{ "modality": "Mammography", "spec_basis": "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.", "how_to_use": "Procedures is more than half the exam (65 of 115 scored questions), so master positioning (39) and anatomy and pathology with BI-RADS (26) first. Then learn Image Production (30), especially MQSA rules and the 2018 ACR Digital Mammography QC tests with their frequencies and limits, and finish with Patient Care (20).", "chapters": [ { "id": "patient-care", "category": "Patient Care", "scored_questions": 20, "weight_pct": 17.4, "topics": [ { "subcategory": "Patient Interactions and Management", "title": "Pre-exam instructions and patient support", "must_know": [ "Tell patients to skip deodorant, antiperspirant, powder and lotion on exam day; aluminum and zinc particles can look like calcifications.", "A two-piece outfit lets the patient undress only from the waist up; remove neck jewelry and move hair away from the field.", "Premenopausal patients with tender breasts are usually more comfortable 1-2 weeks after the start of menses.", "Explain each step and why firm compression matters: lower dose, less motion and blur, less scatter, better tissue separation.", "Give emotional support for anxiety, modesty, pain or past trauma; let the patient know compression can be adjusted and the exam stopped if needed.", "Adapt to physical and mental needs (wheelchair, limited mobility, cognitive or hearing impairment) and document any limitation that affects image quality.", "If an image must be repeated, tell the patient why (motion, artifact, missed tissue) so she understands it is a technical issue, not a finding." ], "memory_tip": "Compression = 'less of everything bad': less dose, blur, scatter, overlap.", "board_traps": [ "The technologist does not give results or interpret findings; that is the radiologist's or provider's job.", "Antiperspirant artifact mimics calcifications, not masses." ], "key_numbers": [] }, { "subcategory": "Patient Interactions and Management", "title": "Screening guidelines, breast imaging modalities and patient dose", "must_know": [ "ACS (average risk): may start yearly mammograms at 40-44, yearly at 45-54, then every 1-2 years from 55 while healthy with 10+ years of life expectancy.", "ACR: yearly screening mammography starting at age 40 for average-risk women, with a breast cancer risk assessment by age 25.", "High-risk women (about 20% or greater lifetime risk, BRCA carriers, chest radiation at a young age) get yearly MRI in addition to mammography, usually starting around age 30 or earlier.", "ACS does not recommend routine breast self-exam (BSE) or clinical breast exam (CBE) for average-risk screening; it encourages knowing what is normal and reporting changes.", "2D digital mammography (FFDM) is the standard; DBT (3D) adds thin reconstructed slices that reduce overlap, lowering recalls and finding more cancers.", "Ultrasound is the first test for a lump in women under 30 and in pregnant or lactating patients, and a supplemental screen for dense breasts; MRI is the most sensitive test.", "Dose is described as average (mean) glandular dose because glandular tissue is the radiosensitive tissue; a typical view is about 1-2 mGy and must be no more than 3 mGy for a standard breast phantom.", "A 4-view screening exam gives an effective dose of roughly 0.4 mSv, about 7 weeks of natural background radiation." ], "memory_tip": "ACS = '40 option, 45 yearly, 55 choose'.", "board_traps": [ "Do not mix ACS and ACR ages: ACR says yearly from 40; ACS says yearly is required from 45.", "ACS no longer recommends BSE as a screening method; breast self-awareness is not the same as a formal monthly BSE.", "Combined 2D + DBT ('combo') roughly doubles dose; synthesized 2D from DBT avoids the separate 2D exposure." ], "key_numbers": [ { "label": "ACS yearly start (required)", "value": "45" }, { "label": "ACR yearly start", "value": "40" }, { "label": "ACR risk assessment by", "value": "age 25" }, { "label": "Typical effective dose, 4-view screen", "value": "about 0.4 mSv" }, { "label": "Dose limit, standard phantom", "value": "3.0 mGy per view" } ] }, { "subcategory": "Patient Interactions and Management", "title": "Results, additional imaging and density notification", "must_know": [ "Results reach patients by mail, phone or electronic portal; every patient must get a written lay-language summary even if told results verbally.", "MQSA: the lay summary goes to the patient and the report to the provider within 30 days of the exam.", "For 'Suspicious' or 'Highly Suggestive of Malignancy', the report and the lay summary must go out within 7 calendar days of interpretation (rule in force since September 10, 2024).", "Every lay summary must say whether the breast tissue is dense or not dense, using FDA wording, and advise talking to a provider about density and risk.", "Additional imaging is needed for an incomplete screen (possible finding), to get prior films for comparison, or for a technical problem.", "Most recalls turn out benign or to be overlapping normal tissue; say so to reduce anxiety.", "A diagnostic mammogram is tailored by the radiologist (spot, magnification, extra views, ultrasound) and is often read while the patient waits.", "The interpreting radiologist and the referring provider explain findings and density; facilities must have a way to refer self-referred patients to a provider." ], "memory_tip": "30 days for everyone, 7 days for suspicious.", "board_traps": [ "'Incomplete: Need prior mammograms' needs a follow-up report with a final assessment within 30 days of the first report.", "Density notification is federal now, not only state law." ], "key_numbers": [ { "label": "Lay summary and report, routine", "value": "within 30 days" }, { "label": "Suspicious or highly suggestive", "value": "within 7 calendar days" }, { "label": "Federal density rule enforced", "value": "September 10, 2024" } ] }, { "subcategory": "Patient Interactions and Management", "title": "Epidemiology and risk factors", "must_know": [ "About 1 in 8 US women (roughly 13%) will develop breast cancer; it is the most common non-skin cancer in women and second only to lung cancer in cancer deaths.", "Biggest risk factors: being female and getting older; most women diagnosed have no family history.", "Longer estrogen exposure raises risk: early menarche, late menopause, never giving birth, or first birth after about 30.", "Personal history of breast or ovarian cancer and inherited mutations (BRCA1, BRCA2, also TP53, PTEN, PALB2, CHEK2) raise risk; about 5-10% of breast cancers are hereditary.", "Chest radiation at a young