{ "modality": "Mammography", "exam_facts": { "scored_questions": 115, "pilot_questions": 30, "time_limit_minutes": 150, "spec_version": "ARRT Mammography Examination Content Specifications, Board approved July 2024, effective September 1, 2025 (current; no newer Mammography version posted on arrt.org). Time limit from ARRT 2026 Postprimary Eligibility Pathway Handbook: 150 min test time, 170 min appointment.", "source_url": "https://assets-us-01.kc-usercontent.com/406ac8c6-58e8-00b3-e3c1-0c312965deb2/b3b1f1be-3ade-4215-81d8-fc303a796a79/Mammography%20Content%20Specifications%202025.pdf" }, "content_categories": [ { "name": "Patient Care", "scored_questions": 20, "subcategories": [ { "name": "Patient Interactions and Management", "scored_questions": 20 } ] }, { "name": "Image Production", "scored_questions": 30, "subcategories": [ { "name": "Image Acquisition and Quality Assurance", "scored_questions": 30 } ] }, { "name": "Procedures", "scored_questions": 65, "subcategories": [ { "name": "Anatomy, Physiology, and Pathology", "scored_questions": 26 }, { "name": "Mammographic Positioning and Procedures", "scored_questions": 39 } ] } ], "sections": [ { "id": "patient-care", "name": "Patient Care", "main_points": [ "Pre-exam instructions: patients should not wear deodorant, antiperspirant, powder or lotion, because metallic particles (e.g., aluminum) can mimic microcalcifications; a two-piece outfit simplifies undressing.", "Build rapport and explain each step, including why compression matters (less dose, less blur, better separation of tissue) and why a repeat may be needed for motion or artifact; acknowledge anxiety and modesty.", "ACS screening guidance for average-risk women: option to begin annual mammography at 40–44, annual at 45–54, then annual or every 2 years from 55 for as long as health is good and life expectancy is at least 10 years.", "The ACR recommends annual screening mammography beginning at 40 for average-risk women, with breast cancer risk assessment by age 25 to identify those who need earlier or supplemental screening.", "ACS does not recommend routine breast self-examination or clinical breast examination for screening average-risk women, but encourages breast self-awareness and prompt reporting of changes.", "Inherent risk factors include female sex, increasing age, early menarche, late menopause, nulliparity or late first birth, personal history of breast/ovarian cancer, family history or gene mutations (BRCA1/2), prior chest radiation, and dense breast tissue.", "Social/modifiable risk factors include alcohol use, tobacco, postmenopausal obesity, physical inactivity, hormone use (combined HRT, some contraceptives, gender-affirming hormones) and reduced access to care.", "Document signs and symptoms (lump, pain, nipple discharge, skin thickening, erythema, dimpling, nipple retraction, edema) and mark scars, moles and palpable areas so the radiologist can correlate them.", "Prior mammograms should be obtained and reviewed before the exam; comparison is one of the strongest tools for detecting subtle change and reducing unnecessary recalls.", "Under MQSA, patients receive a lay-language results summary within 30 days, and sooner for suspicious findings; since September 2024 the summary must also state whether the breasts are dense or not dense.", "Surgical treatment options range from lumpectomy (breast-conserving surgery, usually with radiation) and sentinel node biopsy to simple, modified radical and prophylactic mastectomy, sometimes with implant reconstruction.", "Systemic therapy is guided by receptor status: antiestrogen (hormone) therapy for ER+/PR+ tumors, anti-HER2 drugs such as trastuzumab for HER2-positive tumors, and chemotherapy for many others." ], "vocabulary": [ { "term": "Screening mammogram", "definition": "Routine exam of an asymptomatic patient, usually standard CC and MLO views of each breast." }, { "term": "Diagnostic mammogram", "definition": "Problem-solving exam for symptoms or an abnormal screen, tailored with additional views directed by the radiologist." }, { "term": "Breast self-awareness", "definition": "Being familiar with how one's breasts normally look and feel and reporting changes promptly." }, { "term": "Clinical breast examination (CBE)", "definition": "Physical examination of the breasts by a health care provider." }, { "term": "BRCA1/BRCA2", "definition": "Tumor-suppressor genes whose inherited mutations greatly raise lifetime breast and ovarian cancer risk." }, { "term": "Nulliparity", "definition": "Never having given birth, which slightly increases breast cancer risk." }, { "term": "Menarche", "definition": "First menstrual period; early menarche lengthens lifetime estrogen exposure and increases risk." }, { "term": "Peau d'orange", "definition": "Orange-peel skin texture caused by dermal lymphatic obstruction and edema." }, { "term": "Nipple retraction", "definition": "Inward pulling of the nipple that is significant when new, as it may signal an underlying malignancy." }, { "term": "Lay summary", "definition": "MQSA-required plain-language letter giving the patient her results and breast density status." }, { "term": "Lumpectomy", "definition": "Breast-conserving surgery that removes the tumor with a margin of normal tissue." }, { "term": "Sentinel lymph node biopsy", "definition": "Removal of the first node(s) draining the tumor, found with radiotracer and/or blue dye, to stage the axilla." }, { "term": "Simple (total) mastectomy", "definition": "Removal of the entire breast without an axillary node dissection." }, { "term": "Modified radical mastectomy", "definition": "Removal of the breast plus axillary lymph nodes while preserving the pectoralis major muscle." }, { "term": "Prophylactic mastectomy", "definition": "Risk-reducing removal of a breast without known cancer, often in mutation carriers." }, { "term": "Hormone receptor status", "definition": "Whether tumor cells express estrogen (ER) and/or progesterone (PR) receptors, predicting response to antiestrogen therapy." }, { "term": "HER2/neu", "definition": "Growth-factor receptor overexpressed in some cancers and targeted by drugs such as trastuzumab." }, { "term": "Tamoxifen", "definition": "Selective estrogen receptor modulator used to treat or reduce risk of ER-positive breast cancer." } ], "quiz": [ { "q": "A patient arrives for screening wearing antiperspirant. Why is she asked to wipe it off before imaging?", "options": [ "It increases the patient's radiation dose", "It causes the compression paddle to slip", "Its metallic particles can mimic microcalcifications", "It interferes with the AEC pre-exposure" ], "answer_index": 2, "explanation": "Aluminum and other metallic compounds in antiperspirants and powders can look like calcifications in the axilla or breast and lead to unnecessary recalls." }, { "q": "According to the American Cancer Society, how should an average-risk 50-year-old woman be screened?", "options": [ "Mammography every 3 years", "Annual mammography", "Clinical breast exam only", "Breast MRI every year" ], "answer_index": 1, "explanation": "ACS recommends annual mammography from age 45 through 54, with the option to switch to every two years at 55." }, { "q": "What is the American Cancer Society's position on clinical breast examination for screening average-risk women?", "options": [ "Recommended every year starting at 20", "Recommended every 3 years from 20 to 39", "Required before every mammogram", "Not recommended for screening at any age" ], "answer_index": 3, "explanation": "ACS does not recommend CBE as a screening tool for average-risk women, though providers still evaluate symptoms." }, { "q": "Which of the following is an inherent (non-modifiable) breast cancer risk factor?", "options": [ "Carrying a BRCA1 gene mutation", "Drinking two alcoholic drinks daily", "Postmenopausal obesity", "Current tobacco use" ], "answer_index": 0, "explanation": "Inherited gene mutations cannot be changed; alcohol, weight and tobacco are lifestyle (social) factors." }, { "q": "A 32-year-old reports chest radiation therapy at age 16 for Hodgkin lymphoma. Why is this history important?", "options": [ "It means compression must not be used", "It contraindicates mammography until age 50", "It places her at high risk, so earlier and supplemental screening is often advised", "It has no effect on breast cancer risk" ], "answer_index": 2, "explanation": "Chest irradiation in childhood or young adulthood markedly increases breast cancer risk, so high-risk screening (often including MRI) is typically recommended." }, { "q": "A modified radical mastectomy removes which of the following?", "options": [ "Only the tumor and a margin of normal tissue", "The breast and axillary lymph nodes, sparing the pectoralis major", "The breast, axillary nodes and both pectoral muscles", "Only the sentinel lymph node" ], "answer_index": 1, "explanation": "The modified radical procedure removes the breast and axillary nodes but preserves the pectoralis major, unlike the older radical mastectomy." }, { "q": "Antiestrogen therapy such as tamoxifen is most likely to benefit a patient whose tumor is:", "options": [ "HER2-positive and ER-negative", "Triple-negative", "Phyllodes tumor", "Estrogen receptor-positive" ], "answer_index": 3, "explanation": "Hormone therapy works by blocking estrogen's effect, so it is indicated for ER-positive (and often PR-positive) cancers." }, { "q": "Trastuzumab is a targeted therapy directed against which tumor marker?", "options": [ "HER2/neu", "Estrogen receptor", "Progesterone receptor", "BRCA2 protein" ], "answer_index": 0, "explanation": "Trastuzumab is a monoclonal antibody that blocks the HER2 receptor in HER2-overexpressing breast cancers." }, { "q": "Under MQSA, within what time frame must a facility send the patient a lay summary of her mammogram results?", "options": [ "24 hours", "5 days", "30 days", "90 days" ], "answer_index": 2, "explanation": "Lay summaries must be sent within 30 days; results that are suspicious or highly suggestive of malignancy should be communicated as soon as possible." }, { "q": "A patient reports a red, swollen breast with skin that looks like an orange peel. This finding is most associated with:", "options": [ "Simple cyst", "Lymphatic obstruction, as seen in inflammatory carcinoma", "Fibroadenoma", "Normal premenstrual change" ], "answer_index": 1, "explanation": "Peau d'orange reflects dermal edema from blocked lymphatics and is a classic sign of inflammatory breast cancer, though it also occurs with other causes of edema." }, { "q": "Why should prior mammograms be obtained before a patient's current exam is interpreted?", "options": [ "They are required to calculate dose", "They allow the technologist to skip one view", "They replace the need for a history form", "Comparison helps detect subtle change and reduces unnecessary recalls" ], "answer_index": 3, "explanation": "Stability or change over time is a key interpretive clue, and comparison lowers false-positive callbacks." }, { "q": "Since the 2024 MQSA amendments took effect, what must the patient's lay summary include about breast density?", "options": [ "Whether her breast tissue is dense or not dense", "Her exact percentage of glandular tissue", "Her lifetime cancer risk score", "The kVp used for each view" ], "answer_index": 0, "explanation": "The FDA rule requires the lay summary to state whether the breasts are dense or not dense and explain that dense tissue can hide cancer." } ], "bank": [ { "q": "The USPSTF's 2024 final recommendation for average-risk women advises screening mammography:", "options": [ "Every year from age 50 to 74", "Every year from age 40 with no upper age limit", "Every 2 years from age 50 to 69", "Every 2 years from age 40 to 74" ], "answer_index": 3, "explanation": "In 2024 the USPSTF lowered its starting age to 40 and recommends biennial screening through age 74.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient's calculated lifetime breast cancer risk is 25%. Which supplemental screening is generally recommended for her in addition to mammography?", "options": [ "Semiannual clinical breast exam only", "Annual contrast-enhanced breast MRI", "Molecular breast imaging every 5 years", "Annual whole-breast thermography" ], "answer_index": 1, "explanation": "Women with a lifetime risk of 20% or more are considered high risk, and annual MRI is recommended alongside mammography.", "subcategory": "Patient Interactions and Management" }, { "q": "Which tool is commonly used to estimate a woman's lifetime breast cancer risk when deciding whether she qualifies for supplemental MRI screening?", "options": [ "Tyrer-Cuzick (IBIS) model", "BI-RADS assessment category", "Gleason score", "Glasgow Coma Scale" ], "answer_index": 0, "explanation": "Tyrer-Cuzick incorporates family history, hormonal and other factors to estimate lifetime risk; MRI eligibility is usually based on a ≥20% result.", "subcategory": "Patient Interactions and Management" }, { "q": "During an upright stereotactic biopsy, the patient becomes pale, sweaty and says she feels faint. What should the technologist do first?", "options": [ "Increase compression to keep the breast from moving", "Have her stand up and walk to improve circulation", "Stop and lower her to a reclined position with legs raised", "Finish the stereo pair quickly before she faints" ], "answer_index": 2, "explanation": "These are signs of a vasovagal reaction; stopping and lowering the patient restores blood flow to the brain and prevents injury from a fall.", "subcategory": "Patient Interactions and Management" }, { "q": "How often should the compression paddle and image receptor surface be cleaned during a routine screening day?", "options": [ "Between every patient, with a manufacturer-approved disinfectant", "Weekly, when the phantom image is acquired", "Only after visible contact with blood or body fluids", "At the start and end of each day, with any household cleaner" ], "answer_index": 0, "explanation": "Surfaces that touch skin are cleaned between patients; MQSA requires written infection-control procedures that follow the manufacturer's recommendations.", "subcategory": "Patient Interactions and Management" }, { "q": "Under MQSA, what must a facility do after mammography equipment comes into contact with blood or other potentially infectious material?", "options": [ "Replace the compression paddle before the next patient exam", "Clean and disinfect it per its written, manufacturer-consistent procedures", "Report the event to the FDA within 24 hours of exposure", "Remove the unit from service until a medical physicist inspects it" ], "answer_index": 1, "explanation": "MQSA requires documented infection-control procedures for cleaning and disinfecting equipment after contact with blood or other infectious material.", "subcategory": "Patient Interactions and Management" }, { "q": "Midway through the exam, a patient says the compression is too painful and asks the technologist to stop. The most appropriate response is to:", "options": [ "Tell her the exam cannot be billed unless every view is completed", "Release compression, explain its value, respect her choice and document it", "Continue the exposure because the images are medically necessary", "Keep compressing but apply it more slowly without telling her" ], "answer_index": 1, "explanation": "Patients have the right to refuse; the technologist educates, honors the refusal, documents it, and notifies the radiologist.", "subcategory": "Patient Interactions and Management" }, { "q": "A woman in the waiting room asks the technologist whether her friend's mammogram looked normal. The technologist should:", "options": [ "Tell her only that nothing urgent was seen", "Decline to share any information without the patient's authorization", "Share the result since the patient brought her as a companion", "Show her the images on the acquisition workstation" ], "answer_index": 1, "explanation": "HIPAA protects patient health information; it may not be disclosed to friends or family without the patient's permission.", "subcategory": "Patient Interactions and Management" }, { "q": "Who is responsible for obtaining informed consent before a stereotactic breast biopsy?", "options": [ "The front-desk registrar at check-in", "The referring physician's office staff", "The physician who will perform the procedure", "The technologist who positions the patient" ], "answer_index": 2, "explanation": "The performing physician explains risks, benefits and alternatives; a technologist may serve as a witness to the signature.", "subcategory": "Patient Interactions and Management" }, { "q": "Before a vacuum-assisted breast biopsy, which history item is most important for the technologist to confirm and report?", "options": [ "Whether she uses a fluoride toothpaste daily", "Current anticoagulant or antiplatelet use", "Date of her most recent dental cleaning", "Whether she has ever had a chest X-ray" ], "answer_index": 1, "explanation": "Blood thinners raise the risk of bleeding and hematoma, so the radiologist must know before the procedure.", "subcategory": "Patient Interactions and Management" }, { "q": "A self-referred patient without a primary care provider receives a 'Probably Benign' assessment. Under MQSA, the facility must:", "options": [ "Have a system to refer her to a health care provider", "Mail a copy of the report to her insurance company", "Decline to perform future mammograms on self-referred patients", "Automatically schedule her for a breast surgery consultation" ], "answer_index": 0, "explanation": "MQSA requires facilities that accept self-referred patients to maintain a referral system, including when the assessment is probably benign, suspicious or highly suggestive of malignancy.", "subcategory": "Patient Interactions and Management" }, { "q": "Under the MQSA rules enforced since September 2024, a mammogram assessed as 'Suspicious' must have its lay summary provided to the patient within:", "options": [ "24 hours of the exam", "30 calendar days of interpretation", "7 calendar days of interpretation", "5 business days of the exam" ], "answer_index": 2, "explanation": "Reports and lay summaries for 'Suspicious' or 'Highly Suggestive of Malignancy' assessments must go out within 7 calendar days of interpretation.