HINTS FOR CONVERTING FROM ANALOG TO DIGITAL MAMMOGRAPHY IN THE MODERN BREAST IMAGING DEPARTMENT

OBJECTIVES:

When it comes to beating breast cancer, everyone agrees: the best way to combat the disease is with early diagnosis via routine mammography. There is also agreement that the quality of the mammography image must always be a primary consideration and that digital mammography is becoming an increasing popular method of choice worldwide. Modifying a busy diagnostic practice is a demanding, expensive process fraught with incredible challenges.

What we need to get started:

Radiologists and administrators today have an ever-expanding wish list of features they are looking for in a digital mammography system, including a comprehensive reporting structure, increased flexibility and ease of use, and a workflow that maximizes the efficiency of the department as well as the level of patient care.

Converting a large, busy mammography department to digital, however, requires a considerable investment in planning by many diverse functions: radiology managers and radiologists, facilities managers, interior designers, technologists, PACS administrators, IT network and storage specialists, clerical supervisors, and others. With sufficient attention to detail and a specific concentration on workflow efficiency, while the migration to a digital environment can be challenging, it can result in improved workflow efficiency.

Choosing a vendor:

Implementing a digital mammography workflow is a demanding task that can exceed the IT resources of even large facilities. In this case, managers might decide to work on the design and implementation of an infrastructure with a vendor, or independent mammography consultant. The latter often recommends appointing a project manager with expertise in purchasing and/or integration of all necessary networking, data and management systems. To prevent outdated tasks and routines hampering the new digital system, and to optimize processes, the consultant might suggest a complete revision of scheduling, examinations and reporting. These advisors, either a responsible vendor or a private consultant, can not only help to maximize digital workflow but also help to evaluate the implementation of digital mammography technology, and to decide on either CR or DR.

A close relationship with a vendor capable of understanding the digital imaging world is critical. The sales and support team must meet frequently with the Information Systems and Radiology personnel in order to configure a site-specific solution for the digital environment. If possible, choose a vendor with which you have a prior relationship, one with a proven track record in PACS systems, large department conversion and digital technology in mammography. The most challenging aspect of the project will be satisfying the needs of a busy breast center that has many varied patients a year. This step-by-step methodology will assist in anticipation of the installation of several digital mammography units of varied uses.

Choosing a workstation:

Choosing the right diagnostic workstation is a critical component of the overall project because the interface that radiologists use has to be intuitive and high speed, and must also provide the highest resolution possible.

The first consideration is the actual value of digital mammography over analog mammography. That makes the biggest difference in a diagnostic practice, then the value of a multimodality workstation or a modality specific one can be considered. With the multimodality workstation, the patient’s complete set of imaging exams are available to review together, allowing the radiologist to make faster and more accurate diagnoses. The diagnosis can often be made while the patient is in the exam room, an enormous comfort to the patients. .

Hanging protocols of the station must cover virtually any configuration that might be desired and should accommodate prior digital or digitized film studies. The available tools must allow for the manipulation of images and studies. Because some radiologists prefer to use the mouse to access tools while others choose to program the keyboard to perform many functions the station should easily accommodate both options. In addition to standard tools, the workstation should be programmed with any number of macros to further expand workstation functionality. The workstation must be able to retrieve reports from HIS and can be linked to voice recognition systems.

For patients having a work-up for an abnormality, the workstation should allow the radiologist to view the screening exam, additional views, ultrasound, and MRI exams at a single site. Radiologists must be able to view studies in progress and annotate the images that need additional views. While logged onto the web tool, technologists viewing these annotations should not have to leave the patient.

Five mega-pixel monitors are needed for mammography, but most general radiology PACS do not have them. An example of a useful system is a multimodality diagnostic workstation for digital mammography built on the IMPAX platform with dual 5 mega-pixel flat-panel monitors. The ability to view color images with a large flat-panel monitor is a good option. However, even that flat panel size does not show some image matrix sizes at full resolution – an automatic zoom and pan tool is essential if large volumes of mammograms are to be read. Rather than install dedicated workstations, centers for screening as well as diagnosis might want to opt for multi-modality breast imaging workstations, which enable reviews of all digital mammograms, as well as MR, ultrasound and other general radiography examinations.

Viewing images:

Patient and image data management and storage:

It is essential to fully integrate the radiology information system (RIS) and picture archive computer system (PACS). Along with the patient’s identification (ID) and examination data, it is now generally understood that a RIS can automate mammography-specific activities, such as blind double reading, sending reminder letters for annual screening, producing customized patient letters for screening and diagnostic examinations and other functions. An integrated RIS/PACS Mammography Workstation offers many reporting and image management options. RIS and PACS should be installed before installation of digital mammography or it should be part of a digital conversion. This is a far more complex task than merely installing the capture device.

