Mammography

Mammography

1. MAMMOGRAPHY
Presented by: Sabin Gwachha
B Sc. MIT 2013
Moderator : Mr. RanjitJha
(senior demonstrator)

2. Mammograms
don’t look fun
but they can save
a life!

3. What is mammography..??
Mammography is a radiographic modality to
detect breast pathology and cancer.
Breast cancer accounts for 32% of cancer
incidence and 18% of cancer deaths in women in
the United States.
Approximately 1 in 8 or 9 women in the US will
develop breast cancer over her lifetime.
A mammogram can find breast cancer when it is
very small --2 to 3 years before we can feel it.

4. No screening tool is 100% effective. Good
quality mammograms can find 85-90% of
cancers.
Some cancers are not found
until they reach this size
A mammogram can find
Cancer even when it is micro in
size

5. The standard techniques used for breast imaging
are:
1.Screen film x-Ray mammography.
2.Real-Time ultrasound.
3.Other new techniques include:
MRI
Color Doppler
Contrast ultrasound
Digital Mammography
Scintimammography

6. Principles Of Breast Cancer
Patients in the early stages respond well to
extensive surgery
Patients with advanced disease do poorly
The earlier the diagnosis, the better the
chance of survival
Mammography is the tool for early detection

7. Indication
pain/tenderness
Swelling
Nipple discharge (mild)
Calcification
Benign or malignant tumor
Lymph node enlargement

8. contraindication
Breast implant
Severe nipple discharge
Large palpable mass
Inflammation
Women within reproductive age
15-40 (benefit over risk)

9. BI-RADS mammographic
assessment categories
Categ.0 : incomplete
Categ.1 : negative / normal
Categ.2 : benign finding
Categ.3 : probably benign
Categ.4 : suspicious abnormality
Categ.5 : highly suspicious of malignancy
Categ.6 : known biopsy with prone
malignancy

10. Patient preparation
The patient is requested to take proper bath before coming
for the procedure
Patient should not wear deodorant, talcum powder or
lotion under her arms or on her breasts as these may appear
on the mammogram and interfere with correct diagnosis.
She is suggested to wear loose clothing so that it is easier
for her to change for the procedure
She is asked to bring along any histopathologicalreport if
done before mammography for clinical co-relation
A clean green hospital gown should be provided to the
patient before procedure.
Patient privacy should be maintained and a conducive
environment should be created.

11. Development Of Mammography
In 1913, radiographic appearance of breast cancers was
first reported
1950’s –Industrial grade x-ray film used
1975 –High speed/resolution film introduced by
DuPont
1992 –MQSA implemented

12. MQSA
Mammography Quality Standards Act
Mandated the following:
Formal training and continuing education
Required regular inspection of equipment
Documentation of quality assurance
Report means of reporting results, follow-
up, tracking patients, and monitoring
outcomes

13. Breast Cancer Screening
American Cancer Society(ACS) and American College of
Radiology(ACR) suggest that all women over 50 years should
undergo annual mammography.
Women between 40 and 49 should have one done every
alternate year.
A baseline mammogram should be done at the onset of
menopause.

14. Risk Factors
Age
Incidence increases with age
Hormonal History
More sensitive to carcinogens during
menarche
Family History
Women with positive family members
are more prone to breast cancer

15. Type of mammographic
examination
1.Diagnostic mammography is performed on
patients with symptoms or elevated risk
factors. Two or three views of each breast
may be required.
2.Screening mammography is performed on
asymptomatic women with the use of a two-
view protocol, usually medial lateral
oblique and cranial caudad, to detect on
unsuspected cancer

16. Modern Equipment
Dedicated
Mammography
Equipment
Specialized X-ray
Tubes
Optimized
Screen/Film detector
systems
Breast Compression
Devices

17. How x-ray is produce?
X-raysare produced due to sudden
deceleration of fast moving electrons when
they collide or interact with the target
anode. In this process, 99% of the electron
energy is converted into heat and 1% of
energy is converted into X-ray.
There are two type of x-ray production
1.bremsstrahlung x-ray
2.characteristic x-ray

18. 1.bremsstrahlung x-ray
Bremsstrahlungx-rays
result from the
interaction between a
projectile electron and
a target nucleus.
The electron is slowed
and its direction is
changed.

