Breast

Question 1

A 50-year-old female colleague asks you for information and advice regarding breast screening.
Which of the following statements regarding breast screening in the UK is correct? [B1 Q27]

A. She will not be eligible for screening until she is 55.
B. Screening occurs every 2 years.
C. Compression is not required for screening mammography.
D. There is a 70% reduction in mortality from breast cancer among screened women.
E. Two lives are saved for every over-diagnosed case.

Answer 1

Two lives are saved for every over-diagnosed case.

Over-diagnosis is defined as the diagnosis of cancer because of screening that would not have
been diagnosed in the woman’s lifetime had screening not taken place. Approximately 5.7–
8.8 breast cancer deaths are prevented per 1000 women screened for 20 years starting at age
50 compared with 2.3–4.3 over-diagnosed cases per 1000 women screened for 20 years. The
WHO International Agency for Research on Cancer determined that there is a 35% reduction
in mortality from breast cancer among screened women aged 50–69.

The NHS Breast Screening Programme provides screening every 3 years for women between the ages of 50 and 70. After the age of 70, women are still screened, although they are not automatically called for. Expansion is planned to cover women from 47 to 73. A two-view (cranio-caudal and mediolateral oblique) mammogram is taken, performed with breast compression, which can be uncomfortable for the patient.

Question 2

The current NHS Breast Screening Programme was set up in 1988 because of the Forest Report.
Which one of the following statements regarding the current screening programme is correct?
[B2 Q58]

a. Screening is only available to women aged 50–70 years
b. Women are invited to attend at two-yearly intervals
c. It detects 15 cancers per 1000 women screened
d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS)
e. Breast cancer screening has not been shown to reduce mortality from breast cancer

Answer 2

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

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

Question 3

A female has a cancer detected at the prevalent round of the NHS Breast Screening Programme.
Which of the following ages is she most likely to be? [B4 Q74]

a. 45 years
b. 50 years
c. 55 years
d. 60 years
e. 65 years

Answer 3

50 years

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

Question 4

A well-circumscribed, round, 15 mm mass is identified in the breast on first-round screening
mammography. It has no associated calcification. From the following, choose the most
appropriate management: [B4 Q87]

a. repeat mammography at the normal screening interval
b. repeat mammography in 6 months
c. MRI of the breast
d. wide local excision of the lesion
e. ultrasound examination of the mass

Answer 4

Ultrasound examination of the mass

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

Question 5

At a breast cancer multidisciplinary team meeting, the case of a 60-year-old female patient is
discussed. Following clinical examination, she is thought to have multifocal breast cancer, but
this is not supported by the ultrasound and mammography findings. Which of the following is
the most appropriate next investigation? [B4 Q92]

a. repeat ultrasound scan
b. repeat mammography with additional views
c. MRI
d. CT
e. 18 FDG PET

Answer 5

MRI

Multifocal/multicentric cancer in the breast may alter treatment choice and when clinically
suspected should be investigated with MRI. MRI can also be used to assess the extent of
residual disease in the breast after breast conservation surgery in cases where the surgical
resection margins are positive. An acceptable series of sequences for breast MRI would be:
4mm slice-thickness, transverse, spin echo T2W images of both breasts; 4-mm-thick, sagittal,
spin echo T2W images of the affected breast; 4-mm-thick, sagittal, dynamic contrast-
enhanced T1W gradient echo with fat saturation of the affected breast; and a delayed post-
contrast sequence with the same parameters.

Question 6

A 41-year-old woman presents with a lump in her right breast. Mammography shows a 16 mm
mass with smooth well-defined margins. Ultrasound shows a hypoechoic solid lesion with
internal echoes. What is the correct management for this lesion? [B5 Q39]

(a) No further management
(b) 6-month follow-up mammogram
(c) Core biopsy or FNAC
(d) 12-month follow-up mammogram
(e) Mastectomy

Answer 6

Core biopsy or FNAC

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

Question 7

A 24-year-old woman presents to the symptomatic breast clinic with a palpable left-sided
breast lesion. There is no family history of breast cancer. Clinical examination reveals a smooth,
relatively mobile 2-cm lesion within the left upper quadrant. Ultrasound depicts a well-defined
oval hypoechoic lesion with an echogenic capsule following the tissue planes. No malignant
features are present. The patient states that she has a phobia of needles. What should be the
next step in this patient’s management? [B1 Q32]

A. Reassurance and discharge with advice.
B. Correlation with mammography.
C. Ultrasound guided core biopsy.
D. Ultrasound guided FNA.
E. Referral for MRI

Answer 7

Reassurance and discharge with advice.