The bandwidth:

Computer networks must be able to transmit the very large size of digital mammograms. Internal IT staff, or a network specialist supplied by a contracted vendor, must evaluate an existing network infrastructure and environment and work out what might be needed to produce acceptable image distribution speeds. This is an often-neglected part of an implementation. In a busy screening facility the ability to display a full study, with priors, in a couple of seconds, will test the fastest network; if not addressed up front this aspect can greatly reduce the acceptance of the entire system.

Archiving:

Depending on its capture device, even a small clinical centre, which carries out 20 screenings daily, can generate one terabyte of mammography images within one year. Therefore, the best case scenario would be 25 terabytes of the legally stipulated 25-year image storage. The immediate obvious issue becomes the possible obsolescence of the storage medium and files. A prudent plan must be put in place to migrate data on to current platforms. The failure of such a plan could result in a major cost issue within five to seven years after the first images enter the system. There might be a decided advantage to the use of off-line data centers to manage this type of back-up and migration service.

Managers should factor in an appropriate percentage of growth when coming up with their anticipated storage needs for the immediate future, carefully factoring in the need and increase of diagnostic breast examinations into the storage plans for these files.

When implementing the digital mammography systems it is not always necessary, or even prudent to expand the on sight storage system past the immediate need right away. A decision to outsource image storage to an image management vendor, with retrieval on demand, making a third party responsible for maintaining, backing-up and retrieving archived examinations may be a responsible first step.

SUMMARY

Medical professionals have acknowledged that digital images are at least equivalent to film-based images for identifying breast abnormalities, including cancer. The objective of converting an analogue mammography department to a digital, modern, multi-modality breast center is to allow radiologists to maximize attention devoted to image interpretation while minimizing the effort required to manage a busy workload. In essence, it’s all about the workflow. Indeed, workflow has been an operative phrase for diagnostic efficiency for many years now and it is becoming synonymous with quality patient care.

Dragging ourselves into the future is not always easy and not always cheap but it is worth the effort because of the improved patient outcomes. And so, once again, our attention is where it should be; with the patient.

SCREENING WITH MRI: Now, Later or Never???

OBJECTIVES:
MRI and mammography both take pictures of the breast, but in different ways. An MRI uses magnets that emit radio waves to produce a three-dimensional view of the breast and the underlying structures and vessels. Mammography uses low doses of radiation (x-rays) to produce a two-dimensional image of the breast. Is MRI ready to take a roll in screening? There are two studies out that lend a hopeful light in that direction.

• At Bonn University in Germany mammography and high-resolution breast MRI were offered to more than 7,000 women. From this group, 167 women had a confirmed diagnosis of DCIS. Researchers found that 93 (56%) of these lesions were visible on mammography and 153 (92%) lesions were found with MRI. Of the 89 lesions that were high-grade DCIS, 87 (98%) were found using MRI compared with 46 (52%) by mammography.
• A NEJM study, 969 women with unilateral breast cancer underwent a breast MRI in the contralateral breast soon after diagnosis. Although no abnormalities were found by clinical examination or mammography, MRI detected abnormalities in the unaffected breast in 121 patients (13%). In follow-up biopsies of women with positive MRI findings, 30 patients (25% of those receiving biopsies; about 3% of the total study group) were found to have invasive breast cancer.

WHAT’S NOW AND WHAT’S NEW?
Mammography is currently the standard method for diagnosing DCIS, which accounts for 20% of diagnosed breast cancers and is the earliest diagnosable stage. Left untreated, DCIS could progress over several years to a high-grade invasive breast cancer. At present MRI is used primarily for diagnostic purposes; evaluating augmented breasts, determining metastases or finding chest wall spread post-surgically. There is evidence that MRI may be used for screening. MRI may be considered as another option for screening women at high risk of developing breast cancer, but an MRI most likely will not be substituted for mammography. Women concerned about getting this test should be advised to talk with their physicians and find centers with experience in performing and interpreting breast MRI’s.

The new screening guidelines from the American Cancer Society recommend breast MRI and mammography yearly beginning at age 30 for women at high risk for breast cancer. This population includes women who meet at least one of these criteria:

• Known BRCA1 or BRCA2 gene mutation
• Strong family history of breast or ovarian cancer
• A 20% or greater lifetime risk of breast cancer (this can be calculated using a scientific tool that calculates a person's lifetime risk of developing breast cancer)
• Women who have received radiation therapy to the chest between the ages of 10 and 30
• Women with a first-degree relative with the BRCA1 or BRCA2 gene mutation who have not had testing themselves
• Women who have, or may have, a family history of a cancer syndrome that increases their risk of breast cancer

These ACS guidelines can be an appropriate resource for clinicians. The key is that technology is increasing our ability to detect and treat cancer when it is at its most curable stage. It is important, though, that the breast MRI facility has both experience in early detection and the capacity to perform follow-ups and biopsies.

