Wednesday, May 11, 2005

THE CC: Not always as Simple as it Seems!

OBJECTIVES

The CC view is always passed over in training as a straightforward, trouble-free projection. This is really not the case. Like many other things, it just gives the impression of being simple. I have some suggestions as to how to alleviate some of the headaches associated with achieving good CC’s on some difficult body types.


The “WEE MOUSY”


The tiny patient presents some unique problems when come to adequately demonstrating all the tissue in the CC projection.
  • Start the bucky lower than your eye tells you will be correct.
  • The small patient looks like her IMF is just about even the lower edge of her areola.
  • In reality the IMF is about equidistant with the superior portion of the breast and can be found just above the level of the 6th rib.
  • This patient’s pectoral muscle is usually thin and slightly angled up towards the lateral side of the clavicle
  • This makes the majority of her breast tissue in the tail-of Spence and mostly just skin and fat over bones on the medial side
  • Angle just slightly toward the lateral aspect on the CC (never more than 5˚), this will help loosen and raise the tiny pectoral up toward the clavicle.





The “14x17”


Who said 24x30 was the largest film size one needs for mammography. The very large patient presents her own set of logistical problems when attempting to capture all the tissue in a precise and organized manner.

Mark the breast carefully:
  • Use nipple markers
  • Use lateral and medial markers
  • Use your projection markers ALWAYS correctly at the axilla side of the image
  • Take your time and map the breast carefully. IT IS VERY EASY TO GET LOST!
  • There is nothing sadder (or madder) than a radiologist lost in a large breast
24X30 #1 ------------------------------- 24X30#2



24X30#3 ------------------------------- 24X30#4




The “MS. PANCAKE”


Ms. Pancake is very often the close companion of Mrs. 14X17 and Mme. Pretzel. Her breasts are empty and flaccid. They lay flat and unnoticed against her rib cage. How to handle this flimsy floppy tissue without wrinkles and folds can be a nightmare.
  • Use an appropriate size bucky. The pancake breasts tend to spread and spread and spread like flowing water.
  • Raise the IMF high enough but be careful of the fragile skin under this patient’s breast
  • Smooth the skin over the clavicle and slide it towards the breast
  • Flatten the tissue of the breast forward towards the nipple to smooth the wrinkle (don’t pull back toward the shoulder)
  • When the CC is in place and the skin is coerced forward; place your hands on either side of the breast and stretch the tissue flat from side to side




The “BANDEAU BATHING SUIT”


The patient with little or no demarcation between her breasts can be a real challenge. The bandeau bathing suit or Uni-Breast leaves little clue as to where the left breast leaves off and the right breast begins. It seems to be impossible to position one breast without the other one getting in the picture or pulling the breast of interest out of place. The answer of course is to work with what you are presented with and not to fight the existing anatomy.
  • Acquire a modified view angled 5˚medially when doing your CC to demonstrate the far medial tissue
  • If necessary, acquire an extra XCCL view to demonstrate the tail-of-Spence.






The “PRETZEL”


This is our most delicate and fragile patient. She is elderly, frail, bent, brittle and thin skinned. Her osteoporosis, arthritis, roto-scoliosis, kyphosis and muscular-skeletal woes make this patient a virtual puzzle to image. It seems a daunting task to obtain a CC view free of jaw, skull, shoulder, sternum or ribs. There are a few tricks that will help you and help this most vulnerable patient as well.
  • DO NOT fret about getting perfect images on this patient
  • Just demonstrate as much as you can without doing any damage
  • Angle slightly when acquiring the CC views to demonstrate tail-of-Spence and miss the chin
  • Acquire FB views to accommodate Kyphosis, if required
  • Use cornstarch or resin powder on your hands to assist with grip and protect the delicate skin
  • HANDLE WITH CARE This patient can break very easily




“PENELOPE THE BODY BUILDER”


Penelope is a very difficult client. She is large and muscular with a thick layer of adipose tissue. Her breasts are very small but she has huge thick pectoral grids and bulky upper arms. Penelope is not very agile and has trouble cooperating with the positioning. What to do, oh what to do? Our best that is all we can do.
  • Acquire 1 set of CC views on 24x30 films, slightly angled to accommodate the thick, wide pectoral muscle.
  • Acquire a 2nd set of CC views on 18x24 films to demonstrate the nipple in profile and the anterior breast tissue properly compressed.
  • WARNING Penelope often sees herself as delicate. Don't assume she is as sturdy or brave as she appears: She really is a big old Teddy Bear






“PECTORALIS CARNAVATUM” (THE PIDGEON)


Women with this sternal abnormality used to be called “chicken breasted”: Not very politically correct but descriptive. The sternums in woman with this chest configuration have sternal bodies which bow out into a convex curve. The boney protuberance between the breasts seems to crash into the compression paddle long before we get anywhere near the breast tissue. There are again a few simple tricks to work around this thorny problem.
  • Angle 3-5º medially
  • Carefully raise the breast until the paddle can clear the sternal and rib skeleton protuberance
  • Viola, the medial tissue is demonstrated with no skin abrasion, no bruising and very little patient discomfort





“PECTORALIS EXCAVATUM” (THE CROSSED HEART)


This sternal malformation has the patient’s sternum and ribs bowing in toward her spine. This presents another challenge to obtaining a good CC projection. The medial borders of the breasts are pulled together and in toward the sternum with no discernible method of getting the bucky and paddle in-between them. With a little ingenuity we can make this situation less frustrating and more controllable.
  • Angle 3-5º laterally
  • Gently lift and separate the medial edge of the breast up and away from the sternum and ribs
  • Place the medial tissue up on to the bucky
  • Hold the tissue out and laterally
  • Carefully edge the medial corner of the bucky towards the sternum
  • Compress and voila medial border with little or no cut-off


CONCLUSION

Breast imaging presents a difficult and diverse set of challenges. None of it is easy, not even the CC projection. These tips are designed to help. Keep them handy, use them liberally.
Posted by Anne's Helpful Son at 11:43 PM 0 comments
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