Back to Basics: Mammography

By George Tsoukatos, BPS, RT(R)

Introduction
In the United States, breast cancer is the most common cancer diagnosed in women, excluding
cancers of the skin, and it is the second leading cause of cancer-related deaths.1 According to the
American Cancer Society (ACS), more than 287 000 new cases of invasive breast cancer are
expected to be diagnosed in 2022, and more than 43 000 patients are predicted to die of breast
cancer.2 In addition, more than 51 000 women are expected to be diagnosed with in situ breast
cancer, which is an earlier form of the disease that has not yet begun to infiltrate the surrounding
tissue.2 Breast cancer risk increases as women age, and more than 80% of breast cancers occur in
women older than age 50.3 Breast cancer occurs less often in women younger than age 40 and
generally appears as a more aggressive fast-growing cancer in younger women.4 Age-related factors
have been debated, but the strongest risk factor for developing breast cancer and higher mortality
rates is a woman's age.5 In addition to age, other risk factors for developing breast cancer, including
breast density, have demonstrated more complex relationships.

According to the American College of Radiology (ACR), annual screening mammograms of age-
appropriate asymptomatic women is currently the only imaging modality that has been shown by
the preponderance of data to reduce breast cancer mortality.6 Generally speaking, the majority of
prominent clinical organizations and professional societies recommend screening mammography
as the initial imaging modality for evaluating palpable breast masses in women at or above 40 years
of age.7-10 Even with the wide range of diagnostic imaging modalities available today, breast
screening with mammography is still considered to be the gold standard, and is still the most
efficient and economical method for screening a large number of patients daily.11

Breast Anatomy
Breast Development from Birth to Adolescence
In females, the breast contain the mammary glands, which are accessory glands of the female
reproductive system and are the main structures involved in lactation.12 Breast development begins
in utero and continues into adulthood until a woman's mature breast is made up of approximately
80% fat and connective tissue and 20% glandular tissue. The breast of a newborn is primitive and is
lined with epithelial cells. It also contains stem cells that are the precursors for cellular expansion
during breast development.13-14 During the early stages of development, breast tissue grows along
the milk ridges extending from the axilla to the inguinal regions.15 Nine weeks after conception,
early breast tissue merges into 2 breast buds on the upper half of the chest. Columns of cells then
fold inward and become separate glands with ducts that extend to the nipple.17-18

The development of mature adult mammary glands begins in girls at the beginning of puberty and
continues into adolescence.12,19-20 The commonly known Tanner stages describe the sequence of
recognizable external changes that occur in the nipple, areola, and breast mound as females age.
Internally, the immature prepubertal ductal system enters a ductal growth phase followed by a
lobuloalveolar growth phase.17,20 A few years after menarche, after ovulation begins, the terminal
duct lobular unit’s form. After puberty, the breast will have gone through its primary growth cycle
and evolution.5

Anatomy and Tissues of the Developed Breast

The developed breast is a symmetrical organ located on the front of the chest, situated on both
sides of the midline, and is a modified cutaneous exocrine gland composed of skin, subcutaneous
tissue, breast parenchyma, and breast stroma.21 A fully mature breast can reach superiorly to the
clavicle (at the level of the second or third rib), inferiorly to meet the abdominal wall at the level of
the sixth or seventh rib (at the inframammary fold [IMF] or crease), laterally to the edge of the
latissimus dorsi muscle, and medially to the midsternum.22 Specifically, it occupies the chest region
from the third rib to the seventh rib and from the edge of the sternum to the armpit-axilla area.23-
24 It is comprised of epidermal, dermal, and hypodermal layers.24 The breast can reach superiorly to
the clavicle (level of the second or third rib), inferiorly to meet the abdominal wall at the level of the
sixth or seventh rib (at the inframammary old or crease), laterally to the edge of the latissimus
dorsi muscle, and medially to the mid-sternum.5

Other key anatomical points include5,15:

• A layer of fatty tissue surrounds the breast glands and extends throughout the breast, which
gives the breast a soft consistency and unified contour.

• The breast is responsive to a complex effect of hormones that cause the breast tissue to
develop, enlarge, and produce milk.

• The circular pigmented area around the nipple is called the areola.
 • Each breast contains 15 to 20 lobes arranged in a circular fashion.

• Each breast lobe is comprised of many lobules, at the end of which are small bulb-like
glands, or sacs, where milk is produced in response to hormonal signals.

• Ducts connect the lobes, lobules, and glands; in nursing mothers, these ducts deliver milk to
openings in the nipple.

• Breast tissue is drained by lymphatic vessels that lead to axillary nodes (located in the axilla
region) and internal mammary nodes (which are housed along each side of the sternum).

In fully developed female breasts, the breast ducts are tiny vessels that transport milk from the
lobules to the nipple where the milk is excreted. The breast is anchored to the pectoralis major
fascia by the Cooper ligaments. These ligaments are flexible and allow the breast to move. In most
women, the Cooper ligaments become stretched during the aging process, eventually resulting in a
ptotic breast.25 The major blood supply of the breast is the internal mammary and lateral thoracic
arteries and branches of the internal thoracic, anterior intercostal, and lateral thoracic arteries.
Venous drainage of the breast is performed by veins of the same names.25-27 Overall, at least 60% of
the blood supply to the breast comes from the superomedial perforators, which extend from the
internal mammary artery. The breast also has extensive venous drainage which is divided into the
superficial and deep veins.25 The superficial veins are found along the anterior surface of the fascia;
these veins follow the areola path under the nipple areolar complex, which is often referred to as
the venous plexus of Haller. Deep inside the breast are many large veins, which drain into the chest
wall veins.25 Fibrous tissue and fat provide support for the breast anatomy by holding the tissues in
place and are determinant factors of both breast size and shape (Figure 1) and (Figure 2).16,28
 Rivard et al. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2020.16
For educational purposes only.

Kalli et al. RadioGraphics. 2010.28 For educational purposes only.

Each breast lobe is drained by a collecting duct terminating in the nipple. The collecting duct has
several branches, which ends in a terminal ductal-lobular unit (TDLU) and serves as the functional
and histopathological unit of the breast. A normal TDLU ranges in size from 1 mm to 4 mm and is
composed of a small segment of the terminal duct and a group of ductules, which are the functional
secretory units. Specifically, the TDLU consists of the extralobular terminal duct, the intralobular
terminal duct, and clusters of 10 to 100 sac-like acini that open into the intralobular terminal duct.
These functional structures are surrounded by a specialized type of connective tissue.5,29

Lymph Nodes and Lymphatic Drainage

Lymph is a colorless fluid that that circulates through the body’s lymphatic system and tissues to
cleanse and keep them firm. Lymph nodes are considered the “filters” of the body's lymphatic
system, and their primary function is to trap and filter out bacteria, viruses, cancer cells, etc., and
ensure sure that they're safely excreted from the body.30 In regards to the breast, lymph drains from
the breast to a subcutaneous subareolar plexus and submammary plexus, where it then continues
its course to drain laterally to pectoral nodes in the axilla, superiorly to the infraclavicular and
lower deep cervical nodes, and inferiorly via the subcutaneous plexus to the abdominal wall and the
diaphragmatic nodes (Figure 3).26,31 Medially, the lymph drains to the parasternal nodes and across
the midline to communicate with the plexuses of the contralateral breast.26 Traditionally, axillary
dissection has been used in surgical procedures in breast cancer patients, who are node-positive, to
remove lymph nodes. Sentinel lymph node biopsy has replaced axillary lymph node dissection in
most patients diagnosed with early stage breast cancer.32 The complex network of the lymphatic
drainage system of the breast plays an important role in the spread of breast cancer, and the
axillary lymph nodes are studied to identify disease progression. Scintigraphy is the method of
locating the lymph node(s) through which cancer is potentially spreading from the breast.32

Figure 3. Lymph Nodes of the Upper Limb and Breast

 1. Cubital lymph node

Axillary Lymph Nodes

2. Apical axillary
3. Lateral (surface) axillary
4. Lateral (surface) axillary
5. Central axillary
6. Brachial axillary
7. Interpectoral
8. Paramammary
9. Parasternal (internal mammary)

NIH/National Cancer Institute. SEER Training Modules:

Lymph Nodes of Breast and Arm. Cancer.gov Web site. Available at:
https://training.seer.cancer.gov/lymphoma/anatomy/chains/lymph-upper.html.
Accessed June 10, 2022.31 For educational purposes only.

Changes of the Breast Related to Age and Density

Age-Related Changes
The breast undergoes a variety of physiologic changes throughout the various phases of a woman's
life, which include puberty, pregnancy, lactation, post-lactational involution, and the aging
process.33-34 Histologically, the post-pubertal nulliparous breast is surrounded by undifferentiated
lobular structures referred to as lobules type 1.17,34 After pregnancy and birth, women’s breasts
contain more complex and differentiated type 2 and type 3 lobules, which are comprised of more
ductular structures. If a woman never becomes pregnant, the breast may never achieve full
differentiation. Breast parenchyma regression accelerates when women reach menopause (in a
woman's late 40s or early 50s).17

Changes in Density
By definition, breast density is the ratio of fat to fibroglandular tissue in the breast.35 Breasts are
classified as being dense if they're comprised of more fibrous or glandular tissue than fat. From an
anatomical and physiological perspective, dense breasts have a greater percentage of supportive
and glandular tissue that produces and excretes milk. There are varying degrees of breast density
as well as factors that may lead to the development of dense breasts, which include, but are not
limited to, hereditary factors, age, pregnancy, menopause, and body weight. Dense breasts are
associated with low mammographic sensitivity, which can cause some cancers to be missed.36

As a patient's age decreases and breast density correspondingly increases, screening

mammography's accuracy also decreases. Mammograms of patients with dense breasts are less
sensitive due to X-ray beam attenuation. Glandular and fibrous tissues (dense tissue) absorb many
more X-ray beams than fat does. As a result, denser breast tissue appears whiter on mammograms,
because fewer X-ray beams reach the image receptor (IR). Conversely, fat absorbs fewer X-rays,
which allows more beams to reach the detector. As a result, fat appears darker on mammography
and is easier to read and interpret, making mammography more sensitive for patients with fatty
breasts and less sensitive for patients with dense breasts.5,13

Percent mammographic density is determined by dividing the area of white (dense) breast tissue
by the total breast area.37 Density levels viewed on mammography are usually graded on a scale of
1 through 4 using the Breast Imaging-Reporting and Data System (BI-RADS) classification system,
with 1 being the least dense and 4 being the most dense (Figure 4).38 Generally, whiter
mammogram images indicate denser breasts. Most women normally have between levels 2 to 3
breast densities.38 Studies show that women with extremely dense or dense breasts are about 5
times more likely to develop breast cancer than women with fatty breasts.38 Increased breast
density is the factor most responsible for missed cancers or for the development of interval breast
cancers, which are cancers that develop between mammographic screenings; this type of cancer is
typically detected at an advanced stage and has a poor prognosis.39

Figure 4. Breast Density on Mammograms

 Mammograms showing predominantly fatty tissue (A) (BI-RADS
density 1) and extremely dense fibroglandular tissue (B) (BI-RADS
density 4).

BI-RADS = Breast Imaging-Reporting and Data System.

Lenihan et al. Imaging Med. 2013.38 For educational purposes only.

Anatomical and Topographic “Landmarks” in Mammographic Positioning

There are several radiology-specific topographic “landmarks” developed to assist with
mammography positioning techniques. One of the most essential is the IMF, also known as the
inframammary crease or line.11 The IMF is the natural boundary at the bottom of the breast and is
where the breast and chest meet. The posterior nipple line (PNL) is an imaginary but an important
landmark in mammography positioning. The PNL is considered the axis of the nipple and
essentially delineates the alignment of the nipple to the chest wall. The PNL length is measured on
the craniocaudal (CC) and mediolateral oblique (MLO) mammographic views to determine if
enough tissue has been adequately imaged on the mammogram. On the MLO view, the PNL extends
from the nipple to the edge of the pectoralis muscle; on the CC view, it extends from the nipple to
the pectoralis muscle, or the edge of the IR.41-44

The breast is best studied by dividing it into 4 quadrants by a vertical and a horizontal imaginary
line passing through the nipple. The 4 quadrants are the upper lateral, upper medial, lower medial,
and lower lateral quadrants (Figure 5).45 The upper-outer quadrant, which extends toward the
axilla, is known as the axillary tail (AT), tail of the breast, or tail of Spence. The retromammary
space is the anatomical region that separates the breast from the pectoral muscle. This space is
filled with a layer of adipose or fatty tissue as opposed to the supporting and connective tissue
(stroma), blood vessels, and various ductal structures that make up the glandular and fibrous
tissues of the breast. Most glandular breast tissue is found centrally and extends laterally toward
the axilla in the upper-outer quadrant. This distribution increases or decreases with hormonal
fluctuations but is generally similar in the opposite breast.41-44

Figure 5. Quadrants of the Breast

 An illustration of the 4 quadrants of the breast, which include: the upper outer (superolateral) quadrant,
the upper inner (superomedial) quadrant, the lower outer (inferolateral) quadrant, and the lower inner
(inferomedial) quadrant.

