology uses a powerful magnetic ﬁeld, radio waves, and a computer to produce highly detailed images of the breast. The technology is based on the magnetic properties of hydrogen atoms in the body. MRI technology is extremely sensitive and is now recommended as an adjunctive screening tool for high-risk women. Ultrasound uses high-frequency sound waves to image the breast and mammography uses x-radiation to image the breast (American Cancer Society: Early Detection, Diagnosis, Staging; Herrmann, 727–729; Peart, 163–177).

38. (A) Sound is a mechanical, longitudinal wave that needs a medium to travel. Breast imaging with ultrasound uses high frequencies, above 20,000 Hz, which are beyond human hearing. Microwaves are electromagnetic waves with a short radiofrequency (Andolina, 322–323; Peart, 148–163; Tortora 1095).

39. (D) MRI is an imaging test that uses strong magnets and radio waves to create very detailed breast images. MRI is a promising tool. Because of its sensitivity it can ﬁnd tumors even in very dense breasts, and can ﬁnd very small tumors. It can be used to stage cancers, map the extent of the tumor, evaluate the effectiveness of chemotherapy, and distinguish postoperative or postradiation

Answers and Explanations: 35 through 40

scarring from recurrent cancer. MRI can also be used to image implants for leakage or ruptures (American Cancer Society: Early Detection, Diagnosis, Staging; Herrmann, 727–729; Peart, 163–177).

40. (B) Ultrasound is an adjunctive modality and is useful in determining whether the mass seen on the mammogram is solid versus cystic (malignant vs. benign). Ultrasound is close to 100% accurate in diagnosing cysts

17

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

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CHAPTER 2

Instrumentation and Quality Assurance Summary of Important Points DESIGN CHARACTERISTICS OF FILM-SCREEN MAMMOGRAPHY UNITS

All mammography units are designed to image the soft tissue of the breast while displaying the necessary subtle contrast differences. Older mammography generators were three-phase generators; all modern generators are high-frequency generators. Like the older units, these rectify the input to produce a direct current (DC) voltage waveform, but the modern high-frequency generators essentially provide a constant potential with about 1% ripple. The high frequency allows more efﬁcient x-ray production and therefore produces a higher effective energy x-ray beam. The result is higher x-ray output for a given kVp (peak kilovoltage) and mA (milliamperes) setting. kVp Range The kVp range will depend on the target/ﬁltration material available. The kVp use will depend on a number of factors (eg, radiologist preference, equipment calibration, manufacturer’s recommendations, equipment design, characteristic curve of the screenﬁlm combination, processing, and patient breast size and thickness). The kVp selection can affect the radiographic contrast because contrast is highest in thinner breasts and lowest in thicker breasts. In the thicker breast, more radiation is needed (more kVp) and there is greater tissue absorption of the low-kVp radiation. Increased kVp will allow lower dose but will reduce contrast. Decreased kVp will increase dose and increase subject contrast. Mammography Tube (Anode, Filtration, Window)

In mammography, special target materials and ﬁltrations are combined to provide the low-energy

beam needed. The target-ﬁlter combination will essentially shape the x-ray beam, providing the necessary 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 rhodium ﬁltration • Rhodium target with 0.025 mm (25 μm) rhodium ﬁltration (50 μm rhodium ﬁltration is sometimes recommended) • Molybdenum and tungsten alloy target with molybdenum or rhodium ﬁltration • Molybdenum and rhodium alloy target with molybdenum or rhodium ﬁltration • Tungsten target and silver or rhodium ﬁltration (used on some digital units) The material used for the exit port or window of the x-ray tube is borosilicate glass or beryllium (Be). A regular glass window would harden the emerging beam by eliminating the soft characteristic radiation. The intensity of the beam is less on the anode side than on the cathode side because of the anode heel effect. The cathode-side output of the x-ray tube is always directed to the base; that is, the thickness area of the breast. Compression Devices

Compression in mammography is provided by a flat-surfaced compression paddle. Important design characteristics are: • The flat surface must be parallel to image receptor (IR). • The chest wall edge of the compression paddle should not extend beyond the chest wall edge of the IR by more than 2% of the source-toimage distance (SID).

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2: Instrumentation and Quality Assurance

• A shadow of the vertical edge of the compression paddle should not be visible on the image. • The lip along the chest wall should be 2–4 cm in height. • The lip should have a right angle at the chest wall.

• The entire ﬁlm should be exposed (extraneous light will compromise the perception of ﬁne detail). • Collimation should not extend beyond any edge of the IR by more than 2% of the SID. • Decreasing the x-ray ﬁeld will require an increase in exposure to maintain constant density.

Automatic Exposure Control

Automatic exposure control (AEC) is used in modern mammography units. AEC controls the length of the exposure and will therefore determine the density of the ﬁnal image. The type of AEC device found 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 conventional mammography and occurs when the AEC cell is not placed over the densest area of the breast. Grids

Grids are used to improve radiographic contrast by decreasing the amount of scattered radiation that reaches the IR. The use of grids will always result in increased dose to the patient. General characteristics of common mammography grids: • Thinner than conventional radiography grids • Linear focused grid-movement in one direction 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 mammography use) • A crossed grid. It can reduce scatter in two directions rather than the one direction of the linear focused grid. • Copper as the grid strip. • Air as the interspace material. • 3.8:1 grid ratio.

SYSTEM GEOMETRY (SID, OID, MAGNIFICATION) Focal Spot Size

The recommended focal spot sizes in mammography are: • 0.4 mm or smaller for routine work (the most commonly used is 0.3 mm). • 0.15 mm or smaller for magnification (the most common focal spot size in magnification is 0.1 mm). Size and shape of the focal spot are determined by the • Size and shape of electron beam hitting the anode • Design and relationship of the ﬁlament coil to the focusing cup. • Angle of the anode. Source-to-Image Distance

In mammography the aim is to have the smallest focal spot coupled with the longest SID. The SID in mammography is ﬁxed—generally 50–80 cm. Object-to-Image Distance

The object-to-image distance (OID) should be as small as possible. The only exception is micro focus magniﬁcation. • Magniﬁcation will reduce scatter, but the greater the magniﬁcation factor the greater the skin dose to the patient. • Magniﬁcation causes decrease in image resolution. This is compensated by using a small focal spot 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

Beam Restriction Devices

Beam-restricting or -limiting devices are cones, collimators, or diaphragms used to regulate the size and shape of the x-ray beam. There are three facts to consider when using beam-restricting devices in mammography.

• • • • •

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

Summary of Important Points

• The relationship between the OID and the SID • Characteristics of the screen (faster screens have a lower spatial resolution) Imaging Components

There are two imaging systems in current use: • Screen-ﬁlm system • Digital system Film The ﬁlm can be used to record the image, display the image, and provide archival storage. Mammography ﬁlms are single emulsion and high contrast. Highcontrast ﬁlms generally have limited exposure latitude. Other ﬁlm characteristics such as speed must also be taken into account to reduce patient dose. Screens Single-screen cassette systems are used in mammography to provide the best spatial resolution. Cassettes or Image Receptor Cassette or IR holds and stores the film during exposure. Single-screen IRs are matched with the single emulsion mammography ﬁlms. They can be designed for either daylight or darkroom use. All IRs must have an identiﬁcation system slot, capable of recording patient information on the image. Processors

Mammography images should be processed in dedicated ﬁlm processors. There are two common options: • Standard 90-second processing • Extended processing. This extends the developing time to improve image contrast and reduce patient dose. Factors affecting ﬁlm processing include: developer time, developer temperature, and chemistry composition (developer and ﬁxer). DIGITAL MAMMOGRAPHY

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

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In the direct system, x-rays are absorbed by the detector and the electrical signal is created in one step. Amorphous selenium is the ﬂat-panel detector often used. Thin-ﬁlm transistor (TFT) arrays are then used to transfer the electronic signals from the selenium photoconductor to a computer. The indirect digital systems use a two-step process. A scintillator such as cesium iodide doped with thallium absorbs x-rays and generates a light scintillation that is then detected by an array of thin-ﬁlm diodes (TFDs) or charge-coupled devices (CCDs). Signals from the TDSs or CCDs are collected, converted to electronic signals, and transferred to a computer. The cassette-based system is similar to the computed radiography system used in general radiography. Here the same conventional mammography unit is used but the cassettes are replaced by an IR, which holds an imaging plate during the exposure. The imaging plate has a photostimulable phosphor with an active ingredient-europium-activated barium ﬂuorohalide—which is activated when exposed to x-rays. After exposure, the IR is transported to a computer reader (CR), which uses laser light to read the emission from the image plate. In all digital systems the spatial resolution will depend on pixel size. A pixel is the smallest discrete picture element of an image, usually a single dot. Increased pixel size will increase resolution but will also increase noises that can deteriorate image quality. Digital and Computer-Aided Detector

Digital signals are sent to a computer-aided detector (CAD) reader. The computer prereads the mammograms, identifying areas of suspicion or areas needing additional workup. Digital and Picture-Achieving and Communication System

Digital signals are sent to a picture-achieving and communication system (PACS), enabling teleradiography and ﬁlmless libraries, which can be accessed via telephone, the Internet, or any other off-site location. Digital systems approved by the Food and Drug Administration (FDA): GE Senographe 2000D (approval date: 1/28/00) Fischer Imaging SenoScan (approval date: 9/25/01)

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2: Instrumentation and Quality Assurance

Lorad Digital Breast Imager (approval date: 3/15/02) Hologic/Lorad Selenia FFDM System (approval date: 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 are absolutely essential in producing quality images. Guidelines determined by the Mammography Quality Standards Act and the American College of Radiology provide the standard criteria. These criteria exceed the criteria for processing of radiographic studies done in a diagnostic radiology department. Mammographers must be aware of all performance evaluations and quality control (QC) testings for ﬁlm-screen or digital system. FILM-SCREEN QUALITY CONTROL TEST

FREQUENCY

Darkroom cleanliness Processor quality control Mobile unit quality control Screen cleanliness Analysis of ﬁxer retention in ﬁlm Darkroom fog Screen-ﬁlm contact

Daily Daily Daily Weekly Quarterly Semiannually Semiannually

QUALITY CONTROL TESTS FOR BOTH DIGITAL AND FILM-SCREEN

View boxes and viewing conditions Phantom images Visual checklist Repeat/reject analysis Compression Review of medical physicist’s annual survey report

Weekly Weekly Monthly Quarterly Semiannually Yearly

ALL TESTS ARE MEDICAL PHYSICIST TEST

DONE ANNUALLY

Mammographic unit assembly evaluation Collimation assessment (ﬁeld light and x-ray congruence) Evaluation of system resolution AEC system performance Uniformity of screen speed Artifact evaluation Image quality evaluation kVp accuracy and reproducibility Beam quality assessment Breast exposure and AEC reproducibility Average glandular dose Radiation output rate Measure of view-box luminance and room illuminance The medical physicist must all perform all the manufacturer-recommended digital quality control tests. Some of these are similar to the digital tests performed by mammographers.

DIGITAL QUALITY CONTROL TEST

Monitor cleaning Compression indicator Laser imager test (including SMPTE detector calibration/ﬂat ﬁeld) Signal-to-noise measurement, contrast-to-noise measurement modulation transfer function (MTF) Automatic optimization of parameters (AOP) Monitor calibration and SMPTE pattern

Monthly Weekly Weekly Weekly or biweekly Weekly

Radiologist (Interpreting Physician)

Weekly or monthly Monthly Weekly

Testing Details

Note: Digital quality controls can vary and are manufacture dependent. Other tests can include a weekly artifact evaluation for the printer and electronic detector.

• Primary responsibility—interpreting the mammography and ensuring that they are of optimal diagnostic quality. • Responsible for a yearly review of the medical audit with the lead quality-control mammographer.

Darkroom Cleanliness Purpose: To minimize artifacts on radiographs caused by bits of dust, dirt, or food between the screen and ﬁlm. This is extremely important when using single emulsion ﬁlm, as in mammography, not only because they are more obvious, but because they

Summary of Important Points

can look like microcalciﬁcations and lead to misdiagnosis or repeat examinations. Processor Quality Control Purpose: To conﬁrm and verify that the processor chemical system is working properly according to speciﬁcations. Processor quality control should be carried out daily, at the beginning of the day before processing any ﬁlms. Required: A 21-step sensitometer and a densitometer. Processor quality control records should be saved for 1 year. Sensitometric images should be saved for the last full month. Screen Cleanliness Purpose: To ensure the screens are free of dust or other potential artifacts. Screens should be cleaned at least weekly, but also anytime when dust or other artifacts are noted by the mammographer or radiologist. Illuminators/Viewing Conditions Purpose: To ensure optimal viewing conditions. Viewing conditions can be extremely critical in mammography. High-luminance view boxes with proper masking of each image are essential. Typically, view boxes should have a luminance level of approximately 1500 candela per square meter (cd/m2). For mammography, the luminance level should be at least 3500 cd/m2. (The unit candela per meter is sometimes referred to as the “nit.” The older unit is the footlambert (fL). 1fL = 3.43 cd/m2.) Phantom Images Purpose: To ensure that image density, contrast, uniformity, and image quality are maintained at optimum levels. Required: A mammographic phantom (4- to 4.5-cmthick tissue equivalent breast phantom), with an acrylic disc 4-mm thick permanently ﬁxed on the phantom, in a position that does not obscure any phantom detail. (Digital phantom imaging does not always use the acrylic disc.) Note: The mammographic phantom should always be viewed by the same person, on the same view box, under the same viewing conditions, using the same type of magnifying glass at the same time of day.

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Visual Checklist Purpose: To ensure the mechanical integrity and safety of the mammographic equipment and accessory devices. The system indicator lights, displays, mechanical locks, and detents are all checked. Reject/Repeat Analysis Purpose: To determine the number and cause of repeated mammograms and rejected ﬁlms. The overall repeat rate ideally should not exceed 2%, but a rate lower than 5% is acceptable once the quality assurance program is operational. To be statistically meaningful, a volume of at least 250 patients needs to be measured. The percentage of repeats from each category should be close. If one 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 any processed ﬁlm is an indication of the length of time that film will retain its archival quality (image quality). Excess residual fixer can degrade the quality of the image. Required: Residual hypo test solution, available commercially, or hypo estimator (eg, Kodak Hypo Estimator, publication N-405, or equivalent). If there is an excess of hypo retained on the ﬁlm, the processor wash tanks and water ﬂow rates, in addition to ﬁxer replenishment rates, need to be assessed. Darkroom Fog Purpose: To ensure that the ﬁlm is not fogged as a result of cracks in the safelight or other light sources 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 Identiﬁcation Purpose: To assure optimum contact between screens and ﬁlm in each cassette. Screen-film contact will influence image sharpness. Poor contact will impact image quality. It is important to be able to identify each screen-cassette combination. If a problem occurs with one of the cassettes, for example, if an artifact

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2: Instrumentation and Quality Assurance

is detected in one of the cassettes, appropriate identiﬁcation will allow the mammographer to locate the cassette and correct the problem. Each screen should be marked with a unique identiﬁcation number near the left or right edge of the screen, using a marker approved by the screen manufacturer. The same identiﬁcation number should be placed on the outside of each cassette. Required: Mammographic ﬁlm, a densitometer, and copper wire mesh screens with at least 40 wires per inch grid density. These are commercially available. The mesh can be placed between two thin sheets of acrylic to protect it. The optical density of the ﬁnal image must be measured using a densitometer with at least a 2mm diameter aperture. The density should be between 0.70 and 0.80 when measured near the chest wall side of the ﬁlm. A thin sheet of acrylic can be placed near the x-ray tube window to adjust the density to the ideal level. Any cassette having a large area (>1 cm in diameter) of poor contact that cannot be eliminated should be replaced. Multiple small areas of poor contact (>1 cm) are considered acceptable. Compression Purpose: To ensure that the mammographic system can provide adequate compression in both manual and automatic mode and that too much compression cannot be applied. The compression should be adequate to separate glandular tissue without causing injury to the patient or damage to the compression device. Required: Bathroom scale and several towels. Adequate compression ranges from 25–45 lb in automatic mode (111–200 newton). The initial automatic compression should not exceed 45 lb of pressure. Digital Quality Assurance

Note: Digital quality assurance is manufacturer speciﬁc. Test can include: • SMPTE tests—check communication between AWS (acquisition work station), detector, and printer • Automatic optimization of parameters (AOP)checks auto-timing with auto kVp and/or autoselection of target and ﬁlter • Signal-to-noise ratio (SNR)/contrast-to-noise ratio (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 AWS monitor and/or printer • Artifact evaluation checks for artifacts on printer 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 compression 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 Certiﬁcation

The Mammography Quality Standards Act (MQSA) was enacted on October 27, 1992 to establish minimal national quality standards for mammography. Agencies: The Food and Drug Administration (FDA) and the States as Certiﬁers (SAC) are the only organizations authorized to issue MQSA certiﬁcation. Process: Before a mammography facility can legally perform mammograms, it must be certiﬁed. The facility must ﬁrst contact an accreditation body. Provisional certiﬁcation (valued for 6 months) is usually issued by the FDA as soon as the accreditation has been accepted. The accreditation body will then accept clinical images and other data from the facility to complete the accreditation process. Key Components of the MQSA

The interpreting physician, the physicist, and the mammographer must meet the education and training requirements of the MQSA. All are also required to interpret/inspect/image a minimum number of mammograms or sites per year and obtain a minimum number of continuing education

Summary of Important Points

units within a speciﬁc period. All mammographers (radiographer performing mammograms) must meet the training requirements of the MQSA. Certificate placement—Must be prominently displayed. Consumer complaints mechanism—Facility must have a system in place to collect and resolve serious consumer complaints. Self-referrals—A facility can decide to accept or not to accept self-referrals, but the policy must be stated. Record keeping—Mammograms and medical records of patients must be kept for a period of not less than 5 years, or not less than 10 years if no additional mammograms of the patient are performed at the facility (longer if mandated by state or local law). Records must include: name of patient plus an additional patient identiﬁer, date of examination, name of radiologist interpreting the mammogram, and a ﬁnal assessment ﬁnding. Infection control—All facilities should have a policy in place to prevent and control the spread of infection to employees, patients, and visitors within the mammography facility. Communication of results—All facilities must send each patient a summary of the mammography report written in lay terms within 30 days of the mammographic examination. Either verbal or written results are acceptable. Results must

25

be sent to the physician. Concerned ﬁndings must be sent within 3–5 days. Assessment categories—All reports must have an assessment category. The most commonly used is the Breast Imaging Reporting and Database (BIRAD) system. Medical audit—All facilities must keep a medical outcomes audit to follow positive mammography results and to correlate pathology results with the interpreting physician’s findings. The Health Insurance Portability and Accountability Act (HIPAA) does not affect medical audit because in MQSA documentation patient information can be released without patient authorization. Notes on Digital Terminology

Unfortunately the terminology being used in digital imaging has not yet been standardized. The following is a list of terms in current use. The cassette in computed radiography (CR) has been replaced by a structure similar to the screen-ﬁlm cassette. It is sometimes called imaging plate (IP) or image receptor (IR). This text uses IR. The film in CR and DR has been replaced by a storage phosphor screen. It is often called photostimulable phosphor (PSP), storage phosphor screen (SPS), image recorder (IR) or image or imaging plate (IP). This text uses IP.

Questions

1. In mammography, selecting extremely low kVp 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 provides the best penetration for dense or thick breast? (A) molybdenum target with molybdenum ﬁltration (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 the mammography tube is necessary because (A) The intensity of the beam is less on the anode side than on the cathode side. (B) Regular glass would harden the emerging beam. (C) The intensity of the beam is more on the anode side than the cathode side. (D) Regular glass would soften the emerging beam.

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4. The intensity of the x-ray beam from the cathode side of the tube is generally higher because (A) Soft characteristic radiation emerges from the anode side. (B) The cathode side is directed to the thickest part of the breast. (C) The heel effect causes variation in the intensity of the x-ray beam. (D) The heel effect increases the intensity of the beam at the anode side. 5. The design of the lip of the compression paddle (both height and angle along the chest wall) affects all of the following except that it (A) prevents the posterior and axillary fat from overlapping the body of the breast (B) allows uniform compression of the posterior breast tissue (C) helps to increase structural strength of the compression paddle (D) ensures greater compression of the anterior 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

Questions: 1 through 15

7. AEC failure, resulting in an underexposed radiograph, can be caused by (A) processing deﬁciencies such as ﬂuctuating developer temperature (B) improper placement of the dense breast tissue/size over the detector (C) decreased radiographic contrast (D) inadequate breast compression 8. Most AEC circuitry in modern mammographic imaging has at least three detectors. Three or more detectors are recommended because (A) Multiple detectors allow for maximum variations in breast size and tissue density. (B) AEC detectors eliminate the guesswork in determining the proper exposure factor for each patient. (C) Detectors have the ability to terminate the exposure by back-up timer when a maximum exposure time or maximum milliamperes (mA) per second is reached. (D) All AEC detector systems provide consistent image densities because of the high-contrast mammography ﬁlms. 9. The major difference between the general radiography grid and the grid used in mammography is that the (A) grid used in general radiography causes an increase in exposure (B) grids used in general radiography have higher ratios (C) use of a grid in mammography increases patient dose (D) grids in mammography improve the radiographic image contrast 10. The grid ratio can vary in modern mammography units. A common grid ratio used is (A) (B) (C) (D)

8:1 6:1 4:1 2:1

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11. As the size of the x-ray ﬁeld decreases, to maintain a constant image density the exposure will (A) (B) (C) (D)

increase decrease not change signiﬁcantly decrease inversely

12. The chest wall edge of the compression paddle should be aligned just beyond the chest wall edge of the IR to (A) avoid pushing the patient’s chest away and losing breast tissue (B) properly position and compress the breast (C) permit uniform exposure and reduce patient discomfort (D) avoid projecting the chest wall edge of the 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 focal spot size for routine work is (A) (B) (C) (D)

3 mm 0.3 mm 1 mm 0.1 mm

15. Which of the following characteristics are unique 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

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16. Two main disadvantages of extended processing are (A) decreased film speed and increased film fog (B) increased film speed and decreased film fog (C) increased processing artifact and increased ﬁlm fog (D) decreased processing artifact and increased ﬁlm speed 17. In digital mammography, both the ﬁlm and cassette can be replaced by (A) (B) (C) (D)

a detector and electronic system the CAD technology system a ﬂexible storage phosphor photostimulable plates

18. The greatest difference between digital technology and conventional mammography imaging is (A) The higher resolution system results in an increase in patient dose in digital technology. (B) There is no latent image formation when using digital technology. (C) In digital technology, the ﬁnal image can be manipulated. (D) The image can never be displayed on a ﬁlm in digital technology. 19. All of the following are characteristics of double emulsion ﬁlm/screens combination. Which characteristic makes these systems undesirable in mammography use? (A) They are less susceptible to imaging dust and dirt than the single emulsion systems. (B) They do not require extended processing times to develop optimum contrast and speed. (C) The screens are very efﬁcient at converting x-ray energy to visible or ultraviolet light. (D) The system has a lower spatial resolution than the single emulsion systems.

20. Film fog is best demonstrated on the characteristic curve as (A) (B) (C) (D)

the straight-line portion of the graph the toe of the graph the shoulder of the graph the shift of the graph to the left

21. The characteristic curve, obtained by plotting density values from a sensitometer, can be used to assess all of the following except (A) to compare two different types of ﬁlms (B) to compare the same ﬁlm under different 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 plotted. The curve of ﬁlm A is positioned to the left of the curve of ﬁlm B. 1. ﬁlm A is faster than ﬁlm B 2. ﬁlm B is faster than ﬁlm A 3. 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 quality control tests is performed monthly? (A) (B) (C) (D)

phantom images visual checklist repeat analysis screen cleanliness

24. Adequate “air bleed time” refers to the (A) elapsed time between ﬁlm loading and exposure (B) time taken to release air from the processor drain tank (C) time taken to remove air from the water tank (D) time taken to empty or bleed the processor chemistry

Questions: 16 through 35

25. Which of the following quality control tests does not require a densitometer? (A) (B) (C) (D)

darkroom fog screen-ﬁlm contact screen cleanliness phantom images

26. The criteria to pass the ACR Mammography Accreditation on conventional phantom imaging require a minimum of _______ masses. (A) (B) (C) (D)

two three four ﬁve

27. In establishing processing quality control operating levels, the speed index is designated as the density (A) (B) (C) (D)

closest to but not less than 2.20 closest to but not less than 1.20 closest to but not less than 0.45 2.20 or higher

28. For the daily quality control testing, the baseplus-fog level should remain within (A) (B) (C) (D)

+0.15 of the established levels +0.10 of the established levels +0.30 of the established levels +0.03 of the established levels

29. The screen-cleaning test should be carried out whenever (A) there is an upward drift in the operating data levels (B) there is a change in the types of chemical used (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 each day, the mammographer should (A) check the developer temperature (B) be sure the view boxes are clean

29

(C) clean the cassette screens with screen cleaner (D) check the cassettes for dirt or lint 31. The phantom image background optical density should never be (A) (B) (C) (D)

more than 1.20 less than 1.20 more than 1.40 less than 1.40

32. In the darkroom fog test, the optical density difference between fogged and unfogged areas of the ﬁlm should not exceed (A) (B) (C) (D)

1.20 0.15 0.05 0.02

33. In viewing phantom image, which of the following viewing conditions need not apply? (A) (B) (C) (D)

on the same view box using the same type magniﬁer at the same time of day using the same ﬁlm emulsion batch

34. In the test for screen contact there were multiple points of small areas (<1 cm in diameter) of poor contact. The corrective action is to (A) replace the cassettes; this result is not acceptable (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 the compression test is to (A) (B) (C) (D)

protect the cassette holder ensure that the compression is adequate force slower application of compression simulate 4 cm of compressed breast

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2: Instrumentation and Quality Assurance

36. For the repeat analysis to be meaningful, a patient volume of at least _______ patients is needed. (A) (B) (C) (D)

50 100 250 300

37. Daily processing control can involve all of the following except (A) cleaning the processor feed tray (B) using the sensitometer to measure the densities on the strip (C) recording the temperature of the developer tank (D) mixing the chemicals 38. Proving that a darkroom fog failure is a result of safelight problems involves (A) moving the safelight at least 6 ft from the 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) (B) (C) (D)

semiannually monthly weekly daily

40. Daily processor control is used to 1. determine the ﬁlm speed 2. check the ﬁlm contrast 3. check the stability of the processor (A) 1 and 2 only (B) 2 and 3 only (C) 1 and 3 only (D) 1, 2, and 3

41. If, after examining a phantom image, the number of visualized ﬁbers or masses has changed 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 site is 200 patients per week, the repeat/reject analysis should be done every (A) (B) (C) (D)

week 2 weeks 2 months 3 months

44. All the ﬂuorescent tubes in the mammography view box should be replaced at the same time because (A) Fluorescent tubes decrease in brightness with age. (B) Fluorescent tubes will only last about 18–24 months. (C) They have a higher luminescence than conventional tubes. (D) It saves time to replace them all at the same time. 45. In imaging the phantom, the technical factors used should be the same as those used clinically for a ______ -cm-thick breast of medium glandularity. (A) (B) (C) (D)

6.0–6.5 5.0–5.5 4.0–4.5 3.0–3.5

Questions: 36 through 50

46. Mammography facilities can receive certiﬁcation from 1. the ACR 2. the FDA 3. 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 mammography facility has been accredited. This certiﬁcation is valued for (A) (B) (C) (D)

1 year 2 years 3 years 4 years

48. If any of the visual checks fail, the first step is to (A) (B) (C) (D)

correct or replace the item call the medical physicist call the processor service call the equipment service representative

31

49. Digital images can be viewed on a computer monitor or printed using (A) (B) (C) (D)

dry laser technology single emulsion mammography ﬁlm single emulsion laser ﬁlm double emulsion ﬁlm, sensitive to the red-light spectrum emitted by lasers

50. Hardcopy viewing of the digital imaging describes (A) displaying the image on the mammographer ’s workstation for further enhancement (B) the only image viewed by the mammographer (C) the image that is sent for interpretation (D) the ability to reduce the cost associated with repeats

Answers and Explanations

1. (B) The kVp controls the wavelength or the penetrating power of the beam. Increasing the kVp will decrease the contrast. The kVp will therefore ultimately control the subject contrast, exposure latitude, and image contrast. Remember, however, that as the kVp is reduced, the penetrating ability of the beam is also reduced leading to the use of higher mAs. Higher mAs use increases patient dose (Bushong, 327–340; Peart, 65–85).

3. (B) Mammography uses very low energy x-ray beams and it is important that the x-ray tube window does not attenuate the lowenergy photons therefore hardening the beam. The proper ﬁlter shapes the emission spectrum of the x-ray beam and makes it compatible with the IR and breast characteristics of each patient. In general, mammography units either have borosilicate or beryllium as port windows (Bushong, 327–340).

2. (B) All mammography units are manufactured with tungsten, molybdenum, or rhodium targets matched with the appropriate K-edge filters. These targets have different atomic numbers and therefore different emission spectrums. The characteristic energies of molybdenum are most effective for fatty breast tissue. The characteristic x-rays produced using rhodium targets with rhodium filtration are similar to those from molybdenum but, because rhodium has a slightly higher atomic number, more bremsstrahlung x-rays are produced. However, the energy of the K-characteristic x-rays will be 2–3 keV higher, which provides a better penetration of dense breast although it generally results in lower contrast images. Tungsten targets with tungsten filtration are not used in conventional mammography units because here bremsstrahlung x-rays will predominate at energies above and below the 17- to 24-keV range. The x-rays most useful in maximizing contrast in breast tissue are in the 17- to 24-keV range (Bushong, 327–340; Peart, 65–85).

4. (C) The heel of the anode will reduce the intensity of the x-ray beam on the anode side only. When comparing the beam intensity on the cathode versus the anode side, the intensity on the cathode side will be higher. To compensate for this varying intensity, the mammography tube is turned to position the thickest portion of the breast (posterior) at the cathode end of the tube. In general, the smaller the anode angle, the larger the heel effect because there is increased absorption of the rays (Figure 2-1) (Bushong, 327–340; Peart,

32

65–85).

5. (D) Both the height and angle of the compression paddle make a difference in the ﬁnal image and the overall design is considered to increase the structural strength of the compression paddle. A compression device with a rounded or gently sloping posterior edge does not allow uniform compression of the posterior area of the breast. The height of the compression reduces the chance of chest tissue overlapping on the mammogram. The design of the lip has a lesser effect on the anterior aspect of the breast (ACR, 30–33; Peart, 65–85).

Answers and Explanations: 1 through 11

33

x-ray tube tilted from the horizontal Horizontal

Target

Parallel grid line

Crossed grid lines

A

B

Grid height

Vertical beam parallel to the chest wall C Compression plate Breast Image receptor

Width of interspace material = d

Cross-section of the grid showing the grid strips between the interspace material Grid ratio = h/d Grid frequency = number of grid strips per inch or per centimeter

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

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

6. (B) Compression does all of these, but its primary goal is to reduce the breast thickness uniformly-(separate breast structures) and allow uniform penetration by the x-ray beam

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

(ACR, 30–33; Peart, 65–85).

7. (B) The most common cause of failure of the AEC is improper placement of the detector. Processing affects the mammographic image after exposure and mammographic quality control ensures correct processing conditions. Decreased radiographic contrast is a result of underexposure, not the cause, and inadequate compression, although it causes uneven densities on the mammogram, does not result from AEC failure (ACR, 92; Peart, 65–85). 8. (A) The multiple detector system of the AEC allows the unit to respond to different breast composition and various breast sizes. If the detector is placed over fatty breast tissue, the glandular tissue will be underexposed. To produce an adequate exposure, the detector must be placed over the densest or most glandular areas of the compressed breast (Bushong, 327–340; Peart, 65–85).

10. (C) Higher grid ratios will require too large an increase in exposure. On an average, the grids used in mammography range from 3:1 to 5:1, with frequencies of 30–50 lines per centimeter. Typically, a mammography grid may have a grid ratio of 4:1, and although such a grid will double the patient dose when compared to a nongrid exposure, the increased contrast will be signiﬁcant (Bushong, 327–340; Peart, 65–85) (Figure 2-2). 11. (A) Collimating or decreasing ﬁeld reduces scatter and therefore improves the contrast. However, because collimating reduces the scattered radiation density to the area, the exposure must be increased (Bushong, 327–340; Peart, 65–85).

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2: Instrumentation and Quality Assurance

12. (D) The compression plate is specifically designed to properly position and compress the breast while reducing discomfort to the patient. The placement of the lip, just beyond the chest wall edge of the IR, prevents the projection of an image of the chest wall edge of the paddle on the mammogram (AEC, 30–33; Peart, 65–85). 13. (A) The focal spot size is the area that electrons strike on the target. In the design known as the line-focus principle, the target is angled allowing a larger area for the electrons to strike while maintaining a small, effective focal spot. The effective focal spot size is the area projected onto the patient or IR. It is also the value quoted when identifying a small or large focal spot. The smaller the target angle, the smaller the focal spot size. Although the spatial resolution (the ability to image small objects that have high contrast) is directly related to the focal spot size, changes in the SID, OID, and size of the collimated ﬁeld do not affect the focal spot size (Bushong, 327–340; Peart, 65–85). 14. (B) Mammography machines generally have two focal spot sizes. The large focal spot may be 0.4 or below (generally 0.3 mm) and the small focal spot ranges from 0.15–0.1 (generally 0.1 mm). Routine work utilizes the large focal spot size (Bushong, 327–340; Peart, 65–85). 15. (C) All cassettes are easy to open, durable, and have low absorption characteristics relative to the kVp. Mammography cassettes are designed for use with a single emulsion ﬁlm and are therefore matched with a single intensifying screen (Bushong, 327–340; Peart, 65–85).

of a cassette. CAD technology refers to computer-assisted diagnosis, a technology used to preread mammograms. CAD can be used with both conventional and digital mammography systems. Storage phosphors are used with computed radiography systems; the imaging plates or imaging detectors are coated with storage phosphors or photostimulable plates. X-rays will react with the imaging plate to form the latent image (Figure 2-3) (Bushong, 327–340; Peart, 179–191). 18. (C) One of the greatest advantages of digital technology is the ability to manipulate the ﬁnal image. The image can be adjusted for contrast or brightness or magniﬁed to zoomin on areas of interest. Digital mammograms allow the same or lower patient dose and although the technology is digital, a digital latent image will form in the digital detector. The image is converted to a manifest image after digital processing. Digital images can be viewed on a computer monitor or printed using laser print technology (Figure 2-4) (Bushong, 327–340; Peart, 179–191).

19. (D) Despite the numerous advantages of the double emulsion system, these advantages are outweighed by the single largest disadvantage: the system has a lower spatial resolution than the single emulsion system. In double emulsion systems, the emulsions of both screens are activated by the x-rays and will emit light. This crossover light compromises image quality (Peart, 79–83).

16. (C) An increase in processing time generally increases the developer time with further increase in contrast and ﬁlm speed. The disadvantage of this system is the increased risk of processing artifacts and the increase in ﬁlm fog (Bushong, 342–356; Peart, 87–111).

20. (B) The characteristic curve plots the relationship between the optical density of the ﬁlm and its exposure. The straight-line portion of the curve records the useful range of optical densities. The lowest exposure (base plus fog) is the reading recorded at the toe of the curve, and the highest exposure level is recorded at the shoulder of the curve. A graph shift to the left or right indicates differing ﬁlm speeds (Figure 2-5) (Bushong, 272–283; Peart, 80–81).

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

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

A

B

C

Figure 2–3. (A): A cross-section of an imaging plate. Computer radiography differs from conventional ﬁlm-screen imaging in the acquisition stage. Instead of a ﬁlm-screen as the image detector, computer radiography uses a ﬂexible imaging place (IP) coated with storage phosphors or photostimulable plates. The imaging plates are less than 1 mm thick. They absorb x-ray energy and form a latent image in much the same way a ﬁlm does. The difference is the wide latitude of the storage phosphors. The higher sensitivity of the imaging plates demonstrates a linear 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 and identiﬁcation. With such a similar structure, the IP can be placed in modiﬁed cassettes and exposed with standard x-ray equipment. The x-ray passes through the patient and reacts with the IP to form the latent image. (B): R2 ImageChecker DMax, a CAD device use to preread conventional 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.)

35

36

2: Instrumentation and Quality Assurance

monitor processing conditions by recording changes in the density values. Because of the wide range of variables in x-ray-generating equipment, the sensitometer and not the step wedge is used to produce a uniform optical step wedge on a ﬁlm, from which the characteristic curve can be plotted. This removes the x-ray unit from the equation. The characteristic curve is then used to interpret characteristics of the ﬁlm, such as contrast: the steeper the slope the higher the contrast. By plotting the characteristic curves of two ﬁlms, the speeds of the different ﬁlms can be compared. A characteristic curve obtained by exposing a step wedge or penetrometer, however, is capable of monitoring both the x-ray equipment and ﬁlm-screen combination (Bushong, 272–283; Peart, 80–81). 22. (D) By plotting the characteristic curves of two ﬁlms, the speed of the different ﬁlms can be compared: the curve of the faster ﬁlm will be positioned to the left of the curve of the slower ﬁlm (Figure 2-6). The faster ﬁlm will require less exposure than the slower ﬁlm to produce 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) Schematic diagram of a computer reader. To read the latent image, the IP is inserted into an imaging plate reader or computer reader. The computer reader then scans the image with a laser beam to initiate the emission of light from the storage phosphors. This stored energy leaves the IP in the 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 ampliﬁed and sent to an analog-to-digital converter where it is converted to a digital or electrical signal. The resultant digital information can then be electronically transmitted, manipulated, and stored. The IP can be erased and used again and again by exposing them to strong light.

Answers and Explanations: 22 through 26

mammography quality control tests and frequency are listed in the Summary of Important Points in the beginning of the chapter on page 22 (ACR, 119; Peart, 92–112).

4.0 D

3.0 D e n s i t y

24. (A) The cassette should be loaded with a ﬁlm for at least 15 minutes before testing to release any trapped air. This is the air-bleed time and refers to the time taken for the air trapped in the cassette to dissipate (ACR, 141;

2.0

y 1.0

y C= x

Peart, 92–112).

BF x 0

1.0

SP

2.0

37

3.0

4.0

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

23. (B) The visual checklist is performed monthly, the phantom image check is taken weekly, the repeat/reject analysis is performed quarterly, and screen cleanliness is performed weekly. The complete list of

25. (C) Screen cleanliness requires screen wipes and canned air or a screen cleaner. The densitometer is needed for darkroom fog test to measure the density of the fogged versus the unfogged area of the image. In assessing the screen-ﬁlm contact, the density at the chest wall area of the wire-mesh image should be between 0.7 and 0.8. In phantom image tests, the densitometer is needed to measure the background density and the density inside the disk (ACR, 165–166; Peart, 92–112). 26. (B) The criteria for the number of objects on the phantom necessary to pass the ACR are a minimum of four largest fibers, three largest speck groups, and three largest masses (Figure 2-7). The only exceptions to

4.0

0000 0000

3.0 D e n s i t y

2.0

1.0 A 0

B 1.0

2.0

3.0

4.0

Log relative exposure Figure 2–6. H & D curve-ﬁlm speed. Graph of H & D curves for two different types of radiographic ﬁlms. Film A has a faster speed than ﬁlm B because its speed point is the left of ﬁlm B. Film B has a higher contrast than ﬁlm A because the slope of its curve is steeper than that of ﬁlm A.

Figure 2–7. Diagram of phantom. A schematic diagram of the phantom showing the relative position of the different objects embedded within the phantom.

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2: Instrumentation and Quality Assurance

date are the Hologic and Siemens digital units which require 5 fibers, 4 speck groups, and 4 masses. In addition, the number of test objects of each group type (fibers, specks, and masses) visible in the phantom image should not decrease by more than one-half (ACR, 268; FDA; Peart, 92–112). 27. (B) In establishing processing controls, decide which sensitometer step has an average 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 to 2.20, and which step has a density closest to but not less than 0.45. The difference in densities between these two is the density

difference (DD) or contrast index. Suggested performance criteria for the MD and DD are to be within ±0.15 optical density units of the operating level. If the MD or DD exceeds the operating limits by ±0.15, corrective action needs to be taken. Changes in density can be because of chemistry, temperature, replenishment, or darkroom fog (ACR, 149–164; Peart, 92–112). 28. (D) The base plus fog (B + F) should remain within +0.03 of the established levels. If B + F exceed the normal level by 0.03, immediate corrective action must be taken. Changes in B + F can be owing to chemistry, temperature, replenishment, or darkroom fog (ACR, 149–164; Peart, 92–112).

