it is for general understanding of mammography

1. IMAGING BREAST
MAMMOGRAM
By : DR REKHA KHARE
MD RADIOLOGY

2. What is a mammogram ?
A mammogram is a x-ray exam of the
breast to detect and evaluate any
change in the breast

3. History of mammography
• X-rays were first used to examine breast
tissue by the German surgeon
ALBERT SALOMON about a century ago
• Modern mammography came in to
existence since the late 1960
• Technology has advanced and today’s
machine is different even from those of
the 1980s and 1990s

4. Mammography machine
• Today’s mammography machine expose
the breast to much less radiation
• X-rays do not go through tissue as easily
as those used for routine chest x-ray or x-
rays of extremity

5. Radiation from mammogram
• Modern machine is safe and uses the
lowest dose of radiation possible
If a woman with breast cancer is treated with radiation, she
will get several thousand rads.
If she has yearly mammogram starting at age of 40 and
continues until 90 she will get total of 20-40 rads
Benefits of mammography outweigh any possible harm
from the radiation exposure

6. Types of mammogram
• Screening mammogram
• Diagnostic mammogram

7. Screening mammogram
• Mammogram of the breast for the women
who have no sign or symptom of breast
cancer, usually with two x-ray views
• Finding breast cancer early greatly
improves a woman’s chance for
successful treatment

8. 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

9. What diagnostic mammogram
does? One of three ways----
• It may reveal that an area that looked abnormal
on screening is actually NORMAL—routine
checkup
• It could reveal that an area of abnormal tissue
probably is NOT CANCER but radiologist may
not ready to say it normal based on these
x-rays--- re-check up in 4-6 months
• The results could also suggest that a biopsy is
needed to find out if the abnormal area is
CANCER

10. Types of mammogram machine
• Screen- film units
• Full- field digital mammography units
(better in woman younger than 50/or
with dense breast tissue)

11. How is mammogram done?
• Breast is briefly compressed between 2
plates attached to the mammogram
machine– an adjustable plastic plate on
top and a fixed plate on bottom which
holds the x-ray film or the digital detector
that makes the image

12. Typical views
• For screening: Cranio- caudal view(CC)
Medio-lateral oblique(MLO)
• For diagnostic: CC
MLO
- lateromedial(from side towards center of chest)
- mediolateral(from the center of the chest out)
- Spot compression view

13. Position
• How the breast is
compressed between two
plates

19. How mammogram are read?
• Its challenging must be interpreted by
radiologist
• Must to compare with previous
mammogram

20. Mammogram: Changes in
breast tissue
• Calcification: macrocalcification
microcalcification
• Mass
• Breast density

21. Calcification: Macrocalcification
• Due to changes in breast caused by aging of
breast arteries, old injuries or inflammation
• Coarse/ large Calcium deposit
• Seen in 1 0f 10 women under 50 and about half
over 50
These deposit are related to Non-
cancerous condition and do not require
biopsy

22. Calcification: Microcalcifiation
• Tiny specks of calcium
• If seen it’s a matter of concern though not
necessarily it is cancer or does not mean
biopsy

23. Mass
• Mass with or without calcification
• Noncancerous mass:
Cystic– fluid filled sacs/ simple cyst
Solid – Fibro adenoma
• Complex or mixed mass: suspect cancer
needs FNAC or biopsy
Breast ultrasound is complementary

24. Breast density
• Density is based on
: how much fibrous and glandular
tissue
: how is the distribution within breast
tissue
: how is breast made up of fatty tissue
Dense breasts are not abnormal but they
are linked to higher risk of breast
cancer

25. Findings on mammogram
• Primary signs of breast cancer may
include spiculated masses or clustered
pleomorphic microcalcification
• Secondary signs of breast cancer may
include asymmetrical tissue density, skin
thickening or retraction or focal distortion
of tissue

26. Impression
• Overall assessment of the radiological
findings often includes a classification of
the mammogram using the BI-RADS
system developed by the American
College Of Radiology(ACR)

27. Mammogram - normal

28. X-ray film versus digital
mammogram

29. Mass on mammogram

30. Mass on mammography

31. Mass on mammography

32. Tissue density on mammogram
Fatty versus dense

33. Recommendation(optional)
• No action necessary
• A six month follow up mammogram
• Spot views
• Breast ultrasound
• Biopsy etc….

34. Breast Imaging Reporting
and Data System(BI-RADS)
•Category0: additional view or ultrasound
and or compare prior film
•Category1: negative
•Category2: benign(noncancerous)
•Category3:probably benign,repeat in
6mth

35. BI-RADS category
• Category4: suspicious abnormality
consider biopsy
4A: finding with low suspicion of being
cancer.
4B: finding with an intermediate
suspicion of being cancer
4C: finding of moderate concern of being
cancer but not as high as category5

36. BI-RADS category
• Category5: highly suggestive of
malignancy, biopsy is recommended
• Category6: known biopsy proven
malignancy, appropriate action should
be taken. It is only to see how well the
cancer is responding to treatment

37. BI-RADS for breast density
• The breast are almost entirely fatty
( little fibrous and glandular tissue )
• There are scattered areas of
fibro glandular density
• The breasts are heterogenously dense
( more fibrous and glandular tissue )
• The breasts are extremely dense
( It can lead to missing some cancer )

39. Limitations of mammogram
• Breast cancer screening is the best way to
find cancer early but finding cancer early
does not always reduce a woman’s
chance of dying from breast cancer
• Detecting breast cancer early may not
help prolong the life of a woman who has
other kind of serious or life threatening
health problem like CCF, ESRD,COPD…..

