Breast

Question 1

35. Which of the following is a neoplasm affecting the breast that is least likely to contain bone cartilage or osteoid tissue?

A. Lymphoma

B. Intraductal papillomas with stromal metaplasia

C. Phyllodes cystosarcoma

D. Stromal sarcomas

E. Adenocarcinomas with epithelial metaplasia

Answer 1

A. Lymphoma

B-D can contain bone, cartilage and osteoid tissue. Osteogenic sarcomas may also arise from sarcomatous transformation of connective tissue elements of pre-existing breast neoplasms.

Question 2

38. Which of the following is least likely to suggest a malignant lesion in the breast?

A. Thin halo

B. Ill-defned margin

C. Spiculated morphology

D. Inhomogeneity

E. Focal ductal dilation

Answer 2

A. Thin halo

A wide halo is more suggestive of a malignant lesion but features are not invariable.

Question 3

39. Which of the following is best at distinguishing fbroadenoma from a carcinoma?

A. Poor reflectivity

B. Homogenous echopattern

C. Ill-defned mass

D. Absent far wall echoes

E. Posterior acoustic shadowing

Answer 3

B. Homogenous echopattern

Fibroadenomas classically have a homogenous internal echopattern.

Question 4

@# 5) A 78-year-old man presents with a palpable, non-tender, left breast lump. Mammography demonstrates a well-defined, high-density, lobulated mass in the retroareolar region. Ultrasound appearances are of a hypoechoic mass with an eccentric position relative to the nipple. The ipsilateral axilla appears unremarkable. What is the most likely diagnosis?

a. invasive ductal carcinoma

b. lipoma

c. breast abscess

d. gynaecomastia

e. lymphoma

Answer 4

a. invasive ductal carcinoma

Most symptomatic male breast lesions are benign, with gynaecomastia representing the commonest benign entity.

Characteristic mammographic features are of a central, retroareolar, flame-shaped density.

Male breast cancers are usually invasive ductal carcinomas, which typically appear as a discrete, high-density, well-defined mass with lobulated or spiculated margins at mammography.

Microcalcification is seen less commonly than in females, but secondary signs, such as nipple retraction and skin thickening, occur earlier than in females due to smaller breast size.

Ultrasound scan is particularly helpful in assessing the relationship of the mass to the nipple. An eccentric position is highly suspicious for breast CA.

Axillary lymphadenopathy is seen in approximately 50% of patients.

Question 5

45) A 50-year-old female with a breast carcinoma that clinically involves the skin is to be staged by CT. Other than those related to the primary tumour, there are no specific symptoms. Which CT protocols should be used?

a. post-contrast brain

b. non-contrast brain, neck, chest, abdomen and pelvis

c. non-contrast brain, neck and chest, post-contrast abdomen and pelvis

d. post-contrast brain, neck, chest, abdomen and pelvis

e. post-contrast neck, chest, abdomen and pelvis

Answer 5

e. post-contrast neck, chest, abdomen and pelvis

A T4 stage primary is described. Lower-stage breast cancers (T1/T2, less than 5cm) are not usually staged by CT, as there is a less than 2% incidence of metastases at the time of diagnosis. Incidence of metastases at diagnosis for higher-stage cancers (T3/T4) is 15–20%. When staged with CT, a suitable protocol would be 100–150ml of iodinated intravenous contrast agent used, with the neck and chest scanned 20–25 seconds after injection, and the abdomen and pelvis scanned 70–80 seconds after injection

Question 6

64) Calcification is seen on a screening mammogram. Which of the following patterns is the most likely to be associated with a carcinoma?

a. tortuous tramline calcification

b. thick, linear, rod-like calcifications, some with a lucent centre

c. eggshell, curvilinear calcification

d. popcorn calcification

e. a cluster of 10 calcific particles, all less than 0.5 mm

Answer 6

e. a cluster of 10 calcific particles, all less than 0.5 mm

Microcalcifications are those less than 0.5mm. When there are more than five in a tissue volume of 1cm3, particularly if segmentally distributed, 30% will be malignant.

Other features also suggesting malignancy are a mixture of sizes and shapes of the calcific foci, associated soft-tissue opacity and progression on serial mammography

Question 7

68) Which of the following unusual benign breast tumours is most likely to be locally infiltrating, aggressive and proliferative, and consist of only well-differentiated fibroblasts?

a. neurofibroma

b. granular cell tumour

c. fibromatosis

d. lipoma

e. areolar leiomyoma

Answer 7

c. fibromatosis

In 80% of cases of fibromatosis of the breast, there is b-catenin or adenomatous polyposis coli gene mutation.

Granular cell tumour is most commonly found in the upper inner quadrant corresponding to the supraclavicular nerve territory and is thought to be of Schwann cell origin.

Neurofibromas of von Recklinghausen’s disease are associated in an autosomal dominant fashion with a gene on chromosome 17.

Question 8

74) A female has a cancer detected at the prevalent round of the NHS Breast Screening Programme. Which of the following ages is she most likely to be?

a. 45 years

b. 50 years

c. 55 years

d. 60 years

e. 65 years

Answer 8

b. 50 years

1988 was the year of introduction of the NHS Breast Screening Programme following the recommendation of the Forrest Report (HMSO 1986). Women aged 50–70 are currently invited for breast screening in the UK, with those over 70 encouraged to self-refer, but this age range will shortly be extended to 47–73 years. The prevalent round is the first round of screening, which aims to detect all those in the screened population at that time with the disease. It is a rolling programme, meaning that women receive their first invitation at some time in the 3-year interval from their 50th birthday, so they may in practice be aged 50–53 at their first screening appointment. The incident rounds, at 3-year intervals, aim to detect the cancers that have appeared in this interval. Two mammographic views (mediolateral oblique and craniocaudal) are currently routinely performed at both prevalent and incident rounds.

Question 9

85) A 75-year-old female is investigated for a slowly enlarging breast mass. There are no involved lymph nodes clinically. Following biopsy, clumps of tumour cells floating in pools of extracellular mucin and without a capsule are seen on histology. The 10-year survival rate for this tumour is in the region of 70–90%. Which of the following is the most likely type of breast tumour?

a. mixed mucinous carcinoma

b. pure mucinous carcinoma

c. phyllodes tumour

d. inflammatory carcinoma

e. melanoma metastasis

Answer 9

b. pure mucinous carcinoma

Pure mucinous breast carcinoma tends to be slow-growing, rarely metastasizes and has a good prognosis.

It is important to differentiate this from mixed mucinous carcinomas, which are invasive carcinomas of no specific type with a mucinous component.

The prognosis of mixed mucinous carcinomas is worse than that of pure mucinous carcinoma, tumour behaviour depending on the non-mucinous part.

Mixed mucinous tumours comprise around 2% of breast cancers, and 33–46% have lymph node metastases at presentation.

Pure mucinous carcinoma accounts for 1–2% of breast malignancies with an average age of 65, older than the average for breast cancer in general, which is 60 years.

Many features of pure mucinous tumours mean that there is significant potential for them to be misdiagnosed as benign masses.

Question 10

87) A well-circumscribed, round, 15 mm mass is identified in the breast on first-round screening mamography. It has no associated calcification. From the following, choose the most appropriate management:

a. repeat mammography at the normal screening interval

b. repeat mammography in 6 months

c. MRI of the breast

d. wide local excision of the lesion

e. ultrasound examination of the mass

Answer 10

e. ultrasound examination of the mass

Ultrasound scan is useful in determining whether mass lesions seen on the mammogram are cystic or solid.

Question 11

92) At a breast cancer multidisciplinary team meeting, the case of a 60-year-old female patient is discussed. Following clinical examination, she is thought to have multifocal breast cancer, but this is not supported by the ultrasound and mammography findings. Which of the following is the most appropriate next investigation?

a. repeat ultrasound scan

b. repeat mammography with additional views

c. MRI

d. CT

e. 18FDG PET

Answer 11

c. MRI

Multifocal/multicentric cancer in the breast may alter treatment choice and when clinically suspected should be investigated with MRI. MRI can also be used to assess the extent of residual disease in the breast after breast conservation surgery in cases where the surgical resection margins are positive.

An acceptable series of sequences for breast MRI would be: 4mm slice-thickness, transverse, spin echo T2W images of both breasts; 4-mm-thick, sagittal, spin echo T2W images of the affected breast; 4-mm-thick, sagittal, dynamic contrast-enhanced T1W gradient echo with fat saturation of the affected breast; and a delayed post-contrast sequence with the same parameters.

Question 12

1 A 62 year old female is found to have a localised 4 mm area of architectural distortion and deformity on routine screening mammography. It has multiple long, thin spicules clumped centrally with radiolucent linear structures paralleling the spicules. MRI shows a stellate lesion with equivalent signal intensity to surrounding parenchyma on T1 weighted imaging and slight enhancement after the administration of contrast medium. Which of the following conditions is least likely?

(a) Ductal breast carcinoma

(b) Fat necrosis

(c) Post surgical scar

(d) Radial scar

(e) Phyllodes tumour

Answer 12

(e) Phyllodes tumour

Phyllodes tumours present in the 5th-6th decades with a large firm, discrete mobile palpable mass. They demonstrate strong contrast enhancement on T1 weighted imaging.

A small non-palpable stellate lesion on mammography with architectural distortion has a wide differential including primary carcinoma (up to 50%), fat necrosis, radial scar, fibrosed fibroadenoma and granular cell myoblastoma.

Question 13

15 A 38 year woman who had undergone breast augmentation for cosmesis 5 years earlier presents complaining of loss of contour of her left breast and some associated pain. MRI shows multiple hypointense wavy lines within the i’mplant. What sign is described?

(a) McGregor’s sign

(b) Rubber band sign

(c) Linguine sign

(d) Wire sign

(e) Ladder sign

Answer 13

(c) Linguine sign

Implant rupture is a not uncommon complication with a prevalence of more than 50% at 12 years. US (59-70% sensitive, 57-92% specific) is less accurate than MRI (81-94% sensitive, 93-97% specific).

Classically on MRI, hypointense wavy lines often parallel to the fibrous capsule are seen (linguine sign).

Question 14

27 A number of special techniques are employed in mammography as opposed to conventional radiography. Which of the following is not included in this category?

(a) The use of a molybdenum target

(b) The use of a tungsten target

(c) A low tube current

(d) A focal spot size of 0.3 mm

(e) The use of a grid

Answer 14

(c) A low tube current

High tube currents to reduce exposure time should be used.

Molybdenum targets are used most commonly as they produce a low energy spectrum providing high contrast.

Although tungsten targets produce higher energy spectra they are still used in situations where there is a thicker or a denser breast.

