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1. MAMMOGRAPHY
VIEWS
Dr. Anjali Deshmukh
Junior resident
Department of Radiology

2. Indications of mammography

3. Types of mammography
• Screening mammography
• Diagnostic mammography

4. Mammography Technique

5. Mammography requires special tubes that produce
particularly low-energy radiation in comparison with other
diagnostic X-ray tubes. This is achieved by the use of
Special targets and filters.
The tubes used for mammography must incorporate a high
heat capacity target.
To achieve the required sharpness (spatial resolution),
mammography tubes must have an extremely small focal
spot. A nominal focal spot size smaller than 0.4 is required
today.

6. • Higher-energy radiation is required in dense breasts
(in the presence of abundant fibrotic or glandular tissue)
and in thick breasts.
• With the optimum radiation energy selected, the
absorption is higher in radiodense tissue (fibrotic tissue,
glandular tissue, and malignant tissue) than in radiolucent
tissue (fat or loose connective tissue). These differences in
absorption produce the image pattern.

7. The radiation spectrum created at the target depends on
the kVp setting and on the target material.
The radiation spectrum of molybdenum targets contains a
higher proportion of low-energy radiation (including
characteristic peaks at 17.5 and 19.6 keV) than do the
spectra of tungsten or rhodium tubes.

8. Heel effect
More of the rays that leave the target at obtuse angles
will be absorbed by the target than those leaving the target
at acute angles, owing to the longer path they have to
travel in the target.
The beam created at the target focus is weaker on the
target side than on the cathode aside
This effect is used in mammography by locating the
cathode closer to the chest wall than the anode. Thus the
radiation intensity will be greater close to the chest wall
and less near the nipple, where the breast is thinner.

10. Grid
The grid is placed between the breast and the
image receptor (screen–film system) to reduce
undesired scattered radiation that impairs image
quality.
Grids consist of strips of lead that absorb obliquely
oriented radiation, whereas radiation parallel to
the lead strips passes through. The lead strips are
focused on the focal spot.

11. Breast Compression
• It reduces the thickness through which the beam
passes, significantly reducing scattered radiation, thus
improving contrast.
• In addition, healthy tissue usually spreads, whereas
true masses will persist. This improves visualization
of true masses and diminishes the likelihood of falsely
identifying a lesion.
• —
—
It decreases motion of the breast during the X-ray exposure.
Finally, breast compression also permits a significant
reduction in radiation dosage (see p. 51).

12. Standard Views
Mediolateral Oblique View

15. • Check that the image table is not moved too high in the axilla.
(Usually the table needs to be ~2 cm lower than for the craniocaudal
view; the humerus should not be included in the image.) Correct
positioning is achieved by rotating the tube arm to an angle
corresponding to the course of the pectoralis (1). Then the bucky
is placed under the breast so as to mobilize the breast medially and
superiorly as much as possible (2). Finally (3), the patient is turned
toward the unit and the technologist pulls the breast onto the film
holder. That way as much medial breast tissue as possible is
included, when the compression paddle (not shown) is lowered.
pull the breast tissue anteriorly and superiorly (arrow), moving it
forward and spreading it as much as possible. The patient’s ipsilateral
arm (shown here) should rest on the film holder while she holds the
contralateral breast back with her other hand.

16. QualityCriteria for OptimumPositioning
in the MediolateralOblique
—
. The pectoralis muscle should be visible in the image at
least to the level of the nipple.
—
. It should course superiorly along the lateral border of
the image at an angle of about 20°. (Since visualization
of too much pectoral muscle may interfere with good
compression, some screening programs are presently
changing to recommend an angle of 10–20°.)
—
. The inframammary fold should be included inferiorly.
This is achieved by having the patient turn far enough
toward the mammography unit.
—
. The glandular tissue should appear well spread out in
the image.