ICD-O = International Classification of Diseases for Oncology.

NIH/National Cancer Institute. SEER Training Modules: Quadrants of the Breast. Cancer.gov Web site.
Available at: https://training.seer.cancer.gov/breast/anatomy/quadrants.html. Accessed June 15, 2022.45
For educational purposes only.

Preparing for a Mammogram and Screening Guidelines

Current Mammography Screening Guidelines
Most prominent medical professional associations and organizations recommend routine
mammography screenings and advocate for informed decision-making and patient access to
current screening guidelines. While some of the specifics vary slightly, Table 1 outlines the current
mammography screening recommendations by such organizations.47-56 Most organizations
recommend annual mammograms starting at age 40. The differences in breast screening
recommendations stem from what and how data were accessed while formulating these guidelines
and the benefits and risks that are taken into consideration. Each patient’s personal medical
history, as well as any pertinent family medical history, in addition to any genetic testing and age
are all factors in when to begin screening mammograms and how often they should be repeated.

Table 1. Mammography Screening Recommendations for Average-Risk Women

Starting Age Mammography

Organization Stopping Age
(Years) Interval
AAFP 50 recommended; 74 years Every 2 years
individual decision
from 40–49
ACR/SBI 40 No specified age; Annually
tailored to health status
of patient
ACS 45 recommended; Continue to life Annually between
option to start at 40 expectancy <10 years 45–54; every 1 or
2 years at 55+
ACOG Offer at 40, not later Age 75, then shared Every 1 or 2 years
than 50 decision making
ACP 50; individual decision 75 or with life Every 2 years
from 40–49 years expectancy <10 years
AMA 40 Not stated Annually
ASBrS 40 When life expectancy is Annually
<10 years
NCCN 40 Upper age limit for Annually
screening not
established; consider
severe comorbidities
limiting life expectancy
USPSTF 50 74 years Every 2 years

Note: The ACS and ACP do not recommend clinical breast examinations for BC screening for average-risk
women at any age.

ACOG = American College of Obstetrics and Gynecology; ACP = American College of Physicians; ACR =
American College of Radiology; ACS = American Cancer Society; ASBrS = American Society of Breast
 Surgeons; NCBC = National Consortium of Breast Cancers; NCCN = National Comprehensive Cancer Network;
SBI = Society of Breast Imaging; USPSTF = United States Preventive Services Task Force.

Data from Monticciolo et al. J Am Coll Radiol. 2017; Siu et al; Ann Intern Med. 2016; American Academy of
Family Physicians. Summary of Recommendations for Clinical Preventive Services: July 2017. AAFP.org Web
site. Published July 2017; Monticciolo et al. J Am Coll Radiol. 2018; Oeffinger et al; American Cancer Society.
JAMA. 2015; The American College of Obstetricians and Gynecologists (ACOG). Committee on Gynecologic
Practice. Obstet Gynecol. 2015; Erratum in: Obstet Gynecol. 2016; ACOG. Committee on Practice Bulletins–
Gynecology. Obstet Gynecol. 2017; ACOG. Committee on Practice Bulletins–Gynecology, Committee on
Genetics, Society of Gynecologic Oncology. Obstet Gynecol. 2017; Qaseem et al; Clinical Guidelines
Committee of the American College of Physicians. Ann Intern Med. 2019; AMA Policy Finder. Screening
Mammography. American Medical Association Web site. Updated 2018; American Society of Breast Surgeons.
Position Statement on Screening Mammography. BreastSurgeons.org Web site. Updated April 2019; Helvie et
al. J Natl Compr Canc Netw. 2018; Giering. Breast Cancer Screening: Resolving the Differences between
Benefits and Harm. eRADIMAGING. Published July 23, 2021. Accessed June 17, 2022.46-56 For educational
purposes only.

Pre-examination Patient Preparation

There are a few things patient needs to be aware of prior to scheduling a mammogram, which
include57:
• If the patient is breastfeeding, pregnant, or suspects pregnancy, the patient should inform
their healthcare provider and the mammography scheduling department.
• If the patient is currently experiencing menstruation, it is best it schedule the mammogram
the week before the patient gets their period or during their period. The patient’s breasts
may be tender during this time, which could make the procedure more uncomfortable due
to compression techniques of the mammogram.
• If the patient has breast implants or recently received a COVID-19 vaccine or booster shot,
the patient should inform the scheduling department.

On the day of the mammogram, the patient should follow these guidelines57-58:
• The patient should follow their normal routine, including eating normal meals, drinking
fluids, and taking medications as needed.
• The patient should not wear deodorant, perfume, lotion, or body powder, all of which may
interfere with the accuracy of the mammogram by causing artifacts.
• If the patient has any prior breast images, advise them to bring them to their appointment
so that they can be compared to the current mammogram.
Radiologic technologists (RTs) and mammographers perform a wide variety of tasks in addition to
performing the mammogram; these include: taking the patient’s medical history, confirming the
patient’s identity and the study being performed, reviewing past studies and/or test results,
providing basic instructions and background information, ensuring the patient understands the
procedure as well as any potential follow-up studies, answering all questions quickly and
accurately, describing post-examination care, and coordinating that care with other members of the
healthcare team. Males are often uncomfortable in medical settings, and those who are referred for
mammography may feel particularly ill at ease. The discomfort may be exacerbated by the presence
of changing and waiting rooms designed expressly for women. Radiology facilities should try to
dedicate space for males and offer them the same privacy and respect accorded to women.
Language barriers, disabilities, culturally derived and transsexuality preferences, or concerns must
be addressed and acknowledged by the RT and/or mammographer, and all efforts to make the
patient understand all aspects of the mammogram and feel secure in moving forward with the
examination should be undertaken.59

Screening vs Diagnostic Mammogram

Mammography is a low-dose ionizing radiation medical imaging examination that provides the
clinician with a visible image of the internal structures of the breast from both a screening and
diagnostic perspective.5,36 There are 2 types of mammograms: screening and diagnostic. A
screening mammogram is performed on asymptomatic patients at regular intervals and are
typically 2 standard projections of each breast: MLO and CC.5 On occasion, supplementary views
may be required to visualize breast tissue completely or optimally, but such views are not
ordinarily part of the routine screening examination except for women with breast implants. Some
views may be modified to accommodate patient positioning limitations. If there are suspicious
findings on a screening mammogram, the patient is called back, and a diagnostic mammogram is
performed.60

A diagnostic mammogram is used to either confirm whether a suspicious abnormality is benign or

if additional imaging is required to make a diagnosis.61 The Centers for Medicare and Medicaid
Services further defines a diagnostic mammogram as, “[…] a radiologic procedure furnished to a
man or woman with signs and symptoms of breast disease, or a personal history of breast cancer,
or a personal history of biopsy - proven benign breast disease and includes a physician's
interpretation of the results of the procedure.”62 Diagnostic mammography requires direct
radiologist supervision. A diagnostic mammogram may include MLO, CC, and/or additional views to
evaluate an area of clinical or radiographic concern. Additional views may include spot
compression, spot compression with magnification, tangential views, or other special views.60 In
order to alleviate patient anxiety, it is important that any call backs are discussed with both the
patient and referring clinician as per preset departmental protocols and regulatory guidelines.5

Breast Imaging and Legislation

The Mammography Quality Standards Act
In order to establish uniform national standards for mammography facilities, Congress passed the
Mammography Quality Standards Act (MQSA) in 1992.61 The MQSA provided a general framework
for ensuring national quality standards in facilities performing mammography studies. As a result
of the MQSA, breast screening and diagnostic facilities must now meet minimum quality standards
for personnel, equipment, and recordkeeping, and be certified by the US Food and Drug
Administration (FDA), the federal agency designated to implement MQSA. Specifically, the FDA is
responsible for developing final standards, approving accrediting bodies, certifying all breast-
imaging facilities in the US, evaluating the effectiveness of the program, and implementing
sanctions for noncompliant facilities.64-65

According to the MQSA, each breast imaging facility must be accredited, certified, and follow federal
minimum standards. Accrediting bodies are responsible for reviewing equipment evaluations and
quality control (QC) tests performed by the facility. The MQSA also requires that QC testing
protocols and outcomes be followed and maintained by each facility, which include equipment
evaluation records and an annual physicist survey. Documentation of the daily, weekly, monthly,
quarterly, and semiannual QC tests must be retained for on-site inspections. Accrediting bodies also
are responsible for reviewing the qualifications of all imaging facility personnel, including the
interpreting physicians, medical physicists, and RTs. These members of the imaging team are
qualified to perform QC tests as long as they have met initial educational and continuing education
requirements.64-65

In order to be MQSA compliant, breast imaging facilities typical incur an overall cost increase.63-65
Documentation of meeting these requirements must be available at the time of the inspection, and
maintaining these records can be labor- and time-intensive.64-65 For each patient, the MQSA
requires breast imaging facilities to maintain records of the original mammograms and reports for
a period of not less than 5 years and not less than 10 years if no additional mammography is
performed at the facility.66 Some state and local laws may require longer storage times. Some of the
benefits of being an MQSA-compliant imaging facility include63-65:

• A reduction in radiation exposure to patients by reducing repeat examinations

• Improved overall efficiency of provided diagnostic services
• Improved patient satisfaction and quality of care
• Consistency and reproducibility of image production
• Reducing patient call backs due to suboptimal imaging studies

The Breast Density and Mammography Reporting Act of 2015

As noted, breast density changes over time and decreases with age, pregnancy, menopause, higher
body weight, and the use of tamoxifen in cancer therapy. The Breast Density and Mammography
Reporting Act of 2015 requires mammography facilities to develop an evidence-based process of
informing women of the facts about breast density and potential risks. Radiologists are required to
include current information about the patient’s breast density in both the final written report that
is sent to the patient's physician and the summary of the report that’s given to the patient. The
report summary must convey the effect breast density has on obscuring the presence of breast
cancer on a mammogram, and that patients with dense breasts should discuss questions or
concerns regarding the summary with their physicians and whether or not they would benefit from
additional imaging.66-68

Enhancing Quality Using the Inspection Program (EQUIP) Initiative

In an effort to address the issue of substandard image quality in mammography, the FDA
introduced the Enhancing Quality Using the Inspection Program (EQUIP) initiative in 2016. This
initiative promotes image quality in mammography and emphasizes the need for clinical image
review. It also provides imaging facilities with an overview of the quality of the images they
produce as well as the opportunity to employ systematic image reviews and oversight to improve
quality. The Division of Mammography Quality Standards began conducting reviews of implantation
of the EQUIP initiative in 2017. A mechanism for regular quality control reviews from each RT and
radiologist must be established, and a sample of mammograms for each active RT must be on kept
on file. Documentation of corrective procedures and RT feedback must also be available for
review.69 Quality assurance goals need to be continually reassessed to ensure they reflect changing
technology and updates.44
The Evolution of Mammography Equipment
Dedicated mammography equipment debuted in the US in 1969 and contained 3 critical
components that differentiated it from conventional standard radiography equipment.69 These
components included a molybdenum (Mo) target, compression device, and the ability to use low
kilovoltage peak (kVp) exposure techniques (Figure 6).70-71 Mammography technology has evolved
over time, from conventional analog film-screen (FS), to digital computed radiography (CR)
mammography, to full-field digital mammography (FFDM), to the most recent technological
advancement, digital breast tomosynthesis (DBT).

