1. 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.

2. 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

3. 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

5. 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

8. 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 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

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

11. DANGER!!

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

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

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

16. 20 degree Oblique Views entire glandular island
Good single view for young patients
Good additional view for CA patients

17. 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

18. 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

19. 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

23. 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

26. 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