Question 15

@# 30 A 45 year old previously well woman presents with a breast lump. US shows a round lesion of mixed attenuation. Biopsy determines that the lesion is a metastasis and has significant areas of haemorrhage within it. The other breast is normal. What is the most likely primary tumour?

(a) Malignant melanoma

(b) Ovarian carcinoma

(c) Lung carcinoma

(d) Kaposi sarcoma

(e) Renal oncocytoma

Answer 15

(a) Malignant melanoma

Haemorrhagic metastases to breast include melanoma, renal cell carcinoma, choriocarcinoma and Kaposi sarcoma.

Overall, the commonest non-mammary source of non-haemorrhagic metastases is lymphoma.

Question 16

35 A 60 year old woman undergoes a CTPA. Incidental note is made of a solitary lesion within her breast. Which of the following is more supportive of this being a benign process?

(a) Irregular margin

(b) Irregular shape

(c) Rim enhancement

(d) Large calcifications

(e) Skin thickening

Answer 16

(d) Large calcifications

There are limited features to suggest benignity on CT examination. Rather, evaluation /Of these commonly seen incidental findings should be made by looking for the lack of malignant features and careful evaluation of the clinical history. Small, dystrophic calcification (which in some cases cannot be appreciated at CT resolution) rather than large, round calcifications is a predictor of malignancy.

Question 17

36 With regards to the normal anatomy of the breast which of the following statements is true?

(a) 30% of the lymphatic drainage is via the internal mammary chain

(b) Level I lymph nodes lie lateral to the medial edge of pectoralis minor

(c) Level II lymph nodes lie behind pectoralis major

(d) The breast consists of 15-20 terminal duct lobular units

(e) Increased enhancement of normal breast parenchyma during lactation is seen at MRI

Answer 17

(e) Increased enhancement of normal breast parenchyma during lactation is seen at MRI

Question 18

39 A 53 year old female patient has recently moved to the area and you are asked to review her most recent mammogram prior to clinic review. The mammogram shows a unilateral diffuse increased density of the right breast with skin thickening, a coarse reticular pattern with prominent Cooper’s ligaments and no microcalcification. Which of the following is the least likely to cause these appearances?

(a) Radiotherapy change

(b) Lymphatic obstruction

(c) Inflammatory carcinoma

(d) Granular cell tumour

(e) Recent surgery

Answer 18

(d) Granular cell tumour

These are mammographic signs of an oedematous breast and the differential diagnosis also includes venous obstruction and breast abscess. Granular cell tumour presents as an asymmetric lump with hardness, skin retraction and ulceration. It is typically a well seen spiculated mass 1-3 cm in diameter.

Question 19

@#e 44 A 48 year old female patient presents to the breast clinic with a painless breast lump. Clinical examination reveals a firm 2 cm mass in the right upper outer quadrant. Mammography shows a round, well defined soft tissue opacity in the corresponding location. Which of the following features on US suggest a malignant rather than benign cause?

(a) It is taller than it is wide

(b) It is markedly hyperechoic

(c) It has a thin echogenic capsule

(d) It has 3 lobulations

(e) It does not cast an acoustic shadow

Answer 19

(a) It is taller than it is wide

Malignant features on US include spiculation, being taller than wide, angular margins, accoustic shadowing, being markedly hypoechoic, and having microlobula’tions. Benign features include being hyperechoic, having 2-3 lobulations, being ellipsoid in shape and having a thin echogenic capsule. To characterise a lesion as being US benign, it must have no malignant features. If specific benign features are not found then lesion is indeterminate.

Question 20

9 A 55 year old female patient presents with a history of unilateral breast pain. 11 years earlier she had undergone breast augmentation for cosmetic reasons. Her sister has recently been diagnosed with breast cancer and she is concerned she may also have breast cancer. Which of the following statements is true?

(a) Most implants fail at 5 years

(b) MRI is the initial investigation of choice

(c) Screening mammography is contraindicated

(d) The linguine sign is indicative of rupture on US

(e) Most implants are placed in the retroglandular region

Answer 20

(e) Most implants are placed in the retroglandular region

The typical lifespan of an implant is 10 years.

Standard triple assessment remains the initial investigative of choice even with implants in situ.

The linguine sign is a sign of rupture on MRI. 75% of implants are placed in the retroglandular region. 25% are placed in the sub-pectoral region.

Question 21

11 A 62 year old woman presents with a solitary palpable breast lump. Mammography does not demonstrate any microcalcification within the mass. US demonstrates an irregular solid mass which casts a posterior acoustic shadow. Which of the following techniques is most appropriate for obtaining tissue diagnosis?

(a) Ultrasound guided core biopsy

(b) Ultrasound guided FNA

(c) Stereotactic guided core biopsy

(d) Stereotactic vacuum assisted biopsy

(e) MRI guided biopsy

Answer 21

(a) Ultrasound guided core biopsy

US-guided core biopsy remains the first choice diagnostic test.

FNA is helpful for evaluating lesions with fluid components.

Stereotactic biopsy is useful for lesions with areas of microcalcification.

Vacuum assisted biopsy, whether by US or stereotactic technique helps obtain larger samples but at present its cost means that it is not used as first line.

MRI guided biopsy is reserved for equivocal lesions that cannot be clearly identified on US.

Question 22

33 Regarding breast MRI techniques, which of the following is incorrect?

(a) The patient should be prone

(b) The phase encoding direction should be in the anterior to posterior plane

(c) Reducing the field of view improves the in plane resolution

(d) Chemical shift artefact can be reduced by increasing the bandwidth per pixel of the imaging sequence

(e) Wrap-around artefact can be reduced by increasing the number of sampling points in the phase encoding direction

Answer 22

(b) The phase encoding direction should be in the anterior to posterior plane

Blood flow, cardiac, respiratory and patient motion all cause ‘ghosting’ artifact in the phase encoding direction. If the phase encoding direction is incorrectly set in the anterior to posterior plane, large amounts of breast tissue will be obscured.

Question 23

@# 42 A 72 year old man is referred to breast clinic with a unilateral painless breast lump. He has no significant past medical history and is not on any medication. Which of the following statements is true?

(a) Unilateral swelling makes gynaecomastia unlikely

(b) Gynaecomastia is a risk factor for breast cancer

(c) Male breast cancer presents as earlier stage disease than female breast cancer

(d) Male breast cancer is usually oestrogen receptor positive

(e) Microcalcification in male breast cancer is common

Answer 23

(d) Male breast cancer is usually oestrogen receptor positive

Male breast cancer represents 0.5% of all breast cancers. Gynaecomastia for which there is a wide differential (including physiological, endocrine, neoplastic and drug related causes) may be unilateral and asymmetrical. Male breast cancer presents at a later stage than female breast cancer and at an older age. It is usually ER positive and unlike in female breast cancer, microcalcification is relatively uncommon.

Question 24

50 A 38 year old woman presents with a palpable breast mass. On mammography it is 3 cm, lobulated, well defined with a halo appearance around it. It contains central popcorn calcification. On US it has a length to depth ratio of1 .5:1 and is slightly compressible. What is the likely diagnosis?

(a) Fibrocystic disease

(b) Sclerosing adenosis

(c) Fibroadenoma

(d) Lymphoma

(e) Phyllodes tumour

Answer 24

(c) Fibroadenoma

Popcorn calcification with a halo around a well defined compressible lesion in a pre-menopausal woman is typical of fibroadenoma.

Question 25

52 A 54 year old woman presents with a painful discharging nipple. Clinical examination suggests a small lump. Mammogram shows coarse, smooth bordered rod shaped calcifications in the subareolar area. However, no discrete mass could be identified on magnified views. On MRI dilated tubular structures containing high signal intensity material on T1W and T2WI are seen, with no enhancement following i.v. gadolinium. · What is the likely diagnosis?

(a) Paget’s disease

(b) Lymphoma

(c) Nipple adenoma

(d) Duct ectasia

(e) Subareolar carcinoma

Answer 25

(d) Duct ectasia

Stasis of intraductal secretions leads to dilatation and inspissation of material within the subareolar ducts which can calcify. The diagnosis is much more likely if it is bilateral.

Question 26

74 With regards to the UK national breast screening programme, which of the following statements is incorrect?

(a) All women aged between 50 and 70 are invited to attend

(b) The current detection rate is approximately 16 cancers per 1000 women screened

(c) 2 views are obtained as standard in all rounds

(d) It is recommended that readers should report at least 5,000 screening mammograms/year

(e) Women are invited to return at 3 year intervals

Answer 26

(b) The current detection rate is approximately 16 cancers per 1000 women screened

The current detection rate is approximately 6 cancers per 1000 women screened. At the moment the age range for selection is 50-70 years although plans exist to expand the age range from 47-73 years.

Question 27

@# 10. A 62 year old woman presents with two small masses in her right breast. These are well circumscribed masses in the upper outer quadrant. They show no calcification, no desmoplastic reaction and are not spiculated. They are thought to represent metastases to the breast. The most likely primary in a woman of this age is:

a. Ovarian carcinoma

b. Renal carcinoma

c. Lymphoma

d. Melanoma

e. Bronchial carcinoma

Answer 27

10. c. Lymphoma

Metastases to the breast are infrequent and can be difficult to distinguish from primary breast cancer. The most common primary source is lymphoma, followed by melanoma and then rhabdomyosarcoma.

Most patients who are diagnosed with breast metastases already have a diagnosis of a primary tumour, however, in 25% of cases breast metastases are the first manifestation of malignancy.

Question 28

@# 23. A 62 year old woman with Paget’s disease of the nipple is also found to have a 2 cm spiculate mass in the subarealor region of her right breast suspicious for malignancy. The cancer most commonly associated with Paget’s disease of the nipple is:

a. Invasive ductal carcinoma

b. Invasive lobular carcinoma

c. Tubular carcinoma

d. Ductal carcinoma in situ

e. Medullary carcinoma

Answer 28

23. d. Ductal carcinoma in situ

The most commonly associated is ductal carcinoma in situ (60%). The next most common is invasive ductal carcinoma. Fifty per cent of cases of DCIS are over 5 cm at the time of diagnosis and this often involves the nipple and subareolar ducts.

Question 29

46. A routine screening mammogram of a 54 year old woman shows numerous scattered calcifications. Which of the following statements is true regarding breast calcifications?

a. Parallel lines of calcification are usually venous in origin

b. Malignant calcifications are usually >1 mm in size

c. Less than 5% of microcalcifications in asymptomatic patients are associated with cancers

d. Dermal calcifications are usually central in location

e. Popcorn calcification is seen in fibroadenoma

Answer 29

46. e. Popcorn calcification is seen in fibroadenoma

Popcorn calcification is pathognomonic for fibroadenoma. The majority of biopsied clusters of calcifications represent a benign process (75–80%). Malignant calcifications are usually small (<0.5 mm) and are usually irregular in size and density. They are, however, usually closely grouped. Benign calcifications tend to be numerous and scattered throughout the breast.