age (for example, mantle radiation for Hodgkin lymphoma) puts a woman in the high-risk group.", "Dense breast tissue both hides cancers (masking) and is itself an independent risk factor.", "Lifestyle and social factors: alcohol, tobacco, postmenopausal obesity, inactivity, and hormone use (combined estrogen-plus-progestin HRT, some birth control, gender-affirming estrogen); limited access to care leads to later-stage diagnosis.", "Men account for about 1% of breast cancers." ], "memory_tip": null, "board_traps": [ "Pregnancy and breastfeeding at a younger age lower risk; nulliparity raises it.", "Dense tissue is a risk factor and a masking factor at the same time." ], "key_numbers": [ { "label": "Lifetime risk, US women", "value": "about 1 in 8" }, { "label": "Hereditary share", "value": "about 5-10%" }, { "label": "Male share of cases", "value": "about 1%" } ] }, { "subcategory": "Patient Interactions and Management", "title": "Signs, symptoms and history documentation", "must_know": [ "Suspicious signs: new hard or fixed lump, skin dimpling or thickening, redness, peau d'orange edema, new nipple retraction, and nipple or areola changes such as scaling.", "Nipple discharge is worrisome when spontaneous, from one breast and one duct, and bloody or clear; milky or green discharge from several ducts in both breasts is usually benign.", "Pain alone is usually benign (often cyclic), but focal, persistent pain is documented and can prompt a diagnostic exam.", "Check the order (physician request) and take a history: symptoms with location and duration, prior surgery or biopsy, implants, hormone use, pregnancy or lactation, personal and family history.", "Mark palpable lumps, scars, moles and skin lesions with radiopaque skin markers following facility convention, and chart their location.", "Document gender-affirming care: transgender women on estrogen develop breast tissue; transgender men may have residual tissue after chest surgery. Use the patient's chosen name and pronouns.", "Get prior mammograms before or at the exam; comparison shows subtle change and cuts down false-positive recalls." ], "memory_tip": null, "board_traps": [ "A tattoo or mole on the skin can look like a lesion; marking it prevents a callback.", "The prior to compare against is ideally 2 or more years old, since slow changes are hard to see against last year's exam." ], "key_numbers": [] }, { "subcategory": "Patient Interactions and Management", "title": "Treatment options: surgery", "must_know": [ "Lumpectomy (breast-conserving surgery) removes the tumor with a clear margin; it is usually followed by radiation therapy.", "Sentinel lymph node biopsy removes the first draining axillary node(s), found with a radiotracer and/or blue dye, to stage the axilla.", "Simple (total) mastectomy removes the whole breast without an axillary dissection.", "Modified radical mastectomy removes the breast plus axillary lymph nodes but leaves the pectoralis major.", "Prophylactic mastectomy removes a healthy breast to lower risk, usually in very high-risk women such as BRCA carriers.", "After lumpectomy, expect a scar, distortion and sometimes fat necrosis or calcifications at the surgical site; mark the scar so it is not mistaken for a new lesion." ], "memory_tip": "Modified radical = breast + nodes; radical (old Halsted) also took the pectoral muscles.", "board_traps": [ "Modified radical keeps the pectoralis major; it is not the same as a radical mastectomy.", "A sentinel node biopsy is not a full axillary dissection." ], "key_numbers": [] }, { "subcategory": "Patient Interactions and Management", "title": "Treatment options: radiation, systemic therapy and reconstruction", "must_know": [ "Radiation therapy after lumpectomy causes skin thickening, edema and increased density that usually lessen over time; the breast may be tender.", "Chemotherapy is a systemic treatment given before (neoadjuvant) or after (adjuvant) surgery.", "Hormone (antiestrogen) therapy treats tumors that are estrogen receptor positive (ER+) and/or progesterone receptor positive (PR+): tamoxifen, or aromatase inhibitors after menopause.", "Anti-HER2 drugs such as trastuzumab target tumors that overexpress HER2/neu.", "Triple-negative tumors (ER-, PR-, HER2-) do not respond to hormone or anti-HER2 drugs and tend to be more aggressive.", "Implant reconstruction uses saline or silicone implants, often placed behind the pectoral muscle; flap reconstruction uses the patient's own tissue." ], "memory_tip": null, "board_traps": [ "Hormone therapy blocks estrogen; it is not hormone replacement therapy (HRT), which raises risk." ], "key_numbers": [] } ] }, { "id": "image-production", "category": "Image Production", "scored_questions": 30, "weight_pct": 26.1, "topics": [ { "subcategory": "Image Acquisition and Quality Assurance", "title": "Mammography unit design: kVp, tube, paddles, grids and geometry", "must_know": [ "Low kVp (about 25-35 kVp for most 2D exams; DBT systems often run higher) maximizes subject contrast between fat, gland and tumor.", "Target/filter pairs: Mo/Mo, Mo/Rh, Rh/Rh, W/Rh, W/Ag; denser or thicker breasts need a harder beam (Rh or W target, Rh or Ag filter). Most current digital and DBT units use tungsten.", "K-edge filters remove low-energy photons that only add dose and high-energy photons that lower contrast; a beryllium window keeps inherent filtration low.", "Focal spots: about 0.3 mm for contact views and 0.1 mm for magnification.", "The cathode is placed at the chest wall so the anode heel effect puts more intensity on thicker posterior tissue.", "Paddles: standard flat, flex or tilting, curved, small spot, magnification, biopsy or localization (fenestrated) and implant paddles; the chest-wall edge must be straight and must not show on the image.", "Moving linear or cellular grids with low ratios (about 4:1 to 5:1) remove scatter on contact views; the grid is removed for magnification, which relies on an air gap.", "SID is fixed at roughly 60-70 cm; magnification raises OID with a mag stand, giving about 1.5-2.0x." ], "memory_tip": "Cathode to chest = thick tissue gets the 'heel' boost.", "board_traps": [ "Raising kVp lowers contrast and dose; it is not the way to fix noise from underexposure in a thin breast.", "Magnification uses the small (0.1 mm) focal spot and no grid; using a grid in mag is a classic wrong answer.", "Magnification raises patient dose and exposure time, so motion is more likely." ], "key_numbers": [ { "label": "Mo characteristic x-rays", "value": "17.5 and 19.6 keV" }, { "label": "Rh characteristic x-rays", "value": "20.2 and 22.7 keV" }, { "label": "Contact