Mammography

Question 1

what is mammography?

Answer 1

it is radiographic examination of breasts (usually both) using low energy x-radiations (around 30kVp)

Question 2

what does mammography depend on?

Answer 2

1. equipment - designed to maximise detail within soft tissue and the difference. b/w different densities within the breast
2. expertise - high quality images without repeats are required therefore, it required good communication skills to manoeuvre the women into correct position and help her overcome anxiety and embarrassment

Question 3

what are the components in mammography?

Answer 3

1. Rotating Molybdenum/Tungsten or Rhodium target
2. Small focal spot (0.3mm)
3. Molybdenum filter
4. Detector
5. AEC (automatic exposure control)
6. Compression paddle

Question 4

which are the two standard projections in mammography technique?

Answer 4

1. cranio-caudal (CC)

2. medio-lateral oblqiue (MLO - 45-55 degrees)

Question 5

name six additional projections used in mammography technique?

Answer 5

1. Medial-Lateral – 90 degree lateral (sometimes Lat-Med used)
2. Compression spot views in any projection
3. Magnified spot (x2, x1.5)
4. Tangential views
5. Eklund technique for implants

Question 6

what are the essential features of mammography?

Answer 6

1. Needs to show as much breast tissue as possible, with optimum detail.
2. The film reader can’t see the cancer if the back of breast is missed or if the images are blurred.
3. Technical repeat rates are monitored and audited as part of NHSBSP QA:
   - Standard - <3%
   - Target<2%
4. This does not apply to symptomatic work.

Question 7

what is the procedure involved in CC projection of mammography?

Answer 7

• Patient stands at medial edge and rests against faceguard (protective cone.)
• Elevate breast to ensure minimal drag from compression and raise or lower C-arm to comfortable position.
• Breast pulled forward to include medial edge and as much lateral edge tissue as possible.
• Nipple in profile but not to the detriment of the posterior breast tissue. One view must have nipple in profile or a second nipple view must be taken.
• Compression applied
• Mirror images required as this aids film reading easier to pick up asymmetric densities
• Semi-circles on compression plate indicate automatic exposure device position.

Question 8

what is the procedure involved in MLO projection of mammography?

Answer 8

• Assembly adjusted to individual physique, slim woman steeper 50-60 degrees, average angle 45-55 degrees Nipple must be in profile otherwise could hide SAR lesion.
• Corner of detector in posterior border of axilla.
• Lift breast towards medial and superior borders, to afford better compression and lessen painful drag on the breast.
• Eliminate skin folds as could easily hide calcification.
• Compress until taut if woman comfortable. Increased pressure beyond this contributes very little to the image. Some women will have more sensitive or dense breast tissue increasing the discomfort of a mammogram

Question 9

under what symptomatic conditions can patients be refereed to the breast clinic?

Answer 9

1. lump
2. pain
3. nipple discharge
4. nipple inversion
5. change in contour
6. family history

Question 10

what is the purpose of one stop breast clinic?

Answer 10

the purpose is the patient undergoes temple assessment for breast cancer in one visit

Question 11

what are triple assessments at one stop breast clinic?

Answer 11

1. clinical examination
2. breast imaging
3. biopsy

Question 12

what is gynaecomastia?

Answer 12

increase in glandular tissue forming a breast lump in men

Question 13

when does gynaecomastia commonly occur and what are its causes?

Answer 13

• commonly in puberty and old age

- caused by use of steroids, illegal drugs, prescribed medication and can be related to prostate problems

Question 14

why caution must be taken for breast cancer in men?

Answer 14

• Breast cancer in men is rare. But caution must be taken as <1% of all breast cancers occur in men.
• Around 350 men are diagnosed with the disease each year in the UK compared with over 55,000 women.
• Around 80 men die from breast cancer in the UK every year.

Question 15

what is the aim of NHSBSP?

Answer 15

to reduce mortality from breast cancer

Question 16

what are the features of NHSBSP?

Answer 16

• Inviting women between 50 and 70 years (+ age expansion trial)
• High quality, two view, bilateral mammography
• Three yearly
• Timely recall for assessment
• Identification of small breast cancers
• Prompt referral if cancer diagnosed

Question 17

what are the disadvantages of NHSBSP?

Answer 17

1. Increased risk of radiation induced cancers
2. Not 100% sensitive: Small cancers can hide in dense tissue/ may not be seen maybe mammographically occult/may be minimal sign only detected in hind sight
3. Cancer may occur in women even with regular breast screening
4. Increased anxiety for women waiting for results
5. High levels of false positives
6. Potential over treatment

Question 18

what are the 5 different categories of mammograms and what do they represent?

Answer 18

M1 - normal/ no. significant abnormality
M2 - benign findings
M3 - indeterminate/probably benign findings = small risk of malignancy, further investigation indicated
M4 - suspicious malignancy findings = moderate risk of malignancy, further investigation indicated
M5 - highly suspicious findings = high risk of malignancy, further investigation required

Question 19

why reporting the categorisation is important in mammography?

Answer 19

1. to aid the clinician in decision making,
2. to standardize interpretation between radiologists
3. to be used in statistical analyses of mammography practice.

Question 20

name three types of breast cancer?

Answer 20

1. invasive lobular cancer - carcinoma
2. invasive ductal caner - carcinoma
3. ductal carcinoma in situ (DISC) - non-invasive cancer

Question 21

name four radiological signs used while assessing breast pathology?

Answer 21

1. asymmetry
2. architectural distortion
3. masses
4. calcification

Question 22

name six additional technologies used in mammography?

Answer 22

1. Tomosynthesis
2. Ultrasound
3. MRI
4. Contrast enhanced spectral mammography
5. PET – CT?
6. Molecular breast imaging

Question 23

why is tomosynthesis needed in mammography?

Answer 23

• Superimposed tissue can mask pathology and, often, the pathology in breast disease can be very subtle.
• Breast tomography uses digital radiography to reconstruct planar images of sections of the breast and form a 3D image

Question 24

what are the two methods of acquired breast images in tomosynthesis?

Answer 24

1. The x-ray tube traverses along an arc acquiring images as it travels and the detector remains stationary
2. The x-ray tube traverses along an arc and the detector also rotates
   - The images are then reconstructed using filtered back projection or iterative reconstruction

Question 25

what are the pros and cons of tomosynthesis?

Answer 25

Pros
1. Provides enhanced lesion detection
2. Reduces false positive recalls
3. Allows more precise lesion localisation
4. 3D imaging possible
Cons
1. Higher radiation dose (approximately double)
2. High contrast objects (e.g. surgical clips) can cause significant artefacts
3. Longer interpretation time
4. Requires substantially more data storage

Question 26

what are the ideal qualities of a mammographer?

Answer 26

1. female
2. good communication skills
3. good technique/able to adapt/ low TR Arte
4. ability to work under pressure

Question 27

what are the there assessments involved after breast screening?

Answer 27

1. triple assessment
2. multidisciplinary team
3. referral to surgical breast team