Breast Imaging: A Core Review (40 page)

Reference: Slawson SH, Johnson BA. Ductography: How to and what if?
Radiographics
2001;21:133–150.

29
 
Answer C.
Radiology–pathology correlation should always be performed on all lesions to establish concordance. Surgical excision is always done for atypical ductal hyperplasia (ADH). Atypical lobular hyperplasia (ALH) is a high-risk marker for breast cancer, and controversy remains over whether to excise. Complications after core biopsy include hematoma, infection, pneumothorax, and pseudoaneurysm. Markers can migrate significantly sometimes even to other quadrants in the breast.

References: Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:183–186.
Irfan K, Brem R. Surgical and mammographic follow up of papillary lesions and atypical lobular hyperplasia diagnosed with sterotactic vacuum-assisted biopsy.
Breast J
2002;8:230–233.

30
 
Answer B.
0.2 to 0.3 mL is injected. Rarely does the total contrast volume exceed 1 mL.

Reference: Berg WA, Birdwell RL, Gombos EC, et al.
Diagnostic Imaging Breast.
1st ed. Salt Lake City, UT: Amirsys; 2006:Section V2, 4–5.

31
 
Answer A.
The difference between atypical ductal hyperplasia (ADH) and ductal carcinoma is often determined by the number of ducts involved. Therefore, a larger sample may result in the diagnosis of DCIS when the core biopsy was ADH.

Reference: Kopans D.
Breast Imaging.
3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:200.

32
 
Answer A.
Nephrogenic systemic fibrosis (NSF) is a rare but serious systemic disease characterized by fibrosis of the skin and other tissues throughout the body. The first report on NSF was published in 1997, and there is increasing evidence that this condition is associated with renal failure and the administration of large amounts of gadolinium.

The Food and Drug Administration (FDA) has determined that the risk for patients with chronic insufficiency is greatest when the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m 2. However, a discussion of the patient’s risk-benefit ratio with the referring physicians is necessary to determine if the examination is essential. If intravenous gadolinium-based contrast administration is needed, it is recommended that one use the lowest possible dose to obtain a diagnostic study.

Answer choice B is incorrect because without the use of intravenous gadolinium-based contrast, the breast MRI examination is not a diagnostic study for detection of breast cancer.

Answer choice C is incorrect because the patient has impaired renal function and therefore giving a standard dose of gadolinium-based contrast would be inappropriate.

Answer choice D is incorrect because the GFR measurement is not an absolute contraindication. While administration of intravenous gadolinium- based contrast is not recommended, the study can be performed in instances when the benefits of the study outweigh the risk of developing NSF.

References: American College of Radiology (ACR).
Nephrogenic Systemic Fibrosis.
ACR Manual on Contrast Media. Reston, VA: America College of Radiology; 2010: chap 11, 53.
Juluru K, Vogul-Claussen J, Macura KJ, et al. MR imaging in patients at risk for developing nephrogenic systemic fibrosis: Protocols, practices, and imaging techniques to maximize patient safety.
Radiographics
2009;29:9–22.
www.kidney.org/professionals/tools/pdf/nsf_risk_red.pdf

33
 
Answer C.
The fetal dose from a screening mammogram is negligible at <50 mGy; 3 mGy (0.3 rad) is the FDA/MQSA regulatory limit for average glandular dose per mammogram exposure. The risk of organ malformations (3rd to 8th weeks of gestation) has a threshold of 100 mGy. The risk for severe mental retardation (8 to 15 weeks of gestation) has a threshold of 100 mGy.

References:
http://www.radmd.org/resources/Resident-Resources/BWH-Fetal-Doses.pdf
http://www.radiationanswers.org/radiation-questions-answers/radiation-and-pregnancy.html
Federal Register
/Vol. 62, No. 208/Tuesday, October 28, 1997/Rules and Regulations Quality Mammography Standards, Final Rule; 21 CFR (900.12)(e)(5)(vi)

34
 
Answer C.
Patient safety and comfort are paramount after every breast interventional procedure. Part of patient recovery, especially after a breast biopsy, is pain control. If a patient does not have an allergy to acetaminophen and has no liver problems, the first step in management of the patient’s breast pain is to have the patient take acetaminophen initially and then every 6 hours as needed, up to 4 g/d.

Answer choices A and B are incorrect because they are not the initial management of breast pain. Tylenol 3 and Vicodin may be prescribed, but rarely is such stronger medication used.

Answer choice D is incorrect because aspirin or nonsteroidal anti-inflammatory drugs (NSAIDS) withheld 7 days before biopsy should be avoided 3 days after biopsy to decrease risk of bleeding.

Reference: Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:226–229.

