Mammography

Published on 01/04/2015 by admin

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Chapter 15 Mammography

Karen Dunmall

KEY POINTS

A knowledge of the structure of the breast is essential to allow accurate positioning and interpretation of images during a mammography examination.

Breast positioning follows clear protocols to ensure reproducible and diagnostic images.

Equipment used during mammography is designed specifically for the examinations performed.

SOFT TISSUE RADIOGRAPHY

Within general radiography the differences in density of varying parts of the subject (the subject or patient contrast) is usually visible at 45 kV. This is due to the attenuation of the X-ray beam by various tissues being dependent on the cube of the proton number of the structure (Z³):

• Adipose tissue, Z = 6

• Fibrous/glandular tissue, Z = 7

• Calcium, Z = 20

Therefore bone and soft tissue structures attenuate X-rays at quite different rates and produce an image with visible contrast between 50 kV and 70 kV.

Soft tissue radiography is utilised when imaging structures where the proton numbers of the tissues are very similar to amplify the differences in density to allow the different tissues to be identified.

The relative radiolucency of breast tissue also demands an X-ray beam of penetrating ability (beam quality) of 20–35 kV_p. In mammography the lowest kV_p should be selected so as to give the highest subject contrast, as the absorption coefficient of soft tissue falls rapidly with an increasing kV at low energies. However, if the energy is too low, there will not be enough intensity to penetrate the breast to produce an image. This will just increase the radiation dose and time of the exposure. So there will be a compromise between good image quality and keeping radiation doses as low as reasonably practicable. Therefore, to optimise the image the breast must be compressed; this helps reduce the overall thickness and, consequently, the radiation dose (as there is improved beam penetration), reduce the risk of movement unsharpness, and improve the contrast resolution, by reducing scatter. The compressed breast will be closer to the image receptor, which improves the spatial resolution.

With larger compressed breast thickness there is a need to use a higher energy kV_p, which does cause a slight loss in contrast, but is acceptable due to the dose saving.

ANATOMY OF THE BREAST

The adult breasts are two hemispherical organs situated on the anterior and lateral aspects of the chest wall, on the surface of the pectoralis major muscle (Fig. 15.1). The breast extends from the second rib superiorly (and clavicle) to the sixth rib inferiorly, and laterally from the mid-axillary line to the sternal edge medially. The glandular tissue in the upper outer quadrant of the breast, which extends into the axilla, is known as ‘axillary tail’. The nipple usually lies at the level of the fourth/fifth rib space; however, the breast is a mobile structure, which varies considerably in size and shape, so this should not be seen as a reliable surface marking.

Figure 15.1 Internal structure of the breast.

The adult breast is composed of glandular tissue and fatty tissue, which accounts for the variation in size and shape. The glandular tissue is formed from 15–20 lobes, each consisting of several small lobules. A lobule has a number of secretory alveoli, which open into lactiferous ducts. The lobule and the duct form the basic unit of histopathology as the majority of benign and malignant lesions arise in the terminal ductal lobular unit (TDLU). Each lobe of the breast is drained by one lactiferous duct, which passes upwards to form dilated sinuses (ampulla) behind the areola. The areola is the area of pigmented skin surrounding the nipple. The lactiferous sinuses exit by individual orifices onto the nipple surface. The fatty tissue lies under the skin, separating it from the irregular boundary of the anterior surface of the glandular tissue known as the superficial fascia. Fibrous strands, which extend from the skin to the superficial fascia, form the suspensory ligaments (Cooper’s ligaments).

Figures 15.2 and 15.3 depict, respectively, the venous drainage and arterial supply of the breast.

Figure 15.2 Venous drainage.

Figure 15.3 Arterial supply.

LYMPHATIC DRAINAGE

The lymph drains from the central portion of the breast, the circumareolar region and the skin surface, into a plexus of vessels on the surface of the pectoral muscle (Fig. 15.4). Approximately 75% of lymph drains into the axillary glands with only 25% passing from the medial half of the breast into the internal mammary nodes. There is also a limited amount of crossover between breasts and into the abdominal lymphatics. The relatively high occurrence of cancers in the upper outer quadrant and central areas of the breast and the fact that the majority of the lymphatic drainage passes into the axillary region have a direct importance in the selection of the mediolateral oblique as a screening position for breast cancer.¹

Figure 15.4 Lymphatic drainage.

HISTOLOGY OF THE BREAST AND RADIOGRAPHIC APPEARANCE

The structure of the breast, with its varying amounts of glandular, fibrous and adipose tissue, holds the key to the best age for imaging the breast using X-radiation.

There are three main types of tissue within the breast:

1) Adipose (fatty) tissue – this tends to be radiolucent as it has a proton number of 6 and results in areas of relatively higher optical density on the image.

2) Fibrous tissue – this is indistinguishable from glandular tissue on the radiographic image as it has a similar proton number (7) but does appear as an area of lesser optical density than adipose tissue.