The first FFDM system was approved by the FDA in 2000, and the first DBT unit was approved in
2011.5,36 FFDM systems are typically configured in one of the following ways: 1) slot scanning with
a scintillator and a charge-coupled device (CCD) array; 2) as a flat-panel scintillator and an
amorphous silicon diode array; 3) as a flat-panel scintillator and an amorphous selenium array; 4)
as a tiled type of scintillator with fiberoptic tapers and a CCD array; 5) or, as a high-resolution
photostimulable phosphor plates and readers (CR).70 Digital two-dimensional (2D) mammography
is currently still utilized for most mammographic screening examinations, while DBT systems are
also being incorporated and becoming more common. A major limitation of 2D mammography is
the potential overlap of tissue which could be hiding a potential cancerous lesion, which is one of
the factors that lead to the development of DBT. Additionally, the overlap of normal anatomical
structures in the breast can create a pseudo-lesion, often termed a summation artifact, which can
lead to a false-positive reading.5,72-74
Figure 6. Close-Up View of a Mammography System

MedicalGraphics. Mammography System – Closeup. MedicalGraphics.com (CC BY-ND 4.0).

Accessed June 2022.71 For educational purposes only.
Components, Technical Terminology, and Key Concepts of a Digital Mammography System
Antiscatter Grid
Typically known as “scatter,” scattered radiation occurs during mammography due to the
interaction between radiation and breast tissue and can considerably reduce image quality. The
negative effects on image quality are the most significant when the breast is thick or the breast
tissue is dense. The deterioration in quality is seen primarily as a reduction of image contrast. As a
result, antiscatter grids were developed and are used for contact (nonmagnification) imaging to
reduce noise contributed by scatter. Such grids are special soft X-ray grids that help reduce the
relative proportion of scattered radiation to total radiation from approximately 45% to 15%. A
linear grid is usually used and is characterized by the grid ratio (ie, the height of the grid strips
relative to distance between the strips). The recommended antiscatter grid ratio for mammography
ranges from 4:1 to 6:1. With geometric magnification views, the increased air gap between the
breast and the detector eliminates the need for a grid.75

Automatic Exposure Control (AEC)

Automatic exposure control is a device incorporated into mammographic imaging systems that
automatically terminates the exposure when a preset amount of radiation has been detected and
helps prevent incorrect exposures.76

To calculate the optimum individual dosage, the AEC is placed below the detector to measure the
incident dose. When the desired dose is reached, the exposure is terminated. In DM systems, the
optimum dose is calculated from a test exposure at the beginning of the procedure. This prescan X-
ray dose contributes to the required image acquisition dose. Based on the test exposure, the device
automatically selects the suitable tube current and the optimum anode/filter combination for the
breast being imaged to achieve optimal optical density, which should be between 0.6 and 2.2.75

The design of the AEC in DM units differs from those in analog mammography units. First, the dose
to the detector does not need to be constrained to the relatively narrow range suitable for FS
mammography. As a result, radiation doses can be lower or higher and can vary widely as needed
according to breast thickness. This variability also extends to the choice of technique factors such as
kVp, target, and filter material. Generally, DM systems select X-ray spectra that are more
penetrating than FS mammography. This is possible due to the loss of subject contrast that may be
compensated for by enhancement of displayed contrast during image viewing as well as by
additional computer image processing. Furthermore, a higher detector dose can be used, if desired,
leading to better image noise characteristics. However, it should be noted that once the dose is
increased beyond a noise limited image, the image provides very little subjective indication that the
dose is excessive. As a result, “dose creep” may occur and result in increases beyond optimal
levels.77

Auxiliary Filter
Based on the density and thickness of the breast being imaged, auxiliary filters are sometimes
placed in the radiation path to modify the photon spectrum of the anode material and to optimize
the radiation quality. Customization of the anode/filter combination can improve image contrast
and reduce radiation exposure. The most commonly used filter materials in mammography are Mo
and rhodium (Rh); aluminum and silver can be used as well. Copper and aluminum may be used in
digital spectral mammography.75

Breast Compression Paddle/Device

As appropriate compression of the breast is essential, a plastic paddle is often used to flatten and
immobilize the breast during mammograms. Compression helps reduce motion blurring of the
breast, separates structures in the breast tissue, and decreases the thickness. As a result, this
minimizes the amount of required radiation and the amount of scattered radiation reaching the IR.
The paddle/compression device typically has a flat bottom surface that is parallel to the plane of the
IR, with the edges perpendicular to the plane of the IR to assist in moving breast tissue away from
the chest wall and into the field-of-view. The compression plate in the DM system can be adjusted
manually or by using a foot switch (if available); breast thickness and the pressure are shown on a
display.75,77

Collimation
Collimators are devices used to restrict/narrow X-ray beams and control scatter. This results in
increased signal to noise and decreased patient radiation dose.78 The collimation standard for
mammography is an MQSA requirement, which helps limit excess radiation dose to the patient. All
DM units should have a beam-limiting device that allows the entire chest wall edge of the X-ray field
to extend to the chest wall edge of the detector and should not extend beyond any of the edges on
the detector by more than 2%.

Contrast Resolution
Contrast resolution refers to the magnitude of the difference in signal between the anatomy of
interest and its surroundings in a rendered image; it is influenced by subject contrast and display
(image) contrast. Achieving high radiographic contrast is especially important due to the subtle
differences in soft-tissue densities of normal and pathologic structures, the need to detect and
characterize minute microcalcifications, and the structural characteristics of the margins of
masses.79

Exposure Index
The exposure index is a measure of radiation exposure to the IR.80 It is directly proportional to the
total mAs value used in any given exposure. Since the tube current is normally fixed at 100 mA, the
mAs is essentially an indicator of the exposure time (ie, 100 mAs correspond to a 1 second
exposure).81

Focal Spot and Sizes

The focal spot is where the beam of electrons from the cathode strikes the anode surface. Focal spot
sizes commonly used in mammography are typically smaller than other radiologic imaging studies
and are 0.3 mm and 0.6 mm.82

Focus-to-Detector Distance
The focus to detector distance is the distance between the focal spot of the X-ray tube and the IR.
The standard focus to detector distance in mammography systems is between 60 cm and 65 cm.

Full-Field Digital Mammography (FFDM) Receptor Tray

Full-field DM units supply only 1 detector and grid, which is used for all breasts regardless of size.
With DR equipment, RTs can choose the correct paddle size for the breast or will perform
additional overlapping images to visualize all breast tissue. This is referred to as mosaic imaging, as
image tiles are fitted together to form a complete projection.

Magnification Stand
A platform upon which the breast may be placed so that it’s closer to the X-ray focal spot.83 A
magnification stand and a second, smaller focal spot of nominal size (≤0.15 mm), if magnification
mammography is performed (this capability should be present on systems that are used for
diagnostic mammography) are typically included on DM X-ray units that are specifically designed to
perform mammography.77

Mammographic Projection Labeling

The label to identify the mammographic view should be the standardized projection identifier code
developed by the ACR and the MQSA. Facilities with more than one mammography unit must
identify each unit used on the image.
Spatial Resolution
Spatial resolution refers to its ability to depict 2 adjacent structures as being distinct from one
another.84 Spatial resolution loss occurs because of blurring caused by geometric factors such as the
size of the X-ray tube focal spot and the magnification of a given anatomy of interest.79

Subject Contrast
Subject contrast is the relative difference between the X-ray transmission at the entrance plane of
the IR through different parts of the breast. Subject contrast depends greatly on the X-ray energy
spectrum, which is determined by the target material (in kVp) and on filtration (either inherent in
the X-ray tube or added).78

Target Anode Material

The target anode material for mammography units may be composed of any of the following
material:
• Mo
• Tungsten (W)
• Rh

Tube Current
The tube current is the rate of emission of electrons by the cathode. These electrons are then
accelerated toward the anode by the tube voltage. As a result, the tube current has a decisive effect
on the radiation intensity and consequently on the optical density of the image. Both tube current
(mA) and exposure time (s) have directly proportional effects on the radiation exposure and are
often referred to in combination as the electric charge—the mAs product. Expressed as beam
current in milliamperage (mA) x exposure time (S) = mAs.75

Tube Voltage
The tube voltage is the electric potential across the X-ray tube between the cathode and the anode;
it propels the electrons toward the anode and is expressed as kVp. The higher the voltage that’s
applied, the faster the electrons are propelled. In mammography, low-energy, “soft” X-rays are used
(25 kV–35 kV), because there are only slight differences in intramammary tissue absorption. In
contrast, higher energy, “hard” X-rays (120 kV) are used for chest X-rays.75

X-Ray Generator
The generator is required for delivering, modulating, and regulating the electrical energy required
by the X-ray tube (cathode-heating current, tube current, anode drive, and automatic exposure
control). The wave form (ripple) of the tube current as well as the generator power output help
determine the radiation yield, exposure time, and image quality.75

X-Ray Tube
The X-ray tube is a vacuum tube containing electrodes that emit, accelerate, and decelerate
electrons to produce radiation. The anode material determines the characteristics of the radiation.
Currently, anodes are usually made up of 2 materials: either Mo and Rh, or Mo and tungsten.75

Other features of X-ray tubes in mammography systems include85:

• They are constructed with metal tube housing
• The feature a grounded Mo/Rh anode
• The anode angle: 0°
• Tube tilt: 260°
• Axis of rotation: vertical
• Mo or Rh filters for spectral shaping

X-Ray Tube to IR Configuration

The mammography unit’s X-ray tube to IR is set up as a C-arm configuration. The whole gantry
rotates so that the tube and breast table (IR) are opposite of each other.

It should be noted that optional information that can be included on mammograms includes the
technical factors (ie, kV, mAs, compression force, and breast thickness) and the degree of obliquity
of the projection.11

Radiation Dose
Mammography
US Food and Drug Administration guidelines for the radiation dose received by a patient for FS
mammography and FFDM indicate that the average glandular dose (AGD) delivered by a single CC
view of a 4.2-cm thick, compressed breast consisting of 50% glandular and 50% adipose tissue
must not exceed 0.3 rad (3.0 mGy).6 Furthermore, a combined DM-DBT examination needs to be
below the FDA limit of 3.0 mGy.86 However, in clinical practice, this dose is typically much lower.
The dose depends on the quality of radiation, anode/filter combination, radiation detector (FS,
digital radiography, CR), and thickness and composition of the breast as well as exposure
parameters.78 As noted, the amount of radiation incident on the detector is quantified by an
exposure index parameter, and this value is directly proportional to the total mAs (mA x time) value
used in any given exposure. Since the tube current is normally fixed at 100 mA, the mAs is
essentially an indicator of the exposure time (ie, 100 mAs correspond to a 1-second exposure).81

In breast imaging, skin exposure is not the most relevant factor. The radiation dose to the glandular
tissue and breast lymph nodes is of greater concern due to its radiosensitive nature and the risk for
cancer development. Therefore, in breast imaging, the measurement of the glandular dose (DG),
more commonly referred to as the mean glandular dose (MGD), is most often used. MGD varies in a
complicated way, with differences noted in X-ray beam quality and quantity. As a comparison,
glandular dose is approximately 15% of the entrance skin dose (ESD). The MGD can be calculated
using the following equation67,88-90:
DG × ESD = MGD

The amount of MGD will depend on many factors, including the characteristics of the equipment
used, the examination technique employed, the composition, thickness, shape and lateral dimension
of the patient's breasts, and the X-ray spectra. Generally, dose increases with larger breast size and
increased breast density.67

Many patients complain that they either do not receive adequate information or that the
information they do receive is too technical or complicated to comprehend regarding radiation
dose received during a mammogram. A protocol that is simple to understand should be put in place
to answer this question by the radiation safety committee of each facility. Simplicity, accuracy, and
consistency are key to answering these types of questions pertaining to each of the modalities used
in breast imaging.88-90

All mammography systems include shielding to protect other organs of the body. In general, the use
of additional shielding (lead aprons) is unnecessary. The use of thyroid shields during
mammography examinations are unsupported by the literature and could result in unnecessary
increases in breast dose due to repeated mammograms. Thus, the use of thyroid shields is strongly
discouraged. The use of lap shields is voluntary and is only recommended in women who are or
may be pregnant at the time of the examination.91

Digital Breast Tomosynthesis

Digital breast tomosynthesis (DBT) is a breast imaging technology that provides improved
detection and characterization of breast lesions, especially in patients presenting with dense
breasts. The principle of this technique is to accumulate multiple projection of the breast, which are
then reconstructed, allowing the radiologist to review thin cross-sections, or “slabs.” This allows the
radiologist to view scans that may have been obscured by normal tissue located above and below
the lesion or region in question.72 When performing DBT, the breast is compressed and held
stationary between the compression paddle and the detector, in a similar fashion to that used in
DM.73 The X-ray tube moves in a preprogramed angle and arc overhead providing a series of low-
dose exposures at preset intervals, each from a different angle (Figure 7).92 The total angular range
covered by the X-ray tube in 3D-DBT is known as the scan angle.74 The result is a series of
projection images, which can be as thin as 0.5 mm each, that are reconstructed for
interpretation.5 Breast masses and mass margins that may otherwise be superimposed with out-of-
plane anatomical structures are clearer and more defined in the final reconstructed image, which
the radiologist can adjust using image processing techniques on a workstation.73 If a patient
undergoes either a 2D-DM or DBT for routine screening and questionable findings are discovered,
the patient is then called back for a more specialized diagnostic workup.