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

Question 8

Which of the following ultrasound features of a breast mass are more suggestive
of a malignant than a benign pathology? [B2 Q48]

a. Acoustic shadowing
b. Anechoic contents
c. Hyperechoic pseudocapsule
d. Lack of internal blood flow on colour Doppler
e. Hyper vascular surrounding tissues

Answer 8

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

Question 9

Screening mammogram of a 60-year-old woman shows a well-circumscribed soft tissue
density in the left breast. No calcifications are identified. Ultrasound demonstrates a
homogenous, avascular, hypoechoic lesion with well-defined margins and posterior acoustic
enhancement. No internal echoes are seen. What is the most likely diagnosis? [B5 Q37]

(a) Fibroadenoma
(b) Simple cyst
(c) Carcinoma
(d) Fibroadenosis
(e) Traumatic fat necrosis

Answer 9

Simple cyst

These sonographic features are diagnostic of a simple cyst.

Question 10

A 56-year-old asymptomatic woman undergoes routine screening mammography. Which of
the following forms of calcification raises greatest suspicion of ductal carcinoma in situ (DCIS)?
[B1 Q9]

A. Egg-shell.
B. Sedimented.
C. Tubular.
D. Dot-dash.
E. Coarse

Answer 10

Dot-dash.

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

Question 11

A 60-year-old woman presents with a palpable lump in her right breast. Her recent screening
mammogram 6 months previously was negative. Clinical examination reveals a subtle mass in
the right lower quadrant. Which of the following mammographic findings is the most common
in invasive lobular carcinoma (ILC)? [B1 Q43]

A. Spiculated mass.
B. Architectural distortion.
C. Microcalcification.
D. Nipple retraction.
E. Skin thickening.

Answer 11

Architectural distortion.

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

Question 12

A routine screening mammogram of a 54-year-old woman shows numerous scattered
calcifications. Which of the following statements is true regarding breast calcifications? [B2
Q46]

a. Parallel lines of calcification are usually venous in origin
b. Malignant calcifications are usually >1mm in size
c. Less than 5% of microcalcifications in asymptomatic patients are associated with cancers
d. Dermal calcifications are usually central in location
e. Popcorn calcification is seen in fibroadenoma

Answer 12

Popcorn calcification is seen in fibroadenoma

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

Question 13

Which of the following is least likely to suggest a malignant lesion in the breast? [B3 Q38]

A. Thin halo
B. Ill-defined margin
C. Spiculated morphology
D. Inhomogeneity
E. Focal ductal dilation

Answer 13

Thin halo

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

Question 14

Calcification is seen on a screening mammogram. Which of the following patterns is the most
likely to be associated with a carcinoma? [B4 Q64]

a. tortuous tramline calcification
b. thick, linear, rod-like calcifications, some with a lucent centre
c. eggshell, curvilinear calcification
d. popcorn calcification
e. a cluster of 10 calcific particles, all less than 0.5 mm

Answer 14

A cluster of 10 calcific particles, all less than 0.5 mm

Microcalcifications are those less than 0.5mm. When there are more than five in a tissue
volume of 1cm 3 , particularly if segmentally distributed, 30% will be malignant. Other features
also suggesting malignancy are a mixture of sizes and shapes of the calcific foci, associated
soft-tissue opacity and progression on serial mammography.

Question 15

A 60-year-old woman had a screening mammogram which shows a densely calcified lesion in
the right breast. The lesion is smoothly marginated and has soft tissue density with dense coarse
‘popcorn’ calcification. What is the most likely diagnosis? [B5 Q26]

(a) Breast carcinoma
(b) Ductal carcinoma in situ
(c) Fibroadenoma
(d) Fibroadenosis
(e) Fat necrosis

Answer 15

Fibroadenoma

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

Question 16

A 38-year-old woman with a history seat belt injury in a road traffic accident 1 year ago,
presents with a right breast lump. Mammography shows a ‘hollow’ spherical abnormality
measuring about 4 cm with a rim of thin curvilinear area of calcification in the right breast.
What is the most likely diagnosis? [B5 Q40]