19. Characteristic x-ray
Characteristic x-rays are produced after ionization of a k-
shell electron.
When an outer-shell electron fills the vacancy in the k
shell, an x-ray is emitted.
In mammography, 17.5-19.5kev characteristic x-ray is
produced with Mo target and 23kev is produced with Rh
target.

20. In mammography low kVpis used because
it helps to minimize comptonscattering and
maximize the photoelectric effect inorderto
enhance the differential absorption by
various tissues of the breast.
As glandular tissue of breast is highly
radiosensitive, low kVphelps to reduce
radiation dose to breast.

21. General x-ray tube Mammography tube
1.Bothbremsstrahlungx-ray and
charateristicx-ray produced
only charateriscticx-ray
2.HighkVp50-120 is used. 20-35 kVpis used.
3.Target/ filter: W /Cu ,Al Mo/Rh
4. Window : Glass Berylliumor very thin borosilicate
glass
5. SID: 100 or 180 cm 60-80 cm
6. Anode angulations: 6-20 degree
tube angle : nil
6 degree
tube angle : 23-25 degree
7.Focal spot : 0.1-1mm and0.3-
3mm
0.1mm and 0.3mm

22. Generator and target/ filter
combination
1. High frequency generator with 5-10KHz
power is used
2. Target/filter:
W/60 µm Mo
Mo/30 µm Mo
Mo/50 µm Rh
Rh/50 µm Rh

23. Filtration
Window of x-ray tube should not attenuate x-ray
beam significantly
Be window: Z=4 or very thin Borosilicate glass
window
Inherent filtration of no more than 0.1 mm Al
equivalent
Under no circumstances is total beam filtration
less than 0.5 mm Al equivalent.

24. HTC Grid
http://www.hologic.com/oem/pdf/W-BI-HTC_HTC%20GRID_09-04.pdf
•3.8:1 grid ratio and dose
as conventional linear grids
•Copper as strip and air
interspace

25. Compression
Compression is achieved with a low attenuating lexanpaddle
attached to a compression device
10 to 20 Newtons(22 to 44 pounds) of force is typically
used
Parallel to the breast support table
Spot compression uses small paddles
Principal drawback of compression is patient discomfort

26. Compression
Breast compression is necessary
Spread the anatomy out to minimise overlaying
structures (improve contrast)
Equalise thickness to ensure homogenous density
on the radiograph
Bring the structures closer to the detector to
reduce geometric unshaprness
less scatter, more contrast, less geometric
blurring of the anatomic structures, less motion
and lower radiation dose to the tissues

27. Automatic Exposure Control (AEC)
The AEC, also called a phototimer, is a device that uses a
radiation sensor, an amplifier and .a voltage comparator to
control the exposure.
It is a device that automatically calculates the exposure
time that is required to produce optimum density on the
film.
When the required optimum density is produced, the AEC
terminate the exposure and hence reduces the dose that
may have increased with manual selection of exposure
factor and exposure time.
AEC detector is located underneaththe cassette in
mammography unlike conventional radiography.

28. Anatomy of the Breast
Vary in shape & size
Cone shaped with the post
surface (base) overlying the
pectoralis& serratusmuscles
Axillaries tail extends from lat.
base of the breasts to axillaries
fossa
Tapers ant. from the base
ending in nipple, surrounded
by areola

29. Female Breast
Consists of 15-20 lobes
Divide into several
lobules
Lobules contain
acini, draining ducts
and interlobular
connective tissue.
By teenage years
each breast contains
hundreds of lobules

30. Aducts
Blobules
Cdilated section of duct to hold
milk
Dnipple
Efat
Fpectoralismajor muscle
Gchest wall/rib cage

Enlargement:
Anormal duct cells
Bbasement membrane
Clumen (center of duct)
Breast profile

31. Lymph node:
Lymphatic vessels of the breast
drain laterally and medially
Laterally into the axillary
lymph nodes (C & D)
Medially into the mammary
lymph nodes
Lymph node areas
adjacent to breast area.
Apectoralismajor muscle
Baxillarylymph nodes:
levels
Caxillarylymph nodes:
levels
Daxillarylymph nodes:
levels
Esupraclavicularlymph
nodes
Finternal mammary
lymph nodes

