Mammography is an x-ray test used to aid in the early detection and diagnosis of breast diseases in women. It uses low-dose radiation to produce images of the breast tissue. Screening mammograms are used to look for signs of breast cancer in women without symptoms, while diagnostic mammograms are used when abnormalities are detected or a woman has breast symptoms. Mammograms produce images of the breast tissue and can detect abnormalities such as masses, calcifications, architectural distortions, and asymmetries that may indicate breast cancer. The images are analyzed according to the Breast Imaging Reporting and Data System (BI-RADS) to determine if follow-up is needed. Digital mammography provides enhanced image quality compared to traditional film

1. *

2. *
It is a plain X-ray of soft tissue of breast using
low voltage and high ampearage X-rays.
*Mammography is specialized medical imaging
that uses a low-dose x-ray system to see inside
the breasts.
*A mammography image, called a mammogram,
aids in the early detection and diagnosis of
breast diseases in women.

3. *
Screening
--As a part of annual examination in women over age of 40.
--High risk women ie.. in women with family history from
age 30 onwards or 10 years earlier than at mother’s breast
cancer has been detected.

4. Diagnostic:
*Investigation of benign breast diseases with eczematous skin,
nipple discharge , skin thickening .
*Investigation of a breast lump
*Investigation of occult primary with secondaries.
*Mammography guided biopsy.
Conservative breast surgeries - pre op and post operatively

5. *
 Screening mammograms
*A screening mammogram is used to look for
signs of breast cancer in women who don’t
have any breast symptoms or problems. X-ray
pictures of each breast are taken from 2
different angles.
--Mediolateral oblique view
--Cranio caudal view

6. Best view to image all of the
breast tissue and the pectoral
muscle .
--The C-arm of the
mammographic unit is rotated to
45 degree so that the cassette is
parallel to the pectoral muscle .
--The film holder is kept high up
in the axilla and the patient s
arm is abducted at the elbow by
80degrees.
--The xray beam enters the
breast from the medial side
–compression is applied to the
pectoralis major
muscle .
MEDIO-
LATERAL
OBLIQUE VIEW

8. CRANIO CAUDAL VIEW
--The casette is placed under
the breast at the level of the
inframammary fold .
--The breast is then pulled until
the inframammary fold is taut .
-- Compression is applied and
Xraybeam is directed vertically
from above .
--Postero medial aspect should
also be included .

10. *
*Lateral projections (lateromedial)
*Extended craniocaudal projection
*Cone down compression view
*Angled craniocaudal views
*Tangential views in palpable masses
*Spot and magnification views
*Cleavage view
*Modified compression technique .

11. Diagnostic mammograms
*Mammograms used to look at a woman’s breast
if she has breast symptoms or if a change is
seen on a screening mammogram.
These are called diagnostic mammograms.
They may include extra views of the breast that
aren’t part of screening mammograms.
Sometimes diagnostic mammograms are used to
screen women who were treated for breast
cancer in the past.

13. NORMAL MAMMOGRAM

14. *
* Types of breast changes
---calcifications
---masses
---architectural distortion
---Spiculations
---Duct distortion
---lobulated mass.
---Irregular soft tissue shadow.

15. *Calcifications
*Calcifications are tiny calcium deposits within the breast
tissue. They look like small white spots on a mammogram.
*Two types of calcifications:
---Microcalcifications
---Macrocalcifications

16. *Microcalcifications are tiny specks of calcium in the breast.
When seen on a mammogram, they are more of a concern
than macrocalcifications.
*These calcifications can be
arranged in clusters/ linear
manner/ branching type.

17. *Microcalcifications can be
--Fine Pleomorphic
--Amorphous
--Coarse Heterogenous

18. Fine pleomorphic calcifications are
irregular, small – usually of <0.5 mm size
calcifications which can be fine linear
type or fine branching type.
Have highest probability of malignancy.

19. Amorphous
calcifications are small
<0.5 mm; irregular
calcifications; differ
from fine pleomorphic
type in their
conspicuity and
density.
Edges are not defined
as sharply as that of
pleomorphic type;
present with slightly
higher density
compared to that of
sorrounding glandular
tissue.

20. Coarse heterogenous
calcifications are
irregular and
conspicuous;
generally larger than
0.5 mm and are
associated with more
often benign
conditions such as
fibrosis or
fibroadenomas, can
be associated with
malignancy.

21. *Macrocalcifications are larger calcium deposits
that are most likely due to changes caused by
aging of the breast arteries, old injuries, or
inflammation. These deposits are typically
related to non-cancerous conditions.
*Macrocalcifications become more common as
women get older (especially after age 50).

22. *

23. -Focal
asymmetries
lack convex
outward
borders along
atleast a
portion of their
periphery on
both views.
-Masses display
consistent
convex margins

24. Series of thin straight
lines or spiculations
radiating from an area
that does not have
features of mass or
focal asymmetry.
---can be seen
radiating from a mass
or focal asymmetry-
which strongly suggest
the presence of
malignancy

25. *
*The radiographically visible densities include:
--varying degree of ducts.
--lobular elements.
--fibrous connective tissue.
*The supportive connective tissue is highly cellular and richly
vascularised with significant water density – constitutes the
essence of breast opacity in mammography.
*Adipose tissue comprises a large portion of breast and is
radiolucent.

26. *Sexual hormones influence the degree of hydration of the
adult breast.
*The breast is more radiolucent and better contrasted in the
first part of the menstrual cycle
*Pregnancy and lactation make the glandular and connective
tissue structures hypertrophic and more hydrated which leads
to diffuse increase in breast density

27. The Breast Imaging Reporting and Data System [BI-
RADS] classifies breast density into 4 categories.
Breast comprised
mostly of fatty tissue.
Scattered areas of dense
glandular and fibrous
tissue.

28. Dense glandular and fibrous
tissue (described as
"heterogenously dense").
This can make it hard to see
small tumors in or around the
dense tissue.
Extremely dense, which
makes it hard to see tumors
in the tissue.

29. Breast Imaging Reporting and
Data System
Category Assessment Follow-Up
0 Need additional imaging
evaluation: means that
more studies are necessary
to gather more information.
Additional imaging
needed before a
category can be
assigned.
1 Negative: means that there
is no significant or
noticeable abnormality to
report.
Continue annual
screening
mammography (for
women over age 40).
2 Benign (noncancerous)
finding: means that there
has been a finding, such as
benign calcifications or
fibroadenoma, which is not
cancerous.
Continue annual
screening
mammography (for
women over age 40)

30. Category Assesment Followup
3 Probably benign: means that
there is a finding that is most
likely benign, but should be
followed in a shorter period of
time to see any changes
Receive a 6-
month follow-up
mammogram
4 Suspicious abnormality;
Findings do not definitely look
like cancer but could be
cancer& can have a wide
range of suspicion
levels&divided further:
->4A: Finding with a 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 Category 5
Biopsy should be
considered

33. Category Assessment Follow-Up
5 Highly suggestive of
malignancy – Appropriate
action should be taken
The findings look like
cancer and have a high
chance (at least 95%) of
being cancer
Biopsy is very
strongly
recommended.
6 Known biopsy-proven
malignancy :
This category is only used
for findings on a
mammogram that have
already been shown to be
cancer by a previous
biopsy. Mammograms may
be used in this way to see
how well the cancer is
responding to treatment.
Biopsy is strongly
recommended

34. *
A false-negative mammogram looks normal
even though breast cancer is present.
Overall, screening mammograms do not find
about 1 in 5 breast cancers.
*Women with dense breasts have more false-
negative results as in younger women.

35. False-positive results
*A false-positive mammogram looks abnormal even though no
cancer is actually present. Abnormal mammograms require
extra testing to find out if the change is cancer.
*False-positive results are more common in women who are
younger, have dense breasts, have had breast biopsies, have
breast cancer in the family, or are taking estrogen.
Radiation exposure
*Because mammograms are x-ray tests, they expose the
breasts to radiation. The amount of radiation from each
mammogram is low, but it can still add up over time.

36. *
• 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.

37. Elkland Method for
Imaging with Breast
Implants

38. *
*Digital mammography, also called full-field digital
mammography (FFDM), is a mammography system in
which the x-ray film is replaced by electronics that
convert x-rays into mammographic pictures of the
breast.
*These images of the breast are transferred to a
computer for review by the radiologist and for long
term storage.
*The patient’s experience during a digital
mammogram is similar to having a conventional film
mammogram.

40. *It works like a DR system wherein the x-rays
are converted into photons directly or through
a scintillator indirectly and an electronic signal
detector converts this light/photons into
digitalized form (binary system) to be read
through an external device
*When comparing DM to conventional
mammography, it was found that the overall
diagnostic accuracy of both technologies in
detecting breast cancer detection was similar

41. Nodule at
right outer
quadrant on
right CC view
(black arrow).
(b)Magnification
of
the nodule
shows a rim of
lucent halo
suggestive of a
benign nodule

42. A rounded well defined
calcified nodule in
subcutaneous
fat (CC view)

43. *
Higher contrast resolution.
Ability to manipulate to improve image quality and
visibility.
Reduced false positives.
Simplifies storage and retrieval of images.
Significantly better image acquisition than SFM in
women under 50 years, in pre and perimenopausal
women and in denser breasts.
Able to do stereotactic biopsy.
 Availability of CAD.

44. *
*Expensive
*Less accurate in fatty breasts

45. *
*Xeromammography is a photoelectric method
of recording an X-ray image on a coated metal
plate- using low energy photon beams.
*It is a form of xero radiography.
*This process is developed in late 1960’s and
used to image soft tissue and later focussed on
using the process to detect breast cancer.

47. *
X-rays strike an electronically charged plate of
selenium coated aluminium.
The loss of charge at sites of X-ray
interactions leads to latent image formation
which is converted to visible image by reading
the charge pattern.
This technique gives a very sharp but low
contrast image.

48. *

49. *
*Thermal Imaging / Thermography is the
conversion of Infrared Radiation into Thermal
images.
*A thermal image is an analogue pictorial
representation or visualisation of temperature
differences.
*Thermal imagers detect and record Infra-red
radiation emitted from the surface of any
subject being viewed. The imager does not
have the ability to see below the surface.

50. *
* Thermography is based on the principle that
metabolic activity and vascular circulation in both
pre-cancerous tissue and the area surrounding a
developing breast cancer is almost always higher
than in normal breast tissue.
*In an ever-increasing need for nutrients, cancerous
tumors increase circulation to their cells by holding
open existing blood vessels, opening dormant
vessels, and creating new ones (NEOANGIOGENESIS).
This process frequently results in an increase in
regional surface temperatures of the breast.

51. *Digital Infrared Imaging uses ultra-sensitive
medical infrared cameras and sophisticated
computers to detect, analyze, and produce
high-resolution images of these temperature
variations. Because of DII’s extreme sensitivity,
these temperature variations may be among
the earliest signs of breast cancer and/or a
pre-cancerous state of the breast .

52. *The examination begins with a visual inspection of
the surface of the breasts. This is a standard
procedure that correlates any surface findings with
the infrared images.
* Once this is done, the person will be left for 15
minutes such that his/ her body to reach a steady
temperature state in equilibrium with the special
temperature conditions of the room.
* After this brief waiting time, he/ she will be
positioned in front of the imaging system so that
the surfaces of the breasts, upper chest, and under
arms are imaged.

53. Computerized Medical
Infrared Imaging

54. *The images are captured in real-time from an
ultra-sensitive medical infrared imaging
camera and sent to a sophisticated computer
for storage and analysis.
* Sophisticated computer programs allow the
doctor to isolate temperature differentials,
perform vascular analyses, dynamic thermal
subtraction studies.
*This is followed by digital processing of images
and its grading.

55. *Each breast’s image is placed into one of five
thermobiological (TH) categories:
TH 1 – Normal uniform non-vascular
TH 2 – Normal uniform vascular
TH 3 – Equivocal (questionable)
TH 4 – Abnormal
TH 5 – Severely abnormal

56. Bilateral Breast TH 1 – Normal Uniform Non-Vascular Image
The hotter temperatures are the lighter
colors.
In the normal TH1
image, the color
(temperature) patterns
of the breasts are cool
and very close to
identical when
compared to each
other.

57. The symmetrical
streaks of orange
and red in both
breasts (blood
vessels). This
symmetrical
increase in
metabolism is
commonly caused
by the effects of
hormones.
Left and Right Breast TH 2 – (Grade
3 Mastopathy)

58. Right Breast TH 3 – Equivocal
(Questionable) Image
Note the single hot blood
vessel in the right breast.
This finding will need to
be watched over time for
change. If it remains
stable, or improves, the
finding is normal for the
physiology of this patient.

59. Note the increased temperature
(metabolism) of the right breast. There
are three suspicious areas of higher
temperatures. Especially significant is
the highly vascular area closest to the
right nipple.
Right Breast TH 4 – Abnormal
Image

60. Note the intensely increased
temperature (metabolism) and
vascularity of the entire left breast.
The biopsy results were positive for
inflammatory carcinoma.
Left Breast TH 5 – Severely Abnormal Image

61. *Radiation free.
*Non- invasive.
*Relatively inexpensive.
*Detects early, potentially reversible physiologic
changes associated with later development of
breast cancer.

62. *Monitoring breast health.
*Monitoring for adverse changes after treatment
of breast cancer.
*Helping to monitor hormone replacement
therapy.
--When estrogen dominance is present – this
represents an imbalance between estrogen and
progestrone and we can see a pattern suggestive
of higher risk.

63. *
*Digital Infrared Imaging does not have the
ability to pinpoint the location of a
tumour/lump
* It cannot detect 100% of all cancers.
*It can be positive in infective and inflammatory
conditions also.

64. *

65. *MRI, or magnetic resonance imaging, is a
technology that uses magnets and radio waves
to produce detailed cross-sectional images of
the inside of the body.
* MRI does not use X-rays, so it does not involve
any radiation exposure

66. *
*The American Cancer Society (ACS) recommends that
all high-risk women — those with a greater than 20%
lifetime risk of breast cancer — have a breast MRI and
a mammogram every year. For most women, these
combined screenings should start at age 30 and
continue as long as the woman is in good health.
* According to ACS guidelines, high-risk women include
those who:
--Have a known BRCA1 or BRCA2 gene mutation
--Have a first-degree relative (mother, father, brother,
sister, or child) with a BRCA1 or BRCA2 gene mutation
and have not had genetic testing themselves
--Had radiation therapy to the chest for another type
of cancer, such as Hodgkin’s disease, when they were
between the ages of 10 and 30 years

67. *--Have a genetic disease such as Li-Fraumeni
syndrome, Cowden syndrome or have one of these
syndromes in first-degree relatives.
*Have a personal history of breast cancer, ductal
carcinoma in situ (DCIS), lobular carcinoma in situ
(LCIS), or abnormal breast cell changes such as
atypical ductal hyperplasia or atypical lobular
hyperplasia
*Evaluating a person who has a palpable mass (a
mass that can be felt) that isn’t visible with
ultrasound or mammography

68. *Evaluating a lesion in the densely glandular breast
of a young woman. Young women tend to have
dense breast tissue, which makes it difficult to see
abnormal areas on imaging studies
*Evaluating a person who has breast cancer cells in
an underarm lymph node, but no breast mass that is
not able to feel or to see on a mammogram. In
these cases, where mastectomy is typically
recommended, MRI can help find the precise site of
the cancer’s origin within the breast. Finding the
cancer’s site of origin can expand a woman’s
treatment options from only mastectomy to include
lumpectomy plus radiation

69. *Determining if a cancer is limited to one area of the
breast, or if it is “multicentric” and involves more
than one area. Knowing this affects treatment
choices, since mastectomy is necessary for
multicentric disease. MRI can be particularly useful
for women with invasive lobular cancer, which has a
tendency to be diffuse or multicentric.
*Checking a woman’s other breast for signs of cancer
after she receives her initial cancer diagnosis. The
American Cancer Society recommends that breast
MRI be used to check the other breast for any signs
of cancer.

70. *Examining breast tissue in women who have had
silicone breast implants. MRI scanning can detect
leakage from a silicone-filled breast implant, since
it easily distinguishes silicone gel from surrounding
normal breast and chest wall tissues.
*After treatment for breast cancer, MRI can be useful
for checking scar tissue in women who have
undergone lumpectomy. Any significant changes
could suggest a return of the breast cancer.

71. *MRI scans of other parts of the body — such as the
brain, spinal cord, or bones — may be useful in
people who are known or suspected to have
metastatic breast cancer (cancer that has traveled
outside the breast to other areas of the body).
*Assessing response to neo adjuvant chemotherapy—
motto is to shrink the tumour size pre operatively—
MRI is helpful to predict at an earlier point of time
that which patients are responding to the
chemotherapy.

72. *Before the test, contrast solution (gadolinium-
diethylenetriamine penta acetic acid) injected into
the arm through an intravenous line. The solution
will help any potentially cancerous breast tissue
show up more clearly. Some people experience
temporary discomfort during the infusion of the
contrast solution.
*Cancers need to increase their blood supply in order
to grow. On a breast MRI, the contrast tends to
become more concentrated in areas of cancer
growth, showing up as white areas or
ENHANCEMENT on an otherwise dark background.
*MRI not only produces 3D morphology of breast
tissue but it also provides physiological information
such as vascular density changes associated with
angiogenesis.

73. *The enhancement is in proportion to the
increased vessel density and leakage of
contrast from abnormal tumour vessels which
do not contain all the layers of normal vessels.
*The enhancement within a mass can be
Homogenous/ uniform
Heterogenous/ non uniform
--Peripheral rim enhancement
--Central enhancement

75. *Enhancement may ne non-mass like.
--Linear enhancement but not in ductal
distribution.
--Ductal enhancement is also linear but it
points towards the nipple.

76. Regional enhancement
involves a large
volume.
Enhancement within
these distributions
may be homogenous,
stippled, clumped/
cobble stone like,
reticular / strand like.

77. *
*Breast MRI is expensive and requires highly
specialized equipment and highly trained experts.
Relatively few breast MRI centres exist, especially
outside of major cities.
* MRI produces many uncertain findings. MRI also
cannot detect calcifications (calcium deposits in
breast tissue that could be a sign of cancer).
*MRI can dislodge certain metal devices, such as
pacemakers.
*Can’t be done in patients of Claustrophobia