How Breast Cancer Develops Or Why such a fuss about ‘Calcs’?

Happy March to all, I can feel Spring in the air here. Even up here in the 'great white north' the sun on my face has some punch (at least you can identify as sun).

This month the techtalk is on the physiology and nature of breast cancer. Interesting stuff but more than that it will give us and insight into why "the fuss about calcs".

Also, a short reminder that Louise Miller and QCC is comin' to town (Toronto town) on April 17-18. If you haven't jumped on the bandwagon and registered here is the info and registration form again.

Take care, keep in-touch, as always,

Anne

Objectives:

Breast cancer doesn’t start in the skin of the breast, the fat surrounding the breast tissue or the fibrous supporting structures of the breast. Breast cancer begins with the cellular lining in the breast ducts.

Cancers, all cancers, are cellular diseases. Cancer starts when the normal cell divides abnormally, becomes atypical, starts dividing eccentrically, refuses to die when the body tells it to, begins to affect the surrounding cells and, finally, the cell becomes malignant and begins to feed off healthy cells turning them malignant. These sick cells finally become a malignant tumor and the nasty business continues.

Before or just after the changing cells become malignant many of these erratic malformed cells crowd each other out, deprive each other of oxygen and, basically kill each other off. Some of these dead cells calcify and gather is small clumps or lines. If we are lucky and skilled we can image a cluster of these dead cells and thus identify an early cancerous process before any symptom or sign is present.

The Journey down the malignancy trail:

1. Step one, begins with a healthy terminal duct containing a thick continuous basement layer of cells lined with a homogeneous layer of identical epithelial cells each enclosing a single vigorous nucleus.

2. Step two in the journey is normal hyperplasia. Hyperplasia is a normal effect of aging. As we age, the conventional ‘die trigger’ in the cells slows down and our characteristic epithelial cell layer begins to build up on itself. The cells still represent identical vigorous cells containing healthy nuclei.

3. Step three along the path to breast cancer is atypical hyperplasia. Atypical hyperplasia is considered a pre-cancerous condition. The rapidly building hyperplasic cells begin to deteriorate. The walls of the cells become misshapen. The nuclei commence to look deformed. During this stage in the dark excursion the basement layer of cells remain intact and characteristic. At this step the dead cells are crowded together and sometimes the little dead cell bodies calcify. If this happens it is good because the tiny clusters of calcifications that represent the dead cells inside the duct can lead us to a burgeoning problem.

4. Step four is ductal carcinoma in-situ or DCIS. Step four crosses the line from ‘atypical’ to cancerous. DCIS is the earliest stage of breast cancer and the most advantageous to find. At some stage in the atypia process one or a cluster of uncharacteristic cells become cancerous cells. We have no idea why this occurs, but when it does the process begins to intensify. The malignant cells rapidly collect healthy cells and alter their structure into cancer. These malignant cells begin to form a lesion or mass within the duct. This mass begins to elongate the duct, thin and stretch the basement cell layer. The malignant process tends to create a virtual graveyard of dead cells and, if we are lucky, these cells will calcify and we will be able to pick them up on a mammogram.

5. Step five is infiltrating ductal carcinoma. By this stage in the grim excursion the malignant cluster of cells have broken out of the basement membrane of the duct and has begun to collect breast parenchymal tissue as food for the tumor. Infiltrating ductal carcinoma very often is seen as an ill-defined mass containing malignant type calcifications. Left undetected, infiltrating ductal breast cancer will become a large, palpable stellate mass which often represents a well established metastasized breast cancer.

Summary:

The whole point of high quality mammography screening is to find early signs of breast cancer. Our job is to create the best images we can using all the knowledge we possess about the disease we are trying to discover.


Know your enemy, know where it hides, know how it grows and know how to corner it.


Keep up the good fight.

Ask Annie

I hope everyone has survived the holidays and is comfortably back at work full and happy! Remember...Valentines Day is just around the corner so make some room for chocolate!

This month's techtalk is an "ASK ANNIE". Always popular to hear from our colleagues. I love it. It never fails to prove how clever, innovative and wonderful we really are. Enjoy!

