MAMMOGRAPHY GOALS AND OBJECTIVES

MAMMOGRAPHY GOALS AND OBJECTIVES GOALS: After completion of the mammography rotations, the resident will be able to: 1. Demonstrate learning of the knowledge-based objectives-(practice Base Learning) 2. Accurately and concisely dictate a mammography report-(patient Care 3. Communicate effectively with referring physicians and supervisory staff- Interpersonal Skills) 4. Understand standard patient positioning in mammography-(patient Care) 5. Obtain pertinent patient information relative to radiologic examinations-(patient Care) 6. Demonstrate learning of the clinical indications for obtaining screening mammograms and diagnostic mammograms, and determining when breast ultrasound or MRI are necessary-(system-based Practice) 7. Demonstrate a responsible work ethic-(professionalism) 8. Demonstrate an understanding of ACR and MQSA rules, and regulations for breast imaging.-(medical Knowledge) 9. Become an autonomous consultant and teacher in breast imaging-(practice Based Learning) 10. Correlate pathologic and clinical data with breast imaging studies-(system- Based Practice) 11. Be able to perform common interventional breast procedures (i.e. needle wire localization and ultrasound guided fine needle or cyst aspiration)- (Patient Care) OBJECTIVES: A. KNOWLEDGE-BASED: (Medical Knowledge) 1. Epidemiology Name risk factors and incidence of breast cancer List the breast cancer staging and survival rates 2. Breast Anatomy, Pathology, and Physiology Be able to define or identify: Breast development Normal breast anatomy and histology; alteration with age, pregnancy, menstrual cycle, and hormonal effects Pathologic and mammographic appearance, and clinical significance of benign breast conditions such as adenosis, ductal hyperplasia, fibroadenoma, cysts, papilloma, hamartoma, lipoma, ductal ectasia, radial scar, fat necrosis Atypical ductal hyperplasia (ADH), lobular neoplasia (LCIS), and other histological risk factors Pathologic and mammographic appearance, clinical features, significance, and prognosis of ductal carcinoma in situ (DCIS) 1

Pathologic and mammographic appearance, clinical features, and prognosis of invasive carcinoma including invasive ductal carcinoma not otherwise specified (NOS), mucinous, medullary, papillary, tubular subtypes, and invasive lobular carcinoma Other types of breast cancer, such as Paget s disease and inflammatory carcinoma Histologic grading Pathologic staging Multifocal and multicentric carcinoma Extensive intraductal component (EIC+): definition and significance Margin analysis for surgical specimens containing DCIS 3. Mammographic Interpretation Be able to define or identify: (Medical Knowledge) Normal mammographic anatomy and parenchymal patterns Mammographic features of typically benign calcifications, such as those due to sclerosing adenosis, fibroadenomas, fat necrosis, secretory disease, sebaceous gland calcification, and dystrophic calcification Mammographic features of calcifications of intermediate concern and those having higher probability of malignancy Significance of distribution of calcifications Mammographic features of benign masses and densities such as asymmetric breast tissue, radial scar, hematoma, abscess, cyst, fibroadenoma, intramammary lymph node, hormonal replacement therapy, phyllodes tumor, hamartoma, gynecomastia, lipoma, fat necrosis, edema, ductal ectasia, intracystic papilloma, Mondor s disease Mammographic appearance of malignant masses, densities, and architectural distortion caused by in situ and invasive ductal carcinoma, invasive lobular carcinoma, and metastases to the breast 4. Problem-Solving Mammography Be able to define, identify, or state the significance of: (Medical Knowledge and Patient Care) ACR Practice Standard for the Performance of Diagnostic Mammography Technique, value, and indications for supplementary mammographic views, such as tangential, 90-degree mediolateral (ML), spot compression, exaggerated rotated craniocaudal, cleavage, and blind areas of the breast Criteria and methods for distinguishing focal asymmetric densities, asymmetric breast tissue, and breast masses Technique for evaluation of implants, breast parenchyma, and implant leakage Masses: criteria and methods for assessment by mammography and sonography; likelihood of malignancy Calcifications: criteria for mammographic assessment Magnification mammography: advantages and disadvantages, technique, dose, and indications Localization of lesions seen only on one view; triangulation 2

Criteria for biopsy and follow-up of masses, calcifications, and soft tissue densities Ability to perform breast physical examination Evaluation and management of a palpable mass with no mammographic findings 5. Screening Mammography Be able to define, identify, or state the significance of: (Medical Knowledge and Patient Care) ACR practice standards for screening mammography Knowledge of practical aspects of performance and interpretation of screening mammography Definition of sensitivity, specificity, positive predictive value, negative predictive value, accuracy, interval cancers, false negative rate, false positive rate Relative efficacy of physical examination, breast self-examination, and mammography Screening theory: lead time bias, length bias, selection bias, survival rates, prevalence versus incidence screening, definition of lead time, and interval cancer rate Randomized clinical trials, case control studies, follow-up studies- purpose, methods, results Controversies regarding screening women aged 40-49 years old Radiation risk, biopsy rates, recall rates, cost-effectiveness of screening, value of second reading Screening guidelines of ACR, ACS, and NCI Mammography audit:- Desirable goals for positive predictive value, percent minimal carcinomas, percent node positivity, recall rates, sensitivity and specificity ACR Practice Standards for Screening Mammography 6. Breast Ultrasound Be able to define, identify, or state the significance of: (Medical Knowledge and Patient Care) Equipment and physical principles Technique Need for hands-on experience Indications Normal sonographic anatomy Features of cysts Benign and malignant solid masses: features and reliability in distinguishing Limitations: Detection and differentiation of microcalcifications, screening Need for correlation with mammography Criteria and reliability for evaluation of implant rupture ACR Standards for Breast Ultrasound 7. Breast MRI (Medical Knowledge and Patient Care) 3