WHAT ARE THE PROBLEMS?
Breast MRI may be a more sensitive test than mammography, especially when given with a contrast medium. The dye makes the cancerous area of the breast appear much brighter; however, it may also cause many areas of the breast that do not have cancer to appear abnormal. This causes an increased number of false-positive test results and thus may cause unnecessary biopsies and increased anxiety for many women.

Breast MRI cannot visualize calcifications (calcium deposits) and microcalcifications (irregular deposits of calcium) that typically surround DCIS lesions until or unless these abnormalities have developed vascularization. This usually occurs quite late in the cancer’s development. Mammography, on the other hand, can visualize calcium deposits early and accurately.

A positive finding on an MRI always requires a follow-up biopsy to confirm whether a suspicious finding is cancerous or a false positive. Many facilities are ill-equipped to perform biopsies with MRI guidance. Women may have to repeat MRI testing with a follow-up MRI-guided biopsy at another facility that is equipped to perform the procedure. A positive finding on a mammogram also requires a follow-up test; such as diagnostic mammography, ultrasound, and/or biopsy, but these tests are almost always readily available and do not require the specialized technology of an MRI-guided biopsy.

Obviously, breast MRI has limitations: It is about ten times as expensive as mammograms, a breast MRI costs anywhere from $800 to $2,000, compared with a mammogram, which costs anywhere from $85 to $150. The data supporting screening MRI is not nearly as strong as data supporting screening mammography. Breast MRI has not yet been well studied in women with an average risk for breast cancer and therefore should not be recommended for those women. Most clinicians recommend a mammogram every 12 months on women 40 years of age and older, but almost none will recommend breast MRI for screening. Breast MRI may be recommended for younger women at high risk for breast cancer. Some clinicians may allow for "reasonable and necessary" breast MRI on high risk younger patients.

Currently, no formal practice standards exist for breast MRI as they do for mammography. Training and accreditation (a process to determine if applicable standards are met) of MRI facilities is needed to ensure practice standards remain consistent from one facility to another. Currently breast MRI vastly differs in quality from center to center. Presently, there are no standards. Many poor-quality MRI’s are being done in those facilities that don't have adequate equipment, experience, or guidance. This can create a false reassurance in women who may actually have breast cancer or, alternatively, suspect cancers in women without cancer, leading to excessive, unnecessary biopsies and surgeries. New standards will definitely help address this concern.

CONCLUSIONS:
The use of MRI screening is supported for women with a very high risk of breast cancer. The next step is to adopt standards for performing and interpreting breast MRI, including the ability to biopsy lesions seen only on MRI. Once the quality of breast MRI is established, clinical trials can be implemented to determine whether screening MRI can improve survival without increasing the financial and psychological costs when compared with mammography.

Mammography is the standard method for diagnosing early breast cancers, which accounts for a proven 30% drop in cancer deaths with proper screening and follow-up. Although the early results of breast MRI studies are encouraging, breast MRI should not be substituted for mammography for women at average risk for breast cancer. However, it may be a valuable additional tool to screen for breast cancer in women at high risk for developing the disease.

Another Nifty Quiz from Annie’s Archives: Positioning

1. What portion of the breast is best demonstrated by the CC projection?
   

   1. Axillary

   2. Inframammary crease

   3. Subareolar

   4. Tail of Spence

   5. Pectoralis minor

2. Which area of the breast is
   visualized better on the CC than the MLO?

   1. Axillary

   2. Subareolar

   3. Pectoralis major

   4. Lateral

   5. Medial

3. Where should the opposite arm be
   placed when positioning the CC View?

   1. Forward (holding the handle bar
      if available)

   2. Relaxed at the side

   3. Relaxed in external rotation

   4. Flexed with hand on hip

   5. Relaxed in internal rotation

      
      

4. What is the best view or technique used to demonstrate Ca recurrence on the affected side of a mastectomy patient?

   1. LM

   2. Tangential

   3. Lumpogram

   4. CC

   5. Axillary tail

      
      

5. Which of the following will tighten the pectoral muscle, making positioning and compression
   difficult?

   1. Poor posture

   2. Raising the shoulder

   3. Gripping the handrail

   4. External rotation of the hand

   5. Lowering the chin

      
      

