Digital mammography: the importance of proper technique

and adequate positioning for the diagnosis of breast cancer.

Poster No.: C-1524

Congress: ECR 2017
Type: Educational Exhibit
Authors: 1 1 2
S. P. P. Ribeiro , E. Francolin , R. L. D. M. Ribeiro , M. B. D. G.
3 1 2 3
Funari ; SÃO PAULO/BR, 000/BR, São Paulo, SP/BR
Keywords: Breast, Mammography, Screening, Audit and standards, Cancer,
Quality assurance
DOI: 10.1594/ecr2017/C-1524

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Learning objectives

- Review the mammographic technical and positioning.

- Describe the main parameters used to ensure the quality of images.

- Reiterate the importance of proper placement on mammography, which implies directly

on the accuracy of the test.

Background

Mammography is the primary method for early diagnosis of breast cancer. Researches
show that mammographic screening can reduce up to 30% of specific mortality of this
malignancy (1-6).

However, the accuracy of the method is significantly reduced by low technical quality
exams. Recent data from the Breast Cancer Detection Demonstration Project show that
the false-negative rate of mammography ranges from 8 to 10%. Other retrospective
studies have concluded that the rate of missed breast cancers can reach 35%, and most
of these cases are potentially preventable(1-3; 7-9).

The main factors involved in false-negative mammograms can be classified as non-

modifiable factors (inherent to the patient, type of breast and type of lesion) and
modifiable (related to the observer and examination technique) (10-15).

• Non-modifiable factors

1. Dense parenchyma

2. Injuries outside the field of vision

3. Lesions with subtle malignancy characteristics

4. Slowly growing lesions

• # Modifiable factors

1. Failure to perceive or interpret injuries

2. Incorrect positioning

3. Inadequate techniques

Page 2 of 18
Failures in the perception or interpretation of the lesions are more difficult to overcome
because they depend on the experience of the radiologist and several other factors (12).

The false negatives attributable to improper positioning and technique can be more easily
corrected, as long as the technician and the radiologist care about the quality of the image
acquired (12).

When the quality parameters of mammography are obeyed, the accuracy of the method
increases significantly, reducing the rate of false negatives (16-18).

Having such considerations in view, the objective of this panel is to review mammographic
technique and positioning, emphasizing the main parameters used to ensure image
quality.

Technique and positioning

For proper positioning, we should keep in mind that the lower and lateral margins of the
breasts are mobile. Natural breast mobility should be used for positioning, maximizing
the amount of tissue included in the study and minimizing patient pain (19).

You should always use mammography detectors that are compatible with breast size
(18-21).

The compression of the breasts is very important for the quality of the image. Ideally, it
should be compressed until the breast is taut / stretched, but always respecting the pain
threshold of the patient (19-21).

Movement artifacts impair parenchyma analysis. The patient should be guided and the
examination should be performed as quickly as possible, minimizing movement (19-21).

Proper Positioning - Criteria

• Mediolateral oblique (MLO) view- Figure 1

1. Pectoral muscle must be visualized at the level of the papilla.

2. Greater pectoral muscle must be a convex appearance.

3. We must fully visualize prepectoral fat.

4. The inframammary fold must be open.

• Craniocaudal (CC) view - Figure 2

1. Papilla must be horizontal.

Page 3 of 18
2. Pectoral muscle must be seen in 30-40% of mammograms.

3. The distance from the papilla to the posterior border of the image in the craniocaudal
incidence should be lesser than or equal to 1 cm in relation to the line drawn between
the papilla and the great pectoral in the oblique mediolateral incidence.

