 Next, I'm going to discuss quality determinants of mammography, breast ultrasound, and breast MRI. I'm going to start with part one, which is determinants of quality and mammography. Standards for mammography image quality include looking at positioning, technique, making sure you have adequate MA and KVP, compression, exposure level, contrast, sharpness, noise, and artifacts. As said at the beginning, artifacts will be discussed in a separate presentation. So for positioning, this is very important. The pectoralis muscle should have a convex anterior border and it should extend to or below the posterior nipple line. That is visualized posterior to all fibroclangular tissue, deep and superficial tissue are well separated. There is no evidence of motion blur. The inframammary fold should be open and visualized. The nipple should be in profile on at least one view on each side, and there should be no skin folds. So this is some imaging to discuss positioning. So this is the pectoralis muscle here. This is the nipple. This is the posterior nipple line. And to make sure you've got an adequate tissue on both the CC and the MLO, you want to make sure that the posterior nipple line on the MLO and the CC is within one centimeter, as it is on this. As you can see here, the pectoralis muscle is coming down below, which is great, below the PNL. And you can also see a nice convex positioning. The inframammary fold is here. It is visualized and open. In other words, a nice obtuse angle here you can see, and this is appropriate positioning. Good retro glandular fat here and good separation of the anterior and posterior tissue. Nipple is in profile on one view, the MLO here, not as much, but as long as it's in profile on one view on each side, that's all you need. Now I wanted to talk about inframammary folds. So this is an example of an inframammary fold not being open. So this is the image I want you to look at first. These are the inframammary folds. See how there's an acute angle between the breast and the abdomen. And you see there's some tissue overlapping up here. This is a closed inframammary fold. And what's the problem with this? The problem with this is there could be a mass or calcifications hiding in here and you cannot see it because it's folded. So this technologist was great. Great technologist realized there was some limitation to her film and immediately took IMF views with them open. So you can see the difference specifically here. It still didn't get quite as open here. But look how beautiful this is. You can see everything and we can be 100% sure there is no calcifications and no mass hiding in this inframammary fold. Another issue with inframammary folds is they're not even seen. So these are examples of we don't even see where the breast joins the abdomen. We have no inframammary fold at all. So we have to remember IMFs need to be seen and open. You don't want skin folds. Skin folds can do the same thing a closed IMF can do. It can hide lesions in it, whether it's calcifications or masses. So here is a skin fold laterally on a CC. Here you can see the overlapping skin with air in it. Very classic of a skin fold. We've got air and overlapping skin in the MLO. So these would need repeats to ensure that there's nothing there. So here is the nipple in profile. Again, we talked about this briefly here was an example of a technical recall because the nipple was not in profile. The patient came back and that you can see the nipple in profile here. It is important to remember that all of these technical issues are the responsibility of the interpreting physician. So even if the technologist doesn't notice they made the error or the quality isn't perfect. It is your responsibility. If there is a mass within a skin fold that you miss because there was a skin fold, you are responsible. So interpreting physician radiologist is the final responsibility for image quality. So when you see things like this, these are reasons for technical recalls. Next, I want to talk a little bit about compression. The reason we do compression is multiple fold. It's meant to create uniformity in the thickness of the breast. So that is readily penetrated by the x-ray. It's also meant to smooth out any overlapping tissue to unoverlap it as well as to keep the breast still to prevent blurry from motion. One of the signs of inadequate compression is camel nose. And I actually don't even have an example of this on film because it just doesn't happen for us. So again, we talked about under overexposure from inadequate compression and blur is something else that can be caused by inadequate compression. Per MQSA max automated compression is 45 pounds minimum automated compression is 25 pounds and manual compression needs to be present as well and used at the discretion of the mammographer and the upper limits of compression for that is 65 pounds. This is an example of motion so if you don't compress the patient enough they can move. And you can get respiratory or other motion and we can clearly see there are calcifications here, but it doesn't look like that many it's really hard to tell their morphology right are they they look kind of amorphous they don't look like that many they don't look that concerning. When we redo this to correct for the motion now I'm super concerned. These are pleomorphic calcifications there's over double of the number I thought there were before, and this is all because of motion. So you can see if you have motion it can degrade the ability to adequately diagnose suspicious findings. Here's another example of motion this was a screening mammogram. Nothing looks really sharp here. Everything is fuzzy blurry it looks like they're moving. We had a technical recall come back. It's not crisp sharp, not blurry, much better. So again, motion, mainly will obscure calcifications usually a mass isn't as obscured but it's still good to not have any motion regardless. Camel knows this was that example of camel knows I told you about that I don't have an actual image of. So I have a mock up of it and as you can see everything is sagging the nipple is pointing down it should be up and out. The compression should be up and out nipples should point up and out breast tissue should be up and out from the chest wall with camel knows it's actually down out and sagging. So, as you can see there's, there's not a nice straight line and nice beautiful convex curve to the bottom of the breast like we usually see the nipple is pointing down, Cooper's ligaments are sagging. IMF is non existent. And these are all signs of camel knows an inadequate compression. This is it for quality determinants of mammography.