STudy Material-301 (Module 1)

B.Sc.
-MRIT III Semester

Radiographic Techniques of Mammography, DEXA, Oral Radiography with Image Interpretation -BMRITC301
Academic Session: 2023-2024
Study Material
RADIOGRAPHIC TECHNIQUES OF MAMMOGRAPHY, DEXA, ORAL RADIOGRAPHY WITH IMAGE INTERPRETATION
Module I-MAMMOGRAPHY
Table of Contents:
Introduction/History of Mammography, Mammographic equipment
Mammographic radiation dose and exposure
Patient preparation
Different techniques
Mammographic image evaluation of different views.
Introduction
Mammography is a medical imaging technique used to screen and diagnose breast diseases, particularly breast
cancer. It involves taking X-ray images of the breast tissue to detect abnormalities such as tumors or cysts.
Mammograms are an essential tool in early detection, as they can often identify potential issues before
symptoms become noticeable.
There are two main types of mammography:
1. Screening Mammography: This type of mammogram is performed on asymptomatic women with no
known breast issues. It is used to detect breast cancer in its early stages, even before a lump can be
felt. Regular screening mammograms are recommended for women over the age of 40 or earlier for
those with a family history of breast cancer or other risk factors.
2. Diagnostic Mammography: This type of mammogram is conducted when a potential issue has been
detected during a screening mammogram or when a woman is experiencing breast-related symptoms
like a lump, pain, or nipple discharge. Diagnostic mammography provides more detailed images to
evaluate specific areas of concern.
History of Mammography:
The history of mammography dates back to the early 20th century. Here are some key milestones in the
development of mammography:
1. Discovery of X-rays: Wilhelm Conrad Roentgen discovered X-rays in 1895. This ground breaking
discovery opened the door to medical imaging techniques, including mammography.
Mr. Prashant Kumar Jha Ms. Babina Aryal

Assistant Professor BMRIT (AHS) Assistant Professor BMRIT(AHS) 1
Brainware University, Kolkata Brainware University, Kolkata
B.Sc.-MRIT III Semester
2. First Mammograms: The first recorded attempt using X-rays to image breast tissue was made in 1913
by Albert Salomon, a German surgeon. He used a primitive X-ray machine to detect breast cancer.
3. Development of Dedicated Mammography Machines: In the 1960s, specialized mammography
machines were developed. These machines were designed to focus on breast imaging, allowing for
better image quality and lower radiation exposure.
4. Introduction of Screen-Film Mammography: In the 1970s, screen-film mammography became the
standard technique. This involved using X-ray films to capture the images, which were then developed
and examined by radiologists.
5. Digital Mammography: In the early 2000s, digital mammography emerged as an advancement over
screen-film mammography. Digital mammography uses digital detectors to capture and store images,
providing improved resolution and easier storage and retrieval of images.
6. 3D Mammography (Tomosynthesis): Digital breast tomosynthesis, also known as 3D mammography,
was introduced in the late 1990s and became more widely available in the 2010s. It involves taking
multiple X-ray images of the breast from different angles, which are then reconstructed into 3D images.
3D mammography offers better visibility of breast tissue, reducing overlapping structures that can
sometimes hide abnormalities.
7. Advancements in Breast Imaging: Alongside mammography, other breast imaging techniques have
been developed, such as breast ultrasound and breast MRI. These imaging modalities are often used
in conjunction with mammography for a more comprehensive evaluation of breast health.
8. Digital Breast Tomosynthesis (DBT): DBT is an enhanced form of 3D mammography that provides
even clearer images and improved detection of breast cancers, particularly in women with dense breast
tissue.
9. Continued Research and Improvements: Over the years, there have been ongoing research and
improvements in mammography technology, leading to better image quality, lower radiation doses,
and improved accuracy in breast cancer detection.
Mammographic Equipment
The mammography machine is equipped with special features and accessories for an X-ray exam of the breast.
a. X-ray Generator: - The mammographic unit includes an X-ray generator and an X-ray tube. The X-
ray generator transforms the incoming voltage to the X-ray tube for the production of the X-ray. The
high-frequency generator with 5-10 kHz power is used in mammography.
b. Mammography X-ray Tube: - The mammography X-ray tube produces only characteristic X-ray. In
mammography, low KVp (20-35 kvp) is used because it minimizes the Compton scattering and

maximizes the photoelectric effect.