(a) Vascular calcification
(b) Fat necrosis
(c) Secretory calcifications in ducts
(d) Milk of calcium
(e) Ductal carcinoma in situ

Answer 16

Fat necrosis

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

Question 17

A previously well 70-year-old woman is investigated via CTPA for acute left-sided chest pain
and hypoxia. The test is negative for PE, but an incidental 1.7 × 1.2 cm retro-areolar lesion is
noted in the right breast by the reporting registrar. Which of the following features, if any,
would be suggestive of breast malignancy? [B1 Q13]
A. Ill-defined margin.
B. Spiculated margin.
C. Calcification.
D. Multiple lesions.
E. CT is not reliably predictive of breast malignancy

Answer 17

Spiculated margin.

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

Question 18

A 32-year-old asymptomatic woman who is BRCA1 positive undergoes breast cancer
surveillance via MRI. A lesion within the left breast is identified. Which of the following MRI
features is the most predictive for malignancy? [B1 Q22]

A. Irregular margin.
B. T2WI signal hyperintensity.
C. Progressive enhancement curve on dynamic T1WI post contrast.
D. Plateau enhancement curve on dynamic T1WI post contrast.
E. Washout enhancement curve on dynamic T1WI post contrast.

Answer 18

Irregular margin.

A woman over the age of 30 years who is a BRCA1 or BRCA2 carrier should be offered MRI annually for breast cancer surveillance. The description of the margin of the mass is the most predictive feature of the breast MR image interpretation. Irregular or spiculated margins have a positive predictive value of 84–91% of malignancy on MRI.

T2W signal hyperintensity is suggestive of benign pathology, but not in the setting of an irregular or spiculated mass. There is overlap in enhancement kinetics between benign and malignant disease, and thus reliance on kinetic assessment alone is not recommended.

Enhancement Kinetics:
Progressive enhancement (type I) : Benign pathology.
Plateau (type II) and washout (type III) curves: Malignant disease.

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

Question 19

On breast MRI, which of the following features of a breast mass is more suggestive of a
malignant lesion than a benign lesion? [B2 Q60]

a. Low-signal internal septations
b. Lobulated mass which shows no enhancement
c. Rim-like enhancement of the mass
d. A focal area of hypointense T2 signal adjacent to the mass
e. Stippled enhancement

Answer 19

Rim-like enhancement of the mass

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

Question 20

A 60-year-old male with a history of prostate cancer is referred to the symptomatic breast clinic
complaining of a palpable breast lump which has been present for several months. Clinical
examination reveals a palpable firm mass towards the left subareolar region. A nodular, fan-shaped subareolar lesion is seen on mammography. The mass is hypoechoic on ultrasound and surrounded by normal fatty tissue. Hypervascular flow within the mass is noted on Doppler ultrasound. Which of the following is the most likely diagnosis? [B1 Q4]

A. Invasive ductal carcinoma.
B. Lipoma.
C. Gynaecomastia.
D. Lymphoma.
E. Dermatofibrosarcoma.

Answer 20

Gynaecomastia.

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

Question 21

A 78-year-old man presents with a palpable, non-tender, left breast lump. Mammography demonstrates a well-defined, high-density, lobulated mass in the retro areolar region. Ultrasound appearances are of a hypoechoic mass with an eccentric position relative to the nipple. The ipsilateral axilla appears unremarkable. What is the most likely diagnosis? [B4 Q5]

a. invasive ductal carcinoma
b. lipoma
c. breast abscess
d. gynaecomastia
e. lymphoma

Answer 21

Invasive ductal carcinoma

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

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

Male breast cancers are usually invasive ductal carcinomas, which typically appear as a discrete, high-density, well-defined mass with lobulated or spiculated margins at mammography. Microcalcification is seen less commonly than in females, but secondary signs, such as nipple retraction and skin thickening, occur earlier than in females due to smaller breast size. Ultrasound scan is particularly helpful in assessing the relationship of the mass to the nipple. An eccentric position is highly suspicious for breast cancer. Axillary lymphadenopathy is seen in approximately 50% of patients.

Question 22

A 28-year-old primiparous woman has been breastfeeding for the past 3 months. She is
admitted surgically complaining of warmth and pain in her right breast associated with
swinging fever. A 3 × 2 cm inhomogeneous, hypoechoic abscess within the right lower inner
quadrant is identified on ultrasound. How should this patient be managed? [B1 Q48]

A. 6 weeks’ antibiotic therapy followed by repeat ultrasound.
B. Ultrasound guided needle aspiration.
C. Ultrasound guided catheter drainage.
D. Surgical incision and drainage.
E. Analgesia and advice to stop breastfeeding

Answer 22

Ultrasound guided needle aspiration.

