MAMMOGRAPHY

Mammography is special x ray of breast with compression in order to

recognize any abnormality of breast,with dedicated mammography
unit.

EQUIPMENT

Mammography
machine

Angled Tube Head

Due to the anode heel effect, the x-ray beam is not uniform in the direction
parallel to the anode-cathode axis of the x-ray tube. This property is used in
mammography by aligning the cathode over the chest wall end (higher
energy beam to image thicker area) and the anode over the nipple end (lower
energy beam can penetrate thinner area).
C-Arm Design

The x-ray set is a c-arm. The whole gantry rotates so that the tube and breast
table remain opposite each other.

Fixed Focus-Detector Distance (FDD)

The set is designed for a single examination and the focus-detector distance
(FDD) or focus-to-film distance (FFD) of 65-66cm is considered optimum.
This set FDD is a compromise between lower patient doses (lower doses
with higher FFDs) and higher film doses (lower exposures with higher FFDs).
Also, higher FDDs require longer exposures for a fixed mA resulting in more
movement un sharpness.

Compression Device

The maximum force applied should be no greater than 200 N (approx. 20 kg

weight). Standard compression forces are normally between 100 – 150 N.
The compression plate is angled so that more of the breast is in contact with
the compression paddle.

Fixed Field Size

Unlike in general radiography, only one type of examination is done meaning

collimation creating fixed field sizes are all that are required.

Grids

Moving anti-scatter grids are used in normal mammography imaging. For

magnification views, the breast support table is above the film to give
magnification factors of around 1.8. In this case the large air gap between
the breast and the film works to reduce scatter and so no grid is needed.

Automatic Exposure Control (AEC)

In screen-film mammography a separate AEC was required placed behind

the cassette. With the currently used digital mammography the detectors act
as the AEC. In screen-film radiography an AEC is required to ensure a
suitable exposure to prevent under- or over-exposed film. In digital
radiography, however, windowing can negate the effects of unsuitably
exposed film and the AEC is more to ensure a suitable radiation dose for the
patient and for the working parameters of the digital dector.

Target / filter material

• Need good differentiation of low contrast structures

• Need very high spatial resolution for micro-calcifications

Target

Need material that produces characteristic x-rays with energies of 17-20 keV
(20-30 keV for larger breasts) to produce the best contrast. The commonly
used material is Molybdenum (characteristic x-rays at 17.5 and 19.6 keV).

Filter

A filter with a k-edge of an energy just above the characteristic energies is

used to remove the higher energy x-ray photons and make the beam as
monoenergetic as possible. Molybdenum has a k-edge of 20 keV, just high
enough so that the large increase in attenuation (k-edge) doesn’t fall into the
characteristic energies produced at the molybdenum target.

Alternatives

Mostly MoMo (molybdenum target, molybdenum filter) but this does not give
high enough energies for larger breasts.

• Rhodium has a k-edge at 23.3 keV and we can use a molybdenum

target and rhodium filter (MoRh) to increase the amount of x-rays with
energies in the range of 20 – 23.3 keV.
• Rhodium characteristic x-rays are at 20.2 – 22.7 keV. When used as
a target this produces a beam with a mean energy that is higher than
for MoMo and for MoRh.
• Tungsten (W) target and Rhodium filter. The x-ray output is reduced
as no characteristic x-rays are produced (and, therefore, longer
exposure times) but tungsten is much cheaper. It is mostly used in
breasts with implants or that have been treated with radiotherapy as
they are much larger and denser.
 Contrast Radiation dose

Highest MoMo MoMo

MoRh MoRh

RhRh RhRh

Lowest WRh WRh

The mean energy of the spectrum decreases from WRh to MoMo. Lower
energy photons have a higher probability of interacting with matter and,
therefore, produces better contrast. However, the lower the energy, the
greater the absorption, the more energy is deposited in the matter, and the
higher the dose.