c. Target: - The X-ray tube target materials consist of molybdenum or tungsten, or rhodium.
Molybdenum target with molybdenum/rhodium filter is more suitable and commonly used in
mammography machines. The molybdenum allows the production of low kvp radiation at 26-40kvp.
d. Focal Spot:- In breast imaging, high spatial resolution is required, so a small focal spot of O. 1mm and
0.3mm with a small anode angle of 6 degrees is used.
e. Filters: - The beryllium window or borosilicate window is used as inherent filters for the low
attenuation of X-ray photons. Mo or rh filter is used as added filters. Molybdenum (mo)-.03mm
molybdenum is used for routine lower kVp techniques (below 30 kVp) and rhodium filter of 0.025
mm is used for above 30 kVp for dense breast imaging.
f. SID: - The source to image distance should be 60-80 cm
g. Compressions Paddle: - Compression is achieved with a low attenuating paddle. The compression
paddle is attached to the machine. Breast compression is under the discretion of the mammographer
and will depend on the patient’s breast sensitivity and size. In general, the breast should be compressed
until taut to fingertip pressure to ensure adequate compression. Often, after the automatic compression
stops, manual compression must be applied to adequately immobilize and compress the breast.
Although too little compression will compromise image quality, the compression should not be applied
to cause the patient severe pain.
Main Reason for Breast Compression
• Compression allows a uniform density by flattening the posterior breast to the same degree as the more
anterior regions, permitting optimal imaging of the entire breast on 1 exposure.
Added Advantages of Breast Compression
• The tissue thickness of the compressed breast is less than that of the uncompressed breast which means
that lower radiation is needed to penetrate the compressed breast allowing reduced radiation dose to the
patient.
• Compression brings lesions closer to the detector for more accuracy when evaluating fine detail.
• Compression reduces the possibility of motion by immobilizing the breast during the exposure.
• Compression allows the use of lower peak kilovoltage (kVp) which allows increased contrast.

• Compression separates superimposed areas of glandular tissue by spreading apart overlapping tissue,
allowing visualization of the borders of circumscribed lesions.
• Compression assists in capturing the breast tissue to include the posterior chest wall anatomy.
h. Grids: - The grids are placed in between the screen and the film. It improves the image quality. The
grid ratio of 4:1 or 5:1 linear, moving is used. The HTC (high transmission cellular) grid is used in
modern machines. This grid reduces scatter radiation effectively.
i. Automatic Exposure Control (AEC):- It is a radiation sensor located underneath the cassette. The AC
automatically calculates the correct exposure which is required for optimum density on the film.
j. Screen and Films:- The gadolinium oxysulfide activated with terbium is used as screen phosphor in
the mammography. The mammography films are high-resolution films. The emulsion has a small grain
size, and it is coated on a single side only.
k. Heel Effects: - The breast requires a higher intensity of radiation near the chest wall and lower at the
nipple. For uniform exposure, the cathode is positioned toward the chest wall, and the anode is toward
the nipple.
Fig Conventional Mammography Machine Fig Digital Mammography Machine

