Breast Imaging

Breast Imaging Indian Medical PG Question 1: Which of the following features on mammogram would suggest malignancy?

• A. Smooth borders
• B. Well defined lesion
• C. A mass of decreased density
• D. Areas of spiculated microcalcifications (Correct Answer)

Breast Imaging Explanation: ***Areas of spiculated microcalcifications*** - **Spiculated microcalcifications** are highly suspicious for malignancy due to their irregular shape, distribution, and association with rapid, uncontrolled cell growth. - These calcifications often represent **necrotic cells** within rapidly growing tumors, which can deposit calcium. *Smooth borders* - **Smooth borders** typically indicate a benign lesion, such as a cyst or fibroadenoma, as they suggest gradual, uniform growth rather than invasive spread. - Malignant lesions tend to have **irregular** or ill-defined borders due to their infiltrative nature. *Well defined lesion* - A **well-defined lesion** usually suggests a benign process, as it indicates a mass that is clearly demarcated from surrounding tissue and is likely encapsulated. - Malignancies, conversely, often exhibit **indistinct or irregular margins** as they invade adjacent structures. *A mass of decreased density* - A mass of **decreased density** is generally considered a benign finding, often representing a **cyst** or an area of normal fatty tissue. - Malignant tumors typically present as a **mass of increased density** due to their cellular proliferation and desmoplastic reaction.

Breast Imaging Indian Medical PG Question 2: Which of the following features suggests a malignant lesion on mammography?

• A. Macrocalcifications
• B. Microcalcifications (Correct Answer)
• C. Fat content
• D. Round well defined borders

Breast Imaging Explanation: ***Microcalcifications*** - **Fine, pleomorphic, branching, or linear calcifications** clustered together are highly suspicious for malignancy, particularly **ductal carcinoma in situ (DCIS)**. - They represent calcium deposits within the ducts or stromal calcifications related to tumor cells. *Macrocalcifications* - These are **larger, coarser calcifications** (typically >0.5 mm) which are almost universally benign. - They are often associated with benign conditions such as **fibroadenomas**, old trauma, or vascular calcifications. *Fat content* - Lesions predominantly composed of fat, such as **lipomas**, **oil cysts**, and **hamartomas**, are typically benign. - The presence of fat within a lesion on mammography generally indicates a **benign process**. *Round well defined borders* - A **smooth, rounded, and well-circumscribed margin** on mammography is a strong indicator of a benign lesion. - Malignant lesions typically have **irregular, spiculated, or ill-defined margins** due to invasive growth.

Breast Imaging Indian Medical PG Question 3: Which of the following is the most sensitive investigation for ductal carcinoma in situ (DCIS) of the breast?

• A. PET Scan
• B. Ultrasound
• C. Mammography (Correct Answer)
• D. MRI

Breast Imaging Explanation: ***Mammography*** - **Mammography** is the **gold standard** and **primary imaging modality** for detecting **ductal carcinoma in situ (DCIS)**, primarily because it excels at visualizing **microcalcifications**, which are the hallmark of DCIS. - Approximately **80-90% of DCIS cases** present as **microcalcifications** on mammograms, making it the most important screening and diagnostic tool. - Mammography has **high sensitivity (85-95%)** for detecting DCIS, especially calcified forms, and is widely available and cost-effective. *MRI* - While **MRI** has high sensitivity for invasive breast cancer and can detect non-calcified DCIS, it is **not the primary screening tool** for DCIS detection. - MRI is typically used for **staging known DCIS**, evaluating **extent of disease**, detecting **additional foci**, and screening **high-risk patients**. - However, MRI has lower specificity and higher false-positive rates compared to mammography, limiting its use as a primary diagnostic tool. *PET Scan* - **PET scans** are generally **not sensitive** for detecting **DCIS** because DCIS lesions typically have a **low metabolic rate** and do not avidly take up the **FDG tracer**. - PET scans are primarily used for detecting **invasive cancers** and assessing **metastatic disease**, not for non-invasive lesions like DCIS. *Ultrasound* - **Ultrasound** has **limited sensitivity** for detecting **DCIS** because DCIS often does not present as a palpable mass or a distinct sonographic abnormality. - While ultrasound can be useful for evaluating palpable masses or guiding biopsies, it frequently **misses microcalcifications** that are characteristic of DCIS. - Ultrasound is mainly used as a **complementary tool** to mammography, not as a primary diagnostic modality for DCIS.

Breast Imaging Indian Medical PG Question 4: In which of the following situations is breast conservation surgery not indicated?

• A. SLE
• B. Large pendular breast
• C. Diffuse microcalcification
• D. All of the options (Correct Answer)

Breast Imaging Explanation: ***All of the options*** - All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging. - Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes. *Large pendular breast* - While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery. - The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures. *SLE* - Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery. - They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life. *Diffuse microcalcification* - **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component. - In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.

Breast Imaging Indian Medical PG Question 5: Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?

