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CHAPTER 8

CHAPTER 8. The Nonconforming Patient. PHYSICAL NONCONFORMITY. Everyone is different! Small percentage do not physically conform to two-projection mammogram Modification and/or extra views may be necessary Positioning is more an art than exact science. DETERMINING THE BEST VIEW.

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CHAPTER 8

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  1. CHAPTER 8 The Nonconforming Patient

  2. PHYSICAL NONCONFORMITY • Everyone is different! • Small percentage do not physically conform to two-projection mammogram • Modification and/or extra views may be necessary • Positioning is more an art than exact science

  3. DETERMINING THE BEST VIEW • Many anomalies to body habitus • Extra view should demonstrate breast tissue omitted from standard two views • Each view should complement the other views • Learn to evaluate mammogram to determine from which quadrant(s) tissue is missing • Be familiar enough with supplementary projections to choose the most suitable view to complete study

  4. Barrel chest Pectus excavatum Kyphoscoliosis “Wraparound” breasts Male mammograms Postmastectomy NONCONFORMING SITUATIONS • Base of attachment • Wide pedicle • Thin pedicle • Small-breasted • Large-breasted • Obese

  5. BASE OF ATTACHMENT

  6. WIDE PEDICLE • Wide base of attachment, firm breasted, mobility problem • CC view – extreme posteromedial tissue • MLO view – extreme posterolateral tissue • Additional CC view – possible for anterior tissue • Use compression paddles with tilt design • LM, SIO, SIO with arm up and over, and/or 20° MLO views should be considered

  7. THIN PEDICLE • Skin at the IMF may be delicate and requires careful handling • Use caution in elevating the IMF • Use of pad helps “soften” the breast platform • Possible skin breakdown due to moisture buildup, constant chafing, and possible fungal infection • May need to add 3rd projection of ML or LM for anterior tissue

  8. THIN PEDICLE

  9. THIN PEDICLE

  10. SMALL-BREASTED • Breasts may be quite firm, have wide base, or extend more laterally than medially • May be impossible to image extreme posterior breast tissue • Raise image receptor to correct IMF height

  11. LARGE-BREASTED • Obesity does not equal breast size • Choose imaging surface that correlates to breast size • May require a 3rd view to demonstrate anterior breast • Mosaic imaging • 20° MLO, true ML or LM

  12. LARGE-BREASTED

  13. OBESE PATIENT • Evaluate breast size, not patient size • Choose appropriate size image receptor • Many obese women are small-breasted

  14. BARREL CHEST (PIGEON BREAST) • Chest wall excessively protrudes outward • Breast will extend laterally under the arm

  15. BARREL CHEST

  16. BARREL CHEST

  17. BARREL CHEST

  18. BARREL CHEST

  19. PECTUS EXCAVATUM • Sunken chest (sternum and rib cage)

  20. PECTUS EXCAVATUM • CC view, capture as much medial tissue as possible

  21. PECTUS EXCAVATUM • MLO view to image the posterolateral tissue

  22. PECTUS EXCAVATUM • SIO view to image the extreme medial tissue (may also use LM view)

  23. PATIENT WITH KYPHOSCOLIOSIS • “Hunched-back,” vertebral deformity • Possible rib cage deformity • Possible pectus excavatum or barrel chest or combination of both • Deformity may not be symmetrical from side to side • Allow patient to sit down for CC view • Resourcefulness is the key in positioning

  24. “WRAPAROUND” BREASTS • Breast extends excessively laterally into axilla • Extreme lateral tissue may be impossible to image with standard views • Include one of the following for posterolateral tissue: • 20° MLO (SM-IL) • LM • SIO with arm up and over

  25. MALE MAMMOGRAM • Small, firm-breasted exam • Chest hair may cause breast tissue to slip • Critical to include nipple in profile • Pathology is located directly posterior to the nipple

  26. CANCER PATIENT • Issues to complicate the examination • Physical irregularity • Existing discomfort from treatment • Patient’s emotional and psychological state • Fear of the unknown

  27. CANCER PATIENT • Patients with history of breast cancer • Increased risk of developing cancer in contralateral breast • Usually a primary, not metastases • No longer possible to make comparison of tissue between breasts • A three-view study gives radiologist a better opportunity to diagnose a new malignancy

  28. CANCER PATIENT • Architectural distortion on CC view

  29. CANCER PATIENT • Architectural distortion on MLO view

  30. CANCER PATIENT • Architectural distortion on 20° MLO view

  31. POSTMASTECTOMY PATIENT • Early detection of recurrence will have impact on patient’s survival • Physically occult recurrence evident along chest wall, in the axilla, and along lateral ribs • Three views can be performed as a Standard of Care • Examine prior mammograms to note characteristics of original tumor

  32. POSTMASTECTOMY PATIENT

  33. POSTMASTECTOMY PATIENT

  34. BREAST CANCER PATIENT

  35. BREAST CONSERVATION THERAPY (BCT) • Lumpectomy • BCT with radiation therapy • BCT without radiation therapy

  36. SEARCH FOR PRIMARY CARCINOMA • Is an undifferentiated tumor found elsewhere the result of metastases from an occult breast cancer? • To determine, mammogram should include: • CC view • MLO (SM-IL) • Bilateral axilla views • 20° MLO, if dense glandular tissue

  37. SUSPECTED INFLAMMATORY CARCINOMA • May be difficult to differentiate between infection and inflammatory carcinoma • Clinical indications of inflammatory breast cancer • Reddened skin • Hard, hot breast • Peu d’orange appearance of skin • Axillary nodal involvement

  38. SUSPECTED INFLAMMATORY CARCINOMA • Mammography study should include: • CC view • MLO view • Axilla view on affected side

  39. IMAGING RECONSTRUCTED BREAST

  40. IMAGING RECONSTRUCTED BREAST

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