Mammographic radiation dose and exposure
A typical 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. The usual procedure is to estimate and express the
dose as the average dose or more specifically the mean glandular dose (MGD) within each breast. Women with smaller

than average breasts will receive a lower MGD. Doses are higher for women with larger breasts. Any additional images
that might be required will add to the dose received.
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.
The radiation beam of each mammography machine is usually calibrated so that it delivers a specific and
known absorbed dose to a reference (average size) breast when imaged with a specific set of technique factors.
The major factors determining this dose are the sensitivity of the receptor (film- screen combination,
characteristics of digital receptors), and the setting of the automatic exposure control (AEC) level to produce
a specific film density. The dose generally increases with increased breast size and density, for a given optical
density. With regard to the technique, the selected kV (typical range of 24kV to 32kV) and anode/filter
combination are the major factors that determine the dose. Lower kV values are used to enhance contrast but
do not provide sufficient penetration through thick or dense breast tissue where the higher kV values are
required. When the kV is reduced in a specific examination, the mAs must be increased to produce the
necessary receptor exposure. The combination of reduced kV and increased mAs results in a higher dose.
Dose generally increases with increased breast size and density because more radiation is required to penetrate
the breast and expose the receptor.
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.
Patient preparation:
 Check the unique hospital Id (UHID) of patient.

 Instruct the patient to remove if any metallic object is found on chest and change to hospital gown.
 Explain the procedure to the patient.
 Patient is instructed not use any deodorant, powder, lotion or perfume on the day of your exam.
 Follow ten-day rule.
 Fill the mammography questionnaire before starting the examination. A mammography questionnaire
includes questions like patient demographic information, presence or absence of complains like lump,
pain, tenderness, nipple discharge, etc, detailed history of menstrual status, family history of breast
cancer, hysterectomy, previous history of surgery.
 Collect previous examination reports if available.

Mammography Techniques
Routine Breast Imaging Projection
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.
Positioning- CC Projection
• Position the detector at the level of the raised inframammary crease. The breast must be elevated before
positioning the detector.
• Turn the patient’s head away from the side being examined.
• Position the patient’s feet apart with weight equally distributed.
• The ipsilateral arm is positioned by patient’s side.
• The contralateral arm is raised and the patient can hold the machine for support.
• Optimal compression is achieved if the patient is relaxed. To aid relaxation of the shoulder, place your
hand on the ipsilateral shoulder and gently push down.
• Expose on suspended respiration but try to avoid telling the patient to take a deep breath before the
exposure.

CC Evaluation criteria
• The nipple should be in profile.
• The nipple should be centred on the radiograph; however, do not eliminate breast tissue to center the
nipple.
• The medial and lateral aspects of the breast must be included in the collimated area.
• If possible, include the cleavage and a small amount of contralateral breast at the medial margin.
• The pectoralis major muscle is seen in approximately 30%-40% of the cases. If the pectoral muscle is
seen on all cases imaging may be losing medial breast tissue.
• Appropriate markers and labelling must be used as required by Mammography Quality Standard Act
(MQSA).
• The CC should include, within 1 cm, the posterior nipple line (PNL) measurement of the MLO.
• Dense areas of the breast should be adequately penetrated.
Patient Positioning- MLO Projection
• The degree of tube angulation will vary between 30 and 60 degrees, depending on the patient’s body
habitus. Thin patients require steeper angulation than heavier patients.
• The correct detector or compression paddle size is needed to avoid stretching the pectoralis major muscle.
• Too much pectoral muscle under the compression plate, especially when imaging the male breast, will
reduce compression to the anterior portions of the breast.
• The ipsilateral arm should be draped over the top of the detector.
• The detector should rest in the armpit, posterior to the midaxilla and anterior to the latissimus dorsi
muscle.
• Compression must adequately support the anterior breast tissue to preventing sagging and distortion of
the ductal architecture.
• Appropriate markers and labelling must be used, as required by MQSA.
• Expose on suspended respiration, but try to avoid telling the patient to take a deep breath before the
exposure.

MLO Evaluation criteria
• The pectoral muscle should be wide superiorly with a convex anterior border and should extend to or
below the level of the PNL.
• The inframammary fold should be open.
• Dense areas of the breast should be adequately penetrated.
• There should be no drooping of the anterior breast and distortion of the architectural structures.
• Abdominal tissue should not overlap the breast tissue.

