View
Criteria
MLO
Ensure the whole breast is covered. A back of the breast view (posterior) and front of breast (anterior) may be required (nipple in profile in either one or both views)
Ensure the breast is crease free – particularly in the infra mammary fold (IMF) and the superior breast
Consider a latero-medial oblique (reverse oblique) for a protruding abdomen
CC
All of the breast needs to be included. This includes the medial and lateral breast as well as the anterior and posterior aspects
Consider a laterally extended CC for a large breast that appears to ‘wrap around’
It is easy to exclude the posterior aspect of the breast so ensure the breast is pulled on sufficiently
Nipple should be in profile in accordance with departmental protocol either one or both views
Post-surgical Imaging
All women who have had breast conserving surgery (BCS) should be offered surveillance mammography. This has been shown to improve survival rates by the early detection of local recurrence [11]. The optimal timing and frequency of this is currently a subject of debate and there appears to be no consensus [12]. The current UK NICE Guidance (CG80) [13] states:
Offer annual mammography to all patients with early breast cancer, including DCIS, until they enter the NHSBSP/BTWSP. Patients diagnosed with early breast cancer that are already eligible for screening should have annual mammography for 5 years
On reaching the NHSBSP/BTWSP screening age or after 5 years of annual mammography follow-up we recommend the NHSBSP/BTWSP stratify screening frequency in line with patient risk category.
This guidance is open to interpretation and therefore differing breast screening programmes could have different protocols, which can be confusing to patients who move to a new area.
Technique
Postsurgical changes can often overlap with malignant mammographic features. High quality images are essential. Imaging the surgically altered breast poses challenges to the practitioner and the image reader. There are several benign post-surgical features that make both performing and reading the mammogram challenging. These include, scar formation that can mimic cancer, post irradiation changes, oedema, skin thickening, fat necrosis and seromas [14].
Post-surgical calcification develops in about a third of cases which is caused by trauma to breast fat; this can develop 2–5 years after treatment. Skin thickening is the most common finding [14]. Breast oedema gradually diminishes and resolves for many patients by the second year mark but in the interim period this can make mammography uncomfortable as the breast is enlarged and compression may be difficult [15]. It is important the practitioner is aware of these normal post-operative changes that occur so they approach the patient in an empathetic manner allowing for the production of best quality images.
Below are examples of images
The post-surgical changes demonstrated in the Left upper outer quadrant in Fig. 28.1 have features which overlap with a carcinoma. There is a clear distortion and skin puckering.
Fig. 28.1
Post surgery mammogram with benign macro calcification and distortion. The left image is a left medio lateral oblique the right is a left CC
Post surgical changes can create difficulties in positioning the breast with the nipple in profile. There appears to be a well defined mass on the right medio-lateral oblique (MLO) projection in Fig. 28.2 but this represents the nipple. Skin thickening and oedema are also present on these images.
Fig. 28.2
Oedema and skin thickening. The left image is a right CC the right image is a medio lateral oblique
A common feature seen on post surgical mammography is fat necrosis as seen in the left upper outer quadrant in Fig. 28.3.
Fig. 28.3
Fat necrosis. The left image is a right CC the right image is a medio lateral oblique
The client in Fig. 28.4 has a distortion at the site of previous surgery. It is important that the practitioner records accurate clinical information and surgical procedures with dates and marks the scars for the image reader. The distortion has similar features to a carcinoma. Previous images are paramount for comparison in such cases.
Fig. 28.4
Post surgical changes causing distortion. The left picture is a left medio lateral oblique the right picture is a left CC
Technical points to consider,
It is essential that the practitioner records all scars and takes a brief history so that the image reader is aware of their precise location when reporting the mammogram.
A thorough explanation of the procedure, particularly compression force, is important as this can reduce anxiety.
Review previous images, if available.
If the breast is distorted, a separate projection with the nipple in profile may be required.
Some clients experience tenderness and discomfort longer than others so an empathetic and professional manner is important.
Large posterior seromas can make adequate compression of the breast difficult and additional projections of the anterior of the breast may be required.
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