Fig. 21.1
Left CC IR at IMF
Fig. 21.2
Left CC IMF plus 2 cm
Handy Hints
In order to achieve maximum breast footprint and optimum compression force balance between IR and paddle for the CC projection, you should aim to position the IR approximately 1–2 cm above the level of the IMF.
Cranio-Caudal (CC) View: A Step by Step Guide
Handy Hints
The 5 Ps
Proper Planning and Preparation leads to Perfect Positioning
Practitioners should be aware of their postural techniques at all times during positioning to reduce any risk of repetitive strain injury (see Chap. 23).
Stand the client facing the mammography unit about a hands width back from the IR. Ask the client to stand with their feet hips width apart for stability, with their hand of the side being imaged on their abdomen.
Stand next to the client, at the contralateral side, and ask the client to turn their head to face you and rest their cheek against the face guard.
Ask the client to keep their feet in the same position and bend forwards slightly, pushing their bottom back. Lift the breast being imaged, using its natural mobility (Fig. 21.3).
Fig. 21.3
CC view: Initial client position
With a positive hold, using the breasts natural mobility, lift and pull the breast forwards onto the image receptor at the medial and lateral breast sides (Fig. 21.4), adjust so that the nipple is centrally placed. The nipple is a standard and reliable landmark to ensure accurate breast positioning.
Fig. 21.4
CC view: Placement of breast on Image Receptor
Raising the Breast
Figure 21.5 highlights the extent to which the breast should be raised prior to positioning for the CC view in the first instance.
Fig. 21.5
CC view: Raising breast prior to positioning
Adjust the height of the IR to allow the breast to sit at a 90° angle at the chest wall in the first instance. It is of great importance now to raise the level of the infra mammary fold (IMF) to achieve maximum breast footprint and balance the compression force to the top and bottom of the breast. The amount of uplift will be client dependent; it has been evidenced that an increase in 1–2 cm above the IMF significantly increases breast footprint [6] (Figs. 21.1 and 21.2). It is important to ensure that the IR is not raised too high as this could result in a loss of breast tissue on the image with the nipple inverted down, towards the underneath the breast.
Check for creases and air gaps and smooth the breast tissue. Ensure the nipple is in profile (but not at the expense of breast tissue) and central (Fig. 21.6).
Fig. 21.6
CC view: Nipple position
Handy Hints
It may occasionally help to place the opposite breast onto the image receptor to encourage the medial breast border to be in the field of view – ensure that the opposite breast is not imaged though
Whilst holding the breast securely with one hand, place one arm around the back of the client and gently guide their shoulder down allowing relaxation of the lateral breast tissue.
Place your hand positively around the back of the client to encourage a ‘leaning forwards motion’ followed by compression force application.
Handy Hints
If your client is unsteady, place their hand, opposite to the breast being imaged, onto the bar of the mammography unit
Alert the client that compression is about to commence. Apply compression force slowly and evenly moving your hand towards the nipple as the compression takes over the hand (Fig. 21.7).
Fig. 21.7
CC view: Compression force application
If possible, and available on the equipment, the hand compression dial should be used to allow a slow, measured compression force application.
The breast should be compressed to ensure compression force balance between paddle and IR is achieved; the breast may feel taut and immobile. Client consistency between sequential attendances is imperative [12] and the compression force could be standardised between 90 and 130 Newtons of force [13]. Apply smaller forces if the client experiences discomfort; larger forces if the breast is not immobile.
Check the medial and lateral borders for skin folds, if present smooth out with fingers ensuring not to disturb any breast tissue (Fig. 21.7). Perform a last check to ensure no artefacts are present on the image detector (i.e.: clients hair, chin)
Perform the exposure. Following automatic compression release, lower the height of the column slightly prior to imaging the opposing side; this allows for correct breast uplift.
Medio Lateral (MLO) View: A Step by Step Guide
Initial set up: Reduce the height of the IR slightly from the CC view and angle the tube head to 50°.
Handy Hints
Remember the 5 Ps:
Proper Planning and Preparation leads to Perfect Positioning
Adjust the IR in accordance with the height of the client. It is now of vital importance that the correct angle of the IR is selected. Suboptimal positioning and incorrect angle selection could result in excessive compression force being applied to the chest wall/axilla. This may cause unnecessary discomfort to the client and result in inadequate compression of the breast.
Correct IR Angle Selection
Angle selection for the MLO view is a skill and refinement of the angle selected will be required through positioning. In the first instance a quick observation of the body habitus of the client (Fig. 21.8) will provide a rough indication and enable you to select an appropriate angle to commence.
Fig. 21.8
Guide to appropriate angle selection
The aim on the MLO position is to get the sternal angle and the IR parallel to each other to enable effective compression force balance between IR and paddle with maximum breast footprint on the IR. Figures 21.9, 21.10 and 21.11 illustrate angle positioning for varying body habitus; the parallel lines illustrating correct IR angle selection.
Fig. 21.9
Client would require a 45 or 50 degree angle of the IR
Fig. 21.10
Client would require a 50 or 55 degree angle of the IR
Fig. 21.11
Client would require a 55 or 60 degree angle of the IR
Incorrect angle selection for the MLO will lead to uneven compression force balance which could increase the levels of pain for the client due to higher pressure points. Figure 21.12 illustrates a right sided MLO with the client positioned at an incorrect 45° angle selection and a correctly selected 55° angle (Fig. 21.13) which highlights correct compression force balance
Fig. 21.12
MLO at 45°
Fig. 21.13
MLO at 55°
Following on from correct angle selection, for stability ask the client to face the machine with feet hips width apart. Standing behind the client place your hand at the bottom of the rib cage of the side being imaged. Move the client forwards until your fingertips are just touching the front and bottom aspect of the IR; the client will be about a hands width back from the IR (Fig. 21.14).
Height adjustment of the mammography unit can now commence; adjust to the level of the axilla in the first instance. Rest the arm of the client along the top of the IR (Fig. 21.14).
Fig. 21.14
Client position for MLO
Standing at 90° to the client place your hand to the lateral aspect of the breast and place your other arm, in a supportive position, around her back (Fig. 21.15).
Fig. 21.15
MLO view: Supporting the breast and arm
Using the natural mobility of the breast, lift the breast with one hand and guide the client into the machine with your other hand. Concurrently, ask the client to bend from their waist and lean towards the side of the IR.
Move around to the back of the client and position her arm; lifting it upwards, gently reaching the shoulder over the IR. Adjust the height of the machine; the corner of the IR should be seated into the axilla (mid axillary line between the latissumus dorsi muscle and pectoral muscle), or in the space if the axilla is hollow.
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