Mammography – Chapter 8 17-Feb-20

Mammography - Chapter 8

a copy of this lecture may be found at:

http://courses.washington.edu/radxphys/PhysicsCourse.html

1. Introduction

 Mammography is a radiographic modality used for detecting breast

pathology and cancer
 Approximately 1 in 8 women will develop breast cancer over a
lifetime in USA
 Breast cancer accounts for 32% of cancer incidence and 18% of
cancer deaths in women in the United States
 Breast cancer screening - depend on x-ray mammography because
it is a low-cost, low-radiation-dose procedure that has the sensitivity
for early detection and improved treatment
 In 1992, the federal Mammography Quality Standards Act (MQSA)
came into existence to ensure that all women have access to quality
mammography with optimal patient care and follow-up

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1. Introduction
Continuing refinements in technology have vastly improved mammography
over the last 15 years

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 192. 3

1. Introduction
 Mammographic features characteristic of breast cancer are:

Mass with Clustered

Spiculated heterogeneous Architectural
margins microcalcifications distortion
c.f. Pictorial Essay : Mammographic Features of Breast Cancer, MB Popli, Ind J
Radiol Imag 2001 11:4:175-179 4

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1. Introduction
 Screening Mammography – Identify
Cancer
 the AMA, ACS and ACR recommend
a baseline mammogram by age 40,
biannual examinations between ages
40 and 50, and yearly examinations
after age 50
 NCI recommends women in their 40s,
50s and older should be screened
every one to two years with
mammography
 Require craniocaudal (CC) and
mediolateral oblique (MLO) views of CC MLO
each breast

1. Introduction

 Diagnostic Mammography –
Evaluate Abnormalities
 may require additional
views, magnification views,
spot compression views,
stereotactic biopsy or other
studies using other
modalities

c.f. Radiographics 19 (2): 280

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1. Mammography Imaging Modalities

 Ultrasound Breast Imaging

 used for differentiating cysts (typically benign) from solid
masses (often cancerous), which have similar appearances
on the mammogram
 provides biopsy needle guidance for extracting breast tissue
specimens

 MRI
 has wonderful tissue contrast sensitivity
 useful for evaluating silicone implants
 accurately assess the stage of breast cancer involvement
UW - Dr. Constance
Lehman
7

1. Modern Mammography

 Breast is composed of fatty tissue, glandular tissue and a 50/50

combination of both
 Normal and cancerous tissues in the breast have small x-ray
attenuation differences between them and this difference decreases
with increasing energy
 Need x-ray equipment specifically designed to optimize breast
cancer detection
c.f. Bushberg, et al. The Essential Physics of Medical
Imaging, 2nd ed., p. 193. 8

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1. Modern Mammography

 Detection of minute calcifications important

 high correlation of calcification patterns with disease

 Best differential between the tissues is obtained at low x-ray

energies
 However, the high absorption results in a high tissue dose and
long exposure time

 Mammography equipment
 Low contrast sensitivity

 high resolution

 low dose

1. Modern Mammography

 Dedicated Mammography
Equipment

 Specialized X-ray Tubes

 Breast Compression
Devices

 Optimized Screen/Film
detector systems

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 194.
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1. X-Ray Tube Design

 0.3 mm (contact) and 0.1 mm (magnification) focal spot sizes

 Small focal spot minimizes geometric blurring and maintains
spatial resolution
 Peak Kilovolt below 35 kVp
 100 mA for large (0.3 mm) focal spot
 25 mA for small focal spot

 Anodes: Molybdenum (Mo), and dual track Mo/Rhodium

(Mo/Rh) targets are used
 Targets used in combination with specific tube filters to achieve
optimal energy spectra