• A. Patients are staged as T3 or T4 with any N, without distant metastasis (M0)
• B. It constitutes the bulk of patients of carcinoma breast in India
• C. Neoadjuvant chemotherapy downgrades the disease
• D. Radical Mastectomy is the treatment of choice (Correct Answer)

Breast Imaging Explanation: *Patients are staged as T3 or T4 with any N, without distant metastasis (M0)* - **Locally advanced breast cancer (LABC)** is correctly defined as tumors that are **T3 or T4** or involve regional lymph nodes (**any N**) without distant metastasis (**M0**). - This statement is **correct** regarding LABC staging criteria. *It constitutes the bulk of patients of carcinoma breast in India* - This statement is **correct**. In India, approximately **50-60% of breast cancer patients present with locally advanced disease** at the time of diagnosis. - This is in stark contrast to Western countries where LABC represents less than 10% of cases. - The high prevalence is attributed to lack of screening programs, delayed presentation, limited awareness, and socioeconomic factors. *Neoadjuvant chemotherapy downgrades the disease* - This statement is **correct**. **Neoadjuvant chemotherapy (NACT)** is a cornerstone of LABC management. - NACT aims to **downstage** the tumor, making it more amenable to surgical resection and increasing the feasibility of breast-conserving surgery. - It also provides early treatment of micrometastases and serves as an in vivo test of tumor chemosensitivity. ***Radical Mastectomy is the treatment of choice*** - This statement is **INCORRECT** and is the correct answer to this negation question. - **Radical mastectomy (Halsted mastectomy)** involving removal of breast, pectoral muscles, and axillary nodes is **no longer the standard treatment** for LABC. - Modern treatment involves a **multimodal approach**: neoadjuvant chemotherapy followed by **modified radical mastectomy (MRM)** or breast-conserving surgery with radiation therapy. - MRM preserves the pectoral muscles, providing better functional and cosmetic outcomes while maintaining oncological safety.

Breast Imaging Indian Medical PG Question 6: Best investigation to detect rupture of silicone breast implants is-

• A. Mammography
• B. X-ray
• C. MRI (Correct Answer)
• D. USG

Breast Imaging Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is considered the **gold standard** for detecting silicone breast implant ruptures due to its superior soft tissue contrast and ability to differentiate silicone from other tissues. - It can accurately identify both **intracapsular** (linguine sign) and **extracapsular** ruptures, as well as associated silicone granulomas. *Mammography* - While useful for breast cancer screening, **mammography** has limited sensitivity for detecting silicone implant ruptures, especially subtle ones. - It can show indirect signs like implant contour abnormalities or increased implant density but is often inconclusive for rupture diagnosis. *X-ray* - **X-rays** provide very little information regarding the integrity of silicone breast implants because silicone is radiolucent and does not show up clearly on standard radiographs. - Its utility is primarily for detecting calcifications or foreign bodies, not implant rupture. *USG* - **Ultrasound (USG)** can be a useful initial screening tool for detecting implant ruptures, showing signs like the **"stepladder sign"** for intracapsular rupture or anechoic collections (silicone outside the capsule). - However, its accuracy is highly operator-dependent, and it may miss subtle ruptures or be limited by poor visualization due to scar tissue, making MRI a more definitive choice.

Breast Imaging Indian Medical PG Question 7: Current gold standard to detect ductal carcinoma in situ breast is:

• A. Mammography (Correct Answer)
• B. CT/PET
• C. MRI
• D. USG

Breast Imaging Explanation: ***Mammography*** - **Mammography** is the gold standard for detecting **ductal carcinoma in situ (DCIS)**, often visible as microcalcifications. - It plays a crucial role in early detection and has been a cornerstone of breast cancer screening for decades. *CT/PET* - **CT scans** are primarily used for evaluating tumor extent and metastasis, not for initial DCIS detection. - **PET scans** are not routinely used for DCIS due to their lower resolution for subtle changes and higher false-negative rates for small lesions. *MRI* - While **MRI** is highly sensitive for breast cancer, its specificity for **DCIS** is lower, often leading to false positives. - It is typically used as an adjunct to mammography for high-risk screening or for evaluating the extent of known cancer, not as a primary screening tool for DCIS. *USG* - **Ultrasound (USG)** is effective for evaluating palpable masses or specific areas of concern identified on mammography, but it is not sensitive enough to reliably detect **microcalcifications** characteristic of DCIS. - It is often used to differentiate between solid and cystic lesions or guide biopsies, but not as a primary screening tool for DCIS.