Summary

• General use: MoMo

• Dense breasts: MoRh or RhRh

Spatial Resolution

A very high resolution is required to see microcalcifications. This is achieved

via:

• Focal spot size

• Compression
• Anti-scatter grid

Small Focal Spot Sizes

Broad focal spot size = 0.3 mm

Fine focus focal spot size = 0.1 to 0.15 mm

From a point source, objects are easily resolved as separate on the film.
However, with increasing focal spot size, the radiation comes from all parts
of the source. The radiation creating the image does not provide a sharp
image but has blurring at the edges. If the objects are too close together they
can appear as one or an extra ‘object’ can be created.

Compression

Typical compression force is 100 – 150 N

The compression force:

• Lowers patient radiation dose as the attenuation of the compressed

breast is lower and a lower exposure can be used
• Reduces scatter as the breast is less thick so there is less probability
of scatter happening within the tissue
• Spreads the tissues out so that there is less overlaying of features
• Reduces geometric unsharpness by moving tissue closer to the image
receptor
• Reduces movement unsharpness by holding the breast still
• The compressed breast is of more uniform attenuation

Anti-Scatter Grids

In mammography, moving grids are used for all contact (broad focus)
images. For magnification images using a fine focal spot size or an air gap
technique is used to reduce the amount of scattered radiation reaching the
receptor meaning a grid is not required.

Altering Parameters

Parameters need to be altered to provide optimal imaging of different

breasts. Two factors need to be taken into consideration:

1. Thickness of breast
2. Composition of breast

1. Thickness

In large breasts:

• More radiation absorbed – higher doses needed

• More scatter
• Increased beam hardening (lower contrast)
 • Longer exposure needed at 28 kV MoMo, therefore, movement
artefacts may occur

Thinnest breasts: MoMo at 25 kV

Thickest breasts: MoRh or even WRh for very thick breasts at 32 kV

2. Composition

With more dense breasts, higher doses are needed due to extra attenuation
and more beam hardening. Due to beam hardening, the AEC may cut off the
exposure prematurely (the measured exposure will be of a higher intensity).
To ensure this doesn’t happen, one of two methods may be used:

1. A pre-exposure determines whether the breast is as dense as

expected for this thickness by looking at the dose rate and beam
hardening.
2. Adjustment on dose rate based on measuring the dose detected at the
start of the examination and then adjusting the dose and exposure time
as necessary.

Tomosynthesis

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. There are two main
methods of acquiring breast tomosynthesis:

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
 Pros

• Provides enhanced lesion detection

• Reduces false positive recalls
• Allows more precise lesion localization

Cons

• Higher radiation dose (approximately double)

• High contrast objects (e.g. surgical clips) can cause significant artifacts
• Longer interpretation time
• Requires substantially more data storage

