Mammography Flashcards
1
Q
Breast cancer
A
- one of the most common malignancies diagnosed in women
- etiology unknown
- family history seems to play a role, but most women who develop breast cancer have no family history of disease
2
Q
breast cancer prognosis
A
- one of the most treatable cancers
- best prognosis when detected early
mortality has declined steadily since the 1980s
3
Q
mammography equipment
A
- high frequency generators
- various tube and filter materials
- focal spot sizes that allow tissue magnification
- specialized grids to help improve image quality
- streamlined designs with ergonomic patient positioning aids
4
Q
high frequency generators
A
- higher effective energy x-ray beam
- constant radiation output - excellent linearity and reproducibility
- higher x-ray output for a given peak kVP and mA setting
- improved image quality
5
Q
tube and filter materials
A
Mo/Mo
Mo/Rh
- these two are used for better penetrations of denser breasts
Rh/Rh
6
Q
specialized grids
A
- reduce scatter
- improve image contrast
- moving linear focused
7
Q
high transmission cellular (HTC) grids
A
honeycomb or cross-hatch design, which reduces scatter in two directions
8
Q
soft tissue grids
A
allows the use of higher kVp techniques, improving penetration of dense breast tissue
9
Q
Ergonomic design with patient comfort in mind
A
- more efficient for technologist performing exam
- aids include rounded corner on busy devices and compression paddles
- automatic release of compression after exposure
- foot pedal controls
10
Q
Full-field digital mammography (FFDM)
A
- a mammography system that uses digital technology to capture images of the breast
- replaces x-ray film with solid state detectors
- detectors convert x-rays into electric signals, which are then used to produce digital images of the breast
11
Q
Key features of FFDM
A
- digital image capture
- improved image quality
- lower radiation dose
- computer aided detection
- efficient workflow
12
Q
FFDM digital image capture
A
FFDM captures the entire breast in a single view, allowing for more detailed and manipulatable images compared to film-based systems.
13
Q
FFDM improved image quality
A
It offers higher contrast resolution and a better dynamic range, making it easier to detect abnormalities, especially in dense breast tissue.
14
Q
FFDM Lower radiation dose
A
FFDM often requires less radiation than traditional mammography, enhancing patient safety.
15
Q
FFDM computer aided detection
A
FFDM can be integrated with CAD systems to automatically highlight areas of concern, aiding radiologists in detecting breast cancer.
16
Q
FFDM efficient workflow
A
Digital images can be easily stored and transmitted, facilitating faster diagnosis and follow-up procedures
17
Q
what is Digital Breast tomosynthesis
A
Compared with traditional mammography, digital breast tomosynthesis imaging technology can reconstruct three-dimensional information of objects with high-detailed resolution based on the finite number of projection images.
- 3 projection images were taken when the x-ray tube was moved to three corresponding positions.
18
Q
digital breast tomosynthesis dose
A
- uses low dose x-rays
- may surpass total dose of traditional mammography
19
Q
Computer aided detection (CAD)
A
sensitivity
- to detect lesions
specificity
- to determine whether the lesion is malignant or benign
double reading by a second radiologist can improve detection by 10%
- reduces false negatives
- computer provides second opinion before making a final interpretation
20
Q
Asymptomatic patient imaging
A
screening: 50+ (every 2 years)
Risk factors: 40+ (every 1-2 years)
- baseline/screening mammogram: can be done at any age, used for comparison thereafter
21
Q
diagnostic mammogram
A
performed on patients presenting with signs or symptoms
22
Q
for a mammogram being used as a screening method it must?
A
- be simple ( 2 standard projections ~ 15 mins)
- be acceptable
- show high sensitivity
- show high specificity
- be reproducible
- be cost-effective
- have a low risk to benefit ratio
23
Q
what are screening mammograms
A
- performed on asymptomatic patients
- early detection reduces mortality
- combine clinical breast examination (yearly) with mammography at directed intervals (2 years)
- monthly self breast examination is recommended
24
Q
diagnostic mammograms
A
- all patients with clinical evidence of significant or potentially significant breast disease
- specific projections (additional views) may be performed to show a suspicious area seen on routine screening
25
when are diagnostic mammograms indicated
- palpable mass
- other symptoms (unusual swelling, bleeding or pain/painful lump)
- changes to skin (dimpling, puckering, redness)
- changes to nipple (redness, scaling, crusting or sudden nipple inversion
- unilateral bloody or clear discharge
26
diagnostic mammograms - diagnosis?
