 So our next speaker for this session is going to be Dr. Namita Mohindra. Dr. Namita is going to speak to us about the importance of appropriate mammographic positioning and quality control. Like we can only detect what is there on our imaging which is the mammogram. Therefore, good quality assurance, good quality control and having good mammograms is something important. However, most of the times there's not radiologists who are doing it, it is radiographers. So to teach this to the radiographers to identify what is missing on the mammogram is also part of the role of the radiologist and that is exactly what Dr. Namita is going to speak to us about. Dr. Namita is highly qualified. She is an additional professor with Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow and has a special interest in breast imaging. She's affiliated with the national organizations BISI and IRI, reviewer for multiple journals and she has multiple peer reviewed publications, book chapters and is involved with multiple research projects. She has been a PG guide for MD students and a co-guide for DM students. She's extensively traveled and she's attended many, many courses to upgrade her skills, but most importantly, what I discovered about Dr. Namita through this process is during this COVID pandemic, despite of being a radiologist, she has been working in the wards. Imagine if somebody asked me, a radiologist to intubate a patient, I wouldn't know what I was doing, but as part of her duty in addition to being a radiologist, through this entire pandemic, Dr. Namita has been working in the wards and the ICUs of SGP PGI and through her additional jobs, she's accepted this invite for us and has agreed to do this talk for us. So very, very grateful to you, Dr. Namita, for doing this and please welcome aboard. Over to you. Thank you. Thank you, Dr. Shilpa. Thank you for the kind words and thank you to the organizers for inviting me here. It's been an amazing session till now and let's move ahead with this now back to basic talk. Can I just start sharing my screen? Yes, please. Okay, just give me a second to, so is that visible? Yes, you can start. I just need to move this, can I just minimize that? Am I still visible? Yeah, you can start your talk, no problem. Yeah, okay, so the topic today is the importance of mammographic positioning and systematic viewing. And before we move on, I would just like to draw your attention to some of the reasons for missed cancers. Now these could be errors in techniques or they could be errors in interpretation. And the focus of this talk today is to minimize these errors. So let us see the first case as an example. Now here we have a case where there are bilateral heterogeneously dense breasts and there is a lesion in the right breast. And if you see, it's quite well visible on the MLO view, however, it's not so well seen on the RCC view. And it's just a little bit visible on this view here. So they decided to go ahead and do an extra view on this. Have you noticed here that the lesion is here, however, their centering is a little bit away from that. So the key message is that the knowledge of positioning and localization is important to avoid a struggle in demonstrating lesions, even when you know that it's there, it's sometimes not possible to demonstrate it very clearly. To simplify the issue, let's just divide it into the component steps, which is to find the lesion, check if it's real or not, and identify where exactly it is. So these are three things we will be talking about in this next 20 minutes or so. And we must realize if it's not positioned well, even large amounts of tissue may not be imaged, and then the skill of the interpreter will become irrelevant. As in this case, you can make out there is a mass here. And on the initial view, almost one centimeter of the tissue was not included into the view. So what we actually need is we need a team, we need a trained and motivated technologist to pull and compress as much of the breast tissue away from the chest wall as possible. And we need a cooperative patient who's going to allow pulling in compression. Of course, we need a good mammography system. And we're aware, you know, with all the recent advances, we've got the high resolution detectors, we've got good compression battles, we've got large imaging receptor plates, that's the IR plate. But that has not really made the job of positioning the breast easier. In fact, it's made it more challenging because you've got larger IR plates, and it's more difficult to manipulate the patient onto it. So we'll be talking about these two standard champion views, as we call it in a little bit more detail, that is the mediolateral and the craniocautal leak views. And so important to understand that the direction, it's the direction of the X-ray beam which determines the nomenclature. So the beam coming from the cranial aspect, that's the craniocautal view, beam coming from the medial aspect, that's the mediolateral oblique view. And we're trying to align it along the pectoral muscle. The reason why you want to do it is because the pectoral muscle is fixed. And if you want to move as much of the tissue away from it, it would be easier if you're going along it rather than if you go across it because once you're across the muscle, it's difficult to pull tissue into the field of view. With this, we move on to one of the most important parts of the talk today, that is the actual positioning of the CC view. It's not as if you just pull the breast up and put it onto the plate and compress from top. So that's really now not how it works because you're going to miss out on a lot of tissue if you're going to do just simply that. So there are again a number of steps to it. So we need to elevate the breast, bring it back to the anatomical position. You've got to try and align the posterior nipple line perpendicular to the chest wall and try to include as much of the tissue into the field of view as is possible. So once you've elevated the breast, you brought it on to the level of the PNL, you want to now pull it forward. So we're at the important slide here, that's the positioning for the CC view and what we need to do is actually