1. Chapter 23
Mammography
Radiographic studies of the breast
2/21/2012

2. Breast Anatomy Breast =mammary gland Secondary sex characteristic
Consist of glandular, fat, and fibrous tissue

3. Breast that has been removed

4. Anatomy (cont’d) Base overlies pectoralis major muscles
& serratus anterior
Part of breast extends into axillary fossa
(armpit)

5. Anatomy cont’d Female breasts are divided into 15 – 20 lobes
-each made up of lobules
Supported by Cooper’s ligament which determines firmness

6. Lobule size Affected by age and hormones (pregnancy)
Involution: process of decreasing lobule size with age and after pregnancy
-flatter, saggier breasts

7. Anatomy (cont’d) Axillary nodes are often evaluated on mammograms
Because lymphatic vessels of breast drain into:
Axillary lymph nodes, laterally
Internal mammary lymph nodes, medially

8. Controversy about role of bra
It has been thought that wearing a bra Cooper’s ligaments may atrophy from not being subject to normal weight-bearing loads- thus actually causing increased sagginess later in life!
Health professionals- …”no evidence to suggest that wearing a bra for any amount of time slows sagging of breasts”
Bra manufacturers now state: “bras only affect the shape of breasts while they are being worn”
But, if your are lactating, own large breasts or are exercising, you should wear a bra! Cooper’s ligaments can damaged when stretched to limits of pain or discomfort

9. Women who wore their bra:
24 hours per day had a 3 out of 4 chance of developing breast cancer
more than 12 hour per day but not to bed had a 1 out of 7 risk.
less than 12 hours per day had a 1 out of 152 risk.
rarely or never had a 1 out of 168 chance of getting breast cancer.
The overall difference between 24 hour wearing and not at all was a 125-fold difference

10. Sometimes life is unfair!
Breasts vary in size and shape!

11. Now who’s smiling?
Breasts vary in size and shape!

12. Tissue Variations Breasts consists of both 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- harder to visualize

13. Mammograms comparing 2 different women
19 yr. old (never pregnant)
24 yr. old (has children)

14. During pregnancy, breasts undergo hypertrophy

15. Advancing age
Fatty tissue replaces glandular tissue after lactation and
After menopause, glandular tissue begins to atrophy

16. Definition of breast cancer
Cancer that forms in tissues of breast –
usually in ducts (tubes that carry milk to nipple)
and lobules (glands that make milk)
Can men get breast cancer?
Yes, but rare

17. Breast Cancer
Ranks Nationally as the 2nd leading cause of cancer-related deaths in women
What is first?
lung cancer
Breast cancer in United States in 2009 (estimated):
New cases: 192,370 (female)
Deaths: 40,170 (female)

18. Probability of Developing Breast Cancer Within Next 10 years
By age /1,681
By age 30- 1/232
By age 40- 1/69
By age 50- 1/42
By age 60- 1/29
By age 70- 1/27
Lifetime-1/8
Source: American Cancer Society Breast Cancer Facts & Figures,

19. While breast cancer is less common at a young age (i. e
While breast cancer is less common at a young age (i.e., in their thirties)-
Younger women tend to have more aggressive breast cancers than older women, which may explain why survival rates are lower for young women

20. Breast Cancer Risk increases with:
Age
Hormonal history
early menses
late menopause
pregnancy after age 30
or never had a child
Family history
If daughter, mother, or sister has breast cancer

21. Mammography is the best way for early detection!
Pt.s in early stages respond well to treatment
Patients with advanced disease do poorly
Earlier diagnosis, better chance of survival

22. Mammography Risk vs. Benefit
In 2007, in US –
133 deaths /million from breast cancer
5 deaths/million from mammography induced radiation (using screen film mammography)
Chances are 26 times more likely that a mammogram will save you rather than harm you!
More risky to refuse mammography!

23. What are your chances beating Breast Cancer ?
Excellent if diagnosed early!
If cancer is confined to breast, what is the survival rate for 5 years?
97%
Incidence of breast cancer stable since 1988
-but mortality rate decreased by 29%- mainly do to early detection

24. At what age should a woman have her first mammogram?
In November 2009, the U.S. Preventive Services Task Force (USPSTF) updated their recommendations for routine mammography screening for woman aged 40-49:
The USPSTF recommends against routine screening mammography in women aged 40 to 49 years!
The decision to start regular, biennial screening mammography before age of 50 years should be an individual one and take into account family history and pt's values regarding specific benefits and harms
50-74 should have mammogram every other year

25. American College of Radiology and Society of Breast Imaging strongly disagree!
Annual screening mammography should begin at age 40!
Mammography has reduced breast cancer death rate in United States by 30 percent since 1990
Based on data on performance of screening:
mammography as currently practiced in US, one invasive cancer is found for every 556 mammograms performed in women in their 40s
Mammography only every other year in women would miss 19 to 33 percent of cancers that could be detected by annual screening!