Question 30

48. A 48 year old woman is referred to the breast clinic for investigation of a 1.5 cm lump in the right breast. Which of following US features of a breast mass are more suggestive of a malignant than a benign pathology?

a. Acoustic shadowing

b. Anechoic contents

c. Hyperechoic pseudocapsule

d. Lack of internal blood flow on colour Doppler

e. Hypervascular surrounding tissues

Answer 30

48. a. Acoustic shadowing

Acoustic shadowing along with ill-defined margins, surrounding architectural distortion, heterogeneous internal echoes and a height measurement greater than width measurement (with the transducer parallel to the longitudinal axis) are all features more suggestive of a malignant rather than a benign pathology. A hypoechoic lesion containing echogenic debris along with lack of internal blood flow and hypervascularity of surrounding tissues are in keeping with a breast abscess.

Question 31

58. The current NHS Breast Screening Programme was set up in 1988 as a result of the Forest Report. Which one of the following statements regarding the current screening programme is correct?

a. Screening is only available to women aged 50–70 years

b. Women are invited to attend at two-yearly intervals

c. It detects 15 cancers per 1000 women screened

d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS)

e. Breast cancer screening has not been shown to reduce mortality from breast cancer

Answer 31

58. d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS)

In the 2007–2008 review statistics, eight cancers were detected per 1000 women screened. Women between the ages of 50 and 70 years are invited to attend the Breast Cancer Screening Programme at three-yearly intervals. However, women over the age of 70 are encouraged to make their own appointments to attend. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35% reduction in mortality from breast cancer among screened women aged 50–69 years. This means that out of every 500 women screened, one life will be saved

Question 32

59. A 72 year old woman with breast cancer has the following combination of clinical and radiologic findings: a tumour measuring 3.5 cm in the right breast but with no chest wall/skin involvement; ipsilateral axillary and supraclavicular lymph node involvement with the nodes fixed to underlying structures; no internal mammary node involvement; no bone, lung or liver metastases present. Which one of the following is the correct TNM staging of her disease?

a. T2N2M0

b. T2N2M1

c. T3N1M1

d. T3N2M0

e. T4N2M1

Answer 32

59. b. T2N2M1

The correct TNM staging is T2N2M1. The presence of involved ipsilateral supraclavicular nodes makes the staging M1 even in the absence of other distant metastases. T2 tumours encompass those which are more than 2 cm but less than 5 cm in diameter.

N2 disease signifies involved axillary nodes which are fixed either to one another or to underlying structures.

N3 disease signifies internal mammary involvement.

Question 33

60. On breast MRI, which of the following features of a breast mass is more suggestive of a malignant lesion than a benign lesion?

a. Low-signal internal septations

b. Lobulated mass which shows no enhancement

c. Rim-like enhancement of the mass

d. A focal area of hypointense T2 signal adjacent to the mass

e. Stippled enhancement

Answer 33

60. c. Rim-like enhancement of the mass

Rim-like enhancement is a relatively rare finding, but has a high correlation with malignancy (positive predictive value 84%). A focal area of hyperintense signal on T2 near a lesion is highly suggestive of malignancy. Whilst the other characteristics may be present in a malignant lesion, all are more suggestive of benign pathology. Irregular speculated margins of a mass have a high positive predictive value for malignancy. Other features suggestive of malignancy are heterogenous internal septations and enhancing internal septa.

Question 34

QUESTION 42
You are the radiologist reviewing the mammograms of a 56-year-old woman. When compared with her previous mammograms, areas of calcification previously seen within the left upper outer quadrant have now disappeared. Which of the following is not a possible explanation?

A Breast surgery

B Chemotherapy

C Postmenopausal changes

D Radiotherapy

E Spontaneous resolution

Answer 34

C Postmenopausal changes

Question 35

@#e QUESTION 46
A 52-year-old postmenopausal woman presents for her first screening mammogram. Within the right upper outer quadrant, there is a 2-cm well-defined, oval mass that has dense ‘popcorn’ calcification within it and is surrounded by a thin radiolucent rim. On ultrasound, the mass is well defined and hyperechoic with areas of acoustic shadowing due to contained calcification. What is the most likely diagnosis?

A Fat necrosis

B Fibroadenoma

C Hamartoma

D Oil cyst

E Papilloma

Answer 35

B Fibroadenoma

Fibroadenomas may become calcified, particularly after menopause. Classically the calcifications have a coarse ‘popcorn’ appearance; however, they may also appear small and punctate. An oil cyst typically demonstrates eggshell calcification and is the result of fat necrosis.

Question 36

@# QUESTION 49
A 56-year-old woman is found to have a screen-detected breast cancer on her second screening mammogram. Two breast radiologists both agree that there is no evidence of malignancy on the previous mammograms, even in retrospect. Which one of the following statement best describes this interval cancer?

A An interval cancer has a better prognosis, when compared with other screen detected cancers.

B This is known as a Type 1 interval cancer.

C This is known as a Type 2a interval cancer.

D This is known as a Type 2b interval cancer.

E This is known as a Type 3 interval cancer.

Answer 36

B This is known as a Type 1 interval cancer.

Question 37

QUESTION 54
A 35-year-old woman presents with a painless lump in the outer upper quadrant of her left breast. She is referred for an ultrasound examination of the left breast. Which of the following ultrasound findings would suggest a malignant rather than a benign breast mass?

A A larger transverse than anterior-to-posterior diameter

B Ill-defined echogenic halo around the lesion

C Less than 1 cm in greatest diameter

D Posterior acoustic enhancement

E Uniform hyperechogenicity

Answer 37

B Ill-defined echogenic halo around the lesion

On ultrasound, breast carcinomas are generally ill-defined, hypoechoic masses which can have a surrounding echogenic halo. They also tend to have larger anterior-to-posterior than transverse diameter.

Question 38

QUESTION 58
A 53-year-old woman is recalled to the screening breast outpatient clinic as her initial mammograms have revealed an area of suspected microcalcification. Compared with the standard mammographic projections, which one of the following statements best describes the technique needed to provide magnification views?

A A double-coated film is necessary to avoid parallax and crossover.

B A molybdenum target is used because it provides a low energy spectrum.

C A smaller focal spot of 0.1 mm is used.

D An air gap is avoided as it reduces signal to noise ratio.

E Tube current should be as high as possible to keep exposure times short

Answer 38

C A smaller focal spot of 0.1 mm is used.

To provide magnification views, a focal spot of 0.1 mm should be used (smaller than the 0.3 mm focal spot used for standard mammographic projections) with an air gap of 1 5—30 cm. Options D & E are correct regarding mammography in general and hold true for both standard and magnification views.

Question 39

@# QUESTION 61
A 53-year-old woman is invited to attend a mobile breast screening unit for routine screening mammograms. Which one of the following statements is correct regarding the standard mammographic projections (the mediolateral oblique (MLO) and craniocaudal (CC) views)?

A A well-positioned CC view usually contains all the breast tissue.

B A well-positioned MLO view rarely shows the nipple in profile because of the oblique compression.

C On a well-positioned MLO the nipple should be at the lower border of the pectoralis minor.

D The MLO view is taken with the radiograph beam directed from superomedial to inferolateral.

E The pectoralis major muscle is demonstrated at the posterior border of a CC view in approximately 70% of individuals

Answer 39

D The MLO view is taken with the radiograph beam directed from superomedial to inferolateral.

Question 40

QUESTION 68
A final year medical student attends a breast screening outpatient clinic as part of her clinical attachment. She wishes to know more about the UK NHS Breast Screening programme and asks several questions of the radiology SpR in the breast clinic. Which one of the following statements is true?

A Double reading of all screening mammograms must be performed.

B Incident screens may be performed using only the MLO view.

C The acceptance rate of women invited to breast screening is over 90%.

D Up to 20% of women are recalled from screening for further-assessment.

E Women over 70 years of age may stay in the Breast Screening Programme by choice.

Answer 40

E Women over 70 years of age may stay in the Breast Screening Programme by choice.

Women between the ages of 50 and 70 are invited for screening every 3 years. Women over 70 are encouraged to attend by self-referral but are not invited.

Question 41

@#e QUESTION 79
A 28-year-old woman has a strong family history of breast cancer and is referred for an MRI examination of the breasts. Regarding MRI of the breast, which one of the following statements is correct?

A Breast MRI should be performed during the middle of the menstrual cycle to improve sensitivity.

B Malignant lesions tend to show poor enhancement following intravenous contrast, compared with surrounding breast tissue.

C MRI has a high sensitivity and specificity for the detection of invasive breast cancer.

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

E The patient is imaged in a supine position with the breasts placed in adedicated breast coil to improve signal to noise ratio.

Answer 41

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

Malignant breast lesions enhance postcontrast; however, normal hormonally active breast tissue can also enhance, particularly during the middle of the menstrual cycle (6th—17th days). In younger patients it may be helpful to repeat the scan earlier or later in the menstrual cycle to improve specificity

Question 42

9. A 56-year-old asymptomatic woman undergoes routine screening mammography. Which of the following forms of calcification raises greatest suspicion of ductal carcinoma in situ (DCIS)?

A. Egg-shell.

B. Sedimented.

C. Tubular.

D. Dot-dash.

E. Coarse.

Answer 42

9. D. Dot-dash.

Malignant calcifications vary in shape and size. Pleomorphic calcifications that are more linear or dot-dash in appearance are associated with intraductal carcinoma. DCIS is often detected as a result of such calcifications. Egg-shell calcification is seen in the walls of an oil cyst. Sedimented calcium appears as curvilinear on the lateral projection and as smudged on the cranio-caudal view. This is a feature of benign cysts. Arterial calcification presents as tubular, parallel calcification. Fibroadenomas typically exhibit large, coarse, and irregular calcification.

Question 43

4. A 60-year-old male with a history of prostate cancer is referred to the symptomatic breast clinic complaining of a palpable breast lump which has been present for several months. Clinical examination reveals a palpable firm mass towards the left subareolar region. A nodular, fan-shaped subareolar lesion is seen on mammography. The mass is hypoechoic on ultrasound and surrounded by normal fatty tissue. Hypervascular flow within the mass is noted on Doppler ultrasound. Which of the following is the most likely diagnosis?