- they do not confirm diagnosis
- determines wether or not biopsy is warranted
27
risk factors
- Female
- Age
- Being overweight/obese (for post menopausal breast cancer)
- Use of menopausal hormone therapy
- Physical inactivity
- Alcohol consumption
- Long-term heavy smoking, particularly among women who began smoking at an early age.
- higher breast tissue density
- high bone density
- high dose radiation to chest
28
reproductive risk factors
- long menstrual history (early menstruation/ late menopause)
- recent use of oral contraceptives
- never given birth (nulliparous)
- having first child after the age of 30
29
gene risk factors
family history: first degree relative (mother, sister, daughter)
- account for 5-10% of all female breast cancers
- BRCA1 and BRCA2 gene mutations
30
prevention with BRCA1 and BRCA2
Studies suggest that in individuals with the BRCA1 and BRCA2 gene mutations, prophylactic removal of ovaries and/or breasts decreases the risk of breast cancer considerably.
31
drug prevention
- tamoxifen and raloxifene have been shown to reduce breast cancer in high-risk women
32
breast anatomy
- composed of 15-20 lobes
- lobules contain glandular tissue, draining ducts and connective tissue
- space between loves consists of fatty tissue
33
lymphatic vessels
- lymphatic vessels drain into lymph nodes found medially (internal mammary nodes) and axillary (axillary lymph nodes)
34
mammography on lactating women
- during pregnancy, significant hypertrophy of glands and ducts occur within the breast, causing them to become extremely dense and opaque
- if mammography must be performed on a lactating patient, it is best to have patient nurse or pump prior to imaging
35
lobule size over time
- decrease in size with increasing age - particularly after pregnancy
36
involution
process that removes the milk-producing epithelial cells at weaning
- replaced with increasing amounts of fat
37
contraindications and challenges
- young patients: dense breasts - U/S is an option
- breast to sore
- kyphotic patients - change routine
- wheelchair or stretcher patients
38
Patient preperation
- may recommend ibuprofen 1 hour prior to exam
- caffeine can affect breast tenderness (refrain/reduce intake for 2 weeks prior)
- explain procedure and offer continuous reassurance - mention possibility for extra views
39
patient should wear
- gown open at front
- no jewelry
- hair out of image
- no deodorant or powder
- review complete history
40
why should the patient refrain from wearing deodorant or powder for mammography?
mimic micro calcifications
41
what is included in history?
- previous mamographies
- family history
- reason for exam
- documentation of scars, moles and tattoos
- location and description of problem area
42
localization of anatomy?
- important other define the breast, quadrant and clock time
43
where are most cancer detected?
- most cancers are detected in the upper outer quadrant
44
method of examination
- Both breasts are routinely radiographed.
- Standard projections: Craniocaudal (CC) x2 and Mediolateral oblique (MLO) x2.
- Spot compression and Magnification techniques may be used.
- In symptomatic patients, both breasts should be examined for comparison.
45
craniocaudal (CC) projection
- patient facing IR
- may sit or stand
- CR - parallel to the base of the breast, perpendicular to the receptor
- breast elevated
- adjust height of C arm to the level of the inferior surface of the patients breast
- have patient lean slightly forward from the waist and place breast gently on receptor
- center breast on AEC
- head away from affected side
- keep breast perpendicular to chest wall
- apply compression
- suspend respiration
- compression released immediately after exposure
46
value of compression
1. produces even breast thickness
2. immobilized breast (reduces motion)
3. separates structures within the breast. Minimizes superimposition of parenchyma
4. reduces breast dose and improves contrast by reducing scatter
5. reduces object to image receptor distance, reducing geometric blur
47
compression
- average compressed breast s 4cm
- breast should be compressed till tissue is taut. This may be uncomfortable for the patient, but usually not painful
48
posterior nipple line
Imaginary line drawn from the nipple to the chest wall or the edge of the image on the CC projection. On the MLO view, this line is drawn from the nipple to the pectoralis muscle on an angle
49
CC projection image assessment
- The PNL must extend posteriorly to the edge of the image and measure within 1/3 inch (1cm) of the depth of the PNL on the MLO projection.
- All tissue included - as shown by the retroglandular fat and the absence of fibroglandular tissue extending to the posteromedial edge of the image.
- Nipple in profile (if possible)
- Pectoral muscle seen posterior to retroglandular fat (in about 30% of properly positioned CC images).
- Slight medial skin reflection (arrow) at the cleavage, ensuring adequate inclusion of the posterior medial tissue.
- Uniform tissue exposure if compression is adequate.
50
Mediolateral oblique (MLO) projection
- Patient facing image receptor.
- May sit or stand.