6. In what direction should the prosthesis be displaced when performing
   the ID views?

   1. Anterior/inferior

   2. Posterior/inferior

   3. Lateral/superior

   4. Posterior/superior

   5. Lateral/medial

      
      

7. Where should the arm on the side of the body being imaged be placed when positioning the CC view?

   1. Forward (holding the handle bar if available)

   2. Relaxed at the side

   3. Relaxed in external rotation

   4. Flexed with hand on hip

   5. Relaxed in internal rotation

      
      

8. What plane is referred to when discussing ‘oblique’ for the MLO projection?

   1. Axis of the plane of compression

   2. Axis of the angle of the chest wall

   3. Degree of obliquity between the IMF and the chest wall

   4. Mid-sagittal plane

   5. The clavicular sternal plane

      
      

9. Of the following projections, which one demonstrates the most breast tissue?

   1. MLO

   2. CC

   3. LM

   4. ML

   5. XCCL

      
      

10. What is the proper position of the C-arm for the MLO projection?

    
    

    1. Perpendicular to the pectoralis

    2. Parallel to the IMF

    3. Perpendicular to the chest wall

    4. Parallel to the sternal-clavicular plane

    5. Parallel to the pectoral muscle

       
       

11. Which of the following projections would best demonstrate a lesion in the far medial
    portion of the breast?

    1. AT

    2. XCCL

    3. CV

    4. MLO

    5. SIO

       
       

12. Which of the following views is an exact substitute for the MLO projection?

    1. AT

    2. LMO

    3. 30 ˚ AX

    4. SIO

    5. ML

       
       

13. Before final compression of the MLO view what is the most advantageous direction for the patient to rotate her shoulder?

    
    

    1. Anterior

    2. Externally

    3. Posterior

    4. Inferior

    5. Superior

       
       

14. Which of the following is the proper action when the nipple is not in profile on an otherwise adequate CC view?

    1. Adjust the technique for a lower OD

    2. Reposition the breast until the nipple is in profile

    3. Perform an extra view of the anterior portion of the breast with the nipple in profile

    4. Perform a FB projection

    5. No action should be taken unless the patient is symptomatic

       
       

15. Which area of the breast is not well demonstrated by the CC view

    
    

    1. Inferior/anterior

    2. Superior/posterior

    3. Central/medial

    4. Superior/anterior

    5. Inferior/medial

       
       

16. What is the best technique to remove the fat fold from the axillary area on the CC projection?

    
    

    1. Internally rotate the shoulder

    2. Place the hand on the hip

    3. Move arm anteriorly

    4. Externally rotate the shoulder

    5. Pull up the breast tissue under the clavicle

       
       

17. Which is the preferred possible solution to performing a CC on a kyphotic patient?

    
    

    1. Raise both arms and place the hands behind the neck

    2. Rotate c-arm 15˚

    3. Oblique patient 30˚ to the affected side

    4. Perform a SIO projection

    5. Perform a FB projection

       
       

18. Which of the following actions will assist in the inclusion of the all the medial tissue on the CC image?

    
    

    1. Do a FB view

    2. Rotate C-arm 10˚

    3. Turn patient’s head toward the affected side

    4. Lift and place the opposite breast onto the bucky

    5. Have patient lift and hold opposite breast towards unaffected side

       
       

19. Which of the following describes pectoralis excavatum?

    1. Concave chest wall

    2. Depressed sternum

    3. Barrel chest

    4. Short torso

    5. Kyphotic spine

       
       

20. Which of the following positions are recommended for patients with post-op heart surgery, prominent pace-makers or main line pick catheters?

    1. LMO

    2. MLO

    3. ML

    4. XCCL

    5. RM

21. Which of the following positions would best demonstrate superimposed densities in the tissue?

    1. LM

    2. XCCL

    3. CV

    4. AT

    5. RL

22. Which of the following projections would best demonstrate skin calcifications?

    1. CC

    2. MLO

    3. TAN

    4. AT

    5. RM

       
       

23. The projection pictured below is a:

    1. ML view

    2. LMO view

    3. AT view

    4. LM view

    5. TAN view

24. Lesions at which location in the breast would be best demonstrated by a LM or ML projection?

    
    

    1. L 3:00

    2. R 12:00

    3. L 9:00

    4. R 8:00

    5. L 2:00

25. Which of the following is NOT a contraindication for performing ID views?

    1. Explanted

    2. Tissue firmly encapsulated

    3. Major rupture

    4. Post mastectomy implants surrounded by skin

    5. Very large implants within small breasts

26. Which of the following is a possible solution to very tiny breasts that keep slipping out of
    compression?

    1. Spot compression paddle

    2. XCCL view

    3. CV view

    4. Magnify tissue

    5. Do MLO views only

       
       

27. Which position will best demonstrate a TAN view of a lesion in the lateral region of the
    breast?

    1. CC

    2. MLO

    3. SIO

    4. LMO

    5. LM

CONCLUSION:

It is always a good idea to keep testing our knowledge and reminding ourselves of pertinent information about our specialty. Have fun with the quiz and pass it on.

