Patient Education

• Mammography


  A radiographic procedure that uses special equipment to produce images of high contrast and high resolution for the diagnosis of breast lesions

  
• Mammography


  • High-quality images are required to ensure that subtle but significant findings are not overlooked, because deficiencies in equipment, technique, or interpretation could result in failure to identify a life-threatening tumor

  
• The American Cancer Society recommends annual mammograms beginning at age 40, although recommendations sometimes vary among organizations and agencies

  
• Patients are instructed not to use underarm deodorant and not to apply powder or lotions on the breasts or axillary areas
• Antiperspirant artifact


  Some antiperspirants contain aluminum salts
• Compression devices


  • Should be constructed so that the posterior edges and the surface are straight, not rounded
  • Made of polycarbonate resin
• Breast Self-Examination (BSE)


  Single greatest support to mammographic examination

  
• Examination Positions


  • Erect (shower, easiest & reliable for most women)
  • Supine (bathtub, usually easier for large-breasted women)
• BSE should be done monthly, starting at age 20 years old
• Yearly breast examinations by a health care professional should be performed for women older than age 40 years
• Women younger than 40 should have a health care professional complete a breast examination every 3 years
• Use the pads of the fingers for BSE
• To become fully acquainted with the breast, explore them throughout the month and note how diet and hormones influences them
• BI-RADS


  Breast Imaging-Reporting and Data System: Risk assessment and quality assurance tool developed by ACR, provides a widely accepted lexicon and reporting schema for imaging of the breast, applies to mammography, ultrasound, and MRI

  
• Current regulations of the Federal Drug Administration (FDA) require that all mammograms be identified with the following permanent markings: patient name and any of the following data: date of birth, medical record number, or any additional identifier; date of examination; view/projection and laterally (specific breast), which should be marked near the axilla
• Current FDA regulations require that all mammography reports include the following data within the written summary: patient name and any of the following: date of birth, medical record number, or any additional identifier; date of examination and name of interpreting physician; overall evaluation of the findings classified into one of the following categories: negative, benign, probably benign, suspicious, highly suggestive for malignancy, or incomplete; clinical recommendations for future action, no matter what the diagnosis

  
• Mammography: The First Steps


  • Importance of clinical background
  • Issues of consent and exposure justifications
  • Communication and the development of a rapport with the patient
  • Points of technique relating to all examinations, including anatomical positioning – "the whole-body technique"
  • Compression of the breast – why & how
  • Anatomically derived mammographic principles

  
• Reasons women attend a mammography unit

  • National or Local Screening Programs
  • Family history surveillance
  • Breast symptoms
  • Additional views
  • Stereotactic-guided needle biopsy & marker localization
  • Screening research studies
  • Follow-up mammography
• Screening Mammograms


  No symptoms or signs of breast cancer, average risk for breast cancer, reduces breast ca mortality in 50-70 age group

  
• Diagnostic Mammograms


  Women with symptoms such as a lump, pain, nipple thickening or discharge, changes in breast shape or size, used to evaluate abnormalities detected in screening mammogram

  
• If a request goes outside the normal protocols & the patients may be at risk from unnecessary radiation, RT should not proceed until the situation is clarified and the request is justified
• They need to know that the screening test is not 100% effective and that a recall for further tests is a possibility, before proceeding with the examination
• Those who are brought by relatives and professional care staff can be assisted to understand the process with the use of appropriate guidance; in form of images, sign language and demonstration
• Pre-Mammography Discussion


  • Establishing Rapport (help her feel comfortable and relaxed)
  • Explaining the Procedure (it is uncomfortable rather than painful, it doesn't last long, compression is essential)
  • Relevant History (brief summary of reason for current exam, past history of breast disease, any reported breast symptom, family history of breast cancer, hormone replacement therapy)
  • Observing and Reporting Clinical Signs (ex. pain during positioning/compression, lump, skin tethering or dimpling, recent nipple inversion, eczema of the nipple, nipple discharge)

  
• Film Marking: To assist in orientation, annotations should always be placed on the lateral/axillary edge and at the corner of the film away from the patient
• Anatomical Positioning


  • Mammography is a whole-body technique, correct positioning of feet, arms & spine are crucial
  • The patient can be positioned standing or seated
• Manipulating & Controlling the Breast


