MAMMOGRAPHY

POSITIONING
CHALLENGES
 1.NIPPLE PROFILE PROBLEMS
• Nipple is the only natural breast landmark from
which measurements can be made to indicate
precise lesion location
• A mammogram is considered acceptable as long as
the nipple is projected in profile on one of the two
routine images.
• A nipple that is not imaged in profile presentation
can produce a deceiving appearance on the
mammogram and it may be mistaken for a mass or it
may obscure an underlying mass.
• When it is not possible, an additional anterior
view should be obtained to demonstrate the
nipple and retroareolar structures in a profile
projection.
• It is advisable to clearly mark the film as nipple
not in profile or nipple out of profile, to
alleviate misinterpretation and facilitate follow
up.
 2.FLACCID, PANCAKE BREASTS
• Flaccid breasts that are composed of a little
more than loose skin are extremely difficult to
image free of wrinkles and skin folds,
particularly in the axillary area.
• Its important to be conscious of this and make
every effort to smooth the inferior and
superior tissues as you position the breast on
the image receptor.
• The greatest challenge is during breast
compression, as the compression paddle will
encounter hands long before it is close to the
breast tissue.
• A rubber spatula may be helpful to hold the
tissue in position until the compression paddle
is close enough to secure the patients breasts
in the desired position.
 3.LARGE BREASTS
• Modern equipment comes with two sizes of image
receptors to allow imaging of small, average and large
sized breasts adequately and efficiently.
• Always select the appropriate size of image receptor in
order that all the breast tissue can be included on
each mammography view
• When compression is applied, breast tissue spreads
out, therefore, the breast that just fits on the image
receptor as positioning begins may require a larger
film size once compression has been applied
• Occasionally some large breasts may require imaging in
overlapping sections, the volume of breast may be difficult
to control and position with only one hand
• Often routine positioning protocols may be difficult to
follow, keep in mind the principle of demonstrating all the
breast tissue, one can proceed in a systematic fashion to
cover the entire breast in overlapping sections
• Some images may not include natural landmarks, it is
extremely important to maintain the correct axillary
placement of markers to assist in correct piecing the
examination together.
 4.SMALL BREASTS
• Small breasted women are frequently very slim (not
always the case), they may find mammography positioning
uncomfortable due to a deficiency of fatty tissue which
can act as a cushion and provide padding along their ribs
and thorax.
• Their breasts may be difficult to ease forward onto the
image receptor, despite every conceivable effort, as well as
demonstration of the pectoralis muscle on the MLO view
may be very difficult.
• There are two factors not to be compromised for these
patients:
• 1. Achieve relaxation in the patients shoulder
and pectoral area- essential to ease the breast
tissue forward onto the image receptor.
• Encourage patient to slouch, and roll
shoulders forward, drawing shoulders
together as much as possible, this will help the
breast tissue to fall forward and away from the
chest wall
• 2. Maintain a very firm hold on the tissue, keeping it
against the receptor until the compression paddle has
secure its position.
• Releasing the breast too early will allow the breast to slip
back against the chest wall, a rubber spatula may be
used to hold the tissue in position until the compression
paddle is close enough to secure the patients breast
• Careful attention to these two factors will result in a
successful examination for the majority of small breasted
patients.
 5.AUGMENTED BREASTS
• Mammography of augmented breasts can be difficult and the
presence of breast implants interferes with ideal evaluation
of breast tissue.
• Visualization of breast tissue is compromised due to the
physical presence of implant
• Additional mammography projections(90degrees lateral view,
etc)can provide multiple tangential views of the natural
breast tissue surrounding the implant
• A modified positioning technique called implant displacement
(ID) has been developed to improve visualization of the
natural breast tissue in patients with implants.
6.DEFORMITIES OF THE STERNUM
• 1. Pectus Excavatum (Depressed Sternum, Sunken Chest)
– primary concern on these patients relates to adequate
coverage of the medial breast tissue that extends along
the ribs as they curve inward, toward the sternum.
• The most thorough coverage can be achieved with two
overlapping CC views, one exaggerated medially ( to
include tissue adjacent to medial ribs and sternum over
to the nipple area) and one exaggerated laterally (to
include tissue adjacent to the lateral ribs, over to the
nipple area)
• Both images to include nipples and maintain
standard axillary placement of markers to
provide appropriate orientation of the images
for the radiologist.
• 2. Pectus Carinatum ( Pigeon Chest, Barrel
Chest)-
characterised by a protruding sternum,
creating a very rounded, barrel like thorax.
Modification of technique will also be necessary.
 7.DEFORMITIES OF THE SPINE
• 1. Kyphosis – these patients can be physically
unable to straighten up and stand erect with
their shoulders back.
• These present problems relating to
superimposition of their shoulders, neck and
upper thorax over the breast area
• 2. Scoliosis- condition characterised by lateral
curvature of the spine.
• The challenge is to image the breast tissue as
it follows the abnormal contour of the rib
cage
• According to the severity of the abnormality
with an individual patient, mammography may
follow a completely normal protocol or they
may require significant alteration.
 8.DIFFICULT TO POSITION PATIENTS
• Always attempt to obtain the best possible images on
these patients
• These may not only present a positioning challenge but
also creates an overlying sense of frustration
• Patient may share this frustration, along with an acute
sense of embarrassment
• It will be better and productive to focus on what can be
done
• A positive constructive approach is important to
maintain the trust and cooperation of the patient.
• 1. Patients in wheelchairs
• Two factors to consider:
• - general mobility of the patient, some patients may be able
to stand unassisted for a limited time, so its crucial to assess
first.
• However never compromise their safety
• - ability to remove the side arms of the wheel chair will have
a major impact on the success of the examination.
• Remove one arm at a time to allow them to support on the
other and for security, pillows may be used to support the
patient as you lean them forward on the chair
• 2. Patients on stretchers
• Mammography for these patients are very
time consuming and often awkward, they are
not technically difficult.
• Some patients can seat with their legs over
the side of the stretcher
• If not able to seat, roll them onto side
opposite to the side being imaged
 9. MALE MAMMOGRAPHY
• Only performed when a clinical abnormality has been
detected
• It is crucial for the radiographer to conduct
themselves in a professional, competent manner
when performing a male mammography.
• Many men are extremely self conscious and
embarrassed in this situation, a compassionate and
understanding radiographer can facilitate the
examination and make the situation as comfortable as
possible for the patient.