29. (D) Although recommended weekly, this test must be carried out whenever dust or any other artifact is seen on the image. Changes in the ﬁlm brand, processing chemistry, or processing quality control will not affect screen cleanliness (ACR, 165; Peart, 92–112). 30. (A) The sensitometer strip is used to verify that the processor is operating within normal limits. Of all these answers, only a too high or too low developer temperature will have an impact on the density of the sensitometric strip (ACR, 149–164; Peart, 92–112). 31. (B) The background optical density on the phantom should never be less than 1.2 and should 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 at least 1.4 (ACR, 268–269; Peart, 92–112). 32. (C) The optical density difference between the fogged and unfogged areas of phantom in the darkroom fog test should not exceed 0.05 (Figure 2-10) (ACR, 189–193; Peart, 92–112). Figure 2–8. Sensitometer strip. In conventional imaging the sensitometer will produce a step-wedge pattern of 21 different optical densities. A densitometer is then used to record the base-plus-fog value and the high-, medium-, and low-density measurements. These results are then plotted on the daily processor quality assurance chart.

33. (D) Different individuals will always perceive an image differently. Because of this, the phantom should always be viewed by the same individual, using the same view box and viewing conditions, such as magniﬁcation. In addition, the criteria used for viewing the phantom images should be the same as that used when

Answers and Explanations: 27 through 36

A

39

Figure 2–10. Darkroom fog test. Phantom images showing darkroom fog. A densitometer is used to measure close to the edge separating the fogged and unfogged portions of the phantom image. The density should not be measured over any test object in the phantom.

cleaning the cassette, means the cassette has failed (ACR, 194–198; Peart, 92–112). 35. (A) The towels protect the cassette holder and prevent damage to the compression device. The amount of automatic compression applied is a function of the unit and will not be altered by the presence or absence of a towel. However, the force of the compression device hitting the cassette holder could damage both (ACR, 199–201; Peart, 92–112). 36. (C) The repeat analysis is used to identify problem areas within the department (Figure 2-12). However, for the analysis to be B Figure 2–9. (A): Radiograph of phantom. An actual radiograph of a phantom with 1-cm diameter, 4-mm-thick disc. This disc is used for contrast measurement. Arrows indicate points where density measurements should be made. The image is scored based on what is seen on the ﬁlm. (B) Radiograph of a digital phantom. In digital imaging the acrylic disc is not always needed.

reading mammograms. Because a box of ﬁlms will not last forever, a new box, and therefore, a different ﬁlm emulsion will eventually be necessary (ACR, 167–187; Peart, 92–112). 34. (C) Multiple small areas of poor contact (<1 cm in diameter) are acceptable (Figure 2-11). Large areas (>1 cm in diameter) of poor contact, which remain unchanged even after

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

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2: Instrumentation and Quality Assurance

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

Answers and Explanations: 37 through 44

41

meaningful a sufﬁcient patient volume is needed. The MQSA recommends a meaningful volume of at least 250 patients (ACR, 202–203;

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

Peart, 92–112; Stevens, 275–370).

92–112).

37. (B) A sensitometer is designed to expose a uniform optical step wedge onto a ﬁlm; the densitometer is an instrument that measures the degree of blackening (density) on a ﬁlm. Daily processing control is a means of ensuring that the slight changes in ﬁlm processing will be corrected before they have an impact on the image quality. The developer temperature and the chemistry of the solutions can both impact image contrast. Keeping a clean feed tray reduces ﬁlm artifacts (ACR, 339; Peart, 92–112).

38. (B) The simplest way to conﬁrm that the darkroom fog testing failed because of a safelight problem is to repeat the test with the safelight off. If the test passes, then the safelight is the problem and the ﬁlter could be changed or the light moved to a different location. If the test with the safelight off fails, other areas to check include light leaks around the doors and passbox (ACR, 192; Peart, 92–112).

39. (A) Darkroom fog test is performed semiannually to ensure that the darkroom safelights or other source of light leaks are not fogging the mammographic ﬁlm. Film fog will result in loss of contrast and therefore loss of diagnostic information. This test should also be performed whenever the safelight bulb or ﬁlters are changed (ACR, 119; Bushong, 342–356; Peart, 92–112). 40. (D) The processor quality control test is used to determine that the processor and processor chemistry are stable and consistent. At the beginning of each day, a sensitometric strip is exposed and processed following MQSA guidelines. The medium density evaluates ﬁlm speed, the density difference evaluates image contrast, and the base-plus-fog value evaluates the level of fog present in the processing chain. By checking and correcting any value that exceeds the normal limits,

41. (D) Because the purpose of quality control testing is to ensure optimal conditions before clinical images are processed, signiﬁcant changes must ﬁrst be corrected. Whenever a test fails, the ﬁrst corrective action is to verify that the equipment is operating correctly, and then repeat the test to determine whether the change is real or not. However, the phantom test is a check of the mammography unit and the processing. It will therefore assess the image density, contrast, and uniformity. The phantom test should therefore be performed only after the daily processor quality check. Although this will not totally rule out the processor as the cause of the problem, it will direct attention to the mammography unit. The medical physicist or the equipment service personnel should be called if the problem cannot be isolated or corrected by the mammographer (ACR, 186; Bushong, 342–356; Peart, 92–112).

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

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

44. (A) Because ﬂuorescent tubes decrease in brightness with age, changing the tubes all at the same time ensures that the mammograms or phantom images are always viewed under identical conditions—uniformity in color and luminance. In addition, it is advisable to replace ﬂuorescent tubes every 18–24 months. View boxes used for mammography should be capable of producing a luminance of at

42

2: Instrumentation and Quality Assurance

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

Answers and Explanations: 37 through 44

43

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.

44

2: Instrumentation and Quality Assurance

least 3000 cd/m2. The illumination levels should be 50 lux or less (equivalent to a moonlit room). Luminance is the amount of light either scattered or emitted by a surface and is measured in cd/m2 (candela per meter square). Illuminance is the intensity of light striking 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).

48. (A) Examples of visual checklist items are a check of mechanical locks or display lighting. Many items are for the mammographer’s convenience; some, however, are essential for patient safety and the production of quality images. If the technologist cannot replace or repair missing or broken items, the equipment service personnel should be called

45. (C) The mammographic phantom is equivalent to a 4.2-cm-thick compressed breast consisting of 50% glandular and 50% adipose tissue. The technique used should be the same as that used clinically and the ﬁlm should be processed just like a clinical mammogram. Phantom images are taken to ensure that the optical density contrast and image quality are at optimal levels (Figure 2-14) (ACR, 167; Bushong, 342–356; Peart, 92–112).

49. (A) Most digital hard copy printing is done using a dry processing laser printer. This eliminates the chemical solutions by using a heatsensitive ﬁlm that contains the processing chemicals. Also, this type of ﬁlm can be handled in room light. In dry processing laser printer, heating the ﬁlm produces the manifest image. These systems do not use chemicals and need no water hook up. Disadvantages of the laser-printed ﬁlm are: expense and the lower optical density and latitude. Film-screen mammography uses single emulsion ﬁlms. Because of their lower spatial resolution, double emulsion ﬁlms are not used in mammography. In the past, the laser printer used a single emulsion ﬁlm that is sensitive to the red light emitted by the laser, similar to how blue- and green-sensitive ﬁlms are used in conventional systems. These laser ﬁlms must be handled in total darkness and were used mainly in computed tomography (CT) imaging (Bushong, 199; Peart, 187; Shephard, 359–362).

46. (B) Under MQSA rules, accreditation and certiﬁcation are two separate processes. Both are required by the FDA. Effective on May 2002, certiﬁcation is permitted only by the FDA or certain states—States as Certiﬁers (SAC). The SAC permitted are Illinois, Iowa and South Carolina. States can certify only facilities within their state. Accreditation is a process administered by an FDA-approved accreditation body, which can be a private, nonproﬁt organization or a state agency approved to accredit mammography facilities. The FDA has approved four accreditation bodies—the American College of Radiology (ACR) and the states of Arkansas, Iowa, and Texas. State accreditors can only accredit facilities within their state. These four bodies all have the authority to implement the MQSA standards through the accreditation process (FDA). 47. (C) After completing the accreditation process, the FDA or States as Certiﬁers, SAC state will issue a certiﬁcation that is valid for 3 years and can be renewed as long as the facility remains properly accredited and demonstrates that it meets the MQSA standards during annual inspections (FDA).

(ACR, 213; Peart, 92–112; Stevens, 275–370).

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

Answers and Explanations: 45 through 50

50 (C) In digital imaging, the image is available for viewing within seconds. This initial viewing is often referred to as soft copy viewing by the mammographer. At the soft copy viewing station, the mammographer can enhance the image, modify patient demographics, or accept/reject the image based on standard positioning criteria, before sending the image to the radiologist workstation or to

45

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

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CHAPTER 3

Anatomy, Physiology, and Pathology of the Breast Summary of Important Points LOCALIZATION TERMINOLOGY

The breast is generally described in terms of the face of a clock, and can also be divided into four quadrants. External Anatomy

In the female, breasts are accessory glands of the reproductive system with the function of secreting milk for nourishment of the newborn. The female breast is spherical in shape, and size varies with age, menstrual cycle, and lactation. Hormonal stimulation causes the breasts to grow. The breast is loosely attached to the fascia, covering the pectoralis major muscle. The skin of the breast, like the skin of the body, is ﬁlled with sweat glands, sebaceous glands (oil glands), and hair follicles that open to form the skin pores. The nipple lies at the center point of the breast. The areola is the smooth, circular darkening surrounding the nipple that contains many small protrusions on its surface (Morgagni tubercles). The nipple itself contains multiple crevices, within which are 15–20 oriﬁces, or collecting ducts that transfer milk from the lactiferous ducts. Location

The breasts lie anterior to the pectoralis major. Separating the breast from the pectoral muscle is a layer of adipose tissue and connective fascia referred to as the retromammary space. Internal Anatomy

The breast is made up of a varying mixture of adipose or fatty tissue, glandular or secretory components, connective tissue, lymphatic vessels, and

blood vessels. Cooper ligaments are the supportive structures of the breast. Fibrous and glandular tissues are usually described together as ﬁbroglandular. The pattern and distribution of the glandular tissue is usually the same bilaterally. Blood Supply to the Breast The breast receives its arterial supply from branches of the internal mammary and lateral thoracic arteries. Veins that drain the breast form a venous network under the nipple. This network then drains into the axillary and internal mammary veins. Veins are usually larger than arteries and are located more peripherally. Lymphatic Drainage of the Breast The primary lymphatic drainage of the breast is to the axilla. There is also cross-mediastinal drainage from the medial portion of the breast to the other breast. The majority of normal axillary lymph nodes is less than 2 cm in size and has a kidneyshaped appearance (Figure 3-1). Histology

The average female breast consists of 15–20 lobes containing numerous glandular lobules held together by connective tissue, blood vessels, and branching ducts (lactiferous ducts). Each of the 15–20 lobes in the breast contains a treelike pattern of ductal structures radiating out from the nipple. Factors Affecting Tissue Composition The normal physiological changes that take place in the breast are related to the onset of menarche, the amount of hormone ﬂuctuation whether normal

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48

3: Anatomy, Physiology, and Pathology of the Breast

Lobule containing alveoli

Mammory duct (segmental ducts) Lactiferous sinus (ampulla) Lactiferous duct or connecting duct

Nipple

• Circular/oval lesion may be poorly outlined: circular, oval, or lobulated; and solitary or multiple. • Spiculate/stellate lesions are radiating structures with ill-deﬁned borders. • Calciﬁcations may or may not be associated with a tumor. • Thickened skin syndrome may present over the entire breast and may or may not be associated with an increased density. • There may be any combination of two or more of the above lesions. Characteristics of Malignant Circular/ Oval Lesions • High density—structures such as veins and trabeculae cannot be seen through the lesion • Smooth or lobulated and randomly orientated— not aligned along the trabecular structure of the breast Characteristics of Malignant Spiculated/ Stellate Lesions

Figure 3–1. A schematic diagram of the breast showing the branching distribution system of a collecting duct. The nomenclature of the duct system is varied.

or synthetic, pregnancy, lactation, and menopause. Also, because the breast has a high fat content, weight gain or weight loss will affect breast tissue composition. Malignant Conditions and Mammographic Appearances

Mammographically, the breast will be visualized as less dense areas of fat (which appear black on the radiograph) and denser glandular areas (which appear white or gray on the radiograph). Often blood vessels can be seen, especially if they are calciﬁed, and occasionally lymph nodes are visualized within the breast as kidney-shaped oval densities with lucent centers. The majority of breast diseases occur in the terminal duct lobular units (TDLUs); however, the ﬁbrous or connective tissue can also be involved. Other lesions occur in the larger ducts. Malignant and benign breast lesions can be placed in ﬁve categories:

• Have a distinct central mass. • Sharp, dense, ﬁne lines of variable length radiating in all directions—the larger the central tumor mass, the longer the spicules. • If spicules reach the skin or muscle, it may cause localized skin thickening or skin dimpling (retraction). • Commonly associated with malignant-type calciﬁcations. Characteristics of Malignant Calciﬁcation There are three basic forms of malignant calcifications: • Casting-type calciﬁcations—ﬁne linear branching calciﬁcations seen on the mammogram as linear, fragmented, or occasionally branching calciﬁcations with irregular contours. • Granular-type calciﬁcations—irregular in form, size and density. They resemble granulated sugar or crushed stone. They are usually grouped very close together in single or multiple clusters. • Powderlike calciﬁcations—multiple clusters of powderlike calciﬁcations Skin Thickening Syndrome

Skin thickening may be caused by either benign or malignant conditions.

Summary of Important Points

49

• The skin will appear obviously thickened, generally in the lower dependent portion of the breast.

Some exceptions to these rules are abscess, calciﬁed hematoma, and sebaceous cyst.

• The overall density of the breast is increased owing to the high ﬂuid content (seen as a coarse reticular pattern on the mammogram).

Characteristics of Benign Spiculated/Stellate Lesions

BENIGN CONDITIONS AND MAMMOGRAPHIC APPEARANCE

See Figure 3-2. Characteristics of Benign Circular/Oval Lesions

• Radiolucent, for example, lipoma, oil cyst, galactocele • Radiolucent and radiopaque combined, for example, lymph node, ﬁbroadenolipoma, galactocele, and hematoma • Low density, therefore the surrounding parenchymal structures can be seen through the lesion, for example, ﬁbroadenoma, cyst • Spherical or ovoid with smooth borders generally aligned in the direction of the nipple along the trabecular structure of the breast, for example, cyst • A halo sign which is seen as a narrow radiolucent ring or ring segment around the circumference of the lesion, for example, cyst • A capsule which is a thin curved radiopaque line surrounding the lesion, for example, ﬁbroadenoma

• No solid, dense, or distinct central mass, for example, radial scar. • May have translucent oval or circular area at the center, for example, radial scar. • Very ﬁne linear densities or lower density spicules, for example, radial scars or traumatic fat necrosis. • Never associated with skin thickening or skin retraction. The exception is traumatic fat necrosis. Characteristics of Benign Calciﬁcation • Smooth contours, high uniform density, for example, plasma cell mastitis • Evenly scattered homogenous, for example, calciﬁed arteries • Sharply outlined, spherical, or oval, for example, calciﬁed hematoma • Pear-like densities—resemble teacups or pearl drops on the lateral projection, for example, milk of calcium • Bilateral and evenly scattered following the course of the ducts throughout much of the parenchyma, for example, plasma cell mastitis • Ringlike, hollow, for example, sebaceous gland calciﬁcations • Eggshell-like, for example, oil cyst, papilloma • Large size, bizarre shape, for example, hemangiomas

50

A

3: Anatomy, Physiology, and Pathology of the Breast

B

C

D

H E

F

G

I

M

N

L

K

J

O

P

Figure 3–2. Picture summary of breast lesions. (A) Benign-type calciﬁcations. (B) Cyst. (C) Deodorant calciﬁcations. (D) Benign calciﬁcations: developing oil cysts and calciﬁed hematomas. (E) Fibroadenoma. (F) Epidermoid cyst in posterior breast. Lucency represents air, post biopsy. (G) Calcified galactocele. (H) Lymph nodes. (I) Lymph nodes. (J) Calcified sebaceous glands. (K) Malignant-appearing stellate lesion. (L, M, N) Malignant-type calciﬁcations. (O) Microhematoma. (P) Scar marker. (Q) Oil cyst—benign calciﬁcations. (R) Plasma cell mastitis—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.

Summary of Important Points

R

Q

U

T

S

V

W X

Y Z

AA Figure 3–2.

BB (continued)

CC

51

Questions

1. A lesion located in the upper outer quadrant of the right breast is located in the (A) (B) (C) (D)

5-o’clock position 2-o’clock position 10-o’clock position 7-o’clock position

2. Morgagni tubercles are usually found (A) (B) (C) (D)

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

3. An inverted nipple (A) (B) (C) (D)

always indicates breast cancer sometimes indicates breast cancer never indicates breast cancer usually indicates breast cancer

4. Compression of the breast is most effective and most comfortable when applied against the (A) (B) (C) (D)

medial and lateral aspects inferior and superior aspects medial and superior aspects inferior and lateral aspects

5. The normal breast may have (A) (B) (C) (D)

52

0–5 lobes 15–20 lobes 30–40 lobes 340–350 lobes

6. The structure that gives the breast its support and shape is called (A) (B) (C) (D)

Montgomery ligament Cooper ligament ﬁbroglandular tissue fatty tissue

7. The breast extends vertically from the (A) (B) (C) (D)

ﬁrst through the ninth rib second through the tenth rib second through the sixth rib third through the tenth rib

8. The thickest portion of the breast is the (A) (B) (C) (D)

areola nipple tail of Spence inframammary crease

9. Cooper ligaments attach anteriorly to the (A) (B) (C) (D)

deep fascia of the lobes fascia of the skin posterior surface of the breast connective and supporting stroma

10. Fatty tissue is generally _______ and on the mammogram is seen as areas of _______ optical density. (A) (B) (C) (D)

radiolucent/lower radiopaque/higher radiolucent/higher radiopaque/lower

Questions: 1 through 20

11. Typically, a patient with dense ﬁbrous and glandular tissue throughout the entire breast on a baseline mammogram is (A) (B) (C) (D)

age 20 or younger between age 50 and 60 above 70 below 45

12. Glandular tissue is usually found in the _______ of the breast. (A) (B) (C) (D)

medial and lower inner quadrant central and upper outer quadrant medial and lower outer quadrant central and upper inner quadrant

13. Lymph drainage from the medial half of the breast is generally directed to the (A) (B) (C) (D)

internal mammary lymph nodes external mammary lymph nodes axillary lymph nodes axilla

14. Immediately behind the nipple, the connecting duct widens to form the (A) (B) (C) (D)

lactiferous sinus ampulla acinus TDLU segmental duct

15. The portion of the breast that holds the milkproducing element is the (A) (B) (C) (D)

ampulla segmental duct lobule lactiferous sinus

16. Veins are normally located (A) (B) (C) (D)

in the periphery of the breast central areas of the breast in the axilla area of the breast in the medial areas of the breast

53

17. The TDLU consists of the (A) mammary ducts and the extralobular terminal ducts (ETDs) (B) intralobular terminal duct (ITD) and the segmental 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 compared to her previous mammogram (C) show decreased glandular tissue compared to her previous mammogram (D) show increased fatty tissue compared to her previous mammogram 19. A baseline mammogram shows that the patient’s breast consists primarily of adipose tissue. This patient is most likely to be (A) (B) (C) (D)

on hormone therapy above 60 below 20 above 35

20. A patient is to have a routine baseline mammogram, but it is determined that the woman is lactating. What should be done and why? (A) Lactating breasts are extremely sensitive to compression; the mammogram should be postponed. (B) The mammogram should be done; radiation has no effect on lactation. (C) Although lactating breasts are extremely dense, the mammogram should not be rescheduled. (D) Lactation causes increased glandularity; the mammogram should be postponed.

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3: Anatomy, Physiology, and Pathology of the Breast

21. The craniocaudad mammograms of the same woman prior to menopause and 1 year after the onset of menopause are compared. The woman has never taken synthetic hormones. What is the most likely difference? (A) The mammogram taken prior to menopause shows signs of atrophy. (B) The mammogram taken after the onset of menopause shows signs of atrophy. (C) There will be little or no change in the glandularity of the breast. (D) The mammogram taken after menopause will show increased glandularity. 22. Which of the following will affect the ratio of glandular tissue to total breast tissue? 1. the woman’s genetic predisposition 2. ratio of total body adipose tissue to total body weight 3. drastic weight gain or weight loss (A) (B) (C) (D)

25. An asymptomatic patient presents with an oval, lobulated tumor with unsharp margins. There is no evidence of a halo sign. (A) If the lesion is also radiolucent it is likely to 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) (B) (C) (D)

invasive ductal breast carcinoma a mammographically malignant tumor a mammographically benign tumor a low-density tumor typical of benign lesions

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

23. Hormone replacement therapy could be recommended to? 1. relieve insomnia symptoms 2. prevent osteoporosis 3. reduce weight gain (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

24. A woman is referred to as nullipara. This means (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

Figure 3–3

Questions: 21 through 30

27. The calciﬁcations seen in Figure 3-4 have the typical appearance of (A) mammographically malignant-type calciﬁcations (B) mammographically benign-type calciﬁcations (C) calciﬁcations typical of an oil cyst (D) calciﬁed microhematomas

55

29. The calciﬁcations seen in Figure 3-5 have the typical appearance of (A) (B) (C) (D)

an oil cyst plasma cell mastitis calciﬁcation a small calciﬁed hematoma a calciﬁed sebaceous gland

Figure 3–5 Figure 3–4

28. Characteristics of a malignant stellate tumor include which of the following? 1. The spicules are generally bunched together. 2. The presence of a central tumor mass. 3. The larger the tumor, the longer the spicules. (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 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 central tumor 3. is usually not associated with skin thickening or dimpling over the lesion (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1 and 3 only

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3: Anatomy, Physiology, and Pathology of the Breast

31. A mammogram shows a low-density radiopaque tumor. It is oval, lobulated, and a halo is seen along one border only. The next step should be (A) (B) (C) (D)

pneumocystogram ultrasound biopsy no further testing; the tumor is benign

32. A galactocele (A) (B) (C) (D)

is always radiolucent is usually associated with trauma is associated with nursing usually has irregular borders

36. A benign self-limiting breast tumor that is the result of new disorganized cell growth (A) (B) (C) (D)

sarcoma radial scar invasive lobular carcinoma 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

33. A lipoma (A) is generally seen as a high-density radiopaque lesion on the mammogram (B) can be a huge encapsulated lesion occupying the entire breast (C) may have irregular borders typical of malignant lesions (D) is usually difﬁcult to image mammographically

38. The low-density radiopaque lesions seen in Figure 3-6 suggests a (A) (B) (C) (D)

benign ﬁbroadenoma skin mole galectocele keratosis

34. A rare form of cancer that presents with swelling, warmth, or erythema and mammographically with skin thickening is (A) (B) (C) (D)

inﬂammatory carcinoma invasive ductal carcinoma lobular carcinoma in situ papillary carcinoma

35. Sometimes described as an oil cyst, this lesion represents an encapsulated area on the mammogram and can be caused by surgery, biopsy, trauma, or radiation therapy. (A) (B) (C) (D)

stellate lesion galactocele fat necrosis lipoma

Figure 3–6

Questions: 31 through 40

39. The right craniocaudal (RCC) of the routine imaging series showed a small, irregularshaped lesion at the edge of the image plus scattered calciﬁcations including calciﬁcation clusters (Figure 3-7). The next immediate step would be 1. spot compression including magniﬁcation 2. additional imaging to include the margins of the lesion 3. ultrasound

40. The circular mixed-density lesions seen in Figure 3-8 suggests a (A) (B) (C) (D)

calciﬁed microhematomas galactocele, calciﬁed malignant calciﬁcation epidermoid cyst

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

Figure 3–8

Figure 3–7

57

Answers and Explanations

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

Left

12

12

UOQ

UIQ

9

UIQ 3

LOQ

LIQ

6

UOQ

9

3 LIQ

LOQ

6

Figure 3–9. Breast localization pictures. The breast can be viewed in different ways: (1) As a clock with clock-time descriptions within the breast. (2) Using the four-quadrant method: the upperouter quadrant (UOQ), the upper-inner quadrant (UIQ), the lowerouter quadrant (LOQ), and the lower-inner quadrant (LIQ). Note that the 4-o’clock position on the right breast represents the lowerinner quadrant but on the left breast would indicate the lower-outer quadrant.

2. (D) Morgagni tubercles are elevations formed by the opening of the ducts of the Montgomery glands, which are specialized sebaceous-type glands found on the areola, not the nipple. The terminal ductal lobular unit (TDLU), also called the lobule, is located

58

3. (B) The normal nipple can be either ﬂattened or inverted, both unilaterally and bilaterally. However, a nipple that suddenly becomes inverted or ﬂattened can indicate malignancy (Peart, 35–44; Tortora, 1083). 4. (D) The breast is most secured at the superior and medial aspects. The lateral borders of the breast and the inferior aspect (inframammary crease) are the most mobile portions. To maximize compression of breast tissue, the compression should be applied against the most movable margins (Peart, 35–44; Tortora, 1083).

(Peart, 35–44).

Right

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

5. (B) On an average, a breast has 15 lobes. The number can, however, be as low as 10 or as high as 20 (Peart, 35–44; Tortora, 1083, 13). 6. (B) Cooper ligaments are a network of ﬁbrous and elastic membranes. They incompletely sheath the lobes of the breast. The ligaments start at the most posterior portion (base) of the breast and extend outward to attach to the anterior superﬁcial fascia of the skin. Fibroglandular and fatty tissues make up the breast parenchyma. Montgomery is a gland, not a ligament. It is located on the areola (Peart, 35–44; Tortora, 1083). 7. (C) The breast extends vertically from the clavicle (the second or third rib) to meet the abdominal wall at the level of the sixth or seventh rib and horizontally from the midsternum to the midaxillary line (the latissimus dorsi muscle). However, breast tissue can

Answers and Explanations: 1 through 15

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

59

10. (C) Fatty tissue is radiolucent and will therefore show as higher optical density areas on mammograms (black). Fibrous and glandular tissues are less radiolucent and will show as lower 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 glandular tissue varies with age. Glandular tissue predominates in younger women, whereas fatty tissue predominates in older patients. A patient below 20 is unlikely to have regular mammograms (Andolina, 139–154; Peart, 35–44; Tortora, 1083). Milk lines

12. (B) The majority of glandular tissue is distributed in the breast bilaterally and is located centrally and laterally toward the upper outer quadrant, extending toward the axilla. Most breast cancer arises from the glandular tissue (Andolina, 139–154; Peart, 35–44; Tortora, 1083).

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

8. (C) The upper outer quadrant, which extends toward the axilla, is known as the axillary tail or the tail of Spence. It is the thickest portion of the breast. Thorough knowledge of the anatomic extent of the breast is critical in breast imaging. The nipple is the center point of the breast and it is surrounded by the areola. The inframammary fold or crease (IMF) is the lowest extent of the breast where it attaches to the chest wall (Andolina, 139–154; Peart, 35–44; Tortora, 1083). 9. (B) Cooper ligaments are strands of connective tissue that run between the skin and deep fascia to support the lobes of the breast. They start at the most posterior portion (base) of the breast, extend outward, and attach to the anterior fascia of the skin (Andolina, 139–154; Peart, 35–44; Tortora, 1083).

13. (A) The main direction of drainage from the lateral half of the breast tends to be into the pectoral group of axillary lymph nodes and from the medial half of the breast into the internal mammary lymph nodes. However, there can be cross-mediastinal drainage from the medial portion of one breast to the opposite breast (Andolina, 139–154; Peart, 35–44; Tortora, 1083). 14. (A) From the nipple oriﬁce a connecting or lactiferous duct immediately widens into the lactiferous sinus (or ampulla). The ampulla is a pouch-like structure that holds milk (when it is being produced). The ampulla then narrows to become the segmental or mammary ducts. These will branch into smaller ducts with decreasing diameter until becoming a lobule (Andolina, 139–154; Peart, 35–44; Tortora, 1083).

15. (C) From the nipple, the mammary ducts become smaller and smaller until becoming a lobule. The lobule is also called the TDLU. The TDLU is lined with a single layer of epithelial cells and a peripheral layer of myoepithelial cells and can be further divided into extralobular terminal ducts (ETD), which is a small duct leading into the

60

3: Anatomy, Physiology, and Pathology of the Breast

terminal ductules, and the intralobular terminal ducts (ITD), located at the end of the terminal ductules. The ITDs hold the alveolar glands, which are the milk-producing elements of the breast (Figure 3–11). (Andolina, 139–154;

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

Peart, 35–44; Tortora, 1083).

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

17. (D) The TDLUs are further divided into the ETD, which is a small duct leading into the terminal ductules, and the ITD, located at the end of the terminal ductules. The ETD is surrounded by elastic tissue and lined by columnar cells. The ITD has no surrounding elastic tissue and contains cuboidal cells (Figure 3-11).

Ductules (acinus)

Extralobular terminal duct (ETD)

Intralobular terminal duct (ITD)

Terminal ductal lobular unit (TDLU) Figure 3–11. Picture of TDLU. The TDLU increase and decrease in size and number, depending on menstrual cycle, pregnancy, lactation, and hormone use. The TDLUs are responsible for milk production and it is here that most cancers originate. The ductal system ends at the TDLU. The unit is further divided into ETD and ITD.

18. (B) Increased or decreased glandularity of the breast is a part of the normal physiological changes that take place. Glandularity can be related to menarche, hormonal ﬂuctuation whether normal or synthetic, pregnancy, lactation, or menopause; however, increasing glandularity is usually related to an increase in any of the two most prominent hormones active in the breast. These are estrogen (responsible for ductal proliferation) and progesterone (responsible for lobular proliferation and growth) (Andolina, 139–154; Peart, 35–44; Tortora, 1083).

19. (B) As a person ages, there is a decline in hormones (perimenopause) eventually leading to menopause after which the glandular breast tissue will atrophy. The breast then looses its supportive and connective tissue to fat. Patients above 60 will most likely have fatty breast; glandular tissues predominate in young women and adipose tissue (fat) predominate in older women. Patients below 20 usually have dense breast, but are also less likely to have a mammogram. Hormone therapy is likely to increase the glandular nature of the breast (Andolina, 139–154; Peart, 35–44; Tortora, 1083). 20. (D) Ideally, a mammogram should not be scheduled during lactation unless the patient is symptomatic, has a personal history of breast cancer, or is very high risk. In such cases, the total time of lactation may exceed the recommended time interval for screening. If a mammogram must be done during lactation, the patient should nurse just prior to the mammogram to remove superimposed milk and improve visualization of breast tissue. Because this is a routine baseline mammogram on an asymptomatic patient, the mammogram should be postponed. During lactation, the increased blood supply, milk production, and overall physiologic changes

Answers and Explanations: 16 through 27

cause increased glandularity that reduces the accuracy of the mammogram, making it less effective as a diagnostic tool. Also, the increased density results in increased radiation exposure to the patient (Andolina, 139–154;

gestation) regardless of the outcome. Other terminology is multiparity, regarded as having carried one or more fetuses to viability regardless of the outcome, and primipara, a woman who has delivered a child of 500 g (or of 20 weeks’ gestation) regardless of its viability (Andolina, 139–154; Peart, 35–44; Venes, 1598).

Peart, 35–44).

21. (B) Generally, atrophy of mammary structures begins at menopause and ends 3–5 years later. After menopause, the breast loses its supportive tissue to fat, producing a smaller breast, or a larger, more pendulous one. This process is called involution (Andolina, pp. 139-154; Peart, 35–44). 22. (D) The total amount of glandular tissue increases and decreases with hormonal ﬂuctuations, use of synthetic hormones, and menopause. The amount of glandular tissue versus fatty tissue will also depend on a woman’s genetic predisposition and total body fat. It is therefore possible to ﬁnd young women with fatty breast and older women with extremely dense, glandular breast. Weight gain and loss also increase or decrease the fat content of the breast tissue, thereby affecting the overall glandularity of the breast (Andolina, 139–154; Peart, 35–44). 23. (B) Hormone replacement therapy (HRT) will relieve symptoms of menopause which can include hot ﬂashes, sleep disturbance, fatigue, osteoporosis, and insomnia. HRT can cause increase in glandular tissue, increase in ﬁbroadenomas, and increase in development of breast cyst but it can inhibit involution process. The negative effects of HRT can be severe and include breast and uterine cancer, asthma, dementia, heart attacks, strokes, and blood clots. Most women are now advised to consult their doctors on long-term solutions not involving HRT (Andolina, 139–154; Peart, 35–44).

24. (A) Nulliparous is the condition of not having given birth to a viable offspring. Nullipara would then refer to a woman who has never produced a viable offspring. Parity is the terminology used if a woman carries a pregnancy to a point of viability (20 weeks of

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25. (B) Although a halo is typically present in benign lesions, absence of a halo does not necessarily prove malignancy. However, any circumscribed radiopaque tumor with unsharp borders and no demonstrable halo sign should lead to suspicion of malignancy, regardless of density (Figure 3-12) (Peart, 47–63; Tabár, 17–92).

Round

Oval

Lobulated

Irregular

Spiculated architectural distortion

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

26. (B) The mammogram shows a stellate tumor. Although the mammogram can suggest carcinoma and may be highly suspicious for carcinoma, only a microscopic analysis (histological or cytological analysis) will reveal the exact type. The presence of a central tumor mass with associated spicules is typical of malignant stellate tumors. The spicules are dense and sharp, radiate from the tumor surface, and usually are not bunched together. When they extend to the skin or areolar region, they cause retraction and local thickening. In general, the larger the tumor, the longer the spicules (Peart, 47–63; Tabár, 93–147). 27. (A) These calciﬁcations are typical of mammographically malignant-type casting or granular microcalciﬁcations. Casting calciﬁcations are produced when carcinoma in situ

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3: Anatomy, Physiology, and Pathology of the Breast

ﬁlls the ducts and their branches. The shape of the cast is determined by the uneven production of calciﬁcations and the irregular necrosis of the cellular content. (The cells are reproducing or growing at such a fast rate that they outstrip their blood supply and die—the results seen as calciﬁcations.) The contours of the cast are always irregular in density, size, and length and the casts are always fragmented. A calciﬁcation is seen as branching when it extends into adjacent ducts. Also, the width of the ducts determines the width of the castings. Granulartype calciﬁcations are seen as mammographically similar in appearance to granulated sugar or crushed stones. These are also malignant-type calciﬁcations. Oil cysts are generally seen mammographically as eggshell-like calciﬁcations and a microhematoma or calciﬁed microhematoma can be high-density or a mixed-density oval or circular calciﬁcation (Peart, 47–63; Tabár, 149–238). 28. (C) A typical malignant stellate tumor has a central tumor with dense spicules radiating in all directions. The spicules are separate and increase in length with increased tumor size. If the spicules reach the skin, there is localized dimpling or skin thickening (Peart, 47–63; 93–147). 29. (A) This calciﬁcation has the typical appearance of an oil cyst. Oil cysts are generally seen mammographically as eggshell-like calciﬁcations. Plasma cell mastitis calciﬁcations follow the course of the ducts. Some may be elongated and branching, some needlelike, and some ringlike or oval, but all are sharply outlined, high density, and have smooth borders. If they are periductal, they have central lucencies. Calciﬁed sebaceous glands are typically ringlike oval calciﬁcations with lucent centers; there are two types, depending on where the calciﬁcations started. Calciﬁcations within a sebaceous gland are hollow or ringlike calciﬁcations; calciﬁcations within the cavity are punctate calciﬁcations. A microhematoma or calciﬁed microhematoma can be high-density or a mixed-density oval or circular calciﬁcation (Peart, 47–63; Tabár, 149–238).

30. (D) Radial scar is benign and rarely palpable. It is often mistaken for carcinoma and its exact nature is the subject of some controversy among pathologists. Recent studies suggest that a radial scar may increase a woman’s risk of developing breast cancer. Generally, the radial scar has no central tumor. There can be translucent, oval, or circular areas at the center of the lesion and the lesion’s appearance varies from one mammography projection to another. Regardless of the size of the lesion, there is generally no associated skin thickening or dimpling and no discernible palpable mass (American Cancer Society; Peart, 47–63; Tabár, 93–147). 31. (B) Most highly suspicious lesion will be recommended for biopsy, but if the lesion is suspected to be benign further test is done to prove the benign nature of the lesion. A partial halo around a lesion suggests a mammographically benign tumor. An ultrasound would be the best next step to differentiate solid versus a cyst. After the ultrasound, a pneumocystogram could be used to assess the inside margins of the tumor (Peart, 47–63; Tabár, 17–92). 32. (C) A galactocele is a benign, milk-ﬁlled cyst with high fat content. These lesions are generally associated with lactation. They are usually circular, with sharply deﬁned borders and have densities that are a combination of radiolucent and radiopaque. They are often left alone, but if painful they can be drained using needle puncture. Often they yield a yellow ﬂuid. The galactocele can calcify to a high-density circular or oval radiopaque lesion (Peart, 47–63; Tabár, 17–92). 33. (B) A lipoma is a fatty tumor. It is radiolucent and may be huge, with smooth borders and occupying the entire breast. It is easily seen mammographically and is not metastatic (Peart, 47–63; Tabár, 17–92, Venes, 1253).

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

Answers and Explanations: 28 through 37

thickening. The symptoms result from vascular or lymphatic invasion of the carcinoma but are unfortunately very similar to symptoms of a severe infection. Invasive ductal carcinoma accounts for more than 60% of all breast cancers. It usually presents as a central tumor with radiating spicules and often the associated malignant microcalciﬁcations. Invasive ductal carcinoma is the most common of all breast cancers. This form of cancer is often associated with a tumor and malignant appearing calciﬁcations. Lobular carcinoma in situ is most often asymptomatic. The cells grow within the lobules but do not penetrate through the lobule walls. This form of cancer is not seen mammographically in all cases and is often an incidental ﬁnding on biopsies. Papillary carcinoma is frequently seen as a circumscribed mass on older women. It is often indistinguishable from a cyst mammographically, but on ultrasound is identiﬁed as a complex or solid mass. It is a slow-growing tumor with good prognosis (Peart, 47–63). 35. (C) Fat necrosis can be caused by surgery, biopsy, trauma, or radiation therapy. At the site of the injury there may be hemorrhage, then as the tissue dies, liqueﬁed fat necrotic material and blood remains. The area becomes encapsulated by a thin layer of calciﬁcation, which appears on the mammogram as eggshell-like calciﬁcation described as an oil cyst. Stellate lesions such as invasive ductal carcinoma have a distinct central mass and sharp, dense ﬁne lines of variable length radiating in all directions—the larger the central tumor mass, the longer the spicules. A galactocele is a benign, milk-ﬁlled cyst with high fat content. These lesions are generally associated with lactation and can calcify to a high-density radiopaque circular or oval lesion. A lipoma is a fatty tumor. It is radiolucent and may be huge, occupying the entire breast. It is easily seen mammographically and is not metastatic (Peart, 47–63; Venes, 1435). 36. (D) Hamartomas result from an abnormal formation of normal tissue. The cells of the tumor grow in a disorganized mass and are composed of tissue elements normally found

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at the site. Unlike a cancerous tumor, the hamartoma rarely invade or compress surrounding structures. The cells grow spontaneously, reach maturity, and then do not reproduce. This growth is self-limiting and benign. Radial scars are complex sclerosing lesions. They are not truly scars and are sometimes unrelated to prior surgery or trauma. Some possible cause of the radial scar is localized inﬂammatory reaction or chronic ischemia with slow infection. The radial scar is a benign condition, but can be associated with premalignant—atypical ductal hyperplasia—and malignant condition. A benign radial scar has no central tumor, although there may be long spicules radiating from the center of the lesion. Regardless of the size of the spicules in the benign radial scar, there is no associated skin thickening, dimpling, or nipple reaction. The benign radial scar often resolves over time, but because of the possible association with malignancy it is recommended that all stellate lesions including radial scars should be excised. A sarcoma is a cancerous tumor from mesenchymal tissue such as muscle or bone. Lobular carcinomas are often difﬁcult to diagnose. Invasive lobular carcinoma is a malignant condition where the cancer has spread from the lobular into the surrounding tissue. On the mammogram this can show as a spiderweb appearance or cause skin retraction (Peart, 47–63; Sanders, 358–359; Venes, 1943, 925; Yazici, 438).