divide this into the component steps. We have to elevate the breast and get it back to the anatomical position, bring the posterior nipple line close to and perpendicular to the chest wall. We want to try and include maximum amount of tissue. So we need to pull forward because we actually really don't want the deepest tissue to get missed out. And once we are at it, we need to understand that it's important to include as much of the medial tissue as possible because we don't get this opportunity to do so on the MLO view. We'll be pulling this forward and while we are at it, what we want to do is we want to pull this in place and we'll lift the opposite breast to get more of this into the view. And at the same time, that's not all, we still have to take care of the lateral part. So that's called the tebar maneuver where we want to pull the lateral part of the tissue also into the view. And ultimately, it's still not all, we still have to spread this tissue and finally compressed. So all of these things together, once we've got all this act together, we've got this final image where we are getting the lateral tissue. We have the cleavage also included. We have the nipple in profile and we've got as much of the deep tissue as we could, a little bit of the pectoral muscle peeping in and we're sure that we've got a good amount of the deep tissue. That's the ideal scenario that we are looking for. So let's see the next case. Now on the first look, you might say that these CC views look fine. We've got gas, we've got a good amount of the medial tissue. We've got the nipple in profile, but unfortunately, we've got the lateral part all bunched up. So we've got to have everything in view when we are doing this. Compare and contrast this with the other image here. The nipple is not in profile. However, we see a little bit of the tissue posteriorly. So probably this is a better view than previous one. Now moving on to the MLO view. Here it's a little bit more tricky because you've got to include a very large area right from the axillary tail to the inframammary fold. So that's a huge thing. So we understand the three P's in breast imaging. That is the perimeter of the breast, which is very large. You want to do it as much as possible. And the plane of the pectoral muscle. So you've got to understand that the angle of the pectoral muscle is not constant at 45 degrees. It varies from patient to patient and the rough guide is that it is steeper in women with the longer thorax and less so in women with the shorter thorax. So what we're trying to get is, we're trying to get this MLO view like this, where we're interested in getting the pectoral muscle to relax. It's easier said than done. Sorry, is that a problem? No, no, you're good. Please continue. So right, when we've got this, we're trying to get this to relax. What we could, the practical tip to do that is that we could just tap the shoulder down and depress it. At automatically the muscle would relax. Or we could also ask the patient to inhale and then exhale. So you've got that window of opportunity where the muscle has relaxed and you'll be able to pull more tissue onto it. And that's the final result, what we're looking for. We want this pectoral to be seen up to or even below the level of the posterior nipple line. This is nice and relaxed, got a convex contour. It's wide at the top, tapering at the bottom. We've got the nipple in profile, deep tissue is in place. And we've also got the IMF or the inframabry fold opened up for us. That's the way it should ideally look like an inverted champagne glass appearance. So now we move on to what could go wrong. So a number of things could go wrong. If the angle is too steep, you can understand that you won't be able to pull that much tissue into the plane of view. We could have a drooping breast if you've not lifted it up properly and you can understand that the tissues would be more crowded together. So the chances of superimposition would be more, as you can see in this breast, there's a lesion here. But because of the drooping, there's more superimposition than we would want it because there is a fold in the inframabry region as well. So despite the pectoral coming down to the correct level, the next step is what we've missed out on and that is opening up the IMF. Now another error which we come across more often now is the presence of skin folds. So these skin folds, as it's been said, it's all right if you've got it in the upper part only. But in this case, if you can see that there are folds coming all the way down here and you notice this is actually the same patient. So in this MLO view, you see it's not being pulled out at all. So there's a lot of superimposition. You're likely to miss any architectural distortion which was there. And the next one, again, a very common error. They've tried to get the pectoral down. They've got the nipple in profile. They've got everything happening for them. But they have not included the inframabry fold at all. In fact, there's no effort to do that. So a tip, again, would be that when you're positioning the patient, try to put the inferior edge of the IR plate behind the IMF fold. So this is a landmark study which was done in 1993, which has described the criteria for optimal imaging in which they found that the pectoral muscle should be visible up to the PNL in about 80% cases. And you can actually obtain the IMF in approximately 50% of the women. And they also found that the skin and fat folds were visible in 15% cases. It's even more when we've got the larger IR plates. And finally, we checked for the optimal positioning on both the views together. That's the one centimeter rule. What you want to do is you want to get the posterior nipple line equal on both the CC and the MLO views or within one centimeter of the two. So the line is drawn perpendicular to the nipple up to the back of the film or the pectoral muscle if it's visible. And this is how you need to measure that. Now, a few words about compression. It's just not to hold the breast forward and to prevent motion and spread overlapping tissue. There's a little bit more to it. There's more physics to it. So the compressed breast tissue thickness