3) Glandular tissue – as above; it is usually referred to as fibro-glandular tissue due to the similarity of radiographic appearance. Cancers arise from the epithelial lining of the TDLU and are defined dependent on the varying degrees of proliferation and abnormal growth.

BREAST DEVELOPMENT AND STRUCTURAL CHANGES

The adolescent female breast develops from rudimentary tissues that start to form during fetal development. There are varying periods of inactivity; however, the process speeds up during pre-puberty and puberty. The adolescent breast has a greater amount of developing glandular tissue but the shaping is usually caused by the accumulation of adipose tissue. The breast is a radiosensitive organ that is at greatest risk from radiation between 10 and 19 years of age, but there is also a risk between the ages of 20 and 39.

The adult breast is less dense than that of the adolescent and has a greater fat content. The exception to this occurs during pregnancy and lactation when the TDLU increase in size and the epithelial cells prepare for the secretion of milk. After lactation ceases the TDLU reduce in size and number.

During the menstrual cycle changes occur in the breast which relate to the hormonal effects on the epithelial cells in the TDLU. Although the changes do not appear on the image the discomfort experienced during the pre-menstrual period may produce difficulties in positioning and compression of the tender breast.

The density of the breast tissues on a mammogram image depends on the relative amounts of glandular, fibrous and adipose tissue present (degree of obesity of the patient). There is a gradual decrease in the glandular tissue of the breast, which is termed as involution. This can begin to occur as early as 35 years and is associated with the decline and cessation of ovarian function. In the menopausal and postmenopausal period (45–75 years) there is a more noticeable increase in fat deposition and glandular tissue reduction. Screening mammography is carried out between the ages of 50 and 64+; this correlates to the menopausal/postmenopausal phase of the breast. On a mammogram this is indicated by the majority of the dense tissue occupying the upper outer quadrant, hence the indication for the mediolateral oblique. This also becomes important in the positioning of the automatic exposure control (AEC) chamber (sometimes also referred to as an automatic exposure device, AED), as the exposure will be insufficient to penetrate the dense tissue if the AEC is under an area of adipose tissue.

MAMMOGRAPHY EQUIPMENT

Figure 15.5A shows a typical mammography unit and Figure 15.5B is of an X-ray unit showing the AEC position.

Figure 15.5 A A mammography unit. B A mammography X-ray unit showing position of automatic exposure control (AEC).

X-RAY TUBE AND HOUSING

A constant potential generator supplies the X-ray tube. The source–object distance (SID) is shorter than normal diagnostic X-ray examinations (45–60 cm) and the use of a fine focal spot of between 0.15 and 0.4 mm reduces geometric unsharpness. Image quality needs to be of an absolute high standard (i.e. micro calcifications, fine details).

With mammography equipment the tube housing is more compact than a standard X-ray tube (Fig. 15.6). The lower kV_p employed is a favourable factor in permitting a smaller tube housing. Both high-tension cables enter the tube housing via the anode end to avoid patient contact. One particular type of unit has a system whereby the tube head moves out of the way during procedures such as biopsy or stereotactic localisation. As well as being able to move the X-ray tube head there is also a Perspex face guard to prevent the head from moving into the X-ray field. The tube is orientated with the anode further away from and the cathode closer to the patient, thus utilising the ‘anode heel effect’. The increased output at the cathode side of the X-ray tube is directed at the thicker chest wall edge of the breast whilst the ‘heel effect’ is over the thinner nipple edge.

Figure 15.6 X-ray tube.

The main difference to a normal diagnostic tube is the use of molybdenum (Mb) as the target material. Traditionally, the only way to reduce the beam quality was to use a lower kV_p; however, varying the target material and filtration can improve the penetrating power whilst reducing the glandular tissue dose in dense breasts. Tungsten (W) does not have any characteristic radiation at low voltages, unlike molybdenum (Fig. 15.7). Despite the lower intensity of brehmsstrahlung from molybdenum, this reduction in intensity is offset by the characteristic X-ray emission of molybdenum. Rhodium (Rh) is now also used as a target material and filter, its characteristic radiation is slightly higher than molybdenum,which makes it useful for patients with dense breast tissue or who have undergone radiation treatment or hormone therapy.

• Molybdenum target tube voltage: 24–30 kV_p (K characteristic 20 keV)

• Rhodium target tube voltage: 26–32 kV_p (K characteristic 23 keV)

• Tungsten target tube voltage: 22–26 kV_p (K characteristic 69 keV)

Figure 15.7 Graph to show characteristic radiation of molybdenum.

The filtration of the beam is essential to remove the low energy photons and minimise skin dose. By utilising multiple target and filtration combinations it is possible to tailor the beam quality to the specific tissue-type requirements. The beam penetration can be improved by employing the same material as a filter and target material. The material used for the exit port is also important in ‘hardening’ the beam in general X-ray equipment; however, in mammography a beryllium (Be) window permits the softer radiation to pass through and enhance the subject contrast.