Breast Imaging Indian Medical PG Question 8: Which is not echogenic while doing ultrasonography:

• A. Bile (Correct Answer)
• B. Bone
• C. Gas
• D. Gall stones

Breast Imaging Explanation: ***Bile*** - Bile is largely composed of **water**, which allows ultrasound waves to pass through it with minimal reflection, appearing **anechoic** (black) on ultrasound. - This property makes the gallbladder lumen, when filled with bile, appear anechoic, which is crucial for identifying structures like gallstones. *Bone* - **Bone** is highly dense and reflects a significant portion of ultrasound waves, making it appear very **echogenic** (bright) on ultrasonography. - Due to its high reflectivity, bone often produces a strong **acoustic shadow** behind it, obscuring deeper structures. *Gas* - **Gas** (air) is a strong reflector of ultrasound waves and appears brightly echogenic, often with a characteristic **dirty shadowing** or **reverberation artifact**. - The presence of gas can significantly hinder visualization of underlying tissues due to its strong reflection and scatter of the ultrasound beam. *Gall stones* - **Gallstones** are solid concretions that are highly reflective of ultrasound waves, appearing as bright, **echogenic foci** within the gallbladder lumen. - A classic ultrasound sign of gallstones is an echogenic structure with strong **posterior acoustic shadowing**.

Breast Imaging Indian Medical PG Question 9: Investigation of choice for vascular ring around airway:

• A. PET
• B. Catheter directed angiography
• C. MRI
• D. CT (Correct Answer)

Breast Imaging Explanation: ***CT*** - **CT angiography (CTA)** is the **investigation of choice** for diagnosing vascular rings due to its ability to provide detailed anatomical visualization of the great vessels and their relationship to the trachea and esophagus. - It offers high spatial resolution, allowing precise identification of the type of vascular anomaly, the degree of **airway and esophageal compression**, and guiding surgical planning. *PET* - **PET scans** are primarily used for assessing **metabolic activity**, particularly in oncology or to evaluate organ function, and do not provide sufficient anatomical detail for vascular rings. - While it can detect metabolically active lesions, it is **not suitable** for visualizing the structural abnormalities of blood vessels and their compressive effects on the airway. *Catheter directed angiography* - **Catheter-directed angiography** is an **invasive procedure** involving radiation and contrast, primarily used for assessing blood flow dynamics, identifying stenosis, or guiding interventions. - While it can visualize vessels, CTA is **less invasive**, provides comparable or superior anatomical detail for vascular rings, and is generally preferred for initial diagnosis. *MRI* - **MRI** can provide good soft tissue contrast and visualize vascular structures without radiation, but it is often **less readily available** and can be more challenging for pediatric patients due to the need for sedation and longer scan times. - For comprehensive anatomical detail including bone and calcifications, and in patients who might struggle with breath-holding, **CT angiography** often offers clearer and more consistent images of complex vascular anatomy.

Breast Imaging Indian Medical PG Question 10: What is the next best step for a 22-year-old with a hepatic hemangioma on ultrasound?

• A. Angiography
• B. CT
• C. Biopsy
• D. MRI (Correct Answer)

Breast Imaging Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive and specific imaging modality for confirming the diagnosis of a **hepatic hemangioma** due to its characteristic enhancement patterns. - An MRI with contrast (e.g., gadolinium) can definitively distinguish a hemangioma from other **benign or malignant liver lesions**, especially when the ultrasound findings are equivocal. *Angiography* - **Angiography** is an invasive procedure and is typically reserved for cases where **embolization** or surgical resection of a very large or symptomatic hemangioma is being considered. - It is not the initial diagnostic choice for confirming a suspected hemangioma identified on **ultrasound**. *CT* - A **CT scan** with contrast can also characterize a hemangioma, showing peripheral nodular enhancement followed by progressive centripetal fill-in. - However, **MRI** generally offers superior soft tissue contrast and provides more definitive diagnostic features for hemangiomas, particularly in younger patients where radiation exposure from CT is a concern. *Biopsy* - **Biopsy** of a suspected hepatic hemangioma is generally contraindicated due to the risk of **hemorrhage** and is rarely necessary for diagnosis. - Imaging characteristics (especially on MRI) are usually sufficient to confirm the diagnosis without the need for an invasive procedure.

Breast Imaging Flashcard 1 of 9

Question: Most important sign of malignancy in mammogram is _____ micro calcification

Answer: clustered

Breast Imaging Flashcard 2 of 9

Question: BIRADS is used for reporting _____

Answer: all breast imaging

Breast Imaging Flashcard 3 of 9

Question: Mammography tube has a _____ exit window and molybdenum filter

Answer: beryllium

Breast Imaging Flashcard 4 of 9

Question: Sign of DCIS on MRI is a _____

Answer: ductal enhancement.

Breast Imaging Flashcard 5 of 9

Question: The plastic shell of the breast implant can be seen floating within the silicon, producing a wavy line or _____ sign in MRI of intracapsular implant rupture

Answer: linguini

Breast Imaging Flashcard 6 of 9

Question: The following imaging on mammography represents a _____

Answer: fibroadenoma

Breast Imaging Flashcard 7 of 9

Question: The following imaging on mammography represents a _____

Answer: fat necrosis

Breast Imaging Flashcard 8 of 9

Question: The following imaging on mammography represents a _____

Answer: DCIS

Breast Imaging Flashcard 9 of 9

Question: BIRADS _____ is usually defined as highly suggestive of malignancy (>95% malignant) and followed-up with definitive treatment

Answer: 5