POSITIONING 7.93. Proper position ateral view— Eklund technique Those patients who have subpectoral or intra mammory implants should be positioned in the man ner discussed above. Patients with subpectoral im plants may experience some discomfort during, the conventional views, The patient who has a fibrous encapsulated implant may be cult, and the implant may restrict the amount of breast tissue that can be pulled forward. Consequently, superior and inferior tissue will be missed. A 90° lateral projection is added to the routine if the patient has this type of implant. Spot-compression views or magnification Views can also be taken on implant patients. 4 Stretcher Patients ‘a stretcher patient is a challenge ften requires skill, imagi ination, and pa tience on the part of the technologist, Before posi tioning the patient, the technologist should explain to the patient what she should expect 4.1, Craniocaudal View 1. ‘The patient is recumbent on the stretcher and is, tumed on the side opposite to that which is bei examined (see Chapter 8, Figure 8.4A c The x-ray tube assembly is rotated 90 Figure 7. A Tee seaptlae 3. The inferior surface of the breast is positioned iio forward for the mediolateral oblique view. B. Proper onto the image receptor, The positioning is sir positioning of the modified mediolateral oblique view lar to that of the craniocaudal view. The technol: Eklund technique. €. Modified mediolateral oblique ogist must hold the breast in pkice, Compression view—Eklund technique is applied78 MAMMOGRAPHY FOR RADIOLOGIC TECHNOLOGISTS, 2/6 4.2. Caudocranial View er and is is being The patient is recumbent on the stretel tured on the side apposite to that whic amined (Figure 7.34), ‘The x-ray tube assembly is rotated 90 3. The superior surface of the breast is positioned onto the image receptor. The positioning is simi to that of the caudocranial view. The technol ogist must hold the breast in place, Compression is applied 4.3. 90° Lateral(s) Positioning the 90° lateral(s) will be more comfort able for the patient and may be more achievable than the oblique (see Chapter 8, Figure 8:4B) 43.1. 1, The x-ray tube angle, The in etcher Mediolateral View ly is positioned at the 0 receptor is placed on the 2. The patient is rec mined. The patient’s breast is carefully sitioned on to the image receptor. Compression is applied pent and lying on the side to be Figure 7. Stretcher patient having a caudocranial 4.3.2. Lateromedial View ‘The x-ray tube is positioned at the 0° angle at is recumbent and lying on the site side of the breast that will be examined 3. The height of the image receptor is such that the pationt’s sternum is tightly against the lateral as- pect of the image receptor 4. The patient’ breast is pulled over on top of the image receptor. Compression is applied 4.4, Mediolateral Oblique View 1. If the patient is capable of sitting, the back of the stretcher is raised to support her. 2. The x-ray tube assembly is positioned parallel with the patient's pectoral muscle. ge receptor is positioned between the back of the stretcher and the patient. The patient's humerus rests on top of the image receptor. The breast is positioned on the image receptor, Compression is applied. Often, the positioning is similar to that of the ax- illary tail view Positioning a stretcher patient is often less than optimal. Thus the radiographs are not as “pretty” as those of a patient who is cooperative and can move on her own 5 Problems in Positioning Not every patient is built the same way. It may be- come necessary to modify the normal mammography procedure to ob information. It who is Il the pa logist has in order ns, additional time all the requ is also important to remember that a pat anxious, tense, or uncooperative require tience and understanding a techy to relax, In these types of situ is required for the examination If a patient is physically impaired—for example, a stroke patie I technologist may have to assist. It is helpful to establish guidelines for radi- graphing the difficult patient. This will alleviate un= necessary exposure and anxiety for both the patient and the technologist5.1. Craniocaudal Projection 5.1.1, Nipple Not in Profile Some patients’ habitus makes it difficult to position the breast with the nipple in profile, Care must be taken to make sure the image receptor is not too high or too low so the patient's breast is properly po: sitioned. Sometimes the incorrect height of the im age receptor is the reason why the nipple is not in Figure 7,354 thro If the nipple is not in profile in an otherwise properly positioned image of the full breast, the nip. ple should be imaged separately. One may consider the following: 1. The patient should be positioned in the cranio caudal projection. The posterior breast tissue should be pulled into position, maximizing, the amount of breast to be evaluated. If desired, a nipple marker should be placed over the nipple If this is done, the radiologist will recognize the marker and not misinterpret the nipple as a soft tissue mass, When necessary, supplementary nip ple views are taken with the nipple in profile 2, The breast should be positioned in the craniocan dal projection with the nipple in profile, The breast is centered to the image receptor, An addi tional view for the posterior breast tissue will be Note that in Figure 7.36A the nipple is in profile. In Figure 7.36B the nipple is turned under, and in Figure 7.36C the nipple is turned up on top of the breast. Proper positioning of the full breast is pre ferred. 