A. Invasive ductal carcinoma.

B. Lipoma.

C. Gynaecomastia.

D. Lymphoma.

E. Dermatofibrosarcoma.

Answer 43

4. C. Gynaecomastia.

Most male breast lumps are benign, with breast cancer accounting for <1% of all breast lesions. Gynaecomastia is the most common benign condition of the male breast. The radiological description is in keeping with early nodular gynaecomastia. Lipomas are encapsulated fatty masses on mammography, which are mildly hyperechoic on ultrasound. Approximately 85% of male breast cancer is invasive ductal carcinoma. This is typically retroareolar and hyperdense on mammography with irregular margins. Secondary features such as nipple retraction and skin thickening are usually present. Ultrasound will show a non-parallel, hypoechoic mass. Posterior acoustic features and internal blood flow are not useful for distinguishing benign versus malignant lesions. Lymphoma will exhibit multiple hyperdense lymph nodes on mammography. Dermatofibrosarcoma is hyperechoic on ultrasound.

Question 44

13. A previously well 70-year-old woman is investigated via CTPA for acute left-sided chest pain and hypoxia. The test is negative for PE, but an incidental 1.7 × 1.2 cm retro-areolar lesion is noted in the right breast by the reporting registrar. Which of the following features, if any, would be suggestive of breast malignancy?

A. Ill-defined margin.

B. Spiculated margin.

C. Calcification.

D. Multiple lesions.

E. CT is not reliably predictive of breast malignancy

Answer 44

13. B. Spiculated margin.

A recent study examining incidental breast lesions detected by CT found that spiculated breast lesions and axillary lymphadenopathy should raise concern for malignancy and be referred to the breast clinic. These features were significantly more likely to be present in malignant breast lesions. Genuine mass lesions and spiculation are more easily appreciated in non-dense breasts. The mammographic features of ill-definition and calcification do not appear to be suggestive of malignancy on CT, probably due to poorer resolution, as normal breast glandular tissue appears ill-defined on CT and malignant microcalcification is poorly demonstrated. Lesion size and location also do not differentiate between benign and malignant disease.

Question 45

18. A 48-year-old woman who had bilateral breast augmentation with single lumen silicone gel implants 20 years ago presents with pain in her left breast and distorted breast shape. Which of the following radiological findings on T2WI MRI are in keeping with intracapsular implant rupture?

A. Thickened T2WI hypointense capsular margin.

B. T2WI hyperintense globules surrounding the implant.

C. Multiple curvilinear lines of low T2WI signal within the implant.

D. Inferior extension of the implant beyond the inframammary fold.

E. Marginal low T2WI signal radial folds within the implant

Answer 45

18. C. Multiple curvilinear lines of low T2WI signal within the implant.

Silicone gel implants are high signal on T2WI.

Capsular contracture is caused by constriction of the fibrous capsule that invariably forms to some degree around the implant as a reaction to the foreign object. This is seen on MRI as increased thickening of the T2WI hypointense margin surrounding the implant.

Rupture of the prosthesis is the most common complication with breast implants, occurring in up to 10–20%, although many are not noticed clinically. With intracapsular ruptures, the silicone gel is contained by the capsule. Curvilinear strands of low T2 signal within the capsule may be seen, representing the collapsed implant shell. This finding is known as the ‘linguine’ sign.

T2WI hyperintense globules surrounding the implant are indicative of an extracapsular rupture.

Inferior extension beyond the inframammary fold implies implant migration, which is a relatively uncommon occurrence.

Marginal T2WI hypointense radial folds within the implant are a normal finding

Question 46

22. A 32-year-old asymptomatic woman who is BRCA1 positive undergoes breast cancer surveillance via MRI. A lesion within the left breast is identified. Which of the following MRI features is the most predictive for malignancy?

A. Irregular margin.

B. T2WI signal hyperintensity.

C. Progressive enhancement curve on dynamic T1WI post contrast.

D. Plateau enhancement curve on dynamic T1WI post contrast.

E. Washout enhancement curve on dynamic T1WI post contrast.

Answer 46

22. A. Irregular margin.

A woman over the age of 30 years who is a BRCA1 or BRCA2 carrier should be offered MRI annually for breast cancer surveillance. The description of the margin of the mass is the most predictive feature of the breast MR image interpretation. Irregular or spiculated margins have a positive predictive value of 84–91%. T2W signal hyperintensity is suggestive of benign pathology, but not in the setting of an irregular or spiculated mass. There is overlap in enhancement kinetics between benign and malignant disease, and thus reliance on kinetic assessment alone is not recommended.

Progressive enhancement (type I) is associated with benign pathology,

whereas plateau (type II) and washout (type III) curves are suggestive of malignant disease.

Due to the importance of lesion morphology, the MRI technique should focus on optimizing high spatial and temporal resolution.

Question 47

27. A 50-year-old female colleague asks you for information and advice regarding breast screening. Which of the following statements regarding breast screening in the UK is correct?

A. She will not be eligible for screening until she is 55.

B. Screening occurs every 2 years.

C. Compression is not required for screening mammography.

D. There is a 70% reduction in mortality from breast cancer among screened women.

E. Two lives are saved for every over-diagnosed case.

Answer 47

27. E. Two lives are saved for every over-diagnosed case.

Over-diagnosis is defined as the diagnosis of cancer as a result of screening that would not have been diagnosed in the woman’s lifetime had screening not taken place. Approximately 5.7–8.8 breast cancer deaths are prevented per 1000 women screened for 20 years starting at age 50 compared with 2.3–4.3 over-diagnosed cases per 1000 women screened for 20 years. The WHO International Agency for Research on Cancer determined that there is a 35% reduction in mortality from breast cancer among screened women aged 50–69. The NHS Breast Screening Programme provides screening every 3 years for women between the ages of 50 and 70. After the age of 70, women are still screened, although they are not automatically called for. Expansion is planned to cover women from 47 to 73. A two-view (cranio-caudal and mediolateral oblique) mammogram is taken, performed with breast compression, which can be uncomfortable for the patient.

Question 48

32. A 24-year-old woman presents to the symptomatic breast clinic with a palpable left-sided breast lesion. There is no family history of breast cancer. Clinical examination reveals a smooth, relatively mobile 2-cm lesion within the left upper quadrant. Ultrasound depicts a well-defined oval hypoechoic lesion with an echogenic capsule following the tissue planes. No malignant features are present. The patient states that she has a phobia of needles. What should be the next step in this patient’s management?

A. Reassurance and discharge with advice.

B. Correlation with mammography.

C. Ultrasound guided core biopsy.

D. Ultrasound guided FNA.

E. Referral for MRI

Answer 48

32. A. Reassurance and discharge with advice.

The clinical and radiological findings in this case are typical for fibroadenoma. Standard practice for investigating breast lumps involves triple assessment with clinical examination, imaging with ultrasound, and tissue diagnosis (with either cytology or histology). However, in women under the age of 25 who present with a clinically and radiologically benign lump, biopsy is not needed unless there is overriding clinical concern. To be assessed as definitely benign on ultrasound, there should be no malignant features (spiculation, angular margins, acoustic shadowing, calcification, and marked hypoechogenicity) and the lesion should follow tissue planes (wider than it is tall). The ultrasound should also be performed by an experienced operator. The patient should be advised to seek further assessment if there is any increase in size or change to the mass.

Question 49

37. A 49-year-old woman presents with a rapidly enlarging left-sided breast mass. A large, firm, non-tender discrete mass is noted on clinical examination with overlying skin ulceration. Mammography reveals a 7-cm multilobulated soft tissue density mass in the left upper quadrant. On ultrasound the mass is solid with cystic areas. Posterior acoustic enhancement is demonstrated. What is the most likely diagnosis?

A. Adenoid cystic carcinoma.

B. Fibromatosis.

C. Granular cell tumour.

D. Phyllodes tumour.

E. Melanoma metastasis.

Answer 49

37. D. Phyllodes tumour.

This most commonly manifests as a rapidly growing mass, which is lobulated on mammography. Calcifications are rarely seen. A solid mass containing cystic spaces on ultrasound and demonstrating posterior acoustic enhancement is strongly suggestive of phyllodes tumour. Phyllodes tumour can be benign or malignant, but both have a tendency to recur if not widely excised. Adenoid cystic carcinoma is a slow-growing mass that is well defined on mammography. Fibromatosis presents as an indistinct mass on mammography, which is hypoechoic with posterior acoustic shadowing on ultrasound, simulating malignancy. Granular cell tumours are thought to arise from Schwann cells and have a very variable appearance. Metastatic disease to the breast is much more likely to be multiple or bilateral. Diffuse skin thickening is also a feature.

Question 50

43. A 60-year-old woman presents with a palpable lump in her right breast. Her recent screening mammogram 6 months previously was negative. Clinical examination reveals a subtle mass in the right lower quadrant. Which of the following mammographic findings is the most common in invasive lobular carcinoma (ILC)?

A. Spiculated mass.

B. Architectural distortion.

C. Microcalcification.

D. Nipple retraction.

E. Skin thickening

Answer 50

43. B. Architectural distortion.

ILC is the second most common form of invasive breast cancer, after ductal carcinoma. It exhibits the same mammographic features as invasive ductal carcinoma, although architectural distortion is the most common mammographic finding. Due to the pattern of small cells growing around ducts (‘Indian files’), mammographic findings are subtle and thus ILC is the most frequently missed breast cancer. Prognosis is generally poor due to late diagnosis.

Question 51

48. A 28-year-old primiparous woman has been breastfeeding for the past 3 months. She is admitted surgically complaining of warmth and pain in her right breast associated with swinging fever. A 3 × 2 cm inhomogenous, hypoechoic abscess within the right lower inner quadrant is identified on ultrasound. How should this patient be managed?

A. 6 weeks’ antibiotic therapy followed by repeat ultrasound.

B. Ultrasound guided needle aspiration.

C. Ultrasound guided catheter drainage.

D. Surgical incision and drainage.

E. Analgesia and advice to stop breastfeeding.

Answer 51

48. B. Ultrasound guided needle aspiration.

Breast abscess is a potential complication of mastitis that may occur during breast-feeding, particularly in primiparous women. Staphylococcus aureus is the most common causative organism. Treatment of mastitis usually consists of breast-emptying procedures and antibiotics. Abscesses are difficult to detect clinically and so the patient should be investigated via ultrasound if mastitis does not promptly respond to appropriate therapy. Ultrasound-guided needle aspiration is a suitable method of treatment for abscesses less than 3 cm in maximum diameter. Continuing breast-feeding is not felt to be problematic.