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1. X-Ray Tube Design

Self-filtration

 Heel effect – significant drop in x-ray intensity on the anode side

of the field (self-filtration through anode)
 Thus cathode-anode axis is placed from the chest wall (greater
penetration of x-rays) to the nipple in breast imaging
 More uniform exposure is achieved
 Also minimizes equipment bulk near the patient’s head for easy
positioning
c.f. Bushberg, et al. The Essential Physics of Medical
Imaging, 2nd ed., p. 196.
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1. Tube Port, Tube Filtration & Beam Quality

 Monoenergetic x-rays of 15 to 25 keV are optimal choice to achieve
high subject contrast at lowest possible radiation dose

 Polychromatic spectra compromises:

 High-energy x-rays in the bremsstrahlung spectrum diminish
subject contrast
 Low-energy x-rays in the bremsstralung spectrum have inadequate
penetration and contribute to patient dose without providing a
useful image

 Optimal x-ray energy is achieved by use of specific target materials

and filters to remove the low- and high-energy x-rays

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1. Tube Port, Tube Filtration & Beam Quality

Molybdenum (Mo) and Rhodium (Rh) are used for mammography

targets and produce characteristic x-ray peaks at 17.5 and 19.6 keV
(Mo) and 20.2 and 22.7 keV (Rh)
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1. Tube Port, Tube Filtration & Beam Quality

 1-mm thick Beryllium used as the tube port
 Beryllium provides both low attenuation and good structural
integrity

 Added tube filters of the same element as the target reduce the
low- and high-energy x-rays in the x-ray spectrum and allow
transmission of characteristic x-ray energies

 Common target/filters in mammography include

 Mo/Mo

 Rh/Rh

 Mo/Rh

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1. Tube Port, Tube Filtration & Beam Quality

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1. Tube Port, Tube Filtration & Beam Quality

 A Mo target with Rh filter is
used for imaging thicker
and denser breasts since
this produces slightly
higher effective energy than
Mo/Mo

 20 - 23 keV effective
energy leading to increased
penetration of thick and/or
dense breasts

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1. Tube Port, Tube Filtration & Beam Quality

 Rh target with Rh filter provides the highest effective energy beam

and is useful for the thickest and densest breasts
 Tungsten (W) targets with Mo and Rh filters not usually used but
sometimes are available with the mammography unit

c.f. Bushberg, et al. The Essential Physics of Medical Imaging, 2nd ed., p. 201.
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1. Half Value Layer (HVL)

 The HVL ranges from 0.3 to 0.45 mm Al in mammography

 depends on kVp, compression paddle thickness, added tube
filtration, target material and age of tube
 In general, HVL increases with higher kVp and higher atomic
number targets and filters

 The approximate HVL in breast tissue is ~ 1 to 2 cm (strongly

dependent on tissue composition: glandular, adipose and
fibrous).
 Thus a 4cm breast will attenuate 1-1/24  0.93, or 93% of the
incident primary radiation
 [reduction in beam intensity or fraction transmitted is 1/2n
and attenuation is (1-1/2n)]

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1. Collimation

 Fixed-size metal apertures or variable field size shutters

collimate the x-ray beam
 The field size matches the film cassette sizes
 18 x 24 cm or 24 x 30 cm

 Collimator light and mirror assembly define the x-ray field

 X-ray field – light field congruence must be within 2% of SID
for any edge
 The useful x-ray field must extend to the chest wall edge
without field cutoff

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2. X-Ray Generator

 A dedicated mammography x-ray generator is similar to a

standard x-ray generator in design and function with some minor
differences.
 Generator power rating is 3-10 kW

 The voltage supplied to the x-ray tube (22-40 kVp),

 Automatic Exposure Control (AEC) circuitry different

 High-frequency generators are the standard for mammography

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2. Automatic Exposure Control (AEC)

 The AEC, also called a phototimer, uses a radiation sensor (or
sensors), an amplifier, a voltage comparator, to control the exposure

 AEC detector is located underneath the cassette in mammography

unlike conventional radiography

c.f. Bushberg,
et al. The
Essential
Physics of
Medical
Imaging, 2nd
ed., p. 205.