Images for this section:

Page 4 of 18
Page 5 of 18
Fig. 1: Mediolateral oblique (MLO) view showing adequate positioning, characterized
by: pectoral muscle visualized at the level of the papilla, with a convex appearance; the
prepectoral fat is fully visualize prepectoral fat; the inframammary fold is open.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 6 of 18
Page 7 of 18
Fig. 2: Craniocaudal (CC) view showing adequate positioning, characterized by:
horizontal papilla; pectoral muscle is visualized; and the distance from the papilla to the
posterior border of the image in the craniocaudal incidence is lesser than 1 cm in relation
to the line drawn between the papilla and the great pectoral in the oblique mediolateral
incidence.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 8 of 18
Findings and procedure details

A retrospective study, based on the analysis of the radiologic databases of our institution
(Hospital Israelita Albert Einstein) was conducted.

We selected cases of patients seen between 2015 and 2016 at Hospital Israelita Albert
Einstein, who underwent routine mammograms and were recalled for technical failures
in mammography, whose images properly acquired resulted in the diagnosis of nodules
and calcifications before uncharacterized.

In addition, some cases of adequate positioning or with complementary incidences were

selected to exemplify the quality criteria discussed above and how to ensure complete
study of breasts in dubious cases.

Images for this section:

Fig. 3: CASE 1 - Adequate positioning: CC, MLO and magnification views: Adequate
positioning allowed the identification of amorphous calcifications in the posterior third of
the superolateral quadrant of the left breast - ACR BI-RADS® 4.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 9 of 18
Fig. 4: CASE 2 - Cleavage view: CC and cleavage views: A cleavage view is a
mammogram view that depict the posteromedial portion of both breasts (by placing them
on the detector at the same time and pulling them anteriorly). When there is doubt about
the evaluation of the medial quadrants this incidence may be helpful.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 10 of 18
Fig. 5: CASE 3 - Absolute profile view: MLO (A and B) and absolute profile views: In
A, a skin fold is observed in the axillary extension and the inframammary fold is absent,
limiting the evaluation of the parenchyma. In B, better positioning was observed, but it
was not possible to include the inframammary fold. In these cases, it is possible to choose
the absolute profile incidence, which guarantees the maximum evaluation of the lower
quadrant (C).

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 11 of 18
Fig. 6: CASE 4 - Inadequate detector: CC and MLO views: The use of a small detector
resulted in the exclusion of breast tissue in the superolateral quadrant (A), which was
corrected using an adequate detector (B).

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 12 of 18
Fig. 7: CASE 5 - Inadequate detector: MLO views: The use of small detector resulted in
the exclusion of axillary regions (A), which was corrected using appropriate detector (B).

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Fig. 8: CASE 6: Positioning mistake: unseen nodule: In A, a skin fold extends from
the axillary tail to the lower quadrants. In B, the correct positioning allowed the
characterization of an oval, isodense and obscured nodule in the posterior third of the
superior quadrant, with 2.0 cm, solid in the ultrasound (C).

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

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Fig. 9: CASE 7: Positioning mistake: unseen nodule with calcification: In A, the
inframammary fold was not included and the pectoral muscle did not reach the level of the
papilla. In B, repetition of the incidence resulted in the characterization of a nodule with
gross calcification in the lower quadrants. In C, ultrasound demonstrates a solid nodule
on the same topography.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 14 of 18
Fig. 10: CASE 8: Positioning mistake: unseen steatonecrosis area: CC and MLO views:
In A, inferiorly oriented papilla is observed. Correction of the positioning allowed the
characterization of a focus of steatonecrosis in the posterior third of the junction of the
medial quadrants.

© HOSPITAL ISRAELITA ALBERT EINSTEIN, HOSPITAL ISRAELITA ALBERT

EINSTEIN - SÃO PAULO/BR

Page 15 of 18
Conclusion

Proper placement on mammography implies directly on the accuracy of the test. The
knowledge of the mammographic image quality parameters is essential for technicians
and radiologists. The reconvening of the patient is mandatory in cases of technically
deficient exams, as this reduces the chance of false negatives.

Personal information

S. P. P. Ribeiro; E. Francolin; R. L. D. M. Ribeiro; M. B. D. G. Funari.

Department of Radiology, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701
- CEP 05652-900, São Paulo/SP, Brasil.

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