Dear Annie,

What is the correct KVp. to use for mammography?

Sincerely,

L.B. Norfolk, VA

Dear L.B.,

First, let me make it absolutely clear that I am no service engineer or certainly not a medical physicist. Your K.V. should be fixed firmly within government guidelines, tested at least twice a year and calibrated correctly by the required professional personnel.

The working mammographer however has some control over her exposure values and in that context I can offer some broad guidelines about K.V.

Roughly, the lower the K.V. value used to create the x-ray beam, the higher the image contrast will be. A high contrast picture is not much good to us if the energy or oomph of the beam is not adequate to penetrate the subject we are trying to image. For adequate penetration and a reasonable contrast in modern mammography KVp’s of between 25 and 28 are generally used. The trick, of course, is to choose a K.V. in this range that will give you maximum contrast and still penetrate your subject matter.

Lowering the K.V. to lower than 25 raises the MGD dramatically and is unable to penetrate most breast tissue adequately. An obvious exception to this of course is specimen radiography where dose and penetration are simply not factors.

Raising your K.V. above 28 can result in serious degradation of your image contrast. This can result in a large percentage of missed abnormalities. There are, of course, a few exceptions to this rule of thumb also, although very few. Some examples are:

• You may have to raise your K.V. a couple of steps when attempting to penetrate free injection of silicon into the breast tissues
• It may be necessary to raise your K.V. in order to lower your time sufficiently to freeze subject blur in a patient who is shaking badly
• It may be necessary to penetrate recently radiated tissue
• It may be necessary to raise your K.V. slightly to penetrate an unusual involution of fluid either from lactation, lymphedema or wide spread disease

These suggestions should be regarded as a very general guideline and any major change or adjustment to any of your exposure factors should be implemented solely by your medical physicist.

Hope this helps,

Annie

Dear Annie,

What exactly should I expect my breast compression to do and should my patients feel pain?

C.C. Los Angeles, Ca.

Dear C.C.,

The compression applied to the breast during mammography should be used to accomplish several tasks. The compression should immobilize the pectoral grid and breast mound and freeze your positioning in place. It should spread the breast parenchyma out smoothly over the image surface and it should even out the natural pyramid shape of the breast to reduce its’ thickness.

The premise behind reduction of breast thickness by compressing the natural triangle breast shape is to spread the tissue out to demonstrate hidden lesions and to reduce the MGD by making the subject smaller. The idea is not to crush every breast down to the average 4cm. If the compression is applied parallel to and directly posterior to the pectoral grid and if the compression paddle is used to immobilize the projection and not as a positioning tool; it should not be necessary to cross the line from discomfort to real pain. The breast should be compressed until taut, not blue, not white; just taut to the touch. If the tolerance of the patient does not allow it, apply as much to ensure that motion blur does not compromise the image.

If your patient is completely non compliant, rather than taking useless image after useless image, consult the radiologist for an alternative imaging solution.

Compression is not always objective, take clues from your patient,

Annie

Dear Annie,

Is there an easy method for testing my compression device? This test has fallen to me now that it is required quarterly. What equipment do I need and what am I looking for?

Yours Truly,

N.W. Raleigh, N.C

Dear N.W.,

Your compression device should be tested quarterly or every three months. It must be tested in both manual and automatic power mode for adequate compression weight and for proper automatic release.

The equipment used for this test is economical and easy to come by. You will need an ordinary, flat top, analog bathroom scale and a few thick terrycloth towels.

Method:

1. Place a towel on the cassette holder and then place the scale (dial side up) directly under the paddle.
2. Place a folded towel on top of the scale (leaving the dial visible). Using the power drive allow it to operate until it stops automatically.
3. Read and record the maximum compression achieved and then release device.
4. Using the manual device move the paddle down until it pushes back on its’ own.
5. Read and record the maximum compression achieved and then release the device.

Acceptable compression force is between 30 - 40 lb. (16 - 25 Kg.). This should be about the same in both power and manual modes. If the required performance criteria are not met contact your service engineer to make the appropriate adjustments.