SOLUTION KEY

1=3, 2=5, 3=1, 4=5, 5=2, 6=4, 7=3, 8=1, 9=1, 10=5, 11=3, 12=2, 13=1, 14=3, 15=2, 16=4, 17=5, 18=4, 19=2, 20=1, 21=5, 22=3, 23=4, 24=2, 25=5, 26=1, 27=1.

Psychosomatic Symptom: How and Why Are Our Patients Affected

OBJECTIVES:
Mammographers and, indeed, all medical personnel that deal with the possibility of serious illness are well acquainted with the cancer phobic, the anxiety ridden patient, and the patient with symptoms unrelated to physical cause.
Breast imaging is largely the province of the upper to middle class urban patient. We are living in very stressful economic times. These times are hardest on this sector of the population, a sector which has been, up to now, largely stress-free. With the onset of new and unfamiliar stresses, we will get an influx of anxiety produced symptoms. Stress is the body’s response to external conditions that alter a person’s equilibrium. Almost all the body’s organs participate in this reaction, including the brain, nervous system, heart, blood flow, hormonal level, digestion, and muscular function.
Understanding is our best defense against anxious patients manifesting all manner of unusual symptoms.

What Is A Psychosomatic Illness?
Today the term ‘psychosomatic’ is used to express the existing relationship between the body and the psyche. In general terminology, patients suffer somatization when they present one or more physical symptoms and after a medical exam, these symptoms cannot be explained by a medical illness. Even though a person may really be suffering from an illness, when such symptoms and their consequences are excessive when compared to what would be expected the patient would be considered psychosomatic.

Psychosomatic Disorders
Psychosomatic disorders come in many and varied stripes. They can manifest in all parts of the body and through all of the body’s systems. With each separate system the manifestation of somatization can, and will, be different. Some examples of the possible wide-ranging symptoms in several physiological systems are:

• At the digestive system level: peptic ulcer, gastritis, colitis, constipation, hemorrhoids, and alterations to the gallbladder.
• At the respiratory level: bronchial asthma, bronchitis, allergic rhinitis, and sinus inflammation.
• At the cardiovascular level: hypertension, heart attack, and brain hemorrhages
• At the urinary/genital level: menstrual disorders, sexual dysfunction, urinary discomfort, etc.
• In the Endocrine system: goiter, diabetes, hyperthyroidism, and obesity.
• On the skin: eczema, itches, hives, psoriasis, etc.
• In the Locomotive system: lumbar pain, posture defects, rheumatoid arthritis.

How common is psychosomatic illness?
Of the discomforts we all feel daily, 70% are due to natural causes. Among these, we find those that are caused by our body’s own functions, when we digest, breath, or when we feel body temperature change. Even, the habits of an unhealthy lifestyle such as bad nutrition, bad sleeping habits, or doing little physical exercise can cause us physical discomfort. The environment also influences our body, with factors such as pollution, humidity, heat, etc. Only 5% of our discomforts are due to actual physical illnesses. Furthermore, only 10% of these are serious. Therefore, out of every 1000 discomforts suffered only 4 are really due to serious illnesses.

What are the most common psychosomatic illnesses?

• Depression
• Gastrointestinal disorders (irritable colon, ulcers, diarrhea, constipation, gastritis, indigestion, etc.)
• Cardiac illness (hypertension, heart attacks, hypotension)
• Skin ailments (psoriasis)
• Panic attacks, anxiety disorders
• Insomnia
• Cancer (symptoms and phobias of all sorts)
• Headaches
• Sexual dysfunctions (impotency, menstrual disorders, etc.)
• Senses (burning eyes, conjunctivitis, sensory disorders)
• Skin (allergic eczemas, hives, acne, circulatory disorders of the skin)
• Skeletal (back pain, cramps, rheumatoid pain, and certain cases or arthritis)
• Respiratory system: asthma incidents, rhinitis, and bronchitis.

What psychological factors are responsible for psychosomatic symptoms?

• When someone is continuously in a stressful situation and is not able to resolve it adequately (is in a permanent stressful state).
• When one of these vital emotions is not expressed adequately: Sadness-Anger-Affection-Fear-Happiness
• When there is no practice of healthy habits: Good nutrition, physical activity.
• When deep personal relationships are not shared or established.
• When there is no knowledge on how to relax or adequately eliminate daily tensions.
• When the person believes that they are helpless (a victim of circumstances) and they believe little can be done to alleviate their stress.