32. Quadrants of the breast
MOSTLY SEEN UPPER
OUTER QUADRANT

33. TYPES OF
BREAST TISSUE
GLANDULAR
DUCTS
LOBES
LOBULES
STROMAL
FATTY TISSUE
CONNECTIVE
TISSUE
(COOPER’S
LIGAMENTS –
SUSPENSATORY
LIGAMENTS

34. Breast Classifications
Breast Changes with Age

35. 35
Fibro-glandular Breast
Human breast is
composed of mainly
fibroglandulartissue
which is highly
radiosensitive, hence ,
it is to be protected
from high radiation
exposure

36. 36
Average density
50% fat & 50%
fibro-glandular
Pregnant and lactating
mother are less prone
to breast cancer
Spinsters are more
prone to it

37. 37
Fatty Breast
Fatty
Minimal density
Women 50 and
older
(postmenopausal),
men and children

38. 38
Routine Images -
CC -craniocaudad
MLO –mediolateraloblique
Additional view
“True” Lateral view
Latero-medial oblique view
Paddle compression view
Magnification view
Tangenitalview
Cleavage view
Axillaryview
POSITIONING

40. 40

41. 41

42. 42

43. 43

44. Lundgren’s oblique view
44

45. 45

46. 46

47. 47

48. 48

49. 49
TRUE LAT

50. 50

51. 51
Magnification = increase OID

52. 52
Man –o -gram

53. 53
THE MALE BREAST
Male Mammography and Cancer

54. 54
Male Breast Cancer Statistics:
According to the American Cancer Society, about 0.22
percent of men’s cancer deaths are from breast cancer.
This disease is 100 times more common in womenthan
it is in men.
Benign excessive development of male mammary gland
Occurs in 40% of male cancer pt’s
Survival rates with treatment are 97% for 5 years

55. 55
Gynecomastia:
Prominent Male
Breasts
Most Common Causes:
Puberty (hormonal growth and changes during
adolescence)
Estrogen exposure (female hormone present in the
body and the environment)
Androgen exposure (body-building hormones)
Marijuana use
Medication side effects (older men)
One symptom of Klinefelter'ssyndrome, a
condition in which a male has an extra X
chromosome

56. 56
Gynecomastia
is a benign male breast (non-cancerous)
condition
Some men who have prominent breasts, or
uneven breasts, often feel some embarrassment
about their body image.
This condition can also cause
emotional conflict over
sexual identity.

57. 57
Position?
Best Seen ?

58. 58
Male Mammography
1300 men get breast cancer per year
1/3 die
Most are 60 years or older
Nearly all are primary tumors
Symptoms include:
Nipple retraction
Crusting
Discharge
Ulceration

59. Full-field digital
mammography(FFDM).
Recently approved by the U.S. Food and
Drug Administration (FDA), this technique
involves taking digital images of the breast.
Digital images are captured electronically
and can be viewed on a computer. Their
magnification, brightness and contrast can be
adjusted and enhanced to better reveal
abnormalities.

60. Xeromammography
Xeromammographyis a photoelectricmethod of
recording an x-rayimage on a coated metal plate,
using low-energy photonbeams, long exposure
time, and dry chemical developers.
It is a form of xeroradiography.
[1]
This process was developed in the late 1960s by
Jerry Hedstrom, and used to image soft tissue, and
later focused on using the process to detect breast
cancer.

61. Xeromammography (early years)

62. Tomosynthesis
Tomosynthesis:Tomosynthesisis a special kind
of mammogram that produces a 3-dimensional
image of the breast by using several low dose x-
rays obtained at different angles.For
tomosynthesis, the breast is positioned and
compressed in the same way as for a mammogram
but the x-ray tube moves in a circular arc around
the breast.It takes less than 10 seconds for the
imaging.The information from the x-rays is sent
to a computer, which produces a focused 3-D
image of the breast. The x-ray dose for a
tomosynthesisimage is similar to that of a regular
mammogram

63. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

64. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

65. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

66. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

67. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

68. Ben Johnson, Barts and the London NHS Trust, UKMPG 2011

69. In the scintimammography
procedure, a woman receives
an injection of a small amount
of a radioactive substance
called 99technetium sestamibi,
which is taken up by cancer
cells, and a gamma camera is
used to take pictures of the
breasts.
Also called miralumatest
(when with sestamibi)
Breast Scintomotography
(NMBI)
Isotope matches tumor to node involvement

70. 70
THANK YOU…..!!!!!