Figure 7. DBT Imaging System

An illustration of a commonly used DBT imaging system. The X-ray source rotates around the compressed
breast within a limited angle range and projection images are formed on the detector. The projection images
are then reconstructed into slices through the volume of the breast along the z-direction.

Kiarashi et al. Imaging Med. 2013.92 For educational purposes only.

As DBT technology developed and became more widely used, this also led to concerns about
radiation dose in patients who have had both FFDM and DBT studies. A recent study was conducted
to compare the entrance surface dose (ESD) of radiation and the AGD of radiation between FFDM
and DBT in a population of women with a variety of breast thicknesses. In patients who underwent
2-view FFDM, the highest median for ESD and median total AGD for patients with different breast
thicknesses ranged from 3.3 mGy to 9.1 mGy, and from 3.3 mGy to 6.0 mGy, respectively. However,
radiation doses for patients who underwent single-view DBT ranged from 3.1 mGy to 8.9 mGy and
1.8 mGy to 4.0 mGy. Overall, both ESD and AGD were significantly lower for DBT compared with
FFDM. Data further demonstrated a significant difference in the ESD and AGD values for different
breast thicknesses in depending on the FFDM and DBT imaging techniques that were used.5,93
Research is still being compiled that compares the clinical performance of FFDM in 2 projections
(CC and MLO) and those of DBT in a single projection (MLO) in compliance with dose constraint and
creating a high specificity/sensitivity with the single view findings.94

Current DBT screening protocols may vary based on findings of the 2D-DM, patient history, and a
variety of other factors. During 3D-DBT, the projection images are reconstructed into a data set of
slices through the breast in planes parallel to the receptor. The number of reconstructions depends
on the thickness of the compressed breast tissue, and they can be grouped together as slabs of
various thickness for assessment on the workstation.95 For a patient with an average 55-mm thick
breast, the radiologist will review approximately 250 images on a typical DBT study. For a 2D or
synthesized (composite) views, there are 4 images each. For DBT image slices that are thicker than
average (6, 1-cm thick images for each CC and MLO view) approximately 24 images are generated.96

In 2018, the ACR outlined the function of synthesized mammography (SM) as part of the DBT
imaging process. SM is newly developed software that generates a synthesized 2D image from a
DBT dataset. As outlined by the ACR, the radiation dose of SM combined with DBT is equal to DM
for a phantom image at approximately 2 mGy. The ACR further notes that studies have
demonstrated that radiologist performance using SM plus DBT is comparable to using DM plus DBT.
Moreover, screening patients with SM plus DBT results in decreased recall rates and increased
positive predictive values compared to screening with DM plus DBT, while maintaining the same
rates of cancer detection. As a result, SM is viewed as an acceptable alternative to DM when used in
conjunction with DBT, allowing for the elimination of a separate DM exposure. Because SM is
generated from the DBT dataset, SM should be interpreted in conjunction with the DBT image set.97
Examples of clearer mammograms visible on SM plus DBT versus 2D-DM are shown in Figure 8.98

Figure 8. Invasive Lobular Carcinoma on SM plus DBT vs S2DM

A 62-year-old woman with grade 3 invasive lobular carcinoma initially presented with a right breast lump.
Mammography demonstrates architectural distortion which was easier to see on SM plus DBT than S2DM
alone (arrows).

DBT = digital breast tomosynthesis; S2DM = standard 2-dimensional digital mammography; SM =

synthesized mammography.

O'Brien et al. Cureus. 2021.98 For educational purposes only.

Benign and Malignant Types of Breast Disease
Breast lesions may be benign or malignant. Although mammograms may show radiographic signs
that may suggest the type of lesion it is, the final diagnosis is obtained though the evaluation of
biopsy results by the pathologist.2 Fibrous and glandular tissues of the beast are generally known as
fibroglandular densities. X-rays pass more easily through fatty tissue than through fibrous or
glandular tissue. Fatty tissue is more radiolucent and will appear black on a mammogram.
Fibroglandular tissue is more radiopaque than fatty tissue and will appear as areas of lower optical
density on a mammogram (white areas).99

Benign breast lesions may include fibrotic tissue or cysts, fibroadenomas (smooth, solid lumps of
glandular and fibrous tissue), and intraductal papillomas (small, noncancerous, wart-like growths
that form within the milk ducts). Breast cancers may be either invasive or noninvasive. Invasive, or
infiltrating, cancers originate in the lobules or milk ducts but break through the lobule or duct wall
to invade the surrounding tissues.100 Invasive (or infiltrating) ductal carcinoma, an invasive cancer
that originates in the milk ducts, is the most common type of invasive breast cancer, accounting for
approximately 80% of cases. Invasive (or infiltrating) lobular carcinomas, which are invasive
carcinomas that originate in the lobules, account for approximately 10% of invasive breast cancers.
Other, less common types of invasive disease together make up approximately 10% of invasive
breast cancers.101 Noninvasive breast cancers, which are also called in situ cancers, are confined
within the ducts or the lobules. Noninvasive cancers of the ducts, or ductal carcinoma in situ (DCIS),
account for approximately 83% of noninvasive cancers of the breast, whereas noninvasive cancers
of the lobules, or lobular carcinoma in situ (LCIS), account for approximately 11% of in situ breast
cancers.100

Benign Breast Lesions and Abnormalities

Breast Cysts
Breast cysts are fluid-filled sacs inside the breast and are typically benign. Although breast cysts can
be found in women of any age, they’re more common in premenopausal women who are under the
age of 50. Younger women, premenopausal women, and postmenopausal women taking estrogen
are likely to have higher hormonal levels and therefore have an increased possibility of having
cysts. Breast cysts also commonly occur in postmenopausal women who are undergoing hormone
therapy.102 Breast cysts can be further classified as:
 • Simple cysts—They appear as having smooth, thin, regularly shaped walls and are filled
with fluid. Simple cysts are always benign.
• Complex cysts—These cysts have irregular or scalloped borders, thick walls, and some
evidence of solid areas and/or debris in the fluid. A complex cyst is sometimes aspirated, or
drained with a fine needle, so that the fluid inside can be tested. If blood or any unusual cells
are present, further testing may be needed to rule out breast cancer.
• Complicated cysts—Although complicated cysts share most of the features of simple cysts,
they tend to have some debris inside them. However, they don’t have the thick walls or
obvious solid components that a complex cyst has.103

Angiolipoma
Angiolipoma is a rare benign lesion composed of mature fat cells (adipocytes) associated with a
network of small, narrow-lumen vessels typically containing fibrin thrombus. This type of lesion
typically has superficial topography in subcutaneous tissue and presents as a painless mass. There
are no specific imaging features of angiolipomas, however, biopsy is needed for pathological
confirmation.104

Fat Necrosis
Fat necrosis is a common benign entity, which can be a result from direct trauma, surgery, radiation
therapy, or infection.105

Fibroadenoma
Fibroadenomas are common benign breast lesions that are made up of stromal and epithelial
components. Typically, they are also sensitive to hormones and are found more often in younger
women. Mammographically, fibroadenomas appear as mixed-density, oval, or circular lesions.105

Galactocele
Galactoceles are milk-filled retention cysts caused by a blockage of the breast lactiferous duct. They
are common in pregnant or breast-feeding woman and typically present as a painless lump. On
mammography, they may be visualized as mixed density, and circular/oval, with sharply defined
contours.105
Hamartoma
A hamartoma is a rare, benign, slow-growing breast tumor. Hamartomas are composed of variable
proportions of fat, glandular, and fibrous tissue, which determines their imaging appearance.5

Hemangioma
Hemangiomas are common vascular tumors of the breast, Pathologically, there are 2 types:
capillary and cavernous (the more common subtype) that are related to the size of their vascular
channels on histology.5,104

Hematoma
Hematomas appear mammographically as mixed-density, oval, or circular lesions and are
associated with breast trauma or surgery. Essentially, a hematoma is the result is a pooling of blood,
which can appear on a mammogram as a low-density radiopaque lesion. If calcification occurs, it
slowly becomes a mixed-density oil cyst, with typical eggshell-like calcifications, and then
eventually a high-density radiopaque lesion.99

Intraductal Papilloma
Intraductal papillomas are benign, wart-like tumors that grow within the milk ducts of the breast.
They are made up of glandular and fibrous tissue and blood vessels (called fibrovascular tissue).106
These lesions most often appear close to the nipple in larger milk ducts, but they can also grow
deep in the breast.99

Lipoma
Lipomas are common benign fatty tumors that are composed of mature lipocytes, usually
subcutaneous in location and often unilateral and solitary.5 They usually appear as radiolucent on
mammography with smooth borders and may become quite large.

Lymph Node
Lymph nodes are found under the armpit, above the collarbone, behind the breastbone and in other
parts of the body; they make up the lymphatic system, which is a network of lymph nodes and
lymph ducts that helps fight infection. They trap harmful substances that might be in the lymphatic
system and safely drain them from the body.107 On imaging studies, lymph nodes typically have a
central radiolucent area corresponding to the hilus.
Seroma
Seromas are collections of serous fluid arising unpredictably after interventional procedures or
surgical procedures.5

Cutaneous and Subcutaneous Tissue

Cutaneous refers to the outer layer of the skin, while subcutaneous tissue refers to beneath or
under all the layers of skin. Examples of cutaneous and/or subcutaneous lesions include seborrheic
keratosis, sebaceous cyst, and the epidermoid inclusion cyst, which are mostly seen in the axillary
region of the breast.

Malignant Breast Lesions and Abnormalities

Angiosarcoma
Angiosarcoma is an uncommon breast malignancy of endovascular origin. There are 2 subtypes:
primary, occurring sporadically in young women, and secondary, seen following breast cancer
treatment in older women with prior history of radiation therapy or postsurgical lymphedema.5,105

Calcifications
Breast calcifications are deposits of calcium salts in the breast, which appear radio-opaque on
mammography. The majority are benign, but they can be associated with cancer. The ability to
diagnose and appropriately manage the significant microcalcifications and differentiate them from
innocuous findings is part of the art and science of breast imaging.109

Certain types of calcifications of the breast are almost always benign, such as popcorn-type and rim
calcifications, milk of calcium, and arterial and skin calcifications. As noted by Peart, “Malignant
casting calcifications are produced when carcinoma in situ fills ducts and their branches. The cast’s
shape is determined by the uneven production of calcification and the irregular necrosis of the
cellular debris. The contours of the cast are always irregular in density, width, and length, and the
cast is always fragmented. Eggshell-like and needle-like, sharply outlined, or elongated branching
calcifications on mammography are typically benign. ‘Granulated sugar’ or ‘crushed stone’
calcifications are termed pleomorphic or granular-type calcifications and are often malignant.”99
Approximately 40% to 50% of calcifications represent malignant processes. Malignant
calcifications may appear as clustered, casting, linear, or granular.
Inflammatory Breast Cancer
Inflammatory breast cancer presents with diffuse infiltration. Rather than a single lump, this type of
cancer is characterized by skin warmth and redness, as well as a thick, pitted appearance of the skin
that resembles an orange peel. These changes are not caused by inflammation or infection, but by
the obstruction of lymph vessels by cancer cells. The breast appears inflamed, and the cancer tends
to spread quickly.100

In Situ Carcinoma
In situ cancers are noninvasive cancers and are confined within the ducts or the lobules.
Noninvasive cancers of the ducts, or DCIS, account for approximately 83% of noninvasive cancers of
the breast among women, whereas noninvasive cancers of the lobules, or LCIS, account for
approximately 11% of female in situ breast cancers.100