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2. Automatic Exposure Control (AEC)

 If the transmission of photons is insufficient to turn the exposure

off after an extended exposure time, a backup timer terminates
the exposure
 For a retake, the operator must select a higher kVp for
greater beam penetrability and shorter exposure time

 Inaccurate phototimer response can be caused by

 Breast tissue composition heterogeneity, defective cassette,
faulty detector, inappropriate kVp setting etc.

 Film response to very long exposure times (MAG mode) results

in reciprocity law failure and inadequate film density

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2. Technique Chart

 Technique charts are useful guides to determine the appropriate kVp

for specific imaging tasks, based on breast thickness and breast
composition
 posted near the console

 Proper kVp is essential for a reasonable exposure time, defined as a

range from approx. 0.5 to 2.0 seconds, to achieve an optical density
of 1.5 to 2.0

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3. Compression

 Breast compression is necessary

 it reduces overlapping anatomy and decreases tissue thickness
of the breast
 less scatter, more contrast, less geometric blurring of the
anatomic structures, less motion and lower radiation dose to the
tissues

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 208.
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3. Compression
 Use a low attenuating lexan paddle attached to a compression
device
 10 to 20 newtons (22 to 44 pounds) of force is typically used
 A flat, 90°paddle (not curved) provides a uniform density image
 Parallel to the breast support table
 Principal drawback of compression is patient discomfort

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 208.
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3. Compression

c.f. Bushberg, et al. The

Essential Physics of Medical
Imaging, 2nd ed., p. 208.

Spot compression uses small paddles

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3. Scatter Radiation

 Scatter radiation degrades

subject contrast
 The amount of scatter
increases with breast
thickness and breast area,
and is relatively constant
with kVp (25-35 kVp)
 Without scatter rejection,
only 50 to 70% of the
inherent subject contrast will
be detected

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 209.

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3. Scatter Radiation

 Linear grids with a grid ratio of 4:1 to 5:1 are typical

 Aluminum and carbon fiber are typical interspace materials
 Carbon fiber is preferred – lower attenuation

 Grid frequencies (lead strip densities) range from 30 to 50 lines/cm

for moving grids and up to 80 lines/cm for stationary grids
 Bucky factor (with grid/without grid) is about 2 to 3, so breast dose is
doubled or tripled, but image contrast improves by 40%
 Grids not used in magnification, air gap used

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 209.

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3. Magnification

 Advantages
 Magnification of 1.5x to
2.0x is used
 Increased effective
resolution of the image
receptor by the
magnification factor
 Small focal spot size used

 Reduction of scatter

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 211.
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3. Magnification


 Disadvantages
 Geometric blurring caused
by the finite focal spot size
(more on cathode side)
 Breast dose in general
similar to contact
mammography
 Long exposure times (small
focal spot, low mA)
 patient motion and blur

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 211.
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3. MTF in magnification mammography

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 211.
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Take Home Points

 Breast Cancer – masses, microcalcifications and architectural

distortions in breast
 Low energies used to optimize contrast (photoelectric effect)
 Specialized equipment needed
 Improve contrast and resolution, decrease dose

 kVp range 22- 40 kVp

 Molybdenum and Rhodium targets used in mammography
 Characteristic radiation for Mo at 17.5 and 19.6 keV

 For rhodium, 20.2 and 22.7 keV

 Heel effect due to attenuation in target

 Chest wall on cathode side and nipple on anode side to get
uniform exposure

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Take Home Points

 Common target/filters in mammography include

 Mo/Mo (thin breasts), Rh/Rh (thickest, dense breasts), Mo/Rh
(thicker, denser breasts)
 Tungsten target available on some units but not used

 Generator similar to conventional radiography except for

 lower power rating, different AEC circuitry, low kVp used

 18 x 24 and 24 x 30 cm cassettes used

 AEC detector is located underneath the cassette in mammography
unlike conventional radiography