26. Did you get your annual mammogram?
In 2006: 56% of women of screening age (40 and up) reported having mammogram in past year
What race of women is most likely to have had a recent mammogram?
African American 68%
White 62%
Latino/Hispanic 59%
Asian American 55%

27. History of breast cancer detection
When was the first radical mastectomy introduced?
1898
What year was the radiographic appearance of breast cancer first reported?
1913
When did mammography became a reliable diagnostic tool?
in 1950s when industrial grade x-ray film introduced

28. History of breast cancer detection cont’d
1960’s – Xerography introduced – excellent results and much lower dose than industrial film
1975 – Low- dose mammography (High speed/resolution film) introduced by DuPont-
much lower dose than xerography which was then discontinued

29. Thermography Thermography approved by United States FDA in 1983
Detects localized temperature elevations over cancers in the breast
In more than 90%, a "hot spot" will be evident if cancer is present
A complement to mammography only-
Can only spot superficial hot spots

30. MQSA (Mammography Quality Standards Act)
1992 – MQSA passed by Congress, enacted in 1994
Mammography became 1st and only federally regulated imaging exam, which mandated:
Formal training and continuing education
Required regular inspection of equipment
Documentation of quality assurance
Reporting results, follow-up, tracking pts, and monitoring outcomes

31. Types of Mammograms
Baseline mammogram: very 1st mammogram (or 1st mammo. after surgery)
Screening mammogram: all mammos after baseline- if pt. asymptomatic (no known breast problems)
Diagnostic Mammogram: when woman presents with clinical evidence of:
Breast disease
Palpable mass or other symptom

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

33. Mammography Equipment
designed to produce high-contrast and high-resolution images
More precise control of kVp, mA, and exposure time
Low kVp : 25 – 28
AEC (automated exposure control)
Grid with ratio: 4:1, or 5:1 200 lines/inch

34. Inexpensive Screening Mammograms can be obtained at a Mobile Mammography Van when it comes to your area

35. Screen-Film Systems Now largely replaced by digital imaging
Mammography cassettes contain a single screen
Film is single emulsion
Occasionally, extended time processing is used
(reduces dose and increases contrast)
Now largely replaced by digital imaging

36. Digital Mammography State of the art! No film or chemical processing
Much better definition
Compression needed about 5% less
Radiation dose about 22% less
Fewer repeats do to poor technique selection
Images easily sent over internet
Can give pt. CD of images
Possible downside:
if 1st digital compared to previous film mammo., can give false positives due to increased sensitivity!

37. 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

38. Procedure (con’t) Have Pt put on gown with opening in front
Breasts must be bared for imaging
Cloth will cause image artifact
Remove deodorant and powder from axilla and breast
It can mimic calcifications on image!

39. 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 in profile
Apply proper compression
Place ID markers

40. Compression Decreases thickness of breast- thus reduces exposure dose
Decreases magnification and scatter
Increases contrast
Reduces motion unsharpness

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

42. Magnification Increases visibility of small structures
Uses increase OID
Uses air gap
Why does Radiation dose increase with magnification even though technique is not increased?
-(breast is closer to source)
Digital Mammography now makes “mag films” obsolete

43. Routine Mammography Projections and Positions

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

45. Craniocaudal Projection
Pt 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 pt to press chest to IR holder

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

47. Criteria for adequate Craniocaudal Projection
Nipple should be in profile
maximum amount of breast tissue radiographed
CR – Perpendicular to base of breast
Structures shown – Central, subareolar, medial fibroglandular breast tissue, pectoral muscle

48. Mediolateral Oblique Projection
Position
Center breast with nipple in profile
Hold breast up and out
Compress breast slowly until taut
Pull down on abdominal tissue to open inframammary fold
Instruct pt. to hold opposite breast laterally, out of anatomy of interest
Exposure on suspended respiration
Release compression immediately!

49. Criteria for acceptable Mediolateral Oblique projection
Deep and superficial breast tissues should be well separated
Retroglandular fat well seen
Uniform tissue exposure
(adequate compression)

50. Other positions
Mediolateral
Lateralmedial

51. Breast Implants

52. Mammographer’s Nightmare

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

54. In front or behind pectoral muscle?

55. Saline vs Silicone
Silicone implants have a more natural look and feel –
silicone gel texture similar to breast tissue
But Silicone implant ruptures are harder to detect
When silicone implants rupture, breast often looks and feels same because silicone gel may leak into surrounding areas of breast without visible difference
When saline implants rupture, they deflate -results are seen almost immediately
(MRI and sonography can help determine rupture or leakage)

56. Saline vs Silicone cont’d
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

57. Radiography Of Augmented Breast (implants)
Complications:
Increased fibrous tissue surrounding implant (contracture)
Shrinkage
Hardening
Leakage
Pain!

58. Radiography Of Augmented Breast (implants)
8 projections must be obtained (2x4) (twice as many as non-implants)
Four images of breast including anterior breast and implant
Four images with implant displaced posteriorly into chest wall are obtained

59. Eklund Technique for Radiography
of the Augmented Breast

60. What is Gynecomastia?
The development of abnormally large mammary glands in males- almost entirely fat
Can sometimes cause secretion of milk

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

62. Man won bet for $100,000 that he couldn’t wear breast implants for one year..

63. Treatment For Breast Cancer
Lumpectomy
Partial or radical mastectomy
Radiation
Chemotherapy
(recent study shows that lumpectomy or mastectomy may be no more beneficial than radiation and chemotherapy)
Lesion

64. Needle Localizations Used to localize breast lesions before surgery
Special, open-hole plate may be used for ease of localization

65. Lumpectomy- Breast Specimen Radiography
Imaging of lump by itself after it has been surgically excised

66. Breast reconstruction
Mastectomy

67. Breast Calcifications

68. Calcified Milk Ducts

69. Benign Cyst

70. The End