- CR – parallel to the base of the breast, perpendicular to receptor
- Imaginary line from shoulder to mid-sternum, and angle C-arm parallel to this line
- Obliquity range from 30 – 60 degrees
- 45° average
- 60° tall & thin
- Top of cassette/detector in axilla behind pectoral fold
- Lean into angled bucky
- Elevate and rest arm of affected side over the corner of the image receptor
51
MLO projection - image evaluation
- The PNL must extend posteriorly to the edge of the image and measuring within 1/3 inch (1cm) of the depth of the PNL on the CC projection.
- Inferior aspect of the pectoral muscle extending to the PNL or below if possible.
- Nipple in profile (if possible)
- Open inframammary fold (arrow).
- Deep and superficial breasts tissue well separated when breast is adequately maneuvered up and out form the chest wall.
- Retroglandular fat well visualized to ensure inclusion of deep fibroglandular breast tissue
- Uniform tissue exposure if compression is adequate.
52
Mammography technique
- AEC
- short SID - 24-30in - due to low energy radiation
- kVp range from 25-28 kVp
- short exposure times (high tube current)
53
mammography procedure
- Review previous exam/history
- Clean bucky with disinfectant
- Heating pad or covers may be used to warm receptor.
- Answers any questions and assist patient with positioning.
- Document techniques and any difficulties
- Radiopaque marker should be used on patients with palpable masses prior to procedure to easily identify their location on the image.
- AEC detector under densest portion of breast
54
Marker/ID requirements
- Patient ID: name and medical number
- facility name
- Radiographic marker near the axilla indicating the side examined and the projection used.
- Label the mammography plate with an identification number.
- separate date marker
- label indicating technical factors, target material, degree of obliquity, density setting, exposure time and compression.
- identify mammography unit used
55
mammography of male breast for diagnostic
- most men present with outward symptoms
- gynecomastia - abnormal growth of breast (glandular) tissue usually due to irregular hormone activity or drugs
56
mammography of the male breast screening
- BRCA1, BRCA2 gene mutation
- Family history of breast cancer: first degree relative
- Excessive use of alcohol; cirrhosis or liver disease
- Klinefelter’s syndrome (XXY)
- Hormonal changes (estrogen/androgen levels)
57
mammography routine for male
- Same routine views done.
- Due to size of pectoralis muscle, Caudocranial projection is sometime taken as it may be easier to compress the inferior portion of the breast.
58
imaging of the augmented breast
- Breast augmentation does not increase the risk of developing breast cancer.
- Presence of implant may make detection of the cancer difficult on a mammogram.
- Precautions must be taken to avoid rupture of the augmentation device.
- Standard CC & MLO views (4 images) are performed, but they may not allow the entire breast parenchyma to be visualized.
59
Eklund method
- A second set of images are obtained using the implant displacement technique, aka Eklund Method.
- The implant is pushed posteriorly against the chest wall so that it is excluded from the image, and the breast tissue surrounding the implant is pulled anteriorly and compressed.
- Most effective when used on patients with implant placed posterior to the pectoral muscle.
- Ultrasound and MRI may also be used due to limitations of mammograms in imaging the entire breast tissue; these modalities may also be used on dense breasts.
60
mammography findings - mass shape
- May be described as round, oval, lobular or irregular
- Round/oval – more likely to be benign (cyst or lymph node)
- Irregular: likely malignant or an indication of trauma to breast tissue (hence the importance of taking history)
- Circumscribed (well defined) – Benign
- Obscured (hidden by superimposing tissue) – Suspicious
- Micro lobulated (50/50 chance)
- Ill defined/Indistinct – Suspicious
- Spiculated (fine spicules radiating from the center of the mass) - Worrisome
61
spiculated mass
post biopsy scarring may appear as speculated (accurate pt. hx. can prevent further unnecessary workup)
62
mammography findings - mass density
- High density, equal density, low density or radiolucent.
- Visible mass tends to be higher in density that the fibroglandular tissue surrounding it but can also be isodense.
- Breast cancers NEVER contain fat.
- Radiolucent masses contain fat and are therefore benign. (E. g. Lipoma, cysts)
63
calcifications
- Normal metabolic occurrences: usually benign.
- 15-25% of micro-calcifications are associated with cancer.
- Magnification technique valuable tool for defining microcalcifications.
- Benign calcifications tends to be larger and easily seen versus malignant calcifications which are usually small and often require magnification.
64
quality assurance
- Daily
- Use digital phantom
- Evaluate images regularly.
- Screening Programs are rigorous (Good QA required at Accredited Facilities)
65
alternate modalities
MRI
PET