QUESTIONS:
1. Multiple Choice Questions
Q.NO. Question Option 1 Option 2 Option 3 Option 4 Correct

Option
1. What is the primary purpose Detection of lung Assessment of Screening and Examination ofthe
of mammography? diseases bone density diagnosis of gastrointestinal 3
breast cancer tract
2. Mammography uses which X-rays Gamma rays Ultraviolet rays Infrared rays 1
type of radiation to create
images of the breast?
3. What is the most common Consuming dairy Family history of Lack of physical Frequent exposure 2
risk factor for developing products breast cancer exercise to
breast cancer? sunlight
4. Which breast imaging Ultrasound Positron emission Magnetic Computed 1
technique is often used as a tomography resonance tomography
follow-up after a suspicious (PET) imaging (MRI) (CT)
finding on a mammogram?
5. What is the main advantage Higher radiation Better image Lower cost Inability to store 2
of digital mammography dose resolution images
over traditional film electronically
mammography?
6. What does BI-RADS stand Breast Imaging Biopsy and Benign Invasive Breast Imaging 4
for in the context of Results and Radiology Risk Reporting and
mammography reporting? Diagnosis System Diagnostic Assessment and Data System
System Diagnosis Scale
7. Which type of Screening Diagnostic Tomosynthesis Contrast- 2
mammography is mammography mammography enhanced
specifically recommended mammography
for women with dense
breast tissue?
8. In mammography, Large, solid masses Fluid-filled cysts Tiny deposits of Irregularly 3
microcalcifications are calcium in breast shaped tumors
tissue
9. What is the main advantage Lower radiation dose Faster image Higher image Better 3
of tomosynthesis (3D acquisition resolution and visualization of
mammography) over reduced tissue blood vessels
traditional 2D overlap
mammography?
10. What is a "compression To make the To reduce To flatten and To warm up the 3
paddle" used for during a machine smaller and patient discomfort spread-out breast tissue
mammogram? more during imaging breast tissue before imaging
portable for better
imaging

2. Short Questions Answers:
a. Differentiate between Screening and Diagnostic Mammography.

b. Explain in detail about Mammography equipment.
c. Illustrate the indications and Patient preparation for mammography.
d. Explain he basic mammographic projections.
e. Differentiate between Conventional and Digital Mammography.
f. Explain the use of Automatic Exposure Control and Compression paddle in mammography



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B.Sc.

-MRIT III Semester

Mr. Prashant Kumar Jha Ms. Babina Aryal

Mr. Prashant Kumar Jha Ms. Babina Aryal

maximizes the photoelectric effect.

Main Reason for Breast Compression

Added Advantages of Breast Compression

Mr. Prashant Kumar Jha Ms. Babina Aryal

Fig Conventional Mammography Machine Fig Digital Mammography Machine

Mr. Prashant Kumar Jha Ms. Babina Aryal

 the characteristics of the equipment being used;

 Check the unique hospital Id (UHID) of patient.

Mr. Prashant Kumar Jha Ms. Babina Aryal

Routine Breast Imaging Projection

• Position the patient’s feet apart with weight equally distributed.

• The ipsilateral arm is positioned by patient’s side.

Mr. Prashant Kumar Jha Ms. Babina Aryal

• The nipple should be in profile.

• Dense areas of the breast should be adequately penetrated.

Patient Positioning- MLO Projection

• Appropriate markers and labelling must be used, as required by MQSA.

Mr. Prashant Kumar Jha Ms. Babina Aryal

MLO Evaluation criteria

• The inframammary fold should be open.

• Dense areas of the breast should be adequately penetrated.

• Abdominal tissue should not overlap the breast tissue.

Mr. Prashant Kumar Jha Ms. Babina Aryal

1. Multiple Choice Questions

Q.NO. Question Option 1 Option 2 Option 3 Option 4 Correct

Mr. Prashant Kumar Jha Ms. Babina Aryal

2. Short Questions Answers:

a. Differentiate between Screening and Diagnostic Mammography.

Mr. Prashant Kumar Jha Ms. Babina Aryal

Mr. Prashant Kumar Jha Ms. Babina Aryal

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