mammography

1. Mammography

2.  A mammogram is an x-ray picture of the
breasts. It is used to find tumors and to help
tell the difference between non-cancerous
(benign) and cancerous (malignant)
disease.
 Mammography uses low dose x-ray; high
contrast, high-resolution film; and an x-ray
system designed specifically for imaging the
breasts.

3.  Early detection of breast cancers.
 To help the radiologist or surgeon guide the needle to the
correct area in the breast during biopsy.

4. Anatomy
 The breast is a mass of glandular, fatty, and
fibrous tissues positioned over the pectoral
muscles of the chest wall and attached to
the chest wall by fibrous strands called
Cooper’s ligaments. A layer of fatty tissue
surrounds the breast glands and extends
throughout the breast. The fatty tissue gives
the breast a soft consistency.

5. The breast is composed of:
 milk glands (lobules) that produce milk
 ducts that transport milk from the milk
glands (lobules) to the nipple
 nipple
 areola (pink or brown pigmented region
surrounding the nipple)
 connective (fibrous) tissue that surrounds
the lobules and ducts
 fat

6. – Breast profile:
 A ducts
 B lobules
 C dilated section of duct to hold milk
 D nipple
 E fat
 F pectoralis major muscle
 G chest wall/rib cage

8. Schematic Diagram of the Female Breast

9. Basic Physics of Mammography:
 X-ray images depend on differences in x-ray stopping
power (attenuation) to separate tissues. In general, a clear
separation between normal functioning tissue, and
abnormal cancerous tissues is not possible since their
attenuation if very similar. However both functional tissue
and cancer can be separated from fatty storage tissues
which normally surround active breast tissue, even in lean
persons. This is due to a substantially lower attenuation
caused by fat.
In older women, the functional glandular tissue diminishes,
leaving only thin supporting tissues clearly outlined by fatty
tissues. Mammography in these "mature" breasts is very
effective, since even small cancers are well outlined by fat.
In addition, many cancers develop calcium deposits which
strongly stop X-rays and are easily seen on mammograms.

10. Basic Limitations of Mammography:
 Since mammography cannot separate
normal gland tissue from tumors, it is much
more effective when gland tissue diminishes
with age. Many women retain glandular
tissue as they "mature", and it camouflages
tumors until they are large. As you might
expect, the young women's breast normally
contains more active tissue, which again
interferes with detection of small cancers.

11. Types of Mammography
 Screening
 Diagnostic
 Ductgram/Galactogram (imaging the breast
ducts)

12. Screening mammography
 Screening mammography is an x-ray examination
of the breasts in a woman who is asymptomatic
(has no complaints or symptoms of breast cancer).
The goal of screening mammography is to detect
cancer when it is still too small to be felt by a
woman or her physician. Early detection of small
breast cancers by screening mammography
greatly improves a woman's chances for
successful treatment. Screening mammography is
recommended every one to two years for women
once they reach 40 years of age and every year
once they reach 50 years of age. In some
instances, physicians may recommend beginning
screening mammography before age 40 (i.e. if the
woman has a strong family history of breast
cancer).

13. Diagnostic mammography
 Diagnostic mammography is an x-ray examination
of the breast in a woman who either has a breast
complaint (for example, a breast lump or nipple
discharge is found during self-exam) or has had
an abnormality found during screening
mammography. It is more involved and time-
consuming than screening mammography and is
used to determine exact size and location of
breast abnormalities and to image the surrounding
tissue and lymph nodes. Typically, several
additional views of the breast are imaged and
interpreted during diagnostic mammography.
Thus, diagnostic mammography is more
expensive than screening mammography.

14. Mammography equipment

16. How is Mammography
Performed?
 During mammography, the technologist will
position the patient and image each breast
separately. One at a time, each breast is
carefully positioned on a special film
cassette and then gently compressed with a
paddle (often made of clear Plexiglas or
other plastic). This compression flattens the
breast so that the maximum amount of
tissue can be imaged and examined.

17. Cont…
 At some facilities, mammography technologists
may place adhesive markers to the breast skin
prior to taking images of the breast. The purpose
of the adhesive markers is twofold: first, to identify
areas with moles, blemishes or scars so that they
are not mistaken for abnormalities, and secondly,
to identify areas that may be of concern (e.g. a
lump was felt during physical examination). Some
centers routinely mark the nipple with a small dot
to provide a clear "landmark" for the radiologist on
the mammogram images.

18. Breast compression is necessary in
order to:
 Even out the breast thickness so that all of the
tissue can be visualized.
 Spread out the tissue so that small abnormalities
are less likely to be obscured by overlying breast
tissue.
 Allow the use of a lower x-ray dose since a thinner
amount of breast tissue is being imaged.
 Hold the breast still in order to minimize blurring of
the image caused by motion.
 Reduce x-ray scatter to increase sharpness of
picture.

19. Mammo app of normal breast
Different tissues in the breast absorb
different amounts of x-rays, producing
different shades of black, gray, and white on
the film:
 Fatty tissue absorbs a small amount of x-
rays and appears black or dark gray.
 Normal fibrous and glandular tissues (milk
glands, lymph nodes) contain water fluid
and absorb a moderate amount of x-rays,
and appear light gray.
 Fibrous and glandular tissues may contain
calcium and appear nearly white or white.

21. Breast comp & mammo app..

22. Mammographic views
 Standard views
 Supplemental views

23. Standard views
 CC (cranio-caudal) view
 MLO (medio-lateral oblique) view

24. Supplemental Views
 Lateromedial, LM:
 Mediolateral view, ML
 Exaggerated cranial-caudal,
 Magnification views,
 Spot compression view

25. Mediolateral Oblique View (MLO)
 The mediolateral oblique view (MLO) is
taken from an oblique or angled view.
During routine screening mammography, the
MLO view is preferred over a lateral 90-
degree projection because more of the
breast tissue can be imaged in the upper
outer quadrant of the breast and the axilla
(armpit).

26.  With the MLO view, the pectoral (chest)
muscle should be depicted obliquely from
above and visible down to the level of the
nipple or further down. The shape of the
muscle should curve or bulge outward as a
sign that the muscle is relaxed; the medial
(middle) portion of the breast should be
prominent in the MLO view. It is important
that compression be applied over the whole
image area. The nipple should be depicted
in profile and a small stomach fold should be
visible as a sign that the whole breast is
reproduced.

28. Cranio-Caudal View (CC)
 The cranio-caudal view (CC) images the
breast from above. This view may be taken
during routine screening mammography and
during diagnostic mammography.
 With the CC view, the entire breast
parenchyma (glandular tissue) should be
depicted. The fatty tissue closest to the
breast muscle should appear as a dark strip
on the x-ray and behind that it should be
possible to make out the pectoral (chest)
muscle. The nipple should be depicted in
profile.

31. Spot compression view cont…
 Spot compression views show the borders
of an abnormality or questionable area
better than the standard mammography
views. Some areas that look unusual on the
standard mammography images are often
shown to be normal tissue on the spot
views. True abnormalities usually appear
more prominently and the margins (borders)
of the abnormality can be better seen on
compression views.

33. ASSESSMENT CATEGORIES
 Category 0 / Need Additional Imaging Evaluation
Finding for which additional imaging evaluation is needed.
This is almost always used in a screening situation and
should rarely be used after a full imaging work up. A
recommendation for additional imaging evaluation includes
the use of spot compression, magnification, special
mammographic views, ultrasound, etc. Whenever possible,
the present mammogram should be compared to previous
studies. The radiologist should use judgment in how
vigorously to pursue previous studies.
 Category 1 / Negative
There is nothing to comment on. The breasts are
symmetrical and no masses, architectural disturbances or
suspicious calcifications are present

34.  Category 2 / Benign Finding
This is also a negative mammogram, but the
interpreter may wish to describe a finding.
Involuting, calcified fibroadenomas, multiple
secretory calcifications, fat containing lesions such
as oil cysts, lipomas, galactoceles, and mixed
density hamartomas all have characteristic
appearances, and may be labeled with
confidence. The interpreter might wish to describe
intramammary lymph nodes, implants, etc. while
still concluding that there is no mammographic
evidence of malignancy.

35.  Category 3 / Probably Benign Finding - Short
Interval Follow-Up Suggested
A finding placed in this category should have a
very high probability of being benign. It is not
expected to change over the follow-up interval, but
the radiologist would prefer to establish its stability.
Data are becoming available that shed light on the
efficacy of short interval follow-up. At the present
time, most approaches are intuitive. These will
likely undergo future modification as more data
accrue as to the validity of an approach, the
interval required, and the type of findings that
should be followed.

36.  Category 4 / Suspicious Abnormality - Biopsy
Should Be Considered
These are lesions that do not have the
characteristic morphologies of breast cancer but
have a definite probability of being malignant. The
radiologist has sufficient concern to urge a biopsy.
If possible, the relevant probabilities should be
cited so that the patient and her physician can
make the decision on the ultimate course of
action.
 Category 5 / Highly Suggestive of Malignancy -
Appropriate Action Should Be Taken
These lesions have a high probability of being
cancer

37.  Category 6: Biopsy proven malignancy