What environmental factors that generate stress are responsible for psychosomatic symptoms?

• Violence, physical or psychological: theft, rape.
• Overcrowding: aggressiveness, protecting vital space.
• Overpowering stimuli: social, familial or external
• Joblessness: stressful economic situations, uselessness or marginalization
• Noise: it has been determined that noise over 80 decibels can produce arterial tension, deafness, headaches, anxiety.
• Natural Disasters
• Large Urban congestion
• Work: many stressful situations are generated in the labor environment: lack of motivation, labor instability, changes in supply and demand

How to ameliorate the somatic effects of stress?

• Relaxation helps control stress. It is beneficial to practice an exercise discipline such as yoga or body control exercises, at least 10 minutes daily.
• Good balanced nutrition, with variety that includes fruits and vegetables, cereals and whole rice helps nourish our bodies and reduces stress
• A reduced amount of fat and sugar can lower our stress level.
• Enough sleep on a regular basis at regular time periods eases stress levels
• An established routine before going to bed improves sleep patterns and therefore stress level.
• Avoid alcohol and tobacco (this does NOT help).
• Daily aerobic exercise increases cardiac frequency, reduces anxiety and depression.

SUMMARY:
We can readily see that somatic induced symptoms are quite common. Many of our patients come to us stressed and troubled. If we understand the roots of these manifestations we can deal with them better.
Psychosomatic symptoms may have a root cause that is not medical but the diseases and symptoms can be very real. Treat ALL your patients with the tolerance, tact and empathy they deserve.

MAMMOGRAPHY TECHNOLOGISTS: Do we have a distinct personality?

OBJECTIVES:

Mammographers; who are we? Do we have a distinct professional profile? Breast centers across North America are opening so fast it is hard to know just how many mammographers there really are and how many of us are really happy and fulfilled. One thing is becoming increasingly clear however, there are now enough of us to become a potential force for change. In order to affect our environment we must become aware of who we are, what we need, and what it takes to get what we need.

As breast imagers, we enjoy the most fundamental and individual relationships with the patient. We have, perhaps, the greatest opportunity of all the breast disease team to affect a woman’s decision to return for further screening or follow-up. Our work is often stressful and tedious, but
it must be performed with the same exacting accuracy and commitment to excellence every time.

In a comprehensive series of interviews and research a study out of California indicates that dedicated, longtime mammographers share similar satisfactions, dissatisfactions and requirements. To know ourselves we must understand what makes us tick.

What Do We Feel Gives Us Satisfaction On The Job?

• We believe we provide an invaluable, lifesaving service.

• We feel that we can change people’s attitudes and affect their prejudices by
  providing essential patient education.

• We want to help and support people in their most frightening and difficult time.

• We know that we are skilled professionals who must achieve a high level of mastery.

• We enjoy being part of an integrated team of mutually respectful professionals.

• We want to, and feel we do make a difference!

• Our contribution makes us feel worthwhile.
  

• We strive to, and consider we do create quality, helpful relationships with our patients.

What Causes Us Frustration On The Job?

• Not feeling respected or recognized for the service we provide.

• Not being valued by the rest of the medical hierarchy as true professionals.

• Experiencing the pressure of doing a highly stressful, often repetitive, meticulous job day after day with little encouragement.

• Carrying out important examinations that require some discomfort for our patients

• Being depicted as mean or uncaring by patients and co-workers because of the nature of our work.

• Having inadequate time with each patient.

• Constantly working and dealing with anxious, stressed and ill patients.

• Not being granted the status or respect corresponding with the level and amount of our education and training.

• Receiving inadequate compensation.

• Not being given adequate opportunity to teach and inform our patients about breast health.

• Having inadequate psychological training to deal with difficult, non-communicative or frightened patients.

• Not being supported in obtaining on-going training and education.

• Being constantly caught in the crossfire between; “Speed” vs. “Quality.”

• Not being allowed to submit informed suggestions concerning our images and our patient’s care and condition.

What Do We Feel We Need to Achieve Job Satisfaction?

• Receive adequate training and education on handling difficult patients

• Receive adequate management and life skills education to deal with colleagues and superiors with tact and effectiveness.

• Receive mandates and funding for all pertinent continuing education.

• Be granted enough time and freedom to do a complete and quality job.

• Be given quality guidance and feedback from medical colleagues and administration.

• Attain respect and recognition.
  

• Obtain adequate compensation commensurate with the level of education and skill required for the specialty.

• Get organized as a group in order to speak out and be heard.

• Be offered access to support groups to help dissipate occupational tensions.

