Mammography

Mammography, What Is A Mammography?

What Is a Mammography?
 

• A Mammography is a specialised X-ray image of the breast designed to detect tumours and other abnormalities.  All mammograms are performed by female technicians.  

• A Mammography consists of having two X rays taken from each breast. Both breasts are imaged, even though the problem may be with one breast. Further additional views are acquired in special cases

• The breast will be placed between two plastic plates (compression paddles) so that the entire breast can be seen, the dose of radiation can be minimised and a good quality picture can be obtained. Women may feel pain or discomfort during the procedure, but it is only for a few seconds (5-10sec).  It is important not to move during this short time. The entire procedure will take around 10mins.

• A mammogram uses small doses of radiation, well within safety limits. The benefit of mammography outweighs the small risk of radiation.

Screening and Diagnostic Mammography:
 

• Screening mammography is performed periodically in women who have no signs or symptoms related to breast. The goal is to detect small cancer before they are detected through self-palpation or clinical breast examination.

• Diagnostic mammography is used to investigate suspicious breast changes such as a lump, pain, skin changes, nipple changes, nipple discharge etc. This may involve taking additional special images. 

When to Perform Screening Mammography

• The general population/women with an average risk of breast cancer screening mammography can be performed as part of routine health check from the age of 40, every one or two years.  

• Women with a high risk of breast cancer benefit from screening mammograms before the age of 40. This decision will be taken after discussion with the doctor, evaluating risk factors such as the family history of breast or other cancers or personal history of precancerous conditions. Magnetic resonance imaging (MRI) may also be required in addition to mammograms. 

• Diagnostic mammography is performed in all women from the age of 40yrs presenting with a breast complaint. Occasionally younger women with suspicious breast lump are also advised mammogram as part of the evaluation.
   

How should I prepare for the mammogram?

If the procedure is being done for screening, it can be planned during the first half of the menstrual cycle in premenopausal women, when the breast is least tender to reduce any discomfort during the procedure. 

• A patient will be required to undress from the waist up. Hence wearing two-piece clothing (rather than the single-piece dress) is helpful.  A gown will be offered prior to the procedure. 

• Do not use deodorant, talcum powder, cream or perfused sprays on the breasts, underarms as this will affect the result of the mammograms.

• Bringing the prior mammogram images (CD or hardcopy) is recommended as compared with previous improves detection of early abnormalities on the mammogram.

• Inform the technologist of any prior breast surgeries, any current breast symptoms or problems. 
   

Looking for a mammogram in Bangalore? Consult the best mammogram screening hospital near you.

What Is Digital Mammogram and How Is it Different from Conventional (Analogue, CR System) Mammogram?

• Both use X-ray radiation to produce an image of the breast. In a conventional mammogram, the image is stored directly on a film, whereas in digital mammography, the electronic image is taken and stored directly on a computer. This allows recorded data to be enhanced, magnified and manipulated for further analysis. 

• Digital mammography has a specific advantage in younger women (pre/peri- menopausal, <50yrs and with dense breast tissue) to selectively enhance image contrast in areas of dense gland tissue leading to earlier / better detection of cancer. 

• In digital systems, the radiation dose is around 35% lower than for analogue systems. 

• The digital images are viewed on a computer; hence they can be lightened or darkened, magnified to look at certain areas closely. The images can also be stored electronically and reviewed at a later time.

• In CR systems, Cancer detection rate (fraction) is nearly 15-20% lower compared to digital mammography systems. 

(Breast cancer detection rates using four different types of mammography detector Kenneth C Young PhD et al, Eur Radiol. 2016 Mar 26(3): 874-883)

Digital Breast Tomosynthesis (DBT) / 3D Mammography:

Overview: It is an advanced type of mammography where low dose X rays are used to take multiple images of the breast. These are sent to a computer where it is processed to produce a 3-D image of the entire breast.  This technique overcomes some of the limitations of standard 2D mammography. 

