This document provides information about mammography, including its indications, types of examinations, basics, instrumentation, and procedures. Mammography uses low-energy x-rays to detect breast pathologies. It can be used for screening asymptomatic women, investigating breast lumps, or following up after breast surgery. Diagnostic mammograms use two or three views of each breast, while screening mammograms use a two-view protocol. Modern instrumentation includes flat panel detectors, grids, compression paddles, and automatic exposure control. Procedures involve craniocaudal and mediolateral oblique views. Reporting follows the BI-RADS system for risk assessment.

1. MAMMOGRAPHY
DR. BRIBIN BRIGHT

2. MAMMOGRAPHY - INDICATIONS
 Screening of asymptomatic women.
 Screening of high risk women.
 Follow up of patients after mastectomy of same and opposite breast / same breast with implant
 Investigations of benign breast diseases with eczematous skin,nipple discharge , skin thickening .
 Investigation of a breast lump.
 Investigation of occult primary with secondaries .
 Male breast evaluation .

3. TYPE OF MAMMOGRAPHIC EXAMINATION
 Diagnostic mammography
Is performed on patients with symptoms or elevated risk factors.
Two or three views of each breast may be required.
 Screening mammography
Is performed on asymptomatic women with the use of a two view protocol,
usually medial lateral oblique and cranio caudal , to detect on unsuspected cancer

4. MAMMOGRAPHY - BASICS
 Uses low-energy x-rays (40kVp) for dectecting breast pathologies.
 Higher kV - Poor Contrast
Lower kV - Good Contrast
 Tissues within breast have very small difference in attenuation property - Lacks contrast
 <40kVp - Good photoelectric effect - brings out contrast between the tissues within the breasts.
 Better contrast
Better detailing of structures

5. INSTRUMENTATIONS
 HIGH FREQUENCY X-RAY GENERATOR
 X-RAYTUBE
 ANODE
 CATHODE
 BEAM PORT
 K-EDGE FILTERS
 COMPRESSION PADDLE
 SPOT COMPRESSION
 PARALLEL LINEAR GRID
 IMAGE RECEPTOR
 AEC (AUTOMATIC EXPOSURE CONTROL)

6. X-RAY TUBE
 Rotating Anode type
- Glass or Metal ceramic
Advantage
-Decreases off focus radiation
-IncreasesTube lighting
 Cathode - Dual focalspots
0.3mm (Imaging)
0.1 mm (Magnification)
( Focal spot - Penumbra - Resolution)
Helps identifiying microcalcification

7. ANODE (TARGET)
Usually-Tungsten (xray /Floro/ CT/ cathlab)
 MOLYBDENUM -17.5 & 19.6 keV
 RHODIUM -20.2 & 22.7 keV
 CHARACTERISTIC RADIATION
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 and 23kev is produced with Rh

9.  ANODE ANGLE = 16° to 0 to -9°
 EFFECTIVE ANODE ANGLE
- Angle of anode relative to the horizontal tube mount
 XRAYTUBE TILT
-To reduce unwanted radiation
- focus only to the breast area

10.  SOURCETO IMAGE DISTANCE (SID)
- lesser than usual Radiography -60/65 cm (Chest = 18)
- short SID
- Heel Effect utilized
 At Cathode → chestwall – Thicker tissues
SIDE
 At Anode → Nipple region – LessThickness
SIDE
Non-uniformity of X-ray Intensity
Along the cathode side - More Intensity
Along the Anode side - Less Intensity

11. PARTS OF MAMMOGRAPHY EQUIPMENT
 Beam port - 1 mm Beryllium
Since metal/ Glass is used in XRAYTUBE
metal will absorb the low energy photons from xray tube
 K-edge filters - Cuts unwanted Low energy photons (RADIATION)
/ High energy photons (SCATTER – Reduces contrast)
(0.03mm Mo / 0.025mm Rh)

12. PARTS OF MAMMOGRAPHY EQUIPMENT
To decrease Breast thickness, spreads out the tissue
- Spreads out superimposed anatomy.
 Scatter Radiation - contrast
 Radiation dose to the breast tissue
 Geometric Blurring (closer to image receptor )
 Decreases the kinetic blur .
 Makes breast thickness uniform in film density.
 Differentiates the easily compressible cysts and fibro-
glandular tissue from the more rigid carcinomas
 Separates the super imposed breast lesions .
Compression paddle

13. PARTS OF MAMMOGRAPHY EQUIPMENT
 GRIDS
 Stationary grids or grids placed in between the screen and the film are no longer used as the thin grid lines
compromised on the quality of the image .
 Covered tiny details such as microcalcifications
 Hence oscillating grids are used o Grid ratio of 4 :1 or 5 : 1
 The grid lines are eliminated by the motion of the grid .
 Grids improve the image quality and cause a significant reduction

14. PARTS OF MAMMOGRAPHY EQUIPMENT
 Spot.compression - for imaging particular region
 Parallel Linear grid - (4:1 to 5:1) low grade ratio grids used
to increase the Contrast
 Image Receptor
Screen film
CR Cassette
Flat panel detector - (Digital Mammography)
 AEC -Automatic Exposure Control
KeV selected → MAS automatically chosen.

15. FLAT PANEL DETECTORS - INDIRECT
Indirect Amorphous silicon technology
 Xray scintillator (Gradoliniun Sulphate / Csl)
Produces light flashes when Xray beam falls over it.
 Silicon Photodiode array (Photo detector)
Made of Amorphous silicon
Converts light photons from the scintillator into electrical signal
 TFT-electronic switch
- Reads electrical signal
- Gives positional information
-This data is sent to AEC (Analogue to Digital Converter)
 AEC
Converts it into digital signal and are finally sent to Computer for processing
 Disadvantage - LIGHT SCATTER
Scattering of light within the phosphors leading to unsharpness

16. FLAT PANEL DETECTORS - DIRECT
 Crystals of amorphous selenium
directly converts Xrays into electrical signal that is stored in a capacitor (ready to be read)

17. MAGNIFICATION TECHNIQUE
 To increase the visibility of finer details like microcalcification
Increase O ID - object to Image Distance
Breast is kept over a raised platform
No need for grid as there is presence of air gap

18. SCREEN FILM MAMMOGRAPHY
 Old method
 The image is created directly on a film-Non modifiable
 Less sensitive for women with dense breasts
 Screen film cassette used
Single emulsion film
Single screen
Terbium activated Gadolinium oxysulphide
Screen emits green light
Film will be sensitive to greenlight (ORTHOCHROMATIC FILM)

19. COMPUTER RADIOGRAPHY (CR) MAMMOGRAPHY
 A/K/A Filmless radiography
Electronic radiography
Digital storage phosphor imaging
 Xray images are acquired in digital format
 Photostimulable phosphor plates used
 Imaging plate has high sensitivity to xrays
 COMPONENTS
 storage phosphor cassette
 Storage phosphor reader
 Bar code scanner
 Workstation
Photostimuliable Phosphor (PSP) Cassette
PSP Receptor materials
. BaFBr : Eu2+
. BaF (Br1): Eu 2+
.Ba SrFBr:Eu 2+

20. DIGITAL MAMMOGRAPHY
 Also called full-field digital mammography (FFDM)
-in which the x-ray film is replaced by electronics that convert x-rays into mammographic pictures of the breast.
Display Monitor - HIGH RESOLUTION (5 MP)
 Direct Digital Mammography
- Flat panel detector with amorphous selenium array
 Indirect Digital Mammography
-Flat panel scintillator with amorphous silicon diode array

21. DIGITAL MAMMOGRAPHY
 ADVANTAGE
Better contrast,more details.Better delineation of parenchyma & subcutaneous tissue
Better noise level reduction
Tolerance to over/under exposure (Avoids Repetition?
Post-processing techniques for better diagnosis
Radiation dose is decreased- Mean glandular dose in mammography
Screen Film (2-3m bGy)
Digital (20-30% reduction)
Image can be seen quickly and stored digitally(less storage space )

22. LIMITATIONS OF 2D MAMMOGRAPHY
 20% of cancers will be missed
 10% recalled for additional workup
 75-80% of biopsies result in benign lesions
 sensitivity decreases with increased breast density
 2D mammograms,take images only from the front and side, this may create images with
overlapping breast tissue

23. ADVANCES IN DIGITAL MAMMOGRAPHY
 Computer -Aided Diagnosis
- uses software to detect area of clinical significance and highlight them for better output image
 Digital BreastTomosynthesis (DBT)
XrayTube rotates /moves in a 50-55° arc around the breast,
capturing several (11-25) low dose projections of the breast at different angles.
Then reconstructed to 3D Projection images (1 mm slices)
3D MAMMOGRAPHY

24. DIGITAL BREAST TOMOSYNTHESIS - DBT (3D MAMMOGRAPHY )
Disadvantages of DBT
• Twice the radiation compared to 2D mammo
• More storage requirements
• Takes longer time to read
• Cannot be read on demand
Advantages of DBT
• Increased cancer detection rate
• Lesions are better defined
• Precise location of lesions
• Less false positive recalls
3D MAMMOGRAPHY

25. HOW MAMMOGRAM IS PERFORMED ?

26. HOW MAMMOGRAM IS PERFORMED ?
 CRANIO CAUDAL (CCVIEW)
demonstrate maximum tissue on both medial and lateral
aspects of the breast with the retromammaryspace and some
pectoral muscle
The following points were analyzed on CC view:
 nipple should be in profile
 nipple should point straight and should not be pointing lateral
or medial
 PND (pectoral nipple distance) must be within 1 cm of the
same measurement of the MLO view.

27. HOW MAMMOGRAM IS PERFORMED ?
 MEDIOLATERAL OBLIQUE(MLOVIEW)
demonstrate axilla,axillary tail,and inframammary
fold with all the breast tissue
The following points were analyzed on MLO view:
 Breast should be pulled out with nipple in profile
 The pectoralis muscle margin should be well visualized
 The lower edge of pectoralis muscle should be at the level
of pectoralis–nipple line (PNL) or below
 PND must be within 1 cm of the same measurement of
the MLO view.
 When MLO image of both breasts are viewed as mirror
images,pectoralis muscle should meet in the midline and
form a “V”.

28. OTHER VIEWS
 Latero-medial (LO) - from the outside towards the center
 Medio-lateral (ML) - from the center towards the outside
 Spot compression - compression on only a small area,to get more detail
 Cleavage view - both breast compressed,to see tissue near the center of
the chest
 Magnification -to see borders of structures and calcifications

30. REPORTING A MAMMOGRAM
 Breast Imaging Reporting and Data System (BI-RADS)
RISKASSESSMENT AND QUALITYASSURANCETOOL developed byAmerican college of radiology (ACR)
that provides a widely accepted lexicon and reporting schema for imaging of the breast.
All mammographic, ultrasound and breast MRI findings and reports should closely adhere to the BI-RADS lexicon
and assessment categories.

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