MAMMOGRAPHY

Presenter: Sarose bhandari

Mammography is the radiological study of soft tissue of breast. Specific type of imaging that uses a low dose x-ray system to examine breasts. Breast cancer is the leading cause of cancer deaths in women which occurs mainly between 35-55 years of age. Our chief aim is to discover cancer in the earliest stage. The importance of mammography is directly related to detection and management of cancer of the breast.

The breast is a conical structure with base at chest wall and apex at nipple, located between the deep and superficial layers of the superficial fascia.
It lies over the pectoralis major and serratus anterior muscles extending from 2nd 3rd rib to 6th-7th rib.
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The breast is made up of 1620 lobes which are divided into many lobules. The lobe contains glandular elements called acini, draining ducts, connective tissue and interlobular stroma.

The ducts of each acinus join to form the lactiferous duct that drains the lobe.
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In 1913, a German Physician named Soloman reported the radiographic appearance of breast cancer. By mid 1950s mammography was refined to the point of being a reliable clinical tool.

Refinements include low KV, X-ray tubes, Mo targets and high detail, industrial grade x-ray film.
High speed x-ray film with faster resolution was first introduced by Du-Pont in 1970. Improved Film Screen combinations were developed by Kodak and Du Pont in 1975.
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Direct Exposure film Mammography.

Xero Mammography.
Thermography.

Breast sonography.
Digital mammography. MR mammography PET scanning.
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MR guided breast biopsy. Stereotactic guided breast

biopsy.

Ultrasound guided breast

biopsy.
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Late 1st child. Null parity Common among spinsters. Family history of Ca breast. Age at menarche <12 years. Smoking. Obesity. Age at menopause- whether natural or induced. Hypertension. Metastasis from Ca cervix. May be due to hormonal replacement therapy & unnecessary mammographs.

In our department: Unit name - Mammorax (TOSHIBA) Model name- MGU-100D Output rating- 3.5 kW Max. kVp 39 & Min. kVp 22 Max. mAs 600 & Min. mAs 2 Anode- Molybdenum ( 9700 rpm) Target angle- 10 degree (small) & 16 degree (large) Focal spot size- 0.1mm (small) & 0.3mm (large) SID= 65 cms
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Contd.

Grid ratio: 5:1 Grid density: 31lines/cm Grid movement: reciprocating Inherent filtration: 1mm Be Beryllium window port Anode heat storage capacity: 300 kHU C-arm rotation:180 degree to -150 degree AEC sensors: 7 locations Filter: Mo/Rh

There can be 2 types of Mammography Equipment:

A.

Mammography with general equipment: To modify conventional x-

ray equipment so that it may be successfully used for mammography as well as other radiography.
B.

Specifically designed unit for mammography called the DEDICATED

MAMMOGRAPHY UNIT.

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In this certain changes have to be made in the general tube to maintain longer wavelength radiation (soft radiation). A. Filter Materials: it is removed from the path of the beam so that the longer wavelength for mammography may be retained in its composition. Limitation: in absence of filter, radiograph is adversely affected by scatter radiation when unit is used for other examination.
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B.

long cone used to limit field size to cover area of interest only. Limitation: the filter material and light beam diaphragm has to be replaced if the unit is to be used for general radiography.
C.

Light beam diaphragm: it is replaced by a

Support System: For the patients breast

and the film:
There should be a seat for the patient. Both seat and table should have the provision for varying the heights.
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D.

The Generator: it is modified to provide

kV

range of 20-40 kV. For mammography ideal quality of radiation is related to homogeneity. 6 or 12 pulse generator or constant potential generator should be used.

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 The first such dedicated unit was CGR Senographe introduced in 1969. This unit is specially mammography only. designed for

It is mobile and can be wheeled into position for examining a patient in lying down on an ordinary x-ray table. It can also be a fixed installation.
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It has the following Features:

1.
2. 3. 4. 5.

Cassette Holder.
Breast Compression Device. Breast Cones. Low KV X-Ray Tube. Tube Support.

6.
7. 8. 9.

Full range of movement for Tube Assembly.

Automatic Exposure Timer. H.T. Generator for low KV Range. Patient Seat, Control Panel and Lead Screens.
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A. B. C. D.

Compact and thus requires small space for installation. Allows all projections of breast and axilla to be taken in standing or seated position. Convenient to use and allows speedier mammography. Overall quality of mammograph improved.

DISADVANTAGE: Chest wall is not properly

visualized.

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Cones. Compression Devices. Image receptor support (IRS). Grid.

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A.

Cones: - are required for proper direction of xray beam, proper collimation and for rejecting scatter radiation, protection of chest wall by reduction of dose, it self acts as a compression.