Question 52

9 A 40-year-old woman presents with a breast lump felt over the past four weeks. On examination, there is a firm, discrete, mobile mass palpable in the right upper outer quadrant. Mammography demonstrates a 1-cm well circumscribed round soft-tissue density in the upper outer quadrant of the right breast. What is the most appropriate management of this patient?

a Reassure that the lesion is benign in nature and discharge to primary care

b Perform ultrasound to confirm benign appearance, provide reassurance and discharge to primary care

c Perform ultrasound and ultrasound-guided core needle biopsy if a solid lesion is visible

d Perform stereotactic-guided core needle biopsy

e Discuss at MDT meeting with a view to proceeding to wide local excision

Answer 52

9 Answer C: Perform ultrasound and ultrasound-guided core needle biopsy if a solid lesion is visible

Although this lesion has the features of a fibroadenoma, ultrasound cannot reliably distinguish between a well-circumscribed carcinoma and a fibroadenoma. Usually, histological confirmation of the benign lesion is made via ultrasoundguided core biopsy. In individual cases, some patients may opt for excisional biopsy without prior biopsy.

Question 53

10 A 40-year-old woman presents with a palpable breast lump for several weeks. On examination, a firm, relatively mobile mass is palpable in the left upper outer quadrant. Mammograms demonstrate a well-circumscribed round soft-tissue density in the upper outer quadrant of the left breast. What feature on ultrasound would favour a diagnosis of a breast cyst above that of fibroadenoma?

a Multiple bilateral lesion of similar appearance

b Internal calcification

c A round hypoechoic lesion with a smooth well-defined margin

d A hypoechoic lesion with internal echoes homogeneously distributed within the lesion

e A hyperechoic posterior wall

Answer 53

10 Answer E: A hyperechoic posterior wall

Strict ultrasound criteria for a simple cyst include well-circumscribed margins, round/oval shape, absence of internal echoes, through transmission and posterior acoustic enhancement with a bright posterior wall.

Question 54

11 A 40-year-old obese woman is found to have a painless mass in the right breast by her general practitioner during a routine medical examination. What feature would favour a diagnosis of an oil cyst over that of a lipoma?

a A history of recent lactation

b A rounded lucent lesion on mammography

C A surrounding capsule seen on mammography

d Demonstration of eggshell calcification

e Multiple areas of fatty and fibroglandular density

Answer 54

11 Answer D: Demonstration of eggshell calcification

Both lesions may appear as rounded lucent lesions with a surrounding capsule on mammography. A history of recent lactation and multiple areas of fatty and fibroglandular density would make a galactocoele more likely

Question 55

15 A 51-year-old woman presents to the breast clinic with a palpable lump felt in the lateral aspect of the right breast, which had increased in size since she went through the menopause. It measures 4.5 cm and shows posterior acoustic shadowing on USS. On mammography the margins are partly well-circumscribed and partly obscured. Peripheral egg shell calcification is visible. Her menarche was at 12; she had three pregnancies and has never taken HRT or the OCP. Which of the feature makes a diagnosis other than a breast cyst more likely?

a Margins which are partly well-circumscribed and partly obscured

b Size greater than 4 cm

c An increase in size in the post-menopausal period, in the absence of HRT

d Peripheral eggshell calcification

e Posterior acoustic shadowing

Answer 55

15 Answer C: An increase in size in the post-menopausal period, in the absence of HRT

Cyst margins may be completely or partially defined (or even completely obscured) by adjacent fibroglandular breast tissue. Cysts frequently disappear or subside following menopause. Peripheral eggshell calcification is seen in fat necrosis. Tea cup calcification, seen on the floor of the cyst on an erect lateral film, may be seen in cysts containing milk of calcium (rare).

Question 56

12 A 70-year-old woman presents with invasive ductal carcinoma. Where in breast is it most likely to be located?

a Retroareolar

b Upper inner quadrant

c Upper outer quadrant

d Lower inner quadrant

e Lower outer quadrant

Answer 56

12 Answer C: Upper outer quadrant

Fifty per cent of all breast cancers arise in the upper outer quadrant, which usually contains the most glandular tissue in the breast. The second most common site is the retroareolar region where 18% of cases arise.

Question 57

13 A 50-year-old woman presented with fatigue and her physician was concerned she had metastatic disease of unknown origin. Her diagnostic work-up included a mammogram which demonstrated a suspicious lesion in the left upper outer quadrant. A biopsy confirmed this to be a breast carcinoma. Where is the most likely place for this lesion initially to have metastasised?

a Brain

b Liver

C Bone

d Lung and pleurae

e Lymph nodes other than ipsilateral axillary nodes

Answer 57

13 Answer C: Bone

Most common sites of initial distant metastasis from breast cancer are bone (58%), lung and pleura (26%), and lymph nodes other than ipsilateral axillary nodes (16%). Initial involvement of the liver or brain is less frequent.

Question 58

14 A 62-year-old woman is treated for invasive ductal carcinoma with a wide local excision and axillary clearance. Which of the following is the most appropriate follow-up mammography regime?

a Every six months until the age of 70 and then self-referral at patient’s request

b Every six months for the first year and annually thereafter

c Every six months for the first two years and annually thereafter

d Every year until the age of 70 and then self-referral at patient’s request

e Every year for five years then return to the breast-screening programme

Answer 58

14 Answer C: Every six months for the first two years and annually thereafter

Exact follow-up regimes may vary from centre to centre, according to local policy. In patients treated with radiotherapy mammography skin thickening post-irradiation usually decreases within two years following treatment but may persist longer.

Question 59

16 A 40-year-old woman with a family history of breast cancer presents with a palpable breast lump. Histology confirms a diagnosis of invasive breast carcinoma. What is the most likely pathological type?

a Ductal carcinoma

b Lobular carcinoma

c Medullary

d Sarcomatous carcinoma

e Mucinous (colloid) carcinoma

Answer 59

16 Answer A: Ductal carcinoma

Ductal carcinoma accounts for the majority of invasive breast cancers and lobular carcinoma approximately 5-10%. Medullary and mucinous account for around 2 % each and <1 % of cases are of sarcomatous origin.

Question 60

17 A 56-year-old woman attended for routine mammographic screening. Calcification was noted on her mammograms and after further work-up she was diagnosed as having invasive carcinoma in the area of the calcifications. What is the most likely morphology of the calcifications?

a Spherical with a radiolucent centre

b Popcorn

c Rounded

d Linear, branching

e Rod shaped (thick, linear)

Answer 60

17 Answer D: Linear, branching

Microcalcifications are defined as individual calcific opacities <0.5 mm in diameter. Characteristics suspicious of malignancy include a casting shape, linear, segmental and clustered distribution. Other non-specific characteristics that increase the degree of suspicion include pleomorphism, variation in size, increased density for size, irregular margins, irregular boundaries of the area of calcification, many calcifications per square centimetre (>5/cucm). Scattered small calcifications bilaterally with radiolucent centres are typical of calcified sebaceous glands of the skin, but may present as a localised cluster of calcification. Irregular coarse `popcorn’ calcification may be seen within a fibroadenoma. Calcification within a fibroadenoma is typically peripheral but may be centrally or eccentrically situated, as may be seen in carcinoma.

Question 61

18 A 51-year-old woman with a family history of breast cancer underwent a screening mammogram, which demonstrated an abnormal area of multiple microcalcifications. No other abnormality was visible and this was not seen on an ultrasound. A stereotactic-guided excision was performed which showed invasive carcinoma. How large is it most likely the calcifications were?

a <0.5 mm

b 0.5-1.5 mm

C 1.5-3 mm

d 3-5 mm

e >5 mm

Answer 61

18 Answer A: <0.5 mm

Microcalcifications are defined as individual calcific opacities <0.5 mm in diameter. Characteristics suspicious of malignancy include a casting shape, linear, segmental and clustered distribution. Other non-specific characteristics that increase the degree of suspicion include pleomorphism, variation in size, increased density for size, irregular margins, irregular boundaries of the area of calcification, many calcifications per square centimetre (>5/cucm). Scattered small calcifications bilaterally with radiolucent centres are typical of calcified sebaceous glands of the skin, but may present as a localised cluster of calcification. Irregular coarse `popcorn’ calcification may be seen within a fibroadenoma. Calcification within a fibroadenoma is typically peripheral but may be centrally or eccentrically situated, as may be seen in carcinoma.

Question 62

19 A 65-year-old woman, who was known to have a primary malignancy elsewhere, had a mammogram which showed multiple well-defined soft-tissue opacities. These were proven to be metastases from her primary. What primary is she most likely to have?

a Lymphoma, oesophageal carcinoma, lung carcinoma, renal cell carcinoma

b Lung carcinoma, oesophageal carcinoma, renal cell carcinoma, melanoma

c Lymphoma, cervical carcinoma, colorectal carcinoma, gastric carcinoma

d Lymphoma, melanoma, ovarian carcinoma, lung carcinoma

e Oesophageal carcinoma, cervical carcinoma, ovarian carcinoma, lung carcinoma

Answer 62

19 Answer D: Lymphoma, melanoma, ovarian carcinoma, lung carcinoma

In that order of frequency. Sarcoma can also metastasise to the breast.

Question 63

20 A 42-year-old woman presents with a lump in the left axilla. No mass is clinically palpable in the left breast and mammography is normal. Histology demonstrates an axillary node malignancy and she is referred for an MRI of the breasts to search for an occult primary breast malignancy. Which of the following time-enhancement curves would be most likely to represent a malignant lesion on contrast-enhanced T1W subtraction sequences?

Answer 63

20 Answer C

(a) Type 2 curve.

(b) Type la curve.

(d) Type lb curve. Malignant lesions are associated with a type 3 (approximately 60%) or type 2 curve (approximately 30%).

(e) consistent with a benign lesion.

Question 64

21 A 45-year-old woman presents with a rapidly increasing mass in the right breast of recent onset. Mammography shows a single well-circumscribed round, homogeneous soft-tissue opacity, measuring 8 cm in diameter with no calcification. Histology demonstrates a fibroepithelial tumour with a leaf-like growth pattern. What is the most likely diagnosis?

a Fibroadenoma

b Lipoma

C Invasive ductal carcinoma

d Papilloma

e Phyllodes tumour

Answer 64

21 Answer E: Phyllodes tumour

Causes of large (>5 cm) well-defined opacities include the following: giant cyst, giant fibroadenoma, lipoma, sebaceous cyst, cystosarcoma phyllodes.

