Lecture 1 Introduction to Mammographic Imaging.pdf

L1 Introduction to Mammographic Imaging The Story of Breast Imaging Dr. Wijdan Alomaim fchs.ac.ae Images In the PowerPoint presentations used throughout this lecture series: 1. Images selected from the prescribed text are denoted by name 2. Images selected from other sources are attributed in full....

L1 Introduction to Mammographic Imaging The Story of Breast Imaging Dr. Wijdan Alomaim fchs.ac.ae Images In the PowerPoint presentations used throughout this lecture series: 1. Images selected from the prescribed text are denoted by name 2. Images selected from other sources are attributed in full. 3. Any images not attributed in any way are the property of Monash University. 4. No image is to be reproduced without the express permission of the owner of that image. fchs.ac.ae REFERENCES Eklund G & Cardenosa G ,1992,Art of Mammographic Positioning: The Radiologic Clinics of Nth America Vol 30 No1 Breast Cancer in Australia; an overview – Australian Institute of Health and Welfare + Cancer Australia Oct 2012 www.canceraustralia.org.au Long S, 2010, The Handbook of Mammography, 5th Ed, Mammography Consulting Services Ltd,Canada Kamm B, 2000, The Mammographer’s Role in Addressing Special Needs. Radiologic Technology Vol72 No1 26-40 Andolina,V & Lille, S (2010). Mammographic Imaging: A Practical Guide. Third Edition. Lippincott Williams and Wilkins Peart, O. (2005). Mammography and Breast Imaging: Just the facts. Columbia: McGrawHill fchs.ac.ae Anatomy & Overview fchs.ac.ae Introduction ❖Latin word Breast = Mammary gland. ❖Present in both sexes. ❖Rudimentary in male. ❖Accessory organ of female reproduction system. ❖Well developed in female after puberty. ❖Apocrine gland, Modified sweat gland. fchs.ac.ae Location: In the superficial fascia of the pectoral region. Boundary: Vertically: 2nd to 6th ribs. Horizontally: lateral border of sternum to the mid-axillary line. Extension: Above: Clavicle Below: 7th to 8th ribs Medially: Midline Posteriorly: to the edge of latissimus dorsi fchs.ac.ae BOUNDARIES OF THE BREAST Superiorly: 1st or 2nd rib (clavicle) Inferiorly: 6th or 7th rib (IMF - inframammary fold) Medially: Sternum Laterally: Midaxillary line fchs.ac.ae 2nd rib Pectoralis major Skin 6th rib Fat Axillary Tail of Spence fchs.ac.ae Structure ❖ Skin: Nipple Areola ❖ Parenchyma ❖ Stroma fchs.ac.ae Areola Nipple Tubercle of Montgomery Parenchyma ❑ Lobes: - 15 – 20 in number - Composed of minute glandular structures called lobules Lobules Ductules - Lobules empty via ductulesin lactiferous ducts Lactiferous duct ❑ Lactiferous ducts: - Open on to nipple Lactiferous sinus - Contains ampulla near its end Nipple (Reservoir of milk or abnormal discharge) fchs.ac.ae fchs.ac.ae TERMINAL DUCTAL LOBULAR UNIT TDLU consists of : Extralobular terminal duct Intralobular terminal duct Acini or Ductule TDLU is the site of origin of : Fibroadenoma Most fibrocystic lesions Lobular Carcinoma in situ (LCIS) Ductal Carcinoma in situ (DCIS) Invasive ductal/ lobular cancer fchs.ac.ae Stroma: Partly fibrous & partly fatty ❖ Ligaments of Cooper: Stroma forms the supporting framework of the gland. -There are fibrous bands that provide structural support and insert perpendicularly into the dermis, termed the suspensory ligaments of Cooper. -That is why if the involvement of cooper’s ligament skin retraction fchs.ac.ae Coopers ligaments are connective tissue septa that divide and support the breast tissue fchs.ac.ae - Subcutaneous - Mammary - Retro mammary - Fibrous Fibroglandular tissue - Glandular - Adipose - Anterior - Posterior 3 layers 3 major types of tissue 2 layers of pectoral Fascia fchs.ac.ae Source GE poster 1989 - Subcutaneous - Mammary - Retro mammary fchs.ac.ae Blood supply The mammary gland is extremely vascular. 1. Internal thoracic artery, a branch of the subclavian artery, through its perforating branches. 2. The lateral thoracic, superior thoracic, and acromiothoracic (thoracoacromial) branches of the axillary artery. 3. Lateral branches of the posterior intercostal arteries. fchs.ac.ae Lymphatic drainage Specialized lymphatic channels collect under the nipple and areola and form Sappey’s plexus. 75% axillary nodes 20% internal mammary nodes 5% posterior intercostal nodes fchs.ac.ae TERMS IN MAMMOGRAPHY Contralateral: other side of the body Inframammary Fold (IMF): the most inferior aspect of the breast; where it attaches to the abdominal wall Image Receptor Support Device (IRSD): a one size breast support platform for digital machines; 2 size Buckys for analog and CR imaging Posterior Nipple Line (PNL): an imaginary line running from the pectoral muscle to the nipple on both the CC and MLO views fchs.ac.ae What is a mammogram? ▶ A mammogram is specialized medical imaging that uses a low-dose of x-ray to examine the breast for the early detection of cancer and other breast diseases. It is used as both a diagnostic and screening tool. fchs.ac.ae History of mammography ▪ 1913 (Dr. Albert Solomon) First attempt