BREAST RADIOLOGY

BREAST ANATOMY AND IMAGING MODALITIES

1. A density in the inferior aspect of the MLO view is not seen on the CC
view, but the density is seen more inferiorly on a true lateral view. In what
quadrant is the density located?
A. Upper inner
B. Lower inner
C. Upper outer
D. Lower outer
ANSWER: D. Lower outer. Lateral lesions are seen more inferiorly on a true lateral as
compared with an MLO view, whereas medial lesions are seen more superiorly (Medial
lesions muffins rise; lateral lesions lead sinks).

2. During ultrasound-guided aspiration, the aspirate from a cystic lesion is

bloody. What is the next step in patient management?
A. Discard aspirate and follow up in 1 year.
B. Send aspirate for cytology, mark lesion, and recommend excisional biopsy.
C. Discard aspirate and follow up in 6 months.
D. Send aspirate for microbiologic evaluation and place patient on antibiotics.
ANSWER: B. Bloody aspirates should be sent for cytology and excisional biopsy is
recommended. A marker may be placed to aid in wire localization for excisional biopsy.

3. There is a spiculated mass in the right breast at the 9-o’clock position. In

what aspect of the left breast should one place the transducer for
evaluation of an equivalent location?
A. Medial
B. Superior
C. Inferior
D. Lateral
ANSWER: D. Lesions are described in a clockface location as if the examiner were facing
the patient. Left lateral breast lesions are at 3-o’ clock position and right lateral breast
lesions are at 9-o’ clock position.

4. What is the appropriate position of the localization wire tip relative to

the targeted lesion?
A. Immediately proximal to the lesion
B. 3 cm past the lesion
C. 1 to 1.5 cm past the lesion
D. Within the lesion
ANSWER: C. The localization wire tip should be 1 to 1.5 cm past the targeted lesion.

5. What is the optimum prefire position for an ultrasound-guided core

needle biopsy?
A. Core biopsy needle entirely through the lesion
B. Core biopsy needle perpendicular to the chest wall and 5 cm proximal to the lesion
C. Core biopsy needle perpendicular to the transducer and at the lesion
D. Core biopsy needle parallel to the chest wall and transducer with core biopsy needle
tip just proximal to the lesion
ANSWER: D. The optimum prefire core needle biopsy position for an ultrasound-guided
biopsy is just proximal to the targeted lesion with the needle parallel to both the
transducer and the chest wall.

6. A cluster of amorphous calcifications is seen in the medial breast on CC

view but not seen on the MLO view. What additional view would help
localize the calcifications?
A. Lateral–medial view
B. Medial–lateral view
C. Cleavage view
D. Spot compression
ANSWER: A. A lateral medial view would be optimal as the calcifications would be closer
to the image receptor and this view would assist in localization of the calcifications. A
cleavage view is a modified CC view that improves visualization of medial and posterior
breast tissue. A spot compression view may provide additional information about the
character of calcifications but would not improve knowledge of calcification localization.

7. Which of the following is an indication for breast MRI?

A. High-risk patient screening
B. Evaluation of silicone breast implants
C. Evaluation of extent of disease
D. Evaluation of response to neoadjuvant therapy
E. All of the above
ANSWER: E. Indications for breast MRI include screening high-risk patients, assessment
of extent of ipsilateral disease in newly diagnosed breast cancer patients, assessment of
chest wall or pectoralis muscle involvement, evaluation of the contralateral breast,
surveillance for residual/recurrent disease after breast conservation surgery, evaluation
of response to chemotherapy, further evaluation of mammographic or palpable
abnormality, evaluation of axillary carcinoma with unknown primary, and assessment of
silicone implant integrity.

8. Which of the following statements is false?

A. Magnification views are obtained by moving the breast away from the image
receptor, thereby increasing object to image.
B. Grids are utilized to eliminate scatter radiation.
C. A magnification factor of 1.5X to 1.8X is common.
D. A small focal spot increases exposure time, and this may lead to increased motion
artifact.
ANSWER: B. Grids are not utilized in magnification views because scatter is eliminated
through the air gap.

