MAMMOGRAPHY Presented by: Sabin Gwachha B Se. MIT 2013 Moderator : Mr. Ranjit Jha (senior demonstrator)Mammograms felon \ L 2% yes, | DD HAVE MY MAMMOGRAM TODAY... WHY Do You ASK?What is mammography..?? = Mammography is a radiographic modality to detect breast pathology and cancer. = Breast cancer accounts for 32% of cancer incidence and 18% of cancer deaths in women in the United States. = Approximately | in 8 or 9 women in the US will develop breast cancer over her lifetime. = A mammogram can find breast cancer when it is very small -- 2 to 3 years before we can feel it.= No screening tool is 100% effective. Good quality mammograms can find 85-90% of cancers. RTM Ure lee lla Cole ey Te mee) PW ntutetee-L | io Cancer even when it is micro in Er}The standard techniques used for breast imaging are: Screen film x-Ray mammography. Real-Time ultrasound. Other new techniques include: MRI Color Doppler C@royitarctyeinitecetsey tate) Digital Mammography ScintimammographyPrinciples Of Breast Cancer = Patients in the early stages respond well to extensive surgery = Patients with advanced disease do poorly = The earlier the diagnosis, the better the chance of survival = Mammography is the tool for early detectionIndication = pain/tenderness = Swelling = Nipple discharge (mild) = Calcification = Benign or malignant tumor EB sinolewetlelcnonemesoneettcontraindication = Breast implant = Severe nipple discharge = Large palpable mass = Inflammation = Women within reproductive age 15-40 (benefit over risk)BI-RADS mammographic assessment categories = Categ.0 : incomplete = Categ.1 : negative / normal = Categ.2 : benign finding = Categ.3 : probably benign = Categ.4 : suspicious abnormality = Categ.5 : highly suspicious of malignancy = Categ.6 : known biopsy with prone malignancybere (es elma) ue) oycve-TaCe) 1 = The patient is requested to take proper bath before coming Eran trep cere tive = Patient should not wear deodorant, talcum powder or lotion under her arms or on her breasts as these may appear on the mammogram and interfere with correct diagnosis. = She is suggested to wear loose clothing so that it is easier for her to change for the procedure = She is asked to bring along any histopathological report if done before mammography for clinical co-relation = A clean green hospital gown should be provided to the patient before procedure. = Patient privacy should be maintained and a conducive environment should be created.Development Of Mammography = In 1913, radiographic appearance of breast cancers was first reported = 1950's — Industrial grade x-ray film used = 1975 —High speed/resolution film introduced by DuPont = 1992 -MQSA implementedMQSA = Mammography Quality Standards Act = Mandated the following: ¢ Formal training and continuing education ¢ Required regular inspection of equipment ¢ Documentation of quality assurance « Report means of reporting results, follow- up, tracking patients, and monitoring outcomesAmerican Cancer Society(ACS) and American College of Radiology(ACR) suggest that all women over 50 years should undergo annual mammography. A) Vevnelse SAV Hm OUEe LCR bes) Mele eh yeme) eMC} Vons alternate year. A baseline mammogram should be done at the onset of menopause.Risk Factors Pre ¢ Incidence increases with age = Hormonal History « More sensitive to carcinogens during menarche = Family History ¢ Women with positive family members are more prone to breast cancerType of mammographic feo ecvasubeTet (Oye! |.Diagnostic mammography is performed on patients with symptoms or elevated risk factors. Two or three views of each breast may be required. 2.Screening mammography is performed on asymptomatic women with the use of a two- view protocol, usually medial lateral oblique and cranial caudad, to detect on unsuspected cancer~ Dedicated Mammography Equipment Nypeorel byzcce ice eh Bate me O ey iti rib aecel Screen/Film detector systems » Breast Compression Devices X-ray tube Tube Port Filtration Collimation Screen-film Phototimer detectorHow x-ray is produce? = X-rays are produced due to sudden deceleration of fast moving electrons when they collide or interact with the target anode. In this process, 99% of the electron energy is converted into heat and 1% of energy is converted into X-ray. = There are two type of x-ray production |.bremsstrahlung x-ray 2, characteristic x-rayBremsstrahlung x-rays result from the interaction between a projectile electron