Note: DO NOT allow your compression device exceed 45 lb. This could damage the device. If your automatic release is malfunctioning in this manner, release the device and contact service immediately.

Making sure your compression device is compliant is a legal issue; take care with it,

Annie

Dear Annie,

When checking and charting our cases, our radiologist would like us to point out any unusual or questionable areas we notice in our images. However, the technologist’s comments are always filed with the patient’s chart, so, we must be careful not to diagnose, suggest follow-up or comment on treatment or prognosis. Anne, do you have any suggestions as to making concise, clear, descriptive technical notation?

Thanks in advance,

A.S. Don Mills, Ont.

Dear A.S.,

Great question!! As our specialty gets more scientifically diverse and we need to be more and more technically apt many of our training programs no longer have time to emphasize patient care, medical charting or communication. Sometimes I think old-fashioned concise professional charting is becoming a lost art.

When making an entry in a patient’s medical file always, date your entry, sign your entry, and do not leave room on either end of your entry for unauthorized editing. Remember you are asking about a questionable area not diagnosing a disease, so, always start this type of an entry with a ‘?’ or the word ‘query’. Avoid diagnostic terminology such as cyst, DCIS, LCIS, carcinoma, fibroadenoma, etc. Instead is more to describe what you see according to standard criteria.

Best-Practice Description of Abnormalities in Chart

Visible masses:

Describe as to

• Shape= round, oval, lobulated, well defined\ill defined, stellate, ragged.
• Size and location= in mm at largest point, in what ‘hour of the clock’ and how many cm from nipple base.
• Border= smooth, hallowed, encapsulated\infiltrating, irregular, incomplete
• Density= radiolucent, low density radiopaque (= to parenchyma), high density radiopaque (>parenchyma), radiolucent\opaque combination
• Surrounding tissue= displaced, infiltrated, retracted

Calcifications:

Describe as to

• Form - rounded\irregular
• Size - uniform\varied
• Density - uniform\varied
• Distribution - scattered, Uni\bilateral, clustered, ductal
• Margins - smooth, chunky, well defined\irregular, incomplete, ill defined
• Number - few, separate, easily counted\many, crowded, not easily counted
• In relation to mass - inside, outside, peripheral

Breast Discharge:

Describe as to

• Uni\Bilateral
• Colour
• Clarity
• Spontaneous\expressed

Asymmetry:

Describe as to:

• Shape
• Density
• Size
• Location

THE EINSTEIN IDEA CORNER:

1. Since, unfortunately, lung cancer is edging out breast cancer as a killer of women; our facility has been handing out ‘Stop Smoking and Save our Women’ buttons with each mammogram.

B.L. in Riverside, Ca

2. We have a lot of handicapped, paraplegic and wheelchair bound patients, so, naturally we have some unique mobility and positioning problems. Our department purchased a high quality drafting chair and our handy manager attached an old fashioned, wide, lap type car seat belt to it. We can now quite easily transfer our chair bound clients to this seat, secure them safely and then move them at will within the room or department. This chair is fully adjustable, has a comfortable and secure contour seat, an adjustable foot rest and can be completely immobilized with sandbags. This has been an easy, economical solution to some very difficult positioning problems.

W.L. Rochester, N.Y

3. Instead of masking our mammoviewer with black paper, we have been using exposed, developed x-ray film cut to size for this job. It produces a nice natural ambient background environment and the light coming through the masking is identical to the light coming through the exposed part of our mammograms. This is very effective for increased perception and much easier on the eyes.

M.P. Durham, N.C

4. Now that the A.A.R.T. and the A.C.R. demand higher CME hours to retain our specialty certification in mammography and because, at this facility, we believe continuing education should be a joint responsibility we have set up a CME lottery. All the certified mammography techs in this department put $5.00 a month into the education fund. Every 6 months one tech is chosen to apply for a worth while course, lecture or workshop. After taking the workshop she will present a short synopsis of the information to the rest of the department so we won’t miss out on the new info. Our management matches the fund dollar for dollar and in this way our whole team retains their certification and everyone benefits from the resulting increased technical knowledge.