Invasive Ductal Carcinoma

Invasive ductal carcinoma is the most common (75%) breast cancer, presenting as an
asymptomatic screen detected or palpable mass, which may or may not include nipple discharge.
DCISs are the most common type of noninvasive carcinomas. Some lesions will progress to invasive
cancer, and some will remain clinically irrelevant. It is estimated that 14% to 50% would become
invasive if left untreated.105

Invasive Lobular Carcinoma

Invasive lobular carcinoma is the second-most common type of breast cancer. Histologically, it
infiltrates along the ducts in single rows without a desmoplastic reaction.105

Lymphoma
Primary breast lymphoma is uncommon and occurs when the breast is the only organ affected. The
most common subtype is diffuse B-cell non-Hodgkin's lymphoma. Lymphoma usually affects older
patients, presenting as a palpable mass, sometimes with skin changes, edema, and palpable lymph
nodes.105

Metastases
Metastases to the breast are rare, and most are caused from melanoma, lung cancer, lymphoma, and
ovarian cancer. A typical presentation are fast-growing, painless, palpable masses, which can be
bilateral.105
Medullary Cancer
Medullary cancer is very rare and comprises less than 5% of all diagnosed breast cancers. These
types of tumors grow rapidly and are often palpable masses. On mammography, medullary cancers
are circular/oval type mass lesions with ill-defined or circumscribed margins. The prognosis for
patients diagnosed with this type of breast cancer is better than for other types of invasive breast
cancer, and treatment is similar to treating invasive lobular carcinoma.110

Paget’s Disease of the Breast

Paget’s disease of the breast is a very rare type of breast cancer that affects the nipple region and
accounts for only about 1% to 5% of all beast carcinomas. It originates in the milk ducts and can
spread to the skin of the nipples or areola. Ninety-seven percent of patients diagnosed with this
type of breast cancer are typically also diagnosed with another type of breast cancer, so it's
important to ensure that patients diagnosed with this type of breast cancer undergo thorough
diagnostic imaging studies and tests.5

Phyllodes Tumor
A Phyllodes tumor is a lesion that presents with a leaf-like appearance that extends into the ducts
and rarely metastasizes. These tumors form within the breast’s connective tissue, such as the
ligaments and fatty tissue surrounding the lobules, ducts, lymph, and blood vessels in the
breast. They occur predominantly in middle-aged women from about 40 to 50 years of age. On
mammography, Phyllodes tumors are typically round lobulated dense masses with partially
indistinct or circumscribed margins.111

The ACR’s Breast Imaging Reporting and Data System (BI-RADS)

The ACR’s BI-RADS classification and description system was designed to standardize mammogram
reports. Developed by the ACR in 1993, the goal in creating such a system was to provide
information to physicians, radiologists, and patients in a language that was clear, meaningful, and
standardized about the results of a mammography imaging study. Based on scientific data and
developed by prominent clinicians in the field, the BI-RADS system describes key mammographic
findings and outlines appropriate steps for follow-up and patient management and treatment.112 In
general, the principles for assigning BI-RADS categories to examinations performed with DBT
should be no different from those that apply to standard DM.113-114

When using BI-RADS, breast imaging studies are assigned one out of 7 Categories based on their
visualization on screen113-114:
 • Category 0: Incomplete assessment

o Additional imaging evaluation needed (additional mammographic views)

o Should obtain previous imaging studies that may not have been available at the
time of reading

• Category 1: Negative

o Symmetrical and no masses, architectural distortion, or suspicious

calcifications

• Category 2: Benign

o 0% probability of malignancy

• Category 3: Probably benign

o More than 0% but less than 2% probability of malignancy

o Short-interval (6-month) follow-up suggested

• Category 4: Suspicious for malignancy

o Between 2% to 94% probability of malignancy

o These can be further categorized:

 Category 4A—low suspicion for malignancy (>2% to ≤10%)

 Category 4B—moderate suspicion for malignancy (>10% to ≤50%)

 Category 4C—high suspicion for malignancy (>50% to <95%)

o Biopsy should be considered

• Category 5: Highly suggestive of malignancy

o 95% likelihood of malignancy

o Biopsy should be performed

• Category 6: Known biopsy-proven malignancy

o Surgical removal when appropriate for the patient

Rating Breast Density

The ACR currently supports the rating of a patient’s breast density using a scale of A through D, as
follows113:
 Category A: The breasts are almost entirely fatty.

Category B: There are scattered areas of fibroglandular density.

Category C: The breasts are heterogeneously dense, which may obscure small masses.

Category D: The breasts are extremely dense, which lowers the sensitivity of
mammography.

Some density classification systems use a 1 through 4 numerical scale. However, to reduce
confusion regarding the BI-RADS classification system for breast abnormalities versus the
classification system for density, the ACR recommends employing the system above.113 However,
depending on the imaging facility, referring clinician, or reading radiologist, some RTs and
mammographers may still encounter usage of the numerical density rating scale. With the latter,
some breast density levels viewed on mammography may be categorized as 1 being the least dense
and 4 being the most dense.

Breast Abnormalities on Screen

While descriptions of malignant and benign breast lesions, as well as density, are essential in
learning and understanding the nuances between them, examples of these abnormalities as
captured on screen will effectively supplement this understanding. Figures 9 through 13 depict a
selection of benign and malignant breast abnormalities on mammography and DBT, several of
which also include case descriptions and patient outcomes.104,115
Figure 9. Simple Breast Cyst

A 48-year-old woman complained of a lump in her left breast. A CC (A) and an MLO DM (B) image of the left
breast reveal heterogeneous dense breasts (BI-RADS Category C) with an upper outer quadrant dense
lesion with obscured margin (arrows in A and B). No spiculated masses or microcalcifications were
visualized. CC (C) and MLO DBT (D) images show a well-defined, round, medium dense lesion with smooth
margins and minute peripheral calcific foci, which measured 16 mm × 16 mm and were associated with the
characteristic halo sign (arrows in C and D). The lesion was categorized as BI-RADS 4C on DM and BI-
RADS 2 on DBT. Histopathology after sonography-guided biopsy revealed simple cyst.

BI-RADS = Breast Imaging-Reporting and Data System; CC = craniocaudal; DBT = digital breast
tomosynthesis; DM = digital mammography; MLO = mediolateral oblique.

Basha et al. Insights Imaging. 2020.115 For educational purposes only.

Figure 10. Fibroadenoma
A 36-year-old woman complained of a lump in her right breast. CC (A) and MLO DM (B) images of the left breast
revealed heterogeneous dense breasts (BI-RADS Category C). The DM images were inconclusive and needed
further assessment. CC (C) and MLO DBT images (D) show an upper-inner-quadrant medium density oval-shaped
lesion with macrolobulated margins that measured 22 mm × 20 mm (arrows in C and D). The lesion was categorized
as BI-RADS Category 0 on DM and BI-RADS 3 on DBT. Histopathology after sonography-guided biopsy revealed
fibroadenoma.

BI-RADS = Breast Imaging-Reporting and Data System; CC = craniocaudal; DBT = digital breast tomosynthesis; DM
= digital mammography; MLO = mediolateral oblique.

Basha et al. Insights Imaging. 2020.115 For educational purposes only.

Figure 11. Galactocele on DBT

A DBT image depicts a fat density galactocele (arrow).

DBT = digital breast tomosynthesis.

Journo et al. Insights Imaging. 2018.104 For educational purposes only.

Figure 12. Invasive Lobular Carcinoma
A 35-year-old woman complained of a lump in her right breast. CC (A) and MLO DM (B) images of the right
breast reveal extremely dense breasts (BI-RADS Category D) with an outer central area of architectural
distortion (arrows in A and B). No spiculated masses or microcalcifications were visualized. CC (C) and MLO
DBT (D) images show a definite lesion with spiculated margins that measured 27 mm × 25 mm (arrows in C
and D). The lesion was categorized as BI-RADS 4A on DM and BI-RADS Category 4C on DBT.
Histopathology after surgery revealed invasive lobular carcinoma.

BI-RADS = Breast Imaging-Reporting and Data System; CC = craniocaudal; DBT = digital breast
tomosynthesis; DM = digital mammography; MLO = mediolateral oblique.

Basha et al. Insights Imaging. 2020.115 For educational purposes only.

Figure 13. Hamartoma

A mammogram showing a well-circumscribed, dense, oval-shaped mass, with a slightly heterogeneous

appearance related to its mixed content (fat and stroma) indicative of a hamartoma.

Journo et al. Insights Imaging. 2018.104 For educational purposes only.

Mammography Positioning and Breast Compression
Positioning
The goal of mammography is to obtain optimum images to achieve maximum breast tissue
visualization. Breast positioning is a key factor affecting a mammogram’s diagnostic quality.116 The
CC projection aims to increase early detection of breast cancer, increase sensitivity, and reduce the
incidence of interval cancers (cancers that occur between routine mammographic screenings).44
According to Sweeney et al, “Two views allow for visualization of breast pathologies which manifest
in a single view, either the MLO or CC, as a ‘one-view’ finding of an abnormality and require further
evaluation. Similarly, mammographic features that appear benign in one projection may appear
differently and more suspicious on the other.”44 The CC and MLO views provide the best
combination to cover the anatomy of the breast while keeping patient dose to a minimum. Besides
proper positioning, understanding radiographic exposure for mammography, topographic, and
terminology is key for an RT or mammographer to produce a quality diagnostic image

Breast Compression
Safe and proper use of breast compression in mammography is essential, and it is one of the most
basic principles used to produce a high-quality diagnostic image. Despite compression being a key
factor in image quality, no guidelines or standards exist (as of 2022) that describe an optimal breast
compression technique.119 The MQSA guidelines restrict the maximum automatic compression that
can be applied to 45 lbs with a minimum of 25 lbs. However, manual compression is at the
discretion of the mammographer. Typically, after the automatic compression stops, manual
compression must be applied to immobilize and compress the breast adequately within patient
comfort, safety, and compliance standards. The MQSA guidelines state that the total compression
force should be 111 newtons (N) (25 lbs) or more. Furthermore, as of October 28, 2002, the initial
power drive maximum compression force should be between 111 N and 200 N.120 The subjectivity
and lack of consistency of compression guidelines are key topics for accreditation and compliance
groups to consider recommending for standardization.121

When applying compression, the RT or mammographer should keep their hands between the
breast and the compression plate until the plate touches the back of the hand. Only then should the
RT or mammographer remove their hands, pull the breast out, and apply the final degrees of
compression slowly with manual controls. The mammographer should never apply the final
degrees of compression with automatic controls.11 Some of the benefits of proper compression
include122:
 • It reduces geometric unsharpness by bringing the breast closer to the IR.
• It improves contrast by reducing scatter radiation.
• It diminishes movement unsharpness by allowing shorter exposure times and while acting
as an immobilizing device.
• It reduces radiation dose; since a thinner portion of the breast tissue needs to be penetrated
if the breast is compressed, scatter radiation is reduced.
• The density of the mammogram is more uniform. Homogeneous breast thickness prevents
overexposure of the thinner anterior breast tissues and underexposure of thicker posterior
breast tissues.
• It provides a more accurate assessment of the density of masses. As cysts and normal
glandular tissue are more easily compressed, the more rigid carcinomas can potentially be
enhanced.
• It separates superimposed breast tissues so that lesions are better visualized.

Spot-Compression View
A spot view (also known as a spot-compression view or focal-compression view) is an
additional diagnostic mammographic view performed by applying the compression to a smaller
anatomical region of breast tissue utilizing a small compression paddle (Figure 14).11,123 The spot-
compression technique is used to better define the margins of a mass, because it is less obscured by
superimposed tissue, and the area of interest is moved closer to the IR. It is used to distinguish
between the presence of a true lesion and an overlap of tissues, as well to better show the borders
of an abnormality or a small cluster of faint microcalcifications in a dense area that may require
additional evaluation.123
 Figure 14. Spot-Compression Projection

Peart O. Radiol Technol. 2014.11 For educational purposes only.

Obtaining spot-compression views in both the CC and MLO projections is important, because some
cancers may not look like a mass like on a spot-compression view in one projection and may appear
spiculated in the other projection.124 With some patients, a double-spot compression view may be
needed, which can be obtained by focal compression of both sides of the breast to produce higher
spatial and contrast resolution. This is made possible due to the increased amount of breast
thinning and a significant decreased incidence of blurring because of decreased exposure time. The
double compression technique is performed with an additional device that consists of a spot-cone
incorporated at the top of a plane support combined with a standard spot-compression paddle.125

Magnification View
A magnification view is performed to evaluate and count microcalcifications and their extension (as
well to assess the borders and the tissue structures of a suspicious area or a mass) by using a
magnification device which brings the breast away from the IR and closer to the X-ray source. This
allows the acquisition of magnified images (1.5- to 2-times magnification) of the region of
interest.125 Although mammography is highly sensitive imaging modality, it is sometimes necessary
to use special techniques to define the margins of visualized breast masses, evaluate nonpalpable
lesions, or determine the exact number of calcifications.