5.1.2. Skin Folds or Wrinkling of the Breast (Figure 7.37) Skin folds under the compression paddle can be han: dled one of two ways 1. The breast should be compressed. The skin folds should be gently smoothed out with the technol ogist’s index finger. It is imperative that the pos terior breast tissue not be pulled away. Present imaging techniques make the skin folds easier to ate and evaluate. If the area surrounding OSITIONING 79 y too low for the pat Craniocaudal view imprc CO a ¢ 7.35, A. Craniocaudal view positioned with the the patient. € ned and the image 1 breast tissue80) MAMMOGRAPHY FOR RADIOLOGIC TECHNOLOGISTS, 2/ the skin fold is suspicious, another projection may be required If the first alter w tive is not acceptable, the breast tissue must be smoothed out before compression is applied. Unfortunately, often breast tissue is nised, W should be taken to supplement the breast tissue radiograph, n necessary, additional views compre eliminated from the o1 5.1.3. Lateral Skin Folds If a patient has adipose tiss that rolls over the top of the compression paddle (Figure 7.37), the follow hods to eli imposition should be ing w tried inate sup 1. ‘Tape the “fat roll” out of position 2. Reposition the shoulder area of the side being ex nined by doing the followi + The patient should stand in a military position shoulder back. + The arm should be abducted at right angles to the chest wall. Compression should be applied Figure 7.36, A. Nipple in profile. B. Nipple rolled on the underside of the breast. C. Nipple t xl on top of the breast The arm should be relaxed following compres sion + Reposition the arm: the patient should hold onto the handlebar or should place her palm up un. der the image receptor: Patients Diff Body Habitus alt to Compress Due to Patients who are difficult to compress for the eran iocandal view include patient 14 athletic female patient + A kyphotic patient + A patient with a pacemaker Figure 7.37. Posterior breast tissue rolled over the‘The technologist should consider trying the fol- lowing to improve her or his ability to compress the patient's breast 1, Ifthe mammography equipment is designed to do so, rotate the x-ray tube assembly 180° and per form a caudocranial projection. or The patient should be positioned for the cranio tidal projection, The patient should relax th side of the body being examined. This can be per formed by having the patient relax her shoulder, knee, and hip. When this is done, the breast tis- sue appears to become easier to manipulate onto the receptor. 5.2. Mediolateral Oblique View 5.2.1. Pinching the Patient in the Axilla Area If the patient is positioned as desired but complains of pain when compression is applied, the following should be tried 1. Compression should be released. 2. The patient should remain in position 3. The technologist should walk behind the patient nd lift the arm or axillary area and reposition the patient's arm, Sometimes the patient's pectoral muscle and latissimus dorsi muscles are improp- erly positioned onto th receptor. Only the pectoral muscle should be on the image receptor and the latissimus should be placed tightly along the lateral aspect (chest wall edge) of the image receptor 4. Reposition the breast 5. The height of the receptor should be checked, ‘The receptor should be lowered when necessary. The top of the receptor should be parallel to the patient's arm when abducted 90° from the body Note: Often “pinching” will occur in the MLO view as a result of the incorrect angle selected for the patient or as a result of not “lifting” the breast medi- ally before placing the breast onto the compression device. 5.2.2. Incorrect or Uneven Compression If compression can be applied to the upper half of the breast but not the lower portion 1. ‘The patient's build and the positioning should be reevaluated POSITIONING 81 2. The patient should be repositioned as described in Section 6.2.1 3. When the patient is extremely thick in the upper forearm and upper quadrants of the breast, it be necessary to attempt other projections example, an axillary tail view should be taken for the upper portion of the breast. A contact lat- eral should be taken for the lower portion of the breast When the compression can be applied to the lower half of the breast but not the upper portion of the breast 1. The patient should be reevaluated The height of the image receptor should be ked. angle of the x-ray tube assembly should be image receptor should be parallel to the pectoral muscle 4. The patient’ arm and upper breast tissue should be repositioned onto the image receptor. When necessary, the standard positioning should be substituted to obtain the required informa- tion, 5.2.3. Thin Patient A thin patient can be difficult to position for the MLO view: In such a case, the patient should be as- sessed, A reverse oblique view should be tried. Note the patient in Figure 7.38A and B, In the LMO view, much more of the patient’s breast is visualized. It may be necessary to obtain a MLO (90° lateral) view. Alternatives are to try the following 1, The patient should place her arm along the top of the image receptor. If necessary, the patient’s el: how should be placed behind the image receptor. This may help to bring the pectoral muscle onto the image receptor Once the patient is positioned, the height of the image receptor should be checked. The axillary region should slowly be repositioned. ‘Th illary fat shor receptor. 