37. (B) Infusa-ports are designed to permit repeated access to the venous system for the parenteral delivery of medications, ﬂuids, and nutritional solutions and for the sampling of venous blood. In the treatment of breast cancer the infusa-port or port-a-cath are often used to deliver chemotherapy treatment and are sometime referred to as central venous access devices (CVAD). They are surgically implanted completely under the skin. Patients with infusa-ports can leave the hospital and continue their treatment at home. The infusa-port must be inspected daily for signs of infection. Radiation treatment exposes a speciﬁc body area to various highenergy radiations to destroy cancer cells.

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3: Anatomy, Physiology, and Pathology of the Breast

Radioactive tracers or radioactive isotopes are injected directly into the breast tissue in a technique known as lymphoscintigraphy or sentinel node mapping, the idea being to track the path of metastatic cancer. Injecting medication directly into the arterial system in rarely done. Intra-arterial chemotherapy can be used to give very high doses of chemotherapy to the tumor. The drug is injected directly into the arteries that are close to the cancer through a tube inserted under local anesthetic (Peart, 223; Venes, 1104–1106).

38. (B) The skin markers suggests that these are visible skin lesions. Epidermoid cysts, keratosis, moles, calciﬁed sebaceous glands, and skin tags are the most common. These are skin moles. The epidermoid cyst appears as ﬁrm, round, mobile lumps just below the skin surface. These cysts are often incorrectly referred to as sebaceous cysts but they are not of sebaceous origin. Mammographically, they are seen as mixed-density circular or oval lesion and can be mistaken for an internal lesion if not marked. The keratosis often presents as a raised lesion on the skin surface. Unlike warts, which they resemble, they are not caused by the human papilloma virus. They tend to have a very rough surface with bumps and crevices. Mammographically, they appear as oval mixed-density lesions, often radiolucent but the crevices will appear as higher density areas on the mammogram. Moles, known medically as nevi, can come in a range of colors, but are usually dark brown spots. In rare cases, a mole can become cancerous, but usually they are harmless clusters of pigmented cells. Mammographically, the mole will can appear as a radiolucent circumscribed lesion and can be mistaken for an internal lesion if not identiﬁed. Calciﬁed sebaceous glands are typically ringlike oval calciﬁcations with lucent centers. A skin tag is a benign skin growth that looks like a small piece of hanging skin. Mammographically, it is seen as a lowdensity circumscribed lesion and can be mistaken for an internal lesion if not identiﬁed. The ﬁbroadenoma is a benign radiolucent and radiopaque combined lesion within the

breast. The galactocele is often circular or oval with mixed density and is also located within breast tissue. It is associated with lactation (Peart, 47–63; Tabár, 149–238; Venes, 1171). 39. (A) Further imaging could include spot compression and magniﬁcation. Whenever possible, imaging should demonstrate a lesion in its entirety. Before moving to another modality, the radiologist is likely to recommend further imaging to demonstrate the margins of the lesion and magniﬁcation to assess the calciﬁcations (Peart, 47–63; Tabár, 149–238). 40. (D) Epidermoid cysts are often incorrectly referred to a sebaceous cysts, but they are not of sebaceous origin. The epidermoid cysts appear as ﬁrm, round, mobile lumps just below the skin surface. Mammographically, they are seen as mixed-density circular or oval lesion and can be mistaken for an internal lesion if not marked. A microhematoma or calciﬁed microhematoma can be mixeddensity or a high-density oval or circular calciﬁcation. A galactocele is a benign, milkﬁlled cyst with high fat content. These lesions are generally associated with lactation. They are usually circular, with sharply deﬁned borders and have densities that are a combination of radiolucent and radiopaque. The calciﬁed galactocele is usually seen mammographically as a circular or oval high-density radiopaque lesion. Malignant-type calciﬁcations are often seen in clusters and are typically casting or granular in appearance. Casting calciﬁcations are produced when carcinoma in situ ﬁlls the ducts and their branches. The shape of the cast is determined by the uneven production of calciﬁcations and the irregular necrosis of the cellular content. The contours of the cast are always irregular in density, size, and length and the casts are always fragmented. A calciﬁcation is seen as branching when it extends into adjacent ducts. Also, the width of the ducts determines the width of the castings. Granulartype calciﬁcations are seen as mammographically similar in appearance to granulated sugar or crushed stones (Peart, 47–63; Tabár, 149–238; Venes, 1171).

CHAPTER 4

Mammographic Technique and Image Evaluation Summary of Important Points BREAST COMPRESSION

MAGNIFICATION

Before applying compression, the mammographer should consider the natural mobility of the breast. When applying compression, in order to optimize the amount of tissue under the compression paddle, the compression should not push the breast tissue against its ﬁxed margins. The most movable margins are the lateral and inferior and the ﬁxed margins are the medial and superior. The initial automatic compression should never exceed 45 lb (200 newtons) of pressure; the patient should not be in pain, but the breast must be taut to ﬁngertip contact.

Magniﬁcation is ideal in imaging small areas, such as areas of suspicious microcalciﬁcations or lesions, specimen radiographs, or at surgical sites. Unfortunately, the use of magniﬁcation increases patient dose because the breast is placed much closer to the source of radiation.

Compression

• The main reason for breast compression is to allow a more uniform density by ﬂattening the base of the breast to the same degree as the more anterior regions, permitting optimal exposure of the entire breast in one image. Other reasons for breast compression: • Reduces dose to the breast by reducing tissue thickness • Brings lesions closer to the image receptor for more accuracy when evaluating size • Decreases motion unsharpness because the breast is immobilized • Increases subject contrast, reducing the amount of scattered radiation by decreasing thickness • Separates superimposed areas of glandular tissue; compression spreads apart overlapping tissue, reducing confusion caused by superimposition shadows, and allowing visualization of the borders of circumscribed lesions

• 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 penetrating power of the beam will inﬂuence the subject contrast and exposure latitude, and therefore the image contrast. Consideration should also be given to the patient’s breast tissue structure. Too high kVp will result in loss of contrast (image too dark or gray). Too low kVp will be high subject contrast in the medium-density range, but result in loss of detail visibility in the dense breast tissue. • For a given kVp, increasing the mAs (milliamperes per second) alters the optical density of the ﬁnal mammogram. In general, increasing the mAs increases the mA but not the exposure time. • The reciprocity law states that the density produced on the radiograph is equal to any combination of mA and exposure time as long as the product of mAs is equal. However, the reciprocity law fails at long and short exposures because the ﬁlm is exposed to light from the intensifying screens. With long and short exposures, reduced ﬁlm speed and an increase in

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4: Mammographic Technique and Image Evaluation

exposure factors are required. Most modern automatic exposure control (AEC) systems provide automatic correction for ﬁlm reciprocity failure. If necessary, using a higher kVp, varying the target and/or ﬁltration material, or using a faster screen-ﬁlm combination will correct reciprocity failure. Also, the length of the exposure time must always be considered because of the possibility of motion unsharpness. • When using AEC, the position of the detector varies depending on breast size and tissue composition. AEC selection choices can be: Full automatic mode—all the parameter are automatically selected. Semiautomatic mode—the operator sets the kVp and possibly the ﬁlter and target. Manual mode—the operator sets everything including the kVp, ﬁlter, target, and mAs. Evaluation of Image Quality

Positioning The routine series for breast imaging is the craniocaudal (CC) and the mediolateral oblique (MLO). The CC projection should always demonstrate as much medial tissue as possible because this area is most likely to be distorted on the MLO. The MLO will visualize the maximum amount of breast tissue if the angle used is parallel to the pectoral muscle. Compression Compression produces a uniform tissue thickness and reduces the overall thickness of the breast. Improperly compressed breast tissue will result in overlapping tissue structures, nonuniform exposure (especially of the denser breast tissue), overpenetration of the thinner breast tissue, poor penetration of the thicker portion, and motion unsharpness. Exposure With adequate exposure, it is difﬁcult to see the skin and subcutaneous tissue until the images are masked to block out extraneous view box light. Areas of the image with optical densities less than 1.0 are generally underexposed. The densest area on the image is the area of pectoralis muscle and it is the only area that should have an optical density less than 1.0.

Contrast Radiographic contrast is a product of the subject contrast and the ﬁlm contrast. In breast tissue, contrast is usually highest in thinner breast and lowest in thicker breast owing to more scattered radiation and greater tissue absorption of low-kVp radiation in the thicker breast. Without contrast, breast parenchyma with different tissue densities will have very similar optical densities. Sharpness The ability of the mammographic system to capture ﬁne details in the image is deﬁned as sharpness. If the image is not sharp, it is referred to as unsharp. Unsharpness may be the result of motion blur, poor screen-ﬁlm contrast, characteristics of the screen (faster screens and double emulsion systems results in more unsharpness), and geometric factors such as larger focal spot size, increase in object-to-image receptor distance (OID), or decrease in source-toimage receptor distance (SID). Noise Radiographic noise is represented as nonuniform or nonhomogeneous appearances on the recorded image (similar to “snow” on a television screen). There are four factors contributing to radiographic noise: ﬁlm graininess, structural mottle, quantum mottle, and scatter radiation. Artifacts Any variation of density on the image that is not a reﬂection of the attenuation differences in the subject can be considered artifacts. Examples of artifacts are pick-off, scratches, ﬁngerprints, dirt, lint, or dust. Collimation In mammography, collimation is limited to the size of the image receptor and not to the breast. Labeling Standardized labeling in mammography is important because mammograms can be legal documents and it is important that the radiographs are not misinterpreted. In the ﬁnal rules of the Mammography Quality Standards Act (MQSA), labeling is divided into required, highly recommended, and recommended.

Questions

1. Which of the following statements is (are) true? 1. Compression increases image sharpness by reducing the focal spot size. 2. Compression increases subject contrast by reducing the thickness of the penetrated tissue. 3. Compression increases the uniformity of the image-making diagnosis easier. (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

2. The compression force should not exceed _______ on the initial power drive (automatic) mode. (A) (B) (C) (D)

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 to women with painful breasts include 1. having the patient take ibuprofen prior to the mammogram 2. scheduling the mammogram just after the menstrual cycle 3. explaining, before the examination, the importance of compression (A) (B) (C) (D)

25 lb 35 lb 40 lb 45 lb

3. In assessing the degree of compression for any one patient, the mammographer should take into consideration 1. the maximum to which the patient’s breast can actually be compressed 2. the amount of compression the patient can tolerate 3. compression that should be just sufﬁcient to immobilize the breast (A) (B) (C) (D)

1 only 1 and 2 only 1 and 3 only 2 and 3 only

1 only 1 and 2 2 and 3 1, 2, and 3

6. Compression will do all of the following except (A) (B) (C) (D)

bring tissue closer to the image receptor reduce patient dose improve image subject contrast decrease spatial resolution

7. Compression reduces radiation to the breast by (A) (B) (C) (D)

providing a uniform breast thickness decreasing breast thickness decreasing motion unsharpness separating superimposed areas of glandular tissue

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8. What principle does compression use to visualize the borders of circumscribed lesions? 1. It brings the lesion closer to the image receptor. 2. It spreads apart overlapping tissue. 3. It separates superimposed areas of glandular tissue. (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

9. Ideally, breast compression is maximized when 1. accompanied by a thorough explanation to increase patient cooperation 2. the exposure is made on arrested inspiration to reduce motion 3. the patient recognizes the advantage of compression in reducing radiation dose (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

10. Patients who are allowed to play an active role in applying the compression are usually 1. less likely to tolerate the compression 2. more likely to tolerate the compression 3. more relaxed during the compression (A) (B) (C) (D)

1 only 2 only 1 and 3 only 2 and 3 only

11. Magniﬁcation can be used to assess the (A) (B) (C) (D)

margins of a lesion size of a lesion location of a lesion density of a lesion

12. With calciﬁcations, magniﬁcation can be used to assess 1. the number 2. morphology 3. distribution (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

13. In general, greater magniﬁcation will require the use of a (A) (B) (C) (D)

larger focal spot size smaller OID smaller focal spot larger SID

14. A grid is not necessary during magniﬁcation because (A) grid use decreases spatial resolution (B) the small focal spot used will compensate 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 subject contrast by (A) (B) (C) (D)

increasing scatter reducing scatter reducing motion increasing motion

16. If the magniﬁcation mammography is performed without using a small focal spot, the resulting image will be magniﬁed (A) (B) (C) (D)

and blurred and sharply outlined with increased subject contrast with increased detail

Questions: 8 through 26

17. At higher magniﬁcation factors there is 1. higher skin dose 2. increased scatter 3. decrease source-to-object distance (SOD) (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

18. Magniﬁcation is beneﬁcial in all of the following situations except (A) imaging the surgical site of a patient with a lumpectomy (B) imaging a specimen radiograph (C) evaluating microcalciﬁcations in a lesion (D) routine imaging 19. Using a small focal spot size is recommended for magniﬁcation (A) to reduce the resultant loss of image detail (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) (B) (C) (D)

increased OID increased patient dose decreased subject contrast increased risk of motion unsharpness

21. Optical densities less than 1.0 in the dense glandular tissue of the breast is considered a/an (A) (B) (C) (D)

underexposure overexposure normal exposure above average but not overexposure

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22. In conventional imaging, some causes of underexposure include 1. processing deﬁciencies 2. inadequate compression 3. improper AEC setting (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

23. To select a 12% increase in mAs before exposure, the mammographer could (A) (B) (C) (D)

use the density compensation circuit double the selected mAs activate the backup timer readjust the AEC selector

24. In conventional imaging, the leading cause of false-negative mammograms in dense breast tissue is (A) (B) (C) (D)

motion overexposure underexposure grid lines

25. In conventional imaging, overexposure is sometimes called the recoverable error because (A) it can be corrected during developing (B) high illumination and masking can overcome it (C) magniﬁcation can overcome it (D) the use of small focal spot sizes will reduce it 26. Increased kVp during mammography is sometimes necessary to penetrate dense ﬁbroglandular tissue. Increased kVp, however, generally causes (A) (B) (C) (D)

increased subject contrast decreased subject contrast motion unsharpness less scatter

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27. Rhodium is not used as the primary anode material when imaging thinner breast because (A) rhodium has an emission spectrum similar to tungsten (B) the higher energy of the rhodium beam is 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 radiograph using a (A) (B) (C) (D)

higher kVp setting greater density compensation higher mAs setting different AEC setting

29. The type of x-rays created from displacement of K-shell-binding electrons in the molybdenum atom are called (A) (B) (C) (D)

coherent scattering characteristic radiation Compton effect bremsstrahlung radiation

30. The function of the ﬁlter in mammography is to remove 1. low-energy x-rays not needed to produce the breast image 2. high-energy x-rays that cause a reduction of subject contrast 3. low-energy x-rays that increase patient dose (A) (B) (C) (D)

1 only 2 and 3 only 1 and 3 only 1, 2, and 3

31. If the AEC cell is placed over an area of adipose tissue on a breast with a mixture of adipose and glandular tissue, the areas of glandular tissue will be (A) (B) (C) (D)

underexposed overexposed normally exposed the AEC cell position will not affect the exposure

32. Causes of poor subject contrast include all of the following except (A) (B) (C) (D)

inadequate exposure lower kVp inadequate compression failure to use a grid

33. The use of low kVp and high mAs will serve to (A) reduce radiographic noise and increase subject contrast (B) reduce subject contrast and reduce radiographic noise (C) increase radiographic noise and reduce subject contrast (D) increase subject contrast and increase radiographic noise 34. A highly recommended labeling that is not required by the MQSA is (A) technologist/mammographer identiﬁcation (B) date stickers (C) technical factors (D) ﬂash card identiﬁcation system 35. Lack of breast compression is most likely to cause (A) (B) (C) (D)

geometric unsharpness screen unsharpness motion unsharpness parallax unsharpness

Questions: 27 through 40

36. Increasing the kVp by two points will (A) (B) (C) (D)

force a doubling of exposure time reduce the exposure time by half have no effect on the exposure time increase the subject contrast

37. The mammographer can differentiate motion unsharpness from screen unsharpness because (A) motion unsharpness is generally localized to a small area (B) screen unsharpness is generally localized to a small area (C) motion unsharpness will result in blurring (D) screen unsharpness is less likely at exposures below 2 seconds 38. Increasing the kVp will inﬂuence the 1. optical density on the image 2. penetrating power of the beam 3. subject contrast and exposure latitude (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

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39. The last degree of compression should be applied (A) using manual compression (B) after the breast is released from compression (C) with the automatic compression device (D) with the mammographer’s hand between the breast and the compression paddle 40. Anatomic parts with low subject contract will have (A) (B) (C) (D)

sharp difference in x-ray absorption very little difference in x-ray absorption the same x-ray absorption characteristics similar x-ray absorption characteristics

Answers and Explanations

1. (C) Compression makes the breast tissue more uniform and reduces the thickness through which the x-ray beam must pass. This produces uniform densities that are easier to interpret. Although compression increases image sharpness, compression has no impact on the focal spot size (ACR, 199). 2. (D) According to the MQSA guidelines, the compression force for the initial power drive must be between 111 and 200 newtons (25 and 45 lb). Manual compression should not exceed 45 lb. Too little compression will compromise the image; too much can damage breast tissue (ACR, 200–201). 3. (B) Ideally, compression should be applied until the breast tissue is taut. But if the patient is in pain at maximum compression, this will be a disincentive to return for annual mammograms. The patient will generally be able to tolerate more compression if they are prepared for it, and if it is applied slowly. Although compression immobilizes the breast and reduces motion, compression just adequate to immobilize the breast is usually insufﬁcient to separate breast tissue (ACR, 30–33). 4. (C) The initial compression in mammography should be between 25 and 45 lb in the automatic mode. Manual compression should not exceed 45 lb. In general, the amount of manual compression depends on the patient’s breast size and patient’s tolerance for compression. Some patients may require more manual compression to adequately compress the breast (ACR, 199; Peart, 65–85).

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5. (D) Often the patient will be able to tolerate more compression if the need for compression is explained to the patient. Patients with particularly sensitive breasts will beneﬁt from pain medication prior to the mammogram. (The patient must consult their physician before taking any medication.) Also, the breast is often more sensitive to pain just before or during the menstrual period and is least sensitive 7–10 days after the start of the period (ACR, 33; Peart, 117). 6. (D) The spatial resolution is the ability to image high-contrast small objects such as of microcalciﬁcations. The spatial resolution of the image is limited mainly by the effective focal spot size. Spatial resolution is stated as the number of line pairs per millimeter (lp/mm) that are imaged. A high spatial resolution means smaller objects can be imaged clearly. The compression increases spatial resolution by reducing patient thickness; the tissue is therefore closer to the image receptor. The tissue is thinner; there is therefore less scatter and the subject contrast is improved. Less radiation dose is used to penetrate the thinner breast tissue (Bushong, 219–227, 327–340). 7. (B) Although the primary goal of compression is to provide a uniform breast thickness, compression will also decrease motion unsharpness by immobilizing the breast and it will separate superimposed areas of glandular tissue. Compression also reduces radiation dose to the breast by decreasing the thickness through which the radiation must

73

Answers and Explanations: 1 through 14

pass, thus allowing less exposure (Andolina,

include the entire breast, and density comparisons will be difﬁcult if other densities are not present on the image. Magniﬁcation is, however, capable of providing accurate assessment of the margins of a lesion (Figure 4-1) (ACR, 59–60).

184; Bushong, 334–335; Peart, 117).

8. (D) Compression separates overlapping and superimposed areas of glandular tissue and will bring lesions closer to the image receptor. This action allows visualization of the borders of lesions (Andolina, 184; Bushong, 334–335; Peart, 117). 9. (C) Often, the patient is able to tolerate more compression if the need for compression is explained. Knowledge of the procedure generally alleviates fears, especially fears of the unknown. Any explanation should include a statement on how compression will reduce the radiation dose to help alleviate fears of radiation dangers. Throughout the examination, the patient should be encouraged to relax. Having the patient take a deep breath prior to holding the breath during the exposure is generally contraindicated. The patient may alter her position as the lungs expand, and the expanding ribs and lungs generally contract the pectoral muscles increasing discomfort during the mammogram. The patient should be simply advised to “stop breathing” without moving her body or ﬁrst taking a deep breath (Peart, 117–118). 10. (D) Studies have shown that if a patient plays an active role in applying the compression that patient will be able to tolerate the compression better and will be more relaxed during the compression. The more the patient knows about compression and understands the procedure, the more she will be relaxed. To give the patient an active role in compression, the mammographer can allow the patient to apply the compression or constantly monitor the patient, stopping the compression when the patient indicates (Peart, 117–118). 11. (A) Magniﬁcation cannot be used to assess lesion size because it gives a magniﬁed image of the area which will not be a true representation of size. Location and density are also not easily assessed using magniﬁcation because the magniﬁed image does not

X-ray tube

SOD

SID

Object

OID

Image receptor

Figure 4–1. Schematic diagrams showing the large OID used in magniﬁcation mammography. Note the small SOD which places the breast closer to the x-ray source.

12. (D) Morphology is the form or structure of the calciﬁcation. By magnifying the area of interest, magniﬁcation provides images that can be used to assess the number, distribution, and morphology of the calciﬁcations (ACR, 59–60). 13. (C) To achieve magniﬁcation, the OID is increased. As the magniﬁcation factor increases, the focal spot must be reduced or the thickness of the part decreased to maintain sharp images. Both of these factors are used in breast magniﬁcation. The SID in mammography units is ﬁxed and cannot be adjusted. Magniﬁcation factor = SID/SOD or image size/object size (Figure 4-1) (Andolina, 63–64; Bushong, 336; Peart, 118). 14. (C) Magniﬁcation mammography is necessary to enhance microcalciﬁcations or the borders of a lesion. Grids are necessary in routine mammography image to improve contrast and spatial resolution; however, with

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4: Mammographic Technique and Image Evaluation

magniﬁcation a smaller effective focal spot is used to compensate for the loss of image detail and the air gap (large OID) acts like a grid in reducing the amount of scattered radiation reaching the ﬁlm or electronic detector. The main disadvantage of magniﬁcation mammography is the high patient dose (almost double the routine skin dose because the breast is closer to the radiation source). Grid use in magniﬁcation would further increase exposure times, increasing tube loading, and thus increasing motion artifact owing to long exposure times. Radiation dose to the patient would also increase (Figure 4-2) (Andolina, 63–64; Bushong, 272, 336; Peart, 78–79). Radiation source

X-ray traveling at an angle will be absorbed

Grid

h d

(Image receptor)

Grid ratio = height/distance between lead strips

X-ray traveling straight will be transmitted

Figure 4–2. Schematic diagram demonstrating the use of a grid. The grid strips will transmit x-rays traveling straight while absorbing any scattered rays.

magniﬁcation, there is an increase in focal spot blur. To keep focal spot blur at a minimum, to maintain subject contrast and image detail, and to compensate for the reduced resolution during magniﬁcation, a small focal spot must be used (Andolina, 63–64; Bushong, 336; Peart, 78–79). 17. (C) The magniﬁcation factor equals the source-to-image receptor distance divided by source-to-object distance (SID/SOD). Radiation intensity is related to the square of the distance; therefore, as the patient’s breast is moved closer to the x-ray tube the SOD decreases and patient’s dose increases. With a greater magniﬁcation factor, there is a greater skin dose because the SOD will be smaller. Also, as the magniﬁcation factor increases, a small focal spot must be used to maintain a sharp image. Scatter is insigniﬁcant during magniﬁcation because of the air gap (Bushong, 321–322; Peart, 78–79). 18. (D) Magniﬁcation is ideal for imaging small areas such as the surgical site of a patient with a lumpectomy, specimen radiography, or microcalciﬁcations. With magniﬁcation, microcalciﬁcations that would otherwise be missed can be seen. Magniﬁcation should not be used in routine imaging because the entire breast may not be imaged, and patient dose is increased (Bushong, 336; Peart, 78–79).

15. (B) The large air gap acts like a grid and reduces scatter, thus improving subject contrast. Positioning the breast away from the image receptor takes advantage of the inverse square law: the intensity of the scattered radiation is reduced because the distance between the image receptor and the object is increased. In magniﬁcation, mammography motion is controlled by vigorous breast compression. Grid use in magniﬁcation would further increase overall technical factors including the exposure times (Figure 4-1) (ACR, 59–60; Bushong, 336).

19. (A) The focal spot blur (penumbra or geometric unsharpness are the old terms) is caused by a large effective focal spot. Whenever the relationship between the source, object, and image is altered, as in magniﬁcation, there is an increase in focal spot blur. To keep focal spot blur at a minimum, a small focal spot is used. The small focal spot necessitates a lower mA output and thus results in increased exposure time and risk of motion. Motion unsharpness is controlled by vigorous compression. The increase in patient dose is related to the smaller SOD used in magniﬁcation (Bushong, 326–356).

16. (A) Whenever the relationship between the source, object, and image are altered, as in

20. (B) Unfortunately, magnification increases patient skin dose. Using a magnification

Answers and Explanations: 15 through 27

factor of 1.4 may actually double the radiation dose to the patient because the breast is placed closer to the radiation source. The OID must be increased to achieve magniﬁcation. In magniﬁcation, subject contrast and motion unsharpness are controlled by using a small focal spot size with vigorous breast compression (Bushong, 284, 336; Peart, 78–79). 21. (A) Normally, optical densities on the mammogram should never fall below 1.0–1.25 or go above 2.50–3.0. The optimum is 1.60. In conventional imaging, the trend clinically is to have higher optical densities to adequately penetrate the glandular tissue and produce high-contrast images (ACR, 92; Peart, 74–77). 22. (D) All cause a reduction in the density of the image, which can causes a radiograph to appear underexposed. If the developer temperature decreases, the ﬁlm speed decreases, resulting in lower ﬁlm density. Poor compression causes uneven densities, leading to underpenetration of portions of the breast. Improper selection of the AEC results in inadequate x-ray penetration of the glandular tissue of the breast (ACR, 97; Peart, 116–117). 23. (A) Modern mammography machines are all equipped with a density compensation circuit. The density compensation circuit allows the selection of at least two steps above and two steps below the normal setting. Each step translates to a 12%–15% increase or decrease in the mAs or a 0.15 change in the optical density. The AEC produces a diagnostic density determined by the tissue placed directly over the AEC cells. The backup timer will prevent gross overexposure. In the older mammography units the backup timer for grid technique is preset at 600 mAs and for nongrid at 300 mAs. In the newer units, a test exposure is delivered to check for adequate penetration. The backup timer is activated and the unit will not complete the exposure if the mAs is inadequate. In both cases, if the backup timer is reached during an exposure then the selected mA is too low. To avoid getting the backup times, the kVp setting must be increased because the unit is already

75

exposing at the maximum mA (ACR, 97; Peart, 116–117). 24. (C) Underexposure of dense breast tissue is the leading cause of false-negative mammograms. If the area is slightly overexposed, high illumination and masking can be used to visualize the image. If the area is underexposed, calciﬁcations or even subtle density differences are not detected in the glandular breast tissue. With the moving reciprocating grid systems of modern mammography units, grid lines are not a problem (ACR, 97; Peart, 65–86). 25. (B) Overexposure can sometimes be overcome by using high illumination and masking. Modern automatic processing makes correcting techniques during developing unworkable and adjusting the focal spot size or magniﬁcation will not correct for overexposure. Underexposure is an unrecoverable error in which lost contrast cannot be restored in underexposed areas of the image. The radiograph has to be repeated with increased technical factors. Note that extreme overexposure decreases subject contrast (ACR, 98; Peart, 65–86). 26. (B) The kilovoltage (kV) primarily inﬂuences the quality of the x-ray beam. As the kVp increases, the penetrating quality of the beam increases—more x-rays pass through the breast and reach the ﬁlm at higher kVp. There is, therefore, less differential absorption and thus a reduction in subject contrast. Motion unsharpness is owing to movement of the patient during the exposure and scatter radiation increases at higher kVp levels (Bushong, 327–340; Peart, 65–86). 27. (B) Rhodium targets with rhodium ﬁlters have an emission spectrum similar to molybdenum, not tungsten. However, rhodium has an atomic number of 45 compared to 42 for molybdenum. This means that the emission spectrum for a molybdenum target ﬁltered with 30 μm of molybdenum will have an emission of characteristic x-rays with energies of 19 keV (resulting from K-shell interactions)

4: Mammographic Technique and Image Evaluation

and almost no bremsstrahlung x-rays. The emission from rhodium will be slightly higher (23 keV) and there will be more bremsstrahlung x-rays. Bremsstrahlung x-rays are produced more easily in target atoms with a high atomic number. The signiﬁcance of this in mammography is that the keV energy of the rhodium is designed to penetrate thicker, more dense breast tissue whereas molybdenum is used to image fatty breast. Bremsstrahlung x-rays will predominate in the tungsten target (Bushong, 327–340; Peart, 65–84). 28. (A) In newer mammography units the backup timer is activated if the initial test exposure, delivered to check for adequate penetration, fails. The density compensation circuit and the mAs should not be increased; because the primary reason for backup time is that the beam has low-energy photons that are unable to penetrate the breast. Increasing the compensation circuit does not increase the energy of the beam. Each step on the compensation circuit generally results in a 12%–15% change in mAs. Increasing the mAs increases the overall ﬁlm density, but similar to the compensation circuit, this does not increase the penetrating power of the beam. Selecting another AEC setting may result in an underpenetrated image if the new AEC setting is placed over a less dense area of the breast (Peart, 65–84). 29. (B) The molybdenum anode will produce x-ray photons with energies in the range of 17–20 keV (kilo electron volt). The most prominent of these x-ray photons are characteristic and will account for 30% of the total x-rays in the molybdenum beam at 30 kVp. The emission spectrum shows almost no bremsstrahlung x-rays because bremsstrahlung x-rays are produced more easily in target atoms with high atomic numbers, such as tungsten. Coherent or classical scattering describes the interaction of very low-energy x-rays with atoms in the target. These energies are too low to impact breast imaging. Compton is the most common scattered radiation in imaging. The Compton effect occurs when the incident x-ray interacts with

an outer-shell electron and ejects it from the atom, ionizing the atom. The ejected electron is called a Compton electron or secondary electron. Compton-scattered x-rays can deﬂect in any direction and can retain up to two-thirds of its original energy (Bushong, 327–340; Peart, 65–84). 30. (D) The most useful energy range for maximizing breast tissue is 17–24 keV. To achieve this, added ﬁltration must be used at the tube port window on all mammography machines. It is important that the inherent ﬁltration of the x-ray tube window does not ﬁlter out any of the useful energy beam. Energies below the useful range will contribute to skin dose and energies above will reduce differential absorption in breast tissue. The x-ray tube port is therefore made of beryllium or borosilicate glass and not regular glass. Most mammography tubes have an inherent ﬁltration the equivalent of 0.1 mm Al. The total inherent ﬁltration cannot be less than the equivalent of 0.5 mm Al. The added ﬁltration must be the same element as the x-ray tube target to allow the K-characteristic x-rays to expose the breast while stopping the lower or higher bremsstrahlung x-rays (Figure 4-3) (Bushong, 327–340; Peart, 65–84) .

100%

Unfiltered Mo beam

Percent photons in beam

76

Filtered Mo beam (mirror, breast, thick compression device, or glass tube window)

15

20

25

30

keV (energy) Figure 4–3. Showing the emission spectrum of molybdenum beam ﬁltered and unﬁltered. Note that the ﬁlter beam removes the lower energies (16 keV) that would contribute only to skin dose.

Answers and Explanations: 28 through 34

31. (A) The AEC detects the beam after the x-ray passes through the breast. Because the AEC stops the exposure when it estimates that the correct exposure is reached, positioning the AEC over fatty breast tissue stops the exposure before there is sufﬁcient exposure to penetrate the denser tissue. The result will be an underexposed radiograph (ACR, 97). 32. (B) Radiographic contrast is the product of subject contrast and ﬁlm contrast. In general, lower kVp improves subject contrast, although some mammographic ﬁlm now allows signiﬁcantly higher kVp without sacriﬁcing image contrast. Subject contrast refers to the contrast of the radiograph when it is viewed on the illuminator. This is the difference in quantity of radiation transmitted by a particular structure or body part as a result of the difference in absorption characteristics of the tissues and structures making up that part. Subject contrast, often simply referred to as contrast, is most affected by the selected kVp but body tissue thickness—dependent on breast compression—and the attenuating characteristic of the part will also affect the contrast. The impact of the mAs on contrast is small. However, too low a mA setting will result in low optical density (OD) and therefore reduced radiographic contrast—straight line portion of the H & D curve (characteristic curve) is ﬂattened. Also, too high mAs result in high OD and loss of radiographic contrast. Film contrast represents inherent properties of the ﬁlm such as speed latitude and the different quantities and qualities of radiation effect on them. Low-contrast mammograms will have a uniform appearance, making it difﬁcult to differentiate between different breast tissue thicknesses. Other causes of poor contrast include processing deﬁciencies, lack of a grid (which will result in increased scattered radiation), improper target material, and/or ﬁltration (ACR, 100–101; Bushong, 272–296; Peart, 115–118). 33. (A) Contrast (subject contrast) is the ability to see subtle density differences and will be higher at lower kVp, where there is great tissue absorption and less scattered radiation.

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Noise deﬁnes the ability to see minute structures on the image and is reﬂected as random ﬂuctuations in optical density. Reducing noise mostly involves reducing the scattered radiation and quantum mottle. Noise is therefore lowest when using lower kVp and higher mAs (ACR, 100; 105; Bushong, 272–273, 290; Peart, 115–118) (Figure 4-4).

Figure 4–4. The increased graininess on this image demonstrates quantum mottle.

34. (D) The labeling guideline under MQSA rules is divided into three areas: required, strongly recommended, and recommended. The ﬂash card patient identiﬁcation system is strongly recommended because it is the most permanent and will be reproduced on a copy, unlike the stick-on labels. Required labeling includes: • name of patient (ﬁrst and last) and additional patient identiﬁer such as a unique medical record number • date of examination • projection and laterality (right or left) (placed near the axilla using the standardized codes approved by the FDA) • facility name and location, including the city, state, and zip code • technologist/mammographer identiﬁcation • cassette/screen identiﬁcation

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4: Mammographic Technique and Image Evaluation

• mammography unit identiﬁcation—if there is more than one unit Strongly recommended labels include: • a ﬂash card with a permanent patient identiﬁcation system Recommended labeling includes: • Date stickers—enable easy reading of dates 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 detail on the mammography image, and patient motion is the most common form of unsharpness. Motion blurring is common with exposure above 2 seconds and can be prevented by proper communication. Good compression will reduce breast thickness, therefore allowing shorter exposure times. Screen unsharpness is a result of poor screen-ﬁlm contact and can be caused by air trapped between the ﬁlm and the screen during loading. Geometric unsharpness or focal spot blur is caused by increase in focal spot size or OID or by a decrease in SID. Parallax unsharpness results from the use of double emulsion ﬁlms and is generally not a factor in mammography imaging (ACR, 102; Peart, 115–118). 36. (B) The kVp can have a major impact on the exposure time and dose. As the kVp is increased, the exposure time decreases rapidly—50% for every two-point drop in kVp. The dose will also decrease by 15%–20% for a two-point drop in kVp because a higher kVp setting will allow the use of lower mAs and therefore lower patient doses. As the kVp increases, however, there is less differential absorption leading to a reduction in subject contrast (ACR, 101; Bushong, 290). 37. (B) In screen unsharpness there is a further spread of light from the screen before it reaches the ﬁlm. This type of unsharpness is independent of the exposure time and unlike

motion unsharpness, which covers a wider area, unsharpness because of poor screen contact is usually localized. All unsharp images are referred to as blurry (ACR, 104–105). 38. (B) The kVp controls the wavelength or penetrating power of the beam. Increasing the kVp inﬂuences the subject contrast and exposure latitude, therefore also affecting the image contrast. Latitude refers to the range of exposures over which the ﬁlm responds with optical densities in the acceptable diagnostic range. Wider latitude allows more variation in mAs while still producing an acceptable image. Higher contrast generally results in lower latitudes. The main factor inﬂuencing the optical density is the mA. Increasing the mA will increase the quantity of the electron beam (Bushong, 290; Peart, 116). 39. (A) In applying compression, the mammographer needs to be as gentle as possible. The automatic compression should be applied with the mammographer’s hand between the breast and the compression plate until the plate touches the back of the hand. Only then should the mammographer remove the hand, pulling the breast out, and applying the ﬁnal degree of compression slowly. Always apply the last degree of compression using the manual rather than the automatic compression paddle to avoid unnecessary pain to the patient (Peart, 115–118). 40. (B) Subject contrast is a result of differences in attenuation in body tissue and is greatly affected by the effective atomic number of the tissue being radiographed. Subject contrast is also affected by the size, shape, and energy of the x-ray beam (kVp). Anatomic parts with high subject contrast will have sharp difference in x-ray absorption, for example, bone and soft tissue. Anatomic parts with low subject contrast will have very little difference in x-ray absorption, for example, breast (Bushong, 290; Peart, 116).

CHAPTER 5

Positioning and Interventional Procedures Summary of Important Points 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 examined 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 pectoralis major muscle is seen approximately 20% of the time.) • The craniocaudal (CC) projection (Figure 5-1) should include, within 1 cm, the amount of tissue measured on the mediolateral oblique (MLO) image. • Appropriate markers and labeling as required by 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; thin patients require steeper angulation than heavier patients. • Arm closest to the breast being imaged is draped over the top of IR. The upper border of the IR ﬁts in the armpit.

• Compression must adequately support the anterior breast tissue to prevent sagging and distortion of the ductal architecture. The mammographer supports the anterior breast with one hand during compression and uses the other hand to adjust the skin over the sternum and clavicle to reduce the “pulling sensation.” • The convex-shaped pectoral muscles demonstrated to level of the nipple. • Appropriate markers and labeling as required by the ACR. Common Problems Associated with MLO Imaging • Drooping breast—anterior breast poorly compressed • 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 the standard projections or are difﬁcult to obtain. Other reasons include: • A suspicious area is seen in one of the routine projections but not on the second. • Additional imaging allows the patient to avoid an invasive procedure such as needle localization (eg, a spot compression may prove an area of suspicious density to be overlapping tissues). Exaggerated Craniocaudal (XCCL)

• To image lesions in the lateral aspect of breast not seen on the CC projection

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5: Positioning and Interventional Procedures

A

B

C

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.

Summary of Important Points

Mediolateral (ML) 90 degree

• To verify a ﬁnding or localize a lesion in another dimension (necessary during needle localizations) • To locate a lesion not seen on a CC projection if lesion 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 the medial aspect of the breast • To perform preoperative localization of an inferior and/or lateral lesion • To image the nonconforming patient

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Superior-Inferior Oblique (SIO)

The beam is directed from superior lateral aspect to the inferior medial aspect. • Demonstrates the upper-inner and the lowerouter quadrant • Especially useful in imaging encapsulated implants

MODIFICATIONS Magniﬁcation (M)

• To improve imaging of ﬁne detail, especially when analyzing calciﬁcations Rolled Lateral (RL) or Rolled Medial (RM)

The breast is rolled laterally or medially from the CC position. • This image removes superimposed tissue when 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 the lateral position. • This image removes superimposed tissue when imaging dense breast (the lesion is “rolled” off or away from the dense tissue). Spot Compression

Axillary Tail (AT)

• A 20-degree oblique projection used to visualize the 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 without superimposition of breast tissue • To locate skin calciﬁcations or lesions near the skin Lateromedial Oblique (LMO)

• To image the nonconforming patient when the standard 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

• Applies more compression to a localized area of interest using a smaller compression paddle • Localization of suspected abnormality • To evaluate a suspicious area • Imaging performed in any projection, with or without magniﬁcation Breast Implant Imaging

• The standard series include: the routine CC and MLO projection with modiﬁed compression plus implant displaced (ID) projections. • Standard imaging taken to demonstrate the posterior breast tissue surrounding the margins of the implant. Compression is used for immobilization only. Vigorous compression can rupture the implant. • Implant-displaced imaging requires pulling the natural breast tissue forward while simultaneously pushing the implant back toward the chest wall. Compression is applied only to the breast

82

5: Positioning and Interventional Procedures

tissue. ID projections are taken in the CC, MLO, and sometimes the ML and SIO projections (Figures 5-2a and b).

SPECIAL SITUATIONS Imaging the Nonconforming Patients

Postsurgical Breast • Postlumpectomy imaging can include CC and ML or MLO of the surgical site. • May or may not include magniﬁcation • Postmastectomy imaging or visual inspection by oncologist. • Other imaging may include a spot compression of the area of concern, and/or an AT projection

Small Breast • Manual technique—if the breast does not cover the 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 lateral portions of the breast • CV can be used to image medial breast • LMO replace the MLO imaging Pectus Carinatum (Pigeon Chest—Prominent Sternum) and Barrel Chest (Prominent Ribs and Sternum) • Routine CC imaging for medial breast plus XCCL for lateral breast tissue • Routine MLO plus AT to image missed tissue Elderly Patient • Chair examination if necessary • Document limitations

Irradiated Breast • Mammograms can be performed 6–12 months after 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 0 degree. • 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 unnecessary imaging Skin Folds or Wrinkling of the Breast • Skin folds or wrinkling may be impossible to avoid in the elderly • Smooth folds or wrinkles using the index ﬁnger during compression. • Avoid pushing folds or wrinkle outside of the compression ﬁeld.