9. The terminal duct lobular unit is the site of origin for all of the following
except:
A. Fibrocystic change
B. Ductal carcinoma in situ
C. Papillary neoplasm
D. Infiltrating ductal carcinoma
ANSWER: C. Papillary neoplasms arise within the main lactiferous duct and its major
branches.

10. A round mass is palpated in the axillary tail, which mammographic

view is optimal for lesion evaluation?
A. XCCL view
B. CC view
C. Cleavage view
D. XCCM
ANSWER: A. An XCCL view optimally images the axillary tail. Cleavage and XCCM views
increase visualization of medial breast tissue.

BREAST SCREENING AND BREAST IMAGING REPORTING

AND DATABASE SYSTEM (BI-RADS) LEXICON
1. Which of the following quality control tests are performed weekly for
film–screen mammography?
A. Darkroom cleanliness
B. Phantom images
C. Processor QC
D. Darkroom fog
ANSWER: B. Phantom image testing is performed weekly

2. Which of the following locations is most likely to show motion artifact?

A. Medial aspect of the CC view
B. Central aspect of the CC view
C. Inferior aspect of the MLO view
D. Superior aspect of the MLO view
ANSWER: C. Breast tissue in the inferior and lateral aspects of the breast is mobile.
Motion artifact is secondary to inadequate compression, which is more likely to occur in
the more mobile aspects of the breast.

3. A patient has a negative screening mammogram and 7 months later

develops a palpable mass that is biopsied to reveal infiltrating ductal
carcinoma. This is termed a:
A. False-positive screen
B. True-positive screen
C. True-negative screen
D. False-negative screen
ANSWER: D. A breast cancer that is diagnosed within a year of a negative screening
mammogram is a false negative

4. All of the following are true with respect to film– screen mammography
versus conventional radiography, except:
A. Film–screen mammography has higher resolution.
B. Film–screen mammography has greater exposure latitude.
C. Film–screen mammography has higher film contrast.
D. Film–screen mammography utilizes single emulsion film.
ANSWER: B. Screen–film mammography has narrow exposure latitude. All the other
answer choices are correct.

5. What is the expected number of cancers if interpreting 1000 initial

screening mammograms?
A. 20–30
B. 1–2
C. 6–10
D. None
ANSWER: C. The approximate number of expected breast cancers per 1000 initial
screening examinations is 6 to 10. The expected number of breast cancers per 1000
follow-up routine breast screening examination is 2 to 4.

6. Over a year, 100 cancers are identified, 92 of these were identified

based on biopsy recommendations from screening mammograms and an
additional 8 cancers developed after a negative screening mammogram.
What is the sensitivity in this population?
A. 8%
B. 80%
C. 91%
D. 92%
ANSWER: D. Sensitivity is defined as a positive test in the presence of true disease.
Sensitivity TP/(TP + FN). TP 92 and FN 8. Sensitivity 92/(92 + 8) 92/100 0.92

7. A spiculated mass is identified in the left upper outer quadrant on

screening mammogram. What is the BI-RADS assessment?
A. BI-RADS 0
B. BI-RADS 1
C. BI-RADS 2
D. BI-RADS 6
ANSWER: A. BI-RADS assessment categories 0, 1, and 2 are utilized in screening
mammography. BIRADS category 0 is incomplete assessment requiring additional
evaluation. This finding should be further evaluated with additional mammographic
views, ultrasound and biopsy. BI-RADS category 1 is a negative assessment. BI-RADS 2
assessment is benign finding. BI-RADS 6 assessment designates known malignancy
utilized in evaluation of response to neoadjuvant therapy or in second opinion cases.