3, The angle of the image receptor should be checked. Is the receptor parallel to the pectoral muscle? w poste ld be lifted behind the image82 MAMMOGRAPHY FOR RADIOLOGK Figure 7.38. thin patient, B, Lateromedial oblique view on the same A. 60° mediolateral oblique view on a patient visualizes more breast tissud 2.4, Patient with an Arm remely Obese Upper To position the patient, the technologist should stand pipulate thi pose tissue from the upper arm behind the imay ceptor behind the patient and roll or m 5. Multiple Views Needed When more than one view is necessary to cover the entire breast tissue 1. The axillary tail or the MLO view should be con. sidered for the upper half of the breast A mediolateral (90° lateral) view should be taken. for the lower half of the breast. TECHNOLOGISTS, 2/¢ 5.2.6. Kyphotic or Pacemaker Patients When a patient is a kyphotic or has a pacemaker 1. A lateromedial oblique (reverse oblique) view should be considere 2. A 90° lateromedi ered for the lowe projection should be consid half of the breast 7. Inframammary Region Not Visu When the inframammary region of the breast is not visualized on the radiograph 1, Determine if the pi jont’s build is contributing to this or if it is due to poor positioning (Figure 7.39). 2, Have the patient stand slightly in front of the im: age receptor. The patient should lean back onto the receptor. The patient’s hips may hi too far away from the receptor or behind the re: ceptor fe been 5.2.8. Superimposition of Other Anatomy Care must be taken not to radiograph the patient's ' breast in the final image nd, chin, nose, or the nipple from the opposite 5.2.9. Incorrect Angle for the Body Part the an. ye receptor el to the patient's pectoralis major, The pa When the angle is incorrect for the body patient's build should be reevaluated. The C-arn gle should be adjusted such that the tient should be repositioned. Figure 7.39. bottom of the breast Mediolateral oblique view missing theim 5.3. Mediolateral View The most common problems seen in positioning o the mediolateral projection are as follows 1. Image receptor too high; The height of the image receptor should be reevaluated. The patient's film, The af fected arm should rest on top of the image re breast should be centered to the ceptor 2. Posterior breast tissue missing: Often patients arc positioned with one arm behind the image recep: tor. This will pull the posterior tissue away from the image receptor. The affected arm should be repositioned to rest on top of the receptor. The technologist should manipulate and position the posterior breast tissue onto the film. 3. "Drooping” breast; The patient’s breast should be lifted up onto the image receptor. The breast should be held in position until compression is ap plied. When the breast is allowed to fall, often posterior breast tissue is missed. The final image may appear underexposed, This is usually due to improper positioning of the breast over the pho: tocell detector 4. Abdominal tissue not permitting roper compres sion and positioning of the patient: The patient should step away from the receptor slightly and should bend at the waist into the receptor or tilt the buttocks back away from the equipment 5.4. Sectional Imaging of the Extremely Large Patient Each facility must decide how to address those 0c casions when the patient is too large to allow visual ization of the breast with one exposure per projec tion Suggestion: The patient should be exposed by quadrants, When the various projections are sec- tioned, it is essential to label the films for proper evaluation. Example: mediolateral oblique projection MLO 1 MLO lower MLO anteri MLO posterior Large patients present a challenge to the technolo: gist. Care must be taken not to let the patient know or sense the technologist’s frustration. POSITIONING 83 6. The Male Patient The number of male patients who have mammo- mogram often has more breast tissue than a small woman. Positioning of the male patient should be handled like that of a female patient (Figure 740A Suggestion: It may be difficult to obtain a cranio- caudal view of a muscular male patient. A caudocra- nial view should be taken (see Section 2.1), A. Cranios proper positioning, maximal breast tissueS84 MAMMOGRAPHY FOR RADIOLOGIC TECHNOLOGISTS, Am ssed, as a mammogr dure,” The technologist must be sensit feelings, making the patient as comfortabh ble. ient is often very emb is thought to be a “woman's proc © to tho as possi- le pa eee (, Summary In this chapter, positioning has been discussed. It is imperative that the mammographer assess the pa- tient and tailor the examination to the patient, Whe to perform m pgraphy, it must decide on the standard views to be implemented. If tr supple gist must determine how the patient will be handled to take extra projections facility bey al views, the technolo- References Andersson I. Medical Radiology and Phot Rochester, NY: Eastnan Kodak: 1986,62:10-18, Feig SA. The import graphic views to 19881514041 Sickles EA. Pr phic problems: 1988;151:31 hy RG, E wing of the augmented breast 151:469-473, diagnostic accuracy tical solutions to ce Tailoring the e nnd GW, Job JS, Miller SH. Improv- AJR 1985;