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

Question 23

Which of the following unusual benign breast tumours is most likely to be locally infiltrating,
aggressive, and proliferative, and consist of only well-differentiated fibroblasts? [B4 Q68]
a. neurofibroma
b. granular cell tumour
c. fibromatosis
d. lipoma
e. areolar leiomyoma

Answer 23

Fibromatosis

In 80% of cases of fibromatosis of the breast, there is b-catenin or adenomatous polyposis
coli gene mutation. Granular cell tumour is most commonly found in the upper inner quadrant
corresponding to the supraclavicular nerve territory and is thought to be of Schwann cell
origin. Neurofibromas of von Recklinghausen’s disease are associated in an autosomal
dominant fashion with a gene on chromosome 17

Question 24

A 35-year-old woman with a strong family history of breast cancer presents with a breast lump.
Ultrasound shows a hypoechoic lesion with internal echoes. Gadolinium-enhanced contrast
imaging demonstrates a 2 cm, non-enhancing, oval lesion in the right breast. What is the most
likely diagnosis? [B5 Q38]

(a) Fat necrosis
(b) Fibroadenoma
(c) Cyst
(d) Carcinoma
(e) Radial scar

Answer 24

Cyst

Other lesions are known to show contrast enhancement.

Question 25

A 49-year-old woman presents with a rapidly enlarging left-sided breast mass. A large, firm, non-tender discrete mass is noted on clinical examination with overlying skin ulceration. Mammography reveals a 7-cm multilobulated soft tissue density mass in the left upper quadrant. On ultrasound the mass is solid with cystic areas. Posterior acoustic enhancement is demonstrated. What is the most likely diagnosis? [B1 Q37] A. Adenoid cystic carcinoma. B. Fibromatosis. C. Granular cell tumour. D. Phyllodes tumour. E. Melanoma metastasis

Answer 25

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

Question 26

A 60-year-old woman presents with a palpable lump in her right breast. Her recent screening mammogram 6 months previously was negative. Clinical examination reveals a subtle mass in the right lower quadrant. Which of the following mammographic findings is the most common in invasive lobular carcinoma (ILC)? [B1 Q43] A. Spiculated mass. B. Architectural distortion. C. Microcalcification. D. Nipple retraction. E. Skin thickening.

Answer 26

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

Question 27

A 62-year-old woman with Paget’s disease of the nipple is also found to have a 2 cm spiculate mass in the subarealor region of her right breast suspicious for malignancy. The cancer most associated with Paget’s disease of the nipple is: [B2 Q23] a. Invasive ductal carcinoma b. Invasive lobular carcinoma c. Tubular carcinoma d. Ductal carcinoma in situ e. Medullary carcinoma

Answer 27

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

Question 28

Which of the following is a neoplasm affecting the breast that is least likely to contain bone cartilage or osteoid tissue? [B3 Q35] A. Lymphoma B. Intraductal papillomas with stromal metaplasia C. Phyllodes cystosarcoma D. Stromal sarcomas E. Adenocarcinomas with epithelial metaplasia

Answer 28

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

Question 29

A 50-year-old female with a breast carcinoma that clinically involves the skin is to be staged by CT. Other than those related to the primary tumour, there are no specific symptoms. Which of these CT protocols should be used? [B4 Q45] a. post-contrast brain b. non-contrast brain, neck, chest, abdomen and pelvis c. non-contrast brain, neck and chest, post-contrast abdomen and pelvis d. post-contrast brain, neck, chest, abdomen and pelvis e. post-contrast neck, chest, abdomen, and pelvis

Answer 29

**Post contrast neck, chest, abdomen, and pelvis** AT4 stage primary is described. Lower-stage breast cancers (T1/T2, less than 5cm) are not usually staged by CT, as there is a less than 2% incidence of metastases at the time of diagnosis. Incidence of metastases at diagnosis for higher-stage cancers (T3/T4) is 15–20%. When staged with CT, a suitable protocol would be 100–150ml of iodinated intravenous contrast agent used, with the neck and chest scanned 20–25 seconds after injection, and the abdomen and pelvis scanned 70–80 seconds after injection

