MAMMOGRAPHY VIEWS .ppt

INTRODUCTION
 Mammography is specialized medical imaging that uses A low dose x-ray
system to see inside the breast.
 A mammography exam, called as mammogram, aids in the early detection and
diagnosis of breast diseases generally in women.
 Mammogram is an x-ray picture of breast.
 Breast cancer accounts for 32% of cancer incidence and 18% of cancer deaths
in women in the United States .
 Approximately 1 in 8 or 9 women in US will develop breast cancer over her
lifetime.
 A mammogram can find breast cancer when it is very small ---2 to 3 years
before we can feel it.
 In 1913, radiographic appearance of breast cancer was first reported.

BREAST ANATOMYAND PHYSIOLOGY
 Breast serves as A mammillary gland
located in pair on the upper ventral region.
 Function of breast is to produces and
secretes milk to feed infants.
 In women, morphologically the breast is
Pear-shaped
 In women, breast overlies the pectoralis
major muscles and usually extend from the
level of 2nd rib to the level of 6th rib.
 Externally each breast consist a nipple
which is surrounded by the areola.

 Internally A normal breast mostly contains
fatty, glandular and fibrous tissues.
 This mass of fatty tissue contains a
network of milk producing glands (lobes)
and ducts.
 This network of lobes and ducts is
supported by special ligaments called
cooper’s ligaments.
 These lobes and ducts are distributed
through out the body of the breast.

 The basic unit of breast are the terminal
duct lobular units (TDLU), which produces
the breast milk.
 A lobule consist 10-100 alveoli.
 Alveoli are a few millimeters in size and
form cavities in the breast.
 These cavities fill with milk creating cells
called cuboidal cells, which are surrounded
by myoepithelial cells.
 Multiple lobules comprise a breast lobe.
 A breast consists 15-20 lobes.

 These lobes surround the nipple like
spokes on A wheel.
 Alveoli are the site were milk is
produced and are made up of special
cells called lactocytes.
 Produced milk temporarily store in
alveoli cavities and then drained into
lactiferous ducts through intra lobular
and extra lobular ducts.
 These lactiferous ducts are dilated at
the end and make lactiferous sinuses.

 These lactiferous sinuses are the milk reservoirs.
 These ducts with sinuses are converge and form a branched system and
connect the lobules to the nipple.
 Each nipple has about nine milk ducts.
 In this way milk produced in lobules is transferred by lactiferous ducts to
the nipple at the time of lactation

R
LATERAL
ASPECT
MEDIAL
ASPECT
NIPPLE
AEROLAR
REGION
SUPERIOR
PART
PECTORIS
MAJOR
INFRAMAMMORY
FOLD
RADIOLOGICAL ANATOMY

RADIOLOGICAL ANATOMY
BOTH SIDES CRANIO-CAUDAL VIEW
BOTH SIDES MEDIO-LATERAL OBLIQUE VIEW

ANATOMICAL POSITION OF BREAST
PERIMETER OF BREAST
1. LATERAL
2. INFERIOR
3. MEDIAL
4. SUPERIOR
5. AXILLARY TAIL
1.
2.
3
4 5

LACTATING PHYSIOLOGY
 Lactation is the process of secretion of milk by the mammary glands and the
action of suckling by an infant.
Lactation physiology
MAMMOGENESIS
 Preparation, growth
and development of
breast
 Start from age of
puberty and ends in
3rd sem of pregnancy.
LACTOGENESIS
Takes place during
second half of
Maturation of alveolar
cells and secretion
initiation.
Pregnancy.
GALACTOKINESIS
Ejection and removal of
milk.
Depends upon the
suction exerted by the
baby during suckling.
GALACTOPOIESIS
Maintenance of lactation.
Galactopoietic hormones
and suckling help in
maintaining the lactation.

 Process of lactation is A neural reflex and in under
control of endocrine secretions.
 The two main hormone involves in the process of
lactation are prolactin and oxytocin.
 In human females lactation also stimulate when
she thinks of the baby and hears him crying.
 This is due to oxytocin hormone, as oxytocin is
Also called love hormone.
 This love affection of mother towards new born
stimulates pituitary and secretion of oxytocin takes
place which helps in milk ejection.
PROCESS OF LACTATION

 Neural reflex arc stimulates during
suckling process.
 Baby suckling triggers the mechano-
receptors in nipple and areola of breast.
 And give message to hypothalamus to
activate pituitary gland to secrete
oxytocin and prolactin.
 Oxytocin is responsible for milk
ejection and prolactin is responsible for
milk secretion.

