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Pam Fulmer, BA RT (R)(M)(QM)

MAMMOGRAPHY CLINICAL

IMAGE EVALUATION

MAMMOGRAPHY QUALITY STANDARDS

ACT

• 1987-American College of Radiology provided image

evaluation-Volunteer basis

• 1987-91-Only 70% of mammography units passed on first

attempt.

• MQSA-Enacted October 27, 1992

• MQSA-Mandatory October 1, 1994

• Site inspections started January 1995

MQSA

• All mammography units must be:

• Accredited

• Certified

• Inspected

CERTIFYING AGENCIES• FDA approved certifying states

• States can only certify facilities within their state borders

• Illinois

• Iowa

• South Carolina

• Texas

ACCREDITATION BODIES

• These states have their own accrediting bodies

•Arkansas

• Iowa

• Texas

QUALITY STANDARDS ACT

• Regular quality control testing

• Mandatory initial qualifications for personnel

• Continuing education qualifications for personnel

• Facility inspections

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• Positioning

• Compression

• Exposure

• Contrast

• Sharpness

• Noise

• Labeling

• Artifacts

DIGITAL IMAGE EVALUATION

ACR REQUIREMENTS• Facility’s best work-Each case includes 2 MLOs and 2 CCs

• Reviewed and approved by supervising radiologist

• Must be “Negative” images

• Birads 1

• Birads 2 (benign) with prior approval and report

• Must not be from models or volunteers

• Entire breast must be imaged in a single exposure on each

projection

ACR REQUIREMENTS

• One dense case and one fatty case

• The clinical and phantom images from each unit must

be taken within 30 days of each other. The date

should be included on submitted laser film QC chart

• All clinical images should be clearly dated and labeled

NUMBER 1 REASON FOR ACR FAILURE

POSITIONING

• Artifacts

• Exposure

• Contrast

• Labeling

• Compression

• Noise

• Positioning

• Sharpness

IMAGE REVIEW CATEGORIES

DEFICIENCIES IN POSITIONING

• 1. Inadequate pectoralis muscle

• 2. Sagging of breast on MLO

• 3. Lack of posterior tissue on the MLO

• 4. Skin folds overly breast tissue

• 5. Lack of posterior tissue on CC

• 6. PNL now within 1 cm of MLO

• 7. Excessive lateral or medial exaggeration on CC

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MUST KNOW BREAST ANATOMY

HINTS FOR POSITIONING• Moveable borders

• Fixed

• Superior and Medial

• Moveable

• Lateral and inferior

• Angle of pectoralis muscle

• Compression

COMPRESSION

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Inadequate

Compression

• Poor Separation of

glandular tissue

• Unequal exposures of

tissues

• Motion?

Optimal Compression

• Breast looks uniform in

thickness

– Reduces dose

– Reduces unsharpness

– Subtle density

differences seen in the

breast more likely due to

breast tissue attenuation

differences rather than

uneven breast thickness

http://radiopaedia.org/articles/breast-density

SHARPNESS

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Motion

Unsharpness

SHARPNESS on the

CC View

• Edges of vessels,

calcifications and

cooper’s ligaments

• Near the nipple

• From medial to lateral

(posterior tissues closest

to the ribs)

SHARPNESS on the

MLO View

• Edges of vessels,

calcifications and

cooper’s ligaments

• Anterior edge of

pectoralis muscle

• Near the nipple

• At the IMF

NOISE

Noise

• Decreases the ability

to differentiate tiny

structures on the

mammogram,i.e.,

calcifications

• Loss of the ability to

see low-contrast

Structures

• Noise is more common in

digital imaging

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CC

CRANIAL CAUDAL

MOST COMMON DEFICIENCIES

CC VIEW

• Poor visualization of posterior tissue

• PNL on CC view not within 1 cm of PNL on MLO

• Excessive lateral or medial exaggeration (nipple not in

middle of image)

