Mammography

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Outline
 Imaging features of breast lesions
 Mammography unit
 QC tests
 Role of other existing and developing modalities
in breast imaging

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Primary signs of breast pathology
Two of the most common mammographic
abnormalities are:
 Mass
 Calcifications

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Mass

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What to do if there is a mass?

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Spot Compression View
Compression paddle
- Enables the application of maximal compression to
a small area of breast so that tissue is spread out

24x30cm compression paddle Spot compression paddle

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Spot Compression View
Compression view
– separate superimposed tissue
in a localized area
=> distinguish a mass from
composite of superimposed
normal glandular tissue

- allow better delineation of

mass margin

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Is it a mass?

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Is it a mass?

After spot compression

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Is it a mass?

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Is it a mass?
CC, ML and spot-
compression CC
views show a
lobular mass at 6
o’clock.

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How to tell the location of the
lesion?

MLO view

Lesion at ? o’clock

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How to tell the location of the
lesion?

Lesion at ? o’clock

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Is the mass benign or malignant?

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Mass
Describe in terms of
shape, density and margin

 Shape – round, oval,

lobular, irregular

 Density- high, equal, low,

fat-containing

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Mass
 Margin – circumscribed,
microlobulated,
obscured, ill-defined,
spiculated

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Radiographic Characteristics for
Breast Mass
Benign Malignant

Shape Round, oval, lobulated Irregular

Margin Regular, smooth, well- Spiculated, poorly

circumscribed circumscribed
Density Homogeneous Hetergenerous

Surrounding Tissue Displaced Infiltrated, retracted

Calcifications Few, scattered Numerous, confined to

mass area, along duct

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Mass
 Benign – round, oval, regular border
 Malignant – spiculated, irregular margin

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Calcifications

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Calcifications
 Tiny deposits of
calcium

 Usually found in
rapid dividing cells,
can be results of
aging and injury

 Can be divided into

-Macrocalcifications

-Microcalcifications

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Calcifications
-Macrocalcifications: Benign

-Microcalcifications: like grains

of salt – 30-50% of breast
cancer that are detected by
mammography are identified by
microcalcifications alone

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What to do if there are calcifications?

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Spot Magnification View
Air-gap technique
- No grid should be used to
reduce the radiation dose
as the short SOD
- Scatter radiation is
reduced by the air-gap

Small focal spot

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Spot Magnification View
Magnification view
- Assist in the evaluation of
microcalcification

- Assist in clarifying the

borders of small masses
(generally under 1cm)

- Used in specimen
radiography

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Calcifications
Describe in terms distribution and morphology

 Distribution
- diffuse
- linear
- segmentary
- regional
- grouped

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Calcifications
 Morphology
Benign calcifications
- skin
- vascular
- round
- punctate (small<0.5mm, round)
- popcorn
- eggshell / rim

Intermediate calcifications
– amorphous (no clearly defined
shape)

Malignant calcifications
- pleomorphic
- branching
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Malignant Calcifications

Pleomorphic

Linear,
Branching

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Benign Calcifications
Bilateral CC and MLO views
demonstrate linear and
parallel calcifications

Vascular Calcifications

-Calcifications within the

arterial wall

- Seen in 8–9% of all

screening mammograms

- Increased frequency with

advanced age, diabetes and
renal dialysis

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Benign Calcifications

Punctate, diffuse
calcifications, vascular
calcifications

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Malignant Calcifications
Spot-magnification
demonstrate a segmentary
area of fine linear
branching calcifications

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Mammography
Equipment

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Mammography Unit
 Dedicated machine to
detect breast cancer

 Low kVp technique is

used to enhance low
subject contrast of
breast tissue

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Mammography Unit
 Target
 Filter
 Target angle
 Focal spot size
 Grid
 Compression

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Mammography Unit
Breast tissue compose of adipose, fibrous and glandular
tissue, all with low atomic number

