What is a ‘Diagnostic Follow-up’? (What, Why, Where & How?)

Diagnostic follow-up is a method of further investigation of a lesion or anomaly revealed by careful routine clinical or radiological examination of the breast.

Coned Compression Spot Views:

1. Large Focus X-ray Beam

2. Film Receptor

3. Lesion

4. Small Compression Paddle with Small Aperture

Target Area:

• Small superimposed mass

• Mass with partially obscured borders

• Mass with indeterminate characteristics

• Mass with ragged or spiculated edges

• To demonstrate the obscured or indistinct anomaly clearly and free of superimposed tissue

How to Position a Coned Compression Spot View:

• Identify and localize the lesion to be studied

• Use the large focal spot (.3mm) with the grid and bucky in place

• Position the breast in the CC position

• Place a small mark on the skin directly over the location of the abnormality

• Use the smallest compression paddle and aperture possible in view of the size of the anomaly

• Vigilantly identify the projection and laterality

• With the mass centered in the small aperture, compress the breast as vigorously as possible to clear the mass of superimposed tissue

• Expose the image

• Position the breast in the MLO position

• Place a small mark on the skin directly over the site of the lesion in this projection

• Again, use the smallest paddle/aperture combination possible with the large focal spot

• Vigilantly mark the side and projection

• Carefully center the mass and compress vigorously to clear the mass’s borders and expose

• Assess the images to assure that targeted abnormality is centered on the film, it is clear of all super-imposition and is penetrated adequately

Coned Magnification Spot View:

1. Small Focus X-ray Beam

2. Film Receptor

3. Magnification Table with ‘Air-Gap’

4. Magnified Image of Lesion

5. Lesion

6. Small Compression Paddle with Small Aperture

Target Area:

• A new cluster of calcifications

• An increase in existing calcifications

• A change in the configuration, form or size of calcifications

• A irregular or spiculated mass containing fine calcifications

• Surgical or core biopsy specimen

How to Position a Coned Magnified Spot View:

• Using the scout images identify and localize the area to be magnified

• Use the small focal spot (.1mm) and the film holder without the grid and bucky

• Attach the magnification table at the appropriate magnification for the lesion in question (X1.5, X1.8 or X2)

• Use the least magnification possible and still visualize the area properly because the larger the level of magnification the greater the distortion in the image

• Position the breast in the CC position

• Place a small mark on the skin directly over the area of calcification

• Use the smallest compression paddle and aperture that adequately covers the entire area of interest

• Vigilantly identify the projection, laterality and the level of magnification

• With the skin marker centered in the small aperture, compress the breast as vigorously as reasonably possible to separate and discriminate between calcifications

• Expose the image

• Position the breast in the 90º lateral projection (magnification views of calcifications MUST always include a true lateral view to indicate the presence of ‘milk-of-calcium’)

• Again, place a small mark on the skin adjacent to the area of calcifications in this projection

• Using the small paddle and aperture; center the skin marker and compress the breast as vigorously as the patient can tolerate

• Diligently identify projection, side and magnification level

• Expose the image

• Repeat the procedure for the MLO projection and any other views deemed appropriate or useful (the CC & ML or LM projections are the routine magnification views)

• Assess all the images to verify that the calcifications are all well seen, distinct, clear of superimposition and separate

Roll and Turn View:

1. Superior Breast Lesion

2. Inferior Breast Lesion

1. Superior Breast Lesion Moves Medially

2. Inferior Breast Lesion Moves Laterally

3. Superior Aspect of Breast Turned Medially

4. Inferior Aspect of Breast Rolled Laterally

Target Area:

• To separate superimposed tissue

• To confirm the presence of an abnormality

• To better define a lesion

• To determine the validity and location of an anomaly seen in the CC view

How to Position a Rolled/Turned View:

• Position the patient in a true CC projection centering the identified abnormality in the midpoint of the image

• Place one hand on the superior aspect of the breast and one on the inferior aspect.

• Lift the breast up slightly and ‘Roll’ the top hand toward you and ‘Turn’ the bottom hand away from you (or visa/versa).

• Secure the breast on the bucky, holding the ‘rolled’/’turned’ tissue in place.

• Slide your supporting hand out as the final compression takes hold.

• The direction of the roll/turn (medial or lateral) must be clearly indicated on the film so that you can determine whether the lesion resides in the superior or inferior aspect of the breast.

• A superior lesion moves in the same direction of the roll and an inferior lesion moves in the opposite direction to the roll.

Tangential View:

Lesion located at the 6 o’clock position is demonstrated closest to the skin-line in the 90º lateral projection.

1. Lesion identified at 6 o’clock position

2. Marker placed on patient’s skin directly over lesion

Target Area:

• To project a demonstrated lesion as close to the subcutaneous fat as possible to free it from surrounding parenchyma.

• To establish or exclude micro calcifications as ductal or dermal.

How to Position a Tangential View:

• Place a small visible skin marker on the breast directly over area of concern.

• Marker must be placed on the correct surface. Place the skin marker over the lesion where the abnormality is closest to the skin.

• Correct placement of the skin marker is essential; the fenestrated or multi-hole location paddle can be useful for this purpose.

• Rotate the C-arm and breast tissue until the shadow of the skin marker is projected onto the bucky. This ensures that the lesion or calcifications are tangential to the beam.

Ultrasound:

Ultrasound shows a simple cyst by demonstrating a well circumscribed, thin walled, anechoic structure. There is sharp back wall and enhanced posterior shadowing.

Ultrasound shows a typical fibroadenoma by demonstrating a well circumscribed, hypo echoic nodule with homogeneous echo texture. Its long axis is parallel to the skin and there is enhanced through transmission.

Ultrasound shows an irregular spiculated lesion by demonstrating a poorly circumscribed hypo echoic mass with no through transmission and heightened posterior shadowing. The lesion is greater in height than it is in width.

Target Area:

Ultrasound is not a good screening tool but it is an excellent adjuvant instrument to establish criteria relating to anomalies detected by screening mammography, clinical breast examination or breast self examination. Ultrasound gives us exceptional details of lesions seen or felt in the breast. U/S can determine a whether or not a lesion is a simple cyst with higher than 99% accuracy. It can pinpoint many breast abnormalities for FNA or Core Biopsy. Since U/S’s preferred pallet is parenchyma and not fat as in mammography it can untangle many lesions in the mammographically dense breast.

SUMMARY

Screening mammography makes up a great deal of our daily routine. When we discover some change in the normal parenchymal pattern or find a burgeoning problem in the breast then we have accomplished what we set out to do. Investigating the tiny seemingly innocuous changes in the breast is what our job is all about. Breast imaging is all in relation to ‘do sweat the small stuff’. Find out what the changes mean and save a life!

Until next time friends,

Anne