C.A. Princeton, N.J

Thank you all for your brilliant suggestions. Wow!! What a creative, innovative group we are.

SUMMARY:

Keep the questions and suggestions coming in, I love hearing from you and we can all learn from each other!

SKIN-CONSERVING BILATERAL MASTECTOMY: What, How, If, Who and Why?

OBJECTIVES:

Being identified as high risk doesn't mean the patient will get cancer with 100% certainty, but it does mean that she'll have some important decisions to make. One of which may be whether to have prophylactic (preventive) mastectomy — surgery to remove one or both breasts in hopes of preventing or reducing her risk of breast cancer. Some experts argue that even for high-risk women, prophylactic mastectomy is inappropriate because not all breast tissue can be removed during a surgical procedure.

Our knowledge and technique surrounding determining genetic markers for breast cancer are becoming well developed. We can accurately stage and determine prognosis in women who have already suffered through breast cancer. We can determine risk /benefit ratios and we can determine future heath probabilities with stunning accuracy. When we present a young woman of 20-30 years of age with the alarming possibility of a 90% chance of developing breast cancer in her life time the decision to manage that risk is daunting.

In this article I will discuss this woman’s choices. I will demonstrate the efficacy, method and results of skin conserving mastectomy. We will explore some of the reasons a young woman may opt for that choice.

What is skin-conserving mastectomy?

A skin-sparing operation removes cancerous breast tissue by using the same minimal and judiciously placed incisions used by plastic surgeons for elective breast augmentation. The most common approach is to use a simple, small, circular incision around the edge of the nipple area. The surgeon leaves all or most of the overlying breast skin, preserving the natural skin envelope that can be filled with an implant or with a patient’s own fat tissue from another part of the body.

How is the Surgery Accomplished?

The mastectomy technique has changed dramatically in the past 50 years from the Halsted radical mastectomy, which sacrificed skin and muscle of the chest wall as well as the axillary anatomy. Today it is believed that the skin envelope of the breast can safely be preserved in the absence of direct tumor invasion. The breast tissue and the biopsy scar are included in the resected mastectomy specimen, depending on the clinical circumstance, the nipple areola complex is included in the specimen or can be left intact. In many cases, this can be achieved by performing the mastectomy through an obliquely oriented elliptical incision that encompasses the nipple areola complex (if necessary) and the adjacent biopsy scar. If the diagnosis of cancer has been made by fine-needle aspiration or needle-core biopsy, the mastectomy can be accomplished through a peri-areolar incision in many patients.

Preservation of the infra-mammary fold as well as the skin envelope is critical for an optimum reconstruction. Earlier mastectomy techniques often involved sacrifice of the underlying tissues through the infra-mammary fold area and to the level of the costal margin. This inferior extension is unnecessary for clearance of the cancer. Preservation of the breast skin envelope permits an anatomic reconstruction using either autologous tissue or implants.

The sentinel node approach to the axilla preserves the axillary lymphatic anatomy in the 70% of breast cancer patients who do not have axillary nodal metastases and in whom only the sentinel nodes are removed. Preservation of the axillary anatomy essentially eliminates the risk of lymphedema and post-mastectomy pain syndrome.

A: Incision through which the breast tissue is removed

B: Skin of the breast left in tact to act as the envelope for an implant or an auto-fat transfer

Should Skin Conserving Mastectomy be done? Is it safe?

The main oncological concern in both skin-sparing mastectomy and nipple/skin sparing procedures relates to the possibility of leaving residual tumor within the skin envelope which may manifest later as local recurrence (LR). One large study observed 539 patients over a period of 65 months. 30.6% of cases had non-invasive disease. The LR rate was 5.5%. In most cases, the local recurrence was related to tumor size, grade, nodal status and lymph vascular invasion and was not skin related. After skin-sparing procedures, the overall survival and the local recurrence rate has been reported to be similar to the cases which underwent modified radical or simple mastectomy.