 Oxytocin is released by posterior lobe of pituitary gland.
 Prolactin is released by anterior lobe.
 Prolactin stimulates lactocytes for the synthesis of milk.
 Oxytocin stimulates contraction of myoepithelial cells and help in ejecting the
synthesized milk into lactiferous ducts and through the nipple.
 This is also called let-down reflex.
 Lactation is maintained by regular removal of milk and stimulation of the nipple by
suckling.

BREAST MILKSTAGES
As breast milk is the main and only source of nutrients for the new born,
composition of milk changes dramatically and progresses through three main
stages.
STAGES
COLOSTRUM
1st stage of milk or first milk .
Starts after the baby’s birth and
last for 2 or 4 days.
Colostrum is yellowish & sticky
And is easy to digest.
High in antibodies and wbc.
Protect new born from
infections.
TRANSITIONALMILK
 2nd stage, replaces colostrum.
 Starts after colostrum stage and last for
several weeks.
 It is white and creamy.
 High in protein, vitamins, fat
And lactose
MATURE MILK
Last stage replaces transitional milk.
Milk becomes matureand stays
consistent.
The mature milk will last
Until you wean for the baby.

SURFACE MARKERS and POSTURE FOR
MAMMOGRAPHY
ϰPNL- Posterior Nipple Line
Used to differentiate between CC
& MLO VIEW
The normal length is around 10 cm
Raised shoulders and erect posture prevent the breast from falling
forward and away from the chest wall compared to the patient with
a relaxed posture. A relaxed posture allows the breasts to naturally
fall forward and loosens the skin and muscles of the chest. In
mammography, bad posture is good for imaging.

TYPES OF MAMMOGRAPHY
Screening mammography
Screening mammograms are performed for asymptomatic
patients, who have no symptoms or signs of breast cancer and are
considered at average risk of breast cancer.
Usually involves 2 x-rays of each breast.
Screening mammogram considered a baseline mammogram
against which all future tests will be compared to look changes in
breast tissue.
Organizations such as the national comprehensive cancer
network recommend that women get a screening mammogram
each starting at the age of 40.

 Diagnostic mammograms are performed for symptomatic patients, who
have symptoms such as lump, pain, nipple thickening or discharge.
 Or after suspicious results on a screening mammogram.
 Usually involves more x-ray exposures.
DIAGNOSTIC MAMMOGRAPHY

INDICATIONS
 Post menopausal women
 Post hysterectomy women
 Gynaecomastia
 Symptomatic women :
• Lump , Tenderness , Nipple discharge , Pain ,
Change in shape and texture , Nipple retraction.

CONTRA - INDICATIONS
 Pregnancy
 Lactating women
 Post FNAC or FNAB

Describe the mammographic procedure to the patient.
Schedule mammogram in a week after the end of menstrual period.
Ask the patient to bring previous mammogram if any.
Ask the patient to avoid caffeine containing foods and drinks.
Ask the patient to take an over-the counter pain reliever one hour
before the procedure (after consulting the doctor).
Ask the patient do not apply grooming products.
Ask the patient to wear green open gown before the mammogram.
Ask about any breast related medical history.
Ask about any physical limitations.
PATIENT PREPARATION

INSTRUMENTATION
X Ray tube
Face shield
Compression
paddle
Detector
FUJIFILM AMULET INNOVALITY

Compress the breast firmly in between the two plates to spread the
dense tissue of the breast.
Compression makes it easier for radiologist to see through the breast
tissue and to hold it away from the chest wall.
Breast compression optimizes breast quality by reducing breast
thickness.
Compression unit in mammography machine consist adjustable plate
on top and a fixed plate on bottom which holds the x-ray film and
detector that makes the image.
POSITIONING

STANDARD PROJECTIONS
 Cranio - caudal view
 Medio – lateral oblique view
Typically, the routine 4-projection series in mammography involves imaging in the
craniocaudal (CC) and the mediolateral oblique (MLO) of both breasts. The CC and MLO
projections are complementary.
The idea behind the 4-projection routine in mammography is to image both breasts with
minimal radiation dose to the patient and to include the maximum amount of breast tissue
possible.