8. What is the typical kVp used in screening mammography?

A. 5–15 kVp
B. 24–30 kVp
C. 120–140 kVp
D. 70–90 kVp
ANSWER: B. Kilovoltage peak (kVp) varies dependent on breast size; however, the
typical kVp range for mammography is 24 to 30.

9. Which of the following is a risk factor for development of breast cancer?

A. Early menopause
B. Early first-term pregnancy
C. Late menarche
D. Cowden syndrome
ANSWER: D. There are numerous syndromes that increase risk for breast cancer,
Cowden, Li Fraumeni, Bannayan-Riley-Ruvalcabe. Early menarche (not late) and late
menopause (not early), as well as late first-term pregnancy are also risk factors.

10. The posterior nipple line measures 11 cm on the MLO view. What is an
acceptable PNL measurement on the CC view?
A. 10 cm
B. 6 cm
C. 8 cm
D. 9 cm
ANSWER: A. The PNL measurements should differ no more than 1 cm when comparing
MLO and CC views if there is adequate tissue exposure.

EVALUATION OF BREAST MASSES

1. All of the following are true regarding tubular carcinoma except:
A. Can present as a spiculated mass on mammography
B. A well-differentiated slow-growing tumor
C. Multicentric
D. Large rapidly growing mass in young women
ANSWER: D. Tubular carcinoma is a well-differentiated breast cancer that is slow
growing and is more often seen in older women. Mammographically, it most commonly
presents as a spiculated mass. Tubular carcinoma may be multicentric and bilateral.

2. Which of the following enhancement characteristics is most likely

associated with a malignant mass on dynamic breast MRI?
A. Early enhancement washout
B. Nonenhancing internal septations
C. Progressive enhancement with delayed imaging
D. Slow gradual enhancement
ANSWER: A. Malignant lesions may show early enhancement with rapid washout or
early enhancement that plateaus. Nonenhancing internal septations are seen in
fibroadenomas, benign lesions. Slow gradual enhancement is more suggestive of
benignity.

3. What pathologic finding is responsible for the mammographic

appearance of inflammatory breast cancer?
A. Tumor cells invading the dermal lymphatics
B. Inflammatory cells infiltrating the skin
C. Tumor cells infiltrating epidermis of the nipple
D. None of the above
ANSWER: A. Malignant cells invading dermal lymphatics results in overlying skin
changes seen in inflammatory breast cancer. Tumor cells infiltrating the epidermis of
the nipple are seen in Paget disease.

4. An MRI reveals an oval lesion in the right upper outer breast with
increased T1 signal centrally and low signal in this region on T2 fat-
saturated images. What is the most likely diagnosis?
A. Cyst
B. Fibroadenoma
C. Lymph node
D. Invasive ductal carcinoma
ANSWER: C. The loss of fat signal in the hilum on fat-suppressed sequence is helpful in
the diagnosis of lymph node.

5. Which MRI finding is most often associated with breast cysts?

A. Increased T2 signal
B. Increased T1 signal
C. Diffuse enhancement
D. Decreased T2 signal
ANSWER: A. Increased T2 signal is seen in most cysts consistent with internal fluid
content.

6. What disease is characterized by eczematous skin changes around the

nipple secondary to tumor cells infiltrating underlying epidermis?
A. Inflammatory breast cancer
B. Paget disease
C. Lobular carcinoma in situ
D. Atypical ductal hyperplasia
ANSWER: B. Paget disease is secondary to infiltration of the areolar epidermis with
tumor cells.

7. Which of the following lesions is the least likely to present as a round

mass?
A. Cyst
B. Invasive ductal carcinoma
C. Invasive lobular carcinoma
D. Papillary carcinoma
ANSWER: C. Invasive lobular carcinoma may present as an increased density,
architectural distortion, or a spiculated mass.

8. Which of the following is false regarding phyllodes tumor?

A. Mean age of presentation is greater than 60 years of age.
B. Fibroepithelial tumor
C. Malignancy is rare but can occur.
D. Sonographic findings similar to fibroadenomas
ANSWER: A. The mean age of presentation for phyllodes tumors is 45 years.