focal spot", "value": "about 0.3 mm" }, { "label": "Mag focal spot", "value": "about 0.1 mm" }, { "label": "Grid ratio", "value": "about 4:1 to 5:1" }, { "label": "Magnification factor", "value": "about 1.5-2.0x" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "Digital acquisition: FFDM, DBT, synthesized 2D and receptors", "must_know": [ "FFDM (2D) uses a flat-panel DR detector covering the whole breast; detector size (small and large) is matched to the breast.", "Direct-conversion detectors use amorphous selenium to turn x-rays straight into charge; indirect detectors use a cesium iodide scintillator with amorphous silicon photodiodes.", "DBT (3D) takes many low-dose projections as the tube moves through a limited arc, then reconstructs thin slices (about 1 mm) that reduce tissue overlap.", "Synthesized 2D images are built from the DBT data set and can replace the separate 2D exposure, cutting dose.", "DBT improves cancer detection and lowers recall rates; it is especially good at showing architectural distortion and masses, while calcifications may still be checked on 2D or synthesized images.", "Digital AEC uses the detector itself to set exposure; manual technique is used when AEC can't work properly (full implant views, specimens, very small breasts).", "Underexposure shows as quantum noise (mottle); overexposure raises dose with little visible change, so exposure indicators and AEC must be watched." ], "memory_tip": null, "board_traps": [ "In digital, a dark or light image is not proof of a technique error; noise is the sign of underexposure.", "DBT is not CT: it uses a limited arc, not a full rotation." ], "key_numbers": [] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "Display, informatics, PACS and CAD", "must_know": [ "The acquisition workstation monitor is for checking positioning and technique; final interpretation uses FDA-cleared high-resolution (typically 5 MP) radiologist workstation monitors.", "Monitors are calibrated to the DICOM grayscale display function and checked with test patterns such as AAPM TG18-QC or SMPTE.", "HIS and RIS handle scheduling, demographics and orders; the modality worklist fills patient data to prevent ID errors; the EMR holds the patient chart and results.", "PACS stores, retrieves and archives images; it needs backup and disaster recovery, and FFDM and DBT images must be kept in their original digital form.", "Troubleshooting: if images fail to arrive, check the network or DICOM send queue and demographic mismatches before re-imaging; never repeat an exposure just because of a transfer error.", "CAD marks suspicious calcifications and masses for a second look; the radiologist reads first and decides, CAD does not make the diagnosis.", "Reading rooms keep low ambient light to protect monitor contrast; the 2018 ACR DM QC Manual recommends about 20-45 lux." ], "memory_tip": null, "board_traps": [ "Acquisition monitors are not used for primary interpretation.", "CAD is a second reader, not a replacement for the radiologist." ], "key_numbers": [ { "label": "Interpretation monitor", "value": "typically 5 MP, FDA cleared" }, { "label": "Reading room ambient light (ACR rec.)", "value": "about 20-45 lux" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "MQSA, accreditation, certification and personnel", "must_know": [ "MQSA (1992, enforced by FDA) requires every mammography facility to be accredited by an FDA-approved accreditation body (ACR or a few states) and certified by FDA or a state certifying agency.", "Accreditation and the MQSA certificate run on a 3-year cycle; every facility also gets an annual MQSA inspection.", "A new facility gets a provisional certificate valid up to 6 months to collect clinical images for accreditation, with one possible 90-day extension.", "Technologist initial: state license or ARRT (or ARCRT) radiography certification, plus 40 contact hours of mammography training including 25 exams under direct supervision.", "Technologists need 8 hours of training in each new mammographic modality (for example DBT) before using it on their own.", "Technologist continuing: 15 CEUs in mammography every 36 months and 200 mammograms every 24 months.", "Lapsed experience: perform 25 exams under direct supervision; lapsed CE: earn enough CEUs to reach 15 in the last 36 months. Passing ARRT(M) counts as the CE requirement for 36 months.", "Interpreting physicians: 960 exams per 24 months and 15 CME per 36 months; medical physicists: 15 CE per 36 months plus surveys of at least 2 facilities and 6 units per 24 months." ], "memory_tip": "Tech 40/25/8 to start; 15 in 36 and 200 in 24 to stay.", "board_traps": [ "The FDA certifies; the ACR accredits. They are different steps.", "Requalifying for experience is 25 supervised exams, not another 40 hours.", "200 exams/24 months is for technologists; 960/24 months is for radiologists." ], "key_numbers": [ { "label": "Tech initial training", "value": "40 contact hours, 25 supervised exams" }, { "label": "New modality training", "value": "8 hours" }, { "label": "Tech CE", "value": "15 CEUs / 36 months" }, { "label": "Tech experience", "value": "200 exams / 24 months" }, { "label": "Requalify experience", "value": "25 supervised exams" }, { "label": "Radiologist experience", "value": "960 exams / 24 months" }, { "label": "Provisional certificate", "value": "6 months (+ one 90-day extension)" }, { "label": "Accreditation cycle", "value": "3 years" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "MQSA records, reporting, outcomes audit, policies, EQUIP and density reporting", "must_know": [ "Report assessment categories: Negative, Benign, Probably Benign, Suspicious, Highly Suggestive of Malignancy, Known Biopsy-Proven Malignancy, Post-Procedure Mammogram for Marker Placement, plus 'Incomplete: Need additional imaging evaluation' or 'Incomplete: Need prior mammograms for comparison'.", "The provider report must include the overall assessment, one of four breast density categories, the interpreting physician's name, facility name and location, and recommendations.", "Keep original mammograms and reports at least 5 years, or at least 10 years if the patient has no more mammograms at the facility, or longer if state law says so.", "On request, copies of images and reports must be sent to the patient, provider or another facility within 15 calendar days.", "The medical outcomes audit is done at least yearly: follow up every positive (suspicious or highly suggestive) exam, correlate pathology, and calculate PPV, cancer detection rate and recall rate.", "Required written policies include infection control (clean equipment that touches the patient between patients) and a consumer complaint system; serious unresolved complaints go to the accreditation body.", "EQUIP asks inspectors to confirm: corrective action for poor-quality clinical images, regular review of image quality for each active technologist and interpreting physician, and lead interpreting physician oversight of QC.", "Density: report one of four BI-RADS-based categories; heterogeneously dense and extremely dense count as 'dense' in the patient's lay summary." ], "memory_tip": "Records 5/10: 5 years minimum, 10 if she never comes back.", "board_traps": [ "The lead interpreting physician, not the QC technologist, is ultimately responsible for the QC program and EQUIP.", "Recall rate is the percent of screening exams called back ('Incomplete: need additional imaging'), not the percent that turn out to be cancer." ], "key_numbers": [ { "label": "Record retention", "value": "5 years, or 10 years if no later mammograms at the facility" }, { "label": "Copy transfer on request", "value": "15 calendar days" }, { "label": "Outcomes audit", "value": "at least every 12 months" }, { "label": "Required audit metrics", "value": "PPV, cancer detection rate, recall rate" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "Technologist QC tests (2018 ACR Digital Mammography QC Manual)", "must_know": [ "ACR DM phantom image quality: weekly (and after service); passing scores are fibers 2.0 or more, speck groups 3.0 or more, masses 2.0 or more, with no clinically significant artifacts. Failures are fixed before clinical use.", "Use the same technique each week (AEC mode, paddle, compression, target/filter, kVp) so changes can be traced.", "Compression thickness indicator: monthly; displayed thickness must be within plus or minus 0.5 cm of actual; fix within 30 days.", "Visual checklist: monthly; critical failures (locks, cracked paddle or face shield, cracked breast support, no cleaning solution, DBT motion) are fixed before clinical use, others within 30 days.", "Acquisition and radiologist workstation monitor QC: monthly; monitors must be clean and the test pattern's 0-5% and 95-100% contrast boxes visible with line pairs seen in the center and corners.", "Facility QC review: quarterly, with the QC technologist, lead interpreting physician and manager reviewing QC records and corrective actions.", "Compression force: semiannual; power-drive force must be 25-45 lb (111-200 N), and at least 25 lb must be reached and held in manual mode.", "Repeat analysis is optional and done as needed (needs at least 250 patients): ideal 2% or less, 5% acceptable if the radiologist and physicist agree; investigate a change of more than 2%. Manufacturer detector calibration follows the vendor's schedule." ], "memory_tip": "Phantom '2-3-2' every week; thickness and monitors monthly; review quarterly; force twice a year.", "board_traps": [ "Phantom passing scores for the ACR DM phantom are 2 fibers, 3 speck groups, 2 masses, not the old film phantom's 4-3-3.", "Compression force is checked every 6 months, not monthly.", "A very low repeat rate is not automatically good; it can mean poor images are being accepted." ], "key_numbers": [ { "label": "Phantom image quality", "value": "weekly; fibers >=2.0, specks >=3.0, masses >=2.0" }, { "label": "Compression thickness indicator", "value": "monthly; +/-0.5 cm" }, { "label": "Visual checklist", "value": "monthly" }, { "label": "Workstation monitor QC", "value": "monthly" }, { "label": "Facility QC review", "value": "quarterly" }, { "label": "Compression force", "value": "semiannual; 25-45 lb (111-200 N)" }, { "label": "Repeat rate target", "value": "<=2% ideal, 5% acceptable" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "Medical physicist tests", "must_know": [ "A Mammography Equipment Evaluation (MEE) is done before a new unit, or a unit with a major repair such as a new tube or detector, is used on patients.", "Annual survey of each unit (14 months between surveys is acceptable), plus a yearly review of the technologist QC program.", "Resolution tests include spatial resolution and MTF; criteria are at least 4 lp/mm for 2D contact, 6 lp/mm for 2D magnification and 2 lp/mm for DBT.", "Low-contrast performance is measured by SNR and CNR; AEC performance checks that SNR stays consistent across breast thicknesses.", "Average glandular dose for one CC view of the ACR DM phantom must not exceed 3.0 mGy in 2D or DBT; higher dose must be fixed before clinical use.", "kVp must be accurate within 5% and reproducible (coefficient of variation 0.02 or less); HVL confirms beam quality.", "Collimation: the x-ray field must reach the chest-wall edge of the receptor and not extend past the receptor by more than 2% of SID; the paddle's chest-wall edge must not show on the image or extend past the receptor by more than 1% of SID.", "The physicist also checks artifacts, phantom image quality, compression, paddle alignment, room illuminance and both workstation monitors." ], "memory_tip": null, "board_traps": [ "Technologists need detailed knowledge of their own tests but only the purpose and frequency of physicist tests.", "The 3.0 mGy limit applies to each view separately, not the combined 2D + DBT combo exposure." ], "key_numbers": [ { "label": "Annual survey interval", "value": "yearly, up to 14 months" }, { "label": "AGD limit, CC view of ACR DM phantom", "value": "3.0 mGy" }, { "label": "kVp accuracy", "value": "+/-5%; COV <=0.02" }, { "label": "Spatial resolution", "value": "2D >=4 lp/mm; mag >=6 lp/mm; DBT >=2 lp/mm" }, { "label": "Collimation", "value": "<=2% SID beyond receptor; paddle <=1% SID" } ] }, { "subcategory": "Image Acquisition and Quality Assurance", "title": "Technique factors, labeling and image evaluation", "must_know": [ "kVp controls contrast and penetration; mAs controls the number of photons and therefore noise; AEC sets mAs (and often kVp and target/filter) from breast thickness and density.", "Firm compression is the most important technique factor: thinner breast means lower dose and less scatter, motion, blur and overlap.", "Required image ID: patient name plus a second identifier, exam date, view and laterality placed near the axilla, facility name and location, technologist ID, and unit ID if the facility has more than one unit.", "Use ACR view labels, for example RCC, LMLO, XCCL, CV, AT, TAN, RL/RM, ID, with M for magnification and S for spot compression.", "EQUIP/ACR image quality attributes: positioning, compression, exposure, contrast, sharpness, noise, artifacts and exam ID.", "Motion blurs calcification edges and fine