Summary of Important Points

Figure 5–2.

A

B

C

D

Complete implant series. Modiﬁed compression technique (Eklund method) (A–D) and implaced ID projections (E–H).

83

84

5: Positioning and Interventional Procedures

E

F

G

H Figure 5–2.

(continued)

Summary of Important Points

• Eliminated breast tissue must be imaged separately.

85

• The examination cannot determine if the

lesion is malignant or benign. • Ultrasound can be used to image the ducts.

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—posterior and anterior breast—may be necessary. • Flex paddle avoids overcompression of posterior breast tissue to achieve adequate compression of anterior breast. Patients with Protruding Abdomen • CC imaging with patient standing away from the 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 removed during a biopsy. A radiograph of the specimen is necessary to ensure the area under suspicion is totally removed and the margins are clean. In imaging the specimen: • Speed and efﬁciency are important because the patient may be under anesthesia. • Always use compression when imaging larger specimens. • Magniﬁcation may help to visualize microcalciﬁcations. Interventional Procedures

Ductography • Cannulation of the lactiferous ducts and the injection 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 location and number of lesions.

Cyst Aspiration • Drainage or emptying of a cyst using a needle • Cyst aspiration/pneumocystography is performed either under mammographic or ultrasound guidance. • A pneumocystograph can be performed after the aspiration. Pneumocystography • Injection of air in an aspirated cyst to evaluate the cyst cavity for debris or inner wall of the cyst for abnormal growth. • Ultrasound or mammographic guidance needed Preoperative Needle Localization • Localization of a nonpalpable abnormalities (lesions or microcalciﬁcations) prior to a surgical biopsy • Used if stereo localization is not available • Performed under mammographic or ultrasound guidance Stereostatic Localization • Use of computerized stereostatic equipment to localize 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 cellular material from the breast for cytological analysis, possibly reducing the necessity for a surgical breast biopsy Core Biopsy • Use of a large-gauge needle to remove core samples from the breast. Tissue samples are obtained with an 11- to 14-gauge needle and sent for histological analysis.

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• Commercial modifications of the basic core

biopsy technique include minimally invasive breast biopsy (MIBB); vacuum-assisted core biopsy (VACB); and advanced breast biopsy instrumentation (ABBI).

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

Large-Core Biopsy • Removal of 5–20 mm of breast tissue under local anesthesia • Not popular because of signiﬁcant scaring and complication that can result Radio Frequency Biopsy • Use of a radiofrequency (RF) device to remove areas of suspicion • Electrosurgical introducer with a stainless steel cutting edge inserted into the breast after local anesthesia • Introducer positioned under ultrasound guidance Nipple Aspiration • Removal of ﬂuid from the nipple in a process called “ductal lavage.”

• Method used to determine if cancer has spread to the lymph nodes—axillary node dissection • Generally performed during a mastectomy or lumpectomy Ultrasound Biopsy • The use of high-frequency sound waves to evaluate 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 magnetic properties of hydrogen in the body. Imaging uses a strong magnetic and radiofrequency pulses. • MR-guided biopsy used to evaluate lesions seen only on MR imaging • All equipment used must be MR compatible

Questions

1. Which projection is used to determine if a lesion is medial or lateral to the nipple? (A) (B) (C) (D)

CC MLO TAN ML

5. In positioning for the CC projection, if the Carm of the mammography unit is raised too high the IMF is overelevated, resulting in loss of 1. superior breast tissue 2. inferior breast tissue 3. posterior breast tissue

2. If any breast tissue is poorly imaged or missed on the MLO projection it is likely to be (A) (B) (C) (D)

medial breast tissue lateral breast tissue inferior breast tissue superior breast tissue

3. The posterior nipple line (PNL), visualized on the ML, should be within how many centimeters of the PNL on the CC? (A) (B) (C) (D)

0.25 0.50 1.00 1.50

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

6. The single projection that will best visualize the maximum amount of breast tissue is the (A) (B) (C) (D)

CC MLO ML XCCL

7. In general, when imaging tall, thin patients the angulation is adjusted to

4. Which of the following conditions must be met when imaging the breast in the MLO? 1. The pectoral muscle should extend to or below the PNL. 2. Visualized fat should be posterior to all the ﬁbroglandular tissues. 3. The inframammary fold (IMF) should be open. (A) (B) (C) (D)

(A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

(A) (B) (C) (D)

below 30 degrees between 30 and 40 degrees close to 60 degrees almost 70 degrees

8. The position used to determine whether an abnormality is superior or inferior to the nipple is the (A) (B) (C) (D)

CC MLO XCCL TAN

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9. The principle of mobile versus ﬁxed tissue is used in mammography imaging to image the maximum (A) (B) (C) (D)

medial breast on the MLO projection inferior breast on the CC projection superior breast on the MLO projection medial tissue on the CC projection

10. In the CC projection of the breast, the IR is positioned (A) at the level of the raised inframammary crease (B) below the level of the raised inframammary crease (C) at the level of the inframammary crease (D) just below the level of the inframammary crease 11. In positioning for the MLO, the tube is always angled (A) (B) (C) (D)

90 degree 60 degree 50 degree none of the above

12. What projection/position is shown in Figure 5-3? (A) (B) (C) (D)

CC MLO CV XCCL

13. When positioning for the right CC, where is the patient’s left arm placed? (A) Brought back. This action rotates the shoulder to remove it from the imaging area. (B) Brought forward. The patient can hold the handle bar of the unit. (C) Brought forward. The patient can hold the IR. (D) Remains at the patient’s side. 14. Your patient has had recent chest surgery and has a scarred and painful area running along the sternum. With the medial aspect of the breast immobile, which of the following is an alternative to the RMLO? (A) (B) (C) (D)

RLMO LMLO LLM RML

15. Which projection is best used to visualize the tail of the breast? (A) (B) (C) (D)

LMO TAN LM AT

16. Calciﬁcations seen on the mammogram are suspected to be in the skin. The best projection necessary to prove this theory is the (A) (B) (C) (D)

LMO TAN LM AT

17. The projection best used to demonstrate the true representation of medial breast structures in relation to the nipple is the (A) (B) (C) (D) Figure 5–3. (© 2000 The American Registry of Radiologic Technologists.)

LM AT ML TAN

Questions: 9 through 25

18. A lesion on the lateral aspect of the breast is not seen on the CC. An additional projection used to image the lesion could be the (A) (B) (C) (D)

CV XCCL FB TAN

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23. Identify the position/projection shown in Figure 5-4. (A) (B) (C) (D)

FB XCCL ML AT

19. Which projection can be used instead of the CC to image patients with severe kyphosis? (A) (B) (C) (D)

ML TAN FB CV

20. A lesion moved up on the ML projection from its original position on the MLO. The location of the lesion within the breast is (A) (B) (C) (D)

laterally medially inferiorly superiorly

21. Which projection is used to prove breast calciﬁcations are benign (teacup type)? (A) (B) (C) (D)

CC XCCL FB ML

22. Which projection is used to give a proﬁle image of the area in question without superimposition of breast tissue? (A) (B) (C) (D)

CV TAN LMO AT

Figure 5–4. (© 2000 The American Registry of Radiologic Technologists.)

24. A barrel-chested patient whose chest wall protrudes outward may have breast tissue extending laterally under the arm. What projection, used to image the breast with the beam directed superiorly to inferiorly, should be taken in addition to the CC? (A) (B) (C) (D)

AT XCCL CV MLO

25. The FB projection can be useful in imaging 1. nonconforming patients 2. abnormalities high on the chest wall or superior aspect of breast 3. inferior lesions or lesions near the IMF (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

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5: Positioning and Interventional Procedures

26. Identify the projection shown in Figure 5-5. (A) (B) (C) (D)

MLO CV LM ML

29. In which modiﬁed projection is the superior aspect of the breast rolled medially? (A) (B) (C) (D)

RM RL M LM

30. In the LMO projection, the beam is directed from the (A) upper inner aspect to the lower outer aspect of the breast (B) inner outer aspect to the upper outer aspect of the breast (C) lower outer aspect to the upper inner aspect of the breast (D) superolateral aspect to the inferomedial aspect of the breast 31. Identify the projection shown in Figure 5-6. Figure 5–5. (© 2000 The American Registry of Radiologic Technologists).

27. Why is the MLO preferred to the ML as a routine projection?

(A) (B) (C) (D)

MLO CV LM ML

(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 extreme medial aspect of the breast? (A) (B) (C) (D)

CC MLO ML CV

Figure 5–6. (© 2000 The American Registry of Radiologic Technologists.)

32. Identify the projection shown in Figure 5-7. (A) (B) (C) (D)

RM CV RL MLO

Questions: 26 through 39

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35. All of the following statements about magniﬁcation are true except (A) With magniﬁcation, patient dose increases. (B) Magniﬁcation can be used to image specimen radiographs. (C) Magniﬁcation can be used to assess suspicious lesions. (D) Magniﬁcation images the entire breast with one exposure. Rolled Lateral (RL) Figure 5–7. (© 2000 The American Registry of Radiologic Technologists.)

33. Which projection is especially useful when analyzing calciﬁcations? (A) (B) (C) (D)

RM M LM ML

34. Identify the projection shown in Figure 5-8. (A) (B) (C) (D)

RM CV RL MLO

36. In the RS position, the surface __________ the IR is rolled _______. (A) (B) (C) (D)

furthest from/inferiorly closest to/superiorly furthest from/superiorly closest to/inferiorly

37. Which technique accurately describes how the breast is rolled for the RM? (A) The superior surface is rolled medially and the inferior surface does not move. (B) The superior surface is rolled laterally and the inferior surface is rolled medially. (C) The inferior surface is rolled medially and the superior surface does not move. (D) The inferior surface is rolled laterally and the superior surface is rolled medially. 38. A patient with pectus excavatum may present a positioning problem because the patient has (A) (B) (C) (D)

extensive pectoral muscle barrel chest kyphosis depressed sternum

39. In imaging the augmented breast in the CC position, using the modiﬁed implantdisplaced technique, the breast tissue is pulled/pushed

Figure 5–8. (© 2000 The American Registry of Radiologic Technologists.)

(A) (B) (C) (D)

anteriorly posteriorly inferiorly superiorly

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40. A routine series on patients with encapsulated implants could include an additional projection such as the (A) (B) (C) (D)

AT CC MLO ML

41. Which of the following is used to spread out the tissue and improve resolution on a localized area of interest? (A) (B) (C) (D)

CV AT TAN spot compression

42. How many projections are routinely required to image a patient with implant augmented breasts? (A) (B) (C) (D)

5 6 7 8

43. When is imaging of the irradiated breast recommended? (A) (B) (C) (D)

immediately after treatment 1–2 months after treatment 6–12 months after treatment 1–2 years after treatment

44. Which of the following can be used with any projection with or without magniﬁcation? (A) (B) (C) (D)

spot compression XCCL AT CV

45. In addition to the routine series, many postmastectomy patients will also need a (A) (B) (C) (D)

CC MLO ML CV

46. The standard projection taken on patients with breast implants requires compression 1. for immobilization only 2. to separate the breast tissue 3. to assess areas of lumps (A) (B) (C) (D)

1 only 2 only 1 and 3 only 2 and 3 only

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) (B) (C) (D)

reduce motion unsharpness reduce radiation exposure reduce tissue thickness reduce the magniﬁcation factor

49. Which procedure is performed to obtain cellular material from a suspicious area for cytological analysis? (A) (B) (C) (D)

Ductography Needle localization Pneumocystogram Fine needle aspiration (FNA)

50. Preoperative localization will 1. direct the surgeon to the area requiring biopsy 2. help the surgeon to excise a smaller specimen 3. ensure that the correct area was removed (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

Questions: 40 through 60

51. Core biopsy techniques developed as an alternative to surgical biopsy because this technique provided a larger sample of the area of suspicion and thus more information than (A) (B) (C) (D)

ductography needle localization pneumocystogram FNB

52. An ultrasound of a lesion showed a spherical mass with smooth regular borders, anechoic interior, and acoustic enhancement. The lesion is likely to be a (A) (B) (C) (D)

ﬁbroadenoma abscess simple cyst ductal carcinoma

53. In ultrasound, the term acoustic enhancement refers 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 is cannulated and a small amount of contrast agent is injected into the duct is termed (A) (B) (C) (D)

ductography needle localization pneumocystogram FNA

55. A patient had an ultrasound, which conﬁrmed the presence of a cyst in the breast. The radiologist wished to rule out intracystic tumor. What additional study could be recommended? (A) (B) (C) (D)

ductography needle localization pneumocystogram FNA

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56. Biopsy performed using a 14-gauge needle to remove tissue samples from the breast is termed (A) (B) (C) (D)

core biopsy cytology ductography aspiration

57. Which of the following techniques use a small-gauge needle to obtain cellular samples from a lesion? (A) (B) (C) (D)

core biopsy FNB ductography ductal lavage

58. Stereotactic breast localization is used to (A) obtain two-dimensional information on palpable breast lesions (B) calculate the vertical position of nonpalpable lesions (C) obtain a three-dimensional image of the breast (D) calculate the horizontal, vertical, and depth position of nonpalpable lesions 59. A cyst aspiration can only be performed (A) (B) (C) (D)

under ultrasound guidance using mammographic imaging using MRI guidance none of the above

60. Which of the following biopsy techniques is most accurate? (A) (B) (C) (D)

FNB open surgical biopsy core biopsy MRI core biopsy

Answers and Explanations

1. (A) CC projection determines whether the lesion is medial or lateral and how far it is from the nipple. The MLO or ML determines if the abnormality is superior or inferior to the nipple and how far posterior it is. The TAN projection skims the area of interest and is best used to determine if a suspected abnormality is located in the breast or the skin of the breast (ACR, 43–49; Peart, 115–146). PNL

PNL

2. (A) The MLO best demonstrates the posterior and upper-outer quadrants of the breast. A good MLO must include both the superior and inferior portions of the breast. However, it may not be possible to image the medial area on all patients in the MLO projection. Often, the medial breast is distorted. The CC projection will cover this portion of medial tissue that is most likely to be missed on the MLO (ACR, 43; Peart, 115–146). 3. (C) The PNL measures the perpendicular distance from the nipple to the visualized pectoral muscle on the MLO or from the nipple to the edge of the image on the CC (Figure 5-9). This measurement on the MLO should be within 1 cm of the measurement on the CC projection. In 10% of cases, the PNL will be greater on the CC (ACR, 43–49; Peart, 115–146). 4. (D) In general, guidelines for the MLO include all of these statements. Additionally, the breast should not droop on the image. It may not be possible to meet all these guidelines on all patients. If one or more of these guideline elements are missing, the mammographer or radiologist must determine whether a third projection is necessary (ACR, 34–42; Peart, 115–146).

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PNL

PNL

Figure 5–9. Showing the PNL. Measurement of the posterior nipple line (PNL) on the MLO projection should be within 1 cm of the PNL measurement on the CC projection. In about 10% of cases, the PNL will be greater on the CC projection.

5. (B) If the C-arm is raised too high, IR will elevate the patient’s inframammary fold or crease and the patient will be unable to lean forward and relax. This results in loss of the

Answers and Explanations: 1 through 14

posterior and inferior breast tissue. If the IR is too low, the breast droops and superior and posterior tissue is lost (Peart, 115–146). 6. (B) The MLO best visualizes the posterior and upper-outer quadrants of the breast while allowing distortion and overlap of the anterior structures. However, it is the single best projection to visualize a maximum amount of breast tissue. The CC does not image the lateral breast while the ML does not image the posterior breast. The XCCL will miss the medial breast (ACR, 34; Peart, 115–146).

7. (C) In imaging the MLO, the edge of the IR is placed parallel to the oblique line formed by pectoral muscle. This oblique line varies in individuals; tall, thin patients require steeper angulations (50–60 degrees), average patients require 40–50 degrees and short, heavy patients 30–40 degrees. The angle is usually the same for both breasts. Male breast may require even steeper angulations (ACR, 60–62; Peart, 115–146).

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10. (A) The IR must be placed at the level of the elevated IMF or crease. If the IR is raised too high, the patient will be unable to lean forward and relax. This results in loss of posterior and inferior breast tissue. If the IR is at the IMF or is too low, the breast droops and superior and posterior tissues will be lost (Peart, 115–146). 11. (D) In imaging for the MLO, the edge of the IR is placed parallel to the oblique line formed by pectoral muscle. This oblique line varies in individuals; tall, thin patients require steeper angulations (50–60 degrees), average patients require 40–50 degrees and short, heavy patients 30–40 degrees. The angle is usually the same for both breasts (ACR, 60–62; Peart, 115–146).

12. (A) In the (CC) projection, the beam is directed superiorly to inferiorly, without angulation. The MLO uses tube angulation. The CV shows the medial breast from the CC position and the XCCL images the lateral portions of the breast in the CC position (CR, 43–49; Peart, 115–146).

8. (B) The MLO or ML determines if the abnormality is superior or inferior to the nipple and how far posterior it is. The CC or XCCL projections determine whether the lesion is medial or lateral and how far it is from the nipple. The TAN projection skims the area of interest and is best used to determine if a suspected abnormality is located in the breast or the skin of the breast (ACR, 43–49; Peart, 115–146).

13. (B) Having the patient hold the supporting bars with the contralateral hand stabilizes the patient and helps to bring medial breast tissue closer to the IR. This is important because eliminating medial breast tissue from the CC projection may eliminate this tissue from the study. The patient holding the IR can project body parts in the image (Peart, 115–146).

9. (A) The breast is least mobile at the medial and superior aspects and most mobile at the lateral and inferior aspects. To image the maximum amount of breast tissue, the most mobile parts of the breast must be placed adjacent to the IR while applying compression from the least mobile aspect of the breast. In most cases, compression is applied from the superior aspect for the CC projections— (to image the maximum amount of superior and posterior breast) and from the medial aspect for the MLO projections (to image the maximum amount of medial and posterior breast) (ACR, 34; Peart, 115–146).

14. (A) The right lateromedial oblique (RLMO) is a useful alternative to the right mediolateral oblique (RMLO) in patient with prior pacemaker surgery, open-heart surgery, or any other painful scarring along the sternum where the compression paddle would cause discomfort by pulling on scar tissue. The lateromedial oblique (LMO) projection is a true reverse of the MLO and will demonstrate the same anatomical structures. The ML will not demonstrate adequate posterior breast. The LM can often be used to replace the MLO in the nonconforming patient but in this example a right LM would be needed (Peart, 115–146).

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15. (D) The AT or axilla projection demonstrates the axillary contents or tail of the breast. It is also called the tail of Spence. This projection is especially useful in demonstrating swollen lymph nodes (lymphadenopathy). The study may be unilateral or bilateral. LMO is the reverse of the MLO with an oblique beam traveling from inferiolateral to superior-medial. The TAN is used to image lesions in the skin and the LM is a 90-degree lateral, which can be used to image the medial breast (Peart, 115–146). 16. (B) The TAN projection is used to skim the area of interest. The projection demonstrates skin calciﬁcations or areas free of superimposition. The TAN projection also brings the area closer to the IR. Before obtaining a TAN projection, the abnormality must be palpable or visualized on another projection to determine its approximate location. In the LM, the beam travels from lateral to medial at 90 degrees and best images the medial breast. LMO is the reverse of the MLO with an oblique beam traveling from inferiolateral to superior-medial. The AT or axilla projection demonstrates the axillary contents or tail of the breast (Peart, 115–146). 17. (A) With the nipple in proﬁle, both the ML and the LM are lateral projections that will show the breast structures in relation to the nipple. With the medial breast closest to the IR, the LM projection is best suited to image medially located abnormalities and will give the best image detail; the ML images lateral abnormalities best. In addition, unlike the image produced with the ML, the resultant image from the LM is similar to the MLO. The AT images the tail of the breast and the TAN best images skin lesion and calciﬁcations (Peart, 115–146). 18. (B) The XCCL will best image the posterolateral tissue of the breast, which may not be visualized on the CC. The FB is the reverse of the CC with the beam traveling from inferior to superior (caudocranial). The TAN gives a tangential projection of the area of interest and the CV images the medial breast in the CC position (Peart, 115–146).

19. (C) A patient with kyphosis may also have pectus excavatum (sunken chest), barrelchest or pectus carinatum (pigeon breast). With these patients, it is rarely possible to image the entire breast with the standard two projections. An FB projection in such a situation is often useful. For the FB, the entire mammography unit is rotated 180 degrees and the IR is placed at the superior aspect of the breast. If the FB is not possible because of limitations of the mammography unit, the CC should be performed to image as much medial tissue as possible. Alternatively, the CV can be used to image both medial breasts with a right and left CC for the lateral portion 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 in search for an abnormality, 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. Centrally located lesions show little or no movement (Peart, 115–146). 21. (D) Milk of calcium deposits are benign calciﬁcations that occur in microcysts as radiopaque particles mixed with ﬂuid. On the CC, XCCL, or FB projections, they will appear as ill-deﬁned calciﬁcations. On a true lateral projection, such as the ML, the radiopaque particles settle to the dependent portion of the cyst, forming crescent- or teacup-shaped calciﬁcations. These may be clustered, scattered, or occur bilaterally (Peart, 115–146). 22. (B) The TAN projection is used to skim the area of interest. The projection demonstrates skin calciﬁcation or any area free of superimposition. The TAN projection also brings the area closer to the IR. The CV images the medial breast, and both the LMO and the AT are oblique projections (Peart, 115–146). 23. (D) The AT projection is a 20-degree oblique anterior-posterior projection used to visualize the axillary area or tail of the breast. Generally, the degree of angulation can depend on

Answers and Explanations: 15 through 32

the patient’s body habitus. In the ML, the beam travels from lateral to medial at 90 degrees and best images the lateral breast. The XCCL images the lateral portions of the breast in the CC position, and the FB is a caudocranial projection that best images the superior breast tissue (Peart, 115–146). 24. (B) The XCCL can be used to image the extreme posterolateral tissue missed on the CC. As with the CC projection, the beam is directed superiorly to inferiorly. The CV images the medial breast and the MLO and AT are oblique projections (Peart, 115–146). 25. (A) The caudal-cranial, FB, projection is the reverse of the CC and can be used to image nonconforming patients, such as those with extreme kyphosis. The FB also places superior lesions that are high on the chest wall closer to the IR, providing more detail of the lesion. Inferior lesions are imaged furthest from the IR (Peart, 115–146). 26. (C) The LM projection gives a true representation of breast structure in relation to the nipple. The LM places medially located lesions close to the IR. For the LM, the beam is directed laterally to medially. The CV shows the medial breast from the CC position. In the ML, the beam travels from lateral to medial at 90 degrees and best images the lateral breast. The MLO is a routine projection with the beam traveling from superior-medial to inferiolateral (Peart, 115–146).

27. (C) The MLO projection gives a distorted and overlapping image of the anterior and medial structures of the breast because it is an oblique project. However, it is the single best projection used to image the breast in its entirety. The MLO is also best at visualizing the posterior and upper-outer quadrants of the breast. The ML is poor at visualizing the most posterior and lateral parts of the breast and is not useful in visualizing areas of the breast missed on the MLO (Peart, 115–146). 28. (D) The CV projection is the best at imaging the extreme medial aspect of the breast with

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the beam directed craniocaudal. The CC is a routine projection and will image medial breast tissue, but not extreme medial tissue. The MLO distorts the medal breast and the ML often misses the medial breast (Peart, 115–146).

29. (A) The rolled image helps to move superimposed breast tissue away from a suspected lesion. The breast is rolled in equal and opposite directions through physical manipulation of the patient’s breast. The rolled projections can be performed in any direction. For the RM, the breast is ﬁrst positioned for the CC projection. The upper surface is then rolled medially and the lower surface is rolled laterally. For the RL, the upper surface is rolled laterally and the lower surface is rolled medially. “M” indicates magniﬁcation and ML is a 90-degree lateral projection (Peart, 115–146). 30. (C) The LMO is a reverse of the MLO and results in a similar image. For the LMO, the beam is directed from the inferolateral (lower outer) aspect of the breast to the superomedial (upper inner) aspect In the LM, the beam travels from lateral to medial at 90 degrees and best images the medial breast. The ML is also a true lateral, with the beam traveling from lateral to medial. The MLO is a routine projection with the beam traveling from superior-medial to inferiolateral (ACR, 71; Peart, 115–146). 31. (B) The CV is a cranial–caudal projection used to image the extreme medial aspect of the breast (Peart, 115–146). 32. (C) In the rolled image, the breast is rolled in equal and opposite directions via physical manipulation of the patient’s breast. For the RM, the patient is position for the CC projection. The upper surface of the breast is then rolled medially and the lower surface is rolled laterally. For the RL, the patient is also positioned for the CC projection. The upper surface of the breast is rolled laterally and the lower surface is rolled medially. The MLO is a routine projection with the beam traveling from superior-medial to inferiolateral. The

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CV shows the medial breast from the CC position (Peart, 115–146).

rolled laterally and the lower (inferior) surface is rolled medially (Peart, 115–146).

33. (B) Magniﬁcation mammography (M) is especially useful in assessing or ﬁnding breast calciﬁcations, or to better outline the borders of masses. The other projection will image the calciﬁcation but do not provide a magniﬁed image of the area of concern. The MLO is a routine projection with the beam traveling from superior-medial to inferiolateral. The CV shows the medial breast from the CC position (Peart, 115–146).

38. (D) A patient with pectus excavatum has a sunken or depressed sternum and rib cage, which make imaging the medial and lateral breast tissue difﬁcult on the routine CC projection. Extensive pectoral muscle is mainly a problem when imaging males in the MLO projection. In barrel chest, the chest protrudes and the kyphotic patient has exaggerated thoracic curvature or rounded shoulders (Peart, 115–146).

34. (A) In the rolled image, the breast is rolled in equal and opposite directions via physical manipulation of the patient’s breast. For the RM, the patient is positioned for the CC projection. The upper surface of the breast is then rolled medially and the lower surface is rolled laterally. For the RL, the patient is also positioned for the CC projection. The upper surface is rolled laterally and the lower surface is rolled medially (Peart, 115–146). 35. (D) With magniﬁcation, the breast may be magniﬁed up to twice its original size; therefore, the entire breast is rarely imaged. The patient’s skin dose increases because the breast is closer to the source plus additional exposure is required because of reciprocity law failure. Magniﬁcation can be used to image specimens and lesions and to assess the borders or the presence of calciﬁcations (Bushong, 327–340; Peart, 115–146).

36. (C) For the RS, the patient is positioned for the ML. The surface of the breast away from the IR is rolled superiorly and the lower surface is rolled inferiorly. For the RI, the patient is positioned for the ML. The surface of the breast away from the IR is rolled inferiorly and the lower surface is rolled superiorly (Peart, 115–146). 37. (D) For the RM, the patient is positioned for the CC projection. The upper (superior) surface of the breast is rolled medially and the lower (inferior) surface is rolled laterally. For the RL, the patient is positioned for the CC projection. The upper (superior) surface is

39. (A) In the modiﬁed ID projections, the prosthesis is displaced posteriorly and superiorly against the chest wall while gently pulling the breast tissue anterior away from the prosthesis, onto the IR. The implant or prosthesis is held in place with the compression device (ACR, 73; Peart, 115–146).

40. (D) The routine series for an implant patient includes the routine CC, routine MLO, CC with ID, and MLO with ID. It may be difﬁcult to displace the implant on some patients, especially if the implant is encapsulated. If it cannot be adequately displaced, another projection (such as the 90-degree lateral with the implant included) should be added to the routine CC and MLO projections of the implant. Imaging the patient in three projections ensures visualization of some parts of all four quadrants of the breast. The AT could be used to evaluate silicone spread into the lymph nodes. Another useful projection to image encapsulation is the SIO (ACR, 73; Peart, 115–146). 41. (D) The spot compression projection focuses the compression on a single area to improve resolution and evenly spread out the breast tissues. This is sometimes useful in eliminating pseudomasses. The TAN images skin lesion. The CV images the medial breast and the AT images the axillary tail (ACR, 54; Peart, 115–146). 42. (D) The routine series for an implant patient includes the routine CC, routine MLO, CC with ID, and MLO with ID. The total projections per patient would therefore be eight (ACR, 73; Peart, 115–146).

Answers and Explanations: 33 through 51

43. (C) Radiation-induced changes in the breast usually peak at 6 months after treatment, but may continue for up to 1 year. Initially, the breast may exhibit erythema and edema, or it may harden. The breast may also be extremely sensitive and distorted because of surgery. Although the mammography examination must be adapted for each patient, a mammogram is not recommended earlier than 6 months after radiation treatment (Peart, 115–146). 44. (A) Spot compression focuses compression on a single area to improve resolution and evenly spread out the breast tissues. This is sometimes useful in eliminating pseudomasses. Spot compression can be taken with or without magniﬁcation and in any projection. XCCL, AT, and CV are all speciﬁc supplementary projections with set central ray directions and tube orientations (ACR, 54; Peart, 115–146). 45. (C) With postmastectomy imaging, it is no longer possible to make a comparison between two “mirror-image” breasts. Therefore, an additional projection will give the radiologist a better opportunity to diagnose cancer. The ML or LM is often the preferred additional projection. The CC and the MLO are routine projections and the CV shows the medial breast from the CC position (Peart, 115–146).

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have been removed (Andolina, 313–400; Peart, 115–146).

48. (C) Compression of the specimen reduces tissue thickness, thus improving subject contrast. Structures are spread out, and tissue density is uniform with less superimposition of structures. The specimen can also be magniﬁed to image calciﬁcations. The overall effect is improved visualization and a more uniform density. Motion unsharpness and radiation reduction is not an issue in specimen imaging. Compression will improve visualization of structures in the magniﬁed specimen but will not alter the magniﬁcation factor (Andolina, 313–400; Peart, 115–146). 49. (D) FNA obtains cellular material for cytological analysis. FNA uses small-gauge needles (23 gauge), which limits the amount of cells that can be aspirated. The accuracy of the procedure depends on the radiologist performing the examination and the cytologist interpreting the results. Ductography cannulates 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 for analysis of the inner lining of the cyst (Andolina, 313–400; Peart, 203–217).

46. (A) Caution should be used when compressing implants to avoid implant rupture. Compression should therefore be used for immobilization only and not to separate breast tissue structures. TAN projections and magniﬁcation could be used to evaluate lumps and calciﬁcations, respectively. The implant displaced (ID) compression technique is used to image portions of the breast that would not be visualized because of superimposition of the implant (Figure 5-10) (Peart, 115–146).

50. (D) Preoperative localization is performed on nonpalpable lesions or suspicious areas that are identiﬁed only mammographically. The radiologist assists the surgeon by placing a wire in the suspected tissue as a guide for the surgeon. The surgeon is then able to excise only the lesion and surrounding margins rather than a larger area of the breast. Once excised, the wire in the area of suspicion conﬁrms that the correct area was removed

47. (A) The specimen is radiographed to ensure that the lesion was removed. The lesion should be circled on the radiograph and all the borders checked to conﬁrm that the entire lesion was removed. The specimen can be magniﬁed, especially if calciﬁcations are present to count and conﬁrm that all the calcifications

51. (D) Core biopsy provides a larger sample of breast tissue for histological study. The larger sample (generally an 11- to 14-gauge needle is used) offers a more deﬁnitive diagnosis when compared with FNB. Ductography cannulates a duct to introduce a contrast agent. Needle localization positions a guide wire in

(Andolina, 313–400; Peart, 203–217).

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5: Positioning and Interventional Procedures

Figure 5–10. Diagram of the Eklund method (ID technique). The ID or implant-displaced technique or Eklund method for implants displaces the implant posteriorly and superiorly to image the breast tissue free of the implant. (A) Normal compression. (B and C) Displacing the implant posteriorly and superiorly prior to compression. (D) Compression of the breast tissue free of implant.

a nonpalpable lesion for surgical removal. Pneumocstogram injects air in a cyst for analysis of the inner lining of the cyst (Andolina, 313–400; Peart, 203–217).

52. (C) A ﬁbroadenoma usually has low-level internal echoes and the borders may be smooth, round, or lobulated. An abscess will be ﬂuid ﬁlled and usually has some internal echoes. Their borders are generally well deﬁned, but irregular. Ductal carcinomas typically are taller than they are wide—benign

masses spread out horizontally. Cancers have a spiculated outline with alternating echopenic and echogenic straight lines radiating from the surface of the mass (echopenic means there are few echoes within a structure; echogenic describes a structure that produces echoes; anechoic means no internal echoes). A cyst is usually ﬂuid ﬁlled with smooth walls that allow transmission of sound. Sound traveling through a ﬂuid-ﬁlled structure is barely attenuated; the structures distal to a cystic lesion appear to have more

Answers and Explanations: 52 through 57

echoes than neighboring areas. This process is also referred to as distal echo enhancement. It is rare for calciﬁcations in a cyst wall or debris within the cyst to present through transmission (Peart, 147–162). 53. (C) If the sound traveling through a cyst is barely attenuated then the structure distal to the cyst appears to have more echoes than neighboring areas. The phenomenon is referred to as acoustic enhancement or through transmission (Peart, 147–162). 54. (A) Ductography or galactography can be performed on patients with nipple discharge. A small amount of contrast agent is injected into the duct and radiographs are taken in the CC and lateral positions. The contrast agent outlines these structures to visualize any pathology. Needle localization positions a guide wire in a nonpalpable lesion for surgical removal. Pneumocstogram injects air in a cyst for analysis of the inner lining of the cyst. FNA removes ﬂuid from a cystic lesion for cytologic analysis (Andolina, 313–400; Peart, 203–217).

55. (C) A pneumocystogram may be performed in conjunction with cyst aspiration. Air is injected into the cyst, which has been emptied. The inner walls of the cyst can then be assessed. In general, the air is reabsorbed by the body within a week. Ductography examines the ducts; needle localization is used to locate nonpalpable lesions, and FNA can be used to remove the content of a cyst (Andolina, 313–400; Peart, 203–217; Tabár, 89).

56. (A) Breast biopsy is the taking of a sample specimen of breast cells or tissue for cytological or histological analysis. In a core biopsy, a large-gauge needle (11–16 gauge) is used to remove tissue samples. The core biopsy needles can be mechanical or automatic core “guns” with an inner needle. These needle gun combinations are designed to move a cutting needle rapidly through the breast to obtain a tissue sample. Core biopsies can be performed under mammography, ultrasound, or MRI guidance. Cytology refers to

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the study of cells. Ductography is used to evaluate patients with abnormal nipple discharge. The lactiferous duct is cannulated and a small amount of contrast agent is injected before the area is imaged. Aspiration is a method of removing ﬂuid from a cyst using 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 the needle; (C) postﬁre into the lesion—the needle moves forward, ﬁlling the trough with breast tissue; and (D) postﬁre the outer sheath moves forward to cut the tissue and keep it in the trough.

57. (B) FNA is a technique used to obtain cellular material from a lesion for cytological analysis. FNA can reduce the need for a surgical breast biopsy. Because the technique is performed using a small-gauge needle (20–25), the accuracy of the procedure is dependent on the skills of the radiologist or surgeon performing the procedure. During the procedure, the presence of a cytotechnologist or cytopathologist is recommended to verify the adequacy of the cell samples and to prepare the slides. Core biopsies can be performed under mammography, ultrasound, or MRI guidance. Cytology refers to the study of cells. Ductography is used to evaluate patients with abnormal nipple discharge. The lactiferous duct is cannulated and a small amount of contrast agent is injected before the area is imaged. Ductal lavage is a technique used to collect cells from the lining of the milk duct (Andolina, 332; Peart, 209–215).

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5: Positioning and Interventional Procedures

58. (D) Stereology is the science of determining the three-dimensional location of an object based on two-dimensional images. Stereotactic breast localizations can be used to locate the horizontal, vertical, and depth position of nonpalpable lesions. A computer performs the necessary calculations therefore if the input information is inaccurate, errors in localization will result (Andolina, 334; Peart, 204). 59. (D) Cyst aspiration removes the contents of a cyst for analysis. Although the technique is often done with ultrasound guidance, aspirations can be performed under mammographic guidance for nonpalpable lesions or clinical guidance for large palpable cyst. MRI aspirations are not common because often cysts, if not visualized on mammography, are visualized on ultrasound. The needle size used depends on the viscosity and thickness of the ﬂuid content of the cyst but generally a

small gauge (eg, 21 gauge) is used to reduce patient discomfort (Andolina, 322; Peart, 204). 60. (B) The open surgical biopsy is the most invasive procedure, but it has the lowest falsenegative rates. Open surgical biopsies will need more hospital time, require anesthesia, and will leave visible scars on the breast. These factors all contribute to a higher complication rate with open biopsy than with the other minimal invasive procedure. FNB is the cheapest but least accurate biopsy method. The main cause is insufﬁcient samples because of the small-needle gauge used. Core biopsy is has a lower false-negative rate than FNB, but again insufﬁcient samples can reduce the accuracy. MRI-guided biopsy is usually used for lesions seen only on MR imaging. The technique involves the removal of core samples and is considered a minimally invasive procedure (Andolina, 313–400; Peart, 203–217).

CHAPTER 6

Practice Test 1 Questions

1. A clinical breast examination (CBE) and breast self-examination (BSE) are similar in that both

5. The large air gap used in magniﬁcation functions to 1. increase scatter 2. improve contrast 3. reduce scatter

(A) involve looking and feeling for changes in the breast (B) are done by a trained medical professional (C) are done monthly (D) are done yearly 2. The most common cause of undercompression 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 generally the density closest to (A) (B) (C) (D)

but not less than 2.20 but not less than 1.20 but not less than 0.45 2.20

(A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

6. In high-contrast imaging or conventional imaging (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 when imaging extremely small breasts in the craniocaudal (CC) position?

4. Ductal papilloma is

(A) (B) (C) (D)

spatula ML cleavage (CV) exaggerated craniocaudal (XCCL)

(A) a benign proliferation of tissue in the male 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

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

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6: Practice Test 1

8. In the tangential (TAN) projection, any tube angulation 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 obvious to the individual because it often presents as (A) (B) (C) (D)

skin irritation inverted nipples a painless mass a painful mass

10. Mammography is more accurate in (A) (B) (C) (D)

premenopausal women postmenopausal women women with ﬁbrocystic breast women with dense breast tissue

11. In taking medical history, hormones use (both natural and artiﬁcial) are taken into account because 1. hormones cause breast cancer 2. early menarche can increase breast cancer risks 3. contraceptive use can increase breast cancer risk (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

12. One major difference between collimation in mammography and collimation in general radiography is that (A) in mammography the entire image receptor area is exposed (B) decreasing collimation increases exposure in mammography (C) mammography uses a variety of beamlimiting devices (D) in radiography the entire image receptor area is always exposed 13. Two ﬁlm emulsions are compared on a characteristic 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, the loaded cassette is unloaded under safelight conditions in the darkroom. The ﬁlm in the cassette is (A) stored in the ﬁlm bin during the cleaning process (B) removed from the cassette and discarded (C) returned to the cassette after cleaning (D) returned to the ﬁlm bin 15. The retromammary space is ﬁlled with (A) (B) (C) (D)

supportive and connecting tissue adipose tissue ﬁbroglandular tissue blood vessels

Questions: 8 through 22

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16. The fatty versus ﬁbroglandular nature of breast tissue is affected by which of the following? 1. age 2. hormone use 3. number of pregnancies (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

17. In compression on the XCCL projection, the affected arm should (A) not be raised, but rest along the top of the image receptor (B) be raised, with hand resting/holding on bar 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) (B) (C) (D)

all the time rarely if ever about 30%–40% of the time about 50% of the time

19. Between ages 20 and 39, a woman should have a CBE every (A) (B) (C) (D)

year 2 years 3 years 4 years

20. The lesion seen in Figure 6-1 is not palpable and is not associated with nipple or skin changes. It is likely to be (A) (B) (C) (D)

invasive ductal breast carcinoma a mammographically malignant tumor a mammographically benign tumor nonspeciﬁc; further testing is indicated

Figure 6–1

21. Regardless of the reason, if the proper amount of compression cannot be applied which of the following must apply? (A) (B) (C) (D)

the patient must be told the patient’s doctor must be told the radiologist must be told it must be noted on the patient’s history form

22. Magniﬁcation is contraindicated 1. when imaging the mastectomy site 2. in specimen radiography 3. as a normal/routine screening tool (A) (B) (C) (D)

1 only 3 only 2 and 3 only 1 and 3 only

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6: Practice Test 1

23. If no previous mammograms are available for comparison, the automatic exposure control (AEC) detector should be placed (A) in the central aspect of the compressed area 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 visualized on the CC projection? (A) (B) (C) (D)

medial axial lateral superior

25. Identify the projection in Figure 6-2. (A) (B) (C) (D)

rolled medial (RM) mediolateral (ML) XCCL mediolateral oblique (MLO)

26. Manual technique is sometimes necessary when 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 demonstrate a deep medial lesion not seen on the CC? (A) (B) (C) (D)

axillary tail (AT) XCCL CV MLO

28. After a routine four-projection mammographic series, the nipple is not seen in proﬁle on any of the images. Additional projections are done if 1. the nipple is indistinguishable from a mass 2. a subareolar abnormality is suspected 3. the nipple is not marked with a BB (lead shot) (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

29. Identify the projection in Figure 6-3. (A) (B) (C) (D) Figure 6–2. (© 2000 The American Registry of Radiologic Technologists.)