Question 65

22 A 65-year-old man with an abnormal karyotype presents with a left breast lump and is found to have an invasive ductal carcinoma. What karyotype is he most likely to have?
a 45 XO

b 46XY

c 47 XXY

d 47 XXX

e 47 XY13

Answer 65

22 Answer C: 47XXY

This is Klinefelter’s syndrome in which there is a 20-fold increased risk of male breast cancer. 45 XO (Turners) and 47 XXX (triple X) are females. 46 XY is normal and 47 XY 13 is a male with Patau’s syndrome (trisomy 13)

Question 66

23 A 42-year-old woman presents with a lump in the left axilla. No mass is clinically palpable in the left breast and mammography is normal, but histology demonstrates an axillary node malignancy. What is the appropriate management?

a No further imaging, bilateral mastectomy is indicated

b Repeat mammograms

C Breast ultrasound

d Breast MRI

e Breast CT

Answer 66

23 Answer D: Breast MRI

Breast MRI is indicated when there is an axillary metastasis but no primary is visible on mammography or clinical examination. It is also indicated in a number of other situations: dense breasts plus high risk lesion of LCIS, positive BRCA screen, assessment of response to neoadjuvant chemotherapy and suspected multifocal breast carcinoma. The sensitivity to DCIS is relatively poor

Question 67

1 A 39-year-old female with breast cancer detected on screening is awaiting wide local excision and sentinel node biopsy. What is the appropriate method of evaluating the site of a sentinel node?

a 20-4OmBq of nanocolloid injected subdermally into the quadrant of the breast where the cancer is located

b 20-4OmBq of nanocolloid subdermally into the ipsilateral axilla

c Ultrasound-guided methylene blue injection into the most prominent node in the ipsilateral axilla

d Injection of radio-labelled 20-4OmBq of methylene blue

e 20-4OmBq of nanocolloid injected subdermally into the upper outer quadrant regardless of the site of the cancer

Answer 67

1 Answer A: 20-40 mBq of nanocolloid injected subdermally into the quadrant of the breast where the cancer is located

20-40mBq is given into the skin in the same quadrant as the tumour depending on whether surgery is that day or the next. Surgeons often use methylene blue at the time of surgery, but it is not radio labelled. The surgeon may use both a detector probe and dye at the time of surgery

Question 68

9 A 32-year-old woman underwent breast augmentation mammoplasty two years ago and has recently noted a change in the shape of her right breast. Her surgeon is concerned she has had an intracapsular rupture. What investigation would be most sensitive?

a MLO implant displacement mammographic view

b Breast ultrasound

c T1-weighted MRI sequence

d Standard two-view mammography.

e T2-weighted fast spin echo MRI sequences

Answer 68

9 Answer E: T2-weighted fast spin echo MRI sequences

Intracapsular ruptures are not detectable on mammography because the silicone is contained within the fibrous capsule that forms around the implant. Extracapsular rupture may sometimes be detected on mammography but may also be obscured by the overlying implant or may not be imaged if it occurs in an area of the breast or chest wall not included in the mammogram. Ultrasound has a lower sensitivity (70% vs. 94%) but similar specificity (92-97%) than MRI in detecting implant rupture. The fibrous capsule surrounding the implant is hypointense on T2 and silicone and saline both display high signal intensity on T2. The most effective sequences in evaluating implants are inversion recovery which suppresses fat, with an additional suppression of water for pure depiction of silicone, and with additional s ppression of silicone for pure depiction of the saline component.

Question 69

10 A 50-year-old woman presents with a rapidly increasing mass in the right breast of recent onset. Mammography shows a single well-circumscribed round, homogeneous soft-tissue opacity, measuring 8 cm in diameter with no calcification. Biopsy shows a phyllodes tumour. What is risk of malignant degeneration?

a <1%

b 1-2%

c 5-10%

d 40-60%

e >90%

Answer 69

10 Answer C: 5-10%

Five to ten per cent degenerate into malignant fibrous histiocytoma/ fibrosarcoma/ liposarcoma/ chondrosarcoma osteosarcoma with local invasion and haematogenous metastases to lung, pleura and bone, with axillary metastases being quite rare. Incomplete excision results in recurrence in 15-20% despite their benign nature

Question 70

11 A 65-year-old hypertensive man with diabetes and a past history of colorectal carcinoma resected seven years previously presented with bilateral breast masses situated in the subareolar region. His medication included aspirin, bisoprolol, digoxin, furosemide and metformin. He then underwent mammography which showed a triangular area of subareolar glandular tissue that points towards the nipple. What is the most likely diagnosis?

a Gynaecomastia due to furosemide therapy

b Gynaecomastia due to digoxin therapy

c Normal finding

d Bilateral metastatic disease

e Lobular carcinoma in situ bilaterally

Answer 70

11 Answer B: Gynaecomastia due to digoxin therapy

The normal male breast appears on mammography as a mound of subcutaneous fat without glandular tissue. Gynaecomastia appears as described. It is NOT a risk factor for breast carcinoma. Thiazide diuretics and spironolactone are also recognised drug-induced causes of gynaecomastia. Invasive lobular carcinoma is distinctly uncommon as tubular structures are usually not found in the male breast. Gynaecomastia occurs in 60-75 % of healthy pubertal boys.

Question 71

12 A 50-year-old woman is found to have a breast mass on screening mammography. Her mammograms demonstrate a round well-circumscribed mass measuring 3 cm in diameter of mixed density with a mottled centre, reported as having a `slice of sausage’ appearance, situated in the right upper outer quadrant of the breast. The mass is surrounded by a thin smooth pseudocapsule and has a halo sign. MRI demonstrates a well-circumscribed round lesion with pseudocapsular demarcation containing a mixture of low, intermediate and high signal intensities on T1-weighted sequences and corresponding high and intermediate signal intensities on T2-weighted images. What is the most likely diagnosis?

a Fibroadenoma

b Hamartoma of the breast (fibroadenolipoma)

C Lobular carcinoma

d Lipoma

e Galactocoele

Answer 71

12 Answer B: Hamartoma of the breast (fibroadenolipoma) This description is classical.

Question 72

13 A 32-year-old woman who is currently breastfeeding develops a swelling in her left breast. Which of the following features would favour a diagnosis of galactocoele above that of cold abscess of the breast?

a A retroareolar location

b An anechoic/nearly anechoic area on ultrasound with posterior enhancement

c The presence of pathologic axillary lymph nodes

d A lesion of mixed density on mammography with a fat-water level on a horizontal beam view

e Secondary changes to the breast, including architectural distortion, nipple retraction and skin thickening

Answer 72

13 Answer D: A lesion of mixed density on mammography with a fat-water level on a horizontal beam view

This is a typical appearance in the second phase; a large radiopaque lesion of water density is seen in the first phase. They can also resemble a lipoma (small radiolucent lesion) and may contain a fluid calcium level. Ultrasound usually demonstrates a complex mass. Both conditions occur in the retroareolar portion of the breast. A cold abscess is associated with the features described in (b) and (e). Associated raised inflammatory markers, fever and pain are also seen.

Question 73

14 Regarding screening mammography, to which age range does the National Breast Screening Programme in the UK currently offer invitations for screening? a 45-75 years b 47-70 years c 50-70 years d 49-71 years e 50-73 years

Answer 73

14 Answer C: 50-70 years

There are plans to increase the age range to 47-73 years in due course, but staffing considerations and the impact on current resources will have to be taken into account before this can be introduced.

Question 74

15 A 56-year-old woman attends the mobile mammography unit for a routine screening mammogram. Which initial view(s) are recommended in screening mammography?

a Craniocaudal

b Mediolateral oblique

c Craniocaudal and mediolateral oblique

d Craniocaudal and true lateral

e Medial and lateral

Answer 74

15 Answer C: Craniocaudal and mediolateral oblique (MLO)

Question 75

16 A 46-year-old woman underwent a left mastectomy for multicentric breast carcinoma. She noticed subsequent swelling on the left, which gradually increased in size over two weeks. A subsequent MRI of the left breast demonstrated a circumscribed area of mildly hypointense signal on Ti W sequences which is hyperintense on T2W sequences and hypointense on a water-suppressed STIR sequence. Contrast enhancement was seen in the surrounding parenchyma on enhanced TIW sequences. What are these findings most likely to represent?

a Intracapsular rupture of a silicone implant

b Extracapsular rupture of a silicone implant

c Post-surgical seroma

d Residual breast carcinoma

e Autogenous tissue transplantation breast reconstruction

Answer 75

16 Answer C: Post-surgical seroma

Silicone would appear hyperintense on water-suppressed STIR sequences. The appearances are consistent with a localised collection serum after surgery.

Question 76

17 A 51-year-old woman attends for mammographic screening for the first time. An opacity is seen in the right breast and she is recalled for further views and assessment. Ultimately, she is found to have a radial scar of the breast. Which of the following statements is most accurate?

a It characteristically arises at a site of previous surgery or trauma

b At mammography, the lesion looks similar on both the craniocaudal and mediolateral oblique projections

c Thickening and retraction of the overlying skin is a typical mammographic finding

d Surgical excision is required for a definite diagnosis

e It typically presents as a palpable breast lump

Answer 76

17 Answer D: Surgical excision is required for a definite diagnosis

There is no association with trauma or previous trauma. It has a variable appearance in different projections. No skin thickening or retraction is seen. Frozen section, core needle biopsy or fine needle aspiration should be avoided. It is rarely palpable and is usually detected at screening mammography or occasionally in mastectomy specimens.

Question 77

18 A 50-year-old woman presents with a three-month history of a bloody discharge from the left breast. On examination there is an erythematous, scaly rash involving the left nipple and areola, with areas of ulceration. Retraction of the left nipple is noted, which the patient reported as of recent onset. No mass is identified on palpation. What is the risk of associated malignancy?

a Extensive invasive ductal carcinoma in 80% of cases

b Extensive invasive lobular carcinoma in 60% of cases

c Ductal carcinoma in situ in 60% of cases

d Lobular carcinoma in situ in 40% of cases

e No association with malignancy

Answer 77

18 Answer C: The condition is associated with ductal carcinoma in situ in 60% of cases

This patient has Paget’s disease of the nipple. Associated with invasive ductal carcinoma in 30%, negative mammogram in 50%, and can display linearly distributed subareolar/diffuse malignant calcifications. The diagnosis is often delayed many months as the condition can resemble benign eczema.