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Take Home Points

 Breast compression is necessary

 reduces overlapping anatomy, decreases tissue thickness of the
breast, less scatter, more contrast, less motion and lower
radiation dose to the tissues
 Scatter reduced by grids
 5:1 grid ratio

 Bucky factor of 2 to 3

 Magnification of 1.5 to 2 times in mammography

 Increased resolution, decreased scatter, increased dose, long
exposure times, motion, increase in geometric blur with
increased magnification

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4. Screen/Film Cassettes

 Cassettes have a single phosphor

screen and single emulsion film

 Mammography screen-film speeds

(sensitivity):
 regular (100 or par speed) (12-
15 mR required)
 medium (150 – 190 speed)

 For comparison, a conventional

“100-speed” screen film cassette
requires about 2 mR

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4. Screen/Film Cassettes

 Limiting spatial
resolution is =
15-20 lp/mm
(0.025 - 0.030
mm object size)

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 214. 37

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4. Film Processing

 Film processing is a critical step in the mammographic imaging

chain

 Consistency in film speed, contrast, optical density levels are readily

achieved by following the manufacturer’s recommendations

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4. Film Sensitometry

 A film processor quality control program is required by

Mammography Quality Standards Act of 1992 (MQSA) regulations,
and daily sensitometric strips prior to the first clinical images must
verify acceptable performance

 Film sensitometry confirms proper film contrast, speed and base +

fog values of mammographic film
 Typical fog values are 0.17 – 0.2 OD, Dmax = 3.8 – 4.0 OD and
the target film OD ranges from 1.2 – 1.8

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4. Film Sensitometry

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 216.
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4. Film Sensitometry

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 216.
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4. Extended Cycle Processing

 Extended cycle processing (or push processing) increases the

speed of some single emulsion mammography films by
extending the developer immersion time by a factor of two
(usually from ~ 20 to ~ 40 seconds)
 The rationale is to completely develop all latent image centers,
which does not occur with standard processing

 Up to 35% to 40% decrease in required x-ray exposure is

obtained compared to standard processing for same OD
 On conventional 90 second processor, the processing time is
extended to 180 seconds

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4. Extended Cycle Processing

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 218.
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4. Film Viewing Conditions

 Optimal film viewing conditions are important in detecting subtle

lesions
 Mammography films are exposed to high optical densities to
achieve high contrast, view boxes providing a high luminance are
necessary

 The luminance of a mammography viewbox should be at least

3000 cd/m2
 In comparison, a typical viewbox in diagnostic radiology is about
1500 cd/m2

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4. Film Viewing Conditions

 Film masking is essential for blocking clear portions of the film

and the viewbox

 The ambient light intensity in a mammography reading room

should be low to eliminate reflections from the film

 A high intensity bright light to penetrate high optical density

regions of the film, such as skin line and the nipple area

 Magnifying glass should be available to view fine detail such as

microcalcifications

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Question

 1. Which of the following is not a modern mammography target/filter

combination for screen-film?

 A. Mo/Mo
 B. Mo/Rh
 C. Rh/Rh
 D. W/Al
 E. W/Rh

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Question

 1. The K-characteristic x-rays of molybdenum target tubes comprise

a significant portion of the total x-ray flux. These x-rays have
energies predominantly between _________ keV and _________
keV

 A. 10, 12
 B. 15, 16
 C. 17, 20
 D. 24, 26
 E. 59, 69

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Question

 1. The filtration in mammography units primarily transmits the

characteristic x-rays. The very low-energy bremsstrahlung x-rays
are filtered because they contribute to ___________, and the higher
energy bremsstrahlung x-rays are filtered because they contribute to
_______________.