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient requests that her prior mammograms be transferred to a new facility. Under current MQSA rules, the transfer must take place within:", "options": [ "30 calendar days of receiving the request", "60 calendar days of the request", "15 calendar days of the request", "48 hours of receiving the request" ], "answer_index": 2, "explanation": "The amended MQSA regulations require transfer or release of copies within 15 calendar days of the request.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient had her last mammogram at a facility 6 years ago and has had none there since. Under MQSA, how long must the facility keep that exam at minimum?", "options": [ "5 years from the date of the exam", "Until the patient reaches age 65 or older", "3 years from the date of the exam", "10 years, as no later exams were done" ], "answer_index": 3, "explanation": "Records are kept at least 5 years, or at least 10 years if no further mammograms are done at the facility, or longer if state law requires.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient's serious complaint about her mammography experience cannot be resolved by the facility. Under MQSA, the facility must:", "options": [ "Report it to the facility's accreditation body", "Delete the complaint record after 30 days", "Refer the patient to small-claims court", "Forward it to the patient's insurance company" ], "answer_index": 0, "explanation": "MQSA requires a consumer-complaint mechanism, and unresolved serious complaints are reported to the accreditation body.", "subcategory": "Patient Interactions and Management" }, { "q": "Which condition is a recognized risk factor for male breast cancer?", "options": [ "Turner syndrome", "Klinefelter syndrome", "Down syndrome", "Marfan syndrome (fibrillin defect)" ], "answer_index": 1, "explanation": "Klinefelter syndrome (XXY) raises estrogen relative to androgen and significantly increases male breast cancer risk.", "subcategory": "Patient Interactions and Management" }, { "q": "When imaging a transgender patient, which approach best supports the exam?", "options": [ "Ask an accompanying family member to answer history questions", "Use her chosen name and pronouns; ask about hormones and surgery", "Use the legal name only and avoid asking about her history", "Skip the history, since it does not affect the imaging" ], "answer_index": 1, "explanation": "Respectful communication builds trust, and hormone therapy and surgical history affect risk and how the exam is performed and interpreted.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient in a wheelchair arrives for screening. The best approach is to:", "options": [ "Ask her to stand unassisted while each view is taken", "Image her seated, brakes locked, footrests and armrests moved", "Perform only CC views because MLOs cannot be done seated", "Reschedule her to a hospital-based facility with a lift" ], "answer_index": 1, "explanation": "Most views can be done with the patient seated; locking the chair and clearing obstructions allows safe, complete positioning.", "subcategory": "Patient Interactions and Management" }, { "q": "A premenopausal patient reports her breasts are very tender before her period. When is the best time to schedule her mammogram?", "options": [ "Any day, since timing makes no difference to comfort", "Only on the first day of ovulation each month", "In the week or so after her period starts", "In the few days just before her period starts" ], "answer_index": 2, "explanation": "Breasts are usually least tender and dense early in the cycle, after menses, so compression is better tolerated.", "subcategory": "Patient Interactions and Management" }, { "q": "A 30-year-old pregnant patient has a new palpable breast lump. What is the usual initial imaging exam?", "options": [ "Targeted breast ultrasound", "Molecular breast imaging", "Contrast-enhanced breast MRI", "Contrast-enhanced mammography" ], "answer_index": 0, "explanation": "Ultrasound is the first-line exam for a palpable lump in women under 30 and in pregnant or lactating patients; it uses no ionizing radiation or contrast.", "subcategory": "Patient Interactions and Management" }, { "q": "Before a contrast-enhanced mammogram, which screening question is essential?", "options": [ "Whether she ate within the last 12 hours", "Prior iodinated contrast reaction and kidney function", "Whether she has metal implants or a pacemaker", "Any allergy to gadolinium-based contrast" ], "answer_index": 1, "explanation": "CEM uses an IV iodinated contrast agent, so prior contrast reactions and renal risk factors must be assessed.", "subcategory": "Patient Interactions and Management" }, { "q": "When a patient's breasts are reported as dense, the MQSA lay summary must also tell her that:", "options": [ "She is required to have a breast MRI within 30 days of the report", "Dense tissue means a high-risk lesion has already been found", "Other imaging tests besides mammography may help some people find cancers", "Her mammogram must be repeated in 6 months to confirm the result" ], "answer_index": 2, "explanation": "The FDA-required dense-breast statement notes that supplemental imaging may help some patients and advises talking with her provider.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient scheduled for a screening mammogram tells the technologist she found a new lump last week. The technologist should:", "options": [ "Notify the radiologist so it can be done as a diagnostic exam", "Send her home to see a surgeon before any imaging", "Perform the routine screening views and not mention it", "Tell her to report it again at next year's screening" ], "answer_index": 0, "explanation": "A symptomatic patient needs a diagnostic exam with direct radiologist involvement rather than a routine screen.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient anxiously asks, 'Do you see cancer on my pictures?' The best response from the technologist is:", "options": [ "Explain the radiologist reads them and how she'll get results", "Point out on the monitor any densities that she can see herself", "Tell her the images look normal so she won't worry tonight", "Tell her that a biopsy will probably be needed just to be safe" ], "answer_index": 0, "explanation": "Technologists do not provide interpretations; explaining the result process is honest and supportive.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient worried about radiation asks about the dose from her screening mammogram. Which comparison is most accurate?", "options": [ "About a few weeks of natural background radiation", "No radiation at all, as it is digital", "About the same as an abdominal CT scan", "About 10 years of natural background radiation" ], "answer_index": 0, "explanation": "A standard screening mammogram delivers a low effective dose, on the order of several weeks of natural background exposure.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient who speaks limited English arrives with her 14-year-old daughter, who offers to translate. What is the best way to communicate exam instructions?", "options": [ "Let the daughter translate since she knows the patient", "Use a qualified medical interpreter provided by the facility", "Use gestures and demonstration instead of any translation", "Hand her the English instruction sheet to read first" ], "answer_index": 1, "explanation": "Qualified medical interpreters ensure accurate, private communication; minors and family members should not be relied on to interpret clinical information.", "subcategory": "Patient Interactions and Management" }, { "q": "A patient with saline implants worries that the paddle could break them. What should the technologist tell her?", "options": [ "Tell her implants cannot be harmed by mammographic compression", "Explain the small risk and that compression will be adjusted with care", "Cancel the exam and refer her for breast MRI instead", "Skip compression entirely on all of her images today" ], "answer_index": 1, "explanation": "Implant rupture from mammography is rare but possible, so the patient is informed and compression is applied carefully, with full compression used mainly on implant-displaced views.", "subcategory": "Patient Interactions and Management" }, { "q": "Before starting a diagnostic mammogram, how should the technologist confirm the patient's identity?", "options": [ "Ask the patient to confirm the room number on her chart", "Check that her face matches the photo on the order form", "Verify two identifiers, such as full name and date of birth", "Confirm the name of her referring physician with her" ], "answer_index": 2, "explanation": "The Joint Commission standard is to use at least two patient identifiers, such as name and date of birth, before any procedure.", "subcategory": "Patient Interactions and Management" } ] }, { "id": "image-production", "name": "Image Production", "main_points": [ "Mammography uses low kVp (roughly 25–35 kVp, somewhat higher for DBT) to maximize subject contrast between soft tissues of similar density.", "Common target/filter pairs include Mo/Mo, Mo/Rh, Rh/Rh, W/Rh and W/Ag; thicker, denser breasts get harder beams (Rh or W targets, Rh or Ag filters), and a beryllium tube window limits inherent filtration.", "Focal spots are about 0.3 mm for contact imaging and 0.1 mm for magnification; the cathode faces the chest wall so the anode heel effect delivers more intensity to the thicker posterior tissue.", "Firm compression reduces thickness, dose, scatter, motion and geometric blur, spreads overlapping tissue and evens out density; magnification views remove the grid and rely on an air gap.", "Acquisition modes include full-field digital mammography (2D), digital breast tomosynthesis (low-dose projections over a limited arc reconstructed into thin slices) and synthesized 2D images made from the DBT data set.", "Under-exposure in digital imaging shows as quantum noise (mottle); over-exposure raises dose without an obvious visual cue, so exposure indicators and AEC performance must be monitored.", "Images move through RIS/HIS and EMR to PACS for storage, backup and retrieval; radiologist interpretation monitors must be cleared for mammography (typically 5 megapixel), and CAD marks areas for second review.", "MQSA (enforced by FDA) requires facility certification through an approved accreditation body (ACR or certain states), annual inspections, qualified personnel, a medical outcomes audit, a consumer-complaint process and infection-control policies.", "MQSA technologists need initial mammography training (40 contact hours, including 25 supervised exams), then 15 CEUs per 36 months and 200 exams per 24 months to stay qualified.", "EQUIP makes the lead interpreting physician responsible for corrective action on poor-quality clinical images, regular review of image quality, and oversight of the QC program.", "Key technologist QC (2018 ACR Digital Mammography QC Manual): ACR DM phantom image quality weekly; compression thickness indicator, visual checklist and acquisition/review workstation monitor QC monthly, compression force every six months, facility QC review quarterly.", "Image evaluation (EQUIP/ACR criteria) covers positioning, compression, exposure, contrast, sharpness, noise, artifacts and exam ID, along with patient-related artifacts such as motion, hair, skin folds, clothing and implanted devices." ], "vocabulary": [ { "term": "MQSA", "definition": "Mammography Quality Standards Act of 1992, federal law setting quality standards for U.S. mammography facilities." }, { "term": "EQUIP", "definition": "Enhancing Quality Using the Inspection Program, an FDA initiative that checks clinical image quality oversight during inspections." }, { "term": "Accreditation body", "definition": "FDA-approved organization (e.g., ACR or certain states) that reviews facility images, dose and QC for MQSA certification." }, { "term": "Medical outcomes audit", "definition": "Required yearly tracking of positive mammograms against biopsy results to monitor interpretive accuracy." }, { "term": "Average glandular dose (AGD)", "definition": "Estimated dose to the radiosensitive glandular tissue; at most 3 mGy per view for the ACR phantom." }, { "term": "Anode heel effect", "definition": "Lower beam intensity on the anode side, so the cathode is placed toward the thicker chest wall." }, { "term": "Beryllium window", "definition": "Low-atomic-number tube port that lets the soft, low-energy photons needed for mammography pass through." }, { "term": "Digital breast tomosynthesis (DBT)", "definition": "3D technique acquiring multiple low-dose projections over an arc and reconstructing them into thin slices." }, { "term": "Synthesized 2D image", "definition": "2D-like image reconstructed from DBT data, avoiding a separate 2D exposure." }, { "term": "Automatic exposure control (AEC)", "definition": "System that sets exposure factors from a pre-exposure or detector reading of breast thickness and density." }, { "term": "Reciprocating grid", "definition": "Moving grid that removes scatter in contact mammography without visible grid lines." }, { "term": "Air gap technique", "definition": "Using increased OID in magnification so scatter misses the receptor, allowing the grid to be removed." }, { "term": "Quantum mottle", "definition": "Grainy noise from too few photons reaching the detector, typical of an under-exposed digital image." }, { "term": "Computer-aided detection (CAD)", "definition": "Software that marks suspicious calcifications or masses for the radiologist to review." }, { "term": "PACS", "definition": "Picture archiving and communication system used to store, back up, retrieve and display images." }, { "term": "SMPTE / TG18 test patterns", "definition": "Standard patterns used