In Skin-conserving mastectomy the endangered breast tissue must be removed with safe margins while the spared skin can still function cosmetically. The ideal procedure would have a flap thin enough to remove most of the breast tissue, but thick enough to support an adequate blood supply. Torresan et al. showed a high prevalence of glandular breast tissue and residual disease in a skin flap thicker than 5 mm. As with standard mastectomy, obtaining free surgical margins is essential to skin sparing mastectomy. While skin flap necrosis is a recognized complication of SSM because the skin envelope's blood supply can become compromised during dissection, this can be minimized by leaving a skin flap as close to 5mm margin as possible and selecting patients appropriate for the procedure. Nicotine, previous radiotherapy, diabetes and obesity increase the risk of skin envelope ischemia, skin necrosis and infection; all these factors could amplify these complications additively.

Who?

There are two main groups of women who desire skin saving mastectomy. Both groups are usually quite young, certainly under 50 years old.

1. The first faction include the women who have been assessed as very ‘high risk’. These women fall into the following categories:
• Mutated BRCA genes
• History of cellular atypia with high risk of DCIS
• History of lobular carcinoma in situ (LCIS).
• Higher risk women who have already sought out and received the appropriate genetic and psychological counselling to discuss the psychosocial impacts of the procedure.
2. The second set of women includes those who have suffered breast cancer and have already been treated with a breast resection, radiation and/or chemotherapy.

Why?

These groups of women have a life-time risk of breast cancer of over 90%. The psychological toll on these women year after year, waiting for the diagnosis they just know is coming or waiting for the other shoe to drop and a re-diagnosis to be made can be devastating.

Another choice is to “manage” the patient’s risk. Managing this kind of risk for a long period of time can be arduous and protracted and indeed, in some locals impossible. The proper management should include:

1. Surveillance: The goal of surveillance is to detect any possible cancer at its earliest stage.
• Breast self-exam every month
• Clinical breast exams once or twice a year
• Annual mammograms
• Annual MRI +U/S (offset from the annual Mammogram by 6mos.)
2. Chemo-preventive drug therapy: This method uses drugs to prevent or inhibit cancer cell production
• Tamoxifen, a drug used to prevent recurrence in women who have already had cancer, can also be used as a preventive or risk-reducing measure for high-risk women. Side effects include hot flashes, vaginal discharge, an increased chance of endometrial cancer and blood clots
• Raloxifene is a similar drug to tamoxifen with similar side effects; but raloxifene isn't linked to endometrial cancer.

The Cosmetic Results:

No matter how skilled the plastic surgeon, no matter how proficient the procedure used nothing can compare with the patient’s own external breast as the envelope for the augmentation.

Below are some comparative images of reconstruction methods. The images speak for themselves.

Post-surgical Implants:

Tramflap Reconstruction:

Bilateral Skin Conserving Mastectomy:

SUMMARY:

We are diagnosing breast cancer earlier and earlier. We are able to assess risk/benefit ratios and genetic risks with astonishing precision. Breast cancer is rapidly becoming a chronic, manageable disease rather than a death sentence. The patients we are seeing are younger and younger every year.

Properly placed incisions and skin-sparing, or nipple/skin conserving, surgical approaches provide women undergoing biopsy and surgical treatment for breast cancer with the best option for appropriate cancer eradication while still permitting reconstruction of a more natural looking breast.

Here in Canada and even in the US skin-conserving mastectomy is, more often than not, not offered as an option to the breast cancer or high risk patient. If new surgical techniques can dramatically improved the aesthetic results of mastectomy without sacrificing outcomes should we at least not allow this vulnerable patient to consider this option?

COMMON POSITIONING PROBLEMS: The Solutions!

OBJECTIVES:

No matter which modality we are using, no matter whether we are practicing screening or diagnostic mammography, no matter what: We still have to position our patients so that all the breast tissue is demonstrated.

That is always a challenge and all the help that comes our way is useful. Here are some tips regarding positioning dilemmas with some handy remedies. I hope they are helpful.