Mammography needs low energy x-ray

17-24 keV most useful in maximizing contrast by
enhancing differential absorption of breast tissue

just penetrate the tissue without overpenetration

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Target & Filter
 Target material
- Molybdenum (Z=42) , rhodium (Z=45), tungsten (Z=74)

• Filter material
- Molybdenum, rhodium, silver
- eliminate very low-energy x-ray which only contribute
to patient dose and high-energy photon result in
decrease in radiographic contrast

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Target & Filter Combinations
 Target and filter combinations
- Molybdenum + Molybdenum filter
- Rhodium + Rhodium filter
- Tungsten + Rhodium / Silver filter

Among three target and filter combinations, which

one is better for generating x-ray at 17-24 keV ?

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Target & Filter Combinations
X-ray emission spectra at 26
kVp of Molybdenum (Z=42) +
30μm Molybdenum filter

Characteristic x-ray
- ~ 17keV

=> effective for fatty breast

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Target & Filter Combinations
X-ray emission spectra at 28
kVp of Rhodium (Z=45) +
50μm Rhodium filter

Characteristic x-ray
- ~ 22keV

=> good for dense breast

=> better penetration but
loss in radiographic contrast

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Target & Filter Combinations
Digital mammography system
 Tungsten (Z=74) + Rodium /
Silver filter
 Higher energy produced
~30keV
 Wider dynamic range of
detector
 Superior image resolution
compared with Mo tube
 Reduction in radiation dose

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Target Angle & Tube Tilt
Target angle
- General x-ray 5-15 degree
- Mammography 22 -24
degree

Tube tilt
- 6 degree

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Target Angle & Tube Tilt
Target angle & tube tilt

 Ensure coverage of
24x30cm with ~65 cm SID

 Allow central ray run

parallel to the chest wall,
no tissue is missed

 Greater tissue thickness

is positioned at cathode,
while nipple is positioned
at anode

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Target Angle & Tube Tilt

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Target Angle & Tube Tilt

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Focal Spot
 Small focal spot size is used to improve spatial
resolution

Large focal spot size ~ 0.3mm for routine and

compression use

Small focal spot size ~ 0.1mm for magnification

use for detection of microcalcifications

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Mammography grid
Linear High Transmission
Cellular (HTC)

Structure Linear Crosshair pattern,

copper
Interspace material Carbon fiber Air

Transmission 50% 75-80%

Grid ratio 5:1 8:1

Scatter control One direction Two directions

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High transmission cellular
(HTC) grid
- Similar radiation dose
compared to linear
grid

- => Better scatter

radiation control

- => Higher contrast

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Compression Device
 Reduce tissue thickness
=> Reduce scatter radiation
=> Increase radiographic contrast
 Improve visualization of breast
tissue with less superimposition
=> improve uniformity
 Reduce movement unsharpness as
the breast is immobilized
 Reduce magnification
=> Reduce geometric unsharpness
=> increase resolution

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Digital Mammography
• CR
- Photostimulable phosphor imaging plate

• Full field digital Mammography (FFDM)

- Direct image capture detector (Amorphous Selenium)
- Indirect image capture detector (Cesium Iodide)

X-ray generate mechanism, positioning technique and patient

management skills are same!

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Image Formation

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Computer Aided Diagnosis (CAD)
• Designed to increase productivity and accuracy of the
radiologist interpretation

• Work by first mapping normal healthy breast tissue

• Compare the images with normal reference maps

=> highlight suspicious areas
=> increase detection rate of breast cancer by ~10 %

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Computer Aided Diagnosis (CAD)

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Computer Aided Diagnosis (CAD)

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Digital Mammography
• Limitations
- High resolution images
=> file size ~ 9M/ image
=> storage capacity

- High resolution workstation (5M) is required

- Computer aided diagnosis (CAD)

=> False positive cases
=> Unnecessary further examination and biopsy done

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QA / QC for Mammography

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Quality Assurance for Mammography
• the overall management program that consistently
provide high image quality and enhance patient
care