to check display monitor calibration, contrast and resolution." }, { "term": "Modulation transfer function (MTF)", "definition": "Physicist measure of how well a system preserves contrast at increasing spatial frequencies (resolution)." }, { "term": "Contrast-to-noise ratio (CNR)", "definition": "Measure of how distinguishable an object is from background noise, used in low-contrast performance testing." }, { "term": "Half-value layer (HVL)", "definition": "Thickness of material that cuts beam intensity in half, used by the physicist to assess beam quality." } ], "quiz": [ { "q": "For a 7-cm compressed, extremely dense breast, which target/filter combination is the AEC most likely to choose?", "options": [ "Molybdenum target / molybdenum filter", "Molybdenum target / aluminum filter", "Tungsten target / silver filter", "Rhodium target / molybdenum filter" ], "answer_index": 2, "explanation": "Thick, dense breasts need a more penetrating beam, which tungsten targets with rhodium or silver filters provide at lower dose." }, { "q": "What nominal focal spot size is used for magnification mammography?", "options": [ "0.3 mm", "0.1 mm", "0.6 mm", "1.0 mm" ], "answer_index": 1, "explanation": "Magnification increases geometric unsharpness, so a 0.1-mm focal spot is used instead of the 0.3-mm contact focal spot." }, { "q": "How is scatter controlled on a magnification view?", "options": [ "A higher-ratio grid is added", "kVp is reduced by 10", "The collimator is opened fully", "The grid is removed and the air gap reduces scatter" ], "answer_index": 3, "explanation": "The large OID creates an air gap that lets scatter miss the detector, so the grid is removed to avoid extra dose." }, { "q": "Why is the cathode end of the mammography tube positioned toward the chest wall?", "options": [ "The heel effect makes the beam more intense on the cathode side, where the breast is thickest", "The anode needs to be cooled by the patient's body", "It reduces the source-to-image distance", "It eliminates the need for a grid" ], "answer_index": 0, "explanation": "Intensity is greater on the cathode side, which matches the thicker posterior breast and gives a more even exposure." }, { "q": "Under the 2018 ACR Digital Mammography QC Manual, how often does the technologist perform the ACR DM phantom image quality test?", "options": [ "Daily", "Monthly", "Weekly", "Semiannually" ], "answer_index": 2, "explanation": "The phantom image quality test is a weekly technologist test (and is also repeated after service that could affect image quality)." }, { "q": "The compression thickness indicator test passes when the displayed thickness is accurate to within:", "options": [ "±0.1 cm", "±0.5 cm", "±1.5 cm", "±2.0 cm" ], "answer_index": 1, "explanation": "The displayed thickness must be within 0.5 cm of the actual thickness because the AEC and dose estimates rely on it." }, { "q": "MQSA requires powered compression to deliver an initial force within what range?", "options": [ "25–45 lb (111–200 N)", "10–20 lb (44–89 N)", "50–70 lb (222–311 N)", "No minimum, maximum 45 lb" ], "answer_index": 0, "explanation": "The initial powered compression must be at least 25 lb (111 N) and no more than 45 lb (200 N); the technologist checks it every six months." }, { "q": "What is the maximum average glandular dose allowed per view when imaging the ACR digital mammography phantom?", "options": [ "1.0 mGy", "5.0 mGy", "10 mGy", "3.0 mGy" ], "answer_index": 3, "explanation": "MQSA and the ACR limit the phantom AGD to 3 mGy per view, and the medical physicist verifies it each year." }, { "q": "An under-exposed digital mammogram is most likely to show:", "options": [ "Excessive blackening of the skin line", "Grid lines across the image", "Increased noise (quantum mottle)", "Increased spatial resolution" ], "answer_index": 2, "explanation": "Too few photons reaching the detector produce a noisy image even after processing restores brightness." }, { "q": "Which statement best describes digital breast tomosynthesis?", "options": [ "Multiple low-dose projections over a limited arc are reconstructed into thin slices to reduce tissue overlap", "A single high-dose exposure is processed into 3D", "The breast is imaged without compression while rotating 360°", "It uses ultrasound to add depth information" ], "answer_index": 0, "explanation": "DBT reduces the masking effect of overlapping tissue by reconstructing slices from low-dose projections taken over an arc." }, { "q": "Primary interpretation displays for digital mammography are typically:", "options": [ "1-megapixel general-purpose monitors", "5-megapixel monitors cleared for mammography", "The acquisition workstation monitor", "Tablet displays with automatic brightness" ], "answer_index": 1, "explanation": "Radiologists read on high-resolution (typically 5 MP) displays cleared for mammography that are tested regularly with standard test patterns." }, { "q": "Under EQUIP, who is responsible for making sure procedures exist for corrective action when clinical images are of poor quality?", "options": [ "The equipment vendor", "The FDA inspector", "The quality control technologist alone", "The lead interpreting physician" ], "answer_index": 3, "explanation": "EQUIP places responsibility for clinical image quality oversight, corrective action and QC oversight on the lead interpreting physician." } ], "bank": [ { "q": "Under the 2018 ACR Digital Mammography QC Manual, the acquisition workstation monitor QC is performed:", "options": [ "Annually", "Weekly", "Daily", "Monthly" ], "answer_index": 3, "explanation": "The 2018 manual lists acquisition and radiologist workstation monitor QC as monthly technologist tests.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Which item is checked as part of the technologist's monthly visual checklist?", "options": [ "The average glandular dose to the ACR phantom", "The interpreting radiologist's annual recall rate", "The half-value layer of the x-ray beam", "Paddle cracks and working locks and lights" ], "answer_index": 3, "explanation": "The visual checklist confirms the unit is mechanically safe and working, including paddles, locks, lights and detents.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Under the 2018 ACR Digital Mammography QC Manual, how often does the technologist test compression force?", "options": [ "Weekly", "Every two years", "Every six months", "Monthly" ], "answer_index": 2, "explanation": "Compression force is a semiannual technologist test, and it must pass before clinical use.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "How often is the facility QC review performed under the 2018 ACR Digital Mammography QC Manual?", "options": [ "Quarterly", "Monthly", "Every 3 years", "Weekly" ], "answer_index": 0, "explanation": "The facility QC review, which looks at the QC program as a whole, is a quarterly test.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "When imaging the ACR digital mammography phantom for weekly QC, about how much compression is applied?", "options": [ "About 45 lb (about 20 daN)", "About 12 lb (about 5 daN)", "No compression at all", "The maximum force the unit allows" ], "answer_index": 1, "explanation": "ACR instructions call for lowering the paddle to roughly 12 lb so the AEC behaves as it does clinically.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Which test objects are scored on the ACR digital mammography phantom image?", "options": [ "Line pairs, step wedges and wire meshes", "Contrast vials of iodine and gadolinium", "Lead letters, coins and BBs", "Fibers, speck groups and masses" ], "answer_index": 3, "explanation": "The ACR DM phantom simulates fibrous structures, microcalcification specks and masses, and minimum scores must be met.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "The weekly phantom image fails because of a new artifact. When must corrective action be taken?", "options": [ "Within 30 days", "Only if the radiologist objects", "At the next physicist survey", "Before any further clinical use" ], "answer_index": 3, "explanation": "A failed phantom image quality test requires corrective action before further clinical use.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A mammography unit has a new x-ray tube installed. Before patients are imaged, what is required?", "options": [ "Nothing further until the next annual physicist survey", "A newly issued FDA certificate for the facility", "Only the weekly phantom test performed by the technologist", "A medical physicist's equipment evaluation (MEE)" ], "answer_index": 3, "explanation": "MQSA requires a medical physicist's equipment evaluation after installation or major repair before clinical use.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "MQSA requires a medical physicist's survey of each mammography unit at least:", "options": [ "Annually", "Only when equipment is installed", "Monthly", "Every 3 years" ], "answer_index": 0, "explanation": "Each unit is surveyed by a qualified medical physicist at least once a year (and after major changes).", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Under current MQSA rules, the annual medical outcomes audit must include which of the following for each interpreting physician and the facility?", "options": [ "Average patient wait time and satisfaction", "Number of phantom tests performed", "Repeat images per technologist only", "PPV, cancer detection rate and recall rate" ], "answer_index": 3, "explanation": "The amended rule specifies PPV, cancer detection rate and recall rate for each interpreting physician and the facility overall.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A technologist performed only 170 mammograms over the past 24 months. To requalify under MQSA, she must:", "options": [ "Retake and pass the ARRT mammography exam", "Perform 25 exams under direct supervision", "Wait until the next 24-month period and recount", "Repeat the 40 hours of initial mammography training" ], "answer_index": 1, "explanation": "Falling below 200 exams in 24 months requires 25 supervised exams before performing mammography independently again.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Before independently performing digital breast tomosynthesis for the first time, an MQSA-qualified technologist must complete at least:", "options": [ "15 continuing education credits in DBT", "40 hours of didactic DBT training", "8 hours of training in DBT", "25 supervised DBT exams and nothing else" ], "answer_index": 2, "explanation": "MQSA requires 8 hours of training in a new mammographic modality, such as DBT, before using it independently.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A technologist realizes she earned only 10 CE credits during the last 36 months. What must happen?", "options": [ "Repeat 200 mammograms under direct supervision", "Keep working and catch up during the next 36-month cycle", "Make up the credits to reach 15 before working independently", "Accept automatic revocation of her ARRT credential" ], "answer_index": 2, "explanation": "MQSA requires 15 CE units per 36 months; a technologist who falls short cannot work independently until the deficit is made up.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "The reciprocating grid used for contact mammography typically has a ratio of about:", "options": [ "8:1 to 10:1", "4:1 to 5:1", "12:1 to 16:1", "1:1" ], "answer_index": 1, "explanation": "Low-ratio grids remove much of the scatter while keeping the dose penalty acceptable in low-kVp mammography.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Why do mammography tubes use a beryllium window?", "options": [ "It passes low-energy photons needed for contrast", "It focuses the electron stream onto the anode target", "It serves as the added filter for tungsten-target exposures", "It hardens the beam so that patient dose is reduced" ], "answer_index": 0, "explanation": "Glass would absorb the low-energy photons that give mammography its contrast, so a beryllium window is used.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Why is a molybdenum filter paired with a molybdenum target?", "options": [ "Its K-edge passes Mo characteristic x-rays but absorbs higher energies", "It blocks the characteristic x-rays to lower patient dose", "It raises tube output so thick breasts can be penetrated", "It reduces the effective focal spot size for sharper images" ], "answer_index": 0, "explanation": "A filter of the same element as the target transmits the target's characteristic lines and absorbs photons just above its K-edge, producing a near-monoenergetic beam.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "The source-to-image distance used for standard mammography is typically about:", "options": [ "100 cm", "180 cm", "40–45 cm", "65–70 cm" ], "answer_index": 3, "explanation": "Mammography units use a short SID of roughly 65–70 cm.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A magnification stand typically produces a magnification factor of about:", "options": [ "1.5–2.0", "5.0 or more", "1.05–1.1", "3.0–4.0" ], "answer_index": 0, "explanation": "Magnification views commonly use about 1.5x to 2x, achieved by raising the breast away from the image receptor.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "On a unit where the technologist chooses the AEC sensor position, it is placed under the fatty anterior tissue of a dense breast. The likely result is:", "options": [ "Grid lines appear across the image", "The dense tissue is over-exposed and burned out", "No change, because AEC ignores sensor position", "The dense glandular tissue is under-exposed and noisy" ], "answer_index": 3, "explanation": "The AEC terminates when the fatty area receives enough exposure, leaving the denser glandular tissue under-exposed.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "In a direct-conversion digital mammography detector, x-rays are converted to an electrical signal by:", "options": [ "Photostimulable phosphor read by a laser", "Amorphous selenium", "A silver halide emulsion", "Cesium iodide followed by photodiodes" ], "answer_index": 1, "explanation": "Amorphous selenium converts x-ray energy directly into charge; indirect systems first produce light in a scintillator such as CsI.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A detector with a higher detective quantum efficiency (DQE) can:", "options": [ "Display images on lower-resolution monitors only", "Only be used for magnification views", "Give the same image quality at a lower dose", "Eliminate the need for breast compression" ], "answer_index": 2, "explanation": "DQE measures how efficiently a detector converts incident x-rays into useful signal-to-noise, so higher DQE allows lower dose.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "The limiting spatial resolution of a digital mammography detector is mainly set by its:", "options": [ "Display monitor brightness", "Detector element (pixel) size", "Amount of compression force", "The kVp selected by the AEC" ], "answer_index": 1, "explanation": "Smaller detector elements sample the image more finely, so pixel size largely limits spatial resolution.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A faint residual image of the previous patient's breast appears on the current image. This artifact is called:", "options": [ "Quantum mottle (noise)", "Ghosting (detector lag)", "Anode heel effect", "Grid cutoff artifact" ], "answer_index": 1, "explanation": "Ghosting is a residual signal from a prior exposure retained in the detector; it is documented and reported to service.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Fine parallel lines appear across an entire contact mammogram. The most likely cause is:", "options": [ "Patient breathing during exposure", "Residue left on the compression paddle", "Excess compression of the breast", "The grid did not move during exposure" ], "answer_index": 3, "explanation": "A reciprocating grid must move during exposure; if it stalls, its lead strips image as lines.