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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

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

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

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

35. 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.

36. 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.

37. 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.

38. 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.