• Includes collection and evaluation of data

=> such as repeat radiographs, image quality,
patient types, technical effectiveness, efficiency
and in-service education

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Quality Control for Mammography
• Component of a quality assurance program
responsible for assessing image quality and
equipment integrity

• Actual test to ensure the standards of the quality

assurance program are met

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Quality Control for Mammography
• Personnel includes
- Radiologists
=> Responsible for medical auditing, detect any
discrepancies that may occur

- Medical physicists and service engineer

=> perform operation of equipment monitoring

- Radiographers
=> carry out routine testing procedures

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QC test conducted by radiologists
Weekly

- Film rating

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QC test conducted by Medical
physicist or service engineer

Annual
- Mammography unit assembly evaluation
- Collimation assessment
- kVp accuracy and reproducibility
- Beam quality (HVL) assessment
- Evaluation of system resolution
- AEC performance
- Breast entrance exposure and radiation output

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QC test of digital system conducted
by radiographer
Weekly Biweekly
- Detector Flat Field Calibration • Compression Thickness
- Detector Evaluation Indicator
- Repeat Analysis
- Phantom Imaging
- Visual checklist
Semi-annually
• Compression force
- DICOM Printer Evaluation

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Detector Flat Field Calibration
- To ensure system is calibrated properly and field uniformity

- Use 4 cm gain calibration phantom

- Follow screen instructions

Before the calibration, clean the phantom and detector surface

- Artefacts would affect flat field calibration

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Detector Evaluation
- Detector Evaluation
- Artefact Evaluation
- Signal-to-Noise Ratio Calculation (SNR > 40)
- Contrast-to-Noise Ratio Calculation (within 15% of
the baseline CNR)

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Repeat Analysis
- To determine the number and
cause of repeated/rejected
mammograms.
- => evaluate mammography
tube error and human error
(positioning technique and
patient movement)

- Repeat- reject analysis ( < 5%)

=> ? Need for training
=> ? Call for service

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 Phantom Imaging
- To assure the image quality due to
the imaging system are maintained
at optimum levels.

- Phantom image can be evaluated on

diagnostic review workstation (5M)
and printed film
- Minimum: 5 fibres, 4 specs, 4
masses
- Discrepancy in number gradually
 Indicate deterioration of the
imaging system
 Identify from tube or review
Phantom image
workstation or DICOM printer

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DICOM Printer Evaluation
- To assure consistency of
DICOM printer performance.

- Measure the optical density

of the 10%, 40% and 90%
patches on the SMPTE film

=> value of 10-40%, 40% and

90% must fall +/- 0.15 of the
control limits

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Compression Thickness Indicator
- To assure the indicated compression thickness is within
tolerance.

- Using the Auto-Filter mode, filter and kVp are

determined by compression thickness.

- Compression indicator should be accurate, so that

appropriate exposure factor and setting are used.

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Compression Thickness Indicator

- ACR phantom thickness (~4.2

cm)
- Use 7.5 spot compression
paddle
- Apply full compression ~ 30
lbs
- Displayed thickness +/-
0.5cm of the measured
thickness

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Compression Force
 Compression force range from 25-40 lbs

 Ensure provide adequate compression

but not too much and that compression
is controlled.
=> adequate separation of breast tissue
but not causing injury to patient

• Apply full compression and use bathroom

scale to measure compression force

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Breast Tomosynthesis
 Tradition mammography is a single,
two dimension (2D) image of the
breast. Breast tissues overlapping
may mimic or hide cancer.

 Some studies showed that

mammography diagnosed a large
number of women with breast disease
need not to be treated (benign
lesions), resulting in unnecessary
biopsy and operation.

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Breast Tomosynthesis

 Respond to those high false positive

rate and high negative rate due to
dense breast, 3D mammography have
been invented, called tomosynthesis.

