Mammography technique- Nischal Silakar.pptx

presentation of raadiological positioning of mammography

1. Mammography NISCHAL SILAKAR B. Sc. MIT 2 ND year NMCTH

2. I ntroduction Mammography is the radiological study of soft tissue of breast. Specific type of imaging that uses a low dose x-ray system to examine breasts. Breast cancer is the 2 nd leading cause of cancer deaths in women which occurs mainly between 35-55 years of age. Mammography aids in detection and management of breast cancer in the earliest stage. T reatable with early diagnosis! No screening tool is 100% effective. Good quality mammograms can find 85-90% of cancers

3. ANATOMY: The breast (mammary gland) is one of the accessory organs of the female reproductive system. Consists of two rounded eminences situated on the anterior and lateral walls of the chest. With base at chest wall and apex at nipple Lies over the pectoralis major and serratus anterior muscles extending from 2 nd –3 rd rib to 6 th -7 th rib, and from the lateral border of the sternum to the mid- axillary line. 3

4. Supero -lateral part is prolonged upwards and laterally towards the axilla to form the axillary tail. Nipple is a conical projection just below the centre of the breast, corresponding approximately to the 4 th or 5 th intercostal space. Composed of grandular , fibrous and fatty tissue. Shape, size and consistency vary significantly, depending on the patient’s size, shape and age. 4

5. Breast Made up of 16-20 lobes which are divided into several lobules. Each lobe contains large number of secretory alveoli, drain into a single lactiferous duct for each lobe, before converging towards the nipple into the ampulla before opening onto the surface. 5

6. Blood supply - Derived from branches of the axillary, intercostal and inner mammary arteries. With increasing age ,and especially after the menopause, the glandular elements of the breast becomes less prominent and tend to be replaced by adipose tissue (fat) . Fat attenuates less beam than glandular breast tissue so fatty breast is darker. Younger breast tissue is more sensitive to the adverse effects of ionizing radiation. 6

7. 7

8. POSITIONING TERMINOLOGY: Breast Axis: The line drawn from the center of the circle to which breast is attached to chest wall to the nipple is called breast axis. Saggital plane: Divides the breast into medial and lateral portions. Transverse plane: divides the breast into upper and lower portions. 8 Breast axis Axial plane Attachment to chest wall

9. The four quadrants: 1 Upper outer 2 Upper inner 3 Lower outer 4 Lower inner In normal erect rest position axial plane makes an angle of 20-30* with the sagittal plane of the body and transverse plane makes an angle of 30-50* with horizontal. The RETROMAMMARY SPACE lies behind the glandular tissue and should be visible on a correctly positioned mammogram.

10. Types of mammogram Screening mammogram Diagnostic mammogram 10

11. Screening mammogram Mammogram of the breast for the women w ho have no sign or symptoms of breast cancer, usually with two x-ray views Finding breast cancer early, greatly improves a women’s chance for successful treatment The USPSTF recommends that women who are 40 to 74 years old and are at average risk for breast cancer get a mammogram every two years 11

12. Diagnostic mammogram X-ray of the breast for a woman with breast problem like lump or nipple discharge or an abnormal area found in screening by taking spot view or magnification view 12

13. INDICATIONS Ca breast , Screening , mastectomy. Evaluation of breast signs and symptoms: - pain, mass, discharge, thick skin, nipple eczema. Pre-op evaluation of palpable mass. Follow up of Ca breast patient. Guidance for F.N.A.C. To assess contra lateral breast. To determine size, extent and location of lesion in breast. 13

14. Fibroadenosis – increase in density of breast tissue. Lobectomy – removal of breast lobes. HRT – hormone replacement therapy . In Post-op cases after surgery to confirm: Removal of abnormality. Assess_postprocedural_complications . Detect recurrent tumor at surgical site. 14

15. PATIENT PREPARATION : The patient should be prepared by removing the clothing and dressing of the area under investigation. The patient should be instructed not to put on talcum powder, deodorant or antiperspirant or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots. Explain the procedure to the patient . 15

