mammo guide to the boards
DESCRIPTION
MammoGuide.com presents an overview of breast imaging for the ABR oral board exam.TRANSCRIPT
Oral Boards Simplified
How to take a case
Breast density
Finding
BIRADS (0 or 2)
----------------------------------------------
Workup
Specific findings
Final Impression and BIRADS (2 or 4)
Systematic approach to every breast case
Systematic approach to every breast case
Breast density
Fatty
Scattered
Extremely dense
Hetereogenously dense
Systematic approach to every breast case
Breast density
Finding
Mass
Asymmetry / Focal asymmetry
Calcifications
Architectural distortion
Systematic approach to every breast case
Breast density
Finding
BIRADS (0 or 2) ---------------------------------------------------------
Breast density
Finding
BIRADS (0 or 2)
----------------------------------------------
Workup
Systematic approach to every breast case
Additional views / modalities
Breast density
Finding
BIRADS (0 or 2)
----------------------------------------------
Workup
Specific findings
Systematic approach to every breast case
Breast density
Finding
BIRADS (0 or 2)
----------------------------------------------
Workup
Specific findings
Final Impression and BIRADS (2 or 4)
Systematic approach to every breast case
What to say
“The breasts are heterogenously dense”
“There is a focal asymmetry in the superior and central right breast”
“This is a BIRADS 0, additional evaluation is required”
------------------------------------------------------------------------------------------------
“I would do a lateral view, spot compression and an ultrasound”
“The focal asymmetry persists on the lateral and spot
views. Ultrasound demonstrates an irregular hypoechoic mass with posterior acoustic shadowing”
“This is a suspicious mass. BIRADS 4, biopsy is recommended.”
Final BIRADS at Boards
Avoid BIRADS 3
All cases will be BIRADS 2 Benign or
BIRADS 4 Suspicious
Workups
1
2
3
4
5
Aunt Minnies
1
2
3
4
5
Special
1
2
3
4
5
15 Must-Know Cases
Case 1
Case 1: Solid mass
1. Specific diagnosis is not important 2. How to workup the finding is the key 3. Be consistent – Suspicious descriptors BIRADS 4 Benign descriptors BIRADS 2
Mass Workup
Lateral
Spot Mag
Ultrasound
Mass descriptors - Mammo
Shape (round, oval, lobular, irregular)
Margins (well-circumscribed, microlobulated, partially obscured, indistinct, spiculated)
Density (high density, isodense, low density, fat-containing)
Mass descriptors - US Shape (oval, round, irregular)
Echogenicity (anechoic, hyperechoic, complex/mixed, hypoechoic, isoechoic)
Margins (well-circumscribed, indistinct, angular, microlobulated, spiculated)
Orientation (wider than tall, taller than wide)
Posterior features (shadowing, increased thru transmission, none)
For the boards: We biopsy all new solid
masses
Case 2
You can use the mouse as a magnifying glass
during the exam
Case 2: Suspicious calcifications
Calcifications
Lateral
Mags in CC / 90
(Full or spot)
Case 3
Case 3: Suspicious focal asymmetry
Focal asymmetry /
Architectural distortion
Lateral
Spot Compression
+/- Ultrasound
Same workup for architectural distortion as for focal asymmetry
Case 4
Rolled views
Case 4: Suspicious asymmetry
Boards cases will not be this
subtle
Asymmetry
Only on CC
Rolled CC’s
Spot compression
Only on MLO
Lateral
Spot compression
Case 5
Case 5: Suspicious palpable mass
Always look
for a BB on
the skin =
palpable
Palpable Workup
Put BB on skin
Lateral
Spot in tangent
Ultrasound
* Any patient < 30 years old, start with ultrasound *
Workups Mass
Calcs
Focal asym/arch dist
Asymmetry
Palpable
Aunt Minnies Special
15 Must-Know Cases
Case 6
Case 6: Skin Calcifications BIRADS 2
How to do a skin localization
Remove from compression. Take image with BB in tangent to prove
calcs are in the skin
Keep patient in compression.
Place BB on skin directly over the calcs & image.
Place alpha-numeric grid
over calcifications &
image.
Milk of Calcium
Hyalinized fibroadenoma
Skin calcifications
Secretory calcifications
Other Benign Calcifications
Case 7
Case 7: Breast Hamartoma BIRADS 2
Lipoma Hamartoma Oil cyst
Fat containing breast masses = BIRADS 2
Case 8
Case 8: Bilateral intracapsular & left extracapsular implant rupture
Linguine or keyhole sign = Intracapsular rupture Free silicone = Extracapsular rupture
Intracapsular Extracapsular
Intracapsular Extracapsular Stepladder sign Snowstorm sign
Case 9
Case 9: Fat Necrosis BIRADS 2
Fat Necrosis = oil cysts or coarse dystrophic calcs
Case 10
Case 10: Sternalis muscle BIRADS 2
Workups Mass
Calcs
Focal asym/arch dist
Asymmetry
Palpable
Aunt Minnies Benign calcs
Fat containing
Implant rupture
Sternalis
Fat necrosis
Special
15 Must-Know Cases
Case 11
Case 11: Complex cyst BIRADS 4
Simple Complicated Complex
BIRADS 2 BIRADS 3 BIRADS 4
Case 12
Case 12: Unilateral axillary adenopathy
Bilateral DDx Unilateral DDx Lymphoma Rheumatoid/Autoimmune Granulomatous/Sarcoid Systemic processes
Mets – breast 1⁰ Mets – non-breast 1⁰ Infection
Case 13
Case 13: Multiple round masses BIRADS 2
Multiple round masses = BIRADS 2 Must be:
Bilateral
At least 3 masses
Nonpalpable
No new or suspicious findings
Case 14
Case 14: Suspicious left breast mass w/ pec invasion + axillary nodes
Mass NMLE
Main MRI finding will be obvious Look for secondary findings - multifocal disease - contralateral disease - axillary or IM adenopathy - pectoralis or skin involvement
Mass Shape
(round, oval, lobulated, irregular)
Margins (smooth, irregular, spiculated)
Enhancement (homo, hetero, rim, internal septations)
NMLE Distribution
(focal, linear, ductal, segmental, regional, diffuse)
Enhancement Pattern (homo, hetero, stippled, clumped)
Case 15
Case 15: Male IDC
Gynecomastia Male IDC
Signs of Male IDC: - Eccentric mass - Skin thickening - Skin retraction
Workups Mass
Calcs
Focal asym/arch dist
Asymmetry
Palpable
Aunt Minnies Benign calcs
Fat containing
Implant rupture
Sternalis
Fat necrosis
Special Cysts
Axillary adenopathy
Mult round masses
MRI
Male breast
15 Must-Know Cases
Your Name Here
American Board of Radiology