THE CC PROJECTION: “IF”

A) The nipple is not in profile

If the nipple is not in perfect profile: 1. Elevate the IMF a little higher 2. Lift and pull the breast straight onto the bucky 3. Use both hands to handle the breast 4. (Hint): The nipple points toward the missing tissue

B) The medial Cleavage is not open and visualized

If the medial cleavage is not visualized properly: 1. Position from the medial side 2. Lift and drape opposite breast over the edge of the bucky 3. Do not press the patient’s face against the face protector 4. Place her head beside and beyond the tube

C) The lateral aspect or ‘Tail-of-Spence’ is not demonstrated

If the lateral aspect of the breast is not seen: 1. The Patient’s arm should be relaxed by side 2. Her palm should be supinated with her shoulder externally rotated 3. Control your patient’s posture with your hand around her back on her contra-lateral shoulder 4. She should be relaxed forward bent slightly at the waist 5. Release the breast to the compression with forward and medial orientation of your hand

D) The pectoral shadow is not visible at the chest wall and/or the PNL is not within 1cm of the PNL on the MLO

If the ½ moon of pectoral shadow is not seen at the chest wall of the CC view and/or the PNL is of an inadequate length: 1. Elevate the IMF until the tissue no longer moves easily along the chest wall 2. Identify the edge of the pectoral muscle visible just under the clavicle 3. Loosen the skin over the clavicle so the tissue moves easily 4. Compress parallel to the pectoral edge just under the clavicle 5. Release hand in a forward medial motion

THE MLO PROJECTION: “IF”

A) The pectoral muscle is not demonstrated to or below the level of the nipple

If the pectoral muscle is not seen to the level of the nipple or below: 1. Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle 2. Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum 3. Compress the projection parallel to the pectoral axis along the sternal edge

B) The pectoral muscle is not relaxed and convex in shape

If the pectoral shadow does not appear convexly shaped: 1. DO NOT rest your patient’s arm along the top edge of the bucky 2. Patient’s shoulder should be open, relaxed 3. The corner of the bucky high up and well back in the axilla 4. Patient’s arm should be slightly bent hanging loosely down the back of the bucky 5. Relaxed hand…NO gripping the handle

C) The breast is not ‘up & out’ and/or the retro mammary space is not visualized behind the parenchyma

If the retro mammary space is obscured by parenchyma and the breast is not adequately ‘up & out’: 1. Move the breast from the lateral edge medially 2. Ensure the breast mound moves freely in your grip 3. Support the breast tissue from the inferior border using you entire hand 4. Immobilize the breast tissue on the bucky in the ‘up & out’ position using the edge of your hand to support the pectoral axis along the sternum 5. Release the breast to compression with a distinct out and away motion

D) The Infra-mammary Fold is not clearly seen curving to the abdomen un-obscured by wrinkles, folds or belly

If the IMF is not open and fold free: 1. Support the breast and always release with and up & out motion 2. Have the patient tilt her hips slightly backwards 3. Do not release your hold on the breast until the projection is immobilized by the compression 4. Gently run your thumb and finger down behind the breast along the IMF/belly border to clear folds, wrinkles and tummy

E) Nipple is not in profile

If the nipple shadow is not in perfect profile: 1. Make sure the patient’s feet are directly facing the bucky 2. Control the breast from the mobile lateral border only 3. Immobilize the breast parenchyma parallel to the pectoral muscle until the compression holds the projection 4. (Hint): The nipple points toward the missing tissue

SUMMARY

Mammography is a sensitive, complicated and difficult specialty. All our patients vary as to body habitus, temperament and compliance. It is essential we demonstrate all the tissue, see it clearly and know that all the borders of the breast are verified.

Breast Imaging is an area of DI where we work autonomously much of the time. We are responsible for checking and correcting our own work. I send this article once a year for those who have lost theirs or those who are new to techtalk, I hope they will lend a hand in the arduous task of perfecting your technique and knowledge.

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!

Skin Marking Today

OBJECTIVES

Routine identification of the nipple, lesions and pathology with a skin marker in both screen-film and digital mammography on all patients eliminates uncertainty and the necessity for any repeat examinations. Many mammography facilities use these small self-adhesive skin markers to readily identify the nipples, possible abnormal lesions and pathology of all types. Even with the advent of digital mammography nipple markers continue to be beneficial. The markers allow immediate identification of the nipple without adjusting the window and level settings. These markers are placed on the patient before her mammogram and subsequently serve as a reliable and stable landmark on mammograms for the registration of multiple images.