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Calcifications look blurred on one view though compression appears adequate. Which is the most likely cause and fix?", "options": [ "Heel effect; reverse the tube orientation", "Grid lines; switch to a magnification view", "Motion; improve compression, coach a breath-hold, repeat", "Detector ghosting; recalibrate the detector first" ], "answer_index": 2, "explanation": "Motion blur shows best in fine structures such as calcifications and is corrected with firmer compression, shorter exposure and patient cooperation.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Why is a flat-field (gain) calibration performed on a digital detector?", "options": [ "To measure the beam's half-value layer", "To set the kVp for each breast thickness", "To correct pixel-to-pixel gain differences", "To check compression indicator accuracy" ], "answer_index": 2, "explanation": "Detector elements vary slightly in gain; calibration maps and corrects these differences and dead elements.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "What is the main dose advantage of a synthesized 2D image?", "options": [ "It removes the need for breast compression", "It is acquired with no radiation at all", "It halves the dose of each DBT projection", "It eliminates a separate 2D exposure" ], "answer_index": 3, "explanation": "Synthesized 2D views are reconstructed from the DBT data, so the patient does not receive an additional FFDM exposure.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "DBT data sets are commonly reconstructed into slices about how thick?", "options": [ "About 1 cm", "About 1 mm", "About 0.01 mm", "About 5 mm" ], "answer_index": 1, "explanation": "Thin (around 1-mm) reconstructed slices reduce tissue overlap and let the reader scroll through the breast.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "On DBT, a surgical clip appears as blurred repeated copies in slices above and below it. This is caused by:", "options": [ "Detector ghosting from the prior exposure", "Patient motion between the two views", "Out-of-plane artifact from the limited arc", "Grid cutoff from a misaligned grid" ], "answer_index": 2, "explanation": "Because DBT uses a limited arc, high-density objects spread as blurred ghosts along the tube's direction of travel in other slices.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Contrast-enhanced mammography acquires a high-energy image so that its spectrum lies above:", "options": [ "The K-edge of molybdenum (about 20 keV)", "The K-edge of gadolinium (about 50 keV)", "The K-edge of lead (about 88 keV)", "The K-edge of iodine (about 33 keV)" ], "answer_index": 3, "explanation": "Imaging just above iodine's K-edge maximizes iodine absorption; the low- and high-energy images are combined into a recombined iodine map.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "At the workstation, narrowing the window width will:", "options": [ "Increase displayed image contrast", "Decrease noise in the raw data", "Improve spatial resolution", "Increase patient dose" ], "answer_index": 0, "explanation": "Window width controls the range of values displayed; a narrower window makes small differences look more contrasty.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Which standard allows mammography images to be sent from the acquisition unit to PACS in a common format?", "options": [ "HL7", "JPEG", "HIPAA", "DICOM" ], "answer_index": 3, "explanation": "DICOM governs image format and transfer; HL7 handles text messages such as orders and reports between RIS, HIS and EMR.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Firm compression improves the mammogram mainly by:", "options": [ "Thinning the breast to cut scatter, dose and overlap", "Making the anode heel effect stronger at the chest wall", "Increasing the object-to-image distance for sharpness", "Raising the kVp that the AEC selects for the exposure" ], "answer_index": 0, "explanation": "A thinner, evenly compressed breast needs less radiation, produces less scatter and blur, and separates overlapping structures.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Why does a magnification view usually deliver a higher dose than a contact view?", "options": [ "A high-ratio grid is added for magnification", "The breast is closer to the x-ray source", "A larger focal spot is used for the view", "Compression is removed for the magnified view" ], "answer_index": 1, "explanation": "Moving the breast closer to the focal spot increases entrance exposure, even though no grid is used.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Average glandular dose (AGD) is the standard dose measure in mammography because:", "options": [ "It measures the dose reaching the detector", "It is identical for every breast size", "It equals the entrance skin dose", "Glandular tissue is the tissue most at risk" ], "answer_index": 3, "explanation": "AGD estimates the dose absorbed by the radiosensitive glandular tissue and depends on breast thickness, composition and beam quality.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Under MQSA, which item must be permanently included on each mammographic image?", "options": [ "The referring physician's phone number", "The patient's insurance policy number", "The patient's home address", "The performing technologist's identification" ], "answer_index": 3, "explanation": "Required image identification includes patient name and an additional identifier, date, view and laterality, facility name and location, and the technologist's ID.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Which type of digital image is sent to the radiologist for interpretation?", "options": [ "'For presentation' (processed) images", "Detector dark-current maps", "Flat-field calibration images", "'For processing' (raw) images only" ], "answer_index": 0, "explanation": "Processed images optimized for display are interpreted; raw images may be stored for other uses such as CAD or density software.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "MQSA limits how far the x-ray field may extend beyond any edge of the image receptor to:", "options": [ "10% of the SID", "5 cm", "2% of the SID", "It may not extend beyond the receptor at all" ], "answer_index": 2, "explanation": "Collimation must keep the x-ray field within 2% of the source-to-image distance beyond any receptor edge.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A technologist schedules her QC tasks for the year. At what interval is the compression thickness indicator checked?", "options": [ "Monthly", "Weekly", "Quarterly", "Semiannually" ], "answer_index": 0, "explanation": "The 2018 ACR DM QC Manual lists the compression thickness indicator test as a monthly technologist test, while compression force is semiannual.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "To pass the technologist's weekly ACR digital mammography phantom test, which minimum scores must be met?", "options": [ "4 fibers, 3 speck groups and 3 masses", "3 fibers, 2 speck groups and 3 masses", "5 fibers, 4 speck groups and 4 masses", "2 fibers, 3 speck groups and 2 masses" ], "answer_index": 3, "explanation": "The ACR DM phantom passes with at least 2.0 fibers, 3.0 speck groups and 2.0 masses and no clinically significant artifacts; 4/3/3 was the criterion for the older small phantom.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Current ACR digital QC guidance treats repeat (reject) analysis as a test that is:", "options": [ "Required every quarter with a repeat rate below 2%", "Required weekly along with the phantom image test", "Optional, done as needed such as to investigate a problem", "Done only by the physicist during the annual survey" ], "answer_index": 2, "explanation": "The 2018 manual lists repeat analysis as optional and performed as needed, while facility QC review is the required quarterly review.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Under MQSA, what is the minimum half-value layer allowed for a mammography unit operating at 30 kVp?", "options": [ "0.30 mm aluminum", "0.25 mm aluminum", "0.33 mm aluminum", "0.40 mm aluminum" ], "answer_index": 2, "explanation": "MQSA requires an HVL of at least kVp/100 + 0.03 mm Al, so at 30 kVp the minimum is 0.30 + 0.03 = 0.33 mm Al.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Under MQSA, which training must a radiologic technologist complete before independently performing mammography for the first time?", "options": [ "15 contact hours, including at least 10 supervised exams", "24 contact hours, including at least 50 supervised exams", "8 contact hours, including at least 200 supervised exams", "40 contact hours, including at least 25 supervised exams" ], "answer_index": 3, "explanation": "MQSA initial requirements include 40 contact hours of mammography training, with at least 25 examinations performed under direct supervision.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "A mammogram is reported as 'Incomplete: Need prior mammograms for comparison.' Under current MQSA rules, a follow-up report with a final assessment must be issued within:", "options": [ "7 calendar days of the initial report", "10 business days of the initial report", "60 calendar days of the initial report", "30 calendar days of the initial report" ], "answer_index": 3, "explanation": "Since September 10, 2024, MQSA requires a follow-up report with a final assessment within 30 calendar days of an initial 'Need prior mammograms' report, whether or not priors are obtained.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Which detector layer turns incoming x-ray photons into visible light in an indirect flat-panel mammography system?", "options": [ "A cesium iodide scintillator layer", "An amorphous selenium photoconductor", "A photostimulable phosphor plate", "A thin-film transistor charge array" ], "answer_index": 0, "explanation": "Indirect detectors use a CsI scintillator to make light, which amorphous silicon photodiodes then convert to charge; amorphous selenium is used in direct conversion.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Compared with a narrow sweep, a wider angular range in digital breast tomosynthesis mainly provides:", "options": [ "Higher in-plane resolution for fine calcifications", "Better depth resolution with less overlap between slices", "A shorter scan time with less chance of motion", "A lower dose because fewer projections are taken" ], "answer_index": 1, "explanation": "A wider sweep improves z-axis (depth) resolution and separates overlapping tissue better, though it can lengthen the scan and spread calcifications across more slices.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "Why are primary diagnostic mammography displays calibrated to the DICOM Grayscale Standard Display Function (GSDF)?", "options": [ "So images can be compressed with lossy methods for storage", "So gray levels look consistent and perceptually even across displays", "So the acquisition unit can choose the target and filter", "So the monitor reaches its highest possible brightness" ], "answer_index": 1, "explanation": "GSDF calibration makes equal changes in pixel value appear as equal perceived brightness steps, so images look the same on any calibrated display.", "subcategory": "Image Acquisition and Quality Assurance" }, { "q": "In contrast-enhanced mammography, the recombined (subtracted) image mainly shows:", "options": [ "Calcifications with soft tissue removed from the image", "Fat and glandular tissue without any contrast present", "The skin line and nipple with deeper tissue removed", "Iodine uptake with background breast tissue suppressed" ], "answer_index": 3, "explanation": "Low- and high-energy images are weighted and subtracted to suppress normal tissue and show areas of iodine enhancement; the low-energy image is used like a standard mammogram.", "subcategory": "Image Acquisition and Quality Assurance" } ] }, { "id": "procedures", "name": "Procedures", "main_points": [ "Locate lesions by clock face (as if facing the patient, so the upper outer quadrant is 10:00 on the right and 2:00 on the left), quadrant, and distance from the nipple; triangulation uses the shift of a lesion between MLO and 90° lateral views.", "Medial and superior breast borders are fixed and lateral and inferior borders are mobile; move mobile tissue toward the fixed borders to include as much breast as possible.", "Most breast cancers arise in the terminal ductal lobular unit (TDLU); Cooper ligaments support the breast, and their retraction causes skin dimpling. The upper outer quadrant holds the most glandular tissue and is the most common site of cancer.", "Ducts and lobules are lined by epithelial cells, with contractile myoepithelial cells and a basement membrane beneath; carcinoma is called invasive once it breaks through the basement membrane.", "BI-RADS assessment categories: 0 incomplete, 1 negative, 2 benign, 3 probably benign (≤2% malignancy, short-interval follow-up), 4 suspicious (4A/4B/4C), 5 highly suggestive (≥95%), 6 known biopsy-proven malignancy.", "BI-RADS density categories are (a) almost entirely fatty, (b) scattered fibroglandular density, (c) heterogeneously dense and (d) extremely dense; c and d count as 'dense' for patient notification.", "Suspicious mass features are irregular shape, indistinct or spiculated margins and high density; circumscribed oval or round masses with fat are usually benign (lymph node, lipoma, hamartoma, oil cyst).", "Typically benign calcifications include skin, vascular, coarse 'popcorn', large rodlike, rim/eggshell, dystrophic and milk-of-calcium; suspicious ones are amorphous, coarse heterogeneous, fine pleomorphic and fine linear/branching, especially in linear or segmental distribution.", "Malignancies: DCIS (often calcifications only), invasive ductal carcinoma (most common), invasive lobular carcinoma (subtle, often architectural distortion), inflammatory carcinoma (skin thickening and edema), and Paget disease (nipple eczema with underlying carcinoma).", "The CC and MLO are standard screening views; supplemental views include ML, LM, XCCL/XCCM, cleavage, axillary tail, tangential, rolled, implant-displaced, nipple-in-profile, anterior compression, spot compression and magnification.", "Adapt for patient variation: implants (Eklund), large breasts (mosaic/tiling), kyphosis, pectus deformities, pacemakers and ports, post-surgical or irradiated breasts, male patients and lactating patients (nurse or pump first).", "Interventional work requires history (anticoagulants, allergies), informed consent and a time-out. Stereotactic biopsy calculates depth from ±15° stereo images; clip placement is checked with post-procedure CC and 90° lateral views; specimen radiographs confirm retrieval." ], "vocabulary": [ { "term": "Terminal ductal lobular unit (TDLU)", "definition": "Functional milk-producing unit of lobule and terminal duct where most breast cancers originate." }, { "term": "Cooper ligaments", "definition": "Fibrous suspensory ligaments supporting the breast that can retract and dimple the skin when cancer involves them." }, { "term": "Retroglandular (retromammary) space", "definition": "Fat layer between the deep fascia of the breast and the pectoralis fascia." }, { "term": "Inframammary fold (IMF)", "definition": "Crease where the inferior breast meets the chest wall, which should be open on the MLO." }, { "term": "Posterior nipple line (PNL)", "definition": "Line from the nipple to the pectoral muscle or image edge, used to judge whether enough posterior tissue is included." }, { "term": "Triangulation", "definition": "Locating a lesion in 3D from its position on two or three views at different angles." }, { "term": "BI-RADS", "definition": "ACR Breast Imaging Reporting and Data System lexicon, assessment and density categories." }, { "term": "Architectural distortion", "definition": "Distorted parenchyma with spiculations or retraction but no definite mass." }, { "term": "Focal asymmetry", "definition": "Fibroglandular density seen on two views, lacking convex borders, that occupies