• Garner more trust and greater responsibility in accordance with our educational level.

SUMMARY

We see ourselves as far more than just ‘BUTTON-PUSHERS’. We form critical liaisons with our patients. We empower them to form loyalties to their own bodies and to pay attention to their breast health.

We are meticulous in our task. We are tireless in producing the clearest sharpest most inclusive images. We seek out and use our knowledge to assist our patients, the radiologists, surgeons and pathologists to achieve the best outcome possible. Empowering us with the respect, training and responsibilities we deserve is cost effective both financially and in terms of lives saved.

Embrace your joys, understand and cope with your distresses and make your needs known and understood and, always, continue fight the good fight!

SENTINEL NODE BIOPSY: WHAT, HOW & IF?

INTRODUCTION:

Sentinel node biopsy is a relatively new way of pinpointing the first few lymph nodes into which a tumor drains (called the "sentinel" node). This helps us remove only those nodes of the lymphatic system most likely to contain cancer cells. The sentinel nodes are the first place that cancer is likely to spread. Sentinel node biopsy is most commonly associated with staging breast cancer; however, the procedure is also commonly used to stage malignant melanoma. Sentinel node biopsy may also be called sentinel lymph node biopsy or sentinel lymph node dissection.

In breast cancer, the sentinel node is usually located in the axillary nodes, under the arm. In a small percentage of cases, the sentinel node is found somewhere else in the lymphatic system of the breast. If the sentinel node is positive there may be other positive lymph nodes upstream. If it is negative, it is highly likely that all of the upstream nodes are negative.

LYMPH NODE DISECTION:

If breast cancer has spread beyond the lining of the breast duct, and is picked up by the blood vessels or lymph vessels, then it can potentially spread elsewhere in the body, or “metastasize.” Lymph vesselsare small channels that drain all the tissues of the body. Lymphvessels drain excess fluid back into circulation. As lymph fluid drains back into the circulation, it goes through lymph nodes. Lymph nodes are collections of lymph tissue that have a high concentration of white blood cells, the cells that fight infection and cancer. The lymph vessels of the breast drain into the lymph nodes in the axillaand sometimes into the lymph nodes along the sternum, and above the clavicle.

The first node that the fluid passes through in a group of lymph nodes is called the sentinel lymph node. The term sentinel is derived from the French word sentinelle, which means "to guard over" or"vigilance." Thus, the sentinel lymph node is the protective node that acts as the first filter of harmful materials.

During a sentinel lymph node biopsy, the surgeon usually removes one to five sentinel lymph nodes and sends those nodes for examination by a pathologist to determine if cancer cells have spread to them. If cancer cells are found in these lymph nodes, it means that the cancer might be metastasizing. Therefore, a sentinel node biopsy is an important tool in determining what further treatment is necessary for the cancer as well as determining the patient's prognosis. Sentinel node biopsy has been in use for over 10 years. The traditional procedure for staging breast cancer used to be axillary lymph node dissection (ALND), which involves removing most (usually 10-30) of the lymph nodes in the armpit closest to the breast tumor.

SENTINEL NODES

AXILLARY LYMPH NODE DISSECTION:

Traditionally, with invasive breast cancer, an axillary lymph node dissection (ALND) is recommended in order to see if the cancer has spread to the lymph nodes underneath the arm. During an axillary lymph node dissection, the surgeon makes an incision underneath your arm, and removes the bulk of the lymph node tissue that drains from the breast. The lymph node tissue is then sent to the laboratory, and a pathologist determines if any of them contain cancer. On average, approximately 10 to 30 lymph nodes are removed with this operation. An axillary lymph node dissection usually requires an overnight stay in the hospital. Since the remaining tissues underneath the arm tend to “leak” some lymph fluid when the lymph nodes are removed, a drain is left in place for the first 2-3 weeks after the operation until the area heals. The drain is a flexible plastic tube that exits the skin, and is connected to a plastic collection bulb. When the drainage diminishes to a certain amount, the drain is removed. After discharge the patient requires physical therapy to maintain strength and flexibility in the shoulder while this area heals. Approximately 10-20% of the patients who undergo an axillary lymph node dissection experience chronic problems related to the dissection such as arm swelling (lymphedema), or pain or discomfort in the area of the dissection. Almost all women will have some residual numbness under the inside of the arm.

THE BENEFIT OF ALND:

The single benefit of ALND is that all of the lymph nodes can be examined for the presence of cancer cells, and we can use those findings to make a reliable determination of whether the cancer is spreading.