16. BASIC VIEWS: Cranio -caudal view. Medio -lateral oblique view. 16

17. SUPPLEMENTARY VIEWS: 90 degree lateral (Medio-lateral/ Latero -medial) Axilla Extended cranio -caudal (Lateral /Medial orientation) Caudo -cranial / reverse cranio -caudal Rotated cranio -caudal/ roll view Oblique position / latero -medial projection Cleavage view Tangential Spot compression Magnification Augmented breast 17

18. CRANIO-CAUDAL VIEW 18 Demonstrates the majority of the breast, excluding the superior posterior portion, the axillary tail and the extreme medial portion. Patient position Erect facing cassette holder

19. Part position 1. Stand on the medial side of the breast being examined Place one hand under breast and the other hand on the top of the breast Using upward mobility, gently lift breast (all the way to chest wall) Pull posterior breast wall forward and place breast on holder 2. Place nipple in profile, centered to film 3. Have breast perpendicular to chest wall . 4. Turn pt’s head away from side being examined . 19

20. 5. Have pt press thorax against the cassette holder and lean into machine so that superior breast tissue and inferior margin of breast are on film. 6. Pull as much lateral tissue as possible forward and over cassette holder , making sure medial tissue is not scarified. 7 . Hold the breast with one hand .Use free hand to drape breast not being examine over corner of cassette holder rather than placing it behind cassette holder to aid in demonstrating medial tissue 20 X ray tube X ray Cassette

21. 8. Bring pt’s arms forward (or side not being examined) and have her gently hold handle bar 9. Hold breast in position with one hand Place free arm around pt’s back and rest hand on shoulder of side being examined Gently ask pt to relax shoulder down 10. When pt’s arm is relaxed and hanging down by side being examined, rotate Humerus externally to help remove skin folds 11. Keep hand on pt’s shoulder to keep pt from pulling back as compression is begun ( use fingers to pull skin up over clavicle to relieve any pulling sensation on patient’s skin while breast is being compressed

22. 12 . With other hand continue to hold breast in position while compression is pulled. As compression increases, move hand forward nipple, and smooth lateral tissues forward to eliminate folds Gradually remove hand as compression paddle becomes tight enough to hold breast in position 13. Apply compression until breast is taut and skin film to the touch 22

23. Centering of central ray Perpendicular Adjust cassette holder to a height level with elevated inframammary fold (IMF). Place edge of casette holder flush against chest wall under breast so that inferior breast surface lies comfortably on it. 23

24. Mammography Technique Low K Vp : 25 – 30 mA : 200mA SID : 65 cm Compression : 25-45lbs pounds of pressure Grid with ratio: 4:1, or 5:1 200 lines/inch Breathing instructions Suspend respiration 24

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

26. Evaluation criteria All medial tissue demonstrated Nipple centered and in profile Visualization of pectoral muscle No evidence of motion blur 26

27. Medio lateral oblique Demonstrates more tissue than any other single view. Patient position With pt erect and cassette holder along pt’s lateral side, position her so that she faces cassette holder . Have pt’s hips parallel with bottom of cassette holder(hip not behind it). Lower shoulder on side being examined. Ask pt to loosely rest arm along top of cassette holder and rest hand along handle bar. arm should not be elevated higher than shoulder (be sure that the pt does not grasp the bar because this will make positioning more difficult and tightened muscle will result in less tissue being imaged). 27

28. 5 . Place lateral aspect of breast on cassette holder. 6 . Lift breast medially and pull it up, out and away from chest wall so that maximum amount of breast tissue is visualized (not to roll breast). 7 . Gently yet thoroughly, pull lateral tissue forward feel with finger tips and line ribs up with cassette holder, trapping lateral breast tissue forward and into film view roll patient forward feel sternum and using collimator light, line up as close to ribs and sternum as possible before beginning compression.