EQUIPMENT – FITNESS FOR PURPOSE

Overall, the equipment should be non-threatening in appearance and have a quiet operation level. This is important to reassure the woman and thus encourage the uptake rate and re-attendance. Mammography, by virtue of the technique, may be uncomfortable due to the compression of the breast; however, there are various adaptations, which should enhance the experience.

The anatomical size and shape of breast makes imaging more difficult than other parts of the body. In order to ensure reliability and reproducibility the mammographic image must demonstrate the whole of the breast. The shape of the breast tends to create variation in image density gradients, which have the potential to lead to misdiagnosis.

COMPRESSION PLATES

Compression plates ensure improvement in overall density and minimise motion unsharpness. The breast support table and compression devices must have rounded edges to aid in patient comfort and safety. The radiographer controls the compression, which is normally applied gradually and is indicated by an LED display showing the force in newtons; there is also immediate postexposure auto-release. ‘Hands-free’ compression is enabled by a dual control foot pedal that allows the operators’ hands to be used to guide the positioning of the patient. During biopsies and stereotactic localisations the immediate release of the compression device is overridden, to keep the patient immobilised. In some units a sudden large movement of the patient during compression will trigger automatic release from compression. There are pressure sensor interlocks to prevent overcompression of breast tissue but these can be overridden by a manual control.

SUPPORT TABLE

The support table is connected to the mammography unit and directly centred to the X-ray tube. The beam is automatically collimated by means of a cone which produces a D-shaped field in order to ensure consistent accuracy, protect the patient and enhance the contrast by reducing the area irradiated and hence scatter produced.

The breast support plate must be height adjustable and rotate in different planes to accommodate the different needs of the patient. A digital display indicates the angulation of the breast support, which assists the radiographer in reproducibility of images. Within the support table there is the AEC, which corresponds to D-shaped areas on the Perspex compression plate so that its position relative to the underlying breast tissue can easily be seen. The AEC system has an array of eight solid-state measuring cells. The breast support table also houses the anti-scatter grid mechanism and the cassette tunnel (or the digital imaging system). There is an interlock to prevent double exposure of a cassette or the irradiation of a patient without a cassette in place.

TUBE COLUMN

There are handgrips on the tube column, which are aids for stability of the patient. There are also fail safe interlocks and brakes which act during power cuts to prevent sudden movement of equipment and potentially serious consequences for the patient. The movement of the X-ray tube housing and support table may be motorised to aid the radiographer and reduce strain on the upper arms. The equipment is earthed for electrical safety.

RADIATION PROTECTION FOR STAFF AND PATIENTS

A lead equivalent glass screen affords radiation protection for staff. The presence of a pre-determined collimation area, the automatic optimisation of parameters (GE units) and combinations of target material/filter all assist in minimising the exposure and hence dose to the breast and patient.

Automatic optimisation uses the first 0.015 seconds of the exposure to automatically determine and apply the optimal kV, filter and track selection according to the composition of the breast under study. This results in a potentially lower dose to the patient and a reduction in the number of exposure related repeats.

Some units utilise the digital acquisition of mammography images. This gives the ability to manipulate images (magnification and windowing) and to transfer and digitally archive. Amorphous selenium (aSe) is the next generation of detectors, offering higher digital quantum efficiency with lower dose and higher resolution.

COMPUTER AIDED DIAGNOSIS (CAD)

CAD is a sophisticated tool that identifies suspicious lesions and assists the radiologist/reader in the early detection of breast cancer. Triangular markers indicate possible microcalcification clusters and asterisk-shaped markers highlight regions suggesting masses or architectural distortion. The advantages of CAD may include the reduction in the number of individuals needed to interpret the images, together with an increase in sensitivity. However, research carried out has yet to show clear benefits from this technological advance.^2,³

Technique

The initial part of any radiographic procedure should be to gain consent from the patient to have the examination performed. Screening mammography is no exception, so before any woman is screened an explanation should be given as to what will happen and an indication of the discomfort which may occur. In some screening centres a questionnaire is completed by the mammographer indicating:

• whether there is a family history of breast cancer

• the existence of any known pathology or unusual symptoms; e.g. nipple discharge, pitting, etc.

• menstrual history

• pregnancy history

• any noticeable scars or skin lesions; e.g. moles, skin tags.

It may also be the policy to carry out a manual breast examination prior to mammography.

THE CRANIOCAUDAD PROJECTION

THE MEDIOLATERAL OBLIQUE PROJECTION

This is a routine mammographic projection which demonstrates all the breast tissue (including the axillary ‘tail’). The preparation for the patient is the same as for the craniocaudad; cooperation is vital in mammography as a relaxed patient is somewhat easier to image than someone who has a tense pectoral muscle and stiff upper body. The angle required on the support table can be estimated using the general body shape of the woman so that there is not a lot of alteration of the equipment occurring.

PATIENT TYPES

Hypersthenic individuals

Short and stocky, with broad shoulders (Fig. 15.14), these patients benefit from an angle between the compression plate and horizontal of less than 45° and, potentially, 40°. The support table will then be at an angle, making it parallel to the middle axis of the breast tissue and thereby reducing the degree of foreshortening.