THE DISADVANTAGES OF ALND:

The drawbacks of ALND are that the procedure is associated with postsurgical complications such as movement problems in the shoulder, wound infection, nerve damage, and lymphedema. Lymphedema is swelling, most often in the arms and legs, caused by accumulation of lymphatic fluid (fluid that helps fight infection and disease). Only 10%-20% of women who undergo an ALND develop lymphedema, but it can be a serious, untreatable condition that involves painful and chronic swelling of the arm.

SENTINEL LYMPH NODE BIOPSY:

Experience has shown us that the lymph ducts of the breast usually drain to one lymph node first, before draining through the rest of the lymph nodes underneath the arm. That first lymph node is called the sentinel lymph node. That is the lymph node that helps sound the warning that the cancer has spread. Lymph node mapping helps identify that lymph node, and a sentinel lymph node biopsy removes only that lymph node.

The sentinel lymph node is identified in one of two ways, either by a weak radioactive dye (technetium-labeled sulfur colloid) that can be measured by a hand held probe, or by a blue dye (isosulfan blue) that stains the lymph tissue a bright blue so it can be seen. Most breast cancer surgeons use a combination of both dyes.

PROCEDURE:

The morning of the operation, the patient goes to nuclear medicine the injection of the radioactive dye used for the procedure. The injections are done into the area of the breast where the tumor is (if a NL has been performed to localize the tumor this wire can be used to direct the injections), and around the nipple areolar complex of the breast. The patient returns to the nuclear medicine department a few hours later, and a lymphoscintigram will be taken which shows the pathways the dye takes as it leaves the breast. This helps guide the surgeon in identifying the sentinel lymph node.

At the beginning of the operation, the surgeon injects the blue dye. The surgeon then makes an incision underneath your arm in the area of the axillary lymph tissue. A hand-held sterile probe measures areas that have the radioactive dye. The lymph nodes that have taken up theradioactive dye, or are stained with the blue dye, are removed.

Usually one to three nodes are removed. These nodes are sent to pathology, to determine if the sentinel node contains cancer. The incision is closed. There is no need for a drain, there is no need for physical therapy exercises, and the patient can usually go home from the hospital that day. The sentinel lymph node biopsy can be done in combination with a lumpectomy, or a mastectomy. The procedure is successful in >90% of those patients whom we think are good candidates for the procedure. If the procedure is unsuccessful in identifying the sentinel node, a full axillary dissection must be done.

ADVANTAGES:

The advantages to the sentinel lymph node procedure are many. There is no need to stay overnight in the hospital. There is no need for a drain, or physical therapy exercises. The recuperation from the procedure is faster. The patient is typically doing her regular activities within a few days, and the incision is well healed within a few weeks. A sentinel lymph node biopsy can lead to a more accurate assessment of whether the cancer has spread to the lymph nodes. In a traditional axillary dissection, the pathologist receives 10-30 lymph nodes or more; there is no way of telling which one is the sentinel lymph node. So the pathologist makes one cut in each lymph node and looks for cancer. When the pathologist receives only one, or a few, lymph nodes from a sentinel lymph node procedure, he or she can make many cuts through that lymph node to look for cancer. A negative sentinel lymph node(s) indicates a >95% chance that the remaining lymph nodes in the axilla are also cancer free. Therefore, there is no need to undergo a full axillary lymph node dissection, or to risk the long
term complications and side effects from an axillary dissection.

CONTRAINDICATIONS FOR SENTINEL NODE BIOPSY:

Not all women are good candidates for sentinel node biopsy. A woman with any of the following may be a poor candidate for the procedure:

• Lymph nodes that are palpable (can be felt through the skin) and hard (in this situation a fine needle aspirate of the lymph node can help determine if it is cancerous or not)
• cancer already identified in the lymph nodes (by FNA)
  

• Prior mastectomy.

In addition, the following factors are associated with an increased risk of complications involving most surgeries (but none are specific contraindications to sentinel lymph node biopsy):

• Poor general health

• Long-term illness

• Obesity

• Advanced age

• Smoking

• Conditions that affect the blood

• Using certain medications or
  dietary supplements
  

SUMMARY:

Invasive breast cancer can spread through the lymph ducts and blood vessels to other areas of the body. The sentinel lymph node is the first lymphnode that the lymph ducts drain into. Whether or not the cancer has spread to the sentinel lymph node indicates whether the cancer has started to spread beyond the breast to invade the rest of ourpatient’s body. Sentinel lymph node biopsy identifies this critical lymph node, and allows only this lymph node to be removed.

Removing only the sentinel lymph node can allow our breast cancer patients to avoid many of the complications and side effects associated with a traditional axillary lymph node dissection.

Patients with invasive breast cancer deserve not only every fighting chance to live but also, if at all possible, the right to live comfortably, with dignity and complication free.