9. A patient has a palpable mass on physical examination. What is the least

likely diagnosis?
A. Hematoma
B. Cyst
C. Papillary carcinoma
D. Lobular carcinoma in situ
ANSWER: D. LCIS is usually an incidental finding on biopsy that is associated with an
increased risk for breast cancer. Hematoma, cyst, and papillary carcinoma can all
present as a palpable abnormality.

10. A well-circumscribed solid mass with fat and softtissue density is seen
in the inferior right breast on mammogram. What is the next step in
management?
A. 3-month follow-up
B. 6-month follow-up
C. Excisional biopsy
D. Routine 1-year screening mammogram
ANSWER: D. A well-circumscribed mass with both fat and soft-tissue density is a benign
lesion. Differential diagnosis includes hamartoma, intramammary lymph node, fat
necrosis, galactocele, and lipoma.

EVALUATION OF BREAST CALCIFICATIONS

1. Which of the following is the highest-grade DCIS?
A. Solid type with comedo necrosis
B. Micropapillary
C. Cribriform
D. Medullary type
ANSWER: A. Comedo necrosis is associated with higher-grade DCIS. Micropapillary and
cribriform types are usually low to intermediate nuclear grade. There is no medullary-
type DCIS.

2. Which BI-RADS lexicon descriptors of calcifications are most associated

with malignant pathology?
A. Milk of calcium
B. Lucent centered
C. Popcornlike
D. Fine linear branching
ANSWER: D. Fine linear branching or pleomorphic calcifications have a higher
probability of malignancy. Milk of calcium is calcium suspended in microcysts that shows
variability on orthogonal views. Lucent-centered calcifications are usually benign and
can frequently be seen in skin calcifications. Popcornlike calcifications develop within
the hyalinizing stroma of a fibroadenoma.

3. Large, coarse rodlike calcifications are seen throughout both breasts

without interval change over 2 years. What BI-RADS assessment category
is most appropriate?
A. BI-RADS 6
B. BI-RADS 2
C. BI-RADS 4
D. BI-RADS 5
ANSWER: B. This is a typical mammographic presentation of secretory disease or plasma
cell mastitis, which is benign.

4. Calcifications are seen in the subareolar breast on a CC view and are

amorphous or smudgy. A true lateral view demonstrates high-density
curvilinear calcifications in the subareolar breast with a teacup
appearance. What do these calcifications most likely represent?
A. DCIS
B. Tubular carcinoma
C. LCIS
D. Microcysts
ANSWER: D. The calcifications are milk of calcium seen in microcysts.

5. A cluster of pleomorphic calcifications in the left upper outer quadrant is

biopsied stereotactically. Biopsy results include LCIS without calcifications.
What is the next appropriate step in management?
A. Request polarizing microscopy to evaluate for calcium phosphate.
B. Request specimen radiographs to assess for calcifications.
C. Follow-up 1-year mammogram
D. Follow-up 6-month mammogram
ANSWER: B. Perform radiographs of paraffin blocks to assess for calcifications.
Polarizing microscopy should be requested to assess for calcium oxalate as calcium
phosphate is seen on routine H&E staining.

6. A spiculated mass with associated pleomorphic calcifications is biopsied

under US guidance. Biopsy findings are fibrocystic change with associated
microcalcifications. What is the next appropriate step in management of
this patient?
A. Follow-up routine mammogram in 1 year
B. Follow-up 6-month mammogram
C. Biopsy results are discordant suggesting sampling error; excisional biopsy is
recommended.
D. Breast MRI
ANSWER: C. Malignant findings at ultrasound and mammogram are discordant with the
benign biopsy results, which likely reflect sampling error. Additional tissue is required to
exclude malignancy.