structures; fix with firmer compression, a shorter exposure, and asking the patient to hold still and hold her breath.", "Patient-related artifacts: skin folds, hair, deodorant, jewelry, clothing, chin, nose or shoulder in the field, and implanted devices (port, pacemaker, loop recorder).", "Equipment artifacts include detector dead pixels or lines, grid lines, ghosting, and dust or cracks on the paddle; run the phantom and call service if they persist." ], "memory_tip": null, "board_traps": [ "The laterality and view marker goes near the axilla, not the nipple or inferior edge.", "Noise is from too few photons (low mAs), not from too much compression." ], "key_numbers": [] } ] }, { "id": "procedures", "category": "Procedures", "scored_questions": 65, "weight_pct": 56.5, "topics": [ { "subcategory": "Anatomy, Physiology, and Pathology", "title": "Localization terminology and external anatomy", "must_know": [ "Clock positions are read as if facing the patient: upper outer quadrant runs 9-12 o'clock on the right and 12-3 o'clock on the left. Also note depth (anterior, middle, posterior third) and distance from the nipple.", "Quadrants: upper outer, upper inner, lower outer, lower inner, plus subareolar and axillary tail regions; the upper outer quadrant has the most tissue and the most cancers.", "Triangulation finds a lesion's true location from its position on two or three views (CC, MLO, 90-degree lateral).", "The breast runs from about the 2nd to 6th rib and from the sternum to the midaxillary line; the inframammary fold (IMF) is its lower border.", "Medial and superior borders are fixed; lateral and inferior borders are mobile. Move mobile tissue toward fixed tissue when positioning.", "The areola has Montgomery glands (large sebaceous glands that lubricate the nipple), which open onto the surface as Morgagni tubercles.", "Skin has sebaceous glands, sweat glands and hair follicles; skin calcifications form in these and are benign.", "The axillary tail (tail of Spence) reaches up toward the axilla; the pectoral muscle normally appears at an angle of about 30-60 degrees on the MLO." ], "memory_tip": "Upper outer: 10 on the right, 2 on the left (mirror images).", "board_traps": [ "Clock positions are mirror images: right 10 o'clock and left 2 o'clock are both upper outer.", "Montgomery glands are the glands; Morgagni tubercles are the bumps on the areola where they open." ], "key_numbers": [ { "label": "Right UOQ clock range", "value": "9-12 o'clock" }, { "label": "Left UOQ clock range", "value": "12-3 o'clock" } ] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "Internal anatomy, physiology and cytology", "must_know": [ "The gland sits in the superficial fascia; the retroglandular (retromammary) fat space lies between the deep fascia and the pectoralis major fascia and should be seen on good images.", "About 15-20 lobes each drain through a lactiferous duct to the nipple; the TDLU (extralobular terminal duct plus the lobule's intralobular terminal duct and acini) is where most cancers start.", "Cooper ligaments are fibrous supports; a tumor pulling on them causes skin dimpling or retraction.", "Fibroglandular tissue looks dense (white); fat is lucent. With age and menopause, glandular tissue is replaced by fat; pregnancy, lactation and HRT increase density.", "Blood supply comes mainly from the internal mammary (thoracic) artery and the lateral thoracic artery.", "Most lymph (about 75%) drains to the axillary nodes; medial tissue also drains to internal mammary nodes. Normal intramammary nodes are small, kidney-shaped, with a fatty hilum, usually in the upper outer breast.", "Ducts and lobules are lined by an inner layer of epithelial cells and an outer layer of contractile myoepithelial cells resting on a basement membrane.", "Cancer that stays inside the basement membrane is in situ; once it breaks through, it is invasive." ], "memory_tip": "TDLU = 'the danger lives up here' - origin of most cancers.", "board_traps": [ "The retromammary space is fat, not muscle.", "Myoepithelial cells are contractile (milk ejection); epithelial cells line the lumen and give rise to most carcinomas." ], "key_numbers": [ { "label": "Lobes per breast", "value": "about 15-20" }, { "label": "Lymph to axilla", "value": "about 75%" } ] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "BI-RADS lexicon: masses, asymmetries and architectural distortion", "must_know": [ "A mass is 3-dimensional and seen on two views with convex outer borders; shape is oval, round or irregular.", "Margins: circumscribed, obscured, microlobulated, indistinct, spiculated; spiculated and indistinct are the most suspicious.", "Density relative to gland: high, equal, low or fat-containing; fat-containing masses (lipoma, oil cyst, hamartoma, lymph node) are almost always benign.", "Asymmetry: seen on one view only, usually overlapping normal tissue (summation).", "Global asymmetry covers a large part of a breast and is usually a normal variant; focal asymmetry is seen on two views but lacks the borders of a mass.", "A developing asymmetry is new, larger or more visible than before and needs work-up.", "Architectural distortion: lines radiating from a point or a retracted edge with no visible mass; causes include cancer (often lobular), radial scar and post-surgical scar.", "Associated features include skin or nipple retraction, skin or trabecular thickening, and axillary adenopathy." ], "memory_tip": null, "board_traps": [ "An asymmetry seen on only one view is not called a mass.", "Architectural distortion with no surgery history is suspicious even without a mass, and DBT shows it best." ], "key_numbers": [] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "Calcifications", "must_know": [ "Typically benign: skin, vascular (tram-track), coarse or popcorn (degenerating fibroadenoma), large rodlike (secretory), round, rim/eggshell, dystrophic, milk of calcium and suture calcifications.", "Milk of calcium settles in cysts: smudgy and round on CC, crescent or 'teacup' shaped on the 90-degree lateral.", "Suspicious morphology: amorphous, coarse heterogeneous, fine pleomorphic, and fine linear or fine-linear branching (highest suspicion).", "Distribution: diffuse and regional usually benign; grouped needs looking at; linear and segmental follow a duct and are suspicious.", "Magnification views are used to judge shape, number and distribution of calcifications.", "Calcifications from DCIS are often the only sign of the cancer." ], "memory_tip": "Teacup on the lateral = milk of calcium = benign.", "board_traps": [ "Milk of calcium needs a 90-degree lateral (horizontal beam) to show the layering; an MLO won't show it as well.", "Deodorant and skin calcs can mimic suspicious calcs; tangential views prove a skin location." ], "key_numbers": [] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "BI-RADS assessment and density categories and recommendations", "must_know": [ "0: incomplete, needs additional imaging or prior films; 1: negative; 2: benign; routine screening for 1 and 2.", "3: probably benign, 2% or less chance of cancer; short-interval follow-up, usually 6 months.", "4: suspicious, biopsy recommended; 4A low (more than 2% to 10%), 4B moderate (more than 10% to 50%), 4C high (more than 50% to under 95%).", "5: highly suggestive of malignancy, 95% or more; biopsy. 