Annie Listens

OBJECTIVES:

Very often technologists contact me with problems, send me wonderful ideas and share their professional lives with me. I am proud and happy to receive these calls; it makes me feel confident, professional and secure in my specialty when I realize how many problems, concerns, joys and triumphs we all share. . I would like to share some of these contacts with you.

Dear Annie,

I read your suggestion to 'Hong Kong' regarding localizing the lesion for a needle location. We also have a good method of finding the lesion in the localization window. We put a small skin marker or 'BB' on the patient's skin in the upper right hand corner of the window and when the image is processed the position can be adjusted by moving the window according to the marker. We use this method for stereo biopsies as well and it works well for the technologists and for the radiologists.

Hope you like this idea and pass it on.

Jane

Dear Jane,

Like it; I think it is brilliant. Thanks for the great idea; I'm sure everyone will love it.

If you require a little more control over the orientation of the image a small addition to the idea could be four small markers at each corner of the window.

Welcome to the 'Einstein Corner',

Annie

Dear Annie,

I am a bit confused as to when to use a grid for the mammogram and when not to. I read somewhere that you don't always need a grid but I don't know if it is better or worse to do so.

Can you give me some information about what the grid does and when it is appropriate to use one?

A bit 'grid-dy' in,

California

Dear Grid-dy,

There is so much information out there it sometimes becomes confusing to us all. When studying for our various certification exams we come across tons of material. All of it is useful but some of it is difficult to place into a useable format.

Grids in mammography are used to absorb scatter radiation and by so doing improve contrast of the image. The vast majority of breast tissue we image is over 4cm thick when compressed and between 25% and 75% mammographically dense; therefore, a grid is almost always used for routine breast imaging.

There are a few notable exceptions to using a grid in mammography. When we are performing magnification views the space between the magnification table and the film receptor absorbs the scatter into the air and prevents it from reaching the film. Therefore a grid is not necessary for magnification radiography of any sort, even breast images. Specimen radiograms should be magnified if possible so a grid is not needed for this type of image. Even is the specimen cannot be magnified for some reason (size, equipment availability, preference, etc.) a grid probably will not be required because the thin, tightly compressed nature of the specimen usually will not produce enough scatter to affect the image. Occasionally, we encounter a patient with emaciated type breast tissue that compresses out completely. In these cases, when the paddle is clicking on the bucky through the breast tissue and there is little dangerous of scatter bouncing through a thick dense object, it is sometimes advantageous to remove the grid. These patients are rare and usually very ill or elderly. By removing the grid we can reduce the mAs and therefore help to eliminate image blur by freezing any tremor, movement or feebleness in these fragile patients.

Grids used in mammography must be of a specific category, regular x-ray grids will not do. Mammography grids must always be reciprocating grids and never stationary type. The reason for this is the grid lines produced by stationary grids will obscure the tiny subtle breast abnormalities we are looking for. The interspaces used in mammographic grids should be made from carbon fiber material because carbon fiber allows more of the primary beam through to the film than the traditional plastic or metal fillers in regular x-ray grids or grid cassettes. A mammographic grid must be a very high ratio grid so as to produce the sharpest image possible. A breast imaging grid must be 4:1 or 5:1, the 8:1 grids used in x-ray will not do.

Signs of a faulty grid on breast images include grid lines of course, but also areas of patchy blur or wavy areas within the image.

I hope this will be some help with the grid dilemmas. We can be easily dazed by information overload in this specialty but it always can be sorted out.

Annie

Dear Annie,

I have had patients demand information and instruction on breast-self-examination. They seem to think that I must teach this information as part of taking their mammogram. Do you have any data on what is my responsibility in this area?

Not a teacher in,

Albany, NY

Dear Albany,

The mammographer’s responsibilities when dealing with her patient are to produce quality images, inform the patient about the test she is having, reduce patient anxiety, take a full patient history and treat the patient with professional dignity. Teaching BSE or any other breast health information is not officially the technologist’s task.

Many breast health centers offer information regarding breast health to their clients. Breast imaging is more than pushing buttons and acquiring images. Our patients think of us as trained, specialized health-care providers who can help them improve their knowledge a propos breast disease, breast health and body awareness. Patient health education reduces patient apprehension, relaxes her, and makes her, generally, a healthier, smarter and more adaptable health-care consumer. All very good for us!

Information in relation to the job we do makes us more relaxed about the quality of our work, more confident when it comes to patient relations, more self-assured when dealing other medical professionals and certainly produces a more poised self confident member of the breast imaging medical team. Also, all very good for us!

So after that long verbal ramble, the bottom line here is if the facility we work for does not insist that patient health education is part of their mandate and therefore, part of your mandate, then, patient health education is technically not part of a mammographer’s direct duty. My opinion however is that we owe our patients all the information we can provide to ensure they are healthier, we are cleverer and our professional lives become easier.

I like to teach,

Annie

Dear Annie,

While studying for my certification exams, I have come across a term that I don’t understand. The text keeps referring to the “ipsilateral” arm, the “ipsilateral” breast etc. I have never heard this word before. Do you know what it means?

Wordless in,

Sydney, Aus

Dear Wordless,

Indeed it is a bit obscure. The word refers to the ‘same side’ as the side you are dealing with. It is the antonym to ‘contra lateral’, the opposite side that you are dealing with.

I trust that clears up what the text is talking about. It is amazing how one misunderstood word can mess us up.

A bit wordy,

Annie

Dear Annie,

I read somewhere that the tube should be angled slightly for the ‘CC’ view. Is that correct and, if so, how much should I angle and which way?

Slightly askew in,

Tokyo, Japan

Dear Askew,

The short answer is no. The tube for the ‘CC’ projection should be directly vertical with the central ray and perpendicular with the floor. However, modified and supplemental versions are very often required to visualize all of the breast tissue. To keep the view as craniocaudal never angle more that 5º or 6º at the most. I have included a few helpful CC tips to help with those difficult CC problems.

Hope this informs and also helps,

Annie

A FEW TERRIFIC CC TIPS!

1. For very small breasts, angle 3-5º laterally and start the bucky a little lower than your eye tells you is correct. Then lift the IMF up along the chest wall until the IMF forms a 90º angle with the chest wall.
2. For breasts that have no medial delineation between right and left (like a bandeau bathing suit top) angle 3-5º medially. When the IMF is positioned correctly (90º angle with the chest wall) the contra lateral breast can be pulled straight away from the side you are imaging with no crossover, no downward drag and no patient discomfort.
3. Another excellent use for the slightly modified medially angled CC is pectoralis carnivatum (a very prominent sternum and rib conjunction) that interferes terribly with the compression paddle on the medial side. Again, angle 3-5º medially and carefully raise the breast until the paddle can clear the sternal and rib skeleton on the medial side. Viola, medial tissue with no skin abrasion, no bruising and very little patient discomfort.
4. Conversely, for the opposite sternum/rib abnormality (pectoralis excavatum) where the sternum is sunken into the chest wall, angle 3-5º laterally and gently lift and separate the medial edge of the breast up and away from the sternum and ribs.

SUMMARY

I always love answering your questions, hearing your comments and getting your wonderful suggestions and ideas. I am reassured by the similarity of our problems, the resemblance of our feelings and the universal support we find in each other. Keep ‘em coming!