Triangulating a Lesion Viewed in One View Only:

Very often in Mammography there is a suspicious area of concern that can only be appreciated in one view. There are two recognized methods that identify a plane of possibility where the lesion could be located. These methods help to define an area where the lesion is probably located thereby reducing read time.

The two methods typically used today are; the Arc method and the Right angle or Cartesian methods. Both of these methods benefit from the placement of a nipple marker prior to the exam. The Cartesian method has proved to be more accurate for lesions on the periphery of the breast while both methods are helpful for central lesions.

1. Cartesian Method (right angle) (preferred method)

Guidelines:

To locate lesion in 2nd view draw a line through the nipple and perpendicular to chest wall in each view. Locate depth along that line.

This right angle technique works well for central lesions and is a more reliable technique for localizing peripheral lesions seen on only one view. First, the nipple marker is used to help establish a perpendicular nipple pectoral line on both the CC and the MLO views. Then measure from the nipple marker to the area of concern and transfer this measurement to the projection where the lesion is not immediately appreciated (See Diagram1&2 below).

CC= 1cm 2cm 3cm along PNL

MLO= 1cm 2cm 3cm along PNL to chest wall

The value of this technique can be seen in Image A and B where the lesions noted in the CC view at 40mm, 70mm and 95mm are all found at the same distance in the MLO view. This holds true even for the two more peripheral findings.

2. Arc Method

Guidelines:

To locate lesion in 2nd view swing an arc through the lesion from the nipple .Repeat in second view

To utilize this method locate the nipple, or preferably the nipple marker, and measure the distance to the area of concern in the projection where the lesion is noted. In the projection where the lesion is not evident an arc is established at the distance measured in the first projection (Diagram 3 and 4).

This method will work well for central lesions but is not accurate for peripheral lesions of the breast. Image C and D demonstrate this well, as the lesion noted in the retroareolar area in the MLO view at 7mm is found in the CC view at 40mm.

Arc @2.6cm

C. L-CC D. LMLO

In conclusion, the Right angle technique is the more consistent and most precise method. The Arc technique is fairly accurate for central lesions, but can be a pitfall for lesions at the periphery of the breast in the subareolar area, or in the axilla. These quick techniques are generally helpful for a basic approximation.

Using Nipple-To-Lesion Distance Only To Find a Missing Lesion:

Placement of nipple markers can allow accurate measurement of lesions and their distance from the nipple. Findings on mammographic images are generally reported with the o’clock position and distance from the nipple. If a potential lesion can only be identified in one view additional workup is required and every effort needs to be made to determine its location in another projection.

Using the nipple-to-lesion distance can aid in lesion identification. By determining how far back from the nipple the lesion is on one view the approximate location of the lesion can then be ascertained on the other projection. If two views are not sufficient for lesion identification, triangulation of the lesion with additional imaging is then warranted.

Case study

Case Study 1: A 72 year-old female presented for a screening mammogram. Within the superior aspect of the left breast 15cm posterior to the nipple on the MLO view is a 5mm ill-defined mass. To determine a more precise location for the mass the craniocaudal (CC) view is reviewed. In this example the medial aspect of the breast 15cm posterior to the nipple is clean with no masses. Therefore, based on location and its distance from the nipple using the MLO view this lesion is likely in the far posterior and lateral aspect of the breast on the CC view at approximately one to two o’clock where there is the suggestion of a mass. Additional imaging including a standard 90 degree lateral view and spot compression views were performed along with an ultrasound and ultrasound guided biopsy (not shown). The biopsy findings were compatible with infiltrating lobular carcinoma.

Benefits of Routine Nipple Marking in Mammography:

The placement of nipple markers not only provides a high quality examination for the patient, they also aid the radiologist in reading the mammogram by eliminating confusion and saving time. This is true even when dealing with a FFDM system. The time here is saved with less windowing, less leveling and less magnification.