  • The breast should be held firmly, the hand cupping the breast with the thumb & fingers at the posterior margin of the breast against the chest wall; the internal structures of the breast must be grasped, not just the overlying fat

  
• Compression of the Breast


  • Compression of the breast tissue is essential for good mammography
  • One hand controls the position of the whole body while the other manipulates the breast
  • Standard teaching "not moderate compression but the most vigorous possible compression tolerated by the patient"
  • Much of the resultant pain originated from compression of the axillary muscles & overlying soft tissues
  • In UK, maximum force permitted to be applied to the breast is 200 Newtons

  
• Beneficial Effects of Breast Compression During Mammography

  • Reduction of Internal X-Ray Beam Scatter
  • Improved Contrast
  • Spreading of Breast Tissues: Reduced Superimposition, Clearer Demonstration
  • Reduced Geometric Unsharpness
  • Reduced Movement Unsharpness
  • Reduced Radiation Dose to the Breast
  • More Homogenous Film Density

  
• Range of Force (Newtons) Applied to the Breast During the Production of Good-Quality Mammography


  • Craniocaudal (CC): 70 - 140
  • Mediolateral Oblique (MLO): 100 - 140
  • Lateral: 70 - 140

  
• Cranio-Caudal Projection (CC)


  • Indications: Routine for all initial x-ray examinations of the breast, CC projection combined with MLO
  • Area Demonstrated: Majority of the breast tissue is demonstrated with the exclusion of the extreme medial portion and the axillary tail
  • Equipment position: The breast support table is horizontal and raised to slightly above the level of inframammary angle

  
• Anatomical Position - Left Breast for CC Projection

  • The woman faces the machine, about 5-6 cm back, with her feet pointing towards the machine
  • Arms by her side
  • The breast to be examined should be aligned with the center of the table
  • The mammographer should stand medial of the breast to be examined
  • Lift the left breast up and away from the chest wall with your right hand, hold the woman's left shoulder with your left hand, turn her head to the right

  
• Alternative Technique for the Radiographer of Short Stature for CC Projection

  • Lift the left breast up and away from the chest wall with your right hand, place your left hand on the left scapula, turn her head to the right
  • Encourage her to lean forward, rotating the thorax a few degrees to bring the rib cage directly below the nipple line against the edge of the breast support table
  • Keep hold of her left shoulder and remove your hand from beneath the breast so that the breast rests on the support table
• Using the light beam diaphragm, check that: the nipple is in profile, the medial portion of the breast is on the film, the shoulder is relaxed in order that the upper lateral portion of the breast is on the film, the image field covers all the tissue in front of the thorax

  
• Applying the Compression for CC Projection

  • Hold the left shoulder with your left hand, exerting gentle pressure downwards, place your right thumb on the medial aspect of the breast and apply compression

  
• Cranio-Caudal Projection


  1. Lift the left breast up and away from the chest wall with your right hand

  2. Place your left hand on the left scapula

  3. Turn her head to the right

  4. Encourage her to lean forward, rotating the thorax a few degrees to bring the rib cage directly below the nipple line against the edge of the breast support table

  5. Keep hold of her left shoulder and remove your hand from beneath the breast so that the breast rests on the support table
• Checking the Cranio-Caudal Projection

  1. Check that the nipple is in profile

  2. Check that the medial portion of the breast is on the film

  3. Check that the shoulder is relaxed in order that the upper lateral portion of the breast is on the film

  4. Check that the image field covers all the tissue in front of the thorax

  
• Applying Compression for Cranio-Caudal Projection


  1. Hold the left shoulder with your left hand, exerting gentle pressure downwards

  2. Place your right thumb on the medial aspect of the breast & the first two fingers of your right hand on the superior surface, pulling gently forward towards the nipple

  3. Using the foot pedal, apply compression slowly & evenly, gradually moving your hand towards the nipple until the hand is replaced by the compression plate
• Cranio-Caudal Projection

  • The nipple in profile & pointing towards the center of the long axis of the film
  • The majority of medial tissue
  • The majority of the lateral tissue with the exclusion of the axillary tail
  • Pectoral muscle demonstrated at the center of the film on approximately 30% of individuals
  • The depth of breast tissue demonstrated should be equal to, or no more than 1 cm less than, the distance from the nipple to pectoral muscle on the medio-lateral oblique projection

  
• Medio-Lateral Oblique (MLO) Projection


  Used in all routine mammographic examinations together with the cranio-caudal projection