Indications
1. Focal signs in women aged ≥40 years in the context of triple (i.e. clinical,
radiological and pathological) assessment at a specialist, multidisciplinary
diagnostic breast clinic
2. Following diagnosis of breast cancer, to exclude multifocal/
multicentric/bilateral disease
3. Breast cancer follow-up, no more frequently than annually or less
frequently than biennially for at least 10 years
4. Population screening of asymptomatic women with screening interval of
3 years, in accordance with NHS Breast Screening Program policy: (a) By
invitation, women aged 47–73 years in England, Northern Ireland and Wales,
and 50–70 years elsewhere in UK (b) Women older than 73 years, by self-
referral (There is no upper age limit.)
5. Screening of women with a moderate/high risk of familial breast cancer
who have undergone genetic risk assessment in accordance with National
Institute for Health and Clinical Excellence (NICE) guidance 6. Screening of
a cohort of women who underwent the historical practice of mantle
radiotherapy for treatment of Hodgkin disease when younger than 30 years.
These women have a breast cancer risk status comparable to the high-risk
familial history group.1
7. Investigation of metastatic malignancy of unknown origin
CONTRAINDICATION
1. Asymptomatic women without familial history of breast cancer, aged
younger than 40
2. Investigation of generalized signs/symptoms—e.g. cyclical mastalgia or
nonfocal pain/lumpiness
3. Prior to commencement of hormone replacement therapy
4. To assess the integrity of silicone implants
5. Individuals affected by ataxia-telangiectasia mutated (ATM) gene mutation
with resultant high sensitivity to radiation exposure, including medical x-rays
6. Routine investigation of gynaecomastia
Equipment
Conventional film-screen mammographic technology has been superseded
by full-field digital mammography (FFDM), which has a higher sensitivity in:
1. women aged younger than 50 years
2. pre/perimenopausal women
3. women with dense fibroglandular breast tissue
Developments of FFDM include the following:
1. Tomosynthesis, which creates a single 3D image of the breast by
combining data from a series of 2D radiographs acquired during a single
sweep of the x-ray tube. This technique has a proven significant increased
accuracy in the diagnostic evaluation of masses and parenchymal
distortions, irrespective of breast composition: its increased accuracy in the
morphological and margin extent analysis allows more precise assessment
of tumor size, both in fatty and dense breast tissue, confirming its role in
diagnostic symptomatic and screening practice. Further studies suggest the
potential, within the screening context, to increase sensitivity of the order of
30% with a concomitant reduction in recall rate of 15%, as well as a potential
radiation dose reduction of up to 50% compared with the current two view
mammography.3 It is now possible to carry out x-ray guided biopsy using
tomosynthesis to identify the ‘slice’ most accurately demonstrating the target
lesion, thus avoiding the requirement to carry out stereotactic, paired images
(see the section on image guided biopsy).
2. Contrast-enhanced digital mammography (i.e. angiomamography).
Two approaches are available: temporal sequencing (in which images pre-
and postcontrast are subtracted with a resultant angiomamogram) and dual
energy imaging (in which imaging at low and high energies detailing
parenchyma and fat, respectively, with and without iodine are obtained). The
subsequent views can then be subtracted. Ongoing studies will inform the
future diagnostic role of this technique.
3. Computer-aided detection (CAD) software can assist film reading by
placing prompts over areas of potential mammographic concern. There is
evidence that, even in the screening setting, single reading in association
with CAD may offer sensitivities and specificities comparable to that of
double reading
4 Technique
Standard mammographic examination comprises imaging of both breasts in
two views—namely the mediolateral oblique (MLO) craniocaudal (CC)
positions.

Screening methodology is bilateral, two-view (MLO and CC) mammography

at all screening rounds. Additional views may be required to provide
adequate visualization of specific anatomical sites:
1. Lateral/medial extended CC
2. Axillary tail
3. Mediolateral/lateromedial
Compression of the breast is an integral part of mammographic imaging
resulting in:
1. reduction in radiation dose
2. immobilization of the breast, thus reducing blurring
3. uniformity of breast thickness, allowing even penetration
 4. reduction in breast thickness, thus reducing scatter/noise achieving
higher resolution
Adaptation of the technique can provide additional information:
1. Spot compression, to remove overlapping composite tissue
2. Magnification (smaller focal spot combined with air gap), to provide
morphological analysis In the presence of subpectoral implants, the push-
back technique of Eklund can aid visualization of breast tissue.
TYPES
SCREENING AND DIAGNOSTIC
 References 1. Hancock SL, Tucker MA, Hoppe RT. Breast cancer after
treatment of Hodgkin’s disease. J Natl Cancer Inst. 1993;85:25–31. 2.
Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital
versus film mammography for breast cancer screening. N Engl J Med.
2005;353:1773–1783. 3. Skaane P, Bados AI, Gullien R, et al. Comparison
of digital mammography alone and digital mammography plus tomosynthesis
in a population-based screening program. Radiology. 2013;267:47–56. 17
360 Chapman & Nakielny’s Guide to Radiological Procedures 4. Gilbert FJ,
Astley SM, McGee MA, et al. Single reading with computer-aided detection
and double reading of screening mammograms in the United Kingdom
National Breast Screening Program. Radiology. 2006;241:47–53. 5. Eklund
GW, Busby RC, Miller SH, Job JS. Improved imaging of the augmented
breast. AJR Am J Roentgenol. 1988;151:469–473