Mammography Basic technique

Basic Mammographic Techniques

Mammography is more than just x-ray views of the breast. Mammography is a specialty within itself, essential to the detection and management of breast disease. As a Mammographer, it's important that we consistently produce high quality mammograms as it could aid in the early detection of breast cancer and thus, a better prognosis for our patients. Yet there are many things that need to be considered. Let's talk Mammography.

Patient Care & Background

Before we even dive into mammographic views, the Mammographer needs to get to know the patient well. We're not just talking about confirming patient identity. It's vital we build rapport with our patients as many arrive in the department either anxious about the outcome or about the imaging itself. Long before the patient has talked to you, it's possible they're already primed by stories of "how horrible mammograms can be" and "how your boobs will look like pancakes by the end of it!". No wonder your patient is reluctant to change into a gown! Therefore it's vital that you do your best to help your patient feel as ease. After all, a relaxed & happy patient = relaxed muscles = more breast on your final mammograms. So don't scrimp this bit!
Before jumping into the imaging, it's important that you discuss your patient's circumstances and background by cross-checking their Referral and Mammographic Questionaire. Is your patient here for screening or does he/she have a concerning lump/s? If they have a lump, how long as the lump been a concern and has this been marked on the questionaire? Do you need to put a BB-marker on the breast prior to imaging to help the radiologist locate the area of concern on the images? Has the patient brought previous imaging of the breast (MRI, Ultrasound or Mammography) that your radiologist could compare against? Does your patient have any skin lesions on their body that might need to be marked on the questionaire? Does your patient have implants? If so, they'll most likely need to have ultrasound prior to their mammograms and depending on your company, also sign a legal waiver in the event of rupture. How old is your patient? If your patient is under 35, maybe you need to consult with your radiologist as they might prefer limited mammographic views (ie Medio-oblique views only of both breasts) or ultrasound first. Have you ruled out pregnancy in your patient if they're under 50?

You see, being a Mammographer is very much about being a detective. Asking the right questions will help you and your radiologist serve your patient to the best of both your abilities.


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Views

Cranio Caudal View

• This view includes most of the breast tissue.

• Ensure firstly the bucky height is correct and at the level of the infra mammary fold so the breast is fully elevated including the posterior tissue. This reduces the chance of pulling the skin as the compression comes down.

• The patient stands facing the bucky with her head turned away from the side being examined. Keep one arm around her shoulder and the other hand to position the breast. Position from the medial side of the woman

Criteria for assessing the CC view

1. As much medial and lateral tissue visualised as possible
2. Aim to include pectoral muscle
3. Correct exposure
4. Adequate compression
5. No movement
6. Proper processing
7. No artefacts
8. No skin folds or shoulder in view
9. Images should be symmetrical
10. Correct film ID-patient details, markers, date, and radiographer's initials
11. Nipple in profile-if difficult, do an extra nipple view.

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Medio-Lateral Oblique

• The degree of angulation depends on the angle of the pectoralis major muscle. The film holder should be parallel to the angle of the pectoral muscle at the mid axillary line. Generally taller, slimmer women need a steeper angle. Smaller women may need to be more lateral and larger breasted women less than 45 degrees.
• Ask the woman the place her hand on the bar as the armpit is placed over the bucky corner. Ensure no folds on the lateral side of the breast and check all the lateral tissue is on the edge of the Bucky. The arm should be resting over and on to the back of the bucky.
• Gently push the shoulder down by the hand on the clavicle.
• Once sure there is adequate axillary tissue, position the breast and apply the compression while supporting the inferior aspect. The breast needs to be pulled up and out so that it will be imaged at 90 degrees to the chest wall.
• Ensure no folds and smooth out the inframammary region. To be sure that all the breast tissue has been imaged the top of the compression plate should be just below the clavicle and the inner edge alongside the sternum.

Criteria for assessing the MLO view

Its limitation is that it does not include all of the medial breast tissue.

1. Pectoral muscle viewed to nipple line
2. Full width of pectoral muscle
3. Nipple in profile
4. Visualisation of inframammary fold
5. No skin folds
6. Ideally images should be symmetrical

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Lateral Projection

• This view may be performed as an aid to radiological correlation of a clinical lump. A lateral view may also be performed in examining prostheses to ensure inclusion of as much tissue as possible.
• It is also a work up view of detected lesions.