29. 8. Place nipple in profile. 9. Include axilla, pectoral muscle and IMF on film. 10.If there is superimposition of opposite breast, have pt hold it out of the way. 29

30. 11. Begin compression while holding breast in position and gradually remove hand as enough compression is applied to hold breast in place . 12. Compression paddle should skim sternum , and upper edge of paddle should skim or be just under clavicle Apply compression until breast is taut. Tautness can be determined by feeling superior and inferior edges of breast Pull abdominal tissue down in order to open IMF When large abdomen creates overlapping ask pt to bend knee of side being examination hips will drop down somewhat and aid in smoothing out folds gently ease hips and abdomen out of way (after this, more compression may need to be applied 30

31. Central ray Direct from supero -medial to infero -lateral aspect of breast Slightly above level of nipple Rotate x ray tube so that cassette holder is parallel to pt’s pectoral muscle. Angle will be 30-60* from horizontal To determine correct angle. Place hand on pt’s sternum, which is parallel to pectoral muscle use hand to lift breast and pull both breast tissue and pectoral muscle anteriorly and medially position of hand can then be used to gauge angle needed 31

32. Mammography Technique Low kVp : 25 – 28 Automatic Exposure Control (AEC) Grid with ratio: 4:1, or 5:1 200 lines/inch Breathing instruction suspend respiration 32

33. Evaluation criteria 1 . Pectoral muscle should de well visualized and extend from axilla to at least as low as nipple level of breast 2. Breast should be droop upper outer contour of breast should bulge not sag (with proper positioning-&-adequate compression) 3.Small portion of abdomen inframammary tissue at its junction with breast will be seen just inferior to the breast ( indicates that patient was as near cassette holder as possible, thus including maximum amount of posterolateral breast and axilla ) 33

34. Supplementary Views 90⁰ lateral To demonstrate the exact location of a breast lesion If abnormality seen in MLO but not in CC to demonstrate whether this is due to artifact or superimposed tissue or it’s a true lesion To determine this MLO repeated with slightly different angulation or 90⁰ lateral 34

35. 90⁰ lateral and CC perpendicular so beneficial prior to needle localization lesion appear at different level to the nipple Higher on lateral than MLO, then the lesion is in the medial aspect Lower on lateral than MLO then the lesion is in the lateral aspect Close to the same level on both views then the lesions is in central aspects 35

36. 90* lateral view (contact, true lateral) projection Once the abnormalities and location have been identified, the lateral position that gives the shortest object to image distance should be used to increase geometric sharpness. If the lesion is in the lateral aspect, the MLO projection should be used. If the lesion is in the medial aspect, latero - medial projection should be used. 36

37. 37

38. Axillary also known as a "Cleopatra view ” Valuable in women where lymph gland involvement of a breast carcinoma is suspected or there is accessory breast tissue. Demonstrate of entire axillary tail (separation of parenchyma from thoracic wall indicates that all of axillary has been shown). 38

39. 39

40. Extended CC/ lateral orientation Useful for demonstrating the outer quadrant, axillary tail and axilla . All lateral tissue should be involved and may include pectoral muscle. Orientation select will depend on area of interest helpful when Tissue may be missed on the standard CC view Suspicious area is seen on oblique view but not on CC view Breast tissue extends to lateral chest wall average to obesity 40

41. 41

42. Extended CC /medial orientation Demonstrating lesions in the medial portion of the breast The maximum inclusion of the medio -posterior part of the breast is demonstrated. 42

43. Caudo -cranial /Reverse cranio -caudal Reverse CC may be helpful when Pt is small , or a muscular male. It is easier to compress inferior portion of breast and it will show more breast tissue. Improved resolution is needed for the suspicious area in superior or the upper quadrant of breast. Resolution is better due to reduced part film distance . Patient is dysphoric . Pt has a pacemaker. 43

44. Rotated CC or roll view Used to separate superimposed breast tissue. Can be performed with either lateral or medial orientation. Two exposure are often required with breast rolled in opposite direction from one view to the other e.g. clockwise and then anticlockwise. RL – counter clockwise RM- clockwise of R breast 44