Question 30

A 62-year-old woman presents with two small masses in her right breast. These are well circumscribed masses in the upper outer quadrant. They show no calcification, no desmoplastic reaction and are not spiculated. They are thought to represent metastases to the breast. The most likely primary in a woman of this age is: [B1 Q10] a. Ovarian carcinoma b. Renal carcinoma c. Lymphoma d. Melanoma e. Bronchial carcinoma

Answer 30

**Lymphoma** Metastases to the breast are infrequent and can be difficult to distinguish from primary breast cancer. The most common primary source of breast metastasis: **1- Lymphoma - Commonest** **2- Melanoma** **3- Rhabdomyosarcoma** Most patients who are diagnosed with breast metastases already have a diagnosis of a primary tumour, however, in 25% of cases breast metastases are the first manifestation of malignancy.

Question 31

A 48-year-old woman who had bilateral breast augmentation with single lumen silicone gel implants 20 years ago presents with pain in her left breast and distorted breast shape. Which of the following radiological findings on T2WI MRI are in keeping with intracapsular implant rupture? [B4 Q18] A. Thickened T2WI hypointense capsular margin. B. T2WI hyperintense globules surrounding the implant. C. Multiple curvilinear lines of low T2WI signal within the implant. D. Inferior extension of the implant beyond the inframammary fold. E. Marginal low T2WI signal radial folds within the implant

Answer 31

**Multiple curvilinear lines of low T2WI signal within the implant.** **Silicone gel implants are high signal on T2**. Capsular contracture is caused by constriction of the **Low T2 fibrous capsule** that invariably forms to some degree **around the implant as a reaction to the foreign object**. This is seen on MRI as increased thickening of the T2WI hypointense margin surrounding the implant. Rupture of the prosthesis is the most common complication with breast implants, occurring in up to 10–20%, although many are not noticed clinically. With **intracapsular ruptures, the silicone gel is contained by the capsule**. **Curvilinear strands of low T2 signal within the capsule** may be seen, representing the collapsed implant shell. This finding is known as the **‘linguine’ sign**. **T2WI hyperintense globules surrounding the implant** are indicative of an **extracapsular rupture.** Inferior extension beyond the inframammary fold implies implant migration, which is a relatively uncommon occurrence. Marginal T2WI hypointense radial folds within the implant are a normal finding

Question 32

A 45-year-old male presents with severe epigastric pain radiating to the back. Blood tests reveal elevated serum amylase and calcium. A CT scan of abdomen demonstrates peripancreatic inflammatory stranding, renal medullary nephrocalcinosis, and sacro-iliac joint erosions. What further investigation(s) would you recommend? [B1 Q21] A. Serum parathyroid hormone assay and 99m Tc sestamibi scan. B. Serum parathyroid hormone assay and 111 In pentetreotide scan. C. Serum parathyroid hormone assay and meta-iodobenzyl-guanidine (MIBG) scan. D. Serum parathyroid hormone and 99m Tc pertechnetate scan. E. Serum parathyroid hormone assay and 201 Tl scan.

Answer 32

**Serum parathyroid hormone assay and 99m Tc sestamibi scan**. Clinical findings, blood tests, and CT of the abdomen are diagnostic of pancreatitis. The most common causes for pancreatitis are alcohol and choledocholithiasis. Rarely, it may be caused by hyperparathyroidism. The associated findings on CT are suggestive of hyperparathyroidism, therefore further assessment with serum parathyroid hormone assay and 99m Tc sestamibi scintigraphy is indicated. 99m Tc sestamibi washes out more rapidly from the thyroid gland than from hyperfunctioning parathyroid glands and therefore it can be used on its own. MIBG, a noradrenaline analogue, is used in the evaluation of neuroblastomas and paragangliomas. 99m Tc pertechnetate is taken up by the thyroid gland only and is therefore not useful on its own in parathyroid imaging. However, it can be used in combination with 201 Tl, which is taken up by both thyroid and parathyroid. Subtracting the two scintigrams allows parathyroid localization.

Question 34

A 50-year-old male with thyroid swelling undergoes ultrasound of the thyroid that shows a solitary hypoechoic nodule with punctate calcification and increased vascularity. An ultrasound guided fine needle aspiration is carried out and is reported as benign. What would you do next? [B1 Q26] A. Repeat fine needle aspiration. B. Follow-up ultrasound in 6 months. C. No further follow-up. D. Staging CT. E. 99mTc sestamibi scan.

