Digital Mammography

A mammogram is a radiographic examination showing the morphology and structure of the anatomical elements of the breast tissue and any pathological lesions it may present. Today, three decades after the initial implementation of mammography in preventing breast cancer, it continues to be the method of choice for the early diagnosis of the disease.

The mammography technique

Throughout the examination specialized assistance is given to women reassuring the correct position and posture until the end of the mammographic process.

The examination lasts about 5 minutes.

Women are asked to undress above the waist and put on a gown. The examinee stands in front of the machinery.

During the examination the assistant radiologist places each breast between two special plates receiving gentle pressure for a few seconds.

A total of four images are taken during the examination, two for each breast.

While each image is taken, the examinee should hold her breath for a few seconds in order to perceive maximum image sharpness.

The reliability of mammography

Physical and technical specifications of mammography

In order for mammography to be a reliable examination it should be technically perfect. The radiologist should be trained in the assessment of breast diseases correctly implementing examination study standards. According to literature an experienced radiologist who interprets a greater number of mammographies achieves a higher diagnostic accuracy.

Moreover, in accordance with EU guidelines, apart from specializing in breast diseases, radiologists are responsible for the excellent quality and technique of mammographies. Technologists (assistant radiologists), who must have specific knowledge regarding the technical aspects of mammography, are responsible for the proper functioning of the mammography units.

Criteria for the quality assessment of mammography

Under EU guidelines, the criteria for the quality assessment of mammographies are:

  • Proper placement of the breasts on the mammography unit to allow the inclusion of the entire breast, the sub mammary fold (fold below the breast), the axillary area and a part of the pectoral muscle on the mammography field.
  • The images must be symmetrical and very sharp.
  • The appropriate pressure must be performed to the breasts.
  • There should be no skin folds and the shoulders, lower jaw, hair, the abdomen or foreign objects such as jewellery, belts and other items should be excluded from the examination field.
  • Each breast should be properly included on the image and the examinee’s details should be correct.

Coding of results

For the better cooperation between radiologists and clinicians, which leads to a greater benefit for the patients, the results of mammograpies are coded. This coding started at the American College of Radiology (ACR), which introduced the Breast Imaging Reporting and Data System with the code (BI-RADS ®), being the result of collaboration of the ACR, the National Cancer Institute (NCA), the Center for Disease Control and Prevention, the Food and Drug Administration, the American Medical Association, the American College of Surgeons and the College of American Pathologists.

The results of each mammogram bear a code that depending on what is written is interpreted as:

BI-RADS 0: Assessment is incomplete. Further imaging examinations are needed.

BI-RADS 1: Negative mammogram.

BI-RADS 2: Benign findings.

BI-RADS 3: Probably benign findings, a deviation of 2% may concern lesions representing malignancy.

BI-RADS 4: Findings with a probability of malignancy (3-94%). Further investigation with a biopsy is necessary.

Category 4 is divided into 4a, 4b and 4c.

Category 4a includes lesions that have morphological characteristics that are suggestive of benign causes (degenerating fibroadenomas, complicated cysts).

Category 4b includes lesions that have a higher suspicion of malignancy. A histological examination is necessary.

Category 4c includes lesions that have morphological characters even more suspicious of malignancy. The lesion is further investigated with a biopsy.

BI-RADS 5: Findings with typical malignant characters. Further management is necessary.

BI-RADS 6: Malignant lesions confirmed by histological examination.

The special images taken

If a more thorough and detailed analysis of the breast is necessary, a further mammographic analysis is carried out by the technologist. In diagnostic solving cases an ultrasound is performed. The results of the images are interpreted by the radiologists and if the lesion remains suspicious, a further investigation with biopsy is indicated.

Management in the case of a negative mammogram and a positive clinical finding

There are cases where a woman presents with some clinical finding, such as palpable lump or palpable stiffness, but these findings are not detected on the mammography meaning that the examination results are interpreted as negative. Indeed, if this palpable finding is obscured on mammography due to high breast density but conceals a malignancy, then the consequences for the examinee can be hazardous. To avoid such devastating mistakes, a key requirement is to strictly follow the basic steps in the diagnostic approach and establish a close cooperation between the examinee and the team of experts who monitor the patient.

Specifically, all women should define the reason for their visit and should not rely only on the negative diagnosis of the mammogram. The radiologist should complete the imaging evaluation with an ultrasound and, regardless of the outcome of the examination, if there is a clinical finding, must refer the examinee to a clinician for further evaluation.

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