is actually the most important factor which determines the amount of radiation that the breast is going to get. In this you can see the CBT or the compressed breast tissue thickness was 64 and the average glandular dose was 1.8. And compare it to the opposite side where the CBT was 81 and the average glandular dose was 2.25. So this is what you see. The exposure is also non-uniform and there is more chances of geometrical blur. You're going to see this in the next case. Sorry, can I just let the dog out? I'm so sorry for that. So the amount of compression that is required is something which a number of people ask. So it's not till you get the patient to screen with pain. It is just to compress till the skin is taught because any further compression is not going to increase the resolutions. It is just going to increase the discomfort of the patient. So that's an important point to remember. And with this we see the next case. Now on the first look it looks absolutely fine. There is a mass here with calcifications and the positioning by and large looks okay but when you take a closer look what I need to point out here is that there are these calcifications here. You can see that the CC view is fine. However in the MLO view there is motion blur and the way to look for it is when you zoom into the images try to look at the reticular pattern or the edges of the calcifications and you're not really you don't want the motion blur to be there. So these are all the things that you've got to check before you move on to systematic viewing. So the next section we're moving on to is the systematic viewing. We've checked for the optimal technique. We've got all our preliminary stuff in place and now we sit back and relax. Now we view for a distance in low ambient light. You know avoid the urge to immediately view closely. You want to get the global view. You're looking for asymmetry. You compare the right to the left and in the words of Tabar you'll try to look at the building blocks of the anatomical components and then you use a masking technique if it is needed and of course you cannot miss out on magnifying the images. We'll be looking at all of these as we move ahead. So looking at the building blocks. So if you recall the anatomy and of Suma had presented this earlier as well. What we actually mean is that the nodular densities represent the terminal local mobular units. The linear densities are the fibrous structures blood vessels and ducts. The radial lucent areas are the adipose tissue and the homogeneous structural density is the fibrous tissue. So with this in mind we're going to move ahead but before that we need to understand that we have these five areas demanding special attention and that is the edge of the parent chimera because that's where most of the cancers would be seen. The medial half of the breast is important to take note of that. The retro mammary no man's land. We don't expect any tissue there. The retro areolar regions and the infrared mammary regions. These are the ones that we have to be very very careful about. So with this background information let's start viewing our cases. The first case up is a 35 year lady who's got a heterogeneously dense breast and I'm going to put all of this information in place. I am sitting back and I'm viewing right for left for asymmetry and I am also now trying to see the special areas that is the edges of the parent chimera and when I see this here this is actually what I find. There is a very obvious lesion and so this is the importance in a relatively easy case. Let's see the next one again a 42 year lady who's got a heterogeneously dense breast. I am looking at the right the left for asymmetries and the areas demanding special attention and I am looking at this area. I see a bulging the retro mammary zone which I do not expect. Let's look at this a little bit more in detail. There are two other techniques which you could try and that is to train your eyes to analyze radially. You know you try to train your eyes to look radially and try to look at the blacks to see the whites again in the words of Tabar. What you actually expect is that the parent chimera is to have a cave contour so you try these imaginary sea lines and you're drawing this you see they're all sea lines and when there is a reversal of the sea line that's actually a red flag. So this was the lesion we've been talking about that's the ultrasound and this was a patient with IDC. With this we move to the next case. This is a 45 year lady with bilateral dense breast. Again I'm trying the same thing but this one is a little bit more tough. It's a little bit denser tissue. What we could try here is the masking technique wherein we hide some parts so that subtle changes are more easy to appreciate. You can view this by restricted view of the horizontal view or in the oblique masking technique. You could hide the parts of the images and let's see how this works. So I'm trying the masking technique that's the oblique masking and the horizontal masking and that's a huge lesion here which is visible and this is also very clearly demonstrated on the digital toposynthesis. In the next case up is a 48 year lady for screening mammogram. We do not see any obvious mass or asymmetry but we now need to zoom it up. I'm trying to look at the views I'm trying to see radially and I see some disturbance in the architectural pattern here. When you zoom it up here you can see it even more clearly. There are series of thin straight lines or speculations extending from an area that's an architectural distortion and a digital tomosynthesis revealing the underlying mass so very clearly. Now the next case up is a 56 year lady with a large fungating mass and you might wonder why I put this up at all. So that's the mass here but I'd like to draw your attention to this lesion here. So the key message is to look beyond the obvious. There is a small isodense mass with indistinct margin in the left inframammary fold and this was a proven cancer. So with this let's move on to the next set of things that we might need to do with the advent of digital tomosynthesis. We need the additional views less often but there are certainly some clinical indications