Before performing a magnification view, the RT or mammographer must attach a firm, radiolucent
platform to the unit. This device allows the breast to be elevated from the IR, resulting in an
increased object-to-image distance (OID). 112 The platform may vary in height, depending on how
much the radiologist needs the suspicious area magnified. The standard compression device is
removed from the mammography unit and replaced with a modified compression paddle designed
especially for magnification views.127 The radiologist may also require images that combine spot-
compression and magnification depending on the abnormality that requires further investigation
(Figure 15).116 Because magnification is increased due to the combination of the divergent beam
and the resultant OID, kVp is a factor that must be considered.
 Figure 15. Spot-Compression and Magnification View

A doubtful lesion (arrow in A) is seen; a spot-compression with magnification view (B) shows normal
parenchyma.

Popli et al. Breast Cancer (Auckl). 2014.116 For educational purposes only.

When elevating the breast, a gap is produced between the breast and the IR. No antiscattter grid is
used when implementing the air gap technique. The space created reduces the amount of scatter
that reaches the IR, which is known as the air-gap effect. The intensity of the scattered radiation is
reduced because the distance between the detector and the object is increased.128 To calculate the
amount of magnification used, the mammographer must apply the following 2 formulas127:
 Formula 1
Magnification Factor = Source Image Distance/Source Object Distance

Formula 2
Image Size = Object Size x Magnification Factor

For example, if the source image distance is 20 and the source object distance is 10, the
magnification factor is 2. If the object size is 5 mm and the magnification factor is 2, then the image
size is 10 mm. In other words, because the magnification factor is 2, the visualized abnormality on
the enlarged image is 10 mm, compared to its original size of only 5 mm.127

Another technique used is electronic magnification, which provides an enlarged view of the image
by increasing the size of the matrix used to display the image data. On mammography, the image
data corresponding to the region-of-interest under investigation in the contact image is displayed in
a larger matrix. This results in a magnification factor determined by the ratio of the resulting and
original image matrix sizes.129

Positioning Techniques for Standard CC and MLO Projections

The Importance of Proper Positioning
Research has shown that poor positioning techniques in mammography result in inadequate
imaging studies and contribute to undetected cancers and increased radiation doses. In June 2018,
the FDA cited poor positioning as the single most important factor in optimizing image quality and
issued a reminder to practitioners regarding the importance of accurate mammography imaging.41
Furthermore, the ACR identified improper positioning as the primary cause for the clinical
nonacceptance of a mammography image.130 As a result, it’s vital that RTs and mammographers are
thoroughly versed in patient positioning and other techniques in order to perform accurate
mammography studies for the most important projections, CC and MLO.

Patient Preparation
It is important that premammography protocols and questionnaires be established within the
imaging department and then carried out prior to beginning the mammogram. All pertinent patient
history and information should be reconfirmed and corrected, if needed. The patient should also be
provided with a comfortable examination gown, a thoroughly cleaned and disinfected
mammography system, and confirmation that no artifacts will be created from the patient wearing
antiperspirants or jewelry, which may interfere with the mammogram (Figure 16).108 If this is the
patient’s first mammogram, the RT or mammographer should answer any questions the patient has
about the process and rehearse breathing instructions before the start of positioning.11

Figure 16. Antiperspirant Artifact

A magnified view mammogram shows radiopaque densities

overlying the axilla, which are the result of the patient wearing
antiperspirant during the imaging study.

Dialani et al. Insights Imaging. 2015.108 For educational purposes only.

General Positioning Guidelines

As previously noted, CC and MLO projections are the standard projections for both screening DM
and in most protocols for DBT as well. Quality positioning criteria for each view were originally
developed for film-screen–mammography by Bassett et al in 1993 and are still used today in digital
imaging.131 The most important screening mammography criteria for a successful study are the
inferior extent of the depicted pectoralis muscle on the MLO view, breast compression in both
views, and the depth of tissue visualized on the CC view (Table 2).41-42,131-132
Table 2. Positioning and Evaluation Criteria for MLO and CC Views
MLO View CC View
The depth of tissue visualized is determined by the The depth of tissue should be visualized within 1
PNL that extends from the nipple to the pectoralis cm (1/3″) of the MLO view.
muscle or the edge of the image, whichever comes
first.

Inferior extent of the pectoralis muscle should ideally The pectoralis muscle should be wide, posterior
be 1 cm below the PNL. to medial retroglandular fat, and have
considerable length extending to PNL or below.

A sufficient amount of compression determined by Demonstration of all medial and lateral tissue
uniform exposure levels, separation of tissues, and
upright position of the breast.

The pectoralis muscle should have an anterior In order to visualize medial tissue, there may be
convexity to ensure that the shoulder and axilla are an acceptable level of lateral tissue excluded.
relaxed.

There should be fibroglandular tissue at the posterior There should be a slight medial skin reflection at
edge of the image. the cleavage ensuring enough of the posterior
medial tissue is included.

The nipple should be in profile. The nipple should be in profile and at midline.

There should be a minimal presence of skin folds There should be a minimal presence of skin or
overlying breast tissue. fat folds.

The posterior extension of the IMF should be There should be a sufficient amount of
visualized and appear open. compression determined by uniform exposure
levels and separation of tissues.

The breast should be moved up and out of the chest

wall to demonstrate deep and superficial breast
tissues well separated.
There should be no patient motion.

CC = craniocaudal; IMF = inframammary fold; MLO = mediolateral oblique; PNL = posterior nipple line.

Johnson M. Improving Mammography Positioning: Common Errors and Overcoming Challenges.

eRADIMAGING. Available at: https://www.eradimaging.com/course/930. Published October 15, 2019.
Accessed June 15, 2022.41
To reduce patient motion during a DM, a verbal prompt is often given to the patient to take a deep
breath and hold it during exposure. However, asking the patient to do so may cause their shoulder
or breast to shift out of position just before the exposure is taken. Instead, the patient should be
asked to pause breathing or to breath slowly until the exposure is taken, which helps reduce the
chance their position will shift and image quality may be compromised.11 Similar protocols
regarding reducing patient motion and breath-holds may also be used for DBT studies.

Measuring the PNL

As discussed, the PNL is essentially the axis of the nipple and delineates the alignment of the nipple
to the chest wall. The PNL length is measured on CC and MLO views to determine if enough tissue
has been adequately imaged on the mammogram. On the MLO view, the PNL extends from the
nipple to the edge of the pectoralis muscle; on the CC view, it extends from the nipple to the
pectoralis muscle, or the edge of the IR.41-44 The PNL measurement should be within 1 cm of the
PNL measurement for the MLO projection (Figure 19).11,133
 Figure 19. PNL Measurements

An example of measuring the PNL on mammography.

ERMF = estimated radiographic magnification factor;

PNL = nipple line; IMF = inframammary fold.

Bedene et al. J Health Sci. 2019.133 For educational purposes only.

As CC and MLO projections are the most important for a mammography study, detailed protocols,
patient positioning instructions, and strategies for troubleshooting issues of quality of the images
are outlined in Table 3 and Table 4.11,41-42,116,133-142
Table 3. Positioning Techniques for CC Views

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
CC • Palpable and visible anatomical • The CC projection best visualizes
Figure 17. Positioning for CC View
landmarks should be used. the anterior, central, medial, and
posteromedial portions of the
• Be sure to bring the breast back to
breast.
its true anatomical position or the
• It does not visualize the lateral
position that it will best
and posterior lateral breast tissue
visualized.
well.
• The IR should be positioned at the
• The pectoralis major muscle is
level of the raised inframammary
seen on approximately 30% to
crease, which will require that the
40% of all CC projections;
posterior breast tissue be lifted
however, it is important not to
before positioning the IR (Figure
capture the pectoralis major
17).134
muscle in every image as it’s
• The mammographer should drape possible that other medical breast
the medial contralateral breast on tissue may not be included in the
the corner of the IR to avoid mammogram.11
pulling away medial tissue of the • Retroglandular fat is visualized
ipsilateral breast. behind glandular breast tissue.
The more parallel the IR is to the Centers for Disease Control and Prevention. What
Is a Mammogram? CDC.gov. Available at:
pectoralis muscle, the more tissue
https://www.cdc.gov/cancer/breast/basic_info/mam
 will be included in the mograms.htm. Reviewed September 20, 2021.
• The patient’s head should be
Accessed July 26, 2022.134 For educational
mammogram.11
positioned the opposite way from purposes only.
the breast being imaged.

• The patient should stand with

their feet slightly apart and with
their weight equally distributed
for stability and balance.

• The arm closest to the breast

being imaged should be
positioned at the patient’s side;
the humerus should be rotated
externally to keep the shoulder
from the compression field and
avoid rotating the patient
medially.

• The contralateral arm can be

raised. This technique maximizes
the amount of medial tissue on
the detector or the IR.
• The patient should not take a
deep breath before the exposure
as this may result in pulling the
 patient’s breast tissue from under
the compression plate.
• Instead, instruct the patient to
remain still; the exposure should
then be taken on the patient’s
suspended respiration.11,135

NOTE: It is important to visualize

medial breast tissue since it is not
demonstrated in the MLO projection.

Image Critiques, Problems, and Correction Strategies

Image Critiques
An optimal CC view visualizes the external lateral portion of the breast, the retromammary space (also known as Chassaignac's bursa or
Chassaignac’s bag), the pectoral muscle on the posterior edge, and the nipple in profile should be clearly displayed (Figure 18).116,136

The nipple should point straight back to the midline of the IR, be in profile, and be centered on the image. The medial and lateral borders of the
breast must be included in the collimated field-of-view. The PNL measurement should be within 1 cm of the PNL measurement for the MLO
projection. All images should have the appropriate markers and labeling as required by the MQSA.137

Problems with the Image Correction Strategies

• Nipple not in profile
• Raising the IR too high may prevent the
• Nipple pointing laterally or medially patient from leaning forward and relaxing
• Pectoralis not visualized into position. Over-elevating the IMF may
• Pectoralis not straight/convex also eliminate posterior and inferior Sample Image
• Lower edge of pectoralis muscle above breast tissue (lower-outer quadrant) from
Figure 18. An Ideal CC View
PNL the field-of-view.

• Inadequate coverage of lower quadrant • If the IR is too low and the breast droops,
• Mismatch in pectoralis-nipple distance superior and posterior tissue will be lost
• If the mammographer fails to elevate the from visualization during compression.
IMF on the CC and leaves the IR too low,
• An elevated shoulder tightens the pectoral
the superior and posterior tissues will
muscle and pulls up on the breast,
not be visualized.
removing breast tissue from view, and
prohibits good compression techniques.137

• If the PNL measures less on the CC view

than the MLO view, some posterior breast An example of an ideal CC view with retromammary
tissue may not be imaged. To correct this, space and pectoralis muscle (arrows). Visualization of

the mammographer should ensure that the the pectoralis muscle implies that no breast tissue along
the chest wall was excluded.
IMF is properly elevated and that the PNL
is perpendicular to the thorax.41 Popli et al. Breast Cancer (Auckl). 2014.116 For
educational purposes only.
• Excessive lateral rotation of the breast on
the CC view prevents the medial posterior
portion of the breast to be included on the
image.

• Insufficient lateral rotation will result in

the AT being excluded from the image. If
 the patient does not stretch forward
enough or lean inward, superior breast
tissue may be diminished.41

• If there is insufficient medial breast tissue,

confirm that the patient's medial ribs are
pressed against the IR and that the
compression paddle is adjacent to the
patient's medial rib cage.

AT =axillary tail; CC = craniocaudal; IMF = inframammary fold; IR = imaging receptor; MLO = mediolateral; MQSA = The Mammography
Quality Standards Act; PNL = posterior nipple line.