45. Roll view may be helpful when Medial or lateral aspect of breast is not seen on standard CC view. Pt is obese and breast tissue extends to lateral chest wall. Presence of an abnormality needs to be confirmed. Suspicious area is seen on only one of standard views and needs to be better defined or location needs to be determined. 45

46. Oblique position / LMO projection True reverse oblique May be used to more comfortably patient position To demonstrate more tissue on a patient with pectus excavatum or a prominent pacemaker or who has recently had chest surgery Helpful for evaluating medial side of breast 46

47. Cleavage view (Valley view/ medial view / double breast compression) Depict the postero -medial portion of both breasts (the “valley” between the two breasts) by placing them on the cassette at the same time and pulling them anteriorly . Demonstration of deep medial breast tissue with cleavage included. 47

48. Tangential (TAN) Used for palpable lesions that are obscured by surrounding dense glandular tissue on mammogram. Is often used to locate skin calcification or lesions considered to be near skin. Lead marker may be used to indicate area of interest. Demonstrate Peripheral area : helpful for palpable lesions. 48

49. Spot Compression / Coned down spot view Also known as focal compression spot/spot view ) Performed by applying the compression to a smaller area of tissue using a small compression paddle Results in better tissue separation and allows better visualization of the breast tissue in that area. Used to distinguish between the presence of a true lesion and an overlap of tissues, as well to better show the borders of an abnormality or questionable area or a little cluster of faint micro-calcifications in a dense area.  Helpful in evaluating a suspicious area as it displaces tissue overlying the area of interest for dense tissue. 49

50. Magnification views Performed to evaluate and count micro-calcifications and its extension (as well the assessment of the borders and the tissue structures of a suspicious area or a mass) by using a magnification device which brings the breast away from the film plate and closer to the x-ray source. Needed magnification platform to separate the compressed breast from the cassette 1.5 to 2 time magnification 50

51. Augmented breast series 2 sets of CC and MLO necessary. One with implants in place and second with displaced 1 st – use manual technique and limit compression. 2 nd – push implant posteriorly and superiorly against chest wall, pull breast tissue in front of the prosthesis on to the cassette holder with the implant out of field. 51

52. GALACTOGRAPHY (DUCTOGRAPHY) Also called contrast mammography ductography as the study includes the injection of contrast material into a duct. There is 10% incidence of carcinoma in women operated upon for nipple discharge. It is done for evaluation of spontaneous nipple discharge that is bloody, serous or clear in nature originating from one or two ducts. 52

53. PROCEDURE Clean the nipple with cleansing agent & betadine is applied. Needle is inserted under aseptic conditions into the orifice of discharging duct. C/M is injected about 1-3 ml. Immediate radiographs are taken in cranio - caudal and medio - lateral oblique positions.

54. 54

55. 55

56. 56

57. 57

58. 63

59. BENEFITS OF MAMMOGRAPHY Imaging of the breast improves a physician’s ability to detect small tumors. When cancers are small, the woman has more treatment options and a cure is more likely. The use of screening mammography increases the detection of small abnormal tissue growths confined to the milk ducts in the breast, called ductal carcinoma in situ(DCIS). These early tumors cannot harm the patients if they are removed at this stage and mammography is the only proven method to reliably detect these tumors. It is also useful for detecting all types of breast cancer, including invasive ductal and invasive lobular cancer.

60. 65

61. 66

62. 67

63. 68

64. CONCLUSION Mammography remains the best screening test of the early detection of breast cancer. The diagnostic accuracy of mammography however depends upon several factors like density of the breast and the age of the patient. 69

65. REFERENCES Clark-s-Positioning-in-Radiography-12th-Edition. Encyclopedia of radiographic positioning –Volume 2- Steven B. Dowd , Bettye G Wilson Merrills_Atlas_of_Radiographic_Positions _ Volume_2_ 10th_Edition vol 2 70

66. 71

67. Thank you 72