6: known biopsy-proven cancer awaiting treatment.", "Density categories: a almost entirely fatty; b scattered areas of fibroglandular density; c heterogeneously dense, may hide small masses; d extremely dense, lowers sensitivity.", "Categories c and d are 'dense' for patient notification and may prompt supplemental screening (ultrasound or MRI) depending on risk.", "Recommendations in the report tell the provider the next step: routine screening, diagnostic work-up, short-interval follow-up, biopsy or surgical consult." ], "memory_tip": "3 = 'wait and see' (6 months); 4 and 5 = needle; 6 = already proven.", "board_traps": [ "Category 0 is used for screening recalls; it is not a final assessment.", "Category 6 is for an already proven cancer, not a new suspicious finding." ], "key_numbers": [ { "label": "BI-RADS 3 malignancy chance", "value": "<=2%" }, { "label": "BI-RADS 4A", "value": ">2% to <=10%" }, { "label": "BI-RADS 4B", "value": ">10% to <=50%" }, { "label": "BI-RADS 4C", "value": ">50% to <95%" }, { "label": "BI-RADS 5", "value": ">=95%" } ] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "Benign pathology", "must_know": [ "Cyst: round or oval circumscribed mass, common in women about 35-50; ultrasound shows an anechoic mass with posterior enhancement. Galactocele: milk-filled cyst in lactation, may show a fat-fluid level on a horizontal-beam lateral.", "Fibroadenoma: most common benign solid tumor in young women; oval and circumscribed, may develop coarse popcorn calcifications as it degenerates.", "Lipoma: encapsulated lucent fat. Hamartoma (fibroadenolipoma): 'breast within a breast', mixed fat and gland inside a thin capsule.", "Intraductal papilloma: usually subareolar, a common cause of bloody or clear single-duct nipple discharge; galactography (ductography) can show it.", "Duct ectasia: dilated subareolar ducts with large rodlike secretory calcifications, more common after menopause.", "Hematoma and seroma: fluid or blood at a trauma, biopsy or surgery site that resolves over time. Abscess: painful, red, often during lactation (mastitis).", "Fat necrosis after trauma or surgery forms oil cysts with rim (eggshell) calcifications but can also mimic cancer.", "Normal lymph node: reniform with fatty hilum. Gynecomastia: benign male tissue growth, a flame-shaped density behind the nipple. Edema: diffuse skin and trabecular thickening from heart failure, radiation, or lymphatic blockage." ], "memory_tip": null, "board_traps": [ "Fibroadenoma is the most common benign solid mass in young women; cyst is the most common mass overall in the 35-50 range.", "Fat necrosis can look spiculated and malignant; history of trauma or surgery is the clue.", "Unilateral edema and skin thickening without infection must make you think of inflammatory carcinoma." ], "key_numbers": [] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "High-risk lesions with upgrade potential", "must_know": [ "LCIS: usually invisible on mammograms and found incidentally; a marker of increased risk in both breasts rather than a direct precursor.", "ADH (atypical ductal hyperplasia): often shows as calcifications; usually excised because surgery can find DCIS or invasive cancer.", "ALH (atypical lobular hyperplasia): like LCIS, raises future risk in both breasts.", "Papilloma with atypia and flat epithelial atypia (FEA, usually seen as amorphous calcifications) carry a risk of upgrade and are often excised.", "Radial scar (complex sclerosing lesion): spiculated architectural distortion with a lucent center that mimics cancer; usually excised.", "Phyllodes tumor: fast-growing large circumscribed mass, usually in women in their 40s-50s; looks like a fibroadenoma but can be benign, borderline or malignant, so it is widely excised." ], "memory_tip": "Radial scar = 'black star' (lucent center), cancer usually has a dense center.", "board_traps": [ "LCIS is not DCIS: it is a risk marker and usually has no mammographic finding.", "Phyllodes and fibroadenoma look alike; rapid growth and size favor phyllodes." ], "key_numbers": [] }, { "subcategory": "Anatomy, Physiology, and Pathology", "title": "Malignant pathology", "must_know": [ "DCIS: cancer confined to the duct inside the basement membrane; most often shows as fine pleomorphic or fine linear branching calcifications in a linear or segmental pattern.", "Invasive ductal carcinoma (no special type): the most common breast cancer (about 70-80%); typically an irregular, spiculated, high-density mass, sometimes with calcifications.", "Invasive lobular carcinoma: about 10%; grows in single-file lines and is subtle, often architectural distortion or asymmetry seen on only one view, and more often multifocal or bilateral.", "Inflammatory carcinoma: rapid redness, warmth, peau d'orange and skin thickening from tumor in dermal lymphatics; often no discrete mass. Mastitis that doesn't respond to antibiotics must be checked.", "Paget disease of the nipple: eczema-like scaling or crusting of the nipple with an underlying DCIS or invasive cancer.", "Sarcoma (for example angiosarcoma after radiation) is rare; lymphoma presents as circumscribed masses and enlarged nodes.", "Metastases to the breast (from melanoma, lung, ovarian and others) usually look like multiple round circumscribed masses." ], "memory_tip": null, "board_traps": [ "Lobular cancer is the one that hides: subtle, often seen on only one view.", "Inflammatory carcinoma is a clinical diagnosis (skin changes), not 'just mastitis'." ], "key_numbers": [ { "label": "IDC share", "value": "about 70-80%" }, { "label": "ILC share", "value": "about 10%" } ] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Craniocaudal (CC) view", "must_know": [ "Lift the mobile inferior breast to the highest natural point of the IMF, then set the receptor height there so posterior tissue is included.", "Pull the breast forward onto the receptor; turn the