TAN from below (FB) XCCL ML

Questions: 23 through 37

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33. The operating level density difference (DD) for the phantom should be at least (A) (B) (C) (D)

0.40 0.80 0.02 1.20

34. A ﬁlm was accidentally bent prior to loading into the mammography cassette. If this ﬁlm is used in mammography screening, an artifact would appear as

Figure 6–3. (© 2000 The American Registry of Radiologic Technologists.)

30. Your patient’s sister had breast cancer. Your patient 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 glandular dose received per projection/position during routine screen-ﬁlm mammography cannot exceed (A) (B) (C) (D)

100 mrad 200 mrad 300 mrad 400 mrad

32. When imaging an extremely dense breast using AEC, the exposure sometimes terminates, resulting in an underexposed image because of the action of the (A) (B) (C) (D)

exposure timer backup timer phototimer device timer

(A) (B) (C) (D)

a minus-density artifact a plus-density artifact static lines parallel to the direction of ﬁlm travel

35. Montgomery glands are specialized (A) (B) (C) (D)

sweat glands sebaceous gland Cooper ligaments hair follicles

36. A woman taking estrogen replacement therapy may notice changes in the breast such as 1. breast enlargement 2. lumpy breast 3. cysts (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

37. Paget disease of the breast is a(an) (A) inﬁltrating carcinoma generally limited to the breast (B) form of carcinoma associated with changes of the nipple (C) benign breast condition that is relatively common (D) malignant form of breast carcinoma involving the lobules

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6: Practice Test 1

38. Variation in compression levels causes 1. inadequate exposure on one portion of the breast 2. over- or underexposure in other portions of the breast 3. adequate exposure throughout the breast (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3 only

42. In which of the following modiﬁed projection is the superior surface of the breast rolled medially? (A) (B) (C) (D)

43. Factors that lower breast cancer risk include 1. having your ﬁrst child after age 30 2. breast-feeding your child 3. late menarche

39. What is the major disadvantage of magniﬁcation? (A) (B) (C) (D)

reduced resolution of the image increased patient dose increased scattered radiation none of the above

40. Selection of rhodium anode/ﬁlter combination for a fatty breast 1. overpenetrates the fatty breast 2. alters the penetrating power of the beam 3. results in loss of subject contrast (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

41. When imaging the breast using the MLO projection, drooping breast can be a result of which of the following? 1. too much compression of the anterior breast 2. too little compression of the anterior breast 3. too much axilla included in the compression ﬁeld (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

RM RL M lateral medial (LM)

(A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

44. The minimum and maximum kilovoltage peak (kVp) of a mammography unit depends on 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-density should remain within (A) (B) (C) (D)

±0.15 of the established levels ±0.10 of the established levels +0.30 of the established levels +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

Questions: 38 through 53

47. Total ﬁltration with a rhodium target ﬁltration combination is

Rib Pectoral muscle Vein Retromammary adipose tissue

(A) the added ﬁltration plus the inherent ﬁltration (B) equal to the added ﬁltration (C) equal to the inherent ﬁltration (D) the added ﬁltration minus the inherent ﬁltration

A Subcutaneous adipose tissue

B C

48. According to MQSA regulations, which of the following is not required on the ﬁnal mammographic image?

Areola

(A) date of the examination (B) technical factors used (C) mammographer/technologist identiﬁcation (D) cassette/screen identiﬁcation

second to third rib third to fourth rib fourth to ﬁfth rib sixth to seventh rib

50. Identify Cooper ligament in Figure 6-4. (A) (B) (C) (D)

site A site B site C site D

D

Glandular tissue lobules Artery

49. The inframammary crease is located at approximately the level of the (A) (B) (C) (D)

109

Connective tissue and adipose tissue

Figure 6–4

51. Identify the lactiferous sinus in Figure 6-4. (A) (B) (C) (D)

site A site B site C site D

52. Scattered radiation is reduced during magniﬁcation mammography by (A) (B) (C) (D)

using a small focal spot size using a grid using the air-gap technique increasing the source-to-image receptor distance (SID)

53. Ductography can be used to determine 1. the location of the lesions in the ducts 2. if a lesion is benign or malignant 3. changes or abnormalities associated with the ducts (A) (B) (C) (D)

1 only 1 and 2 only 1 and 3 only 2 and 3 only

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6: Practice Test 1

54. In the CC projection, a technique especially useful in maximizing the amount of lateral breast tissue imaged on the small-breasted patient with rounded shoulders is (A) (B) (C) (D)

5-degree lateral tube angulation 5-degree medial angulation using a straight tube the ML projection

55. During magniﬁcation, positioning the breast away from the image receptor utilizes which law/principle in scatter reduction? (A) (B) (C) (D)

inverse-square law reciprocity law heel effect line focus principle

56. A woman with one ﬁrst-degree relative with breast cancer has a higher risk for breast cancer than a woman with 1. early menarche, taking oral contraceptives 2. a personal history of breast cancer 3. late menopause (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

57. The primary purpose of the grid in mammography is to (A) (B) (C) (D)

improve image sharpness reduce the production of scatter reduce patient dose increase the subject contrast

58. The implant-displaced (ID) projection is possible on all of the following cases except (A) implants placed posterior to the pectoral muscle (B) implants placed anterior to the pectoral muscle (C) soft implants (D) encapsulated implants

59. A palpable mass that is not seen on a diagnostic mammogram generally means (A) breast cancer is ruled out; the mass is probably 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 greatest risk for breast cancer? (A) (B) (C) (D)

A nulliparous woman at age 40 A never married woman A woman, age 70 A woman, age 30

61. A mammographer using a 0.1-mm focal spot size is most likely performing (A) (B) (C) (D)

routine mammography work magniﬁcation imaging spot compression imaging 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 processing 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) (B) (C) (D)

the nipple area of the areola area adjacent to the chest wall axilla area of the breast lower outer quadrant of the breast

Questions: 54 through 71

65. Fibrous tissues are presented radiographically as (A) (B) (C) (D)

black or radiolucent areas gray and less dense areas white or denser areas 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

111

68. In mammography, the AEC detector is placed directly (A) (B) (C) (D)

above the image receptor below the grid above the grid below the image receptor

69. Since 1989, the death rate from breast cancer has declined because (A) more cancers are discovered at a later stage (B) more cancers are discovered at an earlier stage (C) the long-term survival rate for breast cancer 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 speed 2. increased image receptor contrast 3. increased ﬁlm base density (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

71. Spot compression

Figure 6–5

67. The MLO projection demonstrates a large encapsulated lesion occupying almost the entire breast. The contour is sharp and the lesion is radiolucent. This lesion is most likely to be a(an) (A) (B) (C) (D)

oil cyst hematoma ﬁbroadenoma lipoma

1. applies more compression to a localized area 2. can be performed with magniﬁcation 3. employs a coned collimated ﬁeld to limit the area of interest (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1, 2, and 3

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6: Practice Test 1

72. Identify the projection in Figure 6-6. (A) (B) (C) (D)

TAN FB XCCL RM

75. Why is the specimen magniﬁed? (A) to ensure that the lesion has been completely removed (B) to visualize the calciﬁcations within the specimen (C) to compare the magniﬁed and nonmagniﬁed images (D) to check the number and placement of calciﬁcations 76. In digital mammography, a grossly underexposed image (A) (B) (C) (D)

appears excessively noisy is too light is too dark appears correctly exposed

77. Which of the following patients is likely to be diagnosed with pathological gynecomastia? Figure 6–6. (© 2000 The American Registry of Radiologic Technologists.)

73. To reduce the possibility of imaging the abdomen in the MLO position, the mammographer could (A) have the patient stand just at the image receptor and bend back (B) have the patient stand away from the image receptor and bend forward (C) have the patient turn medially to image the lateral breast on the CC (D) discard the MLO and image the breast in the lateral position instead 74. A four-projection mammography series shows a solitary tumor without calciﬁcation in the upper outer quadrant (UOQ) of the left breast. Only the anterior margins are seen. The next recommended step is (A) (B) (C) (D)

biopsy spot compression stereotactic localization aspiration

(A) (B) (C) (D)

lactating woman elderly man premenopausal woman young man

78. Montgomery glands are located on the breasts (A) (B) (C) (D)

skin nipple areola muscle

79. Extended processing increases the amount of time the ﬁlm is immersed in the (A) (B) (C) (D)

developer solution ﬁxer solution dryer both the developer and ﬁxer solutions

80. If the humidity in the dark room drops lower than 30%, the result is (A) (B) (C) (D)

an increase in base fog ﬁlm scratches static patterns on ﬁlm reduced ﬁlm speed

Questions: 72 through 89

81. Over age 40, it is recommended that women have a CBE every (A) (B) (C) (D)

year 2 years 3 years 4 years

82. Fibrous and glandular tissues are more _______ than fatty tissue and result in areas of _______ optical density on the radiograph. (A) (B) (C) (D)

radiolucent/lower radiolucent/higher radiopaque/higher radiopaque/lower

83. Good compression results in 1. increased spatial resolution 2. decreased spatial resolution 3. improved subject contrast (A) (B) (C) (D)

2 only 3 only 1 and 3 only 2 and 3 only

84. Which of the following involves the use of a thin needle to remove cell samples from a suspected cancerous lesion in the breast for cytological analysis? (A) (B) (C) (D)

core biopsy excisional biopsy needle localization ﬁne needle aspiration (FNA)

85. A lesion is superimposed by breast tissue in the CC projection. A projection used to demonstrate the lesion in the same projection and free of superimposition is the (A) (B) (C) (D)

MLO ID XCCL RM

113

86. In imaging the breast in the MLO projection, compression to the lower portion of the breast is compromised if 1. the image receptor is too high 2. the patient has a protruding abdomen 3. too much axilla and shoulder are under compression (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

87. Involution of the breast describes a process by which (A) milk is removed from the breast by suckling (B) breast epithelium proliferates during menstruation (C) breast epithelium decreases because of postmenopausal changes (D) estrogen causes an overall density decrease in the breast 88. In imaging the breast for the CC projection, what technique is used to minimize skin folds in the lateral aspect of the breast? (A) lift the posterior lateral aspect of the breast onto the image receptor (B) drape the contralateral breast over the corners of the image receptor (C) have the patient’s head turned away from the breast being imaged (D) on the side being imaged, the patient’s arm hangs relaxed with humerus externally rotated 89. In the dedicated mammography unit, the single intensifying screen is positioned in contact with the ﬁlm emulsion on (A) the side of the IR away from the x-ray source (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

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6: Practice Test 1

90. Grid use in magniﬁcation mammography is contraindicated because

93. Which statement best describes a parallel or linear grid?

1. grid use increases subject contrast 2. scatter is already minimized 3. the grid results in increased patient dose

(A) Lead strips are aligned adjacent to one another and placed lengthwise in the same direction within the structure of the grid. (B) Lead strips are aligned at right angles to each other. (C) Lead strips are designed to take advantage of the divergence of the x-ray beam as it leaves the x-ray tube. (D) Lead strips are designed to move during the exposure.

(A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

91. The breast can be imaged in the FB projection 1. to improve visualization of lesions in uppermost aspect of breast by reducing object-to-image receptor distance (OID) 2. during needle localization to provide a shorter route to inferior lesions 3. to maximize the amount of tissue visualized in patients with kyphosis (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

94. Mercury in a glass-type thermometer is not recommended 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. (A) (B) (C) (D)

92. Identify the projection in Figure 6-7. (A) (B) (C) (D)

TAN FB XCCL ML

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

95. What factors are used to maintain a sharp image during magniﬁcation? 1. adjustable focal spot sizes 2. decreasing the thickness of the body part 3. decreasing the resolution (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

96. The half-value layer (HVL) of the x-ray beam is measured with a

Figure 6–7. (© 2000 The American Registry of Radiologic Technologists.)

(A) (B) (C) (D)

star pattern slit camera pinhole camera quality-control dosimeter

Questions: 90 through 104

97. The repeat rate should be analyzed if the rate changes from the previous measure rate by more than (A) (B) (C) (D)

±2% ±3% ±4% ±5%

98. A magniﬁcation image of breast shows several oval-shaped radiolucent lesions with eggshell-like calciﬁcations. These are most likely to be (A) (B) (C) (D)

ductal papilloma ﬁbroadenomas oil cysts hematomas

99. The image viewing environment 1. has no effect on the detection of cancerous lesions 2. can obliterate the advantages of optimum image quality 3. should eliminate extraneous viewbox light (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

100. In general, ID series are taken in (A) (B) (C) (D)

AT and MLO projections CC and ML projections CC and MLO projections CC and LM projections

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101. Today all mammographers (radiographer performing mammograms independently) must have 1. satisﬁed the interim requirements of the FDA 2. completed at least 40 contact hours of documented training in mammography 3. performed at least 25 examinations under direct supervision of a qualiﬁed mammographer (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

102. The criteria for a properly positioned MLO includes 1. a concave pectoral muscle on the anterior border 2. fat visualized posterior to the ﬁbroglandular tissues 3. an open inframammary fold (IMF) (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

103. A benign inﬂammatory condition of the lactiferous ducts leading to nipple discharge, nipple inversion, or periareolar sepsis is called (A) (B) (C) (D)

ductal ectasia Paget disease of the breast peau d’o range ductal papilloma

104. The cells lining the alveoli in the lobules are called (A) (B) (C) (D)

epithelial cells myoepithelial cells basement cells superﬁcial cells

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6: Practice Test 1

105. Using a cassette with poor ﬁlm screen contact will result in (A) (B) (C) (D)

a noisy image localized unsharpness motion unsharpness a lower subject contrast

106. A technique describing reshaping of the breast is called (A) (B) (C) (D)

reduction mammoplasty mammoplasty breast augmentation breast biopsy

107. A major cause of radiographic noise is (A) (B) (C) (D)

image graininess quantum mottle poor contrast resolution motion

108. Failure of the hyporetention test will result in what type of long-term artifact marks on the image? (A) (B) (C) (D)

streaks of increased optical density areas of reduced density yellow brown stains round spots of increased density

109. In positioning for the superior-inferior oblique (SIO), the _________ of the breast will rest on the image receptor. (A) (B) (C) (D)

lateral surface superior surface medial surface inferior aspect

110. Imaging males will present the same difﬁculty as imaging small, ﬁrm-breasted females. An added problem may be that (A) males have more problems with the compression (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 compression difﬁcult 111. For the SIO projection, the central ray (CR) is directed (A) (B) (C) (D)

inferolateral to superomedial superomedial to inferolateral inferomedial to superolateral superolateral to inferomedial

112. Which of the following are considered agencies granting accreditation under the FDA regulation? 1. ACR 2. ARRT 3. NY State Department of Health (A) 1 only (B) 2 only (C) 1 and 2 only (D) 2 and 3 only 113. Which alternative projection could be used, in addition to the CC, in imaging a patient with a prominent pacemaker? (A) (B) (C) (D)

ML lateromedial oblique (LMO) XCCL MLO

Questions: 105 through 115

114. During needle localization, breast positioning should provide the shortest skin-toabnormality distance in order to 1. minimize trauma to the breast 2. ensure minimal excursion of the biopsy needle into the breast 3. reduce the possibility of needle deﬂection (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

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115. In addition to the patient’s name, all mammographic reports should have the 1. ﬁnal assessment of ﬁndings 2. hospital number or additional patient identiﬁer 3. name of the radiologist (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

Answers and Explanations

1. (A) Both the CBE and the BSE are examinations of the breast where changes in the shape, contour, and texture of the breast are assessed and the breast is checked for lumps. The CBE is done by a health professional, whereas the BSE is done by the woman on herself. The BSE should always be done monthly after age 20. The CBE is recommended every 3 years for those below 40 and every year for those over 40 (ACR, 10). 2. (B) Studies have shown that although there are many reasons for undercompression, the main reason is a lack of communication between the mammographer and the patient. The mammographer undercompresses the breast either because the patient refuses further compression, is unable to tolerate more compression, or the mammographer wants to “protect” the patient from further pain. Patients generally tolerate more compression if they fully understand the reason for the compression. Faulty or broken compression devices are generally easily repaired (ACR, 90;

from the nipple or if deep within the breast may appear radiographically as a mass. Ductal papillomas are benign and can be visualized with ductography or ultrasound (Andolina, 155–173; Peart, 47–62; Venes, 1584).

5. (C) The large air gap acts like a grid and reduces scatter, thus improving subject contrast. Positioning the breast away from the image receptor takes advantage of the inversesquare law: the intensity of the scattered radiation is reduced because the distance between the image receptor and the object is increased (ACR, 59–60; Bushong, 327–340; Peart, 65–84).

6. (B) To visualize minimal changes in glandular structures, high-contrast conventional mammography provides detail of glandular tissue, but does not show skin detail. The skin is only seen under “bright light.” If the skin is seen normally, the image is underexposed, especially in the glandular regions; detail is lost and lesions may be missed (ACR, 79–110; Peart, 65–84).

Andolina, 184; Peart, 116–117).

3. (D) In calculating the density difference, DD, two average densities are used. The high average density is the density closest to 2.20. The low average density is the density closest to but not less than 0.45. The difference between these two densities is the DD (ACR,

7. (A) The spatula can be used instead of the mammographer’s ﬁngers to pull extremely small breasts into position for compression. The ML is a lateral projection. CV images the extreme medial breast in the CC projection and XCCL images the extreme lateral breast in the CC projection (Peart, 115–145).

151; Peart, 87–112).

4. (D) An intraductal papilloma generally occurs near the nipple within the larger ducts, but can also occur deep within the breast. The papilloma may produce spontaneous discharge 118

8. (B) In the TAN projection, the technique is to take a skimming projection of the area of interest. Because the TAN can be taken in any projection, the degree of obliquity and the projection depends on the location of the

Answers and Explanations: 1 through 13

abnormality. The TAN can be taken in any projection (Figure 6-8) (Peart, 115–145).

Figure 6–8. ((© 2000 The American Registry of Radiologic Technologists.)

9. (C) Although pain can be associated with breast cancer; a painless mass is the more common symptom of breast cancer. Painful masses are associated with cysts. Less common symptoms of advanced breast cancer include skin thickening; skin irritation or distortion; and sudden nipple inversion, discharge, erosion, or tenderness (ACS, 1–17; Peart, 47–62).

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devices. However, unlike general radiography where the beam should be limited to the size of the part, in mammography the entire ﬁeld (not just the breast) is exposed. This is necessary to reduce extraneous light when viewing the image (Peart, 65–84). 13. (A) In conventional imaging, the characteristic curves (also called D log E, sensitometric, or Hurter and Drifﬁeld [H&D] curve) describe the relationship between the radiation exposure and the optical density produced on an image. At the toe and shoulder of the curve, large variations in exposure result in little or no change in density. In the straight-line portion of the curve (the useful region), small changes in exposure cause large changes in density. Calculations of ﬁlm contrast use the average gradient or slope between two points of the curve. Films that have a steeper slope have a higher contrast. Two characteristic curves can also be used to compare ﬁlm speeds (Figure 6-9). The curve that lies to the left (closer to the density axis) is faster (Bushong, 272–281).

4.0

10. (B) On an average, a mammogram will detect 90% of breast cancers in women without symptoms and is more accurate in postmenopausal compared to premenopausal women. Some cancers are not detected mammographically because of increased breast density, as in the ﬁbrocystic breast, faster growth rate, or failure to recognize the early signs of an abnormality (ACS, 1–17).

3.0 D e n s i t y

2.0

1.0

11. (B) Hormone use inﬂuences breast cancer risk, but does not actually cause breast cancer. All factors that affect the reproductive hormones in a woman’s body increase risk for breast cancer (ACS, 1–17). 12. (A) In general, the use of any beam-limiting device in radiography or mammography requires increased exposure. Both imaging methods use varying sized beam-limiting

A 0

B 1.0

2.0

3.0

4.0

Log relative exposure Figure 6–9. Characteristic curve (also called sensitometric curve or Hurter and Drifﬁeld [H & D] curve) from two different types of radiographic ﬁlms. Film A has a faster speed than ﬁlm B because its speed point is the left of ﬁlm B. Film B has a higher contrast than ﬁlm A because the slope of its curve is steeper than that of ﬁlm A.

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14. (B) The ﬁlm in the cassette should be discarded because any attached dirt from the cassette will be carried into the ﬁlm bin or returned to the cassette (ACR, 149; Peart, 87–112). 15. (B) The retromammary space separates the breast from the pectoral muscle. It is ﬁlled with a layer of adipose or fatty tissue as opposed to the supporting and connective tissue (stroma), blood vessels, and various ductal structures that make up the glandular and ﬁbrous tissues of the breast (Peart, 35–44). 16. (D) Generally, glandular tissues predominate in younger women and adipose or fatty tissues in older patients. This ratio is not ﬁxed, and depends on the woman’s age and genetic predisposition. It ﬂuctuates with hormone levels, whether the hormonal changes are caused by medication use or pregnancy, lactation, or menopause (Peart, 35–44). 17. (B) The purpose of the XCCL projection is to image the lateral aspect of the breast. Raising the patient’s arm on the ipsilateral side forces more axilla under the compression paddle. Keeping the ipsilateral arm down or placing the hand at the patient’s hip does not allow adequate compression of the lateral and anterior aspects of the breast. The ipsilateral shoulder should be relaxed and down with the arm raised (Andolina, 174–245; Peart, 115–145). 18. (C) Depending on patient body habitus, the pectoral muscle is imaged on the medial aspect of the breast in about 30%–40% of all CC projections. It may be visualized unilaterally or bilaterally. Routine CC imaging that includes the pectoral muscle can indicate faulty positioning with loss of medial or lateral breast tissue (ACR, 79-110-310). 19. (C) The American Cancer Society (ACS) guidelines for early detection of breast cancer includes having a CBE every 3 years between ages 20 and 39 and every year after age 40 (ACS, 1–17).

20. (D) Whenever a large radiating structure or area of architectural distortion (even when

superﬁcial) is not associated with skin changes or nipple retraction, the mammogram is considered nonspeciﬁc, and further testing is indicated. If the lesion is palpable, malignancy cannot be ruled out. However, the lesion must be biopsied for a deﬁnitive diagnosis. This lesion is a radial scar (see Figure 6-1). Radial scars are rarely palpable and never involve skin changes. Generally the radial scar has no central tumor and its appearance varies from one mammogram projection to another. Some studies suggest that a radial scar may increase a woman’s risk of developing breast cancer (Peart, 47–62; Tabár, 93–147; Tucker, 241–280).

21. (D) Although the mammographer should inform the radiologist and can also inform the patient, anything unusual must be charted on the patient’s medical or history form. The patient’s records are a means of communication between the mammographer and the radiologist and can be important legal documents used to deﬁne what was or was not done to a patient. Records can also be used as evidence in court cases (Peart, 13–31). 22. (B) Magniﬁcation techniques are useful in mammography to assess microcalciﬁcations or the border of a lesion, or to image a specimen to check for calciﬁcations. However, magniﬁcation does not image the entire breast and cannot be used as a screening tool. Magniﬁcation can be used to image the relatively small area of a mastectomy site. (The site can also be imaged without magniﬁcation.) For a woman with thick, dense breast tissue, magniﬁcation is sometimes contraindicated because long exposure times and high kVp degrades the image. The patient also receives an unnecessarily high radiation dose (Bushong, 327–340; Peart, 115–145). 23. (A) If the detector is placed in a single region of adipose tissue in an otherwise glandular breast, the adipose area will be correctly exposed but the glandular area will be underexposed resulting in an increased chance of missed breast cancer. In imaging adipose and glandular tissue, the detector must be under

Answers and Explanations: 14 through 32

glandular breast to obtain proper image density. Glandular tissue is distributed centrally and laterally within the breast; therefore, the AEC should be centrally placed behind the nipple, making sure it is under an area of compressed breast (Peart, 65–84). 24. (C) All effort should be made to image the medial breast tissue on the CC mammogram; eliminating it could eliminate this area of the breast from the study. The CC best demonstrates the anterior, central, medial, and posteromedial portions of the breast but is poor at visualizing the lateral breast tissue. The patient should be rotated slightly medially, even if this means loosing some lateral breast tissue. Although the medial breast is imaged on the MLO, superimposition of glandular structures and increased OID often causes distortion of that area (Andolina, 174–245; Peart, 115–145).

121

28. (D) Putting the nipple in proﬁle is sometimes counterproductive. Breast tissue is lost either superiorly, inferiorly, laterally, or medially, depending on the projection and the location of the nipple on the breast. Missed tissue can then lead to undetected breast cancer. If the nipple is not in proﬁle, additional images are needed for the above reasons, but should not be done solely to place the nipple in proﬁle, even if the nipple is not marked with a BBmarker (small radiopaque marker) (Andolina, 246–310; Peart, 115–145).

29. (C) The XCCL projection best images the posterolateral parts of the breast. The beam is directed superiorly to inferiorly, similar to a standard CC projection. The TAN gives a tangential image of the area in question, the FB image directs the beam caudocranially and the ML is a 90-degree lateral projection (Andolina, 174–245; Peart, 115–145).

25. (D) The MLO projection best demonstrates the posterior and UOQ of the breast. This projection images the breast entirely, but distorts the anterior structures. The ML is a 90-degree lateral, the XCCL images the lateral aspect of the breast in the CC position, and the roll medial rolls the superior surface of 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 on the principle of terminating the exposure when sufﬁcient x-ray reaches the ﬁlm to produce a preset optical density. Because implants are basically radiopaque, if the implant is positioned over the AEC the tube will try to provide sufﬁcient output to penetrate the implant and also provide optimal density with this action stopped only by the backup timer. This generally leads to an excessive radiation dose to the patient (Peart, 65–84). 27. (C) The CV best images the medial breast. The MLO will best demonstrate the posterior and UOQ of the breast. The XCCL and AT will demonstrate the lateral and axilla portion of the breast, respectively (Andolina, 174–245; Peart, 115–145).

30. (A) Although the biggest risk factor of breast cancer is gender (female), having a sister with breast cancer can signiﬁcantly increase a person’s risks for the disease. A personal history applies only if the patient has had breast cancer (ACR, 8–9). 31. (C) The ﬁnal rule of mammography, dictated by the MQSA, states that a single projection/ position screen-ﬁlm mammogram should not give more that 300 mrad (3 mGy) per projection/position average glandular dose when a grid is used and should not exceed 100 mrad (1 mGy) per projection/position without a grid (Bushong, 342–356; Peart, 237–256). 32. (B) Newer mammogram generators have a backup timer that works with the conventional AEC systems. The mammography exposure timer selects the actual time of the exposure which affect patient dose and image optical density, while the AEC cuts the exposure when the correct density is achieved. The phototimer was a type of AEC device used in older x-ray units. Currently most AEC devices are ionization chamber type. The backup timer stops the exposure before the optimal density is reached if the

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energy of the beam is too low. If the backup time is reached during a breast exposure, the mammographer should select a higher kVp setting for the repeat radiograph. Only by selecting a higher kVp is the mammographer able to increase the beam’s energy. The backup timer is preset at 600 mAs for grid work and 300 mAs for nongrid (magniﬁcation) imaging (Peart, 65–84). 33. (A) The MQSA requires that the density difference, DD, created by using the 4.0-mm acrylic disk, should be at least 0.40, and should not vary by more than ±0.05 from the operating level. Also, the phantom image background optical density should be at least 1.40 and should not vary by more than ±0.20 from the operating level (ACR, 186). 34. (A) White (minus-density) artifacts indicate pressure on the emulsion before exposure and dark (plus-density) artifacts indicate pressure after exposure. Static is caused by ﬁlm handling in low humidity. Improperly cleaned or worn rollers cause repeating artifacts that run parallel to the direction of ﬁlm travel (Andolina, 44–94; Peart, 87–112).

ductal carcinoma associated with eczematous changes of the nipple. Generally it presents as a malignant nipple lesion. Inﬁltrating carcinoma implies that the cancer has left the point of origin and is spreading into the surrounding tissues (Venes, 1566; Peart, 47–62). 38. (A) Compression should be applied evenly over the breast by using a ﬂat paddle parallel to the image receptor. Uneven compression leads to false-negative or false-positive results because comparison between relative mass densities is not possible (Andolina, 174–245; Peart, 87–112).

39. (B) The principle disadvantage of magniﬁcation is that the increased OID places the patient’s breast very close to the x-ray tube. Because the radiation intensity is related to the square of the distance, magniﬁcation usually results in about twice the normal patient dose. The small focal spot used in magniﬁcation compensates for the reduced resolution. Magniﬁcation therefore does not decrease resolution. The air-gap technique reduces, rather than increases, the amount of scattered radiation reaching the image receptor (Bushong, 327–340).

35. (B) The Montgomery glands (glands of Montgomery) are seen as protrusions on the surface of the areola and are actually specialized sebaceous glands. (The openings to the protrusions are called Morgagni tubercles.) They usually become more prominent during pregnancy and lactation and secrete a ﬂuid which helps lubricate the nipple and areola (Peart, 35–44).

36. (D) Estrogen and progesterone are two of the many hormones responsible for many physiological changes in the breast. Estrogen is responsible for ductal proliferation and progesterone for lobular proliferation. Once a woman starts estrogen, the changes can be spotty, causing lumps or increased interstitial ﬂuids (cysts), but will generally result in an overall increase in glandular tissue (Peart, 35–44). 37. (B) Paget disease of the breast (ﬁrst described by Jean Paget in 1874) is a special form of

40. (D) Conventional mammography usually uses either molybdenum or rhodium as target materials. Molybdenum has an atomic number of 42 versus rhodium with a slightly higher atomic number of 45. The emission spectrum from a molybdenum target tube has a slightly lower K-edge and less bremsstrahlung x-rays than that of rhodium. This difference in emission spectra allows for slightly higher kVp selections when using rhodium targets. The target material then determines the kVp range and thus the quality of the beam. Rhodium produces better images for thick, dense breast without loss of contrast and with decreased patient dose. However, if used on fatty breast, the contrast will be signiﬁcantly reduced with only a minimal reduction in dose (Peart, 65–84; Bushong, 327–340).

41. (B) The breast droops in the MLO if adequate compression is not applied to the anterior

Answers and Explanations: 33 through 50

breast. Compression should be applied evenly throughout the anterior, posterior, and lateral parts of the breast. If too much axilla is included in the compression ﬁeld, the posterior breast is adequately compressed, but compression is inadequate for the anterior breast (Andolina, 174–245; Peart, 115–145).

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fog must remain within +0.03 of the established operating level (ACR, 159). 46. (B) Gynecomastia is a benign increase of tissue in the male breast. It can occur bilaterally or unilaterally. Gynecomastia does not increase the risk of breast cancer for male patients (Peart, 47–62).

42. (A) In the rolled positions, the top half of the breast is rolled in one direction and the bottom half in the other direction. With the medial roll, the top is rolled medially. In the lateral roll, the top is rolled laterally. The medial and lateral roll (RM and RL) are both useful in separating glandular structures of the breast to clear questions of superimposition. The LM is a lateral projection, with the x-rays traveling from 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 among women who have a ﬁrst child prior to age 30, breast-feed, and experience late menarche or early menopause. Studies have suggested that reproductive hormones inﬂuence breast cancer; therefore, factors that affect reproductive hormones (early menarche [before 12], late menopause [after 55], late age at ﬁrst full-term pregnancy [after 30], use of oral contraceptives, and estrogen replacement therapy) affect breast cancer risk (ACR, 8–9).

47. (A) The total ﬁltration is a combination of the inherent and any added ﬁltration. In any mammography unit, the inherent ﬁltration may fall in the region of 0.1 mm Al or equivalent, but the total ﬁltration should never be lower than 0.5 mm Al or equivalent (Bushong, 327–340).

48. (B) Although the MQSA recommends that technical factors appear on the image, this is not an MQSA requirement. Other recommendations are

• ﬂash card ID versus stick-on labels because the ﬂash ID is more permanent

• separate date stickers because they are easy to read and can be color-coded by year The requirements are

• name of patient and additional patient identiﬁer

• date of examination • projection and laterality (right or left •

marker)—placed near the axilla using the standardized codes facility name and location (must include city, state, and zip code) mammographer identiﬁcation cassette/screen identiﬁcation mammography unit identiﬁcation (if more than one unit per site) (ACR, 26–27).

44. (D) All mammographic x-ray tubes are manufactured with a tungsten, molybdenum, or rhodium target. These targets have different atomic numbers and therefore different emission spectrums. The emission spectrum of the beam is shaped by altering a combination of the target material and the ﬁltration. However, these designs are built into the mammography unit. Although the mammographer can select different targets, the he/she is unable to alter the built-in target material and therefore the emission spectrum of the beam (Bushong, 327–340; Peart, 65–84).

49. (D) The breast can reach superiorly from the clavicle (second or third rib), and inferiorly to meet the abdominal wall at the level of the sixth or seventh rib. This lowest point of the breast is called the inframammary crease or fold (Peart, 35–44).

45. (A) The MQSA requires that the mid-density and density difference, DD be within ±0.15 of the established operating level. The base plus

50. (A) The Cooper ligaments are ﬁbrous membranes that support the lobes of the breast. The ligaments attach to the base of the breast

• • •

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6: Practice Test 1

and extend outward attaching to the anterior superﬁcial fascia of the skin (Figure 6-10)

the amount of scattered radiation reaching the ﬁlm (Bushong, 327–340).

(Peart, 35–44).

Rib Pectoral muscle Vein Retromammary adipose tissue Cooper ligaments Subcutaneous adipose tissue

Mammary ducts or segmental ducts Ampulla or lactiferous sinus Areola Nipple

Glandular tissue lobules Artery

Figure 6–10.

Connective tissue and adipose tissue

Diagram of the breast.

51. (C) Starting at the nipple, the collecting ductal system immediately widens into an ampulla called the lactiferous sinus. This is a pouchlike structure that again narrows and joins one or more segmental ducts, eventually branching further until it ends at the terminal ductal lobular unit (TDLU) (Peart, 35–44). 52. (C) Scattered radiation is produced whenever the useful beam intercepts any object causing it to diverge. There are two methods of reducing the amount of scattered radiation reaching the image receptor: limiting the x-ray ﬁeld size (not an option in mammography) and the use of grids. In magniﬁcation mammography the large air gap acts as a grid in reducing scattered radiation. Grid use in magniﬁcation will therefore unnecessarily increase the exposure dose to the patient. Increasing the SID reduces magniﬁcation but does not reduce the amount of scatter production. It is not used in magniﬁcation mammography. The small focal spot is necessary to increase resolution, but this does not affect

53. (C) Ductography will not determine if a lesion is malignant or benign, but it can determine the location and number of lesions or changes associated with the ducts. Only a cytological or histological analysis can accurately determine the true nature of the lesion (Andolina, 313–330; Peart, 203–220).

54. (A) A 5-degree lateral tube angulation allows the compression paddle to clear the humeral head. The tube angled medially further projects the humeral head in the area of interest. Using a straight tube is a routine CC projection and does not alter the imaging. Other alternatives XCCL image the lateral breast or ML change the orientation of any abnormality in relation to the nipple (ACR, 60; Peart, 115–145). 55. (A) Positioning the breast away from the image receptor takes advantage of the inverse-square law: the intensity of the scattered radiation is reduced because the distance between the image receptor and the object is increased. The heel effect describes the process that causes the radiation intensity at the cathode side of the x-ray ﬁeld to be higher than that on the anode side. The line focus principle is an angled design of the tube target that allows a large area for heating while maintaining a small focal spot. The reciprocity law states that the density produced on a radiograph is equal for any combination of mA and exposure time as long as the product of mA and the ms is equal (ACR, 59–60; Bushong, 327–340).

56. (C) Risk factors increases a woman’s risk for breast cancer. Risks factors are divided into relatively high risk, moderate risks, and minor risks. High-risks factors include gender (female), age, genetic factors, and family or personal history of breast cancer. Moderate risk factors include having one ﬁrstdegree relative with breast cancer, having atypical hyperplasia conﬁrmed on biopsy, high radiation dose to the chest area, high bone density after menopause. Minor risk

Answers and Explanations: 51 through 64

factors are associated with hormonal use or changes in the body and include not having children or having the ﬁrst child after age 30, not breast-feeding, early menarche (before age 12) or late menopause (after age 55), postmenopausal obesity, recent and longterm use of hormone replacement therapy (HRT) or oral contraceptive, alcohol consumption, and obesity (ACS, 1–17). 57. (D) Grids do not improve image sharpness; the sharpness of an image is affected by the focal-spot size, SID, OID, type of intensifying screens, and motion. Grids increase patient dose and reduce the amount of scattered radiation striking the ﬁlm, but do not affect the production of scatter radiation. Grid use will, however, result in increased subject contrast (Bushong, 327–340; Peart, 65–84). 58. (D) As long as the implant is soft and remains free of encapsulation, the ID projections are possible. Once the implant is encapsulated, it is difﬁcult if not impossible to displace. Most modern implants are placed behind the pectoral muscle (subpectoral or retropectoral placement) versus placement in front of the pectoral muscle (subglandular or retromammary placement) that was done in the past. The placement of the implant behind the pectoral muscle allows better imaging and better displacement of the implants for the ID projections (Andolina, 174–245; Peart, 115–145).

59. (B) On an average, a mammogram detects 90% of breast cancers in women without symptoms, and is more accurate in postmenopausal than premenopausal women. Some cancers are not detected mammographically because of high breast density, faster growth rate, or failure to recognize the early signs of an abnormality. If the mammogram is normal and the patient feels a palpable mass, the mass could be normal or abnormal. The patient must contact her doctor immediately for further testing (ACS, 1–17; Peart, 47–62). 60. (C) Risk factors increases a woman’s risk for breast cancer. Risks factors are divided into

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relatively high risk, moderate risks, and minor risks. High-risk factors include gender (female), age, genetic factors, and family or personal history of breast cancer. Moderate risk factors include having one ﬁrst-degree relative with breast cancer, having atypical hyperplasia conﬁrmed on biopsy, high radiation dose to the chest area, high bone density after menopause. Minor risk factors are associated with hormonal use or changes in the body and include not having children or having the ﬁrst child after age 30, not breastfeeding, early menarche (before age 12) or late menopause (after age 55), postmenopausal obesity, recent and long-term use of HRT or oral contraceptive, alcohol consumption, and obesity (ACR, 8–9; ACS, 1–16). 61. (B) The focal spot size is important in mammography and many x-ray tubes have two focal spot sizes—one for routine and one for magniﬁcation work. In routine work, the focal spot size can be 0.4 or smaller. In magniﬁcation work, the focal spot may be 0.15 or smaller. Any work done with a 0.1-mm focal spot size would be for magniﬁcation (Bushong, 327–340; Peart, 65–84).

62. (C) Although the majority of processing units operate at a developer temperature of 95°F, some may not. The actual temperature is suggested by the manufacturer and should be within ±0.5°F of the value speciﬁed by the manufacturer (ACR, 130, 215). 63. (B) Daily QC is used to assess consistency of ﬁlm and ﬁlm processing. Introducing multiple processing variables such as variations in ﬁlm emulsion (by using a ﬁlm from a different box each time) will muddle the results (ACR, 149). 64. (B) The breast includes the nipple, inframammary fold, and tail of Spence. The tail of Spence (tail, axilla, or axillary tail are other names used) describes the area of the breast stretching up into the axilla. The base describes the region where the inframammary fold is located, closest to the chest wall. The apex is the nipple region, and the most distal point of the breast (Peart, 35–44).

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65. (C) Fibrous tissue is usually described with glandular tissue together as fibroglandular densities. X-rays pass more easily through fatty tissue than through fibrous or glandular tissue. Fatty areas appear radiolucent (black or less dense area on the mammogram). The fibroglandular or fibrous tissue is more radiopaque than fatty tissue, and shows as areas of lower optical density (white or dense) on the mammogram (Peart, 35–44).