for the additional views. We might need to triangulate a lesion or show an area of anatomy which is not visible on the standard view or show that area better or to counteract the effect of superimposition of structures. So these are the common views. We will be talking about the indications in brief one by one. So the first up is the medial lateral view. Here again I would just like to draw your attention to the direction of the beam so it is from medial to lateral. You're going across the pectoral muscle so you can make out you know the disadvantage here is that less tissue is included. That's the reason why you don't use it as a standard view. Your standard view remains the MLO view which you are going across it like this and the ML view is when you're going straight lateral from medial to the lateral. So the common indication is to triangulate lesion or to change an angle of view and sometimes you use it to demonstrate calcium layering and also you use it to plan interventions when you're doing tomobided biopsies. So just to see how this works. So suppose you've got a lesion which is visible only on the MLO view. This is what it looks like. We've marked the lesion here and we want to do an additional view. If we find that the lesion falls below the nipple line it is likely or it is actually going to be in the lateral half of the breast. So this is what we call the triangulation and this is a very simple mnemonic to remember this. So if there is a lesion in the lateral half of the breast it will fall below the PNL that's called that is the lead falls and a lesion in the medial half of the breast will be seen above the PNL on the LM view that is muffins rise and this is how we're going to arrange the views with the MLO view in the center. You want to keep the nipple on the same line and then we draw these projections. I thank Dr. Shilpa for providing me these images. Next up is a lady who's come for a screening mammogram. Is there a problem? We're looking at the MLO views and with all the background information what is the problem? Is the left breast small or is it a mass or is it a problem of comparison? So what has actually happened is that the patient has pulled herself away on the MLO view so the left breast you're not able to see problems. So but anyway I still have my CC view to fall back on. So when you're looking at the CC view the right CC view is actually really very well done you can see so much of the pectoral muscle you can see the retro mammary fat the baronchymal bone the nipple is in profile everything is working fine but on the left side we have a problem. There is something here I do not know whether it's an asymmetry is it real or not so what do I do next? I mean of course I could do repeat views but do I do a repeat MLO or do I do a CC view? Well in this case I would like to do an additional view since I'm only interested in the outer half of the breast I could bring this forward rotate this forward and get this in view that's called the exaggerated lateral CC view and as you can see here now I'm not interested in the medial part and we can see that there was no lesion here this was a single lesion. Another case to to show you the same phenomenon here we have a lady with a lump in the right breast so it's not visible on the CC view what has actually happened is that we didn't get the med the deep part of the tissue into the plane so now when you're doing the exaggerated lateral CC view you're able to see this mass and you're able to see the deepest part of the tissue this was a deep seated lesion which is visible on the MLO viewer span. The similar thing we could do when we are thinking of masses on the medial aspect in here you can see the CC view you know we've got the deep part right you know but the nipple is not in the center we haven't got the medial part of the breast well we've got a fold here we don't know whether it's a fold or a lesion so we could do an exaggerated medial view we've just shifted us entering and got this better we could also do a cleavage view where we see the midline tissues so that is the CC view. Another maneuver that we could use was the rolling technique wherein what we do is we just roll the top half of the breast and an lesion which is present in the upper half of the breast will move in the same direction whereas a lesion in the bottom half would stay where it is so these are things which we sometimes require in post-operative cases where if there is a lesion which is seen in view when you want to spread it out and see it better you could use a rolling technique. So till now we've seen the first three indications of the additional views again the diagram is just to reiterate that these arrows denote the nomenclature the direction of the beam is what determines the what the view is going to be called as and we still have to see the additional views if you want to evaluate the characteristics so that's the fourth indication of taking the additional views. Another example up is a 39 year lady she's got no palpable mass and she's come for screening and we do not see any obvious mass asymmetry or architectural distortion but I'm not done yet I have to magnify it that's the rule of the viewing we've got to magnify the images and here we see diffuse bilateral scattered calcifications and again opsemus has covered this really well we don't need to do anything further on this but in case you've got a similar lesion where you want to be very sure on that you could actually do a true lateral to demonstrate layering and you can see these crescent things that's another indication for doing a true natural so I think we can now move on to the calcium assessment I'm just going to take a very short note on it because it's been discussed very well yesterday do we still need magnification views well yes definitely just a little bit of physics to remember is that since the focus spot size reduces so the spatial resolution is much better than the standard views we are taking so it defines the morphology and the number of calcifications better you can bring the breast closer to the focus you're moving it away from the detector that's the air gap technique that it is called but the disadvantage is