B.

Compression Devices: - compression is

applied by a transparent compression plate

attached to the Film Holding Tray to give a

high quality mammogram.
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Advantages of Compression:
Provides uniform thickness of breast. 2. Provides immobilization of the part during exposure. 3. Produces radiograph of uniform density. 4. Reduces geometric unsharpness due to closer subject to cassette distance. 5. Reduces scatter and improves contrast. 6. Reduces tissue overlap and improves spatial and contrast resolution. 7. Enhances recognition of architectural distortion produced by tumours.
1.
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C.

Image Receptor Support:

There are grooves for holding moving grid assembly and cassette holder of sizes 18 X 24 cm and 24 X 30 cm.

Biopsy cassette holder and magnification device can also be fitted in those grooves.
C.

Grids: - moving grids are used.

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Limitations of Mammography:
Its sensitivity is only up to 85% in its specificity.

Particularly less sensitive and less specific in younger women with denser breasts. 40% cases go undetected.
Type of lesion cant be determined.

Features of mammography tube

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Single side emulsion film of small grain size with

a single intensifying screen of rare earth is placed in a carbon fiber cassette. This eliminates parallel & cross-over effects which cause un sharpness. In our department we use single Gadolinium

Oxy-Sulphide screen with single side emulsion Ortho-Chromatic Film of size 18x24cms.

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Ca breast , Screening , mastectomy. Evaluation of breast signs and symptoms: pain, mass, discharge, thick skin, nipple eczema. Pre-op evaluation of palpable mass. Follow up of Ca breast patient. Guidance for F.N.A.C. To assess contra lateral breast. To determine size, extent and location of lesion in breast.

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Fibroadenosis increase in density of breast tissue. Lobectomy removal of breast lobes. HRT hormone replacement therapy. In Post-op cases after surgery and R.T. to confirm:

Removal of abnormality. Assess post-procedural complications. Detect recurrent tumor at surgical site.

Both breasts should be radiographed because comparison is valuable between the two for clinical diagnosis.
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BASIC VIEWS:

CRANIO-CAUDAL VIEW. MEDIO-LATERAL OBLIQUE VIEW.

SUPPLEMENTARY VIEWS:

MEDIO LATERAL VIEW. LATERO-MEDIAL VIEW. AXILLARY VIEW. EXAGGRETED CRANIO-CAUDAL VIEW ( CLEOPATRA VIEW ).
MAGNIFICATION TECHNIQUES & LOCALIZED COMPRESSION VIEW.

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Breast Axis: The line drawn

from the center of the circle to which breast is attached to chest wall to the nipple is called breast axis. Saggital plane: Divides the breast into medial and lateral portions. Transverse plane: divides the breast into upper and lower portions.

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Breast is divided into 4

quadrants In normal erect rest in position the axial plane makes an angle of 20-30* with the sagittal plane of the body and transverse plane makes an angle of 30-50* with horizontal. The RETROMAMMARY SPACE lies behind the glandular tissue and should be visible on a correctly positioned mammogram.

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The patient should be prepared by removing the clothing and dressing of the area under investigation. The patient should be instructed do not wear talcum powder, deodorant or antiperspirant or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots. Explain the procedure to the patient.
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Describe any breast systems or problems to the technologist performing the exam.
If possible, obtain prior mammograms and make them available to the radiologist at the time of the current exam.

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This view is important for demonstrating medial and lateral quadrant lesions.
The patient is in sitting position on an adjustable stool facing the film holder or in an erect position. The height of film holder is adjusted to a height sufficient for the breast to lie comfortably on the holder. The transverse plane of breast should be parallel to the film.
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Now the compression is applied on the breast that much that can be bearable. Head is turned to the opposite side. The vertical beam is centered to the centre of the breast superoinferiorly.

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Limitations:
Retro-mammary space is not fully visualized due to convexity of the chest wall.

Some segments of the medial and lateral parts are not visualized because the breast is curved over the chest wall & the edge of the film is straight. So to overcome this, patient is slightly rotated medially or laterally according to the lesion.

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Nipple should be in profile & in centre. Compression should be even. No skin fold should be superimposed on the breast.

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This view is done to see the lesions located on the upper and lower quadrants. Mammography stand is rotated at an angle of 30-60 degree. Patient is rotated to the opposite side. Nipple is kept in profile & pectoralis muscles are included. Opposite breast is retracted by the opposite hand. Firm pressure is applied. Central ray is perpendicular to the film.
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Evaluation criteria:

Nipple should be in profile. Compression should be even. Pectoralis muscles and lower axillary lymph nodes should be seen clearly. A small portion of infra mammary fold should also be included.

