1. MAMMOGRAPHY

2. 1.SCREENING MAMMOGRAPHY 2.DIAGNOSTIC MAMMOGRAGHY

3. SCREENING MAMMOGRAPHY
-Consist of two views of each breast; A.the craniocaudal(CC) B.mediolateral obique(MLO) -women with no symptoms of breast cancer -women with lumpectomy for breast cancer after 2-5 years from lumpectomy -direct supervision by radiologist is not required

4. SCREENING MAMMOGRAGHY -detection of carcinoma insitu -detection of early stage of invasive carcinoma (mass<1cm)

5. Women age for start annual breast cancer screening with mammogram
Women age for start annual breast cancer screening with mammogram? Appropriate interval for screening mammogram?

6. American Cancer Society Guideline ; -Women ages 40 to44;should have the choice to start annual breast cancer screening with mammograghy -Women age 45 to 54;should get mammograms every year -Women age 55 and older;can get mammograms every 1 or 2 year

7. Screening mammagraghy in high risk women?

8. Start screening mammogram in high risk womem; -at age years before the age of detection in first degree relative

9. DIAGNOSTIC MAMMOGRAPHY
1-Evaluate a breast symptom that may be due to breast cancer 2-Or evaluate an abnormal screening mammogram 3-Women with recent breast cancer -ultrasound is often performed -nearly always performed under the direct supervision and interpretation of a radiologist on site

10. Diagnostic mammogram; -mastalgia -nipple discharge -mass sensation -skin change

11. 37 years old female with mass sensation and
37 years old female with mass sensation and . clinician mammogram request? .46 years old female with mass sensation and clinician sonogram request?

12. Is this an adequate study?
1.Is this the correct patient? 2.Is this the correct study for this patient? 3.Is the positioning adequate? 4.Are any images blurry? 5.Do the images have any correctable artifact?

13. CORRECT PATIENT/CORRECT STUDY
-check of patient name,date of birth -checking the study date -checking the number of images -knowing the indication for the study and the patient history

14. POSITIONING
-No tecnologist is perfect -every technologist occasionally will have patients who are not just positioned well -if a technologist have a high technical recall rate,focused feedback and training are helpful

15. MLO
-image receptor parallel to the pectoralis major muscle(typicaly between 60 and 45 degree angle) and extends into the axilla. -the pectoralis major muscle should be seen to at least the level of the posterior nipple line. -ideally the inframammary fold should be visualized. -”up and out” maneuver ;the breast is pulled up and away from the pectoralis muscle which allows for optimal compression of the breast

16. MLO
-thick pectoralis muscle or large breast;difficult to obtain good compression -1.offering compression paddels that angle to allow compression of the anterior and posterior portions of the breast 2.to obtain separate MLO veiws of the front of the breast without the pectoralis muscle(front compression MLO views) 3.relax their shoulders

19. LMO
-machine is flipped over so that the image receptor is in cleavage and the tube head is nearer the floor. -women with kyphosis or pectus excavtum -when pacemaker or port are present

21. CRANIOCAUDAL VIEW
-Typically performed horizental to the floor,through the receptor may be reported about 5 degrees toward the axilla if needed. The receptor should be elevated in order to mobilize the inferior breast and image the superior breast. -the nipple should be centered in the image and not positioning toward the lateral corner of the image.

22. CC
-The pectoralis muscle should be visualized on at least 30% of CC views. -the measured posterior nipple line should equal or be within at least 1cm of the same line on the CC view

26. BLUR
-breathing motion often result in blur predominantly along the back of the image -blur due to inadequate compression,usually along the anterior portion of the breast or inferior breast on the MLO view -easiest way to assess for blur is to look at the COOPER ligaments;it is thick and fuzzy versus thin and crisp in bluring

28. Correctable artifact
-grid artifact -external artifact -internal artifact

29. OPTIMIZING THE DIAGNOSTIC MAMMOGRAM
-Marker over palpable mass -additional veiws; A.spot compression B.magnification veiw C.lateral view;one view finding,before stereotactic boipsy,when lesion is not seen optimally in CC

32. STANDARD REPORTING

33. 1.Describe the indication for the study -screening,diagnostic,fallow up -mention the patient`s history

34. 2.describe the breast composition -a;the breast are almost entirely fatty -b;there are scattered areas of fibroglandular density -c;the braests are heterogeneousely dense -d;the breasts are extremely dense

36. 3.descibe any significant finding using standardized terminology -mass
A-Use the morphological descriptors:
-mass
-asymmetry
-architectural distortion
-calcification
-associated findings

37. Mamographic Findings Mass Asymmetry Architectural distortion
Calcification
Associated features
Mammographic Findings

38. 1 2 3 3D Stracture Convex Margin Visible on TWO views
Mass 1 2 3
3D Stracture
Convex Margin
Visible on TWO views
If a potensial Mass is seen Only a single Projection it should be called an Asymmetry until it`s 3D is Confirmed.
Mammographic Findings

39. Mass Shape
Mammographic Findings

40. Mass-Margin
Mammographic Findings

41. Mass-Density
Mammographic Findings

42. Mammographic Findings

43. SuperImposition > 75%
Asymmetry
SuperImposition > 75%
Mammographic Findings

44. It Usually Represents An Island Of Normal Dense Breast Tissue
Focal Asymmetry
It Usually Represents An Island Of Normal Dense Breast Tissue
Likelihood of Malignancy <1-3%
Mammographic Findings

45. It is Found in Approximately 3% of Screening Mammograms.
Global Asymmetry
It is Found in Approximately 3% of Screening Mammograms.
It Almost always Reperesents Normal Variant. (if there is any associated finding)
Mammographic Findings

46. It is a Focal Asymmetry that is New, Larger or Denser on current Exam.
Developing Asymmetry
It is a Focal Asymmetry that is New, Larger or Denser on current Exam.
Likelyhood of Malignancy 6-15%
Mammographic Findings

47. KeyPoints
Focal asymmetries are less common manifestations of breast cancer than masses and, therefore, arouse less suspicion than masses when seen at screening mammography.
In a series of nonpalpable breast cancers detected at screening. Although focal asymmetries are a relatively uncommon manifestation of breast cancer, a new or developing focal asymmetry has been reported to represent cancer in 13%–27% of cases.
Sickles found that 3.3% of screening studies included a finding that was seen on only one view; in 82.7% of those studies, the finding was a summation artifact. However, in retrospective reviews of cases of missed breast cancers, 9%–38% of missed cancers were initially visible as a one-view finding or asymmetry.
Mammographic Findings

48. Asymmetry
Mammographic Findings

49. MASS
-a SOL seen in two projections -If seen in single projection it should be called a asymmetry -three caracterise; A.shape B.margin C.density

52. ASYMMETRY
Unilateral deposits of fibroglandular tissue not confirming to the definition of a mass -simple asymmetry;area of fibroglandular tissue visible on only one mammographic projection,mostly caused by superimposition of normal breast tissue -focal asymmetry;visible on two projectinos,hence a real findings rather than supeimposition

53. -global asymmetry;cosisting of an asymmetry over at least one quarter of breast and is usually a normal variant -developing asymmetry;new,larger and more conspicous than on a previous examination

54. Differention between mass and asymetry?

55. 1. lack of conspicuity of mass in asymmetry 2
1.lack of conspicuity of mass in asymmetry 2.Asymmetry appear similar to other discrete area of fibroglandular tissue 3.An asymmetry demonstrates concave outward borders ,a mass demonstrate convex borders 4.an asymmetry usually interspersed with fat,versus mass that appear denser in the center than at the periphery

56. Management of focal asymmetry? Management of developing asymmetry?

57. Local mammo Target sono Increased density Distortion Fixed asymmetry
Facal asymmetry
Local mammo
Target sono
Increased density
Distortion
Mass
calcification
Fixed asymmetry
Spread out
normal
BIRADS3
BIRADS4-5
BIRADS2

58. Developing asymmetry
sonography
cyst
Normal
Finding except cyst

59. CALCIFICATION
Depending on their morphology and distribution are; 1.typically benign 2.suspicious for malignancy 3.probably benign

60. MORPHOLOGY Typically benign -skin cal -vascular cal -coarse cal
-large rodlike cal
-round cal
-punctate cal
-rim cal
-dystrophic cal
-milk of calcium
-suture cal

62. DISTRIBUSION
-diffuse;distributed randomly throughout the breast -regional;occupying a large portion of breast tissue>2cm greatest dimension -grouped;few calcifications occupying a small portion of breast tissue(lower limit 5 calcifications within 1cm and upper limit a larger number of calcifications within 2cm) -linear;arranged in line,which suggests deposits in a duct -segmental;suggests deposits in a duct or ducts and their branches

64. SUSPICIOUS CALCIFICATION
1-amorphous(BIRADS-4B) 2-coarse heterogeneous(BIRADS-4B) 3-fine pleomorphic(BIRADS-4C) 4-fine linear or fine linear branching(BIRADS-4C)

65. PROBABLY BENIGN CALCIFICATION
-An isolated group of punctate calcifications - if is new,increasing,linear,or segmental in distribution,or adjacent to a known cancer can be assigned as suspicious

66. ARCHITECTURAL DISTORTION
-A.Straight lines B.spiculation radiating from a point C.focal retraction D.distortion or straightening at the parenchyma -DDx;1.malignancy 2.scar tissue -If there is a mass that causes architectural distortion,the likelihood of malignancy is increased

68. Associated feature
-Architectural distortion -Skin changes -Edema -lymphadenopathy

69. Special cases
1.skin lesion 2.foreign body 3.lymmph nodes-intramammary or axillary 4.postsurgical chanes 5.fat content lesions as hamartoma or fat necrosis

70. 4. Compare to previous studies
B-Correlate these findings with the clinical information, mammography ,US and MR
C-Integrate mammography and US findings in a single report
4. Compare to previous studies

71. BIRADS ASSESMENT CATEGORIES

72. BIRADS-0
-ASSESMENT INCOMPLITE -Need aditional imaging evaluation and/or prior mammogram for comparison

73. BIRADS-1
-NEGATIVE -BUT add a sentence recommending surgical consultation or tissue diagnosis if clinically indicated

74. BIRADS -2
-BENIGN FINDINS -benign calcification -fat content lesion as intramammary lymph node,hamartoma,fat necrosis -posttreatment changes -skin lesions

75. BIRADS-3
-PROBABLY BENIGN FINDING -short-interval fallow up -have less than a 2 % Risk of malignancy -a.nonpalpable ,circumscribed mass on a baseline mammogram b.facal asymmetry which becomes less dense on spot compression view c.solitary group of punctate calcification

76. BIRADS-3
-Fallow up A.unilateral mammogram at 6months B.bilateral mammogram after 12 months C.bilateral mammogram after 24 months

77. Final Assessment Categories (3)

78. Final Assessment Categories (3)

79. DON'T
Don't use if unsure whether to render a benign (Category 2) or suspicious (Category 4) assessment. Then use Category 4.
Don't use in a screening examination.
Don't use in a diagnostic examination if additional imaging is required to make a final assessment.
Don't use if a lesion, previously assessed as Category 3 has increased in size or extent, like a mass on US with an increase of 20% or more of longest dimension. Then use category 4.
Don't recommend MRI to further evaluate a probably benign finding
Don`t use after lumpectomy for Breast Cancer.
Final Assessment Categories (3)

80. Final Assessment Categories (3)

81. BIRADS-4
-SUSPICIOUS ABNORMALITY -Biopsy should be considered -do not have the classic appearance of malignancy but are sufficiently suspicious to justify a recommendation for biopsy -range of probability of malignancy between 2to 95%

82. BIRADS 4:
Category 4a: Partially circumscribed mass suggestive of atypical fibroadenoma

85. Category 4a:
Partially circumscribed mass suggestive of atypical fibroadenoma
Palpable solitary complex cystic and solid cyst
Probable abscess

86. Category 4b:
Group amorphous or coarse heterogenous calcifications

88. Category 4b:
Group amorphous or coarse heterogenous calcifications
Nondescript solid mass with indistinct margins

91. Category 4c:
New grouped of fine linear& linear branching & fine pleomorphic calcifications
New indistinct irregular solitary mass

94. BIRADS-5
-HIGHLY SUGGESTIVE FOR MALIGNANCY -Have classic finding for breast cancer -with a>95% likelihood of malignancy -a.spiculated,irregular high density mass b.segmental or linear arrangement of fine linear calcifications c.irregular spiculated mass with associated pleomorphic calcifications

95. Final Assessment Categories (5)

96. Speculated, irregular high-density mass.
BI-RADS 5 (Combination of Highly Suspicious Finding)
Speculated, irregular high-density mass.
Segmental or linear arrangement of fine linear calcifications.
Irregular speculated mass with associated pleomorphic calcifications.
BI-RADS 4 Mass+Associated finding (skin retraction,…)
Final Assessment Categories (5)

97. DON'T
Don't use if only one highly suspicious finding is present. Then use Category 4c.
Final Assessment Categories (5)

98. Final Assessment Categories (5)

99. BIRADS-6
-Use after incomlete excision -Use after monitoring response to neoadjuvant chemotherapy