patient's head away and keep her shoulder relaxed and down.", "Show all medial tissue (fixed border) and as much lateral tissue as possible; the nipple should be in profile and ideally near midline.", "Posterior nipple line (PNL) on the CC should be within 1 cm of the PNL measured on the MLO.", "The pectoral muscle is seen on some, but not most, CC views; the retroglandular fat should show.", "Avoid skin folds, the opposite breast, and chin or other body parts in the field." ], "memory_tip": "CC PNL within 1 cm of MLO PNL.", "board_traps": [ "Setting the receptor too high or too low cuts off posterior tissue; lift the IMF first.", "Rolling the body to get lateral tissue without pulling medial tissue in loses medial tissue." ], "key_numbers": [ { "label": "CC vs MLO PNL difference", "value": "within 1 cm" } ] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Mediolateral oblique (MLO) view", "must_know": [ "Angle the receptor parallel to the pectoral muscle, usually 30-60 degrees: steeper for tall, thin patients and flatter for short, broad patients.", "The MLO shows the most breast tissue of any single view, including the upper outer quadrant and axillary tail.", "Pull breast and pectoral muscle forward, lift 'up and out', and compress so the breast doesn't droop.", "Pectoral muscle should reach the level of the nipple (PNL) or lower, with a convex or straight anterior border.", "The IMF should be open and visible, the nipple in profile, and the retroglandular fat shown with no skin folds.", "Measure the PNL from the nipple to the pectoral muscle (or the image edge if the muscle doesn't reach)." ], "memory_tip": "Pec down to the nipple, fold open at the bottom.", "board_traps": [ "A concave pectoral margin means the patient is tense or the angle is wrong.", "Using one fixed angle for every patient fails; match the patient's pectoral muscle." ], "key_numbers": [ { "label": "Usual receptor angle", "value": "30-60 degrees" } ] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "True laterals, triangulation and supplemental views", "must_know": [ "ML (tube on the medial side, receptor lateral) suits lateral lesions; LM (tube lateral, receptor medial) suits medial lesions, because the side nearest the receptor is sharpest with least magnification.", "Triangulation: compared with the MLO, on a 90-degree lateral a medial lesion moves up and a lateral lesion moves down.", "The 90-degree lateral also shows layering milk of calcium and checks clip or wire depth after procedures.", "XCCL (exaggerated CC lateral) shows outer and posterior lateral tissue; XCCM shows medial tissue.", "Cleavage view (CV): both breasts on the receptor to image far posteromedial tissue; manual technique may be needed if the AEC area falls in the gap.", "Axillary tail (AT) view images the tail of Spence when a finding is high in the axillary region." ], "memory_tip": "'Muffins rise, lead sinks': medial (M) lesions rise and lateral (L) lesions sink on the 90-degree lateral versus the MLO.", "board_traps": [ "XCCL is for lateral tissue; XCCM is for medial tissue - don't flip them.", "Pick LM for a medial lesion and ML for a lateral lesion (lesion side to the receptor)." ], "key_numbers": [] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Problem-solving views: spot, magnification, tangential, rolled and others", "must_know": [ "Spot compression uses a small paddle on a focal area to spread tissue; it separates overlap (summation) from a true lesion.", "Magnification (mag stand, 0.1 mm focal spot, no grid) shows the shape and margins of calcifications and masses; it raises dose and exposure time.", "Tangential (TAN) view puts a palpable lump or a suspected skin calcification in profile at the skin surface.", "Rolled views (RL, RM on CC; RS, RI on MLO or lateral) shift tissue layers; the label tells which way the top of the breast was rolled, so you can tell where a lesion sits.", "Nipple-in-profile view is added when the nipple is not in profile on either standard view.", "Anterior compression: a separate image compressing only the anterior breast, useful for large breasts where the front isn't well compressed.", "Other ACR views: LMO (reverse oblique), SIO (superolateral to inferomedial oblique) and FB (from below)." ], "memory_tip": null, "board_traps": [ "A finding that disappears on spot compression is usually summation of normal tissue.", "Rolled view labels name the direction the superior (top) tissue was rolled." ], "key_numbers": [] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Breast augmentation and implants", "must_know": [ "Screening with implants is usually 8 images: a standard CC and MLO with the implant in the field, plus implant-displaced CC and MLO of each breast.", "Implant displaced (Eklund) technique: push the implant back against the chest wall and pull breast tissue forward, then compress only the tissue in front.", "Full-implant views use light compression and usually manual technique, because AEC over the implant can over- or under-expose.", "Implants behind the pectoral muscle (subpectoral) displace more easily than those in front (subglandular); capsular contracture can make displacement impossible, so add a 90-degree lateral.", "Silicone or other free injections make the breast very dense and hard to evaluate; ultrasound or MRI helps.", "MRI without contrast is the best test for silicone implant rupture." ], "memory_tip": "Implants = 4 views per breast (2 with, 2 displaced).", "board_traps": [ "Don't use full routine compression on the non-displaced implant view.", "Label displaced views with ID (for example RCC ID)." ], "key_numbers": [ { "label": "Typical bilateral implant screen", "value": "8 images" } ] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Patient variance and special situations", "must_know": [ "Large breasts: use mosaic or tiling (several images per view) to include all tissue; small breasts and males: smaller paddle or detector and tissue pulled well forward.", "Kyphosis, protruding abdomen, and chest wall deformities (pectus excavatum or carinatum): adjust height and angle, have the patient lean, or use views such as LMO or SIO.", "Implanted devices (pacemaker, port, loop recorder): position to exclude or move around the device when possible, compress gently, and note the device.", "Irradiated or post-surgical breast: may be smaller, firmer and tender; adjust compression, mark scars and image the surgical site as the radiologist requests.", "Reduction mammoplasty: expect periareolar and vertical scars, swirled tissue, possible fat necrosis and calcifications, and a higher nipple.", "Lactating