 A. tube heating, off-focus radiation

 B. heel effect, focal spot blooming
 C. radiation dose, loss of contrast
 D. grid cut-off, septal penetration
 E. coherent scatter, K-edge photons

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Question

 1. The low voltage used in screen/film mammography reduces:

 (A) Subject contrast

 (B) Dose
 (C) Microcalcification visibility
 (D) Scatter
 (E) Film processing time

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5. Radiation Dosimetry

 Risk of carcinogenesis from the radiation dose to the breast is of

concern thus monitoring of dose is important and is required yearly
by MQSA (Mammography Quality Standards Act of 1992)

 Indices used in Mammography

 Entrance Skin Exposure (ESE)

 the free-in-air ionization chamber measurement of the

entrance skin exposure of the breast
 typical ESE values for a 4.5 cm breast are 500 to 1000 mR

 Half Value Layer (HVL)

 Typical HVL from 0.3 to 0.4 mm Al for 25 – 30 kVp

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5. Radiation Dosimetry

 Glandular tissue is sensitive to cancer induction by radiation

 Average Glandular Dose

 Dependent on the composition of breast, breast thickness,
HVL and kVp of beam
 The Roentgen to Rad conversion factor, DgN is used to
convert the measured ESE to glandular dose
 Dg = DgN x XESE

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5. Radiation Dosimetry

 Factors affecting breast dose

 Higher kVp increases beam penetrability (lower ESE and lower
average glandular dose), but decreases inherent subject
contrast
  kVp and  mAs will result in low dose because of greater
penetrability (use higher kVp)

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 223.
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5. Radiation Dosimetry

 Factors affecting breast dose

 Increased breast thickness requires increased dose

 Vigorous compression lowers breast dose by reducing thickness

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 224.
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5. Radiation Dosimetry

 Variables impacting breast dose

 Rh/Rh combination will result in lowest average dose,
followed by Mo/Rh and Mo/Mo (use Rh for thicker, denser
breasts)
 Screen/film speed and film processing conditions (use faster
screen film or digital detectors)

 Higher OD target on film will  dose

 Use of a grid will  dose

 Tissue composition of the breast

 Glandular tissue will have higher breast dose due to
increased attenuation and a greater mass of tissue at risk

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5. Radiation Dosimetry

 The MQSA limits the average glandular breast dose to 3 mGy or

300 mrad per film for a compressed breast thickness of 4.2 cm and
a breast composition of 50% glandular and 50% adipose tissue
(using the MQSA approved mammography phantom)

 If the average glandular dose for this phantom exceeds 3 mGy,

mammography cannot be performed

 The average glandular dose for this phantom is typically 1.5 to 2.2
mGy per view or 3 to 4.4 mGy for two views for a film optical density
of 1.5 to 2.0

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5. Risks and Benefits

 Based on AGD of 3 mGy, the increased breast cancer risk from

radiation is 6 per million examined women
 This is equivalent to dying in an accident when traveling 5000 miles
by airplane or 450 miles by car
 Screening in 1 million women is expected to identify 3000 cases of
breast cancer
 The breast cancer mortality rate is about 50%
 Screening would reduce the mortality rate by about 40%
 That would potentially mean 600 lives being saved due to screening
 The benefits of getting a mammogram far outweigh the risks
associated with the radiation due to the mammogram

c. Huda. Review of Radiologic Physics, 2nd ed., p. 112-113.

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Take Home Points

 Single-screen and single emulsion film used

 15-20 lp/mm resolution

 Film processing is very important

 A film processor quality control program is required by
Mammography Quality Standards Act of 1992 (MQSA) regulations
 The luminance of a mammography viewbox should be at least 3000
cd/m2
 Glandular tissue is sensitive to cancer induction by radiation

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Take Home Points

 Average glandular breast dose limited to 3 mGy or 300 mrad per film
for a compressed breast thickness of 4.2 cm, 50/50
glandular/adipose breast composition
 Increasing kVp reduces dose

 Increased breast size increases dose

 Vigorous compression lowers breast dose by reducing thickness

 Risk of mammogram induced breast cancer is far less than the risk
of developing breast cancer

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6. Stereotactic Breast Biopsy

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 220, 305.