40. False-negative results
• A false-negative mammogram appears
normal even though with breast cancer
• It occur more often among younger
women usually had dense breast
• False-negative results can delay treatment
and promote a false sense of security for
the woman
Overall, screening mammogram miss
about 1 in 5 breast cancers

41. False- positive results
• A false- positive mammogram looks
abnormal but no cancer is actually present
• It requires diagnostic mammogram,
ultrasound, MRI or even biopsy
• It is common in younger woman, have
dense breast, have had breast biopsy or
cancer in family or are taking oesterogen

42. Over diagnosis and
over treatment
• While mammogram can find invasive breast
cancer and DCIS that need to be treated, it is
also possible that some invasive cancer or DCIS
detected on mammography will not keep
growing so not so life threatening and never
would have been detected if a woman had not
gotten a mammogram. Doctors often cannot be
sure which cancers & cases of DICS will
become life-threatening, they are all treated

43. Mammogram – in younger
women
• Difficult to read because breast tissue is
dense and it can hide the tumour
• In some younger women who are at high
risk yearly MRI or mammograms are
recommended at age of 30years
Risk factors: gene mutation,strong family
history or other factors

44. Mammogram plan after BCT
• Radiation and surgery both cause
changes in the skin and breast tissue
• These changes on mammogram, making
it harder to read
• The changes usually peak 6mth after RT
• Mammogram done at this time serves as
a new baseline for the affected breast

45. Mammogram after mastectomy
without reconstruction
• Women who had total or modified radical or
radical mastectomy for breast cancer need
no further routine screening mammogram of
the affected side
• Mammograms are usually continued on the
UNAFFECTED breast each year
• Follow up mammogram does require only in
the cases who had gone for Subcutaneous
mastectomy

46. Mammogram after mastectomy
with reconstruction
• Women who have had a breast fully
removed and reconstructed (rebuilt) with
silicone gel or saline implant do not need
routine mammogram

47. Mammogram after BCT
• BCT: Breast conserving treatment
• Partial Mastectomy (sometimes called
Lumpectomy) is another name for BCT
• It always followed by radiotherapy
• Woman after BCT will need to continue
having regular mammogram of both
breast

48. Mammogram with implants
• Its special challenge to do mammography
of breast with implant
• In order to see as much breast tissue as
possible it needs 4 extra and 4 standard
picture (2 on each breast)
• Extra picture is implant displacement(ID)
view pushing back implant against chest
wall and the breast is pulled forward over
it
• MRI IS BEST WAY TO CHECK IMPLANT

49. 49
Elkland Method for Imaging with
Breast Implants

50. TOMOSYNTHESIS
3D mammography
• Newer technique
• Basically it is an extension of digital
mammogram
• Breast is compressed once, machine
takes many low dose x-rays as it moves
over the breast in an arc, images can then
be combined into a 3-dimensional picture

51. 3 D- Images

52. MRI for Breast
• Just as mammogram is done with
specially designed x-ray machine, Breast
MRI requires special equipment
• MRI is used mainly for following purpose:
To measure the size of the cancer
To look for any other tumour
To look at opposite breast
Screening MRI with yearly mammogram in certain high risk
cases

53. MRI Breast

54. Breast mass on MRI

55. MRI with breast implant

56. Ultrasound for Breast
• It has become a valuable tool to use along
with mammogram because it’s widely
available, noninvasive and cost effective
• It is good to have a closer look at some
breast masses, if required U/S guided
FNAC is possible
• It is also used to look at axillary lymph
nodes

57. Mass on ultrasound

58. Mass on ultrasound

59. Mass on ultrasound

60. Mass on ultrasound

61. U/S versus mammogram

62. FNAC under ultrasound
guidance

63. Ductogram
Galactogram
• Sometimes it is done to find the cause of
any worrisome nipple discharge
• Through a very thin plastic tube contrast is
put in which outlines the duct on x-ray and
can show whether there is a mass inside
the duct

64. Experimental imaging methods
• Scintimammography/ MBI
Radioactive tracer technetium sestamibi
is given IV, it attaches to breast cells and
detected by Gamma camera
• Electrical Impedance imaging
based on idea that breast cancer cells
conduct electricity in a different way than
normal cells

65. Other experimental imaging
• Optical imaging tests pass light into the
breast and then measure the light that
returns or passes through the tissue
• Positron emission
mammography(PEM) uses sugar
attached to a radioactive particle to detect
cancer cells.
• Thermal imaging is a way to measure
and map on the surface of the breast
using heat sensing camera

66. Scintimammography

67. Mammogram report
• Patient information
• Clinical history
• Procedure: Screening or Diagnostic
Findings:mass,calcification,asymmetry
architectural distortion or associated lesion
• Comparision to previous study/Any U/S
• Impression/ Final assessment
• Management Recommendation (optional)

68. Expert quote::
• Before you go to get a mammogram, make sure you
know whether you're there for a screening mammogram
or a diagnostic mammogram. If you're there for your
annual screening mammogram, you may not meet with
the radiologist or get your results the same day.
Sometimes, there's an advantage to this. Getting your
results later often means having two doctors look at your
mammogram. A lump, pain, nipple discharge, breast
implants, or breast surgery automatically make your
mammogram diagnostic. If you have a lump, or other
symptoms, tell the mammography center so they know
what they're dealing with."
•-- Susan Greenstein Orel, M.D.

69. 69
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

70. 70
male breast

71. 71
Gynecomastia
• It 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.

72. Thank you
Have a nice day