2026 ARDMS Breast Exam Prep: BR Specialty
Practice Questions, Answer Rationales, Breast
Ultrasound, Anatomy, Pathology, Imaging Techniques
& Sonography Study Guide
SECTION 1: ANATOMY AND PHYSIOLOGY (Questions 1–18)
1. A sonographer is scanning a lactating patient and observes markedly increased
glandular tissue with prominent ducts. Which of the following best describes the
sonographic appearance of breast parenchyma during lactation?
A) Homogeneous hyperechoic parenchyma with minimal ducts
B) Markedly increased glandular tissue with prominent, dilated ducts and
increased vascularity
C) Homogeneous hypoechoic parenchyma with no visible ducts
D) Atrophic parenchyma with predominantly fatty replacement
Rationale: During lactation, the breast undergoes marked glandular hyperplasia
and ductal dilatation in preparation for milk production. Sonographically, this
appears as increased echogenic glandular tissue with prominent, dilated ducts
(often containing milk) and increased vascularity on Doppler. This is a normal
physiologic change and should not be mistaken for pathology. The Anatomy and
Physiology domain comprises 15% of the BR exam.
2. The suspensory ligaments of the breast that appear as thin, linear echogenic
structures supporting the fat and glandular elements are called:
A) Cooper's ligaments
B) Suspensory ligaments of Astley
C) Lactiferous ligaments
D) Pectoral fascia
Rationale: Cooper's ligaments are thin, linear echogenic structures that support the
breast parenchyma and extend from the skin to the pectoral fascia. On ultrasound,
they appear as thin echogenic lines that may cause acoustic attenuation, which
,should not be mistaken for a lesion. Changing the transducer angle or applying
compression can help differentiate ligament attenuation from a true lesion.
3. A 55-year-old postmenopausal woman undergoes breast ultrasound. The
parenchyma appears predominantly fatty with scattered areas of glandular tissue.
Which of the following best describes this appearance?
A) Homogeneous dense fibroglandular background
B) Homogeneous fat background with minimal glandular tissue
C) Heterogeneous background with marked glandular tissue
D) Complex cystic and solid pattern
Rationale: In postmenopausal women not on hormone therapy, the breast
parenchyma involutes and is replaced by fat. The sonographic appearance is a
homogeneous fat background (dark or echo-poor) with minimal glandular tissue.
The 2025 BI-RADS lexicon categorizes tissue composition as homogeneous fat,
homogeneous fibroglandular, or heterogeneous, with a glandular tissue component
graded as minimal, mild, moderate, or marked.
4. The terminal duct lobular unit (TDLU) is the functional unit of the breast and
the site of origin for most breast pathology. Which of the following is true
regarding the TDLU?
A) It is located in the subcutaneous fat layer
B) It consists of the terminal duct and its associated lobule, and is the site of
origin for most breast carcinomas
C) It is only present during lactation
D) It is located in the retromammary fat
Rationale: The terminal duct lobular unit (TDLU) is the functional unit of the
breast, consisting of the terminal duct and its associated lobule. It is the site of
origin for most benign and malignant breast pathology, including fibrocystic
changes, fibroadenomas, and both ductal and lobular carcinomas. The stroma
surrounding the TDLU appears hypoechoic on ultrasound and is referred to as the
glandular tissue component (GTC).
,5. Which of the following describes the sonographic appearance of the normal
nipple?
A) Hyperechoic structure with posterior acoustic enhancement
B) Echo-poor structure that can cause posterior acoustic shadowing
C) Anechoic structure with no internal echoes
D) Heterogeneous structure with marked vascularity
Rationale: The nipple is an echo-poor (hypoechoic) structure consisting of dense
connective tissue and sub-areolar ducts. It can cause posterior acoustic shadowing,
which may obscure underlying lesions. Applying pressure with the transducer
improves sound transmission and reduces shadowing. Understanding the normal
appearance of the nipple is essential to avoid misinterpretation.
6. A sonographer is scanning the axilla and identifies a lymph node with a thin,
homogeneous, echo-poor cortex and an ovoid, echogenic fatty hilum. This
appearance is most consistent with:
A) A normal axillary lymph node
B) A metastatic lymph node
C) A lymphoma
D) A breast abscess
Rationale: Normal axillary lymph nodes appear as solid, oval structures with a
thin, homogeneous, echo-poor cortex and an ovoid, echogenic fatty hilum. The
presence of a fatty hilum is a reassuring feature. Metastatic lymph nodes typically
show cortical thickening (>3 mm), loss of the fatty hilum, and an abnormal shape
(round rather than oval).