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Breast Tomosynthesis
 A new tool to reduce tissue
overlapping

 Multiple low dose images are

acquired from various angles
as the x-ray tube moves in
an arc

 Enable the acquisition of a

three-dimensional (3D)
volume of thin-section data

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 Breast Tomosynthesis

Basic technologic principles of breast tomosynthesis

©2007 by Radiological Society of North America 73

Breast Tomosynthesis
Image data acquired from
different angles are
reconstructed to provide
separate depiction of two
overlapping structures located
in different planes.

With tomosynthesis,
radiologists can page through
the breast just like the CT
slices.

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False positive

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False positive

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False negative

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False negative

Conventional mammograms 3D mammogram of the

Breast cancer hidden same breast reveal a
malignant tumour
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Other Imaging Modalities

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Ultrasonography
• Radiation-free

• Good for clarification of

abnormalities seen on mammography

• Physicians suggest to do
mammography and ultrasound for
patients with dense breasts to improve
cancer detection rate

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Ultrasonography
Indications

• Characterize mass as cystic or solid

• Characterize solid mass as probably

benign, intermediate or malignant
=> help distinguishing malignant and
benign breast disease, such as cysts,
fibroadenoma

• Investigate palpable lesion

• Allow image-guided biopsy

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Contrast MRI
• Functional study, require use of
gadolinium contrast

• Based on the fact that a carcinoma is

usually highly-vascular Without contrast

=> contrast medium will quickly

accumulate in the tumor With contrast

• Sensitivity to lesions below 1cm ~

90%, but specificity 30-70%

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Contrast MRI
Indications

• Map tumor extent and staging newly diagnosed

breast cancer

• Monitor treatment response

• Screen women who difficult mammogram such

as dense breasts, breasts with breast implant
and surgical scar

• Investigate unknown cause of axillary

adenopathy

• Check silicone rupture

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Contrast MRI
• Limitations
- high false positive rate because of vascularization of
noncancerous abnormalities that can mimic cancer
=> overdiagnosis including unnecessary additional biopsy for
patients

- Can’t detect microcalcifications

- Difficult to perform biopsy

- Expensive

- Time consuming

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PET/CT
- Pre-surgical planning, staging of breast
cancer

- Evaluation of chemotherapy response in

both patients with locally advanced
breast carcinoma and those with
metastatic disease

- Monitor of recurrence

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~ The End ~

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References
 ACR PRACTICE GUIDELINE FOR THE PERFORMANCE OF SCREENING MAMMOGRAPHY, 2004
 Astley, S and F Gilbert. Computer-aided detection in mammography. Clinical Radiology 2004;59:390-399.
 Bashong, S. Radiologic Science for technologists: physics, biology and protection, 9th ed.,
Mosby/Elservier:2008
 Cardenosa, G. The Breast Imaging Companion, 2nd Ed. Philadelphia:2001
 Lee, L., Fundamentals of mammography 2nded., Edinburgh:2003.
 Peart, O. Mammography & Breast Imaging just the facts, 1st Ed. McGraw-Hill Education (Asia):2005
 Papp, J. Quality management in the imaging sciences, 3rd ed., Mosby/Elservier:2006
 Pisano, E, Yaffe, M & Kuzmiak, C, Digital Mammography, 1st ed., Philadelphia:2004.
 Wagner, J., Procedures and documentation for mammography and quality management 1st ed., McGraw-
Hill: 2000
 Hong Kong Cancer Registry, http://www3.ha.org.hk/cancereg/:2013
• Park J M, Franken EA, Garg, M, Fajardo, LL & Nikalason, LT. Breast Tomosynthesis:Present
Considerations and Future Applications. Radiographics 2007;27:S231-S240.
• Rosen E L, Eubank, WB & Mankoff, DA . FDG PET, PET/CT and Breast Cancer Imaging. Radiographics
2007;27:S215-S229.
• Kneeshaw, P et.al. Current applications and future direction of MR mammography. British Journal of
Cancer 2003;88:4-10.

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