breast: have the patient nurse or pump just before imaging to lower density and discomfort.", "Male patients: most findings are gynecomastia; cancer is usually eccentric to the nipple; standard CC and MLO are adapted with smaller paddles.", "Wheelchair or limited mobility: images can be done seated; show as much tissue as possible and document limits." ], "memory_tip": null, "board_traps": [ "The lactating patient should empty the breast before the exam, not after.", "Pacemaker sites are not a reason to skip the exam; you still image the breast and work around the device." ], "key_numbers": [] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Screening vs. diagnostic exams, ultrasound and breast MRI", "must_know": [ "Screening: asymptomatic patient, standard CC and MLO of each breast (2D and/or DBT), read later.", "Diagnostic: symptoms, abnormal screen, short-interval follow-up or personal history; views are chosen by the radiologist and often read during the visit.", "Ultrasound: first test for a palpable lump under 30 or in pregnancy or lactation; tells cystic from solid; supplemental screening in dense breasts; guides biopsy.", "Breast MRI: most sensitive test; uses IV gadolinium with the patient prone in a breast coil; used for high-risk screening, extent of known cancer, and problem solving.", "For premenopausal patients, MRI is ideally scheduled in the second week of the cycle (about days 7-14) to reduce background enhancement.", "MRI requires full MRI safety screening for implants, devices and kidney function as required by facility protocol." ], "memory_tip": null, "board_traps": [ "Ultrasound, not mammography, is first-line for a lump in a woman under 30.", "Implant rupture MRI does not need contrast; cancer MRI does." ], "key_numbers": [] }, { "subcategory": "Mammographic Positioning and Procedures", "title": "Interventional procedures and specimen handling", "must_know": [ "Preparation: history of anticoagulants (aspirin, warfarin, clopidogrel and others) and allergies (lidocaine, latex), signed informed consent, and a time-out to confirm patient, side, site and procedure.", "Stereotactic biopsy (prone table or upright add-on) targets calcifications and mammographic-only findings; depth is calculated from a pair of images taken at plus and minus 15 degrees.", "Vacuum-assisted devices (about 7-11 gauge) are typical for stereotactic biopsy; ultrasound-guided core biopsy (often 14 gauge) is used for findings seen on ultrasound.", "Specimen radiography of stereotactic cores confirms the calcifications were retrieved; surgical specimen radiographs confirm the lesion, wire and clip were removed.", "A marker clip is placed at the biopsy site; post-procedure CC and 90-degree lateral views check its position, since releasing compression can shift it along the needle path (accordion effect).", "Needle (wire) localization before surgery uses a fenestrated paddle with the needle placed parallel to the chest wall by the shortest route; an orthogonal view confirms position. Seed or reflector localizers are alternatives.", "Post-procedure care: pressure and ice, avoid heavy lifting for about 24 hours, watch for bleeding or infection, and know how results will be given.", "Biohazards: specimens go in labeled containers with fixative, sharps go in puncture-resistant containers, and blood or body fluid is handled with standard precautions and cleaned with an approved disinfectant." ], "memory_tip": "Stereo = two looks, +15 and -15, to find depth.", "board_traps": [ "The stereo pair is plus and minus 15 degrees (30 degrees apart), not plus and minus 30.", "Post-clip imaging uses CC and a 90-degree lateral, not an MLO, to judge depth.", "Informed consent is signed before any sedating medication is given." ], "key_numbers": [ { "label": "Stereo pair angles", "value": "+/-15 degrees" }, { "label": "Post-clip views", "value": "CC and 90-degree lateral" } ] } ] } ], "last_minute_review": [ "No deodorant or powder: metallic particles mimic calcifications.", "ACS: option at 40, yearly 45-54, every 1-2 years from 55; ACR: yearly from 40, risk assessment by 25.", "ACS does not recommend BSE or CBE for average-risk screening.", "MQSA lay summary in 30 days; Suspicious or Highly Suggestive in 7 calendar days; every summary states dense or not dense.", "BI-RADS density c (heterogeneously dense) and d (extremely dense) count as dense.", "BI-RADS 3 is 2% or less malignant with 6-month follow-up; 5 is 95% or more; 6 is proven cancer.", "MQSA tech: 40 hours + 25 supervised exams to start; 8 hours per new modality; 15 CEUs/36 months; 200 exams/24 months; requalify with 25 supervised exams.", "Records: 5 years, or 10 years if no later mammograms at that facility; copies sent within 15 calendar days.", "Outcomes audit yearly with PPV, cancer detection rate and recall rate.", "EQUIP: corrective action for poor images, ongoing image review per tech and radiologist, lead interpreting physician QC oversight.", "ACR DM phantom weekly: fibers 2.0, speck groups 3.0, masses 2.0, no significant artifacts; fix before patients.", "Compression thickness indicator monthly, within 0.5 cm.", "Visual checklist and workstation monitor QC monthly; facility QC review quarterly.", "Compression force semiannual: 25-45 lb (111-200 N) in power mode.", "Repeat rate: 2% or less ideal, 5% acceptable; investigate a change over 2%.", "AGD for one CC of the ACR DM phantom: no more than 3.0 mGy.", "Mag: 0.1 mm focal spot, no grid, air gap, more dose.", "Cathode toward the chest wall for the heel effect.", "MLO: receptor parallel to pectoral muscle, pec to nipple level, IMF open; CC PNL within 1 cm of MLO PNL.", "Move mobile lateral and inferior tissue toward fixed medial and superior borders.", "90-degree lateral vs MLO: medial lesions rise, lateral lesions sink.", "LM for medial lesions, ML for lateral lesions; XCCL lateral, XCCM medial.", "Implants: 8 images with Eklund displaced views; manual technique and light compression on full-implant views.", "Milk of calcium layers as a teacup on the 90-degree lateral.", "Most cancers start in the TDLU; most common site is the upper outer quadrant; IDC is the most common type.", "Lobular cancer is subtle, often distortion seen on one view; inflammatory cancer shows skin thickening and peau d'orange.", "Radial scar mimics cancer with a lucent center; LCIS is a risk marker, usually invisible.", "Stereotactic biopsy uses plus and minus 15-degree images; clip checked on CC and 90-degree lateral.", "Ultrasound first for a lump under age 30 or in pregnancy or lactation.", "Lactating patients nurse or pump right before the exam." ] }