Chapter 23 Mammography Lesson 1 Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Introduction and History Breast cancer is second only to lung cancer as cause of death in women Very treatable with early detection Mammography became a reliable diagnostic tool in the 1950s First innovation since radical mastectomy introduction in 1898 Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Introduction and History Research conducted in 1970s clearly showed mammography to be an essential part of early diagnosis program Mammography was the first and only federally regulated imaging examination with the implementation of Mammography Quality Standards Act (MQSA) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Cancer Screening Defined as a procedure performed on an asymptomatic patient or a patient who presents without any known breast problems American Cancer Society and American College of Radiology recommend screening annually for women over age 40 Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Mammogram Recommended for patients with clinical evidence of breast disease Problem-solving examinations that use specific projections to Rule out cancer Demonstrate suspicious area seen on screening Indicated if a woman presents with a palpable mass or other symptom Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Cancer Risk Factors Age Risk increases with age Hormonal history Risk increases with early menses, late menopause, pregnancy after age 30, or nulliparity Family history Risk increases when daughter, mother, or sister has breast cancer Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Terms breast and mammary gland are synonymous Lobulated, glandular structures located in the superficial fascia of the anterolateral wall of the thorax Female breasts are secondary sex characteristics Vary considerable in size and shape Depends on amount of fat and glandular tissue present Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Female breasts vary considerable in size and shape Depends on amount of fat and glandular tissue present and condition of the suspensory ligament Usually cone-shaped with base overlying the pectoralis major and serratus anterior muscles Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Axillary tail of the breast extends from upper, lateral base to the axillary fossa Anterior end tapered, ending in the nipple Areola surrounds nipple Circular area of pigmented skin Cooper’s ligaments support breast 15 to 20 lobes in adult female breast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Each lobe divided into many lobules Lobules are basic structural unit of breast Lobules contain Several acini Draining ducts Interlobule stroma (connective tissue) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Lobule size affected by age and hormones Involution is the normal process of decreasing lobule size with age and after pregnancy Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Acini are glandular elements of lobules Lactiferous ductules formed by openings of each acinus Lactiferous ducts formed by joined ductules One duct for each lobe Ducts join before opening into nipple Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Lymphatic vessels of breast drain into two sets of nodes Axillary lymph nodes, laterally Internal mammary lymph nodes, medially Axillary nodes are often evaluated on mammograms Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Anatomy Anterior view Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Tissue Variations Glandular tissue Connective tissue Fatty tissue Increases during pregnancy and lactation Decreases postpartum and with age Connective tissue Dense and casts homogenous shadow Primary component of postpubertal adolescent breast Fatty tissue Replaces glandular tissue after lactation and advancing age Increases natural radiographic contrast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mammography Equipment Dedicated units have high-frequency generators Provide more precise control of kVp, mA, and exposure time Specially designed to produce high-contrast and high-resolution images Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Procedure Patients dress in open-front gown Breasts must be bared for imaging Cloth will cause image artifact Remove deodorant and powder from axilla and breast Can mimic calcifications on image Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Procedure Complete, careful history and physical assessment Notes made on location of scars, palpable masses, skin abnormalities, and nipple alterations Examine previous mammograms for positioning, compression, and exposure factors Check for areas of improvement Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Procedure Explain procedure to patient, including possibility for additional projections Consider natural mobility of breast before positioning Support breast firmly so that nipple is directed forward Profile nipple, if possible Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Procedure Apply proper compression to produce uniform breast thickness Essential to high-quality mammograms Place ID markers according to standard convention (see next slide) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Sample correct ID, MLO projection ID for Mammograms A – Facility name and address, examination date, patient name, age, DOB, and medical No. B – Side and projection C – Technologist’s initials D – IR No. E – Date F – Exposure factors G – Unit No. Sample correct ID, MLO projection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Sample correct ID, MLO projection ID for Mammograms A-D generally required E-G usually optional Sample correct ID, MLO projection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Essential Projections Mammography Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23

Essential Projections Routine mammography projections Craniocaudal (CC) Mediolateral oblique (MLO) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Craniocaudal Projection Patient position Standing or seated facing IR holder Part position Elevate inframammary fold to maximum height Adjust IR height to inferior surface of breast Gently pull breast onto IR holder with both hands while instructing patient to press chest to IR holder Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Craniocaudal Projection Part position – cont’d Breast perpendicular to chest wall Center breast over AEC Place nipple in profile, if possible Immobilize breast with one hand Use other hand to move opposite breast out of image Shoulder relaxed and in external rotation Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Craniocaudal Projection Part position – cont’d Rotate head away from breast being examined Lean patient toward machine Place hand on shoulder and slide skin over clavicle Compress breast slowly until skin is taut Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Craniocaudal Projection Exposure made on suspended respiration Release compression immediately CR perpendicular to breast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Projection Patient position Standing or seated upright facing IR holder Rotate C-arm until long edge of IR is parallel to upper one third of pectoral muscle Degree of obliquity is 30 to 60 depending on body habitus Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Projection Part position Place top border of IR level with axilla Elevate arm of affected side over corner of IR holder Rest hand on grip adjacent to IR Elbow should be flexed Relax shoulder Have patient lean slightly anterior Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Projection Part position – cont’d Place hand along lateral aspect of breast and gently pull breast and pectoral muscle anteriorly and medially Holding breast with thumb and fingers, lift up, out, and away from chest wall Rotate patient’s body toward IR Ask patient to bend slightly at waist Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Projection Part position – cont’d Center breast with nipple in profile, if possible Hold breast up and out Compress breast slowly until taut Pull down on abdominal tissue to open inframammary fold Instruct patient to hold opposite breast laterally, out of anatomy of interest Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Projection Exposure made on suspended respiration CR perpendicular to base of breast CR angle depends on body habitus Tall, thin patients require more angle Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Image Critique Criteria Mammography Essential Projections Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34

Craniocaudal Posterior nipple line (PNL) extending posteriorly to edge of image Measuring within 1 cm of PNL on MLO All medial tissue included Medial retroglandular fat seen Absence of firbroglandular tissue on posteromedial edge of image Nipple in profile (if possible) and at midline Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Craniocaudal For emphasis of medial tissue, exclusion of some lateral tissue Pectoral muscle seen posterior to medial retroglandular fat Seen in about 30% of CC images Slight medial skin reflection at cleavage Uniform tissue exposure If compression is adequate Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique PNL measuring within 1 cm of PNL on CC Inferior aspect of pectoral muscle extending to PNL or below Pectoral muscle showing anterior convexity to ensure a relaxed shoulder and axilla Nipple in profile, if possible Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

Mediolateral Oblique Open inframammary fold Deep and superficial breast tissues well separated Retroglandular fat well seen Uniform tissue exposure If compression is adequate Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.