Data from Peart O. Radiol Technol. 2014; Johnson M. Improving Mammography Positioning: Common Errors and Overcoming Challenges.
eRADIMAGING. Available at: https://www.eradimaging.com/course/930. Published October 15, 2019; Frank et al, eds. Merrill's Atlas of Radiographic
Positioning and Procedures. 12th ed. Elsevier Mosby; 2012; Popli et al. Breast Cancer (Auckl). 2014; Centers for Disease Control and Prevention. What Is
a Mammogram? CDC.gov. Available at: https://www.cdc.gov/cancer/breast/basic_info/mammograms.htm. Reviewed September 20, 2021; Ogren A.
Back to the Basics. Allina Health Web site. Published February 2, 2019; Pacifici S, Jennings D. Craniocaudal view. Radiopaedia.org. Updated May 30,
2022. Accessed July 2022; Radswiki T, Pacifici S. Posterior nipple line. Radiopaedia.org. Updated January 22, 2018; Andolina et al. Mammographic
Imaging: A Practical Guide. JB Lippincott; 1992.11,41-42,116,134-138 For educational purposes only.
Table 4. Positioning Techniques for MLO Views

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View

MLO
• Palpable and visible anatomical • Best visualizes the optimum
Figure 19. Positoning for MLO View
landmarks should be used. amount of breast tissue in a single
view.
• Position the IR parallel to the
pectoral muscle (Figure 19).11 • Best demonstrates the extreme
posterior and upper-outer
• Tube angulation: Varies between
quadrant; however, there is
30°–70° depending on the patient’s
distortion of the anterior, central,
body habitus.
and medial breast tissue.11
• Primary angle of the MLO
• The IMF should be visualized and
projection: 45°; this may be
open with no overlap of the
adjusted by ±10° based on the
breast or abdominal tissue. The
patient’s body habitus.
anterior breast should be well
o Angle of projection for tall, thin
compressed with adequate
patients: 55°–60°
separation of the tissue and
o Angle of projection for average- without drooping.11 Peart. Radiol Technol. 2014.11
sized patients: 45°–55° For educational purposes only.
• An MLO view should also
o Angle of projection for short, demonstrate axilla, the AT, and
heavy patients: 30°–45° IMF with all the breast tissue.
• The top of the IR should be • The MLO projection must
adjusted to the same height of the represent the whole breast,
sternoclavicular joint, or halfway pectoral muscle, retromammary
between the top of the shoulder part of the breast, and whole
and the axillary crease.139 PNL.116

• The IP must be placed in the axilla

with the patient’s arm draped over
the top of the IP.

• If the IR is too high, the patient’s

arm may be raised too high, and
the pectoral muscle will not be
imaged completely; positioning the
IP too low may result in similar
imaging issues.11

• Hold the breast in an “out and up”

position (known as the “out-and-
up” maneuver) to prevent
drooping during compression; be
sure to apply taut compression.139

• If done correctly, the breast tissue

will be well separated and the IMF
will be well visualized.
 • Do not sacrifice any breast tissue
to show nipple profile.

• The patient should not take a

deep breath before the exposure
as this may result in pulling the
patient’s breast tissue from under
the compression plate.

• Instruct the patient to remain

still; the exposure should then be
taken on the patient’s suspended
respiration.11,135

NOTE: With the MLO view, the patient

should be instructed to lean forward,
toward the unit, for maximum
tissue visualization. The IR should be
positioned parallel to the pectoralis
muscle.11
Image Critiques, Problems, and Correction Strategies
Image Critiques
The MLO view is effective in visualizing the posterior and upper-outer quadrant breast tissue. The pectoral muscle should have a wide border
superiorly, with a convex anterior border, and should extend to or below the level of the PNL (Figure 20).116,140 The PNL on the MLO projection is
drawn from the nipple extending posteriorly to meet the pectoral muscle or the edge of the image at a right angle. The PNL usually is longer on the
MLO than on the CC; however, in approximately 10% of patients, the PNL is greater on the CC view.141 The IMF should be open with no overlap on
the breast or abdominal tissue. The anterior breast should be well compressed with adequate separation of the tissue and without drooping. Dense
areas of the breast must be well penetrated. All images should have the appropriate markers and labeling as required by the MQSA.137

Problems with the Image Correction Strategies Sample Image

• Inappropriate tube rotation/angle • MLO views may reduce angulation. Figure 20. Bilateral MLO
• Nipple not in profile Kyphotic patients, for the CC view the
• Pectoralis muscle not visualized mammographer can try having the
• Edge of pectoralis muscle not well patient sit in a chair and slouch if
defined clinically feasible and safe.135
• Lower edge of pectoralis above PNL line • Check the position of the patient relative
• Inadequate coverage of lower quadrant to the bottom front corner of the IR. The

• IMF not visualized patient should be facing forward, towards

the mammography unit.142

• The lower front corner of the IR should

be positioned directly below the patient’s
nipple and halfway between the anterior-
superior iliac spine and umbilicus.142

• The patient should be instructed to step

towards the RT, who should be standing The pectoralis muscle forms a “V” when
at the medial side of the breast to be viewed as mirror images.
imaged.142
Popli et al. Breast Cancer (Auckl). 2014.116
For educational purposes only.
• If the corner of the IR is placed too far
forward into the axilla, posterior lateral
and medial breast tissue may be excluded
from the image if the pectoralis muscle
margin is narrow. The RT or
mammographer should ensure that the
affected shoulder is rolled forward and
downward and that the compression
paddle is slightly anterior to the
suprasternal notch and latissimus dorsi.41

• A drooping breast on MLO may yield

superimposition and poor visualization of
inferior and anterior breast tissue. To
correct this, the RT or mammographer
should make sure that the patient's
breast is being pulled up and out while
being compressed in that position.41

• An angulation of 55° should be used for

imaging patients with small breasts,
convex sternum, and problems with spine
and pain in their shoulders.133
 • An angulation of 35° should be used for
imaging patients with shorter thoraxes
and large breasts.133

AT = axillary tail; IMF = inframammary fold; IP = imaging plate; IR = imaging receptor; MLO = mediolateral; MQSA = Mammography
Quality Standards Act; PNL = posterior nipple line; RT = radiologic technologist.

Data from Peart O. Radiol Technol. 2014; Johnson M. Improving Mammography Positioning: Common Errors and Overcoming Challenges.
eRADIMAGING. Available at: https://www.eradimaging.com/course/930. Published October 15, 2019. Accessed June 15, 2022; Popli et al. Breast
Cancer (Auckl). 2014; Bedene et al. J Health Sci. 2019; 137. Radswiki T, Pacifici S. Posterior nipple line. Radiopaedia.org. Updated January 22, 2018.
Accessed July 2022; Miller LC. Mammography for Technologists: Basic and Advanced. SBI-ONLINE.org. Presented at the 2016 SBI/ACR Breast Imaging
Symposium; April 8, 2016; Austin, TX; Radiology Key. Mammographic Technique and Image Evaluation: Summary of Important Points.
RadiologyKey.com. Published August 20, 2016. Accessed July 2022; Bassett et al. Breast Imaging: Expert Radiology Series. Philadelphia, PA:
Saunders/Elsevier; 2011; Miller LC. Tips and Trick - The Elusive IMF: What, Why, When and How. Mammography Educators Web site. Accessed July
2022.11,41,116,133,137139-142 For educational purposes only.
Positioning Techniques for Common Supplemental Projections
Mammography often requires the use of supplementary projections or positions for diagnostic
studies. Each supplementary projection outlines anatomic regions and often is needed to
complement routine projections. They also allow better visualization of suspicious
microcalcifications or borders of a lesion or suspicious finding.11 They are crucial in providing
critical imaging data on patients with certain existing conditions in which standard projections are
limited in ruling out questionable regions not fully defined on standard CC and MLO projections.
Some common supplementary projections include the lateromedial (LM) (Table 4), lateromedial
oblique (LMO) (Table 5), Cleopatra/extended craniocaudal (XCCL) (Table 6), Cleavage (CV) or
Valley (Table 7), AT (Table 8), and tangential (Table 9).11,22,99,108,135,139,143,143-150
Table 4. Positioning Techniques for Lateromedial (LM) View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
LM • This projection is used to:
• Position the X-ray tube to the IR Figure 21. Positioning for LM View
o Localize the exact position of
at a 90° angle with the central
a lesion in wire localization
ray traveling lateral to medial.
or core needle biopsy.
• The chest wall edge of the
o Provide a clearer view of a
detector or IP should be
lesion in the lower axillary
positioned to rest on the
area.
sternum (Figure 21).11
o Provide clear imaging of a
• The patient should face forward lesion in the inframammary
with their arm draped over the angle.
mammography unit.11
• It’s also useful for imaging
• It is essential to properly center patients whose sternum or areas
the edge of the IR on the around the sternum are
midsternal line; the width of the compromised to the point where
Peart. Radiol Technol. 2014.11
IR should be pressing into the the patient cannot tolerate any
For educational purposes only.
contralateral breast to assure compression or pulling tissue in
visualization of deep posterior- that area.11
medial breast tissue.139
• It can also help depict lesions
located far medio-posteriorly
 visible on the CC view only, or to
• Ask the patient to place the
depict palpable lesions in the
point of her chin as far forward
inner quadrant not seen on other
as possible on the edge of the
mammographic projections.
object IR holding the table.
• It also provides superior and
• Pull the patient’s breast tissue
inferior orientation to the nipple,
onto the IR, holding the breast
visualizes the 12 o’clock and 6-
up and out while applying
o’clock areas of the breast, and
compression.139
localizes and evaluates milk of
• The patient should not take a
calcium.143
deep breath before the
exposure as this may result in
pulling the patient’s breast
tissue from under the
compression plate.

• Instead, instruct the patient to

remain still; the exposure
should then be taken on the
patient’s suspended
respiration.11,135
Image Critiques, Problems, and Correction Strategies
Image Critiques: A small straight pectoral muscle should be shown. As much of the breast tissue should be imaged and evenly spread out as
possible and the nipple should be in profile (Figure 22).144 All images should have the appropriate markers and labeling as required by MQSA.

Problems with the Image Correction Strategies Sample Image

• Improperly positioned LM projections: the • The top edge of the IR should be Figure 22. LM View
patient’s breasts are separated so that the centered on the midsternal line and the
middle of the IR is centered on the width of the IR pressing against the
midsternal line; this may cause the contralateral breast.139
exclusion of deep medial breast tissue on
the side that is being imaged.139

Desai. Axillary nodes - benign [Case study].

Radiopaedia.org. Published March 25, 2009. Accessed
July 2022.144 For educational purposes only.
LM = lateromedial; IR = imaging receptor; MQSA = The Mammography Quality Standards Act.

Data from Peart Radiol Technol. 2014; Ogren A. Back to the Basics. Allina Health Web site. Published February 2, 2019. Accessed July 2022; Miller LC.
Mammography for Technologists: Basic and Advanced. SBI-ONLINE.org. Presented at the 2016 SBI/ACR Breast Imaging Symposium; April 8, 2016;
Austin, TX.; Hadley R. Derenburger D. Technologist’s Column: Most Commonly Used Additional Views, Part 2: Minimizing Superimposition and
Identifying Location. SBI News. Published 2020. Accessed July 22, 2022; Desai P. Axillary nodes - benign [Case study]. Radiopaedia.org. Published March
25, 2009. Accessed July 2022.11,135,139,143-144 For educational purposes only.
Table 5. Positioning Techniques for Lateromedial Oblique (LMO) View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
LMO
• The X-ray beam should be directed • This projection is necessary Figure 23. Positioning for LMO View
from the breast's lower, outer when the standard MLO
aspect to its upper, inner aspect. projection is difficult to obtain
The angle of the equipment should because of the patient’s body
be between 40°–60°.145 habitus or past surgical
procedures (Figure 24).146
• Step the patient forward so that
the medial aspect of the ipsilateral • It is useful for patients who
breast rests against the IR.22 present with kyphosis, after
undergoing open heart surgery,
• Place the edge of the IR at mid-
patients with pectus excavatum
sternum level.
(ie, sunken chest), and patients
• Adjust the height of the C-arm to
with pacemakers.
center the breast.
• When skimming the patient with
• Raise the patient’s arm up and
the mammography equipment
across the IR, so that the upper Peart. Radiol Technol. 2014.11
and compression paddle, pain
humerus rests safely on the IR For educational purposes only.
from a scar could cause
(Figure 23).11
discomfort.11,99
• The patient’s contralateral hand
should hold the handrail.
 Figure 24. LMO View on DM
• Rotate the patient inward to
capture more lateral breast tissue.