Latero-Medial

• The tube is rotated 90 degrees with the bucky at the level of the sternal notch. The chin is over the top of the bucky and the sternum against the edge so all tissue is shown. The arm of the side of interest holds the c-arm handle and the elbow flexed to relax the pectoral muscle.
• The whole breast is lifted upwards and outwards from the chest wall. With the nipple in profile the compression is applied gradually to include the inframammary area and as much pectoral muscle as possible.

Medio-Lateral

• The tube is rotated 90 degrees and the lateral aspect of the chest wall is along the bucky edge. The height is at the level of the axilla.
• The arm of the side being examined is lifted and supported on top of the bucky.
• The breast is lifted upwards and onwards and compression applied so the nipple is in profile

Criteria for assessing the Lateral view

1. The nipple must be in profile
2. Good visualisation of the inframammary area
3. A short wedge of pectoral muscle at the chest wall edge
4. Breast tissue should be well compressed and lifted up and out at 90 degrees to the chest wall.

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Jigsaws

• To demonstrate the tissue on a large breasted woman with a degree of overlap from film to film so that no tissue is missed, it is necessary to divide the areas of breast tissue. In our clinic the cc view is divided into 1-lateral
• 2-medial portion 3-front/nipple area. With the obl view
  
  • A-pectoral area
    
  • B-inferior portion,
    
  • C- anterior/nipple area.
• The AEC must be placed under the most glandular area of breast tissue to avoid under or over exposed films. It is important to inspect previous films prior to imaging. KV should be 26-28 KVp. For dense breasts Rhodium is used.

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AEC and Kvp Selection

• The AEC must be placed under the most glandular area of breast tissue to avoid under or over exposed films. It is important to inspect previous films prior to imaging. KV should be 26-28 KVp. For dense breasts Rhodium is used.

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Conclusion

• Good basic techniques are necessary in breast cancer detection. Hence high quality image standards are a must as well as good basic positioning techniques to aid in the early detection of breast cancer

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Specialised Views

• Specialized views are to demonstrate tissue not fully seen in routine views, perhaps due to special positioning problems. Specialized views are also performed to help categorise mammographic lesions.

1. Extended CC View

• Normally done with lateral bias
• No body rotation so that sagittal orientation is achieved
• Useful for lateral lesions in axillary tail

2. Cleopatra View

• Used to visualise the axillary tail
• Compresses the lateral aspect close to the pectoral muscle
• Get patient to lean sideways

3. Cleavage View

• Visualises lesions deep in the medial aspect of the breast
• May need to use a manual exposure
• Can be difficult on thin women
• Some tissue posterior to cleavage should be visible if positioned correctly

4. Coned Compression View

• Can be taken in any projection
• Allows better compression over a small area, separating overlying structures and enhancing image detail
• Better definition of lesions against a fatty background
• Separates superimposed ductal structures in the retroareolar area
• The paddle allows further back imaging
• Often combined with magnification

5.Magnification View

• Useful to define calcifications
• Provides sharper more defined image
• No bucky as air gap reduces scatter radiation
• Spot or full compression paddle can be used

6.Pinch View for Breast Prostheses

• Implants may inhibit breast compression and obscure some breast tissue
• An additional latero-medial view is needed if the implant cannot be displaced, to demonstrate all tissue as well as possible
• Manual exposures may be necessary
• For the implant, which can be displaced, the routine views should be taken with the implant in place, and the implant displaced (4 views per breast)
• Modified compression technique enables improved imaging of the breast tissue, free of the implant
• There is always some compromise when imaging the augmented breast

7.Tangential View

• To visualise superficial lesions close to the skin with the least amount of overlying tissue to allow better margin differentiation
• The area may be a mass, a tender area or a skin dimpling
• Place a lead marker over the area of interest
• Rotate the breast until the skin marker is tangential
• Use spot compression
• Can be magnified

8.Axillary View

• Useful for visualising axillary soft tissue
• Often the breast tissue is over penetrated