This document provides an overview of mammography, including definitions, indications, equipment, technique, findings, and assessment categories. It defines mammography as an x-ray examination of the breast to detect changes. Key indications include focal signs in women aged 40 or older and screening for high-risk women. Equipment has advanced from film-screen to digital mammography and tomosynthesis. Standard views are mediolateral oblique and craniocaudal. Findings can include masses, asymmetries, distortions, and calcifications, which are categorized based on characteristics like shape, margin, density, and distribution.

1. MAMMOGRAM
Presented by Dr. LT
15. 6. 2023

2. Presentation outline
Definition
 Indication
Non-Indication
 Equipment
 Technique & Radiological Views
Mammography Lexicon
 BI –RADS Assessment Category
 References

3. What is mammogram?
Mammogram is a x-ray examination of the breast to
detect and evaluate any changes in the breast.
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4. Indications
 Focal signs in women aged ≥40 years in the context of triple
(i.e.clinical, radiological and pathological) assessment at a
specialist, multidisciplinary diagnostic breast clinic
Following diagnosis of breast cancer, to exclude multifocal/
multicentric/bilateral disease
Breast cancer follow-up, no more frequently than annually
or less frequently than biennially for at least 10 years
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5. Investigation of metastatic malignancy of unknown origin
Screening of women with a moderate/high risk of familial
breast cancer who have undergone genetic risk assessment in
accordance with National Institute for Health and Clinical
Excellence (NICE) guidance
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6. Not Indicated
Asymptomatic women without familial history of breast
cancer, aged younger than 40 years
Investigation of generalized signs/symptoms—e.g.
cyclical mastalgia or nonfocal pain/lumpiness
Prior to commencement of hormone replacement therapy
To assess the integrity of silicone implants
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7. Individuals affected by ataxia-telangiectasia mutated
(ATM) gene mutation with resultant high sensitivity to
radiation exposure, including medical x-rays
Routine investigation of gynaecomastia
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8. Equipment
Conventional film-screen mammographic technology has
been superseded by full-field digital mammography (FFDM),
which has a higher sensitivity in:
• women aged younger than 50 years
• pre/perimenopausal women
• women with dense fibroglandular breast tissue
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9. Developments of FFDM include the following:
1. Tomosynthesis, which creates a single 3D image of the
breast by combining data from a series of 2D radiographs
acquired during a single sweep of the x-ray tube. This
technique has a proven significant increased accuracy in
the diagnostic evaluation of masses and parenchymal
distortions, irrespective of breast composition:
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10. Its increased accuracy in the morphological and
margin extent analysis allows more precise assessment of
tumour size, both in fatty and dense breast tissue,
confirming its role in diagnostic symptomatic and
screening practice.
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11. A mammogram and a stationary digital breast tomosynthesis 10

