Guidelines for Positioning Communication!! Exam Identification Posture Mobile Borders of the breast Measurement of PNL Skin Wrinkles Nipple in Profile Markers Communication Enlist pt’s help; give the pt control, listen Exam Identification: overhead ACR-Standard Logan-Young -Describes by direction of beam Posture Best posture is poor posture. Use a “sloppy” stance – bend at waist and let breast fall away from chest wall (pendent positioning) Mobile borders Lateral and inferior Skin Wrinkles A concern in Xero-mammography. Could cause pseudo-architectural distortion or obscure surrounding structures. Nipple in Profile Don’t retake unless nipple is indistinguishable from a mass or positive that there is missed tissue Markers Some Radiologists like markers for nipple, scars, and moles. Preferred on follow up exam but not on screening exams. Introduces noise so instead, do third view to further demonstrate those areas or additional view with a marker.

Guidelines for Positioning Cont. AEC placement Compression Decreased dose and scatter Decreased motion Increased sharpness Increased contrast Separation of breast structures Collimation AEC placement Place just posterior to nipple unless it is a large detector. Compression More compression posteriorly for lg breasted women. May need additional view for ant breast. Collimation No collimation so there is a black apacity around breast to prevent ambient light from degrading image during interpretation

Craniocaudal Projection Areas visualized Tube position Patient position Technologist hand position Tabar Modification Areas visualized Subareolar, central, medial, posteromedial Patient position Patient steps back slightly and bends forward from waist. Droop shoulders. Hold handrail with contra-lateral hand which will stabilize her and bring medial tissue closer. Bring opposite breast onto recepter but out of the way then center breast on film over AEC and have pt rotate slightly to include more medial tissue. Have pt lift chin so you don’t lose superior and posterior tissue and look to contralateral side. Do a final check with light

Assessing Results Retro-Glandular Fat Space Pectoral muscle medially Skin thickening medially Cleavage Retro-Glandular Fat Space seen posterior and centrally Pectoral muscle medially If seen centrally, indicates faulty positioning, demonstrating neither medial nor lateral tissue well Skin thickening medially Skin at the base of the breast is thicker (cleavage area) and tapers toward nipple

Medio-Lateral Oblique Areas visualized Tube position Patient position Technologist hand position Areas visualized Posterior and upper-outer quadrants. Images almost entire breast (except medial tissue) but does so with much overlap and distortion of anterior structures. Tube position Superomedio-inferolateral projection approx 45 degrees. Varies from 30-60.By adjusting the angle to match pt’s build, can demonstrate more posterior. Draw imaginary line from shoulder to mid-sternum. Patient position Pt stand with hips slightly anterior to lower end of receptor. Turn pts feet and body toward unit but not facing it. Assume “poor” posture position. Have ipsilateral arm form 90 degree angle to body to determine height of image receptor. AEC should be just posterior to nipple when breast is lifted. Height of image receptor affects ease of positioning and amt of breast tissue. Bend elbow and have pt “rest” (not grip) hand on handrail. Lift and pull breast up and out. Rotate pts hips to include IMF (which should be open) Compression paddle should rest between humeral head and clavicle Patient can hold other breast out of the way, careful to not pull. Do a final check with light Technologist hand position

Assessing Results Breast should not droop Pectoral muscle visualized to nipple (PNL) IMF Open

DANGER!!

Mediolateral Lateral Uses Localization 3rd view to open structures Problem: misses posterior and lateral tissue

Lateromedial Lateral Uses Localization 3rd projection Replace MLO for nonconforming patients

Exaggerated Craniocaudal (XCCL) May Angle 5-10 degrees Hold with ipsi-lateral arm Doesn’t open structures like 20 degree OBL

20 degree Oblique Views entire glandular island Good single view for young patients Good additional view for CA patients

Superolateral/Inferomedial (SIO) “Reverse” “SL-IM” Tangential of Abnormality Additional view for encapsulated implants Nonconforming patients Perpendicular projection to MLO to rule out mass Typo on page 208 under Performing Study!! Hold on with contralateral arm; ipsilateral at pts side. Can get more posterior and inferior breast with ipsilateral arm up and over image receptor Edge of surface at mid-sternum. Tangential of Abnormality Additional view for encapsulated implants Use when Ecklund modification doesn’t work. 60 degree SIO is a 3rd view to see UIQ & LOQ hidden on CC & MLO of implant pts Nonconforming patients When missing medial UIQ or LOQ tissue Perpendicular projection to MLO to rule out mass

Inferolateral/Superomedial (LMO) “True Reverse” “ILSM” Replacement for MLO Turn c-arm 125 degrees laterally to ipsilateral side Raise arm up and across image receptor Contra-lateral arm hangs on to handrail Replacement for MLO Useful for pacemaker pts, open-heart surgery and others. Medial aspect of breast resting on image receptor. “IMSL” imitates SIO but allows access to inferior aspect of breast for stereotactic biopsy

Eklund Method Routine CC CC with Implant Displacement Routine MLO MLO with Implant Displacement Additional Views SIO for encapsulated implants SIO-ID for soft implants

Axilla Position C-arm 70-90 rotation Image receptor slightly above humeral head Posterior shoulder rests against image receptor. Compression used to minimize motion Kvp range from 28-35

Tangential Abnormality must be palpable or observable on any two projections Draw line from nipple to area of interest Visualization of UIQ or LOQ done with SIO Visualization of UOQ or LIQ done with MLO Skin calcification may only be visualized on one view so must be localized before a tangential can be performed