17. Craniocaudal View

18. a If the breast is not lifted, compression
will cause painful tension (arrows) on the
superior breast tissue, which also hinders
pulling the breast forward from the chest
wall.
b Correct positioning requires mobilizing
the breast as far superiorly as possible.
Raise the film holder accordingly. This
makes it possible to pull the breast
forward to achieve optimum positioning
while making compression far less painful.

19. A good craniocaudal view fulfills the
following quality criteria: The image
should include the entire body of the
gland with the retromammary fat.
This is best achieved with the nipple
centered or positioned slightly medially.
In particularly high-quality images, the
pectoralis will just barely be visible along
the edge of the mammogram and/or the
medial border of the image will include
the medial fold. Inclusion of the pectoral
muscle is, however, only possible in some
patients. It is therefore not considered a
general requirement.

20. a In the mediolateral view the patient
stands directly in front of the unit
facing it. The upper outer corner of
the bucky lies in the patient’s axilla;
her arm rests lightly on the film holder.
Support the patient’s back so that she
will not withdraw when compression
is applied. Lift the breast superiorly,
pulling it away from the chest wall and
spreading it to achieve good tissue
separation until the breast is held in
place by the compression paddle.
b In the lateromedial view the medial
aspect of the patient’s breast is
positioned along the film holder.
The arm of the side being imaged
lies parallel to the upper edge of
the compression cone. As in the
mediolateral view, the technologist
lifts the breast, pulls it forward, and
holds it until it is held in place by the
compression cone.

21. A good mediolateral view fulfills the
following quality criteria: the image
should include the entire body of the
gland with the retromammary fat.
The pectoralis should also be visible
as a narrow band at least in the upper
half of the image. The body of the
gland should be well spread out, and
the inframammary fold should be
discernible.

22. Exaggerated Lateral
Craniocaudal View
This view is used to visualize changes in the axillary tail
of the breast in the craniocaudal plane. It is indicated in
the presence of suspicious clinical findings in this area or
to localize or further clarify uncertain or suspected findings
which may be visible on the mediolateral oblique
view but are not seen on the routine craniocaudal view.

23. The laterally exaggerated craniocaudal
view is performed like the routine
craniocaudal (CC) view, but the patient
is rotated and faces the film holder
obliquely so that the lateral breast tissue
is included in the field of view. In contrast
to the routine craniocaudal view, the
medial breast tissue is excluded.

24. The exaggerated medial craniocaudal view can be used
to image medial findings very close to the chest wall that
are difficult to include on the correctly positioned craniocaudal
view.
The medially exaggerated view is
performed with the patient rotated
in the opposite direction to bring the
medial breast tissue into the field of view.

25. Tangential View
Tangential views are valuable for detecting subcutaneous
Calcifications. The tangential view is also useful for
displacing masses away from an overlying implant.

27. Axillary View
This view is used to evaluate findings in the lower
portion of the axilla not visualized in the oblique view
(this is rare). It is usually done as a 30° oblique, using a
small, rectangular compression paddle. The chest wall
is not included. The exposure can be phototimed.

28. Cleavage View
The cleavage view is a rarely used one that
visualizes the medial breast close to the chest wall
particularly well. In this view, both breasts and the medial
fold (cleavage) between them are compressed and imaged
using a craniocaudal beam and a small compression cone.
Since the photocell is not covered by the breast in this
view, the exposure must be set manually.

29. Indications
1. To help establish the presence of a lesion. These are
usually done to determine if a density that is seen on the CC
view is due to superimposition of structures or it is real.
2. To approximate the location of a lesion seen only on the
CC view.
3. To move a lesion away from surrounding tissue for better
evaluation

30. Rolled Views
The rolled views can be used to determine the depth of a
lesion detectable only in one plane.
If, for example, we roll the upper breast medially from
a craniocaudal position, lesions in the superior quadrants
will move medially, that is in the direction of the roll,
whereas lesions located in the inferior quadrants will
move laterally in the opposite direction.
Today, the imaging modalities for determining the
depth of a lesion detectable in only one plane include
mammographic stereotaxy, sonography, and
contrastenhanced
MRI.
Rolled views can still be extremely helpful in determining
whether dense areas detected primarily in one
plane are real or represent superimposed structures

