The Laterally Exaggerated Cranial-Caudal View (XCCL)
- Lateral Edge Demonstrating Lateral Retro Glandular Fat
- Medial Edge does not Demonstrate medial parenchyma or medial skin line
- The Tail-of-Spence
Target the area:
- To visualize deep lesions in the outer aspect of the breast
- To visualize the Tail-of-Spence entirely
How to Position the XCCL:
- Elevate infra mammary fold to 90º and adjust bucky
- Rotate patient’s lateral side toward bucky
- Using both hands, gently lift and pull lateral aspect of the breast onto bucky.
- Compress the tissue, letting the corner of the paddle begin just under the clavicle and tucked snuggly under the head of the humerus. Angle the bucky 5° laterally if necessary to clear humeral head.
The Cleavage View (CV):
Target Area:
- To visualize lesions in the far postero-medial aspect of the breast.
How to Position the CV View:
- Have patient face the x-ray unit with her head rotated contra-laterally.
- Elevate the infra-mammary folds of both breasts.
- Adjust the height of the bucky and place both breasts on the receptor.
- Gently pull the medial tissue of both breasts anteriorly.
- The mammographer can stand either behind the patient or medial to the side of interest.
- If the photocell is placed under the open soft tissue cleavage area between the breasts; a manual technique must be set.
- Photo-timing can be used if the cleavage is offset a bit and the cell is positioned under the breast of interest.
The 90º Lateral Views (LM & ML)
The Lateral Medial View:
The Medial Lateral View:
What We Should See in the 90º Compressed Image:
- The Nipple in Profile
- The IMF open and gently curving to the Abdomen
- The Axillary Tail and the Tip of the Tail-of-Spence are not always imaged on the Lateral Views
Target Area:
- To demonstrate milk-of-calcium, air or fluid levels.
- To demonstrate lesion location for triangulation.
- To remove superimposition.
- To assure shortest object-to-film distance.
How to Position the 90º ML:
- Rotate tube arm 90°.
- Place bucky along the lateral side of the patient with the superior edge of the bucky at axilla level
- Abduct arm and rest it across the bucky.
- Pull breast tissue anteriorly and medially.
- Lift breast up and out.
- Rotate patient toward bucky until breast is in lateral position.
- Nipple centered and in profile.
- Open the IMF.
How to Position the 90º LM:
- Rotate tube arm 90°.
- Place top of bucky at supra-sternal notch.
- Place patient with her sternum against the bucky, neck extended and her chin turned contra-laterally
- Bring her arm up to rest over top of the bucky with her elbow flexed.
- Rotate the patient until the breast is in the lateral position with the nipple centered and in profile.
- Apply compression WITHOUT compressing the latissimus.
- Open the IMF
The Reverse Oblique Views: (LMO & SIO)
The Superior/Inferior Oblique View:
- Film Receptor
- Axillary Tail
- Medial/sternal border
- X-ray Beam Oriented Superior to Inferior
The Lateral Medial Oblique View:
- Film Receptor
- Axillary Tail
- Medial/Sternal Border
- X-ray Beam Oriented Inferior to Superior
Target Area:
- To improve visualization of the medial breast tissue.
- To maximize the amount of tissue visualized on the male breast.
- To aid in positioning and adequately visualizing tissue on women with severe osteoarthritis, spinal, sternal, musculoskeletal or other bony abnormalities.
- To aid positioning of patients with recent heart surgeries or prominent pacemakers.
How to Position the LMO & SIO Views:
- LMO: Angle C-arm parallel to pectoral muscle with the central ray pointing in an inferior/superior orientation (from bottom to top).
- SIO: Angle C-arm parallel to pectoral muscle with the central ray pointing in a superior/inferior orientation (from top to bottom)
- Adjust the height of the bucky to accommodate the entire axillary tail at the top and to show the IMF at the bottom.
- Lean your patient forward until her sternum is pressed against the edge of the bucky.
- Extend patient’s arm over the top of the bucky with the elbow flexed.
- Gently pull the breast tissue up and out from the chest wall.
- Rotate the patient slightly toward the bucky and bring all of the lateral tissue forward until the breast is centered with the nipple in profile (if possible).
- Remove support on final compression (do not compress the latissimus) with the up and out motion.
- Open the infra-mammary fold.
What Should We See on the Compressed Reverse Oblique Image?
The Reverse Oblique Views should demonstrate the same tissue that the Medial/Lateral Oblique illustrates.
- Complete Axillary Tail & the Entire Tail-of-Spence
- Pectoralis Major relaxed and visible to below the level of the Nipple Shadow
- The Nipple in Profile if possible
- The Infra-Mammary Fold Open and Gently curving to the Abdomen
The 30ºAxillary Tail View:
- Tail-of-Spence
- Entire Axillary Tail
- Medial Edge not Imaged in its Entirety
- Nipple in Profile in the CC Position
- Position of the Humeral Head
Target Area:
- To visualize the far superior lateral aspect of the breast.
- To visualize the entire axillary tail.
How to Position the 30º Axillary Tail View:
- Rotate the C-arm until it is parallel to the axillary tail (approx. 30°).
- Stand on the lateral side of the patient.
- Rotate patient to bring axillary tail in contact with the bucky.
- Keeping the breast in the CC projection; gently lift and pull axillary tail anteriorly.
- Place the patient’s arm behind the bucky, elbow flexed and hand resting on the handlebar.
- Using your whole hand, anchor the breast in the CC projection.
- Bring the compression paddle down slowly so the corner in tucked up under the humeral head.
- Pull your hand out anteriorly and towards the medial side as the compression takes hold of the tissue.
The ‘From Below’ View (FB):
- Tail-of-Spence
- Axillary Tail
- Medial/Sternal Border
- X-ray Beam Perpendicular to the Receptor and in the Caudal/Cranial Orientation
- The Film Receptor
What Should We See in the Compressed Image of the FB View?
In theory, we should produce an identical image on the FB view as we produce on the CC view. However, because we use the FB projection mostly to image patients with severe skeletal/muscular deformations, mobility problems and/or surgical deformity, we rarely get a perfect view using this projection.
- Tail-of-Spence & Axillary Tail
- Medial Curve to Contra-Lateral Side
- Nipple in Profile if Possible
- Crescent of Pectoral Muscle
Target Area:
- To improve visualization of lesions in the superior aspect of the breast.
- To maximize the amount of tissue demonstrated in patients with severe skeletal/muscular deformations, mobility problems and/or surgical deformity
To aid in the demonstration of the male breast. - To produce the shortest distance to a lesion for interventional procedures
How to Position the ‘From Below’ View:
- Rotate the C-arm 180°.
- Face your patient towards the x-ray unit with her legs on either side of the tube head.
- Elevate the IMF to its full extent.
- Adjust the height of the transom to place the bucky in contact with the superior border of the breast.
- Have your patient lean over the bottom of the bucky and rest her head on her folded arms
- Gently pull the breast tissue away from the chest wall.
- Anchor the breast from the inferior aspect and release on final compression with a forward motion.
SUMMARY
It is our responsibility to image all of the breast tissue on a routine mammogram. If we cannot demonstrate it all with the regular CC and MLO projections we must keep going until all is revealed. We never know when a dangerous lesion is hiding just out of sight. Use the ‘extra views’ without restraint be creative and see all there is to see.
Until next time friends,
Anne
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