and Continuous (Bremsstrahlung) X-Ray Production a target nucleus. The electron is slowed and its direction is changed.Characteristic x-ray = Characteristic x-rays are produced after ionization of a k- FS tell ed erence = When an outer-shell electron fills the vacancy in the k shell, an x-ray is emitted. = In mammography, 17.5-19.5kev characteristic x-ray is produced with Mo target and 23key is produced with Rh irene eel= In mammography low kVp is used because it helps to minimize compton scattering and maximize the photoelectric effect inorder to enhance the differential absorption by various tissues of the breast. = As glandular tissue of breast is highly radiosensitive, low kVp helps to reduce radiation dose to breast.1.Both bremsstrahlung x-ray and charateristic x-ray produced 2.High kVp 50-120 is used. 3. Target / filter: W /Cu .Al 4, Window : Glass 5. SID: 100 or 180 cm 6, Anode angulations: 6-20 degree tube angle : nil 7.Focal spot : 0,1-1mm and 0.3- 3mm only charaterisctic x-ray 20-35 kVp is used. Mo/Rh Beryllium or very thin borosilicate glass 60- 80 cm 6 degree tube angle ; 23-25 degree 0.1mm and 0.3mmGenerator and target/ filter combination = |. High frequency generator with 5-10KHz power is used = 2. Target/filter: W/60 tum Mo Mo/30 tm Mo Mo/50 um Rh Rh/50 um RhFiltration = Window of x-ray tube should not attenuate x-ray lofetosmcy canbe ucerer elds = Be window: Z=4 or very thin Borosilicate glass window = Inherent filtration of no more than 0.1 mm Al equivalent = Under no circumstances is total beam filtration less than 0.5 mm Al equivalent.SO KOR Esa! *3.8:1 grid ratio and dose EI Meevenmen eter) Mitte rman Teng ‘CONVENTIONAL GhuD (Limanh) Oly vec cetelere Titty interspace http://www. hologic.com/oem/pdf/W-BI-HTC_HTC%20GRID_09-04-pdfPeake. attached to a compression device ion is achieved with a low attenuating lexan paddle ~ 10 to 20 Newtons (22 to 44 pounds) of force is typically ised ~ Parallel to the breast support table Spot compression uses small paddles + Principal drawback of compression is patient discomfort Spot compression Uncompressed Full compression paddle Spot compression paddle Uniform density across image. Better compression aver small areaCompression DUERMO RAN CM REGAN CLAY ¢ Spread the anatomy out to minimise overlaying structures (improve contrast) « Equalise thickness to ensure homogenous density on the radiograph ¢ Bring the structures closer to the detector to reduce geometric unshaprness ~ less scatter, more contrast, less geometric blurring of the anatomic structures, less motion and lower radiation dose to the tissuesAutomatic Exposure Control (AEC) ~ The AEC, also called a phototimer, is a device that uses a radiation sensor, an amplifier and .a voltage comparator to control the exposure, Bae leer mel ag leom i rtariniceyntnnrecle hres (aU Etc Mtieene Testi ices time that is required to produce optimum density on the pilin » When the required optimum density is produced, the AEC terminate the exposure and hence reduces the dose that may have increased with manual selection of exposure factor and exposure time. » AEC detector is located underneath the cassette in mammography unlike conventional radiography.Anatomy of the Breast Atay nS be ereaniice Cone shaped with the post surface (base) overlying the COUR ao nem elle) Axillaries tail extends from lat. etsen er iii eect Cornell elu tos fossa Tapers ant. from the base ending in nipple, surrounded by areolaFemale Breast = Consists of 15-20 lobes @ Divide into several lobules Lobules contain acini, draining ducts and interlobular connective tissue. « By teenage years each breast contains hundreds of lobulesBreast profile Eins B lobules C dilated section of duct to hold milk Det py pled eile F pectoralis major muscle G chest wall/rib cage Enlargement: A normal duct cells B basement membrane C lumen (center of duct)Lymph node areas Lymph node: adjacent to breast area. A pectoralis major muscle B axillary lymph nodes: oh C axillary lymph nodes: ty | F inten lymph ncBreast Quadrants and Breast CancersTYPES OF BREAST TISSUE GLANDULAR STROMAL = DUCTS > FATTY TISSUE = LOBES >CONNECTIVE = LOBULES TISSUE >(COOPER’S LIGAMENTS — SUSPENSATORY LIGAMENTSBreast Classifications = Breast Changes with Age JAdiolescent + Prepragnancy Reproductive Menopausal Senescent a a se 8 30 a cw enFibro-glandular Breast = Human breast is composed of mainly fibroglandular tissue RAVrCeo mS