12. 2. Contrast-enhanced digital mammography
(i.e.angiomammography). Two approaches are available:
temporal sequencing (in which images pre- and postcontrast are
subtracted with a resultant angiomammogram) and dual energy
imaging (in which imaging at low and high energies detailing
parenchyma and fat, respectively, with and without iodine are
obtained). The subsequent views can then be subtracted.
Ongoing studies will inform the future diagnostic role of this
technique.
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13. The high-energy
image of CEM
The low-energy
image of CEM
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14. The dual-energy subtraction image of CEM.
• This type of image can highlight areas of
contrast enhancement.
• The lesion shows marked enhancement in this
image, whereas the patient shows minimal
degree of background parenchymal
enhancement.
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15. 3. Computer-aided detection (CAD) software can assist film
reading by placing prompts over areas of potential
mammographic concern. There is evidence that, even in the
screening setting, single reading in association with CAD may
offer sensitivities and specificities comparable to that of double
reading.
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16. Technique & Radiological Views
Standard mammographic examination comprises imaging of
both breasts in two views—namely the mediolateral oblique
(MLO) and craniocaudal (CC) positions.
Screening methodology is bilateral, two-view (MLO and CC)
mammography at all screening rounds.
Additional views may be required to provide adequate
visualization of specific anatomical sites:
1. Lateral/medial extended CC
2. Axillary tail
3. Mediolateral/lateromedial
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17.  Compression of the breast is an integral part of mammographic
imaging resulting in:
1. reduction in radiation dose
2. immobilization of the breast, thus reducing blurring
3. uniformity of breast thickness, allowing even penetration
4. reduction in breast thickness, thus reducing scatter/noise
achieving higher resolution
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18. Adaptation of the technique can provide additional
information:
1. Spot compression, to remove overlapping composite tissue
2. Magnification (smaller focal spot combined with air gap),
to provide morphological analysis
In the presence of subpectoral implants, the push-back
technique of Eklund can aid visualization of breast tissue.
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19. the push-back technique of Eklund
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20. ■ If you find any
abnormality, make a
decription and
assessment
category.
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22. BI-RADS Assessment Categories
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23. a- The breast are almost entirely fatty.
Mammography is highly sensitive in this
setting.
b- There are scattered areas of fibroglandular density.
The term density describes the degree of x-ray
attenuation of breast tissue but not discrete
mammographic findings.
Breast Composition
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24. ■ c- The breasts are heterogeneously dense,
which may obscure small masses. Some
areas in the breasts are sufficiently dense
to obscure small masses.
d - The breasts are extremely dense, which lowers the
sensitivity of mammography.
Breast Composition
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25. Mass
A 'Mass' is a space occupying 3D lesion seen in two different projections.
If a potential mass is seen in only a single projection it should be called a 'asymmetry' until its three-
dimensionality is confirmed.
■ Shape: oval (may include 2 or 3 lobulations), round or irregular
■ Margins: circumscribed, obscured, microlobulated, indistinct, spiculated
■ Density: high, equal, low or fat-containing.
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26. The shape of a mass is either round, oval or irregular. Always
make sure that a mass that is found on physical examination is the
same as the mass that is found with mammography or ultrasound.
Location and size should be applied in any lesion, that must
undergo biopsy.
Shape
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27. Margin
The margin of a lesion can be:
■ Circumscribed (historically well-defined).
This is a benign finding.
■ Obscured or partially obscured, when the margin
is hidden by superimposed fibroglandular tissue.
Ultrasound can be helpful to define the margin
better.
■ Microlobulated. This implies a suspicious finding.
■ Indistinct (historically ill-defined).
This is also a suspicious finding.
■ Spiculated with radiating lines from the mass is a
very suspicious finding.
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28. Density
■ The density of a mass is related to the expected attenuation of an equal volume of fibroglandular tissue.
■ High density is associated with malignancy.
It is extremely rare for breast cancer to be low density.
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29.  Here multiple round circumscribed low
density masses in the right breast.
 These were the result of lipofilling,
which is transplantation of body fat to
the breast.
 Here a hyperdense mass with an irregular
shape and a spiculated margin.
Notice the focal skin retraction.
 This was reported as BI-RADS 5 and proved
to be an invasive ductal carcinoma.
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30. Findings that represent unilateral
deposits of fibroglandulair tissue not
conforming to the definition of a mass.
•Asymmetry as an area of fibroglandulair
tissue visible on only one mammographic
projection, mostly caused by
superimposition of normal breast tissue.
•Focal asymmetry visible on two
projections, hence a real finding rather than
superposition.
This has to be differentiated from a mass.
•Global asymmetry consisting of an
asymmetry over at least one quarter of the
breast and is usually a normal variant.
•Developing asymmetry new, larger and
more conspicuous than on a previous
examination.
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31.  a focal asymmetry
seen on MLO and
CC-view.
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32.  global asymmetry
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33. Architectural
Distortion
The term architectural
distortion is used, when the
normal architecture is distorted
with no definite mass visible.
This includes thin
straight lines or spiculations
radiating from a point, and
focal retraction, distortion or
straightening at the edges of
the parenchyma.
The differential
diagnosis is scar tissue or
carcinoma.
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34. Calcification
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35. There is one exception
of the rule: an isolated
group of punctuate
calcifications that is
new, increasing, linear,
or segmental in
distribution, or
adjacent to a known
cancer can be assigned
as probably benign or
suspicious.
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37. Distribution of calcifications
These descriptors are arranged
according to the risk of malignancy:
■ Diffuse: distributed randomly throughout the
breast.
■ Regional: occupying a large portion of
breast tissue > 2 cm greatest dimension
■ Grouped (historically cluster): few
calcifications occupying a small portion of
breast tissue: lower limit 5 calcifications
within 1 cm and upper limit a larger number
of calcifications within 2 cm.
■ Linear: arranged in a line, which suggests
deposits in a duct.
■ Segmental: suggests deposits in a duct or
ducts and their branches.
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39. References
 https://radiologyassistant.nl/breast/bi-rads/bi-rads-for-mammography-and-
ultrasound-2013#mammography-breast-imaging-lexicon-breast-composition
 Chapman & Nakielny's Guide to Radiological Procedures
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40. T h a n k y o u
Have A Nice Day