Indications Technique Characteristics of benign and malignant breast masses Implant rupture B. TECHNICAL, COMMUNICATION, AND DECISION MAKING SKILLS: 1. Mammographic Equipment and Technique Be able to identify, define, or state the significance of: (Medical Knowledge and Patient Care) Features of mammographic equipment units including target, filtration, automatic exposure control, and grids Equipment requirements for ACR accreditation and Mammography Quality Standards Act (MQSA) inspection Familiarity with ACR recommended specifications for new mammography equipment Characteristics of mammographic film screen systems Positioning technique for craniocaudal and mediolateral oblique (MLO) views Viewbox criteria for assessment of positioning, compression, exposure, contrast, sharpness, and noise Rationale for breast compression Selection of technical factors, including effects of milliampere seconds (Mas), kilovolt peak (kvp), and density settings on image quality Film processing Factors affecting exposure contrast, noise, and sharpness Need for dedicated high-intensity viewboxes, viewbox masking, and magnifying glass Standardized labeling of images 2. Mammographic Quality Control Be able to define, identify, or state the significance of: (Medical Knowledge and Patient Care) Purpose and frequency of performance of those quality control tests performed by technologist including phantom images and processor sensitometry Appearance and causes of artifacts, such as roller marks, grid lines, motion unsharpness, dust, poor screen-film contact, pickoff, and scratches Requirements and standards for ACR mammography accreditation and Food and Drug Administration (FDA) MQSA certification Familiarity with ACR Mammography Quality Control Manual 3. Interventional Procedures Be able to understand the principles, indications, and contraindications, and the equipment, technique, advantages, disadvantages, accuracy, preparation, and follow-up for: (Medical Knowledge, Patient Care and System-Based Practice) Needle-wire localization Stereotactic core biopsy and fine-needle aspiration (FNA 4

Ultrasound guided core biopsy and FNA - importance of correlation of pathologic, mammographic, and sonographic findings, and history in determining patient management Mammographic- and sonographic- guided cyst aspiration Galactography Specimen radiography, including paraffin block radiography Pneumocystography ACR Standard for the Performance of Stereotypically-Guided Breast Interventional Procedures ACR Standard for the Performance of Ultrasound-Guided Percutaneous Breast Interventional Procedures ACR image-guided breast biopsy accreditation program 4. Mammographic Reporting and Medicolegal Aspects of Mammography Be able to define the ACR BI-RADS terms for the following:(medical Knowledge, System- Based Practice and Professionalism) Mass shape, margins, and density Typically benign, intermediate concern, and higher probability of malignancy calcifications Distribution modifiers for calcifications Associated findings Lesion localization Categorization of breast composition Final assessment categories Medicolegal aspects of screening, problem-solving mammography, and interventional procedures 5. Therapeutic Considerations Be able to define, identify, or state the significance of: (Medical Knowledge and System-Based Practice) Role of breast imaging in selection and monitoring of breast cancer treatment and post-treatment follow-up Basic understanding of breast cancer treatment options ACR Standard for Diagnosis and Management of Invasive Breast Carcinoma therapy ACR Standard for Diagnosis and Management of DCIS 6. Patient Management Principles Be able to define, identify, or state the significance of:(patient Care, Professionalism and System-Based Practice) Patient interaction and communications Informed consent for invasive procedures Follow-up procedures for positive findings 5

C. CONFERENCES AND OTHER RECOMMENDATIONS FOR RESIDENCY TRAINING IN BREAST IMAGING: (Patient Care, Medical Knowledge and Practice Based Learning) 1. Formal Conferences (lectures, case presentations) are mandatory. 2. Three full-time equivalent months spent in breast imaging during 4-year residency are mandatory; by the end of their residency training, residents should have interpreted a minimum of 1000 mammographic studies 3. Teaching file availability is mandatory 4. Mammographic-pathologic correlation is mandatory 5. Review of hookwire localization and core needle biopsy cases with a pathologist is desirable 6. Direct observation or video of mammographic positioning for routine and supplementary views is mandatory 7. Performance of needle localization is mandatory 8. Performance of breast ultrasound is mandatory 9. Performance of cyst aspiration is highly desirable 10. Performance of ultrasound guided and stereotactic core biopsy is desirable 11. Direct observation of galactography is desirable 12. Availability of mammography textbooks available in department library is mandatory 13. Reprint file on breast imaging is mandatory 14. Record of procedures performed and mammograms and sonograms interpreted by each resident during breast imaging rotation is desirable 6