66. (B) Figure 6-5 shows casting-type calciﬁcations which are often malignant. The shape of the cast is determined by the uneven production of calciﬁcation and the irregular necrosis of the cellular debris. The contours of the cast are always irregular in density, width, and length, and the cast is always fragmented. A calciﬁcation is seen as branching when it extends into adjacent ducts. Also, the width of the ducts will determine the width of the castings. A diagnosis of invasive ductal carcinoma is only made on cytological or histological analysis (Tabár, 149–238).

67. (D) The only huge radiolucent breast lesion here is a lipoma, which is a common benign tumor composed of fatty tissue. Another large lesion is the ﬁbroadenolipoma or hamartoma. It is a benign proliferation of ﬁbrous, glandular, and fatty tissue surrounded by a thin capsule of connective tissue. The oil cyst is benign and appears mammographically as eggshell-like calciﬁcations. Both the ﬁbroadenoma and the hematoma are seen as circularoval lesions with mixed densities and generally will not occupy the entire breast (Tabár, 17–92).

68. (D) The AEC detector is placed directly below the image receptor or cassette in mammography to minimize OID (in x-ray imaging, the AEC detector is most often placed above the image receptor). Because radiation has to pass through the breast before reaching the detector, the primary reason for backup time and inadequate exposure is the inability of low-energy photons to penetrate the breast (Peart, 65–84).

69. (B) The decline in breast cancer mortality is a result of improvement in breast cancer treatment and the beneﬁts of mammography screening. Although there is no guarantee that all patients will survive, the long-term survival rates are actually improving because cancers discovered at an earlier stage have a better prognosis, giving women a better longterm survival rate (ACS, 1–16). 70. (C) Contaminated developer can cause wet ﬁlms, an increase in the base fog, or decreased ﬁlm speed. Increased ﬁlm contrast represents inherent properties of the ﬁlm speed latitude and the different quantities and qualities of radiating effect on them. Processing condition such as the developer temperature being too high, the replenishment rates being too high, or improper mixing of the developer solution and overall radiographic quality will also affect ﬁlm contrast (Bushong, 204–217; Peart, 65–84).

71. (B) Spot compression increases compression to the area of suspected abnormality, allowing the tissue to spread more evenly and eliminating pseudomasses. Because of the need to reduce extraneous light (increase visualization of breast tissue), coned collimated images are no longer taken when imaging with spot compression (Peart, 115–145). 72. (B) The FB or caudal-cranial projection may be useful in nonconforming patients or ﬁnding lesions high on the chest wall. In performing the FB, the image receptor is above the breast and compression is applied at the inframammary fold. The TAN is used to image skin lesions. The XCCL images the far lateral breast in the CC position and RM is the roll medial where the upper surface of the breast is rolled medially (from the CC position) (Peart, 115–1457). 73. (B) If the patient stands away from the image receptor and bends forward, her chest will be brought forward and derriere back, removing the abdomen from the imaging area. If this does not achieve the desired results and the abdomen still protrudes, the mammographer

Answers and Explanations: 65 through 77

cannot sacriﬁce posterior and lateral tissue to image the anterior breast. Two projections may be required—a lateral of the anterior breast and the MLO for the posterior and UOQ of the breast (Andolina, 246–310; Peart,

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quantum mottle) (Figure 6-12) (Andolina, 437–452; Peart, 179–194).

115–145).

74. (B) Spot compression increases compression over the area of interest, spreading out the tissue more evenly and allowing visualization of the margins or borders of lesions. Biopsy is a surgical procedure. Aspiration is generally done to remove the content of a cyst, and stereotactic localization is used to localize nonpalpable lesions. Mammography is the ﬁrst line of defense against breast cancer. Before further testing is undertaken, as much information on the lesion should be gathered from mammography (Andolina, 174–245; Peart, 115–145; Tucker, 241–280).

75. (B) The specimen should always be compressed and radiographed to ensure that the lesion was completely removed. If there are calciﬁcations present, the lesion should be magniﬁed to ensure that all the calciﬁcations were removed (Andolina, 331–402; Peart, 203–220;

Intensity relative of the luminosity

IP Film/Screen

Log of relative exposure Figure 6–11. Characteristic curve (also called sensitometric curve or Hurter and Drifﬁeld [H & D] curve) from ﬁlm-screen versus digital imaging. A graph of the optical density signal and the relative exposure for a digital imaging plate (IP) has a linear response to x-ray. This is unlike the curvilinear response of a ﬁlm-screen system.

Tucker, 241–280).

76. (A) Digital images generally will not appear too light or dark because digital imaging has the advantage of being able to manipulate the ﬁnal image. In digital imaging, if a graph of the optical density (called the signal) and the relative exposure is plotted the relationship is not the characteristic curve (also called Hurter and Drifﬁeld [H & D] or sensitometric curve); rather, it is a straight line (Figure 6-11). The digital image therefore has much wider latitude than conventional mammography. This ability to adjust the ﬁnal image (thus reducing the need for repeats) is one of the greatest advantages of digital imaging. The problem is that, although overexposure can be corrected, the patient dose is high. The mammographer can encounter problems with underexposed images, however. If the digital signal is not enough to produce a “good” image, the image appears excessively noisy (appearance similar to

Figure 6–12. In conventional imaging, quantum mottle occurs when there are not sufﬁcient incident photons reaching the intensifying screen. The effect is similar in digital imaging.

77. (B) Gynecomastia is a benign proliferation of tissue in the male breast. The condition usually has a high rate of spontaneous regression and can occur at birth, during teenage years (can last up to 18 months), or in males above age 50. It is often seen bilaterally but can be unilateral. Gynecomastia is not associated with increased risk for breast cancer in males (Peart, 47–62; Venes, 918).

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78. (C) The Montgomery glands (glands of Montgomery) are seen as protrusions on the surface of the areola. They are actually specialized sebaceous glands that usually become more prominent during pregnancy and lactation (Peart, 35–44). 79. (A) Extended processing extends the time the ﬁlm spends in the developer solution. It may also raise the temperature of the developer solution. The overall effect of extended processing is to increase the speed and contrast of some single emulsion ﬁlms. The ﬁlm requires less exposure; therefore, the radiation dose to the patient can be lowered (Andolina, 45–98; Peart, 65–84).

80. (C) The humidity level in the darkroom should be between 30% and 50%. Low humidity (less than 30%) causes static and high humidity (more than 50%) causes clumping of the film emulsion from water vapor clinging to the film. Dirty rollers may cause scratches on the films. Changes in developer temperature, improperly mixed developer, or contaminated developer can cause reduced film speed or increased base fog (Figure 6-13) (Andolina, 45–98; Peart, 65–84).

81. (A) Above 40, it is recommended that a woman have a CBE at about the same time as the annual mammogram, even if the woman has no symptoms and no signiﬁcantly higher risk for breast cancer (ACR, 10). 82. (D) Fibrous and glandular tissue together are described as ﬁbroglandular densities. X-rays will more easily penetrate through fatty tissue than through ﬁbrous or glandular tissue. Fatty areas appear as radiolucent (black or less dense) areas on the mammogram. The ﬁbroglandular tissue is more radiopaque than fatty tissues and results in areas of lower optical density on the mammogram (white or denser areas) (Peart, 35–44). 83. (C) Compression decreases the thickness of the breast, bringing the breast closer to the image receptor and increasing subject contrast. Spatial resolution (sometimes called image detail) is the ability to image small objects that have a high subject contrast, for example, microcalciﬁcations in breast tissue, and is most affected by focal-spot blur but also improved with decrease geometric blur and motion blur. Contrast resolution (sometimes called visibility of detail) is the ability to distinguish anatomic structures of similar subject contrast and is most affected by scatter radiation and radiographic noise. Resolution affects the image appearance by demonstrating ﬁne detail of structures. Because resolution improves when the OID decreases, compression also increases spatial resolution (ACR, 23–77; Peart, 115–145).

Figure 6–13. darkroom.

Static is often the result of low humidity in the

84. (D) A core biopsy removes a cylinder of tissue using a 14- or higher gauge needle. The sample from a core biopsy is larger than that from FNA. Tissue samples from a core biopsy are assessed histologically. FNA or ﬁne needle aspiration cytology (FNAC) is more difﬁcult to perform. A 20- to 23-gauge needle is used to remove cellular material for cytological analysis. Excisional biopsy is a surgical biopsy where the entire lesion as well as surrounding margins of normal-appearing tissue is removed. Wire localization is a procedure during which nonpalpable lesions or

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Answers and Explanations: 78 through 90

calciﬁcations in the breast are identiﬁed by placing a thin needle into the breast. The needle is guided using mammograms or ultrasound, and a small hook wire is placed to mark the site of the lesion before surgery (Andolina, 313–330; Peart, 203–220).

88. (D) The arm position will help to minimize skin folds. Sliding your ﬁnger under the compression device to roll the folds laterally will also help. (A) will maximize visualization of the posterior lateral tissue. (B) and (C) will improve visualization of the medial breast (ACR, 34–50).

85. (D) The rolled medial or the rolled lateral (RM or RL) are both useful in separating glandular structures of the breast to clear questions of superimposition. The ID projection is used in imaging augmented breast clear of the implants. The MLO is a routine projection and would not be used as an additional projection. The XCCL is best for imaging the posterolateral parts of the breast with the x-ray traveling craniocaudal (Peart, 115–145). 86. (C) The high placement of the image receptor unnecessarily elevates the shoulder, pulling breast tissue from the compression ﬁeld. There will be poor pectoral muscle and possible missed posterior breast but compression of the lower breast will not be compromised. If, however, the patient has a protruding abdomen the compression paddle hits the abdomen, compressing the abdomen and not the lower breast. If too much shoulder muscle and axilla are allowed in the compression ﬁeld, the axilla will be compressed but the thickness of the axilla will not allow for compression of the lower breast (Peart, 115–145). 87. (C) As a woman ages, declining hormone levels affect both the breast stroma and epithelium. The breast loses its supporting structure to fat, producing a smaller breast or a larger, more pendulous breast because of the loss of the epithelial structures and stroma and gain of fat. The duct system remains but the lobules shrink and collapse. This process generally speeds up at menopause and may continue for 3–5 years. It is referred to as atrophy or involution. Increased estrogen or hormone levels, which occur during menstruation, result in an increase in breast stroma and epithelium leading to denser breast tissue (Peart, 13–44).

89. (A) In conventional mammography imaging the x-rays interacts primarily with the entrance surface of the screen. If the screen is between the x-ray tube and the ﬁlm, the excess screen blur will cause increased spatial resolution or image detail. This refers to the ability to image small objects that have a high subject contrast, for example, microcalciﬁcations in the breast. With the ﬁlm between the x-ray tube and the screen (the ﬁlm is placed with the emulsion side to the screen), screen bloom is reduced and spatial resolution is improved (Figure 6-14) (Bushong, 327–340; Peart, 65–84).

90. (B) Although grids increase contrast, in magniﬁcation mammography the large OID or air gap acts like a grid in reducing scatter radiation from reaching the ﬁlm. Grid use in magniﬁcation would increase exposure times, increase tube loading, and thus increase motion artifact because of long exposure times. Patient radiation dose is also increased (ACR, 59; Peart, 65–84).

X-ray tube

X-ray tube Screen bloom Screen

Film

Screen bloom

Film (base and emulsion)

Incorrect screen position Correct screen position Figure 6–14. Position of the ﬁlm and intensifying screen is important in mammography. In the incorrect position, the intensifying screen is placed between the primary beam and the ﬁlm resulting in excessive screen blur. Spatial resolution will improve if the ﬁlm is placed between the primary beam and the intensifying screen.

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91. (D) The FB best visualizes the central and medial abnormalities high on the chest wall and can be done for all these reasons. The beam is directed inferiorly to superiorly

thermometers are easily broken and can damage or contaminate the processor. Even small amounts of mercury can permanently contaminate the processor (ACR, 130; Peart, 65–84).

(ACR, 68; Peart, 115–145).

92. (D) The ML provides a true representation of the breast structures in relation to the nipple, but should not be used as a routine projection because it is poor at visualizing the posterior and lateral aspects of the breast. TAN projection can be used to locate skin lesions. The FB can replace the CC in the nonconforming patient and the XCCL images the far lateral breast tissue in the CC position (Peart, 115–145). 93. (A) Parallel grid designs are common in mammography. Here the lead strips are aligned adjacent and parallel to each other and placed lengthwise in grid structure. Parallel grids allow CR angulation in the direction of the lead strips only and will remove scatter in one direction. Option (B) describes the crossed (crosshatch or crisscross) grid design. This is similar to having two linear grids with their linear patterns at right angles to each other. Crossed grids do not permit any CR angulation and will clean up scatter in both directions. Option (C) describes the focused grid where the lead strips are virtually parallel in the midsection but at the periphery they incline slightly toward the center of the grid. The focused grid must be used at its designed SID to avoid grid cutoff and work will with mammography units which are designed to operate at ﬁxed a SID. Grid cutoff is the unwanted absorption of the primary bema by the lead strips of the grid. Option (D) describes the moving grid. Grids can be stationary or moving. The stationary grid will produce observable images of the grid lines. The moving grid “moves” during the exposure. In breast imaging, the grid is a reciprocating grid that moves to and fro versus the oscillating grid that moves in the circular pattern (Bushong, 248–261; Peart, 77). 94. (B) If the processor does not have an internal digital thermometer, any regular digital thermometer can be used. The mercury-in-glass

95. (A) Mammography units generally have two sets of focal spot sizes, one for routine imaging and the other for magniﬁcation. To maintain a sharp image during magniﬁcation, a small focal spot size is used. The small focal spot size increases spatial resolution. Resolution is also increased by decreasing the thickness of the part under compression, thereby lessening geometric unsharpness (Bushong, 327–340; Peart, 65–84).

96. (D) The half-value-layer (HVL) of the x-ray beam is the thickness of absorbing material needed to reduce the intensity of the beam to half of its original value. Dosimeter equipment and an ionization chamber are just two of a number of methods that can be used to measure the radiation intensity for successively thicker sections of ﬁlters. The slit camera is an effective measuring tool used to determine the focal spot size. The star pattern and the pinhole camera can also be used to measure focal spot size (Bushong, 327–340; Peart, 237–256). 97. (A) The overall repeat rate should be approximately 2% or less, but a rate of 5% is probably adequate. If the repeat rate exceeds the acceptable level (2% or 5%) or if repeat or reject rates change from the previously measured rate by more than ±2%, the change should be investigated and corrective action taken (ACR, 207). 98. (C) Oil cysts show mammographically as high-density tumors with lucent centers and eggshell-like calciﬁcations. They usually form as a result of fat necrosis or are calciﬁed hematomas. Fat necrosis is death of fatty tissue 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. The body then forms a capsule around the oil to protect itself. The capsule generally has a thin layer of calciﬁcations, which give an eggshelllike appearance on the mammogram. Oil cysts

Answers and Explanations: 91 through 104

are benign. Ductal papillomas are benign masses associated with the ducts and are not seen mammographically. A ﬁbroadenoma is a benign radiolucent mass that may or may not contain calciﬁcations. A hematoma is seen as a circular-oval lesion with mixed density. It is a benign mass associated with injury or surgery (Peart, 47–63; Tabár, 17–92).

99. (C) The ﬁnal mammographic image should be evaluated under ideal viewing conditions. Excellent viewing conditions include low ambient room light to minimize light reﬂected off the surface of the image. The view-boxes should be cleaned and checked regularly because they can become dirty or the luminance of the bulbs can fade. Masking the image eliminates extraneous viewbox light, which has not passed through the exposed area of the ﬁlm, from reaching the eye. If the extraneous viewbox light is blocked, it is often possible to see the skin and subcutaneous tissues (ACR, 92; Peart, 87–112). 100. (C) The implant displaced (ID) projection is a method of imaging the augmented breast. The method displaces the implant posteriorly to exclude it from the compression area. ID projections are taken in addition to the routine projections. In general, the routine series of projection for a patient with breast augmentation would be routine CC of both breasts, routine MLO of both breasts, CC with ID of both breasts, and MLO with ID of both breasts (Peart, 115–145). 101. (D) Under the ﬁnal regulations of the US Food and Drug Administration (FDA), all mammographers satisfying the interim regulations can still perform mammograms. All new mammographers must:

• complete at least 40 contact hours of documented training in mammography under the supervision of a qualiﬁed instructor or, before April 28, 1999, have satisﬁed the requirements of the interim regulation of the FDA • perform a minimum of 25 examinations under direct supervision of a qualiﬁed mammographer

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• have at least 8 hours of training in each mammography modality in which the technologist intends to practice (eg, digitalvs. conventional screen–ﬁlm systems) if the mammographer started working in the new modality after April 28, 1999 (Accreditation and Certiﬁcation Overview: Technologist Training)

102. (B) For proper positioning of the MLO, the pectoral muscle is wide superiorly with a convex anterior border, extending to or below the posterior nipple line. Other criteria include that there is no evidence of motion and deep and superﬁcial tissues are well separated (ACR, 42). 103. (A) Ductal ectasia is a benign inﬂammatory condition of the ducts, which leads to nipple discharge, nipple inversion, or periareolar sepsis. The condition may resemble breast carcinoma. Paget disease of the breast is a special form of ductal carcinoma associated with changes of the nipple. Peau d’o range is a condition where the skin of the breast becomes thickened and dimpled, resembling an orange; this may be the result of either benign or malignant conditions. Ductal papillomas are benign masses associated with the ducts and are not usually seen mammographically (Andolina, 155–173; Peart, 35–44). 104. (A) In the immature breast the ducts and alveoli in the lobule are lined by a two-layer epithelium of cells. After puberty this epithelium proliferates, forming three alveolar cell types: superﬁcial (luminal) A cells, basal B cells (chief cells), and myoepithelial cells forming the innermost layer or basal surface of the epithelium. Beneath the epithelium is connective tissue that helps to keep the epithelium in place. Between the epithelium and the connective tissue is a layer called the basement membrane. The basement membrane provides support and acts as a semipermeable ﬁlter under the epithelium (Peart, 35–44; Tortora, 1083).

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105. (B) In this form of unsharpness there is a further spread of light from the screen before it reaches the ﬁlm. Unlike motion unsharpness, which covers a wider area, unsharpness because of poor screen contact is usually localized. Noisy images are mainly because of scatter or quantum mottle. Scatter radiation provides no useful information on the image and will also reduce subject contrast. Most scatter in imaging is the result of Compton effect, where an incident electron interacts with an outer-shell electron and ejects it from the atom, ionizing the atom. The ejected electron is called the Compton electron. When not enough photons are used to form the image, the result is a greater amount of quantum mottle. Subject contrast refers to the variations of tissue density seen on the image (ACR, 104–105). 106. (B) Mammoplasty is the general term used when describing reshaping of the breast. The breast can be lifted to reduce a sagging breast, enlarged (augmented), or reconstructed after the removal of a tumor. Reduction mammoplasty is the term used to describe the reduction of the size of the breast by removing excess breast tissue. A breast biopsy is the removal of breast tissue for histological testing (Peart, 220–234; Tortora, 1096). 107. (B) Quantum mottle is one of the principal causes of radiographic noise. Radiographic noise is the undesirable ﬂuctuation in the density of the image because of ﬂuctuations in the number of x-ray photons interacting with the ﬁlm. The quantum mottle will be higher if the x-rays are produced with few x-ray photons. Image graininess (ﬁlm graininess) is the distribution in size and space of the silver halide grains in the emulsion, and contrast resolution refers to the ability to visually detect separate objects distinct from each other. Contrast resolution is best improved by using collimation. Motion results in blurring unsharpness of the image (ACR, 102–105; Bushong, 272–291).

108. (C) Yellow-brown stains on the ﬁlm are caused by thiosulfate from the ﬁxer, left on

the ﬁlm because of improper washing. This generally indicates a problem with hyporetention from the ﬁxer. The silver sulﬁde slowly builds up and appears as yellow in the stored radiograph. Streaks on the ﬁlm can result from light leaks in the cassette; a round spot of increased density may be caused by low humidity (static). Areas of reduced density could be caused by pressure on the ﬁlm before exposure (Bushong, 204–217). 109. (C) In the SIO projection, the beam is directed from the superolateral to the inferomedial surface of the breast; therefore, the medial breast is closest to the image receptor (Peart, 115–145). 110. (D) In general, male breast imaging will present the same difﬁculty as imaging a small, dense female breast and the breast size of males is sometimes no different than that of females. However, because of chest hair on males, the breast tends to slip from under the compression (Andolina, 246–310; Peart, 115–145). 111. (D) In the SIO, the rays are directed from the lateral portion of the upper axilla to the lower medial portion of the breast, that is, superiolateral to inferomedial. The superomedial to inferolateral is the routine MLO and the inferolateral to superomedial is the LMO. The inferomedial to superolateral has no American College or Radiology (ACR) label (Peart, 115–145). 112. (B) Under current regulations, an accreditation body can be a private, nonproﬁt organization or state agency. Currently, the US Food and Drug Administration (FDA)-approved accreditation bodies are the American College of Radiology (ACR) and the states of Arkansas, Iowa, and Texas. Accreditation bodies can accredit only those facilities located within their respective states (Accreditation and Certiﬁcation Overview). 113. (B) The MLO is one of the routine imaging projections. The reverse of this is the LMO. This projection will give a mirror image of the MLO and is useful in imaging patients with pacemakers. The LMO and also the LM

Answers and Explanations: 105 through 115

are good alternatives to the routine images and both can also be used for patients with infusa-port (port-a-caths inserted for longterm chemotherapy treatment), the kyphotic patient, and patients with recent open-heart surgery. The ML is not a good replacement because it is poor at imaging the posterior and lateral aspects of the breast. The XCCL only images the posterolateral breast tissue (Peart, 115–145).

the abnormality. In addition to these reasons, the greater the distance the needle travels in the breast, the greater the risk of deﬂection (Andolina, 313–330; Peart, 203–220). 115. (D) These are the MQSA requirements. The assessment of ﬁndings refers to the ﬁnal result (eg, benign). Additional patient identiﬁers could be the patient’s age, date of birth, or medical record number (Accreditation and Certiﬁcation Overview: Record Keeping).

114. (D) In breast localization, the shortest skin-toabnormality distance should always be used unless that projection will not demonstrate

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CHAPTER 7

Practice Test 2 Questions

1. Radiation therapy is a treatment that utilizes (A) drugs to treat cancer that may have spread (B) high-energy radiation to destroy cancer cells (C) radioactive tracers to track the path of cancer to the lymph nodes (D) potent pain medication to treat the severe pain from cancer

4. X-ray photons leaving the breast enter the top of the cassette/image receptor 1. to go through the intensifying screen before reaching the ﬁlm 2. then go through the ﬁlm before reaching the intensifying screen 3. interact with the single intensifying screen of the cassette/image receptor (A) (B) (C) (D)

2. Between ages 20 and 30 an asymptomatic woman should be having a mammogram every (A) (B) (C) (D)

year 2 years 3 years none of the above

5. In quality control (QC), if the data consistently exceed the operating level the recommendation is (A) (B) (C) (D)

3. Medical history may include questions on hormone use because (A) synthetic hormones such as hormone replacement therapy (HRT) will always cause breast cancer (B) reproductive hormones are a factor in breast cancer risks (C) family history of hormone use predisposes a woman to cancer (D) personal history of hormone use decreases a woman’s risk for breast cancer

1 and 2 2 and 3 1 and 3 1, 2, and 3

establish new operating limits narrow the control limits widen the control limits improve QC procedures

6. A control ﬁlm crossover should be carried out (A) whenever the processing chemistry is changed (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

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

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7: Practice Test 2

7. In digital imaging, a graph of the density range to the log of relative exposure (the characteristic curve or Hurter and Drifﬁeld (H&D) curve used in conventional imaging) shows a (A) (B) (C) (D)

shallow sloping curve steep sloping curve linear response curve similar to conventional imaging

8. On the American College of Radiology (ACR)-approved accreditation phantom, the total number of ﬁbers, speck groups, and masses are (A) ﬁve ﬁbers, ﬁve speck groups, and ﬁve masses (B) ﬁve ﬁbers, six speck groups, and ﬁve masses (C) six ﬁbers, ﬁve speck groups, and ﬁve masses (D) ﬁve ﬁbers, ﬁve speck groups, and six masses Figure 7–1

9. The circular pigmented area around the nipple is called the (A) (B) (C) (D)

skin areola Montgomery gland ampulla

10. A keratosis is demonstrated mammographically 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) (B) (C) (D)

mammographically benign calciﬁcations malignant calciﬁcations keratosis ﬁbroadenomas

12. What immediate action is used to reduce motion unsharpness in mammography? (A) (B) (C) (D)

compression low mAs (milliamperes per second) low kVp (kilovoltage peak) small focal spot size

13. In magniﬁcation, what immediate role does the large object-to-image receptor distance (OID) play in reducing scattered radiation? (A) The compressed breast allows lower kVp values. (B) Exposure is reduced because a grid is not needed. (C) Most of the scattered radiation misses the image receptor. (D) The larger source-to-image receptor distance (SID) utilizes the inverse square law.

Questions: 7 through 22

14. Quantum mottle on the image is reduced by (A) (B) (C) (D)

high kVp high mAs motion fast intensifying screens

15. What is the best placement for the needle wire during needle localization? (A) The needle wire should pass immediately below the lesion. (B) The needle wire should pass immediately above the lesion. (C) The needle wire should pass through the lesion. (D) The needle wire should pass immediately beside the lesion. 16. Although it often means losing some of the lateral breast tissue, in imaging for the craniocaudal (CC) projection, most experts advise a slight rotation of the patient’s body to maximize 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) projection 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.

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18. In the rolled medial (RM) position, the lower surface of the breast is rolled in which direction? (A) (B) (C) (D)

laterally medially inferiorly superiorly

19. A radiopaque implant used in breast reconstruction that easily adjusts for cup size after placement 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 mediolateral oblique (MLO), a routine series for a postmastectomy patient could also include the (A) (B) (C) (D)

axillary tail (AT) mediolateral (ML) TAN lateromedial oblique (LMO)

21. Men with a family history of breast cancer will (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) should be 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

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7: Practice Test 2

23. The absorbed dose in mammography is generally _______ the entrance skin exposure (ESE). (A) (B) (C) (D)

signiﬁcantly higher than signiﬁcantly lower than about the same as slighter higher than

24. The Mammography Quality Standards Act (MQSA) requires that the maximum compression for the initial power drive not exceed (A) (B) (C) (D)

100 newtons 200 newtons 400 newtons 500 newtons

25. Collimation should not extend beyond any edge of the image receptor by more than (A) (B) (C) (D)

1% of the SID 2% of the SID 3% of the SID 4% of the SID

26. In conventional imaging, the characteristic curve of a particular ﬁlm describes the relationship between the (A) exposure the ﬁlm receives and the density after processing (B) x-ray beam quality of the mammographic unit and ﬁlm speed (C) speed of the ﬁlm and the density at different exposure levels (D) screen-ﬁlm combination as it relates to the selected mAs 27. Under which of the following circumstances is it necessary to reestablish processor QC operating 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 and phantom image were recorded as follows: density inside the disk = 1.23, the middensity = 1.25, the background density = 1.68, the density adjacent to the disk = 1.66, and the highest density = 1.69. What is the density difference (DD) on the phantom image? (A) (B) (C) (D)

0.42 0.43 0.44 0.45

29. Breast tissue can extend medially to the (A) (B) (C) (D)

latissimus dorsi muscle midsternum retromammary space inframammary crease

30. Which of the following hormones has the most inﬂuence on the normal physiological changes of the breast? 1. prolactin 2. estrogen 3. progesterone (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

31. Which of the following is (are) considered a ﬁrst-degree relative? 1. mother 2. aunt 3. sister (A) (B) (C) (D)

1 only 1 and 2 only 2 and 3 only 1 and 3 only

Questions: 23 through 41

32. A woman should perform breast selfexamination (BSE) monthly to (A) (B) (C) (D)

become familiar with both of her breasts localize cancerous lumps recognize breast dimpling discover nipple discharge

33. The breast of a woman below age 35 is (A) (B) (C) (D)

not related to radiation sensitivity less sensitive to radiation less sensitive to low-dose radiation more sensitive to radiation

37. The from below (FB) projection utilizes a beam directed (A) (B) (C) (D)

photoelectric interaction Compton interactions Bremsstrahlung interaction Coherent interaction

35. In digital imaging a repeat analysis test is (A) unnecessary—digital imaging automatically corrects exposure mistakes (B) necessary—digital imaging cannot correct for overexposure (C) unnecessary—digital imaging corrects unsharpness by altering the spatial display (D) necessary—digital imaging cannot correct factors such as motion unsharpness 36. The same mammographer should view the phantom images because (A) subjective judgment about images is always difﬁcult (B) it is not wise to have different individuals handling the phantom (C) not all mammographers know the MQSA regulations (D) given set values, different mammographers will calculate the densities differently

perpendicular to the image receptor horizontally tangentially parallel to the image receptor

38. Radiation changes that the breast may exhibit include 1. erythema 2. edema 3. hardening (A) (B) (C) (D)

34. In the low kVp range using a molybdenum target tube, what type of photon interaction predominates? (A) (B) (C) (D)

139

1 and 2 2 and 3 1 and 3 1, 2, and 3

39. Magniﬁcation in mammography can be useful in all of the following except (A) (B) (C) (D)

specimen radiographs to deﬁne borders of masses to assess calciﬁcation routine screening

40. Which of the following projections could be used to replace the MLO in patients where the MLO is not possible? (A) (B) (C) (D)

ML lateromedial (LM) rolled lateral (RL) AT

41. Contrast resolution in conventional imaging refers to the ability to (A) image high-contrast small objects such as microcalciﬁcations (B) distinguish anatomic structures with similar subject contrast (C) visualize recorded detail when image contrast and optical density are optimized (D) visualize recorded detail

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7: Practice Test 2

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 technique with small breast because the (A) multiple detectors can be moved according to breast size (B) automatic exposure control (AEC) detector may not cover the small breast tissue area (C) AEC detector cannot compensate for breast size (D) AEC cannot compensate for varying breast tissue types 44. If an artifact is noted on some mammographic images, which appropriate MQSA regulation will identify the dirty cassette/ image receptor quickly and easily? (A) (B) (C) (D)

processor QC test screen cleanliness visual checklist standardized image labeling

45. Which of the following tests are performed monthly? (A) (B) (C) (D)

phantom images repeat/reject analysis compression check visual checklist

46. On a reject/repeat analysis, the rate was lower than 5% but one category of the reject/repeat analysis is signiﬁcantly higher than others. What should be done? (A) Although the overall rate is less than 5%, that one area should be targeted for improvement. (B) If the other categories are within normal limits, that area can be disregarded. (C) Because the rate was more than 2%, the entire department needs to be reassessed. (D) With an overall rate lower than 5%, one high rate is statistically meaningless. 47. Typically, grid ratios in mammography range from (A) (B) (C) (D)

7:1 to 8:1 6:1 to 7:1 4:1 to 6:1 3:1 to 5:1

48. Positron emission tomography (PET) imaging is useful in staging tumors because (A) the positron emitting isotopes are radioactive (B) PET imaging can display an image of the tumor bed (C) the positron emitting isotopes destroy the tumor bed (D) PET imaging tracks the increased blood ﬂow from the cancerous tumor 49. Medical history is important in 1. assessing risk factors for breast cancer 2. preventing breast cancer 3. evaluating treatment options (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

Questions: 42 through 58

50. Unlike conventional x-ray tubes, some mammography tubes are tilted 7.5–12 degrees from the horizontal. The effect of this is to 1. allow the use of smaller focal spot size 2. minimize the heel effect 3. increase resolution (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

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 cysts more common?

54. What effect does compression have on Compton interactions? (A) The absolute number of Compton interactions increases. (B) The absolute number of Compton interactions decreases. (C) Compression has no affect on Compton interactions. (D) Compression affects Compton interaction only above 70 kVp. 55. Visual inspection done during CBE involves (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

53. The CC shows a circumscribed oval radiolucent lesion. There was a deﬁnite halo surrounding the lesion. It is most likely to be a (A) (B) (C) (D)

ﬁbroadenoma lymph nodes cyst hematoma

feeling for changes in the breast looking for changes in the breast palpating the breast examining areas under the armpit

56. If the residual hypo in the mammography ﬁlm exceeds 0.05 g/m2 or 5 μg/cm2, this can indicate 1. improper washing of the ﬁlm 2. improper ﬁxer replenishment 3. the ﬁlm will have poor archival quality (A) (B) (C) (D)

1. young women in their early 20s 2. premenopausal woman 3. postmenopausal woman on estrogen therapy (A) (B) (C) (D)

141

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

57. Fatty tissue is generally radiolucent and will show on the mammogram as (A) (B) (C) (D)

glandular areas high-density areas low-density areas medium-density areas

58. The mammogram of a woman age 50 who has recently started estrogen replacement therapy is likely to be (A) more ﬁbroglandular than her past mammographic study (B) more fatty that her previous mammogram (C) less ﬁbrous and less glandular than her previous studies (D) unchanged from her previous mammograms

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7: Practice Test 2

59. The mammogram shows an oval-shaped lesion with mixed density. The lesion has a central radiolucent area and is freely movable. This lesion is most likely to be a (A) (B) (C) (D)

ﬁbroadenoma hematoma lymph node galactocele

60. If a cyst moves down on the ML from its position on the MLO, the cyst is located (A) (B) (C) (D)

centrally medially laterally at the areola

61. Increased OID causes loss of image detail in magniﬁcation mammography. What factors help to compensate for this loss of image detail? 1. compression of the part 2. decreased focal spot size 3. increased OID (A) (B) (C) (D)

64. The density difference, DD on the sensitometric strip is the difference between (A) the average density closest to 2.20 and the 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 from trauma (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) (B) (C) (D)

ruptured implant encapsulated implant herniated implant implant removal

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

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 assessment ﬁnding of Breast Imaging Reporting and Data 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 Figure 7–2

Questions: 59 through 78

67. After a four-projection mammogram, calciﬁcations are visualized superior to the nipple but only on the MLO projection. What additional projection would best be used to locate the position of the lesion? (A) (B) (C) (D)

exaggerated craniocaudal (XCCL) cleavage (CV) ML AT

68. Approximately how much contrast agent is injected into the breast during ductography? (A) (B) (C) (D)

1–5 cc 15–25 cc 30–40 cc 50–100 cc

69. What does the glandular dose measure? (A) (B) (C) (D)

the average dose to the patient’s skin the absorbed dose to the skin the absorbed dose at the tissue level the same as the entrance skin dose

70. Which of the following relationships does not change when moving from routine to magniﬁcation mammography? (A) (B) (C) (D)

OID focal spot size SID source-to-object distance (SOD)

71. Who performs the compression device check for mammography QC? (A) (B) (C) (D)

73. During pregnancy and lactation, the breast (A) (B) (C) (D)

(A) a lesion associated with trauma to the breast (B) a benign milk-ﬁlled cyst (C) associated with eggshell-like calciﬁcation (D) associated with a central radiolucent hilus

shows increased density increases in fatty content atrophy of glandular structures shows decreased density

74. Most of the glandular tissue is arranged in the breast around the (A) (B) (C) (D)

medial and upper inner quadrants lateral and lower inner quadrants central and upper outer quadrants 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 indicated when the (A) (B) (C) (D)

patient is in pain compression paddle stops breast is taut breast feels soft

77. Which factors cause increased skin dose in magniﬁcation? 1. larger OID 2. smaller focal spot size 3. increased mAs (A) (B) (C) (D)

physicist staff technologist radiologist mammographer

72. A galactocele is

143

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

78. In radiology, according to the line focus principle, the effective focal spot is (A) (B) (C) (D)

larger than the actual focal spot smaller than the actual focal spot the same as the actual focal spot decreased as the target angle increases

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7: Practice Test 2

79. Figures 7-3A and 7-3B are mammograms of the same patient. Figure 7-3B was taken 6 months after Figure 7-3A. These mammograms demonstrate a (A) (B) (C) (D)

resolving oil cyst galactocele radial scar hematoma

80. In the optimum position of the patient for the CC 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 would best separate superimposed 12-o’clock and 6-o’clock masses? (A) (B) (C) (D)

MLO XCCL CC AT

82. In positioning terminology, CV means (A) (B) (C) (D)

compressed position Cleopatra view cleavage view compression view

83. Malignant casting-type calciﬁcations appear on the mammogram as A Figure 7–3A

(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 the breast are contained within the (A) (B) (C) (D)

B

Figure 7–3B

lactiferous sinuses lobules ampulla areola

Questions: 79 through 91

85. If the nipple is not imaged in proﬁle on the fourprojection series, indications to take additional projections with the nipple in proﬁle include 1. the nipple cannot be differentiated from a mass 2. the patient has a possible retroareolar mass 3. the patient is male (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

86. The AT projection best demonstrates the (A) (B) (C) (D)

subareolar area medial aspect of the breast axillary aspect of the breast lower inner quadrant of the breast

87. The area of minus density in the upper part of 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

145

88. The patient had trauma to the breast 1 month ago and has developed a lump. Such an injury may show mammographically as a (A) (B) (C) (D)

galactocele hematoma lymph node ﬁbroadenoma

89. In mammography imaging, exposure factors used depends on all of the following except (A) (B) (C) (D)

the patient target material screen/ﬁlm combination viewing conditions

90. If too much upper axilla and shoulder are under the compression paddle when imaging for the MLO, the effect is to (A) inhibit proper compression of the upper breast (B) inhibit proper compression of the lower breast (C) ensure equal compression of the upper and lower breast (D) ensure proper compression of the lower breast 91. Of these four, which would best demonstrate microcalciﬁcations within the breast? (A) (B) (C) (D)

Figure 7–4

ultrasound spot compression spot magniﬁcation TAN projection

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7: Practice Test 2

92. The area of minus density in the upper part of Figure 7-5 best represents (A) (B) (C) (D)

a pacemaker the patient’s chin a hematoma port-a-cath

95. Which projection gives a mirror image of the MLO? (A) (B) (C) (D)

ML LM LMO AT

96. The nominal focal spot size of the mammography 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 magniﬁed images taken of the tumor bed to 1. conﬁrm the removal of the cancer 2. check calcium deposits that may result from radiation and surgical changes 3. check for recurrence of the cancer (A) (B) (C) (D)

Figure 7–5

93. A rolled projection can be performed to 1. remove superimposed tissues 2. separate superimposed breast tissue 3. determine the location of a ﬁnding seen only on one of the standard projection (A) (B) (C) (D)

1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

94. Ideally, in an open surgical biopsy, when should 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

1 and 2 2 and 3 1 and 3 1, 2, and 3

98. A lesion is present on the MLO but is not seen on the CC projection. What projection could best be used to determine whether the lesion is laterally or medially located? (A) (B) (C) (D)

XCCL CV ML AX

99. Delaying the processing of ﬁlms will affect the 1. speed of the ﬁlm 2. ﬁlm contrast 3. density of the ﬁlm (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

Questions: 92 through 109

100. When imaging a small breast, scattered radiation can be minimized by 1. increasing compression 2. reducing kVp 3. reducing ﬁeld size (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

101. The purpose of the certiﬁcation and accreditation 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 mammography facilities and conduct inspections 102. A facility has a sign posted advising patients to contact a designated person within the organization with comments. This facility is meeting the U.S. Food and Drug Administration (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) (B) (C) (D)

147

104. After parturition, contraction of which cells help to eject milk from the alveoli? (A) (B) (C) (D)

epithelial cells myoepithelial cells basement cells superﬁcial cells

105. A ﬁnding of BIRAD 1 on the mammogram means that the mammogram (A) (B) (C) (D)

cannot accurately evaluate the breast showed benign ﬁndings showed suspicious ﬁndings is suggestive for malignancy

106. Erythema of the breast generally indicates (A) (B) (C) (D)

inﬂammatory breast cancer breast abscess breast infections further testing of the breast is necessary

107. Which of the following is used as a treatment for estrogen-dependent tumors in post- and premenopausal women? (A) (B) (C) (D)

radiation therapy chemotherapy tamoxifen antibody therapy

108. Causes of radiographic noise include 1. quantum mottle on the image 2. scattered radiation 3. ﬁlm graininess (A) (B) (C) (D)

a malignant tumor of the breast a benign tumor of the breast associated with trauma of the breast associated with nursing

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

109. A thin supportive layer located between the basal surface of the epithelium and the connective tissue layer of the lobule is called (A) (B) (C) (D)

chief cells myoepithelial basement membrane superﬁcial A cells

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7: Practice Test 2

110. A “camel’s nose” breast contour can be prevented in the MLO projection by (A) including all of the breast under the compression paddle (B) angling the image receptor parallel to the pectoralis muscle (C) properly supporting the breast during compression (D) ensuring that the nipple remains in proﬁle during compression 111. The superior inferior oblique (SIO) will best demonstrate the (A) (B) (C) (D)

OUQ and the LOQ of the breast LIQ and the UIQ of the breast UIQ and LOQ of the breast LIQ and the OUQ of the breast

113. Under the MQSA, how long are facilities required to maintain the records of a patient who died shortly after her ﬁrst mammogram? (A) (B) (C) (D)

114. Under what circumstances are triangulation techniques necessary? 1. to locate an abnormality visualized on one projection only 2. during sterostatic breast biopsy 3. to perform spot magniﬁcation (A) (B) (C) (D)

112. The basic premise of a medical audit is that 1. all positive mammograms should be followed 2. the pathology results of all biopsies performed should be collected 3. all pathology results should be correlated with the radiologist’s ﬁndings (A) (B) (C) (D)

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

5 years 10 years 20 years permanently

1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

115. A dimpled skin condition seen in cases of lymphatic edema of the breast is called (A) (B) (C) (D)

inﬂammatory carcinoma ductal ectasia plasma cell mastitis peau d’o range

Answers and Explanations

1. (B) Many women are choosing conservation therapy that removes the tumor with wide margins (lumpectomy, quadrectomy, or segmental mastectomy) and includes radiation therapy (irradiation with high-energy beams). Treatment starts 3–8 weeks after surgery and includes about 5–6 weeks of daily treatments. Nuclear medicine uses radioactive tracer (also called radioactive isotopes or radiopharmaceutical). Drugs can be hormonal therapy (estrogen therapy) such as tamoxifen or chemotherapy (Andolina, 331–330; Peart, 220–234).