less than a quadrant." }, { "term": "Milk of calcium", "definition": "Calcium sediment in microcysts that looks smudgy on CC and like a teacup/meniscus on the 90° lateral." }, { "term": "Hamartoma", "definition": "Benign encapsulated mix of fat and glandular tissue described as a 'breast within a breast'." }, { "term": "Radial scar", "definition": "Benign lesion with upgrade potential that appears as architectural distortion with a lucent center and is usually excised." }, { "term": "Phyllodes tumor", "definition": "Fast-growing fibroepithelial tumor that can look like a large circumscribed mass." }, { "term": "Ductal carcinoma in situ (DCIS)", "definition": "Malignant cells confined within ducts by an intact basement membrane, often seen as calcifications." }, { "term": "Eklund technique", "definition": "Implant-displaced positioning that pushes the implant back against the chest wall and pulls breast tissue forward into compression." }, { "term": "Rolled view", "definition": "Repeat view with the top of the breast rolled in a labeled direction (RL, RM, RS, RI) to separate superimposed tissue." }, { "term": "Stereotactic biopsy", "definition": "Needle biopsy guided by paired angled images that calculate lesion depth." }, { "term": "Needle (wire) localization", "definition": "Preoperative placement of a hookwire at a nonpalpable lesion to guide surgical excision." }, { "term": "Specimen radiography", "definition": "Imaging of excised or core tissue to confirm that the targeted lesion or calcifications were removed." }, { "term": "Accordion effect", "definition": "Shift of a biopsy clip along the axis of compression when compression is released after placement." } ], "quiz": [ { "q": "A mass is in the upper outer quadrant of the LEFT breast, midway between 12:00 and 3:00. Its clock position is about:", "options": [ "10:00", "2:00", "4:00", "8:00" ], "answer_index": 1, "explanation": "Clock positions are read as if facing the patient, so the left upper outer quadrant spans 12:00 to 3:00, with about 2:00 in the middle." }, { "q": "Most breast carcinomas originate in which structure?", "options": [ "Terminal ductal lobular unit", "Cooper ligaments", "Retroglandular fat", "Pectoralis major muscle" ], "answer_index": 0, "explanation": "The TDLU is the site of origin for most ductal and lobular cancers." }, { "q": "A finding assessed as BI-RADS 3 is best described as:", "options": [ "Negative, with routine screening", "Highly suggestive of malignancy", "Probably benign, with short-interval follow-up", "Known biopsy-proven malignancy" ], "answer_index": 2, "explanation": "BI-RADS 3 findings carry a malignancy likelihood of 2% or less and are usually followed with a 6-month exam." }, { "q": "Which calcification morphology is MOST suspicious for malignancy?", "options": [ "Coarse popcorn", "Large rodlike", "Rim (eggshell)", "Fine linear branching" ], "answer_index": 3, "explanation": "Fine linear or fine linear-branching calcifications suggest cancer filling the ducts (often DCIS) and carry the highest suspicion." }, { "q": "Calcifications look smudgy on the CC view and form crescents (teacup shapes) on the 90° lateral view. They are most likely:", "options": [ "Fine pleomorphic calcifications of DCIS", "Milk of calcium in microcysts", "Vascular calcifications", "Dermal calcifications" ], "answer_index": 1, "explanation": "Milk of calcium layers dependently in microcysts and appears as meniscus shapes on a horizontal-beam lateral, a benign pattern." }, { "q": "A circumscribed, encapsulated mass with a mix of fat and glandular density, described as a 'breast within a breast,' is a:", "options": [ "Hamartoma", "Phyllodes tumor", "Invasive lobular carcinoma", "Galactocele" ], "answer_index": 0, "explanation": "Hamartomas (fibroadenolipomas) contain fat and fibroglandular tissue inside a thin capsule." }, { "q": "After a car accident, a patient's mammogram shows a round radiolucent mass with eggshell-like rim calcification. This most likely represents:", "options": [ "Invasive ductal carcinoma", "Intraductal papilloma", "Oil cyst from fat necrosis", "Lymphoma" ], "answer_index": 2, "explanation": "Trauma can cause fat necrosis, which commonly forms lucent oil cysts that develop rim calcification." }, { "q": "A lesion seen on the MLO projects HIGHER on the 90° ML view. Where in the breast is it located?", "options": [ "Lateral", "Central, directly behind the nipple", "Inferior", "Medial" ], "answer_index": 3, "explanation": "Going from MLO to the 90° lateral, medial lesions move up and lateral lesions move down ('muffins rise, lead sinks')." }, { "q": "How does a stereotactic biopsy system calculate the depth (z-coordinate) of a lesion?", "options": [ "From the compressed breast thickness alone", "From the shift of the lesion between stereo images taken at about ±15°", "From an ultrasound measurement", "From the CC and MLO screening views" ], "answer_index": 1, "explanation": "The parallax shift of the target between the two angled images lets the system triangulate depth." }, { "q": "Why is a post-procedure mammogram (CC and 90° lateral) taken after a biopsy clip is placed?", "options": [ "To document clip location relative to the biopsy site, since the clip can shift", "To check for hematoma requiring surgery", "To meet the MQSA phantom requirement", "To measure the patient's dose" ], "answer_index": 0, "explanation": "Releasing compression can move the clip (accordion effect), so its final position must be documented for future localization." }, { "q": "What is the main purpose of specimen radiography after a wire-localized excision?", "options": [ "To measure tumor grade", "To check the radiation dose to the tissue", "To confirm that the targeted lesion and/or wire was removed", "To determine hormone receptor status" ], "answer_index": 2, "explanation": "The specimen image confirms the target is in the excised tissue before the surgery ends." }, { "q": "How should a lactating patient be prepared for a mammogram?", "options": [ "Stop breastfeeding for two weeks first", "Postpone all imaging until weaning", "Image without compression", "Breastfeed or pump just before the exam" ], "answer_index": 3, "explanation": "Emptying the breasts reduces density and discomfort, improving image quality." } ], "bank": [ { "q": "Vertically, the adult breast typically extends from about the:", "options": [ "Sternal notch to the level of the umbilicus", "2nd or 3rd rib to the 6th or 7th rib", "Clavicle to the 4th rib", "5th rib to the 10th rib" ], "answer_index": 1, "explanation": "The breast lies over the anterior chest wall from roughly the 2nd–3rd to the 6th–7th ribs, and from the sternum to about the midaxillary line.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Most lymphatic drainage of the breast flows to the:", "options": [ "Inguinal nodes", "Axillary lymph nodes", "Supraclavicular nodes", "Internal mammary nodes" ], "answer_index": 1, "explanation": "About three-quarters of breast lymph drains to the axillary nodes, which is why axillary staging is central to breast cancer care.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "The retromammary space is best described as:", "options": [ "Fat between the deep breast fascia and the pectoralis fascia", "The space between pectoralis major and pectoralis minor", "The collecting ducts directly beneath the nipple", "The layer between the skin and the subcutaneous fat" ], "answer_index": 0, "explanation": "This fatty layer allows the breast to glide over the chest wall, and imaging it shows that posterior tissue is included.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "The tail of Spence is breast tissue that extends toward the:", "options": [ "Axilla", "Inframammary fold", "Sternum", "Clavicle" ], "answer_index": 0, "explanation": "The axillary tail (tail of Spence) runs from the upper outer quadrant toward the axilla.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "As a woman passes menopause, the breast typically shows:", "options": [ "Generalized thickening of the skin", "Proliferation of new lobules and ducts", "Involution, with fat replacing glandular tissue", "A sharp rise in fibroglandular density from new growth" ], "answer_index": 2, "explanation": "Falling hormone levels cause involution, so postmenopausal breasts usually become fattier and easier to image.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A 58-year-old's breasts are noticeably denser than on last year's mammogram. Which history item best explains this?", "options": [ "She stopped drinking caffeinated coffee", "She began postmenopausal hormone therapy", "She lost about 5 lb since last year", "She began taking a daily vitamin D supplement" ], "answer_index": 1, "explanation": "Hormone replacement therapy can increase breast density, which can lower mammographic sensitivity.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "During breastfeeding, which hormone causes milk ejection by contracting myoepithelial cells?", "options": [ "Prolactin", "Progesterone", "Estrogen", "Oxytocin" ], "answer_index": 3, "explanation": "Prolactin drives milk production, while oxytocin triggers the let-down reflex by contracting myoepithelial cells around the alveoli.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Which hormone mainly stimulates growth of the breast's ductal system?", "options": [ "Oxytocin", "Insulin", "Estrogen", "Cortisol" ], "answer_index": 2, "explanation": "Estrogen promotes ductal elongation and branching; progesterone mainly drives lobular development.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A 24-year-old has a smooth, rubbery, mobile mass that has been stable for years. The most likely diagnosis is:", "options": [ "Fibroadenoma", "Phyllodes tumor", "Invasive lobular carcinoma", "Inflammatory carcinoma" ], "answer_index": 0, "explanation": "Fibroadenoma is the most common benign solid breast mass in young women; older ones can develop coarse 'popcorn' calcifications.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A 45-year-old has a large, rapidly growing, circumscribed mass that looks like a fibroadenoma. Which tumor is a key concern?", "options": [ "Phyllodes tumor", "Intramammary lymph node", "Oil cyst", "Lipoma" ], "answer_index": 0, "explanation": "Phyllodes tumors resemble fibroadenomas but grow quickly and can be benign, borderline or malignant, so they are excised with margins.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "On ultrasound, which combination of features defines a simple cyst?", "options": [ "Anechoic, thin-walled, with posterior enhancement", "Heterogeneous with internal blood flow", "Echogenic with a fatty hilum", "Hypoechoic and irregular, with posterior acoustic shadowing" ], "answer_index": 0, "explanation": "A simple cyst is fluid-filled, smooth-walled and anechoic and transmits sound well, producing posterior enhancement.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A circumscribed, entirely radiolucent mass with a thin capsule is seen on mammography. It is most likely a:", "options": [ "Fibroadenoma", "Simple cyst", "Lipoma", "Invasive ductal carcinoma" ], "answer_index": 2, "explanation": "A fat-containing encapsulated mass is a benign lipoma; fat-containing lesions are reassuring on mammography.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A breastfeeding patient has a mass that shows a fat-fluid level on the 90° lateral view. This is most likely a:", "options": [ "Hamartoma", "Phyllodes tumor", "Galactocele", "Radial scar" ], "answer_index": 2, "explanation": "A galactocele is a milk-filled cyst; its fat floats on the fluid, producing a fat-fluid level on a horizontal-beam lateral view.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A spiculated lesion with a lucent center and long thin spicules ('black star') is most likely a radial scar. How is it usually managed?", "options": [ "No follow-up, since it is always benign", "Biopsy, often followed by excision", "Routine annual screening mammography", "Six-month follow-up mammograms only" ], "answer_index": 1, "explanation": "Radial scars (complex sclerosing lesions) look like carcinoma and can be associated with atypia or cancer, so tissue sampling is needed.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "In a male patient, a symmetric, flame-shaped density centered behind the nipple most likely represents:", "options": [ "Lipoma", "Male breast carcinoma", "Fat necrosis", "Gynecomastia" ], "answer_index": 3, "explanation": "Gynecomastia shows as subareolar fibroglandular tissue fanning out from the nipple and is often linked to hormones or medications.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Which mammographic finding in a man is MOST suspicious for carcinoma?", "options": [ "An irregular mass eccentric to the nipple", "Symmetric subareolar flame-shaped tissue in both breasts", "Diffuse fatty tissue", "A circumscribed mass with a fatty hilum in the axilla" ], "answer_index": 0, "explanation": "Male breast cancer usually presents as an eccentric, irregular or spiculated mass, unlike the centered, symmetric tissue of gynecomastia.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Invasive lobular carcinoma is often subtle on mammography because its cells:", "options": [ "Form smooth, well-circumscribed cysts", "Infiltrate in single file without forming a mass", "Almost always produce dense calcifications", "Are confined to the skin and nipple" ], "answer_index": 1, "explanation": "Loss of E-cadherin lets lobular cells infiltrate in single file, often causing only architectural distortion or asymmetry.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Ductal carcinoma in situ (DCIS) is most commonly detected on screening mammography as:", "options": [ "A fat-containing mass", "Calcifications", "Enlarged axillary nodes", "Skin thickening" ], "answer_index": 1, "explanation": "Most DCIS is found because of suspicious calcifications, often fine pleomorphic or linear, rather than as a mass.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Which invasive carcinoma can appear as a circumscribed mass that mimics a benign lesion, especially in older women?", "options": [ "Paget disease of the nipple", "Inflammatory carcinoma", "Invasive lobular carcinoma", "Mucinous (colloid) carcinoma" ], "answer_index": 3, "explanation": "Mucinous carcinoma often appears round or oval and fairly circumscribed, so a 'benign-looking' new mass in an older woman still warrants workup.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A patient has a scaly, eczema-like rash of the nipple that has not responded to creams. This most suggests:", "options": [ "Montgomery gland infection", "Mondor disease", "Fat necrosis", "Paget disease of the nipple" ], "answer_index": 3, "explanation": "Paget disease involves malignant cells in the nipple epidermis and is usually associated with underlying DCIS or invasive cancer.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A patient reports a tender, cord-like line under the skin of the lateral breast after exercise. This most likely represents:", "options": [ "Galactocele", "Intraductal papilloma", "Mondor disease", "Inflammatory carcinoma" ], "answer_index": 2, "explanation": "Mondor disease is thrombophlebitis of a superficial breast vein; it is usually self-limiting.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A breastfeeding patient has fever and a red, painful breast with a fluctuant area. The most likely diagnosis and usual first imaging are:", "options": [ "Mastitis with possible abscess; ultrasound", "Inflammatory carcinoma; contrast-enhanced breast MRI", "Fibroadenoma; magnification views", "Galactocele; stereotactic biopsy" ], "answer_index": 0, "explanation": "Lactational mastitis can form an abscess; ultrasound confirms a fluid collection and can guide drainage.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Calcifications in a segmental distribution are concerning because they:", "options": [ "Suggest deposits in a duct and its branches", "Prove that they are vascular in origin", "Indicate a benign fat-containing lesion", "Show that they lie within the skin" ], "answer_index": 0, "explanation": "A segmental pattern follows a duct system, raising concern for a ductal process such as DCIS.