Accurate identification of nipple location on mammograms can be challenging because of variations in image quality and in the nipple projections. This can result in some nipples being nearly invisible on the image. The small radiopaque marker placed on each nipple allows the nipple to be viewed as a reference point on the film for concise nipple-to-lesion distance, helpful in cases with subareolar masses, and in the post-surgical breast with architectural distortion.

Disposable nipple markers make routine nipple marking in mammography possible because they are readily accepted by the patient, easy to use, and cause no significant patient delay.

Using nipple markers helps to eliminate the cost of repeat examinations. In addition to the actual cost for the repeat examination there is the hidden cost of time lost at work for those outpatients who had to return for additional radiographs. Of even greater importance to the patient is the anxiety generated by the report needed for additional imaging which can be eliminated with routine nipple marking.

Case Studies

Subareolar Masses

Nipple markers are particularly helpful in cases with subareolar masses. Depth divides the breast arbitrarily into anterior, middle and posterior thirds, and immediately behind the nipple is the subareolar region.

When a nipple marker is not used it can be difficult to distinguish the nipple from a well-circumscribed mass in the subareolar region. Additional imaging would be required which may invoke unnecessary anxiety for the patient.

Case 1

Case Study 1: A 39 year-old female presents with a history of a tender palpable right breast mass. The mass underwent ultrasound guided core needle biopsy with results compatible with a fibroadenoma. Previously behind the right nipple is one bi-lobed mass versus two separate nodules. (A biopsy clip is noted to be positioned 1.5cm medial to the most medial portion of the lesion.) The fibroadenoma in this case is just beneath the skin surface. The nipple marker is extremely useful to eliminate any uncertainty in identifying the mass from the nipple.

Case 2

Case Study 2: An asymptomatic 72 year-old female presents with a stable 1cm well-circumscribed mass directly behind the left nipple since 2002. The mass is slightly superior on the MLO view. The nipple marker is extremely useful to quickly identify the mass from the nipple.

Suboptimal Exposure

Variations in image quality can make accurate identification of the skin line and of the nipple difficult. The absence of the nipple as a stable landmark in these circumstances generates additional read time for the radiologist. The generally simple registration of medial from lateral on the CC view and superior from inferior on the MLO view is challenged when the nipple and skin line are not visualized. Even with the advent of digital mammography nipple markers continue to be beneficial. The markers allow immediate identification of the nipple without adjusting the window and level settings.

Case 3

Case Study 3: A 74 year-old female presented for a screening mammogram. The skin surface cannot be seen and the use of a nipple marker allows the nipple to be identified.

Post-Surgical-architectural Distortion

In patients with a history of lumpectomy or reconstructive breast surgery there can be significant post-surgical architectural distortion which not only affects the appearance of the breast parenchyma but can also alter the position of the nipple. Without placement of nipple markers during initial and subsequent post-surgical imaging, the nipple may be mistaken for a mass requiring additional imaging.

In these cases, translucent scar markers are also valuable to visualize the scar bed as the surgical trauma heals. The scar bed can easily be mistaken for a new lesion and more critically a new lesion can be dismissed as the scar bed.

Case 4

Case Study 4: A 42 year-old female presents with a history of left lumpectomy for malignancy. She has additional history of reduction surgery performed many years prior to lumpectomy surgery. The nipple in these images is markedly displaced by post-surgical changes identified with a nipple marker.

Case 5

Case Study 5: A 70 year-old female presents with a history of right lumpectomy for malignancy followed by radiation therapy. There is post-surgical deformity in the upper aspect of the breast leading to marked displacement of the nipple identified with a nipple marker.

SUMMARY:

The old saying goes…”the more things change, the more they stay the same”. This is so true for breast imaging. Our specialty is specific, intense and detailed. To identify tiny distortions in wildly varying complicated breast tissue all landmarks are useful. We, as the technologist, are charged with demonstrating all the breast tissue clearly and precisely. Marking the landmarks, lesions and scars help us to recognize what projections are needed to show any and all missing tissue. These inexpensive innocuous little markers help the radiologist to make quick, expert, accurate decisions regarding breast abnormalities.

The breast imaging team’s job is to save lives, make treatment shorter, easier and more affective. Any aids that assist us in that mission are more than welcome.