2. (D) An annual mammogram is generally recommended for asymptomatic women above age 40 who have not been identiﬁed as having signiﬁcantly higher risk. The mammogram is not an effective screening tool for younger women (ACS, 1–16). 3. (B) Studies have suggested that synthetic such as hormone replacement therapy (HRT) or reproductive hormones inﬂuence breast cancer risk as well as promote cancer growth. Early menarche (less than 12 years), late menopause (equal to or more than 55 years), oral contraceptive use, and fewer pregnancies will all increase a woman’s risk by affecting estrogen levels in the body. Hormones or hormone use, however, are not known to always cause breast cancer (ACS, 1–16). 4. (B) When exposed to radiation the intensifying screen will emit light, which then exposes the ﬁlm emulsion and forms a latent image. However, photons can travel through the intensifying screen interacting with the back

of the screen and also emitting light. Since the light diverges as it travels, the image formed at the back is not an exact replica of the one formed in front—effectively decreasing the recorded detail of the image. In conventional mammography imaging, the x-ray beam should therefore travel through the breast, through the ﬁlm, and then strike the intensifying screen. This placement will reduce screen blur. There is high x-ray absorption by the screen phosphors closest to the ﬁlm emulsion reducing the diffusion of light emitted from the screen. The result is less noise and greater spatial resolution (Figure 6-14) (Bushong, 327–340).

5. (D) If data seldom exceed the operating limits by ±0.1%, the medical physicist or radiologist may wish to narrow the control limits. If the limits are consistently exceeded, it is necessary to improve the QC procedures or repair or replace the appropriate equipment. Establishing new limits are allowed only under speciﬁc circumstances, such as if the ﬁlm is changed or there are changes in processing method (equipment or solutions, for example). Widening the control limits is never allowed (ACR, 134–135). 6. (B) Whenever a new box of ﬁlm is opened for QC, a crossover must be carried out. Radiographic ﬁlms are produced in batches, which will have slight variations in characteristics of the ﬁlm emulsion. This will affect the sensitometric characteristics of the ﬁlm. The crossover is carried out only with seasoned processor chemistry that is operating within plus or minus 0.10 of the control limits.

149

150

7: Practice Test 2

Figure 7–6. The crossover worksheet is used to calculate the difference in the average values between the new and old boxes of ﬁlm and thus 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 new operating levels must be reestablished using the original method of establishing processor QC operating levels.

The crossover is used to compare the average density difference (DD), mid-density (MD) and base-plus-fog of ﬁve ﬁlms from the old box with ﬁve ﬁlms from the new box. The new operating level is established by adding the difference (new minus old operating values) to the old operating level. If the difference is positive, the new operating level is increased. If the difference is negative, the new operating level is decreased (Figure 7-6). If control limits consistently exceed the normal values, the equipment needs to be repaired or replaced. Whenever new equipment is installed (processor, sensitometer, or densitometer), the processor QC operating levels must be reestablished (ACR, 161; Peart, 87–112).

7. (C) Digital detectors have image characteristic similar to the response of screen-ﬁlm except that the response in digital is linear (Figure 7-7). This means that regardless of the

Intensity relative of the luminosity

IP Film/Screen

Log of relative exposure Figure 7–7. Characteristic curve for digital imaging. A graph of the optical density signal and the relative exposure for a digital imaging plate (IP) will have a linear response to x-ray. This is unlike the curvilinear response of a ﬁlm-screen system.

Answers and Explanations: 7 through 13

intensity of the x-ray beam, a small change in the intensity is recorded as the same change in the electronic image. In digital imaging, this is possible because there are different devices for acquisition and display, and each can be separately optimized. Digital imaging therefore has a much wider latitude than conventional imaging. Digital imaging can enhance the contrast resolution of the ﬁnal image (Andolina, 437–452; Peart, 179–194). 8. (C) This is the total number in each group, but the criteria for the number of objects to meet accreditation requirements are a minimum number of four ﬁbers, three speck groups, and three masses (Figure 7-8). The only exceptions to date are the Hologic and Siemens digital units which require ﬁve ﬁbers, four speck groups, and four masses. When scoring, each ﬁber, speck group, or mass is counted as 1 point. Partial ﬁbers, speck groups, or masses are counted as 0.5 point or not at all (ACR, 268).

Figure 7–8. Schematic diagram of the phantom showing the relative position of the different objects embedded within the phantom.

9. (B) The areola is the smooth, darkened area that surrounds the nipple. Skin covers the entire breast, and the Montgomery glands are specialized sebaceous glands on the areola. The ampulla is another name for the lactiferous sinus, a part of the ductal system in the internal breast anatomy (Peart, 35–44; Tortora, 1083).

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10. (A) A keratosis forms on the skin surface of the breast and gives a typical mammographic appearance. They are multilobulated, with sharply outlined borders. An example of a mixed-density lesion with a radiolucent center is a lymph node. Other mixed-density circular or oval lesions are hematomas, galactoceles, or ﬁbroadenolipomas. Halos are narrow radiolucent rings or ring segments typically seen around the periphery of benign circular or lesions (Peart, 47–62; Tabár, 17–92: Venes, 1171). 11. (A) Plasma cell mastitis, periductal mastitis, or ductal ectasia is an inﬂammatory reaction characterized by the presence of plasma cells surrounding a dilated duct. It is a benign condition. Intra- and/or periductal calciﬁcations are the ﬁnal results of this condition. The calciﬁcation can be located around or inside the dilated ducts. Most are elongated and sharply outlined with smooth borders; some are needlelike with high density or may have a lucent central area. The ﬁbroadenoma is an oval lesion that may contain calciﬁcations. Keratoses rarely calcify and mammographically appear as lobulated lesions. Mammographically malignant calciﬁcations often appear in clusters (Peart, 47–62; Tabár, 17–92; Venes, 1171). 12. (A) There are numerous advantages of compression, but the immediate action of compression in reducing motion unsharpness is immobilization. With the breast held still, the possibility of motion blur is minimized. Changes in the mAs mainly affect optical density and patient dose. The kVp has a direct effect on subject contrast. There are only two focal spot sizes in breast imaging—the routine larger focal spot and the small focal spot for magniﬁcation imaging (ACR, 23–77; Bushong, 327–340). 13. (C) The large air gap acts like a grid and reduces scattered radiation, thus improving contrast. Positioning the breast away from the image receptor takes advantage of the inverse square law: the intensity of the scattered radiation is reduced because the distance between the image receptor and the object is increased. The SID does not change in magniﬁcation and, although a grid is not

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used, there is no signiﬁcant reduction in exposure because of reciprocity law failure. Grid use in magniﬁcation increases exposure times, increasing tube loading, thus increasing motion artifact owing to long exposure times. 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 conventional imaging it occurs when insufﬁcient x-rays interact with the intensifying screen to form the image. The use of high mAs, low kVp, and slower ﬁlm/screen combinations reduce quantum mottle. Motion does not affect quantum mottle (Bushong, 272–273). 15. (C) The localization needle wire should be positioned to pass just through the lesion. Most surgeons feel for the tip of the wire before making an incision in the patient’s breast. Because the tip is being used as a locator, it should pass through the lesion, not above, below, or beside it (Andolina, 313–330; Peart, 203–220). 16. (A) The medial breast is the most important aspect of the CC projection. The other routine projection, the MLO, often does not image medial breast clearly because of distance from the image receptor and superimposition of glandular structures. Eliminating the medial breast on the CC would therefore eliminate it from the study (Peart, 115–145). 17. (D) In the TAN projection, the x-ray beam just skims the area of interest. The beam is always tangential or perpendicular to the skin surface. This projection demonstrates the area of interest free of superimposition. The TAN is possible in any direction or projection (ACR, 65; Peart, 115–145). 18. (A) In the RM position, the breast is position for the CC. The top surface of the breast is rolled medially and the bottom surface laterally (Andolina, 174–245; Peart, 115–145). 19. (D) Both saline and silicone implants are radiopaque. The saline implant can be

inserted as an adjustable sac (similar to tissue expanders) where the ﬂuid content is adjusted as needed. The only radiolucent implant available is the autologous myocutaneous ﬂaps. This involves transplanting tissue from another area of the body to the breast. The most popular is the transverse rectus abdominis myocutaneous or TRAM ﬂap, using the rectus abdominis muscle, but the procedure can also be done using the latissimus dorsi or the gluteus maximus. Mammographically, the breast has a fatty or muscular appearance (Andolina, 306). 20. (B) After mastectomy, a three-projection series including the CC, MLO, and ML is generally recommended. Without the other breast for comparison, this series gives the radiologist a better opportunity to diagnose any new malignancy. The AT images the axilla and the TAN images skin lesions. The LMO is the true reverse of the MLO (Peart, 115–145). 21. (A) Even though men generally have a low risk of developing breast cancer, they should be aware of the risk factors, especially family history which could be associated with genetic changes. However, a family history of breast does not mean breast cancer will develop. Slightly over 1% of males in the United States develop breast cancer each year (ACR, 8; ACS, 1–16).

22. (A) The CBE is a clinical examination by a trained health-care professional and should be performed every 3 years for women below 40 and every year for women above 40. To be effective, the CBE should be performed in combination with a mammogram (ACS, 1–16). 23. (B) Because of the low x-ray energies used in mammography, the dose to the skin may be high, but dose falls off rapidly as the beam penetrates the breast. The dose to the skin may be as high as 800–1000 mR/projection (8–10 mGy/projection); the dose to the midline of the breast (the average radiation dose to the glandular tissue or glandular dose) will be only 100 mrad (1.0 mGy). The ﬁnal rules of mammography dictated by the

Answers and Explanations: 14 through 33

MQSA state that a single projection screenﬁlm mammogram should not give more than 300 mrad/projection average glandular dose when a grid is used and should not exceed 100 mrad/projection without a grid (Bushong, 327–340; Peart, 65–84).

24. (B) A compression force of a least 111 newtons (25 lb) and a maximum of 200 newtons (20 decanewtons or 45 lb) is required for the initial power drive. This is an MQSA requirement, necessary to avoid injury to patients (ACR, 201).

25. (B) This is the MQSA requirement to avoid excess radiation dose to the patient. All units should have a beam-limiting device that allows the entire chest wall edge of the x-ray ﬁeld to extend to the chest wall edge of the image receptor and should not extend beyond any of the edges on the image receptor by more than 2% (ACR, 109). 26. (A) The characteristic curve measures the optical density or degree of blackness of the ﬁlm to the log of the relative radiation exposure. A single characteristic curve can be analyzed to determine the contrast (slope of the straight-line portion of the curve) and the ﬁlm latitude (the range of exposures over which the ﬁlm responds with optical densities in the diagnostically useful range). Two characteristic curves of different ﬁlms are needed to compare ﬁlm speeds (Bushong, 272–291; Peart, 65–84).

27. (D) Establishing a new limit is allowed only under speciﬁc circumstances, such as, if the ﬁlm emulsion changes or there are changes in processing or assessment methods (new equipment or new solutions, new densitometer or sensitometer, for example). If the limits unexpectedly changed (up or down), it is necessary to improve the QC procedures or repair 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

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directly adjacent to the disk (to the left or right perpendicular to the anode-cathode axis) is recorded. The DD is the difference between these densities. The background density is the density measured at the center of the phantom image. The mid-density and highest density are both obtained from the sensitometric strip (ACR, 167). 29. (B) The breast can reach superiorly to the clavicle (level of the second or third rib), inferiorly to meet the abdominal wall at the level of the sixth or seventh rib (at the inframammary fold or crease), laterally to the edge of the latissimus dorsi muscle and medially to the midsternum (Peart, 35–44). 30. (B) The most prominent hormones active in the breast are estrogen and progesterone. Estrogen is mostly responsible for ductal proliferation and progesterone is responsible for lobular proliferation and growth. Studies have shown the two actually work together to produce full ductal–lobular–alveolar (terminal ductules) development. Prolactin is present in the breast during initial breast growth, pregnancy, and lactation (Peart, 35–44). 31. (D) First-degree relatives are immediate relatives such as mother, sister, or daughter (ACR, 8). 32. (A) The BSE involves looking and feeling for changes in the breast. With routine BSE, a woman will become familiar with both the normal appearance and feel of her breasts so that even small changes are noticeable. For this reason BSE should be performed regularly at the same time every month (about 5–10 days after the period begins, when the breasts are least tender) (ACS, 1–16; American Cancer Society).

33. (D) Unnecessary exposure should be avoided with any radiographic examination. Some studies have shown that the dense cellular breast structure of women younger than 35 is more susceptible to radiation. Dense breast tissue will also need more radiation to penetrate, translating to increased dose (ACR, 79–110; Peart, 65–84).

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34. (A) For mammography tubes made with molybdenum, the most prominent x-rays are characteristic. Characteristic x-rays are produced after a photoelectric interaction. If the target is ﬁltered with molybdenum, the characteristic energy of 19 keV from the K-shell interaction will be prominent. This is within the range of energies that are most effective for mammographic imaging. Characteristic radiation is produced when an outer shell electron ﬁlls an inner shell void. If the outer shell electron ﬁlls the void in the K-shell, the x-ray emissions are termed K-characteristic x-rays. Bremsstrahlung x-rays are produced when an outer projectile electron is slowed by the electric ﬁeld of the target atom nucleus. This interaction is common in tungsten targets. Coherent or classical scattering describes the interaction between low-energy electrons and atoms. The x-ray loses no energy but changes direction slightly. In Compton scattering, moderate-energy x-rays interact with an outer-shell electron and eject the electron from the atom. The ejected electron is the Compton electron (Bushong, 117–187; Peart, 65–84). 35. (D) The QC testing for digital imaging has most of the components of conventional imaging plus additional tests on the display, laser printer if used, and imaging system. Repeat analysis is still needed for repeats because of positioning, patient motion, noisy images (underexposure), and equipment failure, to name just a few. Digital imaging can correct for overexposure, although excessive overexposure increases the patient dose. Digital imaging has a harder time correcting for extreme underexposure, and creates a noisy image (similar to quantum mottle). Digital imaging can enhance the spatial display by enhancing the edges of spiculation or calciﬁcations, making them more visible. Digital imaging cannot correct unsharp images, especially unsharpness caused by motion (Andolina, 437–452; Peart, 87–112, 179–194; Stevens, 275–370).

36. (A) Different individuals perceive different numbers of test objects images or may count a different number of objects in the same image. For consistency, the same individual should

examine the images each time using the same criteria (same time of day, same viewbox, same magniﬁer, and same viewing conditions). The density calculations are mathematical formulas that do not change. All mammographers should be at least familiar with the basic MQSA guideline (ACR, 184). 37. (A) The FB (from below) is the reverse CC projection. The beam is directed caudocranially to form an angle of 90 degrees with the image receptor (Peart, 115–145). 38. (D) After radiation therapy the breast may appear red and swollen and may gradually get tighter or harden. The breast may also get smaller and be distorted from the surgical technique. These changes are a result of the radiation and although newer radiation treatment has less effect on the breast, the mammographer should still handle these patients with care because the skin may be delicate and the patient may have many tender or painful areas (Andolina, 331–402; Peart, 220–234). 39. (D) Magniﬁcation is ideal for imaging small areas such as the surgical site of a patient with lumpectomy, specimen radiograph, or microcalciﬁcations and masses. Magniﬁcation, however, should not be used for routine imaging because the entire breast may not be imaged completely and the patient dose is increased (Bushong, 327–340; Peart, 65–84). 40. (B) The LMO provides a mirror image of the MLO. The next best position is the LM projection, which is a true lateral projection useful in imaging medially located lesions that are high on the chest wall or extremely posterior in the inferior half of the breast. The image on the LM is very similar to the MLO, the difference being that the MLO images the lateral portion of the breast closer to the image receptor. The ML, although also a true lateral projection, cannot be used because it does not image the posterior breast. The AT best images the tail of Spence and the RL has the breast positioned for the CC with the upper surface rolled laterally while the lower surface is rolled medially (Peart, 115–145).

Answers and Explanations: 34 through 48

41. (B) Contrast resolution is the ability to distinguish anatomic structures with similar subject contrast. High-contrast resolution is needed in mammography to distinguish similar soft-tissue densities. Spatial resolution is the ability to image high-contrast small objects such as microcalciﬁcations. The spatial resolution of the image is limited mainly by the effective focal spot size. Spatial resolution is stated as the number of line pairs per millimeter (lp/mm) that are imaged. The higher the number, the smaller the object that can be imaged and the better the spatial resolution. High screen speed generally has lower spatial resolution and spatial resolution can be improved by using smaller phosphor and thinner phosphor layers. The term recorded detail is a less precise term referring to the degree of sharpness of structural lines on a radiograph, while the ability to visualize recorded detail when image contrast and optical density are optimized refers to visibility of detail (Bushong, 219–227, 272). 42. (C) The best time to perform the BSE is 5–10 days after the start of the period when the breast is least tender or swollen. If a patient is not having regular periods, the BSE should be done on the same day every month (American Cancer Society).

43. (B) For the AEC to be effective, the thickest portion of the compressed breast, regardless of its size or tissue density, must be directly over the AEC detector. If the AEC detector does not cover the small breast tissue area, the correct optical density will not be recorded, resulting in an underpenetrated ﬁnal image (Peart, 65–84). 44. (D) Processing control makes sure the processor is working at optimal levels. The visual checklist veriﬁes that the room equipment, including the mammography unit, has all the necessary accessories available and is safe for patient and mammographer. Screen cleanliness ensures clean screens, but to determine which screen has the artifact all the screens would have to be opened and cleaned. Standardized image labeling identiﬁes the mammographic

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unit (if there is more than one), the cassette or image receptor by number, the mammographer performing the examination, the patient, the facility name, and the projection. It is important to be able to identify each cassette/image receptor. Dirty cassettes/image receptors are thus easily identiﬁed and cleaned (ACR, 127).

45. (D) Phantom images are done weekly. The repeat/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 a rate of 5% is acceptable once a QC program has been established. An analysis of the number of repeated mammograms and rejected ﬁlms identiﬁes ways to improve efﬁciency and reduce cost and patient exposure. Because the main purpose of the reject/repeat analysis is to determine problem areas within the department, the one high-rate area should be targeted for improvement (ACR, 202; Stevens, 275–370). 47. (D) The linear-type grids used in mammography typically have a very low ratio because even with the common grid ratio of 4:1, patient exposure doubles (grid ratio = the height of the lead strips/the distance between the strips; ratio = h/d). Most grids are focused to the SID to increase contrast. Grids in mammography typically have a frequency of 30–50 lines per centimeter. The high-transmission cellular (HTC) grid used in some units has the characteristics of a crossed grid. It can reduce scattered radiation in two directions rather than the one direction of the linear or focused grid. These grids use copper rather than lead as the grid strip, and air rather than wood or aluminum as the interspace material. When compared to a similar ratio linear grid, the HTC grids result in equal or less radiation dose to the patient (Bushong, 327–340; Peart, 65–84).

48. (B) The staging of breast cancer is useful to determine the extent of the spread of the cancer. In general, the higher the stage of the

7: Practice Test 2

cancer, the poorer the prognosis. The PET technique injects extremely short-lived nuclides into an arm vein. The technology works on the principle that because of the increase in metabolic activity, most cancerous tissue uses vast amounts of sugar (glucose) and at a much higher rate than benign tissue. The radioactive substance used is metabolized in the body like sugar and will therefore go to tissues that are most active. A gamma camera can then be used to measure the emitted radiation signals making the cancer’s location visible. The extent of the cancer is then known, which aids the oncologist in determining treatment and monitoring therapy. Currently, PET imaging is also used to stage lymph node involvement, detect metastases, and in staging and restaging cancerous breast lesions and is becoming a useful tool in molecular imaging (Peart, 179–194, 220–234). 49. (C) During the medical history documentation, the physician collects information on the patient’s risk factors for benign or malignant breast conditions and any other health problems. Information on past mammograms is also collected because of the importance of comparison. Although the medical history does not prevent breast cancer, it is the ﬁrst step in evaluating both symptomatic and asymptomatic women and an important step in evaluating treatment options (ACS, 1–16; American Cancer Society).

50. (D) The smaller the focal spot size, the greater the resolution. General radiography uses target angles of 5–15 degrees but in conventional mammography units the target is angled about 23 degrees (line-focus principle). The large target angle would force the use of larger focal spot sizes and result in the heel effect (Figure 7-9). As a result of the heel effect, some of the useful beam must travel through the target material. This reduces the intensity of the useful beam at the anode end of the tube; however, with the cathode positioned to the chest wall and with the tube tilted about 6 degree, the central rays parallel the chest wall so no tissue is missed, the heel effect is minimized, and small focal spots are

possible, resulting in increased resolution. The small focal spot sizes used in mammography are therefore achieved using a combination of 23 degrees target angle and 6 degrees tube tilt (Bushong, 327–340; Peart, 65–84).

t targe

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Horizontal

Compression plate

Breast Breast Image recorder Figure 7–9. Mammography tube tilt. With the x-ray tube tilted about 6 degrees off the horizontal, the central rays run parallel to the chest wall so no breast tissue is missed. Tilting the tube allows a smaller target angle and therefore a smaller effective focal spot size while minimizing the heel effect. Tilting also allows greater anode heat capacity because the actual focal spot size is not further reduced.

51. (A) The retromammary space separates the breast from the pectoral muscle. This space is ﬁlled with a layer of adipose or fatty tissue as opposed to the supporting and connective tissue (stroma), blood vessels, and various ductal structures that make up the glandular and ﬁbrous tissues of the breast (Peart, 35–44). 52. (D) Cysts occur in the terminal ductal lobular units when the extralobular terminal duct becomes blocked. Fluid accumulates faster than it can be reabsorbed. Cysts vary in size and respond to hormonal ﬂuctuations, but the development of a cyst also depends on a woman’s genetic predisposition. Younger

Answers and Explanations: 49 through 62

women, premenopausal women, and postmenopausal women taking estrogen are likely to have higher hormonal levels and therefore have an increased possibility of having cysts (Andolina, 155–173; Peart, 35–44). 53. (C) By the process of elimination, the best choice is that the lesion is a cyst. Although the ﬁbroadenoma, hematoma, and lymph node are all oval or circular lesions, all are of mixed density (radiolucent and radiopaque) (see Figure 3-2) (Tabár, 17–92). 54. (B) Regardless of the kVp, as the kVp increases, the relative number of x-rays undergoing Compton interaction also increases. With compression the part is thinner, 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 inspection and palpation of the breast. A visual inspection involves looking for changes in the shape and size and appearance of the breast and nipple while noting any skin dimpling, redness, or swelling (ACS, 1–16; American Cancer Society). 56. (D) The hypo estimator provides an estimate of the amount of residual hypo in the ﬁlm in units of grams per square meter. It should be 0.05 g/m2 or 5 μg/cm2 or less. If the stain indicates that the residual hypo has increased, the test should ﬁrst be repeated. If the result is the same then the ﬁrst check should be the water wash tank—it should be full. Water wash ﬂow rates should meet manufacturer’s guidelines. The ﬁxer replenishment rate must also be checked, because they too should meet manufacturer’s guideline

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and results in areas of lower optical density on the mammogram (white or denser areas) (Peart, 35–62).

58. (A) Estrogen and progesterone are two of the many hormones responsible for many physiological changes in the breast. Estrogen is responsible for ductal proliferation and progesterone for lobular proliferation. Once a woman starts any of these hormones including HRT, the changes can be spotty, causing lumps or increased interstitial ﬂuids (cysts) but will generally result in an overall increase in glandular tissue (Andolina, 155–173; Peart, 47–62). 59. (C) By process of elimination, the lesion is likely to be a lymph node. Lymph nodes are lesions with mixed density and generally have a radiolucent center corresponding to the hilus. The ﬁbroadenoma, hematoma, and the galactocele are all mixed-density oval or circular lesions, but none has the lucent center typical of the lymph nodes (see Figure 3-2) (Tabár, 17–92). 60. (C) When comparing the MLO projection to the ML, a lateral abnormality will move down on the lateral from its position on the MLO. A medial abnormality will move up on the lateral from its position on the MLO. A centrally located lesion or a lesion at the areola will show little or no movement (Peart, 115–145). 61. (A) As the magniﬁcation factor increases, to maintain a sharp image the focal spot must be reduced or the thickness of the part has to decrease. A greater magniﬁcation factor will therefore need a smaller the focal spot. Small focal spot is therefore used in magniﬁcation mammography. Increasing OID increases the magniﬁcation factor (Bushong, 117–187; Peart, 65–84).

(ACR, 211; Stevens, 275–370).

57. (B) Fibrous and glandular tissues are together described as ﬁbroglandular densities. X-rays pass more easily through fatty tissue than through ﬁbrous or glandular tissues. Fatty areas are more radiolucent and will appear as high-density areas (black or less dense) on the mammogram. The ﬁbroglandular tissue is more radiopaque than fatty tissues

62. (A) The actual focal spot size is the area on the anode target that is exposed to electrons from the tube current. Because the target is angled, the effective area of the target is made much smaller than the actual area of electron interactions. The effective target is the area projected onto the patient and the image receptor. The nominal focal spot size is a measure of the effective focal spot size and

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is the value used when identifying large or small focal spots (Peart, 65–84). 63. (C) The MQSA governs ﬁnal assessment ﬁnding in the evaluation of mammographic images. In an effort to guide referring physician and radiologist in the breast cancer decision making process, the ACR came up with the BIRAD, which is a standardized mammographic reporting system that can be used as a coding and assessment system. To ensure recognition of the system the ACR collaborated with the National Cancer Institute (NCI), the Center for Disease Control and Prevention (CDC), the FDA, the American Medical Association (AMA), the American College of Surgeon and the American College of Pathologist. The BIRAD system is now well recognized and used by radiologist, physicians, and surgeons across the United States. The MQSA also has a category assessment; however the ACR assessment categories were already in existence prior to the publication of the ﬁnal regulations of MQSA. Because the assessment categories developed by the ACR are so widely recognized, the FDA accepts the ACR’s BIRAD categories; however to avoid confusion in addition to the category name (eg, BIRAD 1) the report must include the word identiﬁer, for example, BIRAD 1: negative. BREAST IMAGING REPORTING AND DATA

(BIRAD) BIRAD 0: Need additional imaging information and/or prior mammograms for comparison BIRAD 1: Negative BIRAD 2: Benign ﬁnding BIRAD 3: Probably benign ﬁnding—short interval follow-up suggested BIRAD 4: Suspicious abnormality—biopsy should be considered BIRAD 5: Highly suggestive of malignancy—appropriate action should be taken BIRAD 6: Known biopsy proven malignancy—appropriate action should be taken SYSTEM

(Papp, 203; Peart, 246).

64. (D) The DD on the sensitometric control strip is the difference between the average density closest to 2.20 (high density, HD) and the average density closest to but not less than 0.45 (low density, LD). Base plus fog is the density over a clear area of the strip and the mid-density is that closest to 1.20 (ACR, 151). 65. (C) Epithelial hyperplasia is also known as proliferative breast disease and is an overgrowth of cells that line either the ducts or the lobules. When hyperplasia involves the duct, it is called ductal hyperplasia or duct epithelial hyperplasia. When it affects the lobules, it is referred to as lobular hyperplasia. Depending on how it looks under the microscope, it may be classiﬁed as usual or atypical. An epidermoid cyst, often incorrectly referred to a sebaceous cyst, is a pimple-like cyst that occurs in the oil glands of the skin, and the hematoma is a pooling of blood as a result of trauma. Over time a hematoma may slowly calcify, resulting in the formation of an oil cyst, and later a calciﬁed hematoma (American Cancer Society; Peart, 47–62). 66. (A) A ruptured implant shows extracapsular leakage—silicone may leak into the ﬁbrous capsule or may escape from the capsule leaking into the surrounding breast tissues and muscle causing pain or discomfort. In the encapsulated implant, the implant hardens or calciﬁes but does not rupture. A herniated implant shows the implant pushing out of ﬁbrous capsule, but does not indicate a silicone leak. Patients with implant removal may have traces of residual silicone in the breast (Andolina, 246–310; Peart, 115–145). 67. (C) The ﬁrst step is to determine the location of the lesion by applying the rules for lesion movement. When comparing the MLO projection to the ML, a lateral abnormality will move down from its position on the MLO. A medial abnormality will move up from its position on the MLO. A centrally located lesion and lesions at the areola will show little or no movement. Once the location of the lesion is determined, an XCCL for a lateral lesion or the CV for medial lesions will locate

Answers and Explanations: 63 through 77

the lesion in the CC position. The AT images the axilla of the breast only and is not needed (Andolina, 155–173; Peart, 115–145).

68. (A) During ductography, a collecting duct that ends at the nipple is cannulated and a small 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 mammography because the biological effects of radiation are most likely to be related to the total energy absorbed by glandular tissue. The glandular dose is the average radiation dose to the glandular tissue in the middle of the breast. The other measure of dose is the ESE. The ESE is most often referred to as the patient dose. It is the exposure at the skin’s surface. In mammography the ESE may be very high because of low-energy x-rays but the dose falls quickly as the x-rays penetrate the breast (Bushong, 590–591). 70. (C) Obtaining a magniﬁed image requires that the OID be increased while maintaining a constant SID. Any change in OID will result in a corresponding change in SOD. To maintain a sharp image, a small focal spot must be used in magniﬁcation (Bushong, 327–340; Peart, 65–84). 71. (D) QC testing should always be performed by the dedicated QC personnel or the same individual. Here the mammographer would be the most obvious person (ACR, 90; Andolina,

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blood supply. The changes are a result of the action of estrogen, progesterone, and prolactin, which cause a proliferation of the ductal and lobular structure of the breast and an increase in blood ﬂow (American Cancer Society; Peart, 35–44).

74. (C) With the four quadrants terminology, the breast can be described as: the upper outer quadrant (UOQ), upper inner quadrant (UIQ), lower outer quadrant (LOQ), and lower inner quadrant (LIQ). The exact locations within the quadrant are represented by viewing each breast separately as a clock face. The upper outer quadrant, which extends toward the axilla, is known as the axillary tail, tail of the breast or tail of Spence. Most glandular tissue is found centrally and extends laterally toward the axilla in the UOQ. This distribution increases or decreases with hormonal ﬂuctuations, but generally mirrors the opposite breast (Peart, 35–44). 75. (C) Mammography uses very low-energy kVp and it is very important that the x-ray tube window not attenuate the low-energy photons. Most mammography units have either borosilicate or beryllium windows. The low atomic number of these materials allows an inherent ﬁltration of approximately 0.1 mm Al (aluminum). The material of the glass window has no effect of scattered radiation, nor can it increase or decrease the output of the x-ray tube (Bushong, 327–340; Peart, 65–84).

72. (B) Galactoceles are small, milk-ﬁlled cysts with a high fat content. These are associated with lactation, may be mixed density, and are circular–oval with sharply deﬁned contours. A hematoma is associated with breast trauma and the oil cyst appears mammographically as eggshell-like calciﬁcations. Lymph nodes typically have a central radiolucent area corresponding to the hilus (Tabár, 17–92).

76. (C) Compression is important in mammography to reduced breast thickness, radiation dose, and motion unsharpness. Compression also separates superimposed areas of the breast tissue and brings abnormalities closer to the image receptor. Unfortunately, compression is painful for some women. In general, the breast should be compressed until taut to ensure adequate compression. Compression, however, should not be applied to cause the patient severe pain (ACR, 23–77; Peart, 115–145).

73. (A) During pregnancy and lactation, breast density increases because of physiological changes, milk production, and increased

77. (C) The greater the magniﬁcation factor, the greater the skin dose to the patient. In magniﬁcation the patient dose increases because

45–98; Peart, 87–112).

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the breast is closer to the source and because additional exposure is required because of reciprocity law failure. The small focal spot size used to maintain a sharp image requires that the mA be reduced with a corresponding increase in exposure time (Bushong, 197–198; Peart, 65–84).

78. (B) The actual focal spot size is the area on the anode target that is exposed to electrons from the tube current. As the size of the focal spot decreases, the heating of the target is concentrated into a smaller area. In the design known as the line focus principle, the target is angled allowing a larger area for heating while maintaining a small effective focal spot. Because the target is angled, the effective area of the target is made much smaller than the actual area of electron interactions. The effective target is the area projected onto the patient and the image receptor. As the target angle is made smaller, the effective focal spot decreases (Figure 7-10) (Bushong, 137–138; Peart, 65–84). Target angle

trauma. Some possible cause of the radial scar is localized inﬂammatory reaction or chronic ischemia with slow infection. The radial scar is a benign condition, but can be associated with premalignant—atypical ductal hyperplasia— and malignant condition. A benign radial scar has no central tumor, although there may be long spicules radiating from the center of the lesion. Regardless of the size of the spicules in the benign radial scar, there is no associated skin thickening, dimpling, or nipple reaction. The benign radial scar often resolves over time, but because of the possible association with malignancy radial scars should be monitored carefully. In this case the lesion was the result of surgery. As shown in Figure 7-3b, the lesion is resolving. A galactocele is a benign, milk-ﬁlled cyst with a high fat content. These lesions are generally associated with lactation. They are usually circular, with sharply deﬁned borders, and have densities that are a combination of radiolucent and radiopaque. They are often left alone, but if painful they can be drained using needle puncture. Often they yield a yellow ﬂuid. Oil cysts are generally seen mammographically as eggshell-like calciﬁcations. Hematomas are generally associated with trauma. They are mixed density oval or circular calciﬁcation (American Cancer Society; Peart, 47–63; Tabár, 17–92, 93–147; Tucker, 125–129).

Electrons from cathode

Ac

tua

l fo

cal

spo

t si

ze

Effective focalspot size Figure 7–10. Line focus principle. As the size of the focal spot decreases, the heating of the target concentrates into a smaller area. Angling the target makes the effective focal spot size much smaller than the actual focal spot size. This line focus principle allows a large area for heating while keeping the effective focal spot small. Decreasing the target angle causes a corresponding decrease in effective focal spot size.

79. (C) Radial scars are complex sclerosing lesions and are often indistinguishable from carcinoma. They are not truly scars and are sometimes unrelated to prior surgery or

80. (B) The patient’s face should be turned away from the side under examination, curving the neck and head around the face shield. This ensures that medial tissue can be pulled onto the image receptor. This is important because eliminating medial breast tissue from the CC projection may eliminate this tissue from the study (Andolina, 174–245; Peart, 115–145). 81. (A) Using clock face terminology there are four main clock positions (12-o’clock, 3-o’clock, 6-o’clock, and 9-o’clock). In the XCCL and the CC, the central rays are directed superiorly to inferiorly; therefore, 12-o’clock and 6-o’clock lesions will be superimposed. The AT images the axilla and would miss any 6-o’clock lesion. In the MLO, the beam is directed medially to laterally separating the

Answers and Explanations: 78 through 89

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 terminology adopted by the ACR. The Cleopatra view is an old term given to a projection similar to the current AT. All projections in mammography are compression or compressed projections (ACR, 24; Peart, 115–145). 83. (D) Casting calciﬁcations are produced when carcinoma in situ ﬁlls the ducts and their branches. The shape of the cast is determined by the uneven production of calciﬁcation and the irregular necrosis of the cellular debris. The contours of the cast are always irregular in density, width, and length and the cast is always fragmented. A calciﬁcation is seen as branching when it extends into adjacent ducts. Additionally, the width of the ducts determines the width of the castings. Eggshell-like and needlelike, sharply outlined, or elongated branching calciﬁcations are typically benign mammographically. Granulated sugar or crushed stone calciﬁcations are called granular-type calciﬁcations and are mammographically malignant (Peart, 47–62; Tabár, 149–238).

84. (B) From the nipple oriﬁce, a connecting duct immediately widens into the lactiferous sinus or ampulla. The ampulla is a pouchlike structure that holds milk (when it is being produced). These ducts branch into smaller and smaller ducts until becoming a lobule. The lobule is also called the terminal ductal lobular unit (TDLU) and holds the milk-producing elements of the breast (Peart, 35–44).

85. (D) The nipple cannot always be imaged in proﬁle because some women will not have a centrally located nipple. (It will either be in the top half or bottom half of the breast.) In such situations imaging the nipple in proﬁle will actually lose posterior breast tissue. Additional projections of the nipple area are only necessary if the nipple looks like a lesion, the woman has a nipple or retroareolar abnormality (such as nipple discharge or a lesion), for

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proper measurement in preoperative localizations, or if the patient is male. Male patients have rudimentary breast buds lying directly behind the nipple. Only by placing the nipple in proﬁle will this area be visualized clearly (Andolina, 246–310; Peart, 115–145).

86. (C) The AT projection best demonstrates the axillary tail of the breast. The medial and subareolar areas are not visualized on the AT projection. With the four quadrants terminology, the breast can be described as the upper outer quadrant, upper inner quadrant, lower outer quadrant, and lower inner quadrant. The exact locations within the quadrant are represented by viewing each breast separately as a clock face. The upper outer quadrant, which extends toward the axilla, is known as the axillary tail, tail of the breast, or tail of Spence. The LIQ describes the medial portion of the breast (Andolina, 174–245; Peart, 115–145). 87. (C) In this case the patient’s chin was not elevated for the MLO projection. Pressure on the ﬁlm after the exposure causes plus-density artifacts. This is inconsistent with malposition of the mirror, which would cause a rectangularshaped artifact in the center of the ﬁlm. The other alternative, the patient’s shoulder, would only be imaged if the entire axilla were also imaged (Peart, 115–145). 88. (B) A hematoma is associated with breast trauma. Generally, the trauma results in a pooling of blood, which can show mammographically a low-density radiopaque lesion. If the hematoma calciﬁes, it slowly becomes a mixeddensity oil cyst with the typical eggshell-like calciﬁcations and then eventually a high-density radiopaque lesion. Galactoceles are small, milkﬁlled cysts with a high fat content associated with lactation. Fibroadenomas are benign tumors common in women at any age and the intramammary lymph nodes can be found in any quadrant of the breast and are not related to injury (Andolina, 155–173; Peart, 47–62; Tabár, 17–92).

89. (D) Patients have breast tissue ranging from fatty to thicker, more glandular tissue.

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Adequate penetration of the glandular tissue depends on the kVp selection. In mammography, the use of single emulsion ﬁlms with single-backed screens is necessary to enhance contrast, but results in a relatively higher patient dose. Dose in mammography is kept low because of the inherent soft tissue structure of the breast. Viewing conditions should not determine the exposure selection, but the target material determines the energy of the x-ray beam produced (Peart, 65–84). 90. (B) Generally, when the shoulders are not relaxed or if the height of the image receptor is too high, most of the axilla and shoulders will fall into the compression area. The thick area of the axilla and shoulder will cause the compression paddle to stop at maximum without adequate compression being applied to the lower breast (nipple area) (Peart, 115–145).

assess calciﬁcations. The specimen should also be compared to the initial mammograms. Imaging the specimen before the surgery is completed will allow the surgeon to take an additional biopsy specimen if indicated (Andolina, 313–330; Peart, 203–220).

95. (C) The LMO is useful for patients with prior chest surgery or patients with pacemakers, which prevent compression to the medial breast. The LMO is an inferolateral to superomedial projection. The x-ray tube is angled approximately 125 degrees (Figure 7-11). The image receptor is positioned at the medial aspect of the breast and compression is applied from the lateral aspect. AT images the tail of the breast (tail of Spence); LM and ML are both 90-degrees lateral projections (Peart, 115–145).