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Parallel 'tram-track' calcifications along a tubular structure most likely represent:", "options": [ "Dermal calcifications", "Vascular calcifications", "Milk of calcium", "DCIS" ], "answer_index": 1, "explanation": "Vascular calcifications outline vessel walls in parallel lines and are typically benign.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Large, smooth, rod-shaped calcifications pointing toward the nipple in both breasts of an older woman are most likely:", "options": [ "Skin calcifications", "Dystrophic calcifications from surgery", "Secretory (plasma cell mastitis) calcifications", "Fine linear branching calcifications of DCIS" ], "answer_index": 2, "explanation": "Large rodlike secretory calcifications follow the ducts toward the nipple, are often bilateral, and are benign.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "In BI-RADS, architectural distortion means:", "options": [ "A diffuse increase in density in both breasts", "Clustered round calcifications within the skin", "A circumscribed mass containing a fatty hilum", "Tissue pulled toward a point, without a definite mass" ], "answer_index": 3, "explanation": "Distortion is an important, often subtle sign of malignancy, though it can also come from surgery or a radial scar.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A focal asymmetry that is new compared with prior mammograms is called a:", "options": [ "Global asymmetry, a normal variant", "Summation artifact needing no follow-up", "Developing asymmetry, needing workup", "BI-RADS 2 benign finding by definition" ], "answer_index": 2, "explanation": "A developing asymmetry is new or larger than before and carries a meaningful risk of malignancy, so it needs further evaluation.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A finding assessed as BI-RADS 4A carries a likelihood of malignancy of:", "options": [ "0%", "95% or more", "More than 2% up to 10%", "More than 50% but less than 95%" ], "answer_index": 2, "explanation": "BI-RADS 4 is subdivided into 4A (>2–≤10%), 4B (>10–≤50%) and 4C (>50–<95%) and calls for tissue diagnosis.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A patient with biopsy-proven cancer has a mammogram before starting neoadjuvant chemotherapy. The appropriate BI-RADS assessment is:", "options": [ "Category 3, probably benign", "Category 0, incomplete", "Category 5, highly suggestive of malignancy", "Category 6, known biopsy-proven malignancy" ], "answer_index": 3, "explanation": "Category 6 is used for imaging after a cancer has been confirmed by biopsy but before definitive treatment is complete.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Which imaging exam is best for detecting intracapsular rupture of a silicone breast implant?", "options": [ "Two-view screening mammography", "Molecular breast imaging with sestamibi", "Non-contrast silicone-sensitive MRI", "Contrast-enhanced dual-energy mammography" ], "answer_index": 2, "explanation": "MRI is the most sensitive test for silicone implant rupture; folded shell layers create the 'linguine sign'.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Lobular carcinoma in situ (lobular neoplasia) found at biopsy is best described as:", "options": [ "A benign lesion with no change in risk", "An invasive cancer that requires mastectomy", "A risk marker usually not seen on mammography", "A calcified, degenerating fibroadenoma" ], "answer_index": 2, "explanation": "LCIS is usually an incidental finding and signals higher risk in both breasts, guiding closer surveillance or risk reduction.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A core biopsy of calcifications shows atypical ductal hyperplasia (ADH). The usual next step is:", "options": [ "Return to routine annual screening mammography", "Repeat the mammogram in 5 years", "Begin systemic chemotherapy", "Surgical excision, since it may be upgraded" ], "answer_index": 3, "explanation": "ADH has a notable upgrade rate to DCIS or invasive cancer at excision, so surgical removal is commonly recommended.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Skin dimpling over a breast cancer is caused by:", "options": [ "Inflammation of the pectoralis muscle", "Blocked dermal lymphatic channels", "Tumor retraction of Cooper ligaments", "Enlargement of Montgomery glands" ], "answer_index": 2, "explanation": "Cooper ligaments connect the deep fascia to the skin; a tumor that involves and shortens them pulls the skin inward.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "On a correctly positioned CC view, the nipple should be:", "options": [ "Rolled under the breast", "Pointed toward the axilla", "At the far edge of the receptor", "In profile and roughly centered" ], "answer_index": 3, "explanation": "A centered nipple in profile shows that the breast is not rotated and that medial and lateral tissue are balanced.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "For the MLO, the image receptor angle is chosen to match the:", "options": [ "Angle of the patient's chin", "Height of the nipple", "Slope of the pectoralis major muscle", "Width of the patient's shoulders" ], "answer_index": 2, "explanation": "Setting the receptor parallel to the pectoral muscle lets it be included broadly, which brings more posterior tissue into the image.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "On a well-positioned MLO, the inframammary fold should be:", "options": [ "Hidden behind the patient's abdomen", "Excluded from the image to reduce dose", "Folded up over the lower breast tissue", "Open and visible inferiorly" ], "answer_index": 3, "explanation": "An open IMF shows that inferior posterior tissue was lifted out and included.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "How is the posterior nipple line (PNL) measured on an MLO?", "options": [ "From the lateral skin line up to the axilla", "Horizontally from the nipple to the image edge", "Vertically from the nipple down to the IMF", "Nipple to pectoral muscle, perpendicular to it" ], "answer_index": 3, "explanation": "On the MLO the PNL is drawn from the nipple perpendicular to the pectoral muscle (or to the image edge if the muscle ends first).", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A suspicious finding is in the medial breast. Which 90° lateral view gives the sharpest image of it?", "options": [ "Mediolateral (ML)", "Lateromedial (LM)", "Exaggerated CC lateral", "Axillary tail view" ], "answer_index": 1, "explanation": "In an LM view the medial side is against the receptor, so the medial lesion has the least object-to-image distance and blur.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "For a 90° mediolateral (ML) view, the x-ray beam:", "options": [ "Is angled 45° from the axilla", "Is directed up from below the breast", "Enters laterally, with the receptor medial", "Enters medially, with the receptor lateral" ], "answer_index": 3, "explanation": "In an ML view the tube is at 90° and the beam travels medial to lateral, with the receptor along the lateral breast.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A finding seen only on the CC view moves laterally when the top of the breast is rolled laterally. Where is it located?", "options": [ "In the inferior part of the breast", "Directly behind the nipple", "In the superior part of the breast", "In the skin of the medial breast" ], "answer_index": 2, "explanation": "Rolled CC views move superior tissue in the direction the top is rolled and inferior tissue the opposite way, which locates a one-view finding.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A possible lesion is seen only on the MLO. Which view is usually obtained next to help locate it?", "options": [ "A nipple-in-profile view", "A repeat MLO at the same angle", "A 90° lateral (ML or LM) view", "An exaggerated CC lateral" ], "answer_index": 2, "explanation": "Comparing the lesion's position on the MLO and a true lateral lets the technologist triangulate its location for the CC view.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "When taking a cleavage (valley) view, if the AEC sensor would sit under the gap between the breasts, the technologist should:", "options": [ "Use the AEC in its usual central position", "Switch to the 0.1-mm focal spot for detail", "Use manual technique or move tissue over the sensor", "Turn off the grid to shorten the exposure time" ], "answer_index": 2, "explanation": "An AEC sensor under empty space would end the exposure too early, under-exposing the medial tissue.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient with severe kyphosis cannot lean in far enough for a CC. Which view puts the superior breast closest to the receptor and often works better?", "options": [ "Axillary tail view", "Exaggerated CC medial", "From-below (FB) view", "Lateromedial oblique" ], "answer_index": 2, "explanation": "In the FB view the tube is under the breast and the receptor on top, which helps kyphotic patients, men and small breasts.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient has a prominent pacemaker in the upper outer chest. Which view helps avoid compressing the device while imaging the breast?", "options": [ "Lateromedial oblique (LMO)", "Standard MLO with extra compression", "Exaggerated CC lateral", "Axillary tail view" ], "answer_index": 0, "explanation": "The LMO reverses the beam direction so the receptor is against the medial side, which also helps patients with pectus excavatum or a recent sternotomy.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "An anterior compression view is used to:", "options": [ "Bring more pectoral muscle into the image", "Better compress under-compressed anterior tissue", "Image implants without needing displacement", "Show more of the axillary tail of the breast" ], "answer_index": 1, "explanation": "In large or dense breasts the anterior tissue may not be compressed well; a separate anterior view evens out thickness and exposure there.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "For a routine screening mammogram of a patient with breast implants, how many images are typically taken?", "options": [ "Eight: CC, MLO, ID-CC and ID-MLO of each breast", "Two: one MLO of each breast with the implant", "Four: CC and MLO of each breast only", "Six: MLO, ML and CC of each breast" ], "answer_index": 0, "explanation": "Standard implant imaging adds implant-displaced views to the full-implant views, giving four images per breast.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient's breast is too large to fit on the largest receptor in one CC view. What is the best approach?", "options": [ "Use a magnification stand", "Take only the MLO view", "Leave out some anterior tissue", "Take overlapping (mosaic) images" ], "answer_index": 3, "explanation": "Tiling the breast with two or more overlapping exposures ensures no tissue is missed.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Six months after lumpectomy and radiation therapy, which mammographic finding is expected?", "options": [ "New fine linear branching calcifications", "Complete absence of residual breast tissue", "A new fat-containing mass in the axilla", "Skin thickening and edema that lessen over time" ], "answer_index": 3, "explanation": "Radiation causes edema and skin thickening that peak early and gradually decrease; new suspicious findings at the site still need evaluation.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "When planning a stereotactic biopsy, the approach is usually chosen to give:", "options": [ "An approach through the pectoral muscle", "An approach through the nipple", "The longest needle path, to obtain more samples", "The shortest skin-to-lesion distance" ], "answer_index": 3, "explanation": "The shortest skin-to-lesion path is most accurate and least invasive.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "During a stereotactic biopsy, the system reports a negative stroke margin. What does this mean?", "options": [ "The breast is too thin for the needle's throw", "The lesion is too superficial to be seen", "The patient moved between the stereo images", "The stereo images were taken at the wrong angle" ], "answer_index": 0, "explanation": "A negative stroke margin means not enough tissue behind the lesion; options include a different approach, a lateral-arm approach or a spacer.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "In stereotactic biopsy, the first image taken after compression is usually a 0° scout. What is its purpose?", "options": [ "To assign the breast density category", "To confirm the lesion is in the paddle window", "To confirm the clip's final location", "To calculate the lesion's depth (z-coordinate)" ], "answer_index": 1, "explanation": "The scout ensures the target is centered in the aperture before the angled stereo pair is taken to compute depth.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Vacuum-assisted breast biopsy devices most often use needles of about what gauge?", "options": [ "25 gauge", "20 to 22 gauge", "4 gauge", "9 to 11 gauge" ], "answer_index": 3, "explanation": "Large-bore vacuum-assisted needles collect bigger, contiguous samples, which improves sampling of calcifications.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "After a stereotactic biopsy for calcifications, the cores are radiographed mainly to:", "options": [ "Measure the size of the tumor for staging purposes", "Confirm the target calcifications were sampled", "Determine the hormone receptor status", "Check the position of the marker clip" ], "answer_index": 1, "explanation": "Core specimen radiographs show whether target calcifications were sampled; cores with calcifications are often separated for the pathologist.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "On the post-biopsy mammogram, the clip has moved several centimeters along the direction of compression. This is known as the:", "options": [ "Heel effect", "Partial volume effect", "Edge enhancement effect", "Accordion effect" ], "answer_index": 3, "explanation": "When compression is released, tissue re-expands along the needle path and can carry the clip away from the biopsy site.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "During a needle localization through a fenestrated compression plate, after the needle is placed over the lesion, the next image is:", "options": [ "An orthogonal (90°) view to check needle depth", "A targeted breast ultrasound only", "A synthesized 2D image from a DBT sweep", "A repeat image in the same projection" ], "answer_index": 0, "explanation": "The first projection shows the needle aligned over the lesion; the orthogonal view shows how deep it is before the wire is deployed.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "With radioactive seed localization, how does the surgeon find the lesion during surgery?", "options": [ "By palpating a blue dye injection site", "By following a hookwire to the lesion", "With intraoperative breast MRI", "With a gamma probe detecting the I-125 seed" ], "answer_index": 3, "explanation": "An I-125 seed is placed in the lesion, sometimes days before surgery, and located with a gamma probe; non-radioactive reflector and magnetic seeds are alternatives.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "For sentinel lymph node mapping, which agents are commonly injected?", "options": [ "Gadolinium-based contrast only", "Tc-99m sulfur colloid and/or blue dye", "Barium sulfate suspension", "Iodinated contrast injected into the nipple duct" ], "answer_index": 1, "explanation": "The radiotracer and blue dye travel through lymphatics to the first draining node(s), which the surgeon finds with a gamma probe and by color.