This view is done to demonstrate posterior breast structure and laterally placed lesion. Patient is made to lie on a table in supine position or in erect position. Hand of the side to be examined is kept under the head if supine. The film is placed under the breast supported by a foam pad. Nipple is in profile. Opposite hand is used to retract the opposite breast. C.R. is perpendicular to the mid-point of the breast.
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This view is mainly done for medial part of breast to see medially placed abnormalities. Film holder is placed against the patients sternum. Elevate the ipsilateral arm. Patient is asked to pull herself forwards. Apply compression. Nipple is brought in profile. C.R. is directed horizontally to the mid portion of the lateral side of the breast.

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AXILLARY TAIL VIEW

This view demonstrates the axillary lymph nodes & axillary portion of breast tissue specially in patients having breast malignancy.
exposure by

NOTE : Increase the approximately 2 kVp.

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AXILLARY TAIL VIEW *Patient is in erect position. *Arm of the affected side is abducted at 90 degree. *Patient is rotated through 30degree towards the affected side. *The breast is allowed to fall away from chest wall, then compression is applied. *C.R. is directed 5c.m. below apex of axilla.

EXAGGRATED CRANIO-CAUDAL OR CLEOPATRA VIEW

This projection is done only if a significant amount of breast tissue lies in axillary region. This is modified view of cranio-caudal projection. For this position, patient is rotated medially to place the lateral aspect of the breast on the cassette & compression is applied. The patient is asked to hold the cassette firmly against the chest wall. This view often demonstrates lateral aspect and axillary tail of the breast.

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EXAGGRATED CRANIO-CAUDAL VIEW

Magnification

views

of

the

specific

quadrant of breast can be taken by

increasing the object film distance using

fine focal spot less than 0.15mm.

The amount of magnification usually

ranges from 1.5 to 2.5 times.
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Useful in evaluating the characteristic of breast calcification. Margins of the breast masses to determine whether breast lesions are likely to benign or malignant.

If other positions indicates the presence of a lesion, magnification may clarify whether a lesion is present or not.
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With specialized compression

plate device area is spread

more better effectively delineation removing of the superimposed structures, thus margins of a suspected area.

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ADVANTAGES:

High resolution and contrast. High background density. Reasonable exposure latitude. High speed. Reduction in exposure dose to patient. Eliminates parallel and cross over effect & No absorption of x-rays by front screen
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ULTRASOUND:

It is a valuable addition to conventional mammography in evaluation of a dense breast. A 7.5 MHz linear probe with real time imaging is used.

High frequency U.S (10-13MHz) is used for

high resolution imaging.
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1. 2.

Differentiation of cyst from solid mass. Evaluation of palpable mass that is occult in mammography.

3. 4.

Used for FNAC. Evaluation of lymph node status.

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Contd..
Evaluation of ruptured silicon breast implant. Evaluation of abscess. No radiation hazard.

In younger patient, lactating mother and pregnant women having dense breasts

1.

2. 3.

4.

5.

Differentiation of benign from malignant solid masses. Inability to detect micro-calcification. Difficulty in scanning near nipple where there is concentration of ductal tissue. Movement of underlying tissue by pressure can small lesions being missed. Poor portrayal of skin detail by contact scanning will cause difficulty in identifying lesions in this area.

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It is also called full field digital mammography (FFDM ). X Ray film is replaced by solid state detectors that convert x-rays into electrical signals. These detectors are similar to those found in digital cameras. The electrical signals are used to produce images of the breast that can be seen on a computer screen or printed on special film similar to conventional mammograms.

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1. 2. 3. 4.

Post acquisition manipulation possible. Enhances detection of anomalies. Selectively increases magnification. Distinguishes benign lesions. between malignant and

5.

High contrast resolution.

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6.

Eliminates loss of film and the need for

film library.

7.

Speed (10 12 sec vs 3 min for screen

film).

8.
9.

Potential in reduction of radiation dose.

Storage and transfer of image possible.

10.
11.

Lower image noise.

Quicker than conventional mammography.
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High cost.

Fixed sizes of image receptors.

low spatial resolution compared to that of screen film.

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Useful to see small lesion because of edge enhancement. It employs a dry electro-photographic technique It uses a charged aluminum plate coated with selenium powder instead of traditional x-ray film The electro-static image is made visible by dusting the selenium layer with a fine layer of charged powder which brings out a fine grain image For a permanent image the powder image is electro-statically transferred on paper
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Demonstrates high sensitivity in breast cancer detection.

Permits visualization of breast lesion usually enhanced after administration of I.V. contrast media
A special breast detecting surface coil is used for high signal ratio.

Reduced slice thickness provides optimum resolution.