7. The retromammary fat layer is located:
A) Between the skin and subcutaneous fat
B) Posterior to the breast parenchyma and anterior to the pectoral muscle
C) Within the glandular tissue
D) Within the axilla
Rationale: The retromammary fat layer is located posterior to the breast
parenchyma and anterior to the pectoral muscle. It appears as a hypoechoic (dark)
, layer on ultrasound. The retromammary space is an important landmark for
assessing posterior margins of breast lesions and for planning biopsy approaches.
8. Which of the following describes the normal sonographic appearance of the
pectoral muscle?
A) Hyperechoic structure with posterior acoustic shadowing
B) Echo-poor structure of varying thickness with thin lines of supporting
stroma coursing along the long axis
C) Anechoic structure with no internal echoes
D) Heterogeneous structure with marked vascularity
Rationale: The pectoral muscle (anterior to the ribs) appears as an echo-poor
(hypoechoic) structure of varying thickness. It contains thin lines of supporting
stroma that course along the long axis of the muscle. Understanding the normal
appearance of the pectoral muscle is important for determining the depth and
posterior extent of breast lesions.
9. The skin layer of the breast appears on ultrasound as:
A) A thin, hypoechoic line
B) Two hyperechoic lines separated by a hypoechoic line representing the
dermis and epidermis
C) A single hyperechoic band
D) An anechoic layer
Rationale: The skin appears as two hyperechoic (bright) lines separated by a
hypoechoic (darker) line representing the dermis and epidermis. Normal skin
thickness is approximately 2 mm. The skin is the most superficial layer and should
be evaluated for any thickening, dimpling, or disruption, which may indicate
underlying pathology.
10. Which of the following is the correct sequence of breast tissue layers from
superficial to deep?
A) Skin, retromammary fat, subcutaneous fat, breast parenchyma, pectoral muscle
B) Skin, subcutaneous fat, breast parenchyma, retromammary fat, pectoral
Practice Questions, Answer Rationales, Breast
Ultrasound, Anatomy, Pathology, Imaging Techniques
& Sonography Study Guide
SECTION 1: ANATOMY AND PHYSIOLOGY (Questions 1–18)
1. A sonographer is scanning a lactating patient and observes markedly increased
glandular tissue with prominent ducts. Which of the following best describes the
sonographic appearance of breast parenchyma during lactation?
A) Homogeneous hyperechoic parenchyma with minimal ducts
B) Markedly increased glandular tissue with prominent, dilated ducts and
increased vascularity
C) Homogeneous hypoechoic parenchyma with no visible ducts
D) Atrophic parenchyma with predominantly fatty replacement
Rationale: During lactation, the breast undergoes marked glandular hyperplasia
and ductal dilatation in preparation for milk production. Sonographically, this
appears as increased echogenic glandular tissue with prominent, dilated ducts
(often containing milk) and increased vascularity on Doppler. This is a normal
physiologic change and should not be mistaken for pathology. The Anatomy and
Physiology domain comprises 15% of the BR exam.
2. The suspensory ligaments of the breast that appear as thin, linear echogenic
structures supporting the fat and glandular elements are called:
A) Cooper's ligaments
B) Suspensory ligaments of Astley
C) Lactiferous ligaments
D) Pectoral fascia
Rationale: Cooper's ligaments are thin, linear echogenic structures that support the
breast parenchyma and extend from the skin to the pectoral fascia. On ultrasound,
they appear as thin echogenic lines that may cause acoustic attenuation, which
,should not be mistaken for a lesion. Changing the transducer angle or applying
compression can help differentiate ligament attenuation from a true lesion.
3. A 55-year-old postmenopausal woman undergoes breast ultrasound. The
parenchyma appears predominantly fatty with scattered areas of glandular tissue.
Which of the following best describes this appearance?
A) Homogeneous dense fibroglandular background
B) Homogeneous fat background with minimal glandular tissue
C) Heterogeneous background with marked glandular tissue
D) Complex cystic and solid pattern
Rationale: In postmenopausal women not on hormone therapy, the breast
parenchyma involutes and is replaced by fat. The sonographic appearance is a
homogeneous fat background (dark or echo-poor) with minimal glandular tissue.
The 2025 BI-RADS lexicon categorizes tissue composition as homogeneous fat,
homogeneous fibroglandular, or heterogeneous, with a glandular tissue component
graded as minimal, mild, moderate, or marked.
4. The terminal duct lobular unit (TDLU) is the functional unit of the breast and
the site of origin for most breast pathology. Which of the following is true
regarding the TDLU?
A) It is located in the subcutaneous fat layer
B) It consists of the terminal duct and its associated lobule, and is the site of
origin for most breast carcinomas
C) It is only present during lactation
D) It is located in the retromammary fat
Rationale: The terminal duct lobular unit (TDLU) is the functional unit of the
breast, consisting of the terminal duct and its associated lobule. It is the site of
origin for most benign and malignant breast pathology, including fibrocystic
changes, fibroadenomas, and both ductal and lobular carcinomas. The stroma
surrounding the TDLU appears hypoechoic on ultrasound and is referred to as the
glandular tissue component (GTC).
,5. Which of the following describes the sonographic appearance of the normal
nipple?
A) Hyperechoic structure with posterior acoustic enhancement
B) Echo-poor structure that can cause posterior acoustic shadowing
C) Anechoic structure with no internal echoes
D) Heterogeneous structure with marked vascularity
Rationale: The nipple is an echo-poor (hypoechoic) structure consisting of dense
connective tissue and sub-areolar ducts. It can cause posterior acoustic shadowing,
which may obscure underlying lesions. Applying pressure with the transducer
improves sound transmission and reduces shadowing. Understanding the normal
appearance of the nipple is essential to avoid misinterpretation.
6. A sonographer is scanning the axilla and identifies a lymph node with a thin,
homogeneous, echo-poor cortex and an ovoid, echogenic fatty hilum. This
appearance is most consistent with:
A) A normal axillary lymph node
B) A metastatic lymph node
C) A lymphoma
D) A breast abscess
Rationale: Normal axillary lymph nodes appear as solid, oval structures with a
thin, homogeneous, echo-poor cortex and an ovoid, echogenic fatty hilum. The
presence of a fatty hilum is a reassuring feature. Metastatic lymph nodes typically
show cortical thickening (>3 mm), loss of the fatty hilum, and an abnormal shape
(round rather than oval).
7. The retromammary fat layer is located:
A) Between the skin and subcutaneous fat
B) Posterior to the breast parenchyma and anterior to the pectoral muscle
C) Within the glandular tissue
D) Within the axilla
Rationale: The retromammary fat layer is located posterior to the breast
parenchyma and anterior to the pectoral muscle. It appears as a hypoechoic (dark)
, layer on ultrasound. The retromammary space is an important landmark for
assessing posterior margins of breast lesions and for planning biopsy approaches.
8. Which of the following describes the normal sonographic appearance of the
pectoral muscle?
A) Hyperechoic structure with posterior acoustic shadowing
B) Echo-poor structure of varying thickness with thin lines of supporting
stroma coursing along the long axis
C) Anechoic structure with no internal echoes
D) Heterogeneous structure with marked vascularity
Rationale: The pectoral muscle (anterior to the ribs) appears as an echo-poor
(hypoechoic) structure of varying thickness. It contains thin lines of supporting
stroma that course along the long axis of the muscle. Understanding the normal
appearance of the pectoral muscle is important for determining the depth and
posterior extent of breast lesions.
9. The skin layer of the breast appears on ultrasound as:
A) A thin, hypoechoic line
B) Two hyperechoic lines separated by a hypoechoic line representing the
dermis and epidermis
C) A single hyperechoic band
D) An anechoic layer
Rationale: The skin appears as two hyperechoic (bright) lines separated by a
hypoechoic (darker) line representing the dermis and epidermis. Normal skin
thickness is approximately 2 mm. The skin is the most superficial layer and should
be evaluated for any thickening, dimpling, or disruption, which may indicate
underlying pathology.
10. Which of the following is the correct sequence of breast tissue layers from
superficial to deep?
A) Skin, retromammary fat, subcutaneous fat, breast parenchyma, pectoral muscle
B) Skin, subcutaneous fat, breast parenchyma, retromammary fat, pectoral