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "During ductography (galactography), which duct is cannulated?", "options": [ "Any duct draining the upper outer quadrant", "The largest duct, whatever the symptoms", "The duct shown to produce the discharge", "All visible ducts, one after another" ], "answer_index": 2, "explanation": "A small amount of iodinated contrast is injected into the discharging duct, followed by CC and 90° lateral (often magnified) images.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Which condition is a contraindication to ductography?", "options": [ "Acute mastitis or active infection", "Clear, single-duct nipple discharge", "A prior normal screening mammogram", "Heterogeneously dense breast tissue" ], "answer_index": 0, "explanation": "Cannulating an infected duct can worsen infection and is very painful, so ductography is deferred until it resolves.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient has a large, tender simple cyst. If it is aspirated under ultrasound, what usually happens to clear or straw-colored fluid?", "options": [ "Usually discarded; bloody fluid goes to cytology", "Stored for review at the annual MQSA inspection", "Always sent to pathology for bacterial culture", "Re-injected into the cyst after it is imaged" ], "answer_index": 0, "explanation": "Non-bloody cyst fluid is typically benign and discarded; bloody fluid or a residual mass raises concern and prompts further testing.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "During an ultrasound-guided core biopsy, the needle is ideally kept:", "options": [ "Outside the transducer's field of view", "Angled steeply toward the pectoral muscle", "Parallel to the chest wall, in plane", "Perpendicular to the chest wall surface" ], "answer_index": 2, "explanation": "A parallel, in-plane approach lets the operator see the entire needle and avoids entering the chest wall.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "When is an MRI-guided breast biopsy indicated?", "options": [ "When a suspicious lesion is seen only on MRI", "For simple cysts seen on ultrasound", "For calcifications seen on mammography", "For any palpable lump" ], "answer_index": 0, "explanation": "Findings not visible on mammography or targeted ultrasound must be sampled under MRI guidance.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "For contrast-enhanced breast MRI, the patient is typically positioned:", "options": [ "Prone, with the breasts in a breast coil", "Supine with the arms at her sides", "Standing upright against a receptor", "Decubitus on the affected side" ], "answer_index": 0, "explanation": "The prone position with a breast coil reduces motion and lets the breasts be imaged with high signal.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "In contrast-enhanced mammography, when does imaging typically begin after the IV iodinated contrast injection?", "options": [ "Immediately, during the injection", "The day after the injection", "About 2 minutes after injection", "About 30 minutes after injection" ], "answer_index": 2, "explanation": "A short delay allows contrast to reach the breast; the low- and high-energy view pairs are acquired within a few minutes.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Molecular breast imaging (MBI) commonly uses which radiopharmaceutical?", "options": [ "Gallium-68 DOTATATE", "Technetium-99m sestamibi", "Fluorine-18 FDG", "Iodine-131 sodium iodide" ], "answer_index": 1, "explanation": "MBI uses Tc-99m sestamibi, which concentrates in metabolically active tumor cells, imaged with dedicated gamma cameras.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "How does positioning for DBT compare with standard 2D mammography?", "options": [ "Only the MLO view can be acquired with DBT", "The breast is not compressed for a DBT acquisition", "Same positioning, but a longer exposure", "The patient lies prone on a dedicated table" ], "answer_index": 2, "explanation": "DBT uses standard views and compression; the longer sweep makes motion more likely, so coaching matters.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Where should the laterality and view marker be placed on a mammogram?", "options": [ "Over the area of clinical concern", "At the inferior edge of the image only", "Directly over the nipple", "Near the axilla, away from breast tissue" ], "answer_index": 3, "explanation": "Standard practice places the marker near the axilla so it shows orientation without covering tissue.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Which ACR view abbreviation designates the caudocranial view?", "options": [ "XCCM", "FB", "LMO", "SIO" ], "answer_index": 1, "explanation": "FB stands for 'from below,' the caudocranial view in which the beam enters from the inferior breast.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A skin fold appears at the lateral edge of the CC view. How is it best prevented?", "options": [ "Increase the kVp for the exposure", "Smooth the lateral skin out as compression is applied", "Turn the patient's head toward the imaged side", "Set the IR below the inframammary fold" ], "answer_index": 1, "explanation": "Smoothing tissue and skin forward and out during compression removes folds that can hide or mimic findings.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "On an MLO, the humeral head and shoulder overlap the upper image and the pectoral muscle is narrow. What is the most likely cause?", "options": [ "The shoulder was tense and raised", "Too little kVp was selected", "The patient held her breath", "The image receptor was set too low" ], "answer_index": 0, "explanation": "A relaxed shoulder, with the arm resting on the receptor and elbow bent, lets the pectoral muscle be pulled into the field.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Hair overlapping the superior part of the CC image can be prevented by:", "options": [ "Securing hair back, behind the face shield", "Turning the patient's head toward the receptor", "Using a smaller spot compression paddle", "Increasing the exposure time to blur the hair" ], "answer_index": 0, "explanation": "Hair can create streaky artifacts; pulling it back and away from the face shield keeps it out of the field.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient has firm capsular contracture, so her implants cannot be displaced. Which additional view is commonly added?", "options": [ "A 90° lateral view with the implant in place", "A second MLO at the same angle", "A from-below view with full compression", "Magnification views of the implant" ], "answer_index": 0, "explanation": "When displacement is not possible, a 90° lateral adds another projection so more of the tissue around the implant is seen.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Which is an advantage of a prone stereotactic biopsy table over an upright unit?", "options": [ "It requires no compression of the breast at all", "The patient lies down out of view, so fainting is less likely", "It uses no ionizing radiation for targeting", "It makes lesions very close to the chest wall easier to reach" ], "answer_index": 1, "explanation": "Prone tables keep the patient lying down and out of view of the needle, which reduces fainting; upright units can be better for posterior lesions.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Why is the local anesthetic for a breast biopsy often lidocaine with epinephrine?", "options": [ "Epinephrine reduces bleeding and prolongs the block", "Epinephrine is the main pain-relieving agent", "It makes the lesion more visible on mammography", "It prevents infection at the biopsy site" ], "answer_index": 0, "explanation": "Vasoconstriction from epinephrine limits bleeding and keeps the lidocaine in place longer.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "After a vacuum-assisted biopsy, which care step is standard?", "options": [ "Vigorous massage of the biopsy site", "Manual pressure, then a dressing and cold pack", "Removal of the marker clip before discharge", "Warm compresses for the first 24 hours" ], "answer_index": 1, "explanation": "Pressure prevents hematoma; a dressing, ice pack and instructions to avoid strenuous activity are typical.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Immediately before a breast biopsy begins, the procedural time-out confirms:", "options": [ "The date of the most recent phantom test", "The technologist's current CE credit total", "The patient's insurance coverage and copay", "Correct patient, breast, site and procedure" ], "answer_index": 3, "explanation": "A time-out is a universal safety pause to prevent wrong-patient, wrong-side or wrong-site procedures.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Which finding on a CC view best indicates that posterior tissue was well included?", "options": [ "Inframammary fold seen at the bottom", "Pectoral muscle seen at the posterior edge", "Nipple rolled laterally out of profile", "A skin fold along the lateral edge" ], "answer_index": 1, "explanation": "The pectoral muscle is seen on only some CC views; when present it confirms excellent posterior coverage.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A palpable lump is hidden by dense tissue on standard views. Which view can project it into the subcutaneous fat for better visibility?", "options": [ "A from-below (FB) caudocranial view", "An implant-displaced (Eklund) view", "A tangential view of the lump", "A cleavage (valley) view of both breasts" ], "answer_index": 2, "explanation": "Angling the beam tangent to the skin over the lump places it against fat, where its margins are easier to see.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A screening exam is recalled for a new group of calcifications. Which views are typically obtained at the diagnostic workup?", "options": [ "Repeat standard CC and MLO without magnification", "Implant-displaced views", "Cleavage and axillary tail views", "Spot magnification CC and 90° lateral views" ], "answer_index": 3, "explanation": "Spot magnification shows calcification morphology and distribution, and the 90° lateral also checks for milk of calcium layering.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A suspicious architectural distortion is visible only on tomosynthesis. Which biopsy method is most appropriate?", "options": [ "DBT-guided (tomosynthesis-guided) biopsy", "Ultrasound-guided biopsy without a correlate", "Prone 2D stereotactic biopsy only", "Wait for it to appear on 2D" ], "answer_index": 0, "explanation": "DBT-guided biopsy can target findings seen only on tomosynthesis, which are common for subtle distortions.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Calcifications extend over 5 cm and will be excised. How might the surgeon be guided to remove the whole area?", "options": [ "A single wire placed in the center", "Bracketing with two or more wires or seeds", "Skin marking with a surgical pen only", "A post-procedure mammogram only" ], "answer_index": 1, "explanation": "Bracketing marks the boundaries of an extensive finding so the surgeon can remove the full extent.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Contrast-enhanced breast MRI in premenopausal women is ideally scheduled for:", "options": [ "The first day of menses", "Any time, because the cycle has no effect", "The second week of the menstrual cycle", "The week before menses" ], "answer_index": 2, "explanation": "Background parenchymal enhancement is usually lowest early in the cycle (days about 7–14), which reduces false positives.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Which artery supplies most of the blood to the breast, mainly its medial and central parts?", "options": [ "Lateral thoracic artery", "Internal thoracic (internal mammary) artery", "Thoracoacromial artery", "Intercostal arteries" ], "answer_index": 1, "explanation": "About 60% of breast blood supply, mainly medial and central, comes from perforating branches of the internal thoracic artery; the lateral thoracic artery supplies much of the rest.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "In BI-RADS, a breast composition described as 'heterogeneously dense, which may obscure small masses' is category:", "options": [ "c", "a", "b", "d" ], "answer_index": 0, "explanation": "BI-RADS density categories are a (almost entirely fatty), b (scattered fibroglandular), c (heterogeneously dense) and d (extremely dense).", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Breast cancers in women with a BRCA1 mutation are most often:", "options": [ "Low-grade and estrogen receptor positive", "HER2 positive with lobular features", "High-grade and triple negative", "Mucinous and slow growing" ], "answer_index": 2, "explanation": "BRCA1-related cancers are commonly high-grade, triple-negative tumors that can grow quickly and may look circumscribed on imaging.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "Accessory breast tissue (polymastia) is most often found in which location?", "options": [ "The axilla, along the embryonic milk line", "The upper inner quadrant near the sternum", "The retromammary space behind the breast", "The infraclavicular area above the breast" ], "answer_index": 0, "explanation": "Accessory breast tissue develops along the milk line from axilla to groin and is most common in the axilla.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A screening mammogram shows new enlarged lymph nodes only in the left axilla. Which history item is most helpful to record?", "options": [ "A recent dental cleaning procedure", "A family history of colon cancer", "Use of an antiperspirant last week", "A recent vaccine given in the left arm" ], "answer_index": 3, "explanation": "Recent vaccination in the arm on the same side can cause temporary reactive axillary adenopathy, which affects how the finding is managed.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "A radiologist describes a new breast mass by its shape and margin. Which pairing carries the highest cancer risk?", "options": [ "Oval shape with circumscribed margins", "Round shape with a fatty center", "Irregular shape with spiculated margins", "Oval shape with a thin lucent halo" ], "answer_index": 2, "explanation": "Irregular shape and spiculated margins carry the highest likelihood of malignancy among BI-RADS mass descriptors.", "subcategory": "Anatomy, Physiology, and Pathology" }, { "q": "When positioning for the MLO, where should the upper corner of the image receptor be placed?", "options": [ "Against the sternum, just medial to the nipple", "Below the clavicle, in front of the pectoral muscle", "Against the lower ribs, under the inframammary fold", "High in the axilla, just behind the lateral edge of the pectoral muscle" ], "answer_index": 3, "explanation": "Placing the receptor corner high in the axilla behind the free pectoral margin lets the muscle and axillary tissue be drawn onto the receptor.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A patient had a right mastectomy without reconstruction and is due for screening. The routine screening exam usually includes:", "options": [ "CC and MLO views of both chest sides", "An MLO of the right chest wall and left CC", "Ultrasound of the right side and left MLO", "CC and MLO views of the left breast only" ], "answer_index": 3, "explanation": "After mastectomy without reconstruction, routine screening covers the remaining breast; the mastectomy side is evaluated clinically or with targeted imaging if a concern arises.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "To place a spot compression paddle over a finding seen on the CC and MLO, the technologist uses which measurements?", "options": [ "Its distance from the chest wall edge on the MLO view only", "Its distance behind the nipple and from the nipple line on each view", "Its distance from the skin surface on the CC view only", "Its distance from the axilla on the MLO and the IMF on CC" ], "answer_index": 1, "explanation": "Measuring depth behind the nipple plus medial/lateral (CC) and superior/inferior (MLO) offset from the nipple lets the technologist map the finding onto the breast.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Before imaging a patient who reports a palpable lump, the technologist usually places which marker over the lump?", "options": [ "A linear radiopaque wire along the skin", "A lead blocker taped over the lump", "A small round radiopaque marker such as a BB", "A triangle marker on the nipple only" ], "answer_index": 2, "explanation": "A small round marker over the palpable area shows the radiologist exactly where the lump is; linear markers are typically used for scars.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Why is it especially important to tell the patient to stay still during a DBT acquisition?", "options": [ "The tube is fixed, so any motion moves the breast off the detector", "The tube sweep takes several seconds, so motion can blur slices", "DBT uses no compression, so the breast can easily shift", "DBT exposures are shorter, so motion causes ghost images" ], "answer_index": 1, "explanation": "A DBT acquisition sweeps the tube over several seconds, longer than a 2D exposure, so breathing or movement can blur the reconstructed slices.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "After needle localization, the orthogonal images show the wire tip 3 cm beyond the lesion. What should the technologist do?", "options": [ "Tell the radiologist, who may reposition it or place another wire", "Pull the wire back 3 cm and repeat the orthogonal images", "Send the patient to surgery since the wire is in the breast", "Apply firm compression to push the wire back into place" ], "answer_index": 0, "explanation": "Only the radiologist decides whether to reposition or add a wire; the technologist must not pull back a hooked wire or ignore a poor placement.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A solid mass is clearly visible on both mammography and ultrasound. Which biopsy guidance is usually preferred?", "options": [ "Ultrasound, for real-time needle viewing without radiation", "Stereotactic, because it is faster than ultrasound", "MRI, because it shows the mass in the most detail", "Tomosynthesis, because it uses the least compression" ], "answer_index": 0, "explanation": "When a lesion is seen on ultrasound, US-guided biopsy is preferred because it is real-time, comfortable, avoids radiation and needs no compression.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "Why does a well-positioned MLO show more breast tissue than any other single view?", "options": [ "It follows the pectoral muscle and includes the upper outer quadrant and tail", "It compresses the breast from top to bottom along the chest wall", "It uses a shorter SID that projects more tissue onto the detector", "It images both the medial and lateral borders at a 90 degree angle" ], "answer_index": 0, "explanation": "Because the receptor is parallel to the pectoral muscle, the MLO includes the axillary tail and upper outer quadrant, where much glandular tissue lies.", "subcategory": "Mammographic Positioning and Procedures" }, { "q": "A view labeled LMO is taken with the beam directed:", "options": [ "From the superomedial side to the inferolateral side", "From the superolateral side to the inferomedial side", "From the inferolateral side to the superomedial side", "From the inferomedial side to the superolateral side" ], "answer_index": 2, "explanation": "The lateromedial oblique (reverse oblique) is the opposite of the MLO: the beam enters inferolaterally and exits superomedially, with the receptor against the medial breast.", "subcategory": "Mammographic Positioning and Procedures" } ] } ], "body_regions": [ { "region": "breast", "label": "Craniocaudal (CC) view", "common_exams": [ "Screening mammography (CC)", "Diagnostic mammography", "Exaggerated CC lateral/medial (XCCL, XCCM)", "DBT CC acquisition" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/thumb/2/2e/40F_CC_DMMG.png/960px-40F_CC_DMMG.png", "caption": "Bilateral digital mammogram, craniocaudal (CC) views, 40-year-old woman.", "credit": "Nevit Dilmen", "license": "CC BY-SA 3.0 (also GFDL)", "page_url": "https://commons.wikimedia.org/wiki/File:40F_CC_DMMG.png" }, "questions": [ { "q": "For the CC view, where should the image receptor be set before compression?", "options": [ "At the level of the sternal notch", "At the height of the elevated inframammary fold", "At the level of the umbilicus", "As low as possible so the breast hangs" ], "answer_index": 1, "explanation": "Raising the IMF (a mobile border) and setting the receptor at that height brings more posterior and inferior tissue into the image." }, { "q": "On a well-positioned CC view, the posterior nipple line should measure within what distance of the PNL on the MLO?", "options": [ "1 cm", "3 cm", "5 cm", "It does not need to be compared" ], "answer_index": 0, "explanation": "A CC PNL within 1 cm of the MLO PNL shows that enough posterior tissue was included." }, { "q": "Which breast tissue must be included on the CC view because it may not be fully seen on the MLO?", "options": [ "Axillary tail", "Inferior tissue at the IMF", "Lateral tissue near the latissimus", "Medial tissue" ], "answer_index": 3, "explanation": "Medial posterior tissue is easily missed on the MLO, so the CC must include all medial tissue without rotation." } ] }, { "region": "breast", "label": "Mediolateral oblique (MLO) view", "common_exams": [ "Screening mammography (MLO)", "Diagnostic mammography", "DBT MLO acquisition" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/thumb/d/d8/40F_MLO_DMMG.png/960px-40F_MLO_DMMG.png", "caption": "Bilateral digital mammogram, mediolateral oblique (MLO) views, 40-year-old woman.", "credit": "Nevit Dilmen", "license": "CC BY-SA 3.0 (also GFDL)", "page_url": "https://commons.wikimedia.org/wiki/File:40F_MLO_DMMG.png" }, "questions": [ { "q": "Which describes optimal pectoral muscle on an MLO?", "options": [ "A thin straight strip ending at the top of the image", "Absent, so the breast is not obscured", "Wide at the axilla, convex anteriorly, reaching to or below the PNL", "Concave and ending well above the nipple level" ], "answer_index": 2, "explanation": "A relaxed, convex pectoralis that extends to the PNL shows that posterior tissue was pulled into the field." }, { "q": "For a tall, thin patient, the MLO tube angle is usually:", "options": [ "Steeper, about 50–60°", "Shallower, about 30–40°", "Always exactly 45°", "0°, the same as the CC" ], "answer_index": 0, "explanation": "The receptor is set parallel to the pectoral muscle, which is steeper in tall, thin patients and flatter in short, heavier ones." }, { "q": "On an MLO, the breast droops and the inferior tissue folds over the IMF. What corrects this?", "options": [ "Lower the receptor and use less compression", "Lift the breast up and out and hold it while compression is applied", "Increase the kVp", "Rotate the patient away from the receptor" ], "answer_index": 1, "explanation": "Supporting the breast up and out keeps the IMF open and the tissue spread before the paddle takes over." } ] }, { "region": "breast", "label": "Axillary tail and upper outer quadrant", "common_exams": [ "Axillary tail (AT) view", "Exaggerated CC lateral (XCCL)", "MLO with axilla included", "Lateral (ML) view" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/thumb/4/48/Patron_predominio_fibroadiposo_OML.JPG/960px-Patron_predominio_fibroadiposo_OML.JPG", "caption": "Bilateral MLO mammogram including the axillary region, showing the upper outer breast and pectoral muscle (BI-RADS 1, predominantly fatty pattern).", "credit": "SCiardullo", "license": "CC BY-SA 4.0", "page_url": "https://commons.wikimedia.org/wiki/File:Patron_predominio_fibroadiposo_OML.JPG" }, "questions": [ { "q": "Which supplemental view best shows lateral and axillary tail tissue in a craniocaudal-type projection?", "options": [ "Cleavage view", "Lateromedial (LM)", "Exaggerated CC lateral (XCCL)", "Rolled inferior (RI)" ], "answer_index": 2, "explanation": "The XCCL rotates the patient so the lateral breast and axillary tail are pulled into a CC-type projection." }, { "q": "Which breast borders are mobile and should be moved toward the fixed borders during positioning?", "options": [ "Lateral and inferior", "Medial and superior", "Medial and inferior", "Superior and lateral" ], "answer_index": 0, "explanation": "The lateral and inferior borders move freely, so moving them toward the fixed medial and superior borders brings in more tissue." }, { "q": "An oval, circumscribed density with a fatty notch (hilum) is seen in the axillary tail. It most likely represents:", "options": [ "Spiculated carcinoma", "Galactocele", "Phyllodes tumor", "A normal lymph node" ], "answer_index": 3, "explanation": "Intramammary and low axillary nodes are typically small, oval or kidney-shaped, with a lucent fatty hilum." } ] }, { "region": "breast", "label": "Implant-displaced (ID) views", "common_exams": [ "Standard CC and MLO with implant included", "Implant-displaced CC and MLO (Eklund)", "90° lateral (ML) for encapsulated implants", "Breast MRI for implant integrity" ], "image": null, "questions": [ { "q": "How are the standard CC and MLO views taken with the implant in the field?", "options": [ "Full compression with AEC", "Manual exposure with only enough compression to reduce motion", "AEC with the grid removed", "Magnification technique" ], "answer_index": 1, "explanation": "An implant blocks AEC readings and could be damaged by firm compression, so manual technique and light compression are used." }, { "q": "In the Eklund implant-displaced technique, the technologist:", "options": [ "Pushes the breast tissue back toward the chest wall over the implant", "Images only the implant with magnification", "Pushes the implant back against the chest wall and pulls breast tissue forward into compression", "Angles the tube 15° to project the implant off the receptor" ], "answer_index": 2, "explanation": "Displacing the implant posteriorly lets the anterior breast tissue be compressed and imaged without the implant overlapping it." }, { "q": "Implant displacement is usually easier and more effective when the implant is placed:", "options": [ "Behind the pectoralis muscle (subpectoral)", "In front of the muscle with severe capsular contracture", "Directly under the skin", "In the axilla" ], "answer_index": 0, "explanation": "Subpectoral implants sit deeper and move more easily, while firm encapsulated implants may not displace well." } ] }, { "region": "breast", "label": "Nipple and subareolar region", "common_exams": [ "Nipple-in-profile view", "Anterior compression view", "Spot compression of subareolar area", "Breast ultrasound for nipple discharge" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/0/06/Normal_mammography_of_left_breast_in_MLO_view_showing_the_nipple_location.jpg", "caption": "Normal left breast, MLO view, with the nipple labeled.", "credit": "Cerevisae", "license": "CC BY-SA 4.0", "page_url": "https://commons.wikimedia.org/wiki/File:Normal_mammography_of_left_breast_in_MLO_view_showing_the_nipple_location.jpg" }, "questions": [ { "q": "Why is the nipple shown in profile on at least one view?", "options": [ "It lowers the dose to the areola", "It is required for AEC detector placement", "It prevents the paddle from slipping", "So it is not mistaken for a mass and the subareolar tissue can be evaluated" ], "answer_index": 3, "explanation": "A nipple not in profile can mimic a retroareolar mass and hide the tissue directly behind it." }, { "q": "Montgomery glands of the areola are best described as:", "options": [ "Lymph nodes draining the nipple", "Sebaceous glands whose openings form small raised bumps (Morgagni tubercles)", "Milk ducts that open on the nipple tip", "Smooth muscle fibers that make the nipple erect" ], "answer_index": 1, "explanation": "Montgomery glands are sebaceous glands of the areola, and their openings form Morgagni tubercles." }, { "q": "Spontaneous, bloody discharge from a single duct of one breast is most often caused by:", "options": [ "Galactocele", "Lipoma", "Intraductal papilloma", "Duct ectasia with popcorn calcifications" ], "answer_index": 2, "explanation": "Intraductal papilloma is the most common cause of single-duct bloody discharge, though malignancy must be excluded." } ] }, { "region": "breast", "label": "Spot compression and magnification (diagnostic work-up)", "common_exams": [ "Spot compression view", "Magnification view (often with spot paddle)", "Rolled views", "Targeted breast ultrasound" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/thumb/8/85/Spot_compression_view_mammography_to_spread_out_breast_tissues_and_visualise_lesion_in_an_area.jpg/960px-Spot_compression_view_mammography_to_spread_out_breast_tissues_and_visualise_lesion_in_an_area.jpg", "caption": "Spot compression view spreading overlapping tissue in a questioned area; no lesion persists.", "credit": "Cerevisae", "license": "CC BY-SA 4.0", "page_url": "https://commons.wikimedia.org/wiki/File:Spot_compression_view_mammography_to_spread_out_breast_tissues_and_visualise_lesion_in_an_area.jpg" }, "questions": [ { "q": "What is the main purpose of a spot compression view?", "options": [ "To spread overlapping tissue and tell a true lesion from summation of normal tissue", "To show the whole breast at lower dose", "To image the axillary lymph nodes", "To check the compression force for QC" ], "answer_index": 0, "explanation": "Focal compression separates superimposed tissue, so pseudo-lesions disappear while real masses persist." }, { "q": "A magnification view requires which combination of factors?", "options": [ "0.3-mm focal spot with the grid in place", "Grid in place and decreased OID", "Larger focal spot and shorter SID", "0.1-mm focal spot with the grid removed" ], "answer_index": 3, "explanation": "Magnification uses the small focal spot to limit blur and removes the grid because the air gap controls scatter." }, { "q": "Which is a drawback of magnification mammography?", "options": [ "Lower spatial resolution", "Longer exposure time, which increases the chance of motion blur", "Calcifications cannot be counted", "The grid adds visible lines" ], "answer_index": 1, "explanation": "The small focal spot limits tube output, so exposures are longer, raising the risk of motion and increasing dose." } ] }, { "region": "breast", "label": "Skin lesions and tangential (TAN) views", "common_exams": [ "Tangential view", "Skin marker placement (moles, scars, palpable lumps)", "CC and MLO with markers" ], "image": { "url": "https://upload.wikimedia.org/wikipedia/commons/thumb/e/e6/Lesion_cutanea_CC.JPG/960px-Lesion_cutanea_CC.JPG", "caption": "Bilateral CC mammogram with axillary extension; a superficial pseudo-nodule in the inner right breast represents a raised skin lesion.", "credit": "SCiardullo", "license": "CC BY-SA 4.0", "page_url": "https://commons.wikimedia.org/wiki/File:Lesion_cutanea_CC.JPG" }, "questions": [ { "q": "What does a tangential view accomplish for a suspected skin lesion or skin calcifications?", "options": [ "It magnifies the lesion two times", "It removes the lesion from the image completely", "It projects the finding into the subcutaneous fat to confirm it is in the skin", "It places the finding at the chest wall" ], "answer_index": 2, "explanation": "Aiming the beam tangent to the skin at the finding shows whether it lies in the skin rather than in the breast tissue." }, { "q": "Grouped round calcifications with lucent centers lying just beneath the skin line are most likely:", "options": [ "Dermal (skin) calcifications, which are typically benign", "Fine pleomorphic calcifications of DCIS", "Amorphous calcifications needing biopsy", "Vascular calcifications in an artery" ], "answer_index": 0, "explanation": "Lucent-centered, polygonal calcifications near the skin are typical of dermal (sebaceous gland) calcifications." }, { "q": "A linear radiopaque skin marker on a mammogram typically indicates:", "options": [ "A palpable lump", "The nipple", "A mole", "A surgical scar" ], "answer_index": 3, "explanation": "Linear markers are placed along scars so post-surgical distortion is not misread as a suspicious finding." } ] } ] }