Question 78

19 A 35-year-old women presents with a swollen, erythematous and uncomfortable right breast. On mammography, there is a diffuse increase in density of the right breast, which displays a coarse reticular pattern with prominent Cooper ligaments and a skin thickness of 1.8 mm. The left breast appears normal. What is the most likely cause?

a Inflammatory carcinoma

b Left subclavian vein thrombosis

C Rheumatoid arthritis

d Congestive cardiac failure

e Previous wide local excision for carcinoma of the right breast seven years ago

Answer 78

19 Answer A: Inflammatory carcinoma

One might expect these changes with recent surgery, but not seven years later, and the findings raises the suspicion of inflammatory carcinoma or lymphatic obstruction in a patient with previous breast malignancy

Question 79

20 A 32-year-old woman underwent breast augmentation mammoplasty two years ago. She has recently noted a change in the shape of her right breast and underwent assessment with mammography. A dense area is visible contiguous with the implant on both views and an ultrasound and MRI are performed for further assessment. What finding would be in keeping with an extracapsular rupture of silicone gel-filled implants?

a Stepladder sign on ultrasound

b Linguine sign on MRI

C Inverted teardrop/lasso sign on MRI

d Snowstorm sign posteriorly on ultrasound

e Water droplet/salad-oil sign on MRI

Answer 79

20 Answer D: Snowstorm sign posteriorly on ultrasound

The snowstorm sign is a hyperechoic nodule, which is well-defined anteriorly with indistinct echogenic noise posteriorly (= free silicone droplets mixed with breast tissue). The other options are signs of intracapsular rupture

Question 80

21 A 60-year-old woman presents with erythema of the right breast. Ultrasound demonstrates a superficial hypoechoic tubular structure containing low-level internal echoes. She is diagnosed with Mondor disease. What treatment would be most appropriate?

a Surgical excision of this area

b Image-guided drainage

C Immunosuppression

d High-dose antibiotics and lifelong prophylaxis

e Symptomatic treatment only

Answer 80

21 Answer E: Symptomatic treatment only

Mondor disease is a usually self-limited thrombophlebitis of the subcutaneous veins of the breast and anterior chest wall, of unknown cause. It may be associated with carcinoma (in up to 12 %) and DVT. There are further possible associations with trauma, exertion, surgery, dehydration and inflammation.

Question 81

22 An asymptomatic 54-year-old woman had a mammogram which demonstrates multiple long needle like dense calcifications orientated with their long axis pointing toward the nipple. The appearance in both breasts was symmetrical. What is the most likely diagnosis?

a Phyllodes tumour

b DCIS

c LCIS

d Plasma cell mastitis

e Osteosarcoma metastases

Answer 81

22 Answer D: Plasma cell mastitis

Mammary duct ectasia or plasma cell mastitis is often asymptomatic, but may present with breast pain, nipple discharge and retraction or a subareolar mass. The mean age at which it occurs is 54 years. Duct dilatation is seen up to the nipple, with ducts usually measuring >2 mm on ultrasound. It is often bilateral and symmetric but may be unilateral and focal. It is a rare aseptic inflammation of the subareolar region. Intraductal calcifications associated are fairly uniform, linear, often needleshaped, of wide calibre and occasionally branching. Periductal calcifications appear as oval/elongated rings around dilated ducts with very dense peripheries (due to surrounding deposits of fibrosis and fat necrosis).

Question 82

23 A 43-year-old woman with a previously treated malignancy developed a solitary mass in the upper outer quadrant of the right breast, which is proven on biopsy to represent a haemorrhagic metastasis. What is the most likely primary?

a Non-Hodgkin’s lymphoma

b Basal cell carcinoma

c Choriocarcinoma

d Ovarian cystadenocarcinoma

e Transitional cell carcinoma of the bladder

Answer 82

23 Answer C: Choriocarcinoma

Malignant melanoma, renal cell carcinoma and Kaposi sarcoma would be other possible primaries.

Question 83

9 A 65-year-old woman presents with a palpable breast lump, which on mammography corresponds to a spiculated/stellate soft-tissue density seen on both MLO and CC views with associated pleomorphic microcalcification. Wide bore core needle biopsy confirms a malignant lesion. She has no family history of breast cancer. Which of the following histological types is most likely in this case?

a Intracystic carcinoma

b Mucinous tumour

c Invasive ductal carcinoma

d Medullary carcinoma

e Papillary carcinoma

Answer 83

9 Answer C: Invasive ductal carcinoma

This is most likely to appear as a spiculated mass, usually on both mammographic views. It is also the most common histological type of breast cancer. The other types most often appear as rounded lesions with a smooth border and may display a halo sign.

Question 84

10 A 54-year-old post-menopausal woman attends for routine mammographic screening and is found to have a well-defined 10-mm mass in the left upper outer quadrant. What additional feature would raise the likelihood of this malignancy in this lesion?

a The presence of a central lucency in the mass

b A fatty peripheral notch in the border of the mass

c Predominantly peripheral microcalcification within the mass

d A normal mammogram three years previously

e Lack of clear delineation of the posterior border of the mass on standard views, which appears well-defined on cone-down compression magnified views

Answer 84

10 Answer D: A normal mammogram three years previously

Neither cysts nor fibroadenomas grow after the menopause and any new mass lesion should be regarded with suspicion, despite an otherwise apparently benign appearance.

Question 85

11 A 52-year-old woman presents with a mass in the left axilla which is found to have malignant cytology on FNA. No mass is palpable in the left breast and mammography is normal. An MRI is arranged. Which of the following findings on MRI are strongly suggestive of malignancy?

a Increased signal on T2-weighted images

b Peripheral wash-in on contrast-enhanced T1-weighted images

C Signal intensity increase up to 50% of baseline steadily over the first three minutes following contrast-enhanced T1-weighted images

d Gradual washout phase on contrast-enhanced T1-weighted images

e Spiculated lesion with a plateau in the post-initial phase on contrastenhanced T1-weighted images

Answer 85

11 Answer E: Spiculated lesion with a plateau in the post-initial phase on contrast-enhanced T1- weighted images

Malignant morphology always trumps kinetics. Features of malignancy on breast MR include reduced signal on T2 WI, irregular morphology, lymphangitic bridges, and the following on CE Ti WI: rapid wash-in -90/90 rule (SI increase of >90% in the first 90s), centripetal wash-in, plateau/rapid washout in postinitial phase, markedly higher amplitude than normal parenchymal tissue.

Question 86

12 A 42-year-old woman with previously treated lobular carcinoma, undetectable on mammography, is scheduled for MRI follow-up. Which of the following represents optimal timing of the MRI scan?

a First seven days of the menstrual cycle

b Last seven days of the menstrual cycle

c Six months after radiation therapy

d Six months after open biopsy

e Nine months after neoadjuvant chemotherapy

Answer 86

12 Answer D: Six months after open biopsy

Optimal timing of MR of the breast includes 7-20 days after the beginning of the menstrual cycle, six months after open biopsy and 12 months after radiation therapy.

Question 87

13 A 39-year-old woman presents with a palpable breast lump, which has a benign appearance on both mammography and ultrasound imaging. A biopsy confirms the diagnosis of a fibroadenoma. What is the most common site of benign breast masses?

a Upper inner quadrant

b Upper outer quadrant

C Retroareolar

d Lower inner quadrant

e Lower outer quadrant

Answer 87

13 Answer B: Upper outer quadrant

Fifty-four per cent occur in the UOQ, 14% in the UIQ, 15% are retroareolar, 7% in the LIQ and 10% in the LOQ

Question 88

14 A 46-year-old woman undergoes lumpectomy for a breast mass. Malignant involvement is found to extend to the resection margins on histological examination of the specimen. An MRI is performed 10 days later which shows an ill-defined distorted mass of low-signal intensity on both Ti- and T2- weighted images with a peripheral ring of high signal on Ti and low signal on T2. Post-contrast Ti images demonstrate a moderate diffuse reactive enhancement surrounding the lesion with continuous post-initial increase in enhancement. No central uptake is demonstrated within the lesion itself. What is the most likely explanation for these findings?

a Seroma

b Residual tumour mass

c Post-surgical haematoma

d Fat necrosis

e Breast abscess

Answer 88

14 Answer C: Post-surgical haematoma

Deoxyhaemoglobin of subacute haematoma. Seroma and abscess would display high signal intensity on T2 images due to fluid content. Fat necrosis usually occurs up to six months following insult, and would display increased signal intensity on T2 due to reactive oedema in a fresh lesion.

Question 89

15 A 31-year-old woman, who is currently breastfeeding her three-month-old daughter, presents with a painful right breast. She has a temperature of 38°C. WCC is raised. Ultrasound demonstrates a nearly anechoic area in the central subareolar region with posterior acoustic enhancement. She rapidly improves with a course of antibiotics. Which of the following best describes the expected MRI findings?

a Low signal on T1, high on T2-weighted images with moderate peripheral enhancement on contrast enhanced T1 images

b High signal on T1- and T2-weighted images with avid enhancement of entire lesion and surrounding adjacent tissue on contrast-enhanced T1 images

c Low signal on Ti- and T2-weighted images with no enhancement seen on contrast-enhanced T1 images

d High signal on T1- and T2-weighted images with avid peripheral enhancement without central uptake on contrast-enhanced T1 images

e High signal on T1- and low on T2-weighted images with moderate centripetal enhancement on contrast-enhanced T1 images

Answer 89

15 Answer D: High signal on T1- and T2 -weighted images with avid peripheral enhancement without central uptake on contrast-enhanced T1 images

High Ti SI is due to the high protein content of fluid in a chronic/cold abscess of the breast in a lactating woman. The abscess wall enhances strongly post contrast.

Question 90

16 A 62-year-old woman has declined her previous routine screening mammograms and presents with a palpable mass, which is diagnosed as invasive ductal carcinoma on biopsy. What is the approximate cancer detection rate of the NHS Breast Screening Programme?

a 0.3 per 100 women screened

b 2 per 100 women screened

C 6 per 1000 women screened

d 13 per 1000 women screened

e 30 per 10 000 women screened

Answer 90

16 Answer C: 6 per 1000 women screened

Question 91

17 A 35-year-old woman presents with a history of cyclical breast fullness, tenderness and pain. On examination there is generalised thickening of the breast tissue with palpable nodules. An enlarged nodular pattern is seen on mammography. A ductal pattern is seen on ultrasound, with duct ectasia, cysts and ill-defined lesions. Which of the following statements relating to this condition is most accurate?

a It tends to be asymptomatic in microcystic disease

b Symptoms occur during menstruation

C Symptoms are aggravated during pregnancy

d It is detected in 35% of the screening population >55 years

e Calcification may be present

Answer 91

17 Answer E: Calcification may be present

The patient has fibrocystic changes of the breast. Tea cup calcification on horizontal beam lateral view, low-density round calcification on CC projection (milk of calcium)/oyster pearllike'/psammoma like/involutional type’ fine punctate calcifications in one or more lobes against fatty background are all described. Symptoms usually occur with ovulation; regress with pregnancy and at menopause. It is the most common diffuse breast disorder, found in 72% of the screening population >55 years of age.