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6. Stereotactic Breast Biopsy

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 220.
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7. Full-Field Digital Mammography (FFDM)

c.f. www.gehealthcare.com/rad/xr/education/dig_xray_intro.html

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7. Full-Field Digital Mammography (FFDM)

 Advantage
 Wide dynamic range
(1000:1) compared with
SFM (40:1)
 Dynamic image
manipulation
 Ability to post-process

 Soft-copy read
accompanied by computer-
aided-diagnosis (CAD)
 3D imaging

Radiographics 2004:24,1749 62

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7. Full-Field Digital Mammography (FFDM)

 Advantage
 Each component of the mammographic process can be
optimized with digital mammography

Radiographics 2004:24,1750 63

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7. SFM vs. FFDM

SFM: Half mAs, Automatic exposure control, Double mAs

FFDM: Same technique factors as SFM, W/L adjusted

Radiographics 2004:24,1750 64

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7. SFM vs. FFDM

Radiographics 2004:24,1751 65

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7.Technologies for FFDM

 Indirect Capture
 a scintillator such as cesium
iodide (CsI) absorbs x-rays
and generates a light
scintillation
 detected by an array of
photodiodes or charge-
coupled devices (CCDs)
 Resolution degradation

http://www.hologic.com/wh/pdf/R-LM-016_Radiology_Management.pdf 66

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7. Technologies for FFDM

 Direct Capture
 X-ray photons are directly
captured by a
photoconductor such as
amorphous selenium (a-
Se), which converts the
absorbed x-rays directly to a
digital signal
 Spatial resolution limited to
pixel size

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7. Technologies for FFDM – Indirect Capture

Slot Scanning with a Scintillator and a CCD Array
(SenoScan; Fischer Imaging (now Hologic))
 A narrow slot-detector and a
narrow fan beam of x-rays are
scanned synchronously across
the full field of view to cover
the entire breast
 System consists of phosphor
(thallium-activated CsI) with a
fiberoptic coupling to a CCD
 Detector is 1 cm wide and 22
cm long, consists of 4 CCDs
abutted together

Seibert, AAPM Meeting Handout Radiographics 2004:24,1752 68

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7. Technologies for FFDM – Indirect Capture

Flat-Panel Scintillator with an a-Si Diode Array
(Senographe 2000D, DS, GE Healthcare)

 In this system, the digital

detector array is constructed
from an a-Si thin-film transistor
(TFT) matrix deposited on a
glass substrate
 The CsI scintillator is
deposited on the a-Si detector
 Each light-sensitive diode
element is connected by TFTs
to control and data lines so
that charge produced in the
diode is read out in response
to light emission from the
scintillator

Radiographics 2004:24,1753 69

69

7. Technologies for FFDM – Indirect Capture

Flat-Panel Scintillator with an a-Si Diode Array
(Senographe 2000D, DS, GE Healthcare)

 The GE Senographe 2000D

system was the first FFDM
system to be approved by the
FDA in USA
 1,920 x 2,304 detector
elements on a 19.2 x 23-cm
area
 Each pixel is 100 mm, largest
pixel size of the available
FFDM systems

Radiographics 2004:24,1753 70

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7. GE Senographe DS FFDM system

Can use in association with CAD systems

c.f. private document, GE Medical Systems

71

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7. Technologies for FFDM – Indirect Capture

Photostimulable Phosphor Plates (Computed Radiography)
(Fuji – not approved for Mammography yet)

When x-rays
are absorbed,
electronic
charges are
stored
proportionally
in “traps” in the
phosphor

Seibert, AAPM Meeting Handout 72

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7. Technologies for FFDM – Direct Capture