Minrede Ag radiosensitive, hence , it is to be protected from high radiation exposure i) Se36 « Average density # 50% fat & 50% fibro-glandular = Pregnant and lactating mother are less prone Loe rece eneoe = Spinsters are more jodcoye Tom KOyy LeBui Fatty ¢ Minimal density Women 50 and older (postmenopausal) men and childrenPOSITIONING . Routine Images - = CC - cranio caudad = MLO — mediolateral oblique a “True” Lateral view = Latero-medial oblique view m Paddle compression view = Magnification view L Tig ierrrerp rel aviewy m Cleavage view L ieatel eta yavioyyC4 ,/¢ rl es (E11 ez eG | eG egrot Craniocaudal (CC) Projection Mamie medi ¢ Me EU Ia grit Nipple in profile Wrinkles and folds smoothed out « CR perpendicular Breast Positioning (ery ses) Cee : . cat rae ee ty “dullCriteria Summary: (ee) Sau tF Pci weet) i NECR and Cassette ok (IR) angled =45° 7 emer etc ayer) cert esac Le ND... Eyota . ee eer cmCriteria Summary: (MLO) scle to level of nipple TEE Sei dels Sead iaMi Ie AE a fyi ila fiiMagnification = increase OID 514 x Okey, Mr. Smith. Just stick it an between those two devices,THE MALE BREAST Male Mammography and Cancer54 According to the American Cancer Society, about 0.22 percent of men’s cancer deaths are from breast cancer. This disease is 100 times more common in women than Tipton mer ten Benign excessive development of male mammary gland Occurs in 40% of male cancer pt’s Survival rates with treatment are 97% for 5Gynecomastia: Prominent Male Mime R Ry Most Common Causes : MERU EOE LES O ee TM a ete mt ard adolescence) Estrogen exposure (female hormone present in the Mee SIMARD) Androgen exposure (body-building hormones) Marijuana use NCCC Cora roe Com One symptom of Klinefelter's syndrome, a condition in which a male has an extra X CaO TSGynecomastia = = is a benign male breast (non-cancerous) condition = Some men who have prominent breasts, or uneven breasts, often feel some embarrassment about their body image. = This condition can also cause emotional conflict over sexual identity.Bt Male Mammography = 1300 men get breast cancer per year Vem tc = Most are 60 years or older = Nearly all are primary tumors = Symptomis include: ¢ Nipple retraction CAG uliienntey ¢ Discharge ¢ UlcerationPulteney fap mimography (FFDM) Recently approved by the U.S. Food and Drug Administration (FDA), this technique involves taking digital images of the breast. Digital images are captured electronically and can be viewed ona computer. Their magnification, brightness and contrast can be adjusted and enhanced to better reveal Flo Overt leyXeromammography = Xeromammography is a photoelectric method of recording an x-ray image on a coated metal plate, using low-energy photon beams, long exposure time, and dry chemical developers. It is a form of xeroradiography This process was developed in the late 1960s by Jerry Hedstrom, and used to image soft tissue, and later focused on using the process to detect breast cancer,mammography (early years) Copyright © 2003, Mosby, Inc. All Rights ReservedTomosynthesis = Tomosynthesis: Tomosynthesis is a special kind of mammogram that produces a 3-dimensional image of the breast by using several low dose x- rays obtained at different angles. For tomosynthesis, the breast is positioned and compressed in the same way as for a mammogram but the x-ray tube moves in a circular arc around the breast. It takes less than 10 seconds for the imaging. The information from the x-rays is sent to a computer, which produces a focused 3-D image of the breast. The x-ray dose for a Teosnulesn ya ntehsteas ior erexoice STON Ie aren Heel orev ecmnercatl ete mammogramBen Johnson, Barts and the London NHS Trust, UKMPG 2011 Shift and Add (Hologic)Ben Johnson, Barts and the London NHS Trust, UKMPG 2011 Shift and Add (Hologic)Ben Johnson, Barts and the London NHS Trust, UKMPG 2011 Shift and Add (Hologic) Hi | iu | — | atBen Johnson, Barts and the London NHS Trust, UKMPG 2011 Shift and Add (Hologic)Ben Johnson, Barts and the London NHS Trust, UKMPG 2011 Shift and Add (Hologic)Shift and Add) (Hologic)Breast Scintomotography (NMBIT) Isotope matches tumor to node involvement = In the scintimammography procedure, a woman receives an injection of a small amount of a radioactive substance called 99technetium sestamibi, which ts taken up by cancer cells, and a gamma camera is used to take pictures of the le) kee ht m Also called miraluma test (when with sestamibi)