Oral Boards Simplified

How to take a case

Breast density

Finding

BIRADS (0 or 2)

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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”

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“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