7. Punctate clustered calcifications are seen in the left upper inner

quadrant that show interval increase in number on screening
mammogram. Stereotactic biopsy is performed and fibrocystic changes
with birefringent crystals on polarizing microscopy. Which of the following
is true?
A. Calcifications are likely composed of calcium oxalate.
B. US should be performed.
C. Excisional biopsy is recommended.
D. No calcifications were identified; paraffin blocks should be radiographed.
ANSWER: A. Calcifications composed of calcium oxalate are not seen on routine
hematoxylin and eosin staining like calcium phosphate but require polarizing
microscopy. Calcifications composed of calcium oxalate are seen within benign
processes such as fibrocystic changes. Imaging findings are concordant with biopsy
results. 999

8. An oval mass is seen in the left lower inner quadrant with associated
coarse popcornlike calcifications. What is the most likely diagnosis?
A. LCIS
B. ILC
C. Hyalinized fibroadenoma
D. IDC
ANSWER: C. The findings are consistent with hyalinized fibroadenoma.

9. Lucent centered calcifications are newly seen near the areola. What
view would be best for localization to the skin?
A. Cleopatra views
B. Tangential views
C. True lateral view
D. Craniocaudal view
ANSWER: B. Tangential views are utilized to localize lesions to the skin.

10. What distribution of calcifications is most likely to be benign?

A. Diffuse
B. Linear
C. Clustered
D. Grouped
ANSWER: A. Diffuse or scattered calcifications are randomly distributed throughout the
breast and are likely benign.

THE SURGICALLY ALTERED BREAST

1. Which of the following mamographic findings can be seen after
reduction mammoplasty?
A. Dystrophic calcifications
B. Oil cysts
C. Elevated nipple
D. All of the above
ANSWER: D. All of the statements are true.

2. Extracapsular silicone breast implant rupture can be recognized on US

by which of the following?
A. Keyhole sign
B. Linguini sign
C. Snowstorm sign
D. Highway sign
ANSWER: C. The snowstorm sign on ultrasound is seen with extracapsular rupture. The
linguini sign is low signal implant shell fragments floating in high signal silicone seen on
MRI in cases of intracapsular rupture. The “keyhole” sign is a single layer loop of implant
envelope within the lumen that may represent a partial rupture or possible silicone or
gel bleed.

3. What is a contraindication to breast conservation therapy for newly

diagnosed invasive ductal carcinoma (IDC)?
A. Previous excisional breast biopsy with benign findings
B. Previous augmentation
C. Previous reduction mammoplasty
D. Previous radiation therapy
ANSWER: D. Previous radiation therapy is a contraindication for breast conservation
therapy.

4. Mammography 2 years after right breast conservation therapy for IDC

demonstrates interval increased density in the RUO architectural
distortion with fine linear and pleomorphic calcifications. What is the BI-
RADS assessment?
A. BI-RADS 0
B. BI-RADS 1
C. BI-RADS 2
D. BI-RADS 3
ANSWER: A. Interval change in lumpectomy site at 2 years is suspicious for recurrence.
Additional magnification views, ultrasound, and core biopsy should be considered.

5. A patient had a right mastectomy 4 years ago for ILC. She now reports a
newly palpable mass at the mastectomy site. What is the next appropriate
step?
A. US and physical examination
B. Mammogram
C. Follow-up in 6 months
D. MRI
ANSWER: A. The most appropriate next step would be to perform a physical
examination and targeted US.

6. What is the most common type of breast cancer?

A. Invasive lobular carcinoma
B. Invasive ductal carcinoma (IDC)
C. Tubular carcinoma
D. Phylloides tumor
ANSWER: B. IDC is the most common histologic type of breast cancer.

7. The linguini sign of intracapsular silicone breast implant rupture is seen

on which imaging modality?
A. US
B. MRI
C. Mammography
D. All of the above
ANSWER: B. The Linguini sign is seen on MRI. Intracapsular silicone implant rupture
cannot be seen on mammography. Extracapsular rupture of silicone implant is seen as
the snowstorm on US.

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