at mammography ▪ 1950 (Robert Egan) First utilized low kVp and high mAs techniques ▪ 1960 Development of xero-mammography ▪ 1990 Screen-film mammography was accepted 2 5 fchs.ac.ae 2 6 fchs.ac.ae 2 7 MAMMOGRAPHY - INDICATIONS ◾ Screening of asymptomatic women. ◾ Screening of high-risk women. ◾ Follow up of patients after mastectomy of same and opposite breast / same breast with an implant ◾Investigations of benign breast diseases with eczematous skin, nipple discharge , skin thickening. ◾Investigation of a breast lump. ◾Male breast evaluation. fchs.ac.ae Mammographic requirements Ratio benefit (lives saved / deaths caused) of Mammography is 1000:1. Two types of Mammography examinations: 1. Diagnostic: Symptomatic or elevated risk. 2 views per breast + or – Additional views and Ultrasound. 2. Screening: Asymptomatic. 2 views per breast. fchs.ac.ae TYPE OF MAMMOGRAPHIC EXAMINATION ◾Diagnostic mammography Is performed on patients with symptoms or elevated risk factors. Two or three views of each breast may be required. ◾Screening mammography Is performed on asymptomatic womenwith the use of a two-view protocol, usually medial lateral oblique and craniocaudal, to detect unsuspected cancer. fchs.ac.ae MAMMOGRAPHY - BASICS ◾ Uses low-energy x-rays (40kVp) for detecting breast pathologies. ◾ Higher kV - Poor Contrast Lower kV - Good Contrast ◾ Tissues within the breast have a very small difference in attenuation property – Lack contrast ◾ 30 years old) Pregnant or lactating women Radiographically dense Very little fat 6 3 fchs.ac.ae ❖ Fibrofatty breast (Pre-Menopausal Breast): Mixture of fibro-glandular tissue + radiolucent fat 30 to 50 years Young women with three or more pregnancies Average radiographic density 50% fat and 50% fibroglandular 6 4 fchs.ac.ae ❖ Fatty Breast (Post Menopausal Breast): composed primarily of radio lucent fat ( depends on Hormone replacement therapy (HRT) use) >50 years Postmenopausal Minimal radiographic density Breasts of children and men fchs.ac.ae Digital Versus Analogue fchs.ac.ae fchs.ac.ae SCREEN FILM MAMMOGRAPHY ◾Old method ◾The image is created directly on a film-Non modifiable ◾Less sensitive for women with dense breasts ◾Screen film cassette used fchs.ac.ae DIGITAL MAMMOGRAPHY ◾Also called full-field digital mammography (FFDM) -in which the x-ray film is replaced by electronics that convert x-rays into mammographic pictures of the breast. Display Monitor - HIGH RESOLUTION (5 MP)  The stages in digital imaging : Image capture by a digital detector Conversion of late the next image into a digital data set Processing of image data Display of processed image Transmission and archival of the data set fchs.ac.ae DIGITAL MAMMOGRAPHY ◾ ADVANTAGE Better contrast, andmore details.Better delineation of parenchyma & subcutaneous tissue Better noise level reduction Tolerance to over/under exposure (Avoids Repetition? Post-processing techniques for better diagnosis Radiation dose is decreased- Mean glandular dose in mammography Screen Film (2-3m bGy) Digital (20-30% reduction) Image can be seen quickly and stored digitally (less storage space ) fchs.ac.ae LIMITATIONS OF 2D MAMMOGRAPHY ◾20% of cancers will be missed ◾10% recalled for additional workup ◾75-80% of biopsies result in benign lesions ◾sensitivity decreases with increased breast density ◾2D mammograms, take images only from the front and side, this may create images with overlapping breast tissue fchs.ac.ae ADVANCES IN DIGITAL MAMMOGRAPHY ◾Computer -Aided Diagnosis - uses software to detect areas of clinical significance and highlight them for the better output image 3D MAMM O GRAPHY ◾Digital Breast Tomosynthesis (DBT) Xray Tube rotates /moves in a 50-55° arc around the breast, capturing several (11-25) low dose projections of the breast at different angles. Then reconstructed into 3D Projection images (1 mm slices) fchs.ac.ae Introduction to 3D (Tomosynthesis) fchs.ac.ae D IGITAL BREASTTO M OSYNTHESIS - D BT (3D MAMMO GRAPHY ) 3D MAMMO GRAPHY Advantages of DBT Increased cancer detection rate Lesions are better defined Precise location of lesions Less false positive recalls Disadvantages of DBT Twice the radiation compared to 2D mammo More storage requirements Takes longer time to read Cannot be read on demand fchs.ac.ae The Density of Breasts Breast density is a term that describes the relative amount of these different types of breast tissue as seen on a mammogram. Dense breasts have relatively high amounts of glandular tissue and fibrous connective tissue and relatively low amounts of fatty breast tissue. BI-RADS Stands for Breast Imaging Reporting and Data System. Was established by the American College of Radiology (ACR). BI-RADS is a scheme for putting the findings from mammogram screening into a small number of well-defined categories. See the attached file at the email (BI-RADS) fchs.ac.ae The Density of Breasts fchs.ac.ae fchs.ac.ae fchs.ac.ae fchs.ac.ae Please watch the below Introduction to Mammography Video Introduction to Mammography fchs.ac.ae