35
 
Answer C.
There are two basic designs of stereotactic breast biopsy units: the dedicated prone table and upright add-on unit. Both units have advantages and disadvantages. When using a prone table, the ability to visualize very posterior lesions and lesions located deep in the axillary tail may be challenging or result in an unsuccessful biopsy or cancellation of the procedure. When using the add-on stereotactic biopsy unit, patients with lesions located deep in the axillary tail of the breast will likely require special positioning such as slight rolling of the breast forward from the lateral decubitus position, which can help bring the lesion in the field of view and maintain its position during biopsy.

References: Cousins JF, Wayland AD, de Paredes ES. Stereotactic breast biopsy units: Pros and cons.
Appl Radiol
1998;27(9):8–14.
Reynolds A. Stereotactic breast biopsy: A review.
Radiol Technol
2009;80(5):447M–462M.

36
 
Answer D.
Surgical procedures such as breast conservation surgery, mastectomy, and axillary lymph node sampling can be performed when the patient is pregnant. Radiation to the breast or chest wall is postponed until after delivery. Chemotherapy is not given in the first trimester because there is a significant risk of spontaneous abortion.

Reference: Hahn K, Johnson PH, Gordon N, et al. Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero.
Cancer
2006;107(6):1219–1226.

37
 
Answer D.
The most common mammographic and sonographic imaging appearance for pseudoangiomatous stromal hyperplasia (PASH) is a circumscribed mass that resembles a fibroadenoma. Postsurgical scar, radial scar, and tubular carcinoma commonly present as an irregular mass. Therefore, an irregular spiculated mass is most likely discordant with pathology results of PASH.

References: Bassett LW, Jackson VP, Fu KL, Fu YS.
Diagnosis of Diseases of the Breast
. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005:438–439.
Goel NB, Knight TE, Pandey S, et. al. Fibrous lesions of the breast: Imaging-pathologic correlation.
Radiographics
. 2005;25:1547–1559.

QUESTIONS

1
 What is the primary purpose of using mammography grids?

A. Increase contrast

B. Decrease production of scatter

C. Decrease dose

D. Increase image sharpness

E. Decrease motion

2
 Adequate breast compression results in which of the following?

A. Increase in radiation dose

B. Magnification

C. Decrease in scatter radiation

D. Increase in dynamic range

3
 Which of the following is usually taken in consideration in the design of the mammography reading room?

A. Monitors at a given station should be placed on the arc of a circle so that the viewer can minimize head movement.

B. Walls should be a light gray to maintain the background light at a comfortable level for viewing and for walking safely within the room.

C. Monitors for all the work stations should be along one wall only with all the viewing surfaces in a line to avoid reflected light.

D. A mammography view box, placed in a room for viewing film from prior examinations, should have one of its lights left on to provide illumination for moving about the room.

4
 Which target/filter combination is likely the most penetrating?

A. Mo/Mo

B. Mo/Rh

C. Rh/Rh

D. W/Ag

5
 For mammography, which of the following statements concerning scatter radiation is correct?

A. Though breast compression has many benefits, it increases the effect of scatter which is why a grid is used in contact mammography.

B. One of the disadvantages of the low tube potentials used for mammography is that the increased number of photons required for an exposure leads to higher scatter.

C. Because of breast compression, scatter is not an issue in mammography.

D. Scatter is enhanced during magnification mammography, which necessitates a grid for this special examination.

E. Both breast compression and the use of a grid contribute to the reduction of scatter to the image detector.

6
 Which of the following is usually involved in mammographic displays?

A. The higher the perceived brightness (luminance) of the display, the better since a brighter display overcomes the effects of ambient light.

B. The higher the contrast ratio (luminance ratio), that is bright to dark ratio presented by the display, the better since this allows us to perceive even small differences in tissue density.

C. A digital display should, at a minimum, have a luminance ratio corresponding to film density ranges on a standard view box. On the other hand, if the contrast ratio is too high, it will exceed the capabilities of the human vision system.

D. In the presentation of contrast between closely matching tissue, the best a modern liquid crystal display (LCD) can do is mimic top quality mammography film.

7
 Which of the following is usually involved with contrast threshold, the
fractional
change in luminance required to be perceivable?

A. The contrast threshold is highest when the screen is dim, dropping as the screen gets brighter but changing very little for luminance values above 100 cd/m
²
.

B. The contrast threshold is lowest when the viewing surface is bright (e.g., the brightness of an uncovered mammography view box).

C. The contrast threshold is almost constant throughout the brightness range perceivable by the human vision system.

D. The contrast threshold is highest for dim screens and decreases linearly throughout the range of brightness perceivable by the human visual system.

8
 For a fixed mAs, the x-ray tube potential increases from 25 to 29 kVp, an increase of 16%. The measured increase in entrance exposure is 60%. Which of the following accurately describes the mean glandular dose (MGD)?