Answer 34

**Repeat fine needle aspiration.** The features suspicious for malignancy on ultrasound are calcification, irregularity, solid lesion, and irregular halo- and hypervascularity. A repeat biopsy should be considered if there is discordance between imaging findings and cytology

Question 35

A 30-year-old male with a thyroid nodule is referred for an ultrasound guided FNA. The FNA cytology reveals medullary thyroid carcinoma, which is treated by total thyroidectomy. The following year he undergoes a CTPA examination, which shows a small nodule in the thyroid region. Which of the following serum markers is useful in assessing recurrence? [B1 Q31] A. CA 19-9. B. Calcitonin. C. CA 125. D. Thyroglobulin. E. Calcium.

Answer 35

**Calcitonin**. Medullary thyroid carcinoma arises from the parafollicular C cells of the thyroid that secrete calcitonin, therefore calcitonin is a useful tumour marker for medullary thyroid carcinoma. CEA is another tumour marker produced by neoplastic C cells. Thyroglobulin is produced by follicular cells and is therefore not useful in medullary carcinomas.

Question 36

A 54-year-old woman is noted to be hypercalcaemic after complaining of lethargy and abdominal pain. Subsequent biochemical testing reveals an elevated parathyroid hormone. She is referred for scintigraphy with 99m Tc sestamibi. Which of the following radiological findings would suggest a diagnosis of parathyroid adenoma? [B1 Q71] A. Focus of decreased radionuclide activity within the lower pole of the right lobe of thyroid on initial and delayed images. B. Focus of decreased radionuclide activity within the lower pole of the right lobe of thyroid on delayed images only. C. Focus of increased radionuclide activity within the lower pole of the right lobe of thyroid on initial and delayed images. D. Focus of increased radionuclide activity within the lower pole of the right lobe of thyroid on initial images only. E. Focus of increased radionuclide activity within the lower pole of the right lobe of thyroid on delayed images only.

Answer 36

**Focus of increased radionuclide activity within the lower pole of the right lobe of thyroid on delayed images only**. Solitary parathyroid adenoma accounts for 85% of cases of primary hyperparathyroidism, with parathyroid hyperplasia (10%), multiple adenomas (4%), and carcinoma (1%) making up the remainder. When 99m Tc MIBI is used for parathyroid imaging, immediate and delayed images of the neck and mediastinum are performed. Parathyroid adenomas may or may not be visualized on initial imaging, but they retain radiopharmaceutical on delayed (1–2 hours) images, whereas the normal thyroid washes out.

Question 37

A patient informs you she has a medical condition prior to pelvic MRI for evaluation of a pelvic malignancy. Which of the following would contraindicate buscopan injection? [B3 Q23] A. Hypertension B. Angina C. CABG 3 years ago D. Myasthenia gravis E. Multiple sclerosis

Answer 37

**Myasthenia gravis** Antimuscarinics are contraindicated in myasthenia gravis (but may be used to decrease the muscarinic side effects of anticholinesterases), paralytic ileus, pyloric stenosis and prostatic enlargement. They should be used with caution in Down’s syndrome, GORD, diarrhoea, ulcerative colitis, acute myocardial infarction, hypertension, conditions characterised by tachycardia (hyperthyroidism, cardiac insufficiency, cardiac surgery), pyrexia, pregnancy and in individuals susceptible to angle closure glaucoma. HBB improves image quality and lesion visualisation in oncologic pelvic MR.

Question 38

A diabetic patient with long-standing mild renal impairment requires an angiogram, and it is decided that iodinated contrast will be used. Which of the following is most likely to prevent the patient from developing contrast-induced nephropathy? [B4 Q94] a. prior administration of acetylcysteine b. thorough hydration of the patient c. oral fluid restriction d. concurrent diuretic administration e. use of high-osmolar contrast medium