Breast is a 3D object with different internal structures that can overlap and cause confusion when viewed on a 2D image. This is one of the reasons why small breast cancer may be missed or normal tissue may appear abnormal leading to unnecessary further investigations.

How Does the Procedure Work:

The traditional 2D mammography obtains just a single image. During 3D mammography, The X-ray arm sweeps in a slight arc over the breast, taking multiple images. The computer converts these images into a stack of thin layers, creating a 3D picture of the breast. This allows the radiologist to review the entire breast, one layer at a time.

How Is the Procedure Performed:

It is performed on an outpatient basis. A trained female technologist will perform the procedure. 

During the procedure, the breast is placed on a special platform and gradually compressed with clear plastic paddles. Breast compression is essential to even out the breast thickness for better visualisation and to reduce/prevent superimposition of tissues so that small abnormalities can be seen.

A lower dose of X-ray can be used as the tissue imaged is thinner. It Stabilises breast and minimises blurring of the image. Also Improves Resolution/ clarity of the image. 

Once the breast is compressed, the X-ray tube moves from side to side in an arc obtaining multiple images of the breast. In addition to 3D images, from the available data, 2D standard images are synthesised.

The procedure will take around 20 minutes. Once the examination is complete, the technologist will review the images to determine that all the necessary images have been obtained. 

Advantages: 
 

• 3D mammography is similar to having a regular mammogram and takes just a few seconds longer than a regular mammogram.

• It improves breast cancer detection in dense breast tissue, detects more cancers than a standard mammogram alone and decreases the need for follow up imaging. It helps to assess the cancer size better than on a regular mammogram and reduces false positives.

• A 3D mammogram releases the same amount of radiation as an analogue mammogram, little more than a digital mammogram. 

Contrast-Enhanced Mammography (CEM): 

Also known as contrast-enhanced spectral mammography (CESM) and contrast-enhanced digital mammography (CEDM).  Standard Iodinated Intravenous contrast/dye,  similar to the one used for a typical CT scan is used in combination with mammography. The cancers take up more contrast than the surrounding breast tissue and are seen better. 

How Is It Performed:

The iodinated contrast is injected into a vein and two minutes later mammograms obtained with standard positioning. Although it resembles standard procedure, the equipment is also taking a higher energy mammogram that is absorbed by iodine as well as lower energy diagnostic mammogram.  Subtraction is performed to create an ‘Iodine only` image. This Subtracted image is reviewed together with a low energy diagnostic mammogram. 

Similar to breast MRI, cancer takes up more contrast/dye than surrounding breast tissue and shows up white on the mammogram.  The normal breast tissue and most of the non-cancerous (benign) lesions appear dark on CEM. 

Advantages: 
 

• CEM is comparable to MRI breasts. It is superior to both standard mammography and breast ultrasound. 

• It can be adapted to existing digital mammography equipment. So the procedure can be performed at a lower cost compared to MRI

• Shorter Examination takes only 10mins compared to 40mins of Standard Breast MRI. 

Considerations: 

CEM requires a cannula / IV line to be placed in the arm for injection of contrast agent/dye.

A small increase in the radiation dose compared to standard mammograms, but less compared to combined 2D and 3D mammography. Currently no technology available to biopsy areas of enhancement seen only on contrast mammography. This has to be correlated with ultrasound/mammogram / MRI to locate the abnormality for biopsy.

Iodinated contrast used for the procedure carries some risks. Women with poor kidney function or prior history of contrast reaction should avoid it. Mild allergic reactions such as rashes can occur in 1% of patients. A severe allergic reaction is rare (estimated around 1 in 200,00). 
 