Flat-Panel a-Se Array (Lorad Selenia, Hologic)

 a-Se, a good photoconductor is

deposited directly onto the a-Si
TFT substrate enabling direct
capture
 The a-Se detector directly
converts x-rays to electron-hole
pairs
 The a-Si TFT converts the
electron-hole pairs to electronic
signal
 25 x 29-cm field of view, the
largest among all systems
 Accommodates all breast sizes
 Pixel size is 70 mm

http://www.hologic.com/wh/digisel.htm 73

73

7. Technologies for FFDM – Direct Capture

Flat-Panel a-Se Array (Mammomat Novation, Siemens)

 Approved recently
 24 x 29-cm field of view
 Accommodates all breast sizes

http://www.medical.siemens.com 74

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7. Technologies for FFDM

Fischer Lorad/Hologic
Fuji/Kodak GE
(Hologic) Siemens
http://www.hologic.com/oem/pdf/DROverviewR-007_Nov2000.pdf 75

75

7. Technologies for FFDM

Radiology 2005:234,353
76

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7. FFDM – Radiation Dose

 DS system
 Contrast mode - 219 mrad or 2.19 mGy

 Standard mode - 109 mrad or 1.09 mGy (28 kV, 48 mAs)

 Dose mode – 89.2 mrad or 0.892 mGy

 Film-screen
 Standard mode – 151 mrad or 1.51 mGy (28 kV, 65 mAs)

77

77

7. Storage of Digital Images

 Signals are digitized into one of 2n intensity levels within each pixel, where n
is the number of bits
 If 12 bits, 4,096 signal values, if 14 bits, 16,384 signal values
 A digital detector of N pixels requires 2N bytes of storage (2 bytes per pixel)

Radiographics 2004:24,1755
78

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7. Display of Digital Images

Radiographics 2004:24,1757
79

79

7. Economics of FFDM

 SFM systems cost well under $100,000

 FFDM systems cost in the range of $300,000 - $450,000
 One attractive reason for centers to “go digital” is the higher
reimbursement rates approved by Medicare in 2003
 SFM - $82.77
 FFDM - $132.06
 Nearly 60% higher !

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7. Expected Benefits of FFDM

 The costs of FFDM systems should be compared along with the

inherent benefits of the digital technology prior to the purchase:
 Reduced recall rates

 Increased patient throughput

 Increased early detection of breast cancer

 Decreased false-negative biopsy results

 Decreasing film and processing costs

 Increasing the caseload of each mammography room

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7. Clinical Trials and Phantom Studies

 Larger screening study screened 49,500 women
 Digital Mammographic Imaging Screening Trial (DMIST), funded by
NCI and conducted by ACRIN
(http://www.acrin.org/6652_protocol.html)

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7. Advantages and Disadvantages

 Advantages
 Optimize post-processing of images

 Permit computer-aided detection to improve the detection of

lesions
 Storage of images easier

 Disadvantages
 Image display and system cost

 Limiting spatial resolution is inferior to film, 10 lp/mm vs. 20

lp/mm

83

83

Take Home Points

 Quality Assurance important and regulated by MQSA in

mammography
 Radiologist oversees program

 Physicist and technologist responsibilities

 Phantom – 4 fibers, 3 masses, 3 specks should be seen

 Stereotactic units used for breast biopsy, use geometry to calculate

lesion location
 Digital mammography becoming common
 GE, Fischer, Lorad/Hologic, Siemens approved by FDA

 Indirect and Direct systems used

 CAD used in association with digital systems

 Advantages and disadvantages

84

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8. Quality Assurance & Quality Control

 Regulations mandated by the MQSA of 1992 specify the

operational and technical requirements necessary to perform
mammography in the USA

 For a facility to perform mammography legally under MQSA, it

must be certified and accredited (ACR or some states)

85

85

8. Quality Assurance & Quality Control

 The accreditation body verifies that the mammography facility

meets standards set forth by the MQSA such as initial
qualifications, continuing experience, education of physicians,
technologists and physicists, equipment quality control etc.