• Skin folds overlying breast tissue

CRANIO CAUDAL

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CRANIAL CAUDAL TIPS

• Image receptor placed at elevated inframammary crease

• Both hands pull breast onto receptor

• Patient leans into unit

• Nipple centered and straight on image

• Absence of skin folds

• PNL within 1 cm of PNL on MLO

RCCRCC RCC

CHECK LIST FOR CCCHECK LIST FOR CCCHECK LIST FOR CCCHECK LIST FOR CC

• Breast centered on image receptor

• Nipple centered and in profile (without sacrificing

breast tissue)

• Tissue well separated

• Visualization of breast tissue back to retromammary

fat space

• Pec muscle visualized at least 30% of the time

• Visualization of cleavage or contralateral breast

• PNL must be within 1 cm of PNL measurement on MLO

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Nipples Centered and Straight ??

RCC LCC

RCC LCC

RCC LCC

LCCSkin Folds on

the CC View

MLO

MEDIOLATERAL OBLIQUE

MOST COMMON DEFICIENCIES ON

MLO

• 1. Inadequate pectoralis muscle

• 2. Sagging breast

• 3. Poor visualization of posterior muscle

• 4. Skin folds overlying breast tissue

• 5. Portion of breast cut off

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MLO

IMF

Medial Lateral Oblique

MLO POSITIONING TIPS

• Hips in front of image receptor

• Convex pectoralis muscle to the nipple line

• Breast lifted up and out

• All posterior tissue seen

• IMF open

• Absence of skin folds

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CHECK LIST FOR MLOCHECK LIST FOR MLOCHECK LIST FOR MLOCHECK LIST FOR MLO

• All the breast tissue included within the perimeter

• Visualization of the breast tissue back to the

retro mammary fat space

• Nipple elevated and in profile (if possible)

• Tissue well separated

• Pectoralis muscle visualized down to PNL

• Pectoralis muscle with wide margin at the axilla

• Pectoralis muscle convex (vs concave)..or at least straight

• Pectoralis muscle radiolucent

• Visualization for IMF

Inadequate Pectoralis

Muscle?

• Shape

• Concave

• Shape: Concave , Triangular Shaped

• Length: inadequate

• IMF excluded

INADEQUATE PECTORAL MUSCLE?

http://www.koningcorporation.com/Case_coverage.aspx

Sagging/Drooping Breast

BREAST DENSITY FOR

ACR

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LABELING• MQSA Requirements

• Patient name and identifying number

• Date of examination

• View and laterality

• Facility name, city, state and zip code

• Technologist’s identification

• Cassette screen number-CR

• Mammography unit number, if more than one

LABELING• Recommended by MQSA

• Date

• Technical factors

• Target filter

• kVp and mAs

• Compression force

• Compressed breast thickness

• Degree of obliquity

ADDITIONAL VIEWS

LATERAL MEDIAL MEDIAL LATERAL

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• Medial lesion evaluation- If there is any question of medial

tissue exclusion on the MLO view

• Triangulate lesion

• If seen on CC view, determine upper or lower quadrant

• If seen only on MLO, determine location medial or lateral

• Milk of calcium

• Benign calcifications

LATERAL VIEW:

90 DEGREES TO CC

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MEDIAL LATERAL

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LATERAL MEDIAL

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TANGENTIAL

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CASE STUDY

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EXAGGERATED CRANIAL CAUDAL

EXAGGERATED

CRANIOCAUDAD

For postero-lateral tissue

Tube angled up to 5°

Used for localization of lesions in far lateral

breast

Compression of anterior tissue is not

optimized

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Implants

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Implants displaced on same

patient (Eklund Technique)

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Mammography

Radiopaque

Obscures tissue

Hides cancer

Hides leaks

Manual exposure

Difficult to localize

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Position of implant

Sub glandular

Sub muscular

Size of implant

Amount of breast tissue

Presence of contracture

Patient Compliance

POSITIONING THE

AUGMENTED BREAST

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IMPLANTS IN RELATIONSHIP TO MUSCLE

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GOOD POSITIONING IS

CREATIVITY. IF YOU DON’T

PLACE THE TISSUE ON THE

DETECTOR, THE RADIOLOGIST

WILL NEVER SEE THE

CANCER.

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