Question 92

18 A 39-year-old woman who had a reduction mammoplasty one year previously presents with a lump in her right breast. This corresponds to an irregular spiculated lesion on mammography and was found to be of low reflectivity with poorly defined borders on ultrasound. An attempted biopsy yielded a small amount of yellow fluid and an area of fat necrosis is suspected. What is the risk of malignant transformation in this area?

a 0% It is not pre-malignant

b 5-15%

c 20-40%

d 45-55%

e 85-95%

Answer 92

18 Answer A: 0% It is not pre-malignant

Fat necrosis is not pre-malignant but is an important differential for carcinoma, particularly if it causes distortion of the skin or breast tissue or has mammographic features which are indistinguishable from malignancy as in this case.

Question 93

19 A 30-year-old woman presents with a spontaneous serosanguinous nipple discharge. She has also noticed an intermittent mass which disappears with discharge from the nipple. The nipple discharge is produced on compression of a specific trigger point in the areolar region. A mammogram demonstrates subareolar amorphous coarse calcifications. On ultrasound a hypoechoic mass is identified within an isolated dilated duct. A MRI shows round lesion with signal isointense to parenchyma on T1-weighted images. Following contrast there is homogeneous enhancement above that of parenchyma on T1-weighted images with a continuous post-initial increase. What is the most likely diagnosis?

a Paget’s disease of the nipple

b Central solitary papilloma

C Fibroadenoma

d Galactocoele

e Papillary carcinoma

Answer 93

19 Answer B: Central solitary papilloma

Papillary carcinoma is a rare form of ductal carcinoma. MRI features usually differ slightly in that the lesion is hypointense on T1-weighted images, shows strong initial enhancement with contrast sometimes with ring enhancement and a postinitial plateau or washout. T2 -weighted images demonstrate a well-circumscribed intermediate intensity lesion in a signal-intense cyst.

Question 94

26. A 60-year-old woman had a screening mammogram which shows a densely calcifed lesion in the right breast. Te lesion is smoothly marginated and has soft tissue density with dense coarse ‘popcorn’ calcifcation. What is the most likely diagnosis?

(a) Breast carcinoma

(b) Ductal carcinoma in situ

(c) Fibroadenoma

(d) Fibroadenosis

(e) Fat necrosis

Answer 94

26. (c) Fibroadenoma

Fibroadenomas are benign lesions often seen in young women. With advancing age, they shrink and may degenerate. This can then calcify resulting in a typical ‘popcorn’ type calcifcation.

Question 95

37. Screening mammogram of a 60-year-old woman shows a well-circumscribed soft tissue density in the left breast. No calcifcations are identifed. Ultrasound demonstrates a homogenous, avascular, hypoechoic lesion with well-defned margins and posterior acoustic enhancement. No internal echoes are seen. What is likely diagnosis?

(a) Fibroadenoma

(b) Simple cyst

(c) Carcinoma

(d) Fibroadenosis

(e) Traumatic fat necrosis

Answer 95

37. (b) Simple cyst

These sonographic features are diagnostic of a simple cyst.

Question 96

38. A 35-year-old woman with a strong family history of breast cancer presents with a breast lump. Ultrasound shows a hypoechoic lesion with internal echoes. Gadolinium-enhanced contrast imaging demonstrates a 2 cm, non-enhancing, oval lesion in the right breast. What is the most likely diagnosis?

(a) Fat necrosis

(b) Fibroadenoma

(c) Cyst

(d) Carcinoma

(e) Radial scar

Answer 96

38. (c) Cyst

Other lesions are known to show contrast enhancement.

Question 97

39. A 41-year-old woman presents with a lump in her right breast. Mammography shows a 16 mm mass with smooth well-defned margins. Ultrasound shows a hypoechoic solid lesion with internal echoes. What is the correct management for this lesion

(a) No further management

(b) 6-month follow-up mammogram

(c) Core biopsy or FNAC

(d) 12 month follow-up mammogram

(e) Mastectomy

Answer 97

39. (c) Core biopsy or FNAC

For lesions as described, the appropriate management for lesions 15–20 mm in size is core biopsy or FNAC to exclude the possibility of malignancy.

Question 98

40. A 38-year-old woman with a history seat belt injury in a road trafc accident 1 year ago, presents with a right breast lump. Mammography shows a ‘hollow’ spherical abnormality measuring about 4 cm with a rim of thin curvilinear area of calcifcation in the right breast. What is the most likely diagnosis?

(a) Vascular calcifcation

(b) Fat necrosis

(c) Secretory calcifcations in ducts

(d) Milk of calcium

(e) Ductal carcinoma in situ

Answer 98

40. (b) Fat necrosis

‘Egg shell’ calcifcations are seen in patients with fat necrosis. This can be secondary to blunt trauma or it can be post-surgical.

Question 99

9. Which of the following are correct regarding screening tests for breast cancer in the general population? (T/F)

(a) Screening mammography has been shown to reduce mortality from breast cancer.

(b) Screening using ultrasound has been shown to reduced breast cancer mortality in patients less than 35 years

(c) Two views of the breast are obtained for all screening assessments.

(d) Cancers showing casting linear calcifications on mammography are associated with a poorer prognosis.

(e) In the UK, mammographic screening is currently advocated for women aged over 40 years.

Answer 99

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Not correct

Explanation:

Two views of each breast are taken as baseline, but single view is taken as follow up. However two views are recommended as follow up as it increases lesion detection. Ultrasound currently has no role as a screening tool in any age group. In UK, screening is available for patients from 50-65 yrs.

Question 100

10. Which of the following are correct regarding invasive breast cancers? (T/F)

(a) Rim calcification is frequently seen in medullary carcinoma.

(b) There is an association between tubular carcinoma and radial scar.

(c) The most common invasive cancer in the male breast in invasive lobular carcinoma.

(d) Colloid carcinoma has a worse prognosis than invasive ductal carcinoma.

(e) The likelihood of axillary spread of invasive ductal carcinoma depends on the size of the tumour.

Answer 100

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Medullary carcinoma presents as well defined mass which may show lobulated margins or halo sign. Calcification is not a feature. The most common invasive cancer in male breast is invasive ductal carcinoma. Colloid carcinoma is seen in older age group (over 60 yrs) and has a good prognosis as tumour is slow growing.

Question 101

11. Which of the following are correct regarding calcification detected on mammography? (T/F)

(a) Skin calcifications typically have central lucent centres. (b) Milk of calcium has a typical appearance on the cranio-caudal view. (c) “Bilateral scattered punctate calcifications are probably benign. (d) Rim calcification is a feature of fat necrosis. (e) Sutural calcification are usually linear in appearance.

Answer 101

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

Milk of calcium appears amorphous and ill-defined on cranial caudal view. On medial-lateral oblique view it is typically sharply defined, semilunar or crescent shaped and upwardly concave

Question 102

12. Which of the following statements are correct regarding fibroadenomas? (T/F)

(a) They occur bilaterally in 25% of cases.

(b) The incidence is higher in women receiving hormone replacement therapy.

(c) The typically demonstrate posterior acoustic shadowing on ultrasonography.

(d) Internal septations are typical on gadolinium-enhanced MRI.

(e) They are clinically palpable in the majority of cases.

Answer 102

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Correct

(e) Correct

Explanation:

Fibroadenomas are multiple in 10%- 20% of cases but are found bilaterally in only 4 % of cases. They are well circumscribed masses with homogenous internal echoes but variable posterior acoustic pattern.

Question 103

13. Which of the following are correct regarding sclerosing adenosis? (T/F)

(a) It has an association with lobular carcinoma.

(b) It is a condition with high premalignant potential.

(c) Biopsy is required to make a definitive diagnosis.

(d) It presents with a palpable mass in the majority of cases.

(e) It commonly presents as focal or diffuse calcification.

Answer 103

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Not correct

(e) Correct

Explanation:

Sclerosing adenosis is only mildly associated (2.5 folds) with increase in risk of infiltrating breast cancer. The condition in itself is non-malignant. It is frequently detected only on mammography, though may present as a palpable mass.

Question 104

35. Which of the following are correct regarding metastases to breast: (T/F)

(a) Rhabdomyosarcoma is the most frequent primary in adolescent females.

(b) Lymphoma is the most common primary in adults.

(c) Are associated with skin changes in more than 75% of cases.

(d) The majority are located in the lower outer quadrant.

(e) Are characteristically hypoechoic and have a well-defined posterior wall on ultrasound examination.

Answer 104

Answers:

(a) Correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

50% of metastases are superficial with no associated skin changes. Diffuse skin involvement is seen in melanoma. The metastases are more commonly located in outer upper quadrant, without speculation, calcifications or desmoplastic reaction as in primary carcinoma.

Question 105

42. Which of the following are correct regarding phyllodes tumour: (T/F)

(a) Typically presents in women between 30 years and 50 years of age.

(b) Benign phyllodes tumours do not recur after excision.

(c) Axillary nodal metastases are common at presentation.

(d) Calcifications are commonly seen at mammography.

(e) 1-5% contain areas of malignant degeneration at histology.

Answer 105

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Not correct

Explanation:

Phyllodes tumour presents as a large well circumscribed oval or lobulated mass which may have radiolucent halo on mammography. Coarse plaque like calcification is rare. On ultrasound it appears as inhomogeneous solid appearing mass. Cystic spaces within the mass with posterior acoustic enhancement are typical of phyllodes tumour. On histology is appears like a giant fibroadenoma, with upto 25% containing areas of malignant degeneration with infiltrative borders. 10% of phyllodes tumours are true sarcomas presenting with hematogeneous spread. Nodal spread is rare. Both benign and malignant have a tendency to reoccur if not widely excised.

Question 106

45. Which of the following are correct regarding imaging of silicone-gel breast implants: (T/F)

(a) The incidence of rupture increases with increasing implant age.

(b) A reverberation band parallel to the anterior surface of the implant is a sign of on ultrasound.

(c) The majority of ruptures are extracapsular.

(d) Water-suppressed inversion-recovery T2 weighted MRI images are useful.

(e) The linguine sign on MRI implies intracapsular rupture.

Answer 106

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Correct

Explanation:

A band of linear striated reverberation in the anterior aspect of implant approximately equal in thickness to the breast tissue overlying the implant is a normal finding indicating an intact silicone gel implantUltrasound signs of intracapsular rupture include the ‘stepladder sign’ (a series of parallel horizontal echogenic lines indicating a collapsed implant shell). A ‘snowstorm’ pattern has been described in extracapsular rupture indicating free silicone droplets within the breast tissue. 22% of ruptures are extracapsular.