31. Spot Compression
In spot compression, a small compression
paddle is used to compress only the area of
the breast of interest, with the beam
collimated on this area of interest.
We recommend not using too small a
paddle and collimating in a way that allows
visualization of sufficient surrounding tissue
to countercheck whether the field of view
was correctly chosen. Otherwise a
significant risk of misinterpretation may
exist. Spot compression can be performed
in any imaging plane.

32. Advantages
—
. Dense areas resulting from summation of superimposed
images can be spread out; malignant foci and architectural
distortion will mostly remain.
—
. Spreading of the surrounding parenchyma means that
the outline of masses (possibly also of microcalcifications)
is less obscured by superimposed tissue and
may be better visualized. Note: Magnification may add
information about the contours of masses.
—
. Better localized compression (reduction in the thickness
to be penetrated) and, to a lesser extent, the
collimation reduce scattered radiation and improve
contrast.
—
. The increased compression makes its possible to
decrease the distance between some structures and
the image receptor and thus to decrease geometric
blurring.
—
. Occasionally, findings close to the chest wall are more
accessible with a small, round cone.

33. Magnification Technique
Magnification mammography involves the
following:
—
. The breast is placed on a platform located at a
defined
distance from the grid holder.
—
. The area of interest is compressed and the
image field
is collimated as described with spot
compression.
—
. A small focal spot is selected and the grid
removed.

35. Indications
—
. Determining whether microcalcifications are present.
—
. Analyzing the geometry and distribution of
microcalcifications
—
. Detecting additional fine calcifications for improving
the differential diagnosis of microcalcifications.
—
. Excluding or verifying the presence of multiple foci
and assessing the extent of carcinomas with
microcalcifications
—
. For analysis of the contours of masses and for their
differentiation as smooth, lobulated, or spiculated

36. Advantages
—
. Improved resolution of fine details by overcoming blurring
due to the screen–film system.
—
. Magnified details are easier to observe, that is, there is
more information on the image receiver of the area
imaged.
—
. When spot compression is used along with magnification,
structures are less obscured by displacing the
superimposed tissue.
—
. Dense areas representing summation of superimposed
tissue can be differentiated from real findings.

37. The craniocaudal view shows a group of pleomorphic microcalcifications at the
margin of the parenchyma (a). An additional
magnification view (b) clearly reveals them to be suggestive of malignancy.

38. The craniocaudal view reveals a focal density with
ill-defined contour with central and marginal microcalcification
(a). The magnification mammogram (b) with spot compression
clearly demonstrates highly suspicious spiculations. In addition to the above-
mentioned suspicious microcalcifications, more pleomorphic microcalcifications are
shown on this magnification view extending toward the nipple.

39. Disadvantages
—
. Magnification mammography increases the dose
required, but this is largely compensated for by using a
low-dose screen–film system, increasing the kVp, and
eliminating the grid.
—
. Contrast could be decreased owing to the lack of a
grid and the higher kVp setting. This can largely be
compensated for with good compression of the area
of interest (pushing superimposed tissue aside) and
good collimation (air gap reduces scattered radiation).

40. Indications
A. To evaluate the medial and posterior tissue of the breast not seen or
not completely seen on the CC view. Fig 15
Lesions located posteriorly against the pectoral fascia and in the medial
aspect of the breast may be better visualized in the CC projection by
bringing both breasts onto the film and centering the x-ray beam over
the cleavage between the breasts. [5]
Manual techniques must be used when the x-ray beam is centered
between the breasts. With no breast tissue between the x-ray source and
the automatic exposure control (AEC), exposure time will be prematurely
terminated by the AEC, resulting in an underexposed projection. By
positioning the medial portion of the breast being examined over the
AEC, photo timing is feasible.