SUPPLEMENTARY PROJECTIONS
 Extended cranio – caudal (Kleopatra)
view
 Cleavage view
 Axillary tail view
 Rolled view
 Magnified projections
 Lateral view
 Localised compression view

CRANIO – CAUDAL PROJECTION
To demonstrate majority of the breast

CRANIO – CAUDAL PROJECTION
 No overlying structures.
 The nipple should be in profile.
 The medial portion of the breast should be included
on the film.
 There should be no folds in the breast tissue.
ESSENTIAL IMAGE CHARACTERISTICS

CC PROJECTION - BOTH SIDES
When both cranio-caudal
projections are viewed
together “mirror image”
must be symmetrical.

MEDIO - LATERAL OBLIQUE PROJECTION
To demonstrate the greatest amount of breast tissues

MEDIO - LATERAL OBLIQUE PROJECTION
ESSENTIAL IMAGE CHARACTERISTICS
 The axilla, the axillary tail, glandular tissue, pectoral
muscle and infra mammary fold should be
demonstrated.
 The pectoral muscle should be demonstrated to nipple
level.

MLO PROJECTION - BOTH SIDES
When both medio-lateral oblique projections are
viewed together “mirror image” must be
symmetrical, matching at the level of the
pectoral muscle as a deep ‘V’ and at the inferior
border of the breasts

EXTENDED CRANIO – CAUDAL VIEW
If a lesion is seen on the MLO view but was not seen on the CC
view then , Extended CC view is recommended.
EXTENDED CC LATERALLY
ROTATED
EXTENDED CC MEDIALLY
ROTATED
Outer quadrant Medial portion of the breast

EXTENDED CRANIO – CAUDAL VIEW

CLEAVAGE VIEW
The cleavage view attempt at maximum visualization of medial breast tissue.

AXILLARY TAIL VIEW
When lymph gland involvement of breast carcinoma is suspected or there is accessory
breast tissue axillary tail view is suggested.

ROLLED VIEW
Rolled views are taken to separate the super imposed tissue and to demonstrate
persisting lesion better.

Magnification view is often used to evaluate the margins of a mass.
MAGNIFICATION VIEW

LATERAL VIEW
Taken to localize the exact site of a lesion and to demonstrate gravity dependent materials.

A lesion in the breast is isolated by
marker and only the tissues containing
the lesion are compressed.
LOCALISED COMPRESSION VIEW

MALE MAMMOGRAPHY
 Done in males who develop
Gynaecomastia.
 Standard cranio - caudal and
medio - lateral oblique view is obtained
along with lateral view if necessary.

MAMMOGRAPHIC IMAGE EVALUATION
 The first step is to evaluate is to determine if the study is technically adequate.
There should be adequate tissue imaged on both CC and MLO views.
The posterior line of the nipple is a line drawn from the posterior nipple to the
pectoralis muscle or edge of the film on the CC view. The posterior nipple line drawn on
the CC and MLO views should be within 1 cm of each other.
The image must be free from blur and artifacts.
The nipple of each breast should be in profile in at least one view.

MAMMOGRAPHIC REPORT
1) Indication
2) Breast Composition:
A: Entirely fatty breast tissue
B: Scattered fibroglandular breast tissue
C: Heterogeneously dense breast tissue
D: Extremely dense breast tissue

MAMMOGRAPHIC REPORT
 Important Findings: Mass, Asymmetry, Architectural distortion, Calcifications, Associated
Features.
Comparison to previous studies.
Final Assessment Category
Give management recommendations.
Communicate unsuspected finding with referring physician.

FINAL ASSESSMENT CATEGORIES
GRADING CATEGORY MANAGEMENT
0 Need additional imaging or prior
examinations
Recall for additional imaging or await
prior examinations
1 Negative Routine Screening
2 Benign Routine Screening
3 Probably Benign Short interval follow up (6 months) or
continued
4 Suspicious Tissue Diagnosis
5 Highly Suggestive malignancy Tissue Diagnosis
6 Known Biopsy Proven Surgical excision when clinical
appropriates

BIRADS
 BI-RADS (Breast Imaging-Reporting and Data System) is a risk assessment
and quality assurance tool developed by American College of Radiology that
provides a widely accepted lexicon and reporting schema for imaging of the
breast.
It is designed to standardize breast imaging reporting and to reduce confusion in
breast imaging interpretations.
It applies to mammography, ultrasound, and MRI
Breast imaging studies are assigned one of seven assessment categories:

Breast Imaging-Reporting and Data System
 BI-RADS 0: incomplete
Need additional imaging evaluation (additional mammographic views or ultrasound) and/or for
mammography, obtaining previous images not available at the time of reading.
 BI-RADS 1: negative
symmetrical and no masses, architectural distortion, or suspicious calcifications.
 BI-RADS 2: benign
0% probability of malignancy
 BI-RADS 3: probably benign
<2% probability of malignancy
short interval follow-up suggested

Breast Imaging-Reporting and Data System
 BI-RADS 4: suspicious for malignancy
2-94% probability of malignancy
For mammography and ultrasound, these can be further divided:
BI-RADS 4A: low suspicion for malignancy (2-9%)
BI-RADS 4B: moderate suspicion for malignancy (10-49%)
BI-RADS 4C: high suspicion for malignancy (50-94%)
biopsy should be considered
 BI-RADS 5: highly suggestive of malignancy
>95% probability of malignancy
appropriate action should be taken
 BI-RADS 6: known biopsy-proven malignancy

MICRO - CALCIFICATION DUCTAL CALCIFICATION

Mammographic radiation dose and exposure
 Atypical mammographic screening examination involving 2 views of each breast
(total 4 mammograms) delivers a dose of between 3 and 5 mGy to the glandular
tissue.
 Dose expresses the X-ray energy absorbed in a specific tissue. In the breast it is the
glandular tissue that is the most radiosensitive.
 Women with smaller than average breasts will receive a lower mean glandular dose
(MGD). Doses are higher for women with larger breasts. Any additional images that
might be required will add to the dose received.
 According to Atomic Energy Regulatory Board, the average effective dose for Chest
X-ray is 0.10 mSv whereas for a mammogram it is 0.04mSv

Mammographic radiation dose and exposure
The dose to the breast of an individual patient is determined by a combination of three factors:
• the characteristics of the equipment being used
• the technique factors selected for the examination
• the size and density of the patient’s breasts.
Exposure: Mammography uses low x-ray tube voltages, typically 25 kV or so, x-ray tube
currents of 100 mA, and exposure times of 1 second or more depending on the thickness of the
compressed breast.

LIMITATIONS
Sensitivity in Dense Breast Tissue: Mammography may not be as effective in detecting breast cancers
in women with dense breast tissue. Dense tissue appears white on mammograms, and tumors also appear
white, making it difficult to distinguish them. This can result in false negatives, where cancer is present
but not detected.
False Positives: Mammography can also lead to false-positive results, where abnormalities that are not
cancerous are identified as potential tumors. This can lead to additional testing, such as biopsies, which
can be emotionally and physically taxing for patients.
Radiation Exposure: Mammography involves exposure to ionizing radiation, which carries a small risk
of radiation-induced cancer over time. While the benefits of early breast cancer detection often outweigh
this risk, it's a consideration, especially for women who may undergo frequent mammograms.

LIMITATIONS
Inability to Distinguish Tumor Types: Mammograms can identify suspicious areas but
cannot determine the type of tumor. Further testing, such as biopsies, is required to confirm
whether a tumor is benign or malignant and to identify its specific characteristics.
Size Limitations: Mammography may not reliably detect very small tumors, and it may also
miss some types of breast cancer, such as inflammatory breast cancer, which doesn't always
present as a mass or tumor.
Discomfort and Anxiety: Mammography can be uncomfortable and, for some women,
painful. This discomfort can deter some women from undergoing regular screenings.
Additionally, the anxiety associated with waiting for results and the possibility of false-positive
findings can have a negative impact on a person's well-being.

LIMITATIONS
Limited for Women with Breast Implants: Women with breast implants may face challenges
with mammography. Specialized techniques, such as implant displacement views, may be
needed to ensure that all breast tissue is adequately visualized.
Cost and Accessibility: Mammography equipment is expensive, and the procedure may not be
readily accessible to everyone, especially in low-resource areas or in countries without
comprehensive healthcare systems.
Compliance and Awareness: Despite its effectiveness, not all eligible women undergo regular
mammograms. Factors like lack of awareness, cultural beliefs, socioeconomic barriers, and
fear can lead to low compliance with recommended screening guidelines.

CONCLUSION
 Mammography along with Self examination of the breast is the method of choice for
early detection of cancer.
 After 40 years every woman must undergo mammography at regular intervals for
early detection of breast carcinoma.
 As a health care worker we should create awareness among
people about mammography and it’s necessity.

MAMMOGRAPHY VIEWS .ppt

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