91. (C) Ultrasound does not image microcalciﬁcations well. The TAN projection is useful in assessing skin calciﬁcation and the spot compression increases compression over a speciﬁc area to eliminate pseudomasses. Magniﬁcation, however, magniﬁes the area of interest allowing the number, distribution, and type of calciﬁcations to be clearly seen. Magniﬁcation can be used with and without spot compression (ACR, 59–60; Peart, 147–162). 92. (D) In this case the circular lucency in the center suggests a port-a-cath. A pacemaker generally presents with high-density wiring. A hematoma is generally associated with trauma. They are mixed-density oval or circular calciﬁcation. The patient’s chin would present as a uniform area of low density (Peart, 47–63). 93. (A) The rolled positions are helpful when dense breast tissue is superimposed on a lesion. The dense tissue is rolled off the lesion (ACR, 67; Peart, 115–145).

94. (D) The specimen must be imaged after biopsy to ensure that the lesion was completely removed. In imaging the specimen, it should be compressed and magniﬁed to prevent the appearance of pseudomasses and to

Figure 7–11. nologists.)

(© 2000 The American Registry of Radiologic Tech-

96. (B) The actual focal spot size is the area on the anode target that is exposed to electrons from the tube current. Because the target is angled, the effective area of the target is made much smaller than the actual area of electron interactions. The effective target is the area projected onto the patient and the image receptor. The nominal focal spot size is a measure of the effective focal spot size and is the value used when identifying large or small focal spots (Peart, 65–84).

Answers and Explanations: 90 through 104

97. (D) Radiation and surgical treatment will cause changes in the breast and can cause calcium formation. Although the rate of recurrence after lumpectomy is relatively low, magniﬁcation images are best to assess any calciﬁcation at the tumor bed. These images should be compared with radiographs taken after surgery but before radiation treatment

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inspections, and enforce the MQSA quality standards. After October 1994, the MQSA required all legal providers of mammography services to be accredited by an approved accreditation body and certiﬁed by the FDA. The FDA cannot ensure that all women have access to a certiﬁed mammography facility (Accreditation and Certiﬁcation Overview).

(Peart, 203–234).

98. (C) The ML is useful in determining whether a lesion is medially or laterally located. If the MLO projection is compared to the ML, a medial lesion will move up from its position on the MLO. A lateral lesion will move down from its position on the MLO. A lesion that is centrally located will show little or no movement. The XCCL best images the lateral breast from the CC position. The CV best images the medial breast from the CC position and the AT best images the tail of the breast (Peart, 115–145). 99. (D) Films should be processed promptly because of latent image fading. If the time between the creation of the latent image and processing is 8 hours or more, the biggest change will be in loss of ﬁlm speed. However, both density and contrast will also decrease (ACR, 132; Peart, 87–112). 100. (A) All three methods can be used to minimize scattered radiation in general radiography. The higher the kVp, the higher the level of scattered radiation and reducing the thickness of the part will allow a reduction in kVp, hence, a reduction in scattered radiation. Scattered radiation increases as the ﬁeld size increases; therefore, reducing the ﬁeld size will reduce the amount of scattered radiation. Unfortunately, reducing the ﬁeld size is not an option in mammography. Mammography units have only two available ﬁeld sizes, regardless of breast size (Bushong, 117–187, 327–340). 101. (B) The MQSA was established on October 27, 1992, to establish minimum national standards for mammography. Under the MQSA requirements, the FDA can authorize individual states to certify mammography facilities, conduct

102. (D) The MQSA ﬁnal regulations require facilities to have a written and documented policy of resolving consumer complaints. The facility may select its own format. Medical outcome audit is required by MQSA to follow up positive mammographic assessments and to correlate pathology results with the radiologist’s ﬁndings. Record keeping refers to the section of MQSA standards dealing with the maintenance of mammograms and reports in a permanent ﬁle (for not less than 5 years, or not less than 10 years if no additional mammograms of the patient are performed at the facility, or longer if required by state or local laws). To satisfy the communication-of-results section of the standards, all mammographic facilities must send each patient a summary of the report, written in lay terms, within 30 days of the mammographic examination. If assessments are suspicious or highly suspicious for malignancy, the facility should contact the patient as soon as possible with the results (Accreditation and Certiﬁcation Overview). 103. (B) A harmartoma is a benign tumor. It is considered self-limiting because the tumor consists of an overgrowth of normal tissue and the tumor cells do not reproduce. Breast lesions associated with trauma and nursing are 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 epithelium of cells lines the ducts and alveoli. After puberty this epithelium proliferates, forming three alveolar cell types—superﬁcial (luminal) A cells, basal B cells (chief cells), and myoepithelial cells forming the innermost layer or basal surface of the epithelium. The myoepithelial cells are arranged in a branching,

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starlike fashion located around the alveoli and excretory milk ducts. Contraction of the myoepithelial cells helps to propel milk toward the nipples. Beneath the epithelium is connective tissue that helps to keep the epithelium in place. Between the epithelium and the connective tissue is a layer called the basement membrane. The basement membrane provides support and acts as a semipermeable ﬁlter under the epithelium (Peart, 35–44; Tortora, 1083–1084).

105. (B) A benign ﬁnding means that although something was seen it is considered totally benign. When using the BIRAD, the verbal identiﬁer must be used to avoid confusion with the MQSA assessment. The MQSA categories places all mammographic ﬁndings in categories similar to 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: Negative BIRAD 2: Benign ﬁnding BIRAD 3: Probably benign ﬁnding—shortinterval follow-up suggested BIRAD 4: Suspicious abnormality—biopsy should be considered BIRAD 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 of the skin. Although it can indicate inﬂammatory breast cancer, it can also be an indication of breast abscess or other infectious changes. Further evaluation and testing, including mammography, would be necessary to determine the cause (Peart, 47–62; Tabár, 17–92). 107. (C) Tamoxifen is a nonsteroidal antiestrogen given to patients with breast cancer. It is

considered an antiestrogen drug because it prevents estrogen from latching onto tumor cell receptors and will shrink or stop the recurrence of breast cancer. Tamoxifen will also lower the risks of breast cancer recurrence in postmenopausal women. Tamoxifen is considered a palliative treatment because it will not cure the disease. The drug can cause serious side effects including an increased risk for endometrial cancer, uterine cancer, pulmonary embolism, stroke, deep vein thrombosis, blood clots, and increased menopausal symptoms. Because of these risks, tamoxifen should not be taken for more than 5 years and there are now a number of similar drugs on the market with less side effects. Radiation therapy may be used to destroy cancer cells remaining after surgery or to reduce the size of a tumor before surgery. Chemotherapy uses a combination of drugs to kill undetected tumor cells that may have migrated to other parts of the body. Antibody therapy works by blocking the effect of the protein HER-2—important in regulating the growth of breast cancer cells (ACS, 1–16; Peart, 220–234).

108. (D) Noise on the mammogram is an undesirable ﬂuctuation in the optical density of the image and will show on the radiographs similar to “snow” on a monitor. The principal cause of radiographic noise is scattered radiation produced by Compton scattering, which reduces contrast. Quantum mottles and ﬁlm graininess also result in noise on the radiography. Quantum mottle refers to the way x-rays interact with the ﬁlm. If the image is produced with a few x-ray photons, the quantum mottle will be higher than if the image is produced with many x-ray photons. Film graininess refers to the distribution in size and space of the silver halide grains in the emulsion and is a factor inherent in the image receptor. This factor is not under the control of the mammographer (Bushong, 272–291; Peart, 65–84).

109. (C) After puberty, the epithelium of the lobules proliferates, becoming multilayered and forming three alveolar cell types, superﬁcial

Answers and Explanations: 105 through 113

(luminal) A cells, basal B cells (chief cells), and myoepithelial cells. The innermost layer or basal surface of the epithelium consists of myoepithelial cells. Beneath the epithelium is connective tissue that helps to keep the epithelium in place. Between the epithelium and the connective tissue is a layer called the basement membrane. The basement membrane provides support and acts as a semipermeable ﬁlter under the epithelium (Peart, 35–44; Tortora, 1083).

110. (C) The “camel’s nose” contour refers to the sloping of the breast in the MLO projection caused by insufﬁcient compression. The result is poor separation of the breast tissues. Preventing “camel’s nose” involves pulling the breast up and out and supporting it during the initial stage of compression. The mammographer should use one hand to maintain support of the breast until enough compression is in place to keep the breast in position (Figure 7-12) (ACR, 38–40).

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111. (C) With the four quadrants terminology, the breast can be described as UOQ, UIQ, LOQ, and LIQ. The exact locations within the quadrant are represented by viewing each breast separately as a clock face. The SIO best demonstrates the UIQ and the LOQ of the breast, free of superimposition. This projection can be used to demonstrate these quadrants free of the implant especially when using the implantdisplaced ID or Eklund compression techniques (Figure 7-13) (Andolina, 174–245; Peart, 115–145).

Direction of x-rays

Image receptor

Figure 7–13. In the SIO position, the beam is directed from the superior lateral aspect to the inferior medial aspect of the breast.

112. (D) The medical audit is used to check the reliability of the mammographic image. The interpreting physicians should evaluate all mammographic results for clarity and accuracy at least once every 12 months. The medical audit should also include any cases of breast cancer found after a negative mammography reading (Accreditation and Certiﬁcation Overview: Medical Outcomes Audit Program).

Figure 7–12. Poor compression of the anterior breast in the MLO projection results in drooping of the anterior breast “camel nose.”

113. (B) The MQSA requires facilities to maintain records to the original mammograms and report for a period of not less than 5 years and not less than 10 years if no additional mammograms of the patient are performed

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at the facility. Some state and local laws may require longer storage times. Facilities are also allowed to permanently or temporarily transfer a patient’s records to another medical institution, physician, or health-care provider if requested by the patient (Accreditation and Certiﬁcation Overview: Record Keeping).

114. (B) Triangulation is used to determine the location of a nonpalpable lesion seen mammographically. One of the purposes of triangulation is to spot compress the lesion for improved separation of breast tissue. Triangulation is also used to determine the shortest skin-to-abnormality distance for the purpose of sterostatic biopsy. To determine the location of the lesion relative to the nipple, the mammographer should measure (1) the distance from the nipple to the level of the lesion posteriorly on the CC or MLO projection, (2) from that level 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 the skin surface (Figure 7-14) (ACR, 56). 115. (D) Peau d’o range describes the skin of the breast wherein the breast skin thickens and resembles an orange. The condition occurs secondary to obstruction of the axillary lymphatic and may be a result of either benign or malignant conditions such as inﬂammatory carcinoma. Plasma cell mastitis or ductal ectasia are both inﬂammatory conditions. Plasma cell mastitis calciﬁcations follow the course of the ducts. Some may be elongated and branching, some needlelike, and some ringlike or oval, but all are sharply outlined,

high density, and have smooth borders. If they are periductal, they have central lucencies. Ductal ectasia involve the lactiferous ducts and may or may not cause nipple discharge or inversion. Both conditions are characterized by the presence of plasma cells surrounding a dilated duct (Peart, 35–44; Tabár, 239–243).

3

2

Lesion

1

Figure 7–14. The triangulation technique is used to determine the shortest skin-to-abnormality distance in the MLO and CC projections. 1 = distance from nipple to the level of the lesion posteriorly, 2 = distance from level to lesion, 3 = distance from lesion to skin surface.

Index

A ABBI. See advanced breast biopsy instrumentation Acoustic enhancement, 93, 101 ACR. See American College of Radiology ACS. See American Cancer Society Adipose tissue, 47, 53, 60 Advanced breast biopsy instrumentation (ABBI), 86 AEC. See automatic exposure control American Cancer Society (ACS), breast examination guidelines of, 1, 7, 12–14, 120 American College of Radiology (ACR), 22, 37, 79, 116, 132, 136, 151 Amorphous selenium, 21 Anatomy, of breast, 47–64, 110, 125 Angiogenesis, 4 Areola, 47, 136, 151 Artifacts, image quality relating to, 23–24, 66, 107, 122, 140, 155 AT. See axillary tail Atypical hyperplasia, 2 Augmentation, of breasts, 4, 92, 98 Automatic exposure control (AEC), 106, 107, 111, 120–121, 126 instrumentation and quality assurance relating to, 20, 27, 33 mammographic technique and image evaluation relating to, 66, 69, 70, 75–76

Axillary node dissection, 86 Axillary tail (AT), 2, 81–82, 88–89, 89f, 96–97, 145, 161 B Backup timer, 70, 76 Barrel chest and pectus carinatum, 82, 89, 97 Basement membrane, 147, 164 Beam, x-ray, 19, 26, 32, 33f, 114, 130 Beam restriction devices, 20, 27, 33 Benign breast lesions. See breast, lesions of Benign cancer, of breast. See breast Beryllium, 19, 143, 159 Biopsy. See also ABBI core, 4, 85–86, 93, 99–101, 101f large, 86 FNB, 4, 85, 93, 99, 102 lymph node, 86 MIBB, 86 MR, 86 open surgical, 4, 86, 93, 102, 146, 162 radio frequency, 86 VACB, 86 BIRAD. See breast imaging reporting and database system Blood supply, to breast, 47 Breast anatomy of, 47–64, 110, 125 augmentation of, 4, 92, 98 blood supply to, 47 camel’s nose, 148, 165, 165f cancer of diagnostic options for, 2–4 ductal carcinoma, 7, 12

intervention options for, 4 lobular carcinoma, 2, 7 malignant, 2, 6, 11, 48–49, 55, 55f, 61–62 posttreatment options for, 5 radiographs of, 2 risk factors for, 1–2, 6, 11, 107–108, 110, 121–125 survival rate of, 9, 15, 15t symptoms of, 1–2, 6, 11 treatment options for, 4–5 changes in, 1, 7, 8 compression of. See compression disease of benign, 2, 6 malignant, 2, 6, 11 Paget, 107, 122 drooping, 79 examination of, 1, 135, 149. See also BSE, CBE ACS guidelines for, 1, 7, 12–14, 120 fatty tissue of, 47, 49, 52, 59, 105, 120, 141, 157 histology of, 47 implants for, imaging of, 81–82, 83f–84f, 92, 99, 106, 121, 137, 152 involution of, 113, 129 irradiated, 82, 92, 99 large or wide, 82 lobes of, 47, 52, 58 lymphatic drainage of, 47, 48f, 53, 59 male, 82, 116, 132, 137, 152 malignant conditions and mammographic appearances of, 48 167

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Index

Breast (Cont.): masses in, 61f medial and lateral aspects of, 79, 81–82, 87–90, 94–97 pathology of, 47–64 physiology of, 47–64 postsurgical, 82 quadrants of, 47, 52, 58, 58f, 81 reconstruction of, 4–5, 10, 16 scintigraphy of, 3 skin folds or wrinkling of, 82–85 small, 81–82, 103, 118, 140, 147, 155, 163 tissue composition of, 47–48, 138, 153 tumor of, 48–49, 54, 54f, 56, 61–62, 93 veins of, 47, 53, 60 Breast, lesions of, 50f–51f benign calcification, 49, 81, 136, 136f, 151 circular/oval, 49 skin thickening syndrome, 2, 6, 11, 48–49 spiculated/stellate, 49 malignant calcifications, 48, 55, 55f, 61–62, 111, 111f, 126, 144, 161 circular/oval, 48 circumscribed, 2 skin thickening syndrome, 2, 6, 11, 48–49 spiculated/stellate, 48, 55, 62 visualized with compression, 65, 68, 73 Breast 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, 76 BSE. See breast self-examination C C-arm. See contralateral arm CAD. See computer-aided detector

Calcifications of breast lesions benign, 49, 81, 136, 136f, 151 malignant, 48, 55, 55f, 61–62, 111, 111f, 126, 144, 161 casting-type, 2, 48 ductal, 2 granular-type, 48 mammogram relating to, 81, 88–89, 96 powderlike, 48 teacup-shaped, 81, 89, 96 Camel’s nose breast, 148, 165, 165f Cancer, of breast. See breast Cannulation, of lactiferous duct, 85, 93, 101 Carcinoma ductal. See ductal carcinoma. inflammatory, 56, 62–63 lobular. See lobular carcinoma. Cassette-based digital systems, 21 Cassette-less digital systems, 21 Cassettes or image receptor, 3, 21, 27, 34, 116, 132 Casting-type calcifications, 2, 48 Caudocranial or FB projection, 81–82, 89, 97, 112, 112f, 114, 126, 130, 139, 154 CBE. See clinical breast examination CC projection. See craniocaudal CCD. See charge-coupled devices Cell stage, 16t Cells, epithelial, 115, 131 Central venous access devices (CVAD), 63 Certification process, 24–25 Characteristic curve, 19, 28, 34–36, 37f, 104, 119, 119f, 138, 153 Charge-coupled devices (CCD), 21 Chemotherapy, 5, 7, 10, 12, 15–16 Circular/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 relating to, 20, 66, 104, 119, 138, 153 Color Doppler ultrasound, 3 Compression, 24, 33, 52, 58 considerations of, 65, 67, 72, 143, 159 devices for, 19–20 image quality relating to, 66 lesions visualized with, 65, 68, 73 levels of, 108, 122 manual, 67, 72 MLO relating to, 66, 79, 81–82, 85, 116, 133 patient knowledge of, 68, 73 QC tests for, 23, 29, 39 radiation relating to, 65, 67, 72–73 reasons for, 65 spot, 57, 57f, 64, 81–82, 92, 98–99, 111–112, 126–127 Compression paddle, 19–20, 26–27, 32, 34, 81, 85 Compton effect, 70, 76, 141, 157 Computed tomography (CT), 4 Computer-aided detector (CAD), 21 Contaminated developer, 111, 126 Contralateral arm (C-arm), 79, 87, 94 Contrast, image quality relating to, 66, 70–71, 77, 77f, 78 Contrast digital mammography, 3 Contrast resolution, 139, 155 Control film crossover, 135, 149–150, 150f Conventional 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 interventional procedures relating to, 79, 80f, 81–82, 85, 87–88, 88f, 91, 94–95, 98

Index

CT. See computed tomography CT laser mammography, 4 CV. See cleavage CVAD. See central venous access devices Cyst, 141–142, 156–157 aspiration of, 4, 85, 93, 102 epidermoid, 49, 57, 57f, 64 oil, 49, 55, 55f, 62, 115, 130–131 Cytological analysis, 92, 99 D Darkroom cleanliness, QC tests for, 22–23 Darkroom fog, QC tests for, 23, 28–30, 38, 41 Deep inferior epigastric artery perforator flap (DIEP), 5 Densitometer, 24 Depressed sternum. See pectus excavatum Developer temperature, 21, 110, 112, 125, 128, 128f DIEP flap. See deep inferior epigastric artery perforator flap Digital imaging, 2–3, 31, 44, 136, 150, 150f Digital mammogram/ mammography, 2, 21, 28, 34, 35f contrast, 3 Digital quality assurance, 24 Digital systems, 21–22 cassette-based, 21 cassette-less, 21 Digital technology, 28, 34, 36f Digital tomosynthesis, 4 Disease, of breast. See breast Documentation and medical history, 1, 8, 140, 156 Doppler ultrasound, color, 3 Drooping breast, 79 Ductal calcifications, 2 Ductal carcinoma, 7, 12 invasive or infiltrating, 2 in situ, 2 Ductal ectasia, 103, 115 Ductal lavage, 86 Ductal papilloma, 103, 118

Ductography, 4, 85, 93, 101, 109, 124, 143, 159 E Eklund method, implants relating to, 100f Elderly patients, 82 Electrosurgical introducer, 86 Encapsulated implants, 81, 92, 98 Entrance skin exposure, 138, 152 Epidermoid cyst, 49, 57, 57f, 64 Epithelial cells, 115, 131 Epithelial hyperplasia, 142, 158 Erythema, 147, 164 ETD. See extralobular terminal duct Exaggerated craniocaudal (XCCL), 79, 82, 89, 96, 97, 105–106, 107f, 120–121 Exposure. See also AEC image quality relating to, 66 log relative, 37f radiation dose relating to, 1, 9, 14–15, 65, 69, 74–75 Extended processing, 21, 112, 128 Extralobular terminal duct (ETD), 53, 60, 60f F False-negative mammograms, 69, 75 Fat necrosis, 49, 56, 63 Fatty tissue, of breast, 47, 49, 52, 59, 105, 120, 141, 157 FB. See from below FB or caudocranial projections, 81–82, 89, 97, 112, 112f, 114, 126, 130, 139, 154 FDA. See Food and Drug Administration FDG. See fluorodeoxyglucose Fibroadenolipoma, 49 Fibroadenoma, 49, 56, 56f, 64, 93, 100 Fibroglandular tissue, 47, 105, 113, 120, 128 Film, analyses of fixer retention in, 23 Film fog, 23, 28, 34 Filtration, 109, 123

169

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, 23 Flap surgery DIEP, 5 gluteal-free, 5 latissimus dorsi, 5 TRAM, 5 Fluorescent tube, 30, 41–44 Fluorodeoxyglucose (FDG), 3 FNA. See fine needle aspiration FNB. See fine needle biopsy Focal spot size, 110, 114, 125, 130, 142–143, 146, 157, 160, 160f, 162 mammographic technique and image evaluation relating to, 65, 69, 74 patient education and assessment relating to, 20, 27, 34 Food and Drug Administration (FDA), 4, 21, 24, 112, 116, 131, 147, 163 From below (FB), 81–82 Frozen shoulder, patients with, 85 G Galactocele, 49, 56, 62, 143, 159 Geiger counter, 4 Glandibular dose, 1, 143, 159 Glandular tissue, 47, 53–54, 59, 61, 143, 159 Gluteal-free flap surgery, 5 Granular-type calcifications, 48 Grid ratio, 20, 140, 155 Grids HTC, 20 mammography, 20, 27, 33, 110, 125 parallel, 114, 130 radiography, 20, 27, 33 use of, 114, 130 Gynecomastia, 108, 112, 123, 128 H Halo sign, 49, 54, 61, 61f Hamartomas, 56, 63, 147, 163

170

Index

Health Insurance Portability and Accountability Act (HIPAA), 25 Hemangiomas, 49 Hematoma, 49, 145, 161 Herceptin, 5 High-transmission cellular grid (HTC), 20 HIPAA. See Health Insurance Portability and Accountability Act Histology, of breast, 47 Hormone replacement therapy (HRT), 2, 5, 54, 61, 107, 122, 141, 157 Hormones synthetic, 47–48, 53–54, 60–61 use of, 47, 104, 119, 135, 138, 149, 153 HRT. See hormone replacement therapy HTC. See high-transmission cellular grid Hyperplasia atypical, 2 epithelial, 142, 158 Hypo estimator, 23, 141, 157 Hypo-retention test, 23, 116, 132 I ID projections. See implant displaced projections Image evaluation. See mammographic technique and image evaluation Image quality artifacts relating to, 23–24, 66, 107, 122, 140, 155 collimation relating to, 20, 66, 104, 119, 138, 153 compression relating to, 66 contrast relating to, 66, 70–71, 77–78, 77f exposure relating to, 66 labeling relating to, 66, 70, 72, 77–79, 82 noise relating to, 66, 116, 132, 147, 164 overexposure relating to, 69, 75 positioning relating to, 66

sharpness relating to, 66, 70, 78 underexposure relating to, 66, 69, 75, 112, 127, 127f unsharpness relating to, 65, 66, 71–78, 137, 151 Image receptor (IR), 3, 21, 79, 85, 88, 95 cassettes or, 3, 21, 27, 34, 116, 132 Image viewing environment, 115, 131 Images, phantom, QC tests for. See phantom images, QC tests for Imaging components of digital system, 21–22 screen-film system, 21 digital, 2–3, 31, 44, 136, 150, 150f of implants. See implants, imaging of. Miraluma, 3 of nonconforming patients elderly, 82 irradiated breast, 82, 92, 99 kyphotic, 81–82, 89, 96 large or wide breast, 82 male breast, 82, 116, 132, 137, 152 pectus carinatum and barrel chest, 82, 89, 97 pectus excavatum, 82, 91, 98 postsurgical breast, 82 small breast, 81–82, 103, 118, 140, 147, 155, 163 stretcher/cart, 82 wheelchair, 82 postlumpectomy, 82 ultrasound, 3, 10, 17 Imaging plate, 3, 21 IMF. See inframammary fold Implant displaced (ID) projections, 81–82, 110, 115, 125, 131 Implants Eklund method relating to, 100f encapsulated, 81, 92, 98 imaging of, 81–82, 83f–84f, 92, 99, 106, 121, 137, 152 ruptured, 142, 142f, 158 Inflammatory carcinoma, 56, 62–63

Inframammary fold (IMF), 79, 87–88, 94–95, 109, 123 Infusa-port, 56, 63 Instrumentation and quality assurance, 19–46 Intensifying screen, 104, 113, 120, 129, 129f, 135, 149 Intracystic tumor, 93 Intraductal papilloma, 118 Intralobular terminal duct (ITD), 53, 60, 60f Involution, of breast, 113, 129 IR. See image receptor Irradiated breast, 82, 92, 99 ITD. See intralobular terminal duct K Keratosis, 136, 151 kVp (peak kilovoltage) range of mammography units, 19, 26, 32, 108, 123 technique and image evaluation relating to, 65–66, 69, 70–71, 75, 77, 78 Kyphotic patient, 81–82, 89, 96 L Labeling, image quality relating to, 66, 70, 72, 77–79, 82 Lactation, 47, 53, 60–61, 143, 159 Lactiferous duct, 47–48, 48f cannulation of, 85, 93, 101 Lactiferous sinus, 48f, 109, 109f, 124, 124f Large core biopsy, 86 Lateromedial (LM), 81–82, 85, 88, 90, 90f, 96–97 Lateromedial oblique (LMO), 81–82, 85, 90, 97, 139, 146, 154, 162 Latissimus dorsi flap surgery, 5 Lesions, of breast. See breast, lesions of Lesions visualized with compression, 65, 68, 73 Lipoma, 49, 56, 62, 111, 126 LM. See lateromedial LMO. See lateromedial oblique Lobes, of breast, 47, 52, 58 Lobular carcinoma, 7

Index

invasive, 2 in situ, 2 Lobules, 2, 47 Localization needle, 79, 117, 133, 137, 152 preoperative, 4, 81, 85, 92, 99 stereostatic breast, 4, 85, 93, 102 Log relative exposure, 37f Lumpectomy, 4, 9, 15, 86, 146, 163 Lymph node, 1, 49, 142, 157 biopsy of, 86 Lymphatic drainage, of breast, 47, 48f, 53, 59 Lymphedema, 11 Lymphoscintigraphy, 3–4 M Magnetic resonance imaging (MRI), 3, 7, 10, 12, 16–17 Magnetic resonance (MR) biopsy, 86 Magnification, 103, 105, 108, 110, 112, 118, 120, 122, 124, 127, 139, 154 disadvantage of, 65 mammographic technique and image evaluation, 65–66, 68–69, 73–74, 73f, 74f positioning and interventional procedures relating to, 81, 85, 91, 98 spot, 145, 162 Male breast, 82, 116, 132, 137, 152 Malignant asymmetric densities, 2 Malignant breast lesions. See breast, lesions of Malignant cancer, of breast, 2, 6, 11, 48–49, 55, 55f, 61–62 Malignant circumscribed lesions, 2 Mammogram/mammography accuracy of, 104, 119 benefits and risks of, 1 calcifications relating to, 81, 88–89, 96 conventional, 2, 21, 28, 34–36, 103, 118 CT laser, 4 digital, 2, 21, 28, 34, 35f contrast, 3 false-negative, 69, 75

filter used in, 66, 70, 76 grids relating to, 20, 27, 33, 110, 125 mortality reduction, 1, 111, 126 optical densities relating to, 66, 69, 75 radiation dose, exposure relating to, 1, 9, 14, 15, 65, 69, 74–75 screening, routine, 1 tube relating to, 19, 26, 32, 141, 156, 156f units relating to AEC, 20, 27, 33, 66, 69, 70, 75–76, 106–107, 111, 120–121, 126 compression devices, 19–20 design characteristics of, 19–20 kVp range, 19, 26, 32, 108, 123 Mammographers, 143, 159 requirements of, 22, 24, 115, 131 Mammographic appearances, of breast, 48 Mammographic technique and image evaluation, 65–78 AEC relating to, 66, 69, 70, 75–76 breast compression, 65 focal spot size relating to, 65, 69, 74 kVp relating to, 65–66, 69, 70–71, 75, 77–78 magnification, 65–66, 68–69, 73–74, 73f, 74f, 103, 105, 118, 120 MLO relating to, 66 Mammography 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, 132 mAs (milliamperes), 19, 65–66, 69, 74–75 Mass in breast, 61f painless, 104, 119 palpable, 110, 125

171

Mastectomy, 86 modified radical, 4 radical, 4 Medical audit, 25, 148, 165 Medical history and documentation, 1, 8, 140, 156 Medication, for pain, 5 Mediolateral (ML) 90 degree, 114, 114f, 130, 143, 146, 158, 163 positioning 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 and image evaluation relating to, 66 positioning and interventional procedures relating to, 79, 81–82, 85, 87, 89–90, 94–97 Menarche, 2, 47 Menopause, 2, 48 MIBB. See minimally invasive breast biopsy Milk lines, 59f Minimally invasive breast biopsy (MIBB), 86 Miraluma imaging, 3 ML. See mediolateral (ML) 90 degree MLO. See mediolateral oblique projection Mobile v. fixed tissue, 88, 95 Modifications, to imaging. See positioning and interventional procedures Modified radical mastectomy, 4 Molybdenum, 19, 70, 75–76, 76f, 139, 153 Montgomery glands, 107, 112, 122, 128 Morgagni tubercles, 47, 52, 58 Morphine, 5 Mortality reduction, mammography relating to, 1, 111, 126

172

Index

MQSA. See Mammography Quality Standards Act MR biopsy. See magnetic resonance biopsy MRI. See magnetic resonance imaging N Needle localization, 79, 117, 133, 137, 152 Nipple, 47–48, 48f, 52–53, 58–59, 79, 87, 95 aspiration of, 86 markers for, 82 Nipple not in profile, 82, 106, 121, 145, 161 Noise, image quality relating to, 66, 116, 132, 147, 164 Nuclear medicine, 3 Nullipara/nulliparous, 54, 61 O Obesity, postmenopausal, 2, 8, 14 Object-to-image receptor distance (OID), 20–21, 66, 69, 75, 78, 136, 142, 151, 157 OID. See object-to-image receptor distance Oil cyst, 49, 55, 55f, 62, 115, 130–131 Open surgical biopsy, 4, 86, 93, 102, 146, 162 Overexposure, image quality relating to, 69, 75 P Pacemaker, 81, 146, 146f, 162 PACS. See picture-achieving and communication system Paget disease, of breast, 107, 122 Pain medication, 5 Painless mass, 104, 119 Palpable mass, 110, 125 Papilloma, 49 ductal, 103, 118 intraductal, 118 Parallel grid, 114, 130 Parturition, 147, 163 Pathology, of breast, 47–64 Patient. See also imaging

compression knowledge of, 68, 73 education and assessment of, focal spot size relating to, 20, 27, 34 with frozen shoulder, 85 postmastectomy, 82, 92, 99, 137, 152 with protruding abdomen, 85 with uneven breast thickness, 85 Peau d’orange, 148, 166 Pectus carinatum and barrel chest, 82, 89, 97 Pectus excavatum, 82, 91, 98 PET. See positron emission tomography Phantom images, QC tests for, 107, 122, 136, 139, 140, 151, 151f, 154–155 instrumentation and quality assurance relating to, 23, 29, 30, 37–39, 37f, 39f, 41, 44 Physiology, of breast, 47–64 Picture-achieving and communication system (PACS), 21–22 Piezoelectric effect, principle of, 3 Pigeon chest-prominent sternum. See pectus carinatum and barrel chest Pneumocystography, 85 PNL. See posterior nipple line Positioning, image quality relating to, 66 Positioning and interventional procedures additional positions/projections AT, 81–82, 88–89, 89f, 96–97 caudocranial 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, 81–82 TAN projection, 81, 88–89, 95–96, 104, 118–119, 119f, 137, 152 XCCL, 79, 82, 89, 96–97, 105–106, 107f, 120–121 modifications breast implant imaging, 81–82, 83f–84f, 92, 99 magnification, 81, 85, 91, 98, 110, 112, 124, 127 RL or RM, 81, 90, 91f, 97–98 RS or RI, 81 spot compression, 81–82, 92, 98–99 special situations imaging nonconforming patients, 81–82, 89, 92, 96–99 solving special problems, 82–85 specimen radiography core biopsy, 4, 85–86, 93, 99–100, 101, 101f cyst aspiration, 4, 85, 93, 102 ductography, 4, 85, 93, 101, 109, 124, 143, 159 FNA, 4, 85, 92, 99, 101, 113, 128–129 FNB, 4, 85, 93, 99, 102 large core biopsy, 86 lymph node biopsy, 86 MR biopsy, 86 nipple aspiration, 86 open surgical biopsy, 4, 86, 93, 102, 146, 162 pneumocystography, 85 preoperative needle localization, 4, 81, 85, 92, 99 radio frequency biopsy, 86 stereostatic localization, 4, 85, 93, 102 ultrasound, 85–86, 93, 100–101 standard projections CC, 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

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, 82 Postmastectomy patient, 82, 92, 99, 137, 152 Postmenopausal obesity, 2, 8, 14 Postsurgical breast, 82 Posttreatment options, for breast cancer, 5 Powderlike calcifications, 48 Preoperative needle localization, 4, 81, 85, 92, 99 Processors, 21, 28, 34 quality control of, QC tests for, 23, 30, 41, 42f, 43f, 103, 108, 118, 123 Projections. See implant displaced projections; positioning and interventional procedures Prominent ribs and sternum. See pectus carinatum and barrel chest Protruding abdomen, patients with, 85 Q QC tests. See quality assurance Quadrants, of breast, 47, 52, 58, 58f, 81 Quality assurance. See also Mammography Quality Standards Act digital, 24 instrumentation and, 19–46 QC tests for analyses of fixer retention in film, 23 for compression, 23, 29, 39 for darkroom cleanliness, 22–23 for 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 and identification, 23, 29, 39, 39f, 110, 125 for visual checklist, 23, 28, 31, 37, 44 radiologist relating to, 22 Quality control (QC) tests. See quality assurance Quantum mottle, 66, 137, 152 R Radial scar, 49, 55, 62, 105, 105f, 120, 144, 144f, 160 Radiation bremsstrahlung, 70, 76 compression relating to, 65, 67, 72–73 dose of, exposure relating to, 1, 9, 14–15, 65, 69, 74–75 scattered, 20, 65, 109, 124 Radiation therapy, 4, 9, 15, 82, 135, 139, 149, 154 Radical mastectomy, 4 Radio frequency biopsy, 86 Radiographs, of breast cancer, 2 Radiography. See positioning and interventional procedures Radiography grid, 20, 27, 33 Radiologist, 22 Radiopaque tumor, 49, 56, 62 Raloxifene, 5 Receptor. See image receptor Reciprocity law, 65 Reconstruction, of breast, 4–5, 10, 16

173

Reject/repeat analysis, QC tests for, 23, 30, 39–41, 40f, 115, 130, 139, 140, 154–155 Repeat/reject analysis, QC tests for, 23, 30, 39–41, 40f, 115, 130, 139, 140, 154–155 Resolution contrast, 139, 155 spatial, 21, 67, 72 Retromammary space, 47, 104, 120, 141, 156 Rhodium, 19, 70, 75–76, 108, 122 RI. See rolled inferior Right lateromedial oblique (RLMO), 88, 95 Right mediolateral oblique (RMLO), 88, 95 Risk factors, associated with breast cancer, 1–2, 6, 11, 107–108, 110, 121, 123–125 RL. See rolled lateral RLMO. See right lateromedial oblique RM. See rolled medial RMLO. See right mediolateral oblique Rolled inferior (RI), 81 Rolled lateral (RL), 81, 90, 91f, 97–98 Rolled medial (RM), 81, 90–91, 91f, 97–98, 108, 113, 123, 129, 137, 152 Rolled projections, 81, 146, 162 Rolled superior (RS), 81, 91, 98 Routine mammography screening, 1 RS. See rolled superior Ruptured implant, 142, 142f, 158 S SAC. See States as Certifiers Scar, radial, 49, 55, 62, 105, 105f, 120, 144, 144f, 160 Scar tissue, 86, 88, 95 Scattered radiation, 20, 65, 109, 124 Scattering, coherent, 70, 76 Scintigraphy, of breast, 3 Scintillator, 21

174

Index

Screen cleanliness of, QC tests for, 23, 29, 37, 38 intensifying, 104, 113, 120, 129, 129f, 135, 149 Screen/film contact and identification, QC tests for, 23, 29, 39, 39f, 110, 125 Screen-film system, 21 Selective estrogen receptor modulators (SERMs), 5, 14 Sensitometer, 23, 29–30, 38, 38f, 41, 138, 142, 153, 158 Sentinel node mapping, 3–4 SERMs. See selective estrogen receptor modulators Sharpness, image quality relating to, 66, 70, 78 SID. See source-to-image receptor distance SIO. See superior-inferior oblique projection Skin folds or wrinkling, of breast, 82–85 Skin thickening syndrome, 2, 6, 11, 48–49 Small breast, 81–82, 103, 118, 140, 147, 155, 163 SMPTE tests, 24 SOD. See source-to-object distance Soft copy viewer, 44f Source-to-image receptor device (SID), 20–21, 66, 68, 74, 78, 143, 159 Source-to-object distance (SOD), 69, 74 Spatial resolution, 21, 67, 72 Spatula, 82, 103, 118 Specimen radiography. See positioning and interventional procedures Spiculated/stellate breast lesions benign, 49 malignant, 48, 55, 62 Spot compression, 57, 57f, 64, 111, 112, 126–127 positioning and interventional procedures relating to, 81–82, 92, 98–99 Spot magnification, 145, 162

States as Certifiers (SAC), 24 Stereostatic localization, 4, 85, 93, 102 Stretcher/cart, patient in, 82 Superior-inferior oblique (SIO) projection, 81–82, 116, 132, 148, 165, 165f Surgery. See flap surgery Surgical reconstruction, 5 Survival rate, of breast cancer, 9, 15, 15t Synthetic hormones, 47–48, 53, 54, 60, 61 System geometry, 20–21, 28, 34 T Tail of Spence, 52, 59 Tamoxifen, 5, 9, 14–15, 147, 164 TAN. See tangential projection Tangential (TAN) projection, 81, 88–89, 95–96, 104, 118–119, 119f, 137, 152 TDLUs. See terminal duct lobular units Teacup-shaped calcification, 49, 81, 89, 96 Technetium, 3 Terminal duct lobular units (TDLUs), 48, 52–53, 58–60, 60f TFD. See thin-film diodes TFT. See thin-film transistors Thin-film diodes (TFD), 21 Thin-film transistors (TFT), 21 Tissue adipose, 47, 53, 60 composition of, 47–48, 138, 153 fatty, 47, 49, 52, 59, 105, 120, 141, 157 fibroglandular, 47, 105, 113, 120, 128 glandular, 47, 53–54, 59, 61, 143, 159 mobile v. fixed, 88, 95 scar, 86, 88, 95 TRAM flap. See transverse rectus abdominus muscle flap Transverse rectus abdominus muscle flap (TRAM), 5, 9, 14

Triangulation techniques, 85, 148, 166, 166f Tubes angle of, 79, 82, 85, 88, 95 fluorescent, 30, 41–44 mammography, 19, 26, 32, 141, 156, 156f Tumors, of breast, 48, 54, 54f, 61 intracystic, 93 radiopaque, 49, 56, 62 Tungsten, 19 U Ultrasound, 85, 86, 93, 100–101 color Doppler, 3 Ultrasound imaging, 3, 10, 17 Undercompression, 103, 118 Underexposure, image quality relating to, 66, 69, 75, 112, 127, 127f Uneven breast thickness, patients with, 85 Unsharpness, image quality relating to, 65–66, 71, 78, 137, 151 UOQ. See upper outer quadrant Upper outer quadrant (UOQ), 112, 127 V VACB. See vacuum-assisted core biopsy Vacuum-assisted core biopsy (VACB), 86 Valley view, 81 Veins, of breast, 47, 53, 60 Visual checklist, QC tests for, 23, 28, 31, 37, 44 W Wheelchair, patient in, 82 Wide or large breast, 82 X X-ray beam, 19, 26, 32, 33f, 114, 130 X-ray photons, 135, 149 XCCL. See exaggerated craniocaudal

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