Answer 38

**Thorough hydration of the patient** A significant contribution to the evidence base used to guide practice in contrast-induced nephropathy (CIN) comes from the NEPHRIC study group. The trial was a randomized, prospective, double-blind, multicentre study performed in 17 centres in Denmark, France, Germany, Spain and Sweden, and consisted of 129 patients. CIN is acute renal impairment with an absolute increase in serum creatinine of at least 0.5mg/dl (44.2 mmol/l) or a relative increase of at least 25% from baseline. A rise of 1mg/dl is less frequently used as the definition. CIN usually peaks on day 2 or 3 following iodinated contrast injection, with a return to baseline within 2 weeks. Return to baseline is not always seen. Low-osmolar iodinated contrast media have a low rate of CIN in the general population – less than 2%. In patients with increased risk of CIN due to diabetes mellitus or pre-existing renal impairment, this rate rises significantly. It has also been shown that low-osmolar contrast causes less CIN than high- osmolar (order of 1800 mosmol/kg water) contrast in high-risk patient groups. No difference in CIN rate is observed in lowrisk groups when iso-osmolar is compared with low-osmolar contrast agents. The NEPHRIC study group shows that in people with diabetes or those with renal impairment having iliofemoral or coronary angiography there is a reduced rate of CIN when using iso-osmolar iodinated contrast as opposed to low-osmolar contrast medium. Osmotic diuresis causing increased sodium load to the distal nephron, with consequent increased medullary work, possible hypoxia and volume depletion giving rise to activation of vasoregulatory hormone systems, is suggested as the reason for the findings. Vigorous hydration is encouraged as perhaps the most important measure to try to avoid CIN. There is evidence both supporting and rejecting the nephroprotective effect of the free radical scavenger acetylcysteine when given before the iodinated contrast media.

Question 39

A clinical trial of a novel chemotherapy agent for renal cell carcinoma is being undertaken. The response of the primary tumour and nodal and distant metastases will be assessed according to the RECIST criteria. On axial imaging, the long axis of every lesion present on the pre-treatment scan has decreased on the post-treatment CT. However, the patient has progressive disease. Which additional feature from the list below would explain this? [B4 Q97] a. the improvement in the summed long axes of five lesions is not more than 30% b. a new site of disease is identified c. the lesions have not all disappeared d. sustained improvement was not proven by a repeat CTat 4 weeks e. the improvement in the summed products of bidimensional measurements is not more than 50%

Answer 39

**A new site of disease is identified** Two criteria are commonly used for assessing cancer response to treatment: WHO and RECIST. The latter stands for Response Evaluation Criteria in Solid Tumours, and it is this tool that is usually used in treatment trials. The WHO criteria compare a summed area product (longest axial dimension multiplied by the longest axial dimension perpendicular to this). RECIST sums the longest axial dimension and compares this across scans. Complete response for both criteria is disappearance of disease, confirmed at 4 weeks. A partial response according to the WHO is 50% or more reduction in the summed area product following treatment and confirmed at 4 weeks. RECIST requires a 30% or greater decrease in the summed longest diameters, confirmed at 4 weeks. Progressive disease is defined as a 25% increase in summed area product for the WHO criteria and a 20% increase in summed longest diameter according to RECIST. Progressive disease also results from the appearance of any new site of disease. Stable disease reflects changes of magnitude that do not achieve partial response or progressive disease.

Question 40

A plain abdominal radiograph is acquired for left-sided abdominal pain. The lumbar spine is osteoporotic with intervertebral disc space narrowing, vacuum phenomenon and calcification. Marginal osteophytes and endplate sclerosis are also present. In addition to nephrocalcinosis, a radio-opaque calculus is noted along the path of the left ureter. Which of the following is the most likely pattern of inheritance? [B4 Q98] a. autosomal recessive b. autosomal dominant c. autosomal dominant with partial penetrance d. mitochondrial e. X-linked

Answer 40

**Autosomal recessive** Alkaptonuria is the unifying diagnosis and is usually autosomal recessive. In this condition the absence of homogentisic acid oxidase causes accumulation of homogentisic acid, which is excreted in urine and sweat. Ochronotic deposition in the cardiovascular system causes atherosclerosis, aortic and mitral valve calcification, and myocardial infarction.

Question 42

A 12-year-old pre-pubertal girl presents with vaginal bleeding. What is the most likely diagnosis? [B5 Q41] (a) Vaginal foreign body (b) Endometrial hyperplasia (c) Ovarian fibroma (d) Sarcoma (e) Endometrioma

Answer 42

**Vaginal foreign body** This is a very common cause of vaginal bleeding in pre-pubertal girls. Other causes include vaginal rhabdomyosarcoma, precocious puberty, haemangioma and vascular malformation