that it's at the cost of increased radiation dose and you see a very small part of the tissue because as you can see you know the paddle is actually really very small just a few images to demonstrate this phenomenon this is a digitally zoomed image it's all blurred here you can see it's so much better on the other view that's a true magnification view another case showing the same thing this is digitally zoomed image it's all blurred and here you've got the magnification where you're seeing that the number of calcifications the morphology is so much better visible now a few words about spot compression now we see here this is a 54 year old lady who's got a right breast painless lump and you're not able to see it on the cc view because it's quite deep what we could actually do to demonstrate this better is that since we are seeing it in the same view we can actually identify the area of concern and you spot compress it what you want to do is just spread the surrounding tissue away from it so you see the margins better classically you do it for evaluation of patients with asymmetry or architectural distortion so you are trying to move away the surrounding tissue and it's traditionally said that an asymmetry which becomes less dense on spot compression is more likely to be denied this case was actually an organized abscess uh till now we've understood why we need additional views but there are some instances where you actually can avoid the additional views as in this case you can see there's a patient who's got a left breast lump and the technician's already told me that she's got a skin lesion on the other side so this was a skin lesion of course even the mammographic features are very classical they've got this rim and these crevices which are visible of the skin lesion so in this case we don't really need to do an additional view we don't need to know when not to do so and to sum up my systemic viewing evaluation the extent evaluations as important as picking up the lesion and describing it it's not just that you talk about the index lesion you've also got to talk about the satellite nodules and the extent so when you're going to zoom it up you see all these nodules you see that there are calcifications which are far away from the actual lesion so that's important to comment upon and then now the last case up for the day this is a 38 year lady whose mother had breast cancer at the age of 50 is it possible to put the polling option on on this one yeah let me test that okay so actually I can't see can we can we show the answer now okay so most of you think it is a by rat three okay but I think it is a by rat four now the reason why I put this up was can I just yeah because this is you know most of us think that this is the lesion this is a sub-areola region which is visible but the actual culprit is actually behind this nation so the key message again is to look beyond the obvious there is an irregular spiculated mass and this is a proven cancer so with this I wind up the key messages are that you need to optimize your technique get maximum tissue in view you need to optimize perception use systematic viewing mirror mirror image views look for asymmetry look usually masking techniques look at the blacks to see the whites use magnifier tools always and you need additional views when needed spot compression for asymmetry and architectural distortion and magnification for suspicious calcifications with this we have a few polling questions do we have time to go ahead with it yes ma'am yeah so okay so that's the first question up optimal cc view positioning is you've got the options here could we start the polling please yeah okay right so I think most of you got this right so yes we've talked about this to see a nipple line on cc view should be equal to or within it we would like the nipple to be in profile but that's not essential inclusion of the deeper tissue is more important and we know that pectoral muscle is visible in approximately 30% of the cases but that's also not always there so that's also not an essential criteria the next question is a 50-year lady with the left breast lump are the cc views optimal okay so we've got quite a number of people saying no nipple is not in profile is it but actually the nipple is not in profile but that's not a mandatory thing we need to see that as much of the deep tissue we can see the pectoral muscle a little bit so I think that's fine and the next question is optimal mlo view positioning is what are these options here okay so the correct answer is the pectoral muscle visible up to the level of nipple we've discussed this before most of you got it right and we need to remember that the IMF is visible in only about 50 cases but we still got to try and get that to you then optimal breast compression is okay so most of us got this right as well I just like to point out that why why did I put this magic number of six centimeters is so the when the compressed breast tissue thickness exceeds seven centimeters you know the filters change and the amount of radiation actually increases a lot because the filter changes from rhodium to silver so it's important to remember if you're getting close to the seven centimeter it's not a bad option to just bring it down to maybe 6.8 or 6.9 so that's the reason why I put this then this is a lady who's come for screening are these views optimal what these are the options there's a second last question okay so the answer is see most of you got this right because in the mlo view you can make out you know the pectoral is not really well into the view so that's not really the ideal view to do now the last question for the day this is a 45-year lady with a lump in the left breast is the position optimal here okay so we've got divided views on this right so basically the cc views are not optimal the reason why I'm saying it is that if you can notice here that the retro mammary or the retro glandular fat is not in view so almost you know this much above one centimeter the tissue is something which you could have tried and got into view so that's the reason why I am saying it's not the ideal view and that is all that I have thank you so much for your attention thank you