(Lewin JM, Isaacs PK, Vance V, Larke FJ. Dual-energy contrast-enhanced digital subtraction mammography: feasibility. Radiology 2003; 229:261-268 iiJochelson MS, Dershaw DD, Sung JS, et al. Bilateral Contrast-enhanced Dual-Energy Digital Mammography: Feasibility and Comparison with Conventional Digital Mammography and MR Imaging in Women with Known Breast Carcinoma. Radiology 2013; 266:743-751

iiiJochelson MS, Pinker K, Dershaw DD, et al. Comparison of screening CEDM and MRI for women at increased risk for breast cancer: A pilot study. Eur J Radiol 2017; 97:37-43

ivLewin J. Comparison of Contrast-Enhanced Mammography and Contrast-Enhanced Breast MR Imaging. Magn Reson Imaging Clin N Am 2018; 26:259-263

vSorin V, Yagil Y, Yosepovich A, et al. Contrast-Enhanced Spectral Mammography in Women With Intermediate Breast Cancer Risk and Dense Breasts. AJR Am J Roentgenol 2018; 211:W267-W274

viPhillips J, Steinkeler J, Talati K, et al. Workflow Considerations for Incorporation of Contrast-Enhanced Spectral Mammography Into a Breast Imaging Practice. Journal of the American College of Radiology 2018;15(6):881-885 )
 

Hologic Selenia Dimensions 6000 - The 2D/3D TM System: 

At Manipal hospital installation of Hologic top-class digital mammography equipment has revolutionised breast imaging. This provides for
 

• 2D mammography

• 3D mammography exam

• Stereotactic biopsy

• Contrast-enhanced mammogram

The equipment is based on the principle of better lesion detection leading to early cancer detection and reducing the number of biopsies. The revolutionary Selenia Dimensions System, which has set standards in mammography screening, provides:
 

• Exceptionally sharp images

• Advanced clinical applications 

• World’s first and only Tomosynthesis guided biopsy

• Ergonomic design and sophisticated tools for patient comfort and ease of operation.

The Equipment`s 3D Mammography Offers
 

• Proven to detect 20-65% more invasive breast cancers compared to 2D alone, an average increase of 41%

• Proven to reduce callbacks by up to 40% compared to 2D alone

• FDA approved as superior for women with dense breasts compared to 2D alone

Features:
 

1. FAST Paddle System: Conforms to natural contours of the breast, providing greater comfort for the patient and even compression across the breast.

2. Equipment design makes positioning easier and provides ample space for interventional procedures.

3. High-resolution inch screen 12MP display providing fine detail of images, reading workflows and  software  tools to evaluate the images

(Reference: 1. Results from Friedewald, SM, et al. ``Breast cancer screening using tomosynthesis in combination with digital mammography." JAMA 311.24 (2014): 2499-2507; a multi-site (13), non-randomized, historical control study of 454,000 screening mammograms investigating the initial impact of the introduction of the Hologic Selenia® Dimensions® on screening outcomes. Individual results may vary. The study found an average 41% increase and that 1.2 (95% CI: 0.8-1.6) additional invasive breast cancers per 1,000 screening exams were found in women receiving combined 2D FFDM and 3D™ mammograms acquired with the Hologic 3D Mammography™ system versus women receiving 2D FFDM mammograms only.  2. Freidewald SM, Rafferty EA, Rose SL, Durand MA, Plecha DM, Greenberg JS, Hayes MK, Copit DS, Carlson KL, Cink TM, Carke LD, Greer LN, Miller DP, Conant EF, Breast Cancer Screening Using Tomosynthesis in Combination with Digital Mammography, JAMA June 25, 2014.  3. Bernardi D, Macaskill P, Pellegrini M, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-2): a population-based prospective study. Lancet Oncol. 2016 Aug;17(8):1105-13.  4. FDA submissions P080003, P080003/S001, P080003/S004, P080003/S005)

Looking for breast cancer ultrasound and mammography costs in Bangalore. Manipal Hospitals, Old Airport Road provides breast ultrasound also called ultrasound mammogram which helps in diagnosing breast cancer. If you feel any symptoms of breast cancer then consult the breast cancer specialist near you.