 Certification is the approval of a facility by the U.S. FDA to

provide mammography services, and is granted when
accreditation is achieved

86

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8. Radiologist Responsibilities

 Responsibilities include

 Ensuring that technologists are appropriately trained in

mammography and perform required quality assurance
measurements

 Providing feedback to the technologists regarding aspects of

clinical performance and QC issues

87

87

8. Radiologist Responsibilities

 Responsibilities include

 Having a qualified medical physicist perform the necessary tests

and administer the QC program

 Ultimate responsibility for mammography quality assurance rests

with the radiologist in charge of the mammography practice

 The medical physicist and technologist are responsible for the

QC tests

88

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8. Mammography phantom

 Is a test object that simulates the radiographic characteristics of

compressed breast tissues, and contains components that model
breast disease and cancer in the phantom image

 It is intended to mimic the attenuation characteristics of a “standard

breast” of 4.2-cm compressed breast thickness of 50% adipose and
50% glandular tissue composition

89

89

8. Mammography phantom

 6 nylon fibers, 5 simulated calcification groups, 5 low contrast disks

that simulate masses

 To pass the MQSA quality standards, at least 4 fibers, 3 calcification

groups and 3 masses must be clearly visible (with no obvious
artifacts) at an average glandular dose of less than 3 mGy

90

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8. Mammography Phantom

c.f. Bushberg,
et al. The
Essential
Physics of
Medical
Imaging, 2nd
ed., p. 228.

91

91

8. Technologist Quality Control

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 226.

92

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8. Technologist Quality Control

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 226.

93

93

8. Technologist Quality Control

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 226.

94

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8. Technologist Quality Control

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 226.

95

95

8.
Physicist
Quality
Control

c.f. Bushberg, et
al. The Essential
Physics of Medical
Imaging, 2nd ed.,
p. 227.

96

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Question

 1. The average glandular dose for a 4.2 cm compressed breast is

about:

 A. 1.3 mGy (130mrad)

 B. 1.7 mGy (170mrad)
 C. 3.0 mGy (300 mad)
 D. 120mR
 E. 170mR

97

97

Question
 1. Breast doses in mammography are most likely to be reduced by
increasing the:

 (A) X-ray tube voltage

 (B) X-ray tube current
 (C) Focal spot size
 (D) Grid ratio
 (E) Number of views taken

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Question
 1. Mammograms cannot be processed if the weekly phantom does
not pass. A passing score would be:

 Fibers Speck Masses Disk

Groups Contrast
 A. 4.0 3.0 3.0 0.40
 B. 5.0 2.5 3.0 0.50
 C. 3.5 4:0 3.0 0.50
 D. 4.0 4.0 2.5 0.50
 E. 6.0 5.0 2.5 0.5

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99

Question

 1. In mammography, a fiber interspaced grid is preferred over

aluminum because it:

 (A) Reduces the dose

 (B) Improves resolution
 (C) Removes more scatter
 (D) Reduces image mottle
 (E) Improves contrast

100

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Question

 1. Ideally, the AEC (phototimer) sensor in mammography should be

placed:

 A. As close to the chest wall as possible.

 B. Under the densest portion of the breast.
 C. Under the least dense portion of the breast.
 D. Under the most anterior portion of the breast.
 E. In the center of the breast.

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Question

 1. Which grid would be the best choice for use as a stationary grid in
mammography?

 A. 44 lines/cm, 5:1 ratio

 B. 44 lines/cm, 12:1 ratio
 C. 80 lines/cm, 5:1 ratio
 D. 80 lines/cm, 12:1 ratio
 E. Any of the above, as long as they are made of carbon fiber

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Question

 1. Which of the following is not true? Vigorous compression in

mammography reduces:

 A. Patient dose.
 B. Scatter.
 C. Motion unsharpness.
 D. Subject contrast.

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103

Question

 1. Magnification radiography using current imaging equipment:

 (A) Reduces the entrance skin exposure

 (B) Improves the definition of fine detail
 (C) Requires large focal spots larger than 0.3 mm
 (D) Reduces film density
 (E) Requires moving the film further from the tube

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