• Gently lift the breast and pull it

upward and outward; apply
compression.22

• Instruct the patient to remain

still; the exposure should then be
taken on the patient’s suspended
respiration.11,135

Catanzariti et al. Insights Imaging. 2021.146

For educational purposes only.

DM = digital mammography; IR = imaging receptor; LMO = lateromedial oblique.

Data from Peart Radiol Technol. 2014; Lillé, Marshall. Mammographic Imaging: A Practical Guide. 4th ed. Philadelphia, PA: Wolters Kluwer; 2019; Peart.
Lange Q & A: Mammography Examination. 4th ed. New York, NY: McGraw-Hill Education; 2018; Ogren. Back to the Basics. Allina Health Web site.
Published February 2, 2019. Accessed July 2022; Clinical image evaluation: mediolateral oblique view positioning. Hendrick et al; American College of
Radiology Committee on Quality Assurance in Mammography. In: ACR 1999 Mammography Quality Control Manual. Reston, VA: American College of
Radiology; 1999; Catanzariti et al. Insights Imaging. 2021.11,22,99,135,145-146. For educational purposes only.
Table 6. Positioning Techniques for Cleopatra/Extended Craniocaudal (XCCL) View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
Cleopatra/XCCL
• Begin positioning the patient as if • This projection is used to depict Figure 25. Positioning for XCCL View
they were undergoing a CC posterior lesions of the outer
projection. aspect of a breast’s AT.

• Direct the X-ray beam from • It can also be used to evaluate

superior to inferior. lateral breast tissue, including
some of the prominent AT of
• Turn the patient toward the
Spence.
contralateral side.
• It may also be used for
• Lift and gently pull the breast onto
localization of lesions in the far
the imaging surface.
lateral breast.
• Raise the C-arm so that the
Peart. Radiol Technol. 2014.11
posterolateral breast is in contact
For educational purposes only.
with the IR.

• Lean the patient slightly toward

the ipsilateral side (Figure 25).11

• Relax the patient’s shoulder down

and backwards.
 • Apply compression, while holding
the breast in place.147

• Instruct the patient to remain

still; the exposure should then be
taken during the patient’s
suspended respiration.11,135

NOTE: For better visualization of

posterior-lateral breast tissue, the X-
ray tube may be angled up to 5°.
Image Critique, Positioning Problems, and Solutions

Image Critiques: This view is performed to visualize lateral posterior breast tissue not visualized in a CC projection. Additional criteria are as
follows:
• The AT is completely imaged.
• A small straight pectoral muscle is shown in the lateral part of the breast (Figure 26).148
• The nipple is in profile.
• All images should have the appropriate markers and labeling as required by MQSA.

Problems with the Image Correction Strategies

• If a large amount of the pectoral muscle
• A large amount of the pectoral muscle
displays a bulging convex contour, the
displays a bulging convex contour.
image is more like a shallow oblique view
• The AT is not completely imaged.
and not an XCCL projection.147
 • Consult with colleagues or the radiologist Sample Image
• The nipple is not in profile.
about the positioning error. If necessary, Figure 26. XCCL View
repeat the projection or consider an
alternative projection.

Knipe. Axillary tail breast cancer [case study].

Radiopaedia.org. Published March 3, 2016. Accessed
July 20, 2022.148 For educational purposes only.

AT = axillary tail; CC = craniocaudal; MQSA = The Mammography Quality Standards Act; XCCL = extended craniocaudal.
Data from Peart Radiol Technol. 2014; Ogren. Back to the Basics. Allina Health Web site. Published February 2, 2019. Accessed July 2022; Cardenosa.
Breast Imaging Companion. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2001; Knipe. Axillary tail breast cancer [case presentation].
Radiopaedia.org. Published March 3, 2016. Accessed July 20, 2022.11,135,147-148 For educational purposes only.
Table 7. Positioning Techniques for Cleavage View (CV) or Valley View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View

CV or Valley
• Ask the patient to step towards the • This view is useful for visualizing Figure 27. Positioning for CV
mammography unit. deep lesions in the or Valley View
posteromedial aspect of the
• Turn the patient’s head toward the
breast that are closest to the
contralateral breast.
chest wall, where the medial
• To position the patient from
quadrants of both breasts are
behind, the RT should stand
visualized on the same image.145
behind the patient and wrap their
• This view may also be performed
arms around the patient’s front to
when some of the breast being
reach the breasts.143,145
imaged is pulled or left out due
• RTs can also position the patient
to the opposite breast being left
by standing on the medial side of
out of the compression field.
the breast of concern.
• It’s also useful when a finding in
• Elevate the IMF to the natural
the MLO view cannot be seen on
height and place both breasts on Peart. Radiol Technol. 2014.11
the CC view.145
For educational purposes only.
the IR; the area of interest should
• This view is beneficial for
determine the height of the IR.
imaging a heavier patient or one
• Gently shift the patient’s breast
with large breasts.
tissue forward, so that all of the
 cleavage is included in the image
(Figure 27).11

• To use the sensor cell on the AEC

for equipment defined exposure,
remember to off-center the
cleavage, so that the breast of
concern covers the photocell. The
cleavage will not be in the center of
the IR.145

• If there is not enough breast tissue

to cover the photocell, a manual
technique must be used.145

• Be sure to apply proper

compression.

• Instruct the patient to remain

still; the exposure should then be
taken on the patient’s suspended
respiration.11,135

Image Critiques, Problems, and Correction Strategies

Image Critiques: Having the posteromedial aspect of both breasts visualized on one image in patients with normal-size breasts. All images should
have the appropriate markers and labeling as required by MQSA.
 Problems with the Image Correction Strategies Sample Image

• Both breasts are not fully visualized on • Review positioning strategies used initially. Figure 28. Cleavage View
screen after imaging a patient with large Reposition the breasts as needed.
breasts.
• Make sure the breast of interest is directly
• The breast of concern is underexposed. over the AEC sensor cell.

Holland M. Normal mammographic cleavage view

[Case study]. Radiopaedia.org. Published October 25,
2013. Accessed July 2022.149
AEC = automatic exposure control; CC = craniocaudal; CV = cleavage view; IMF = inframammary fold; IR = imaging receptor; MLO =
mediolateral oblique; MQSA = Mammography Quality Standards Act; RT = radiologic technologist.

Data from Peart Radiol Technol. 2014; Ogren. Back to the Basics. Allina Health Web site. Published February 2, 2019. Accessed July 2022; Hadley R. Derenburger D.
Technologist’s Column: Most Commonly Used Additional Views, Part 2: Minimizing Superimposition and Identifying Location. SBI News. Published 2020. Accessed July
22, 2022; Clinical image evaluation: mediolateral oblique view positioning. Hendrick et al; American College of Radiology Committee on Quality Assurance in
Mammography. In: ACR 1999 Mammography Quality Control Manual. Reston, VA: American College of Radiology; 1999; Holland. Normal mammographic cleavage view
[Case study]. Radiopaedia.org. Published October 25, 2013. Accessed July 2022.11,135,143,145,149 For educational purposes only.
Table 8. Positioning Techniques for Axillary Tail (AT) View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
AT
• Determine the angle of the • The AT view isolates the AT in an Figure 29. Positioning for the AT View
machine based on the patient’s anteroposterior plane.
body habitus. The angle should be
• This view is used only to provide
parallel to the AT of the breast in
focal compression of the AT and
the anteroposterior plane, which is
will not provide true orientation
generally 25°–30° (Figure 29).11
to the nipple in the sagittal or
• The patient’s arm should be axial plane.143
draped behind the top of the IR
• This view may also be used to
with the elbow bent and flexed.
examine swollen lymph nodes.99
• The edge of the IR should be
placed along the edge of the chest
wall.
Peart. Radiol Technol. 2014.11
• Gently pull the AT region of the For educational purposes only.
breast away from the chest wall
and onto the IR.

• Hold the axillary region in place

while applying compression. Only
 the lateral tissue should be
visualized.143,145

• Central tissue should not be

included in the field-of-view.143

• Instruct the patient to remain

still; the exposure should be taken
on the patient’s suspended
respiration.11,135

NOTE: As this view is an oblique

projection of the axillary area or tail of
the breast, and the degree of obliquity
often depends on the radiologist’s
preference.145
Image Critiques, Problems, and Correction Strategies

Image Critiques: This view is used to visualize glandular tissue that extends high into the axillary region without superimposition of pectoral
muscle.147 All images should have the appropriate markers and labeling as required by MQSA.
 Problems with the Image Correction Strategies Sample Image
• The humeral head is included with the • Re-image the patient making sure the Figure 30. AT View
image. humeral head is not included during
• Central breast tissue is included in the compression. Inclusion may suggest that
image. compression of the breast during imaging
was inadequate.
• If central breast tissue is included in the
field-of-view, visualization of the axillary
region may have been excluded.

Peart. Radiol Technol. 2014.11

For educational purposes only.

AT = axillary Tail; IR = imaging receptor; MQSA = The Mammography Quality Standards Act.

Data from Peart Radiol Technol. 2014; Peart. Anatomy, physiology, and pathology of the breast. In: Lange Q & A: Mammography Examination. 4th ed. New York, NY:
McGraw-Hill Education; 2018; Ogren. Back to the Basics. Allina Health Web site. Published February 2, 2019. Accessed July 2022; Hadley R. Derenburger D.
Technologist’s Column: Most Commonly Used Additional Views, Part 2: Minimizing Superimposition and Identifying Location. SBI News. Published 2020. Accessed July
22, 2022; Clinical image evaluation: mediolateral oblique view positioning. Hendrick et al; American College of Radiology Committee on Quality Assurance in
Mammography. In: ACR 1999 Mammography Quality Control Manual. Reston, VA: American College of Radiology; 1999; Cardenosa. Breast Imaging Companion. 2nd ed.
Philadelphia, PA: Lippincott, Williams & Wilkins; 2001.11,99,135,143,145,147 For educational purposes only.
Table 9. Positioning Techniques for the Tangential View

Mammographic
Patient Positioning Techniques Anatomy Best Depicted Patient Positioning Example
Projection/View
Tangential Figure 31. Positioning for
• After reviewing the CC and MLO • The tangential view can be used
Tangential View
screening views, identify the breast to locate skin calcifications and
quadrants that contain the area(s) to minimize the superimposition
of interest. of dense glandular tissue when
imaging palpable
• Before positioning the patient, set
abnormalities.143
the mammography unit’s automatic
compression release to 0. • This view also assists with
confirming suspected
• Using the fenestrated biopsy paddle
calcifications near the skin that
with alphanumeric coordinates,
are seen upon initial screening,
position the fenestrated portion of
although, the implementation of
the paddle over the approximate
DBT has decreased the need for
location of the calcifications. Be Peart. Radiol Technol. 2014.11
this view. For educational purposes only.
certain the proper skin surface is
closest to the paddle window • This view is also useful for
(Figure 31).11,143 placing dermal calcifications or a
palpable abnormality over the
• Take the exposure.
subcutaneous fat, allowing
• Using the coordinates, mark the
visualization of the
location of the area of concern with
abnormality.150
 a BB marker and release
compression.

• Visualize an imaginary line from the

BB marker to the nipple. Form a
mound with the breast tissue along
this line. Be sure that the nipple is
at one end and the marker is at the
other. Place the marker tangential
to the X-ray beam.

• Rotate the gantry so the IR is

parallel to the imaginary line.
Reposition the patient or the breast
to align as needed.

• This positioning is similar to a

nipple-in-profile view, but this
approach demonstrates the BB
marker in profile.143

• Instruct the patient to remain

still; the exposure should then be
taken upon the patient’s suspended
respiration.11,135
Image Critique, Problems, and Correction Strategies

Image Critiques: This projection is only used to localize the abnormality in question and its anatomical location and lesion categorization (Figure
32).108 All images should have the appropriate markers and labeling as required by MQSA.
Sample Image
Problems with the Image Correction Strategies
Figure 32. Tangential View
• The patient and breast tissue may be • If the patient cannot tolerate the extended
manipulated for a longer than normal time needed to complete the view, discuss
period of time for this view. the patient's options with department
colleagues or the radiologist.
• The breast tissue must remain compressed
until the marker has been placed on the • Determine if imaging the area in question
skin (which may involve several minutes of with DBT would be a better option.
uncomfortable compression), which the
patient may not be able to tolerate.

A sebaceous cyst or epidermal inclusion cyst

captured on a tangential view.
Dialani et al. Insights Imaging. 2015.108
For educational purposes only.
CC = craniