1. Mammography

2. Introduction and History
Breast cancer is 2nd only to lung cancer as cause of death in women
Very treatable with early detection!
1st innovation since radical mastectomy introduction in 1898
In 1913, radiographic appearance of breast cancers was first reported
Mammography became a reliable diagnostic tool in 1950s when industrial grade x-ray film introduced

3. History Of Mammography (cont’d)
1960’s – Xerography introduced – much lower dose
Research conducted in 1970s clearly showed mammography to be essential part of early diagnosis
1975 – High speed/resolution film introduced by DuPont
1992 – MQSA implemented (Mammography Quality Standards Act)

4. Occurs in both men and women (male breast cancer is rare)
Definition of breast cancer:
Cancer that forms in tissues of breast, usually ducts (tubes that carry milk to nipple) and lobules (glands that make milk).
Occurs in both men and women (male breast cancer is rare)

5. MQSA
Mammography was 1st and only federally regulated imaging exam with implementation of Mammography Quality Standards Act (MQSA)
Mandated following:
Formal training and continuing education
Required regular inspection of equipment
Documentation of quality assurance
Reporting results, follow-up, tracking pts, and monitoring outcomes

6. Principles Of Breast Cancer
Pt.s in early stages respond well to treatment
Patients with advanced disease do poorly
Earlier diagnosis, better chance of survival
Mammography is tool for early detection

7. Risk v. Benefit More risky to refuse mammography!
Breast cancer in United States in 2009 (estimated):
New cases: 192,370 (female); 1,910 (male) Deaths: 40,170 (female); 440 (male)
Us population 306 million in deaths /million
Mortality risk from mammography induced radiation is 5 deaths/ million pts. using screen film mammography
More risky to refuse mammography!

8. Breast Cancer Screening
Very 1st Mammogram is Baseline (or first mammo. after surgery)
There after: screening mammogram pt. must be asymptomatic – no known breast problems
American Cancer Society and American College of Radiology recommend screening annually for women over age 40

9. Diagnostic Mammogram
For woman presenting with clinical evidence of breast disease, palpable mass or other symptom
Uses specific projections to
Rule out cancer
Demonstrate suspicious area seen on screening mammogram

10. Breast Cancer Risk Factors
Risk increases with age
Hormonal history
Risk increases with early menses, late menopause, pregnancy after age 30, or nulliparity
Family history
Risk increases -daughter, mother, or sister has breast cancer

11. Breast Anatomy Breast same as mammary gland
Lobulated, glandular structures located in superficial fascia of anterolateral wall of thorax
Secondary sex characteristic

12. Base of breast overlies pectoralis major and serratus anterior muscles
Part of breast extends into axillary fossa

13. Anatomy (cont’d) Breasts vary in size and shape!
Consist of glandular, fat, and muscle tissue

14. Breast Anatomy Lobule size affected by age and hormones
Involution: process of decreasing lobule size with age and after pregnancy

15. Anatomy The breast tapers anteriorly ending in the nipple
Encircled by areola: area of pigmented skin
Breasts are supported by Cooper’s ligament which determines firmness or lack thereof
Female breasts are divided into 15 – 20 lobules

16. 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)

17. 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

18. Tissue Variations Breasts -glandular and connective
Ability to visualize depends upon amount of fat within and around breast lobules- provides contrast
Postpuberty breasts contain primarily dense connective tissue

19. During pregnancy, breasts undergo hypertrophy

20. Fatty tissue replaces glandular tissue after lactation and advancing age
After menopause, glandular tissue begins to atrophy

21. Typical Mammography Unit
Equipment is C-arm
SID is fixed at 24 – 26”

22. 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

23. Mammography uses Low kVp : 25 – 28 AEC
Anode material made of molybdenum, with rhodium target
Grid with ratio: 4:1, or 5:1 200 lines/inch

24. Magnification Increases visibility of small structures Increase OID
Uses air gap
Radiation dose increases with magnification

25. Compression Device
Compression decreases thickness of breast, magnification and scatter
Increases contrast
Reduces motion unsharpness
Reduces dosage

26. Compression Device Made of firm plastic
Amount of compression: between 25 and 40 pounds pressure
Compression may be uncomfortable!

27. Screen-Film Systems Mammography cassettes contain a single screen
Film is single emulsion
Occasionally, extended time processing is used
(reduces dose and increases contrast)

28. Digital Mammography State of the art! No film or chemical processing
Images easily sent over internet
Much better definition
Possible downside-if 1st digital compared to previous film mammo., can give false positives due to increased sensitivity!
- Slightly higher dosage

29. Procedure Complete, careful history and physical assessment
Take notes on location of scars, palpable masses, skin abnormalities, and nipple alterations
Examine previous mammograms for positioning, compression, and exposure factors

30. Procedure (con’t) 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

31. Procedure (cont’d)
Explain procedure to pt., 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

32. Positioning

33. Procedure Apply proper compression to produce uniform breast thickness
Essential to high-quality mammograms
Place ID markers according to standard convention

34. Routine mammography projections
Craniocaudal (CC)
Mediolateral oblique (MLO)

35. 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

36. Craniocaudal Projection
Arrange breast on film so nipple is in profile and maximum amount of breast tissue is radiographed
CR – Perpendicular to base of breast
Structures – Central, subareolar, medial fibroglandular breast tissue, pectoral muscle

37. Craniocaudal Positioning (cont’d
Immobilize breast with one hand
Use other hand to move opposite breast out of image
Shoulder relaxed in external rotation

38. Craniocaudal Projection (cont’d)
Rotate head away from breast being examined (watch out for hair!)
Lean pt. toward machine
Place hand on shoulder and slide skin over clavicle
Compress breast slowly until skin taut

39. CC Projection

40. Mediolateral Oblique Projection
Position
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

41. Mediolateral Oblique positioning
Instruct pt. to hold opposite breast laterally, out of anatomy of interest
Exposure on suspended respiration
Release compression immediately!

42. Mediolateral Oblique Open inframammary fold
Deep and superficial breast tissues well separated
Retroglandular fat well seen
Uniform tissue exposure
If compression is adequate

43. Mediolateral Oblique Degree of obliquity is 30° to 60°
Depends on body habitus
Tall, thin patients require steeper angulation
CR perpendicular to base of breast
Structures – lateral aspect of breast and axillary tail

44. Mammographer’s Nightmare

45. Radiography Of Augmented Breast (implants)
8 projections must be obtained (2x4)
MRI and sonography can help determine rupture or leakage
Four standard images with implant displaced posteriorly into chest wall are obtained

46. Breast Implants

47. Saline vs Silicone
Some surgeons feel silicone implants have a more natural look and feel because silicone gel texture similar to breast tissue.
Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate -results are seen almost immediately. When silicone implants rupture, breast often looks and feels same because silicone gel may leak into surrounding areas of breast without a visible difference.
Replacing a ruptured silicone gel implant is more difficult than repairing saline implant. Silicone implants have higher rate of capsular contracture (scarring and hardening around implant).
Saline implants inflated to desired size with saline, then valve is sealed by surgeon

48. Implants can be in front of pectoral muscle or behind

49. Radiography Of Augmented Breast (implants)
Complications:
Increased fibrous tissue surrounding implant (contracture)
Shrinking
Hardening
Leakage
Pain

50. Male Mammography
Approximately 1000 males develop breast cancer every year
Standard CC and MLO are obtained
Males not screened- mammogram only if lump discovered

51. Gynecomastia

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53. Treatment For Breast Cancer
Lumpectomy
Partial or radical mastectomy
Radiation
Chemotherapy

54. CC view ( lesion)

55. Needle Localizations Used to localize breast lesions before surgery
Special, open-hole plate may be used for ease of localization
Plate contains grid to plot coordinates
Operative stereotactic surgery may be used
Two offset images are obtained to create a 3-dimensional image

56. Needle Localization

57. Breast Specimen Radiography
Performed after surgery once lump has been excised
Determines extent of calcifications within specimen
Magnification technique may be used

58. Breast Specimen Radiograph

60. 24 yr. old (has children)
19 yr. old (never pregnant)

61. Calcified Milk Ducts

63. Various abnormal mammograms

64. The End