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MRI is used to guide the radiologists to

insert instrument to the suspicious

area. The procedure is less invasive

than surgical biopsy, requires only a

local anesthetic leaves little or no

scanning and can be performed in less

than an hour.
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It is the procedure by which heat naturally emitted by the body is detected, measured & imaged. The most commonly used method of thermography is infra-red thermography. In this heat radiation emitting from the skin is detected & is electronically changed in to signal which is used to generate an image.
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Advantages:
1.

Totally non-invasive & quite safe. No ionizing radiation is used.

2.

3.

Convenient & inexpensive compared to the other imaging modalities. May be readily repeated for comparison purpose without concern for patient safety.
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4.

Disadvantages:
1.

Relatively insensitive in recording small tumors. Inability to achieve reliable & consistent interpretation of images has been achieved.

2.

Breast tissue is obtained by introducing a hollow needle through the skin into the suspicious lesion with the help of special breast x-ray in the way show whether the lesion is malignant or benign. This method is stereotactic biopsy or x-ray guided biopsy.
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Decrease the number of surgical breast biopsies. Less expensive. Cause less inconvenience to patient.

Prevent deformity that might result from surgical

biopsies.

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It is also called contrast mammography ductography as the study includes the injection of contrast material into a duct. There is 10% incidence of carcinoma in women operated upon for nipple discharge. It is done for evaluation of spontaneous nipple discharge that is bloody, serous or clear in nature originating from one or two ducts.
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Clean the nipple with cleansing agent & betadine is applied.

Needle is inserted under aseptic conditions into the orifice of discharging duct.

C/M is injected about 1-3 ml.

Immediate radiographs are taken in cranio - caudal and medio - lateral oblique positions. Heavy compression is not applied because c/m will ooze out due to pressure. So light compression is given.

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Latest developments in Mammography Units

Introduction of dual metal x-ray tube (having dual track of molybdenum/vanadium and rhodium). Rhodium track and filter produces a slightly higher spectrum for superior penetration of the dense breast tissues in the younger women and in those who have undergone radiation treatment or are under hormone therapy.
Molybdenum / tungsten dual track with a high emission flat emitter cathode with different K edge filters Mo and Rhodium meant for normal and dense breast.

BENEFITS OF MAMMOGRAPHY

Imaging of the breast improves a physicians ability to detect small tumors. When cancers are small, the woman has more treatment options and a cure is more likely.
The use of screening mammography increases the detection of small abnormal tissue growths confined to the milk ducts in the breast, called ductal carcinoma in situ(DCIS). These early tumors cannot harm the patients if they are removed at this stage and mammography is the only proven method to reliably detect these tumors. It is also useful for detecting all types of breast cancer, including 77 invasive ductal and invasive lobular cancer.

There is always a slight chance of damage to cells or tissue from radiation. The effective radiation dose from a mammogram is about 0.7mSv, which is about same as the average person receives from background radiation in three months. Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.
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It is achieved by ALARA (As low as Reasonably achievable ) principle: 1. Limitation of field size by using collimators. 2. Use of gonad shielding. 3. Careful preparation of patient. 4. Use of lead apron. 5. Presence of essential staff inside the mammographic room. 6. Use of high speed screen film combination, high mA , short exposure time.
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Quality of the Mammography Film: A mammogram is among the most technically demanding of all the radiographic procedures. The early detection of breast cancer and other changes can be detected only by a high quality imaging. Whole of the breast tissue must be imaged with high contrast and high resolution at the lowest dose with as little noise as possible and at reasonable cost.
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It specifies the overall management programme, which includes policies and procedures designed to optimize the control of the performance of the facilities and its equipments. The technologist should ensure: 1. Images are obtained and processed satisfactorily. 2. Analysis and interpretation of such images should be organized and monitored. 3. Information derived is accurately and effectively conveyed to the patient.
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It is the segment of the overall QA program that specifies and implements measurements of the mammographic procedure to detect any variations from the optimum so that corrective measures can be taken promptly. A sequence of elements in the imaging chain must function properly beginning from equipment acceptance which is foundation. All components should be optimized and monitored.
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THE TECHNOLOGIST MUST :

1. 2. 3.

4.

5.

6.

Conduct herself professionally. Respond to the patients queries. Serve humanity with full respect for the dignity of mankind. Deliver patient care irrespective of nature of disease, sex, race, religion, and socioeconomic status. Take proper care as far as radiation protection is concerned. Produce good quality mammographs so that the patient is diagnosed properly and returns home satisfied.

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Mammography remains the best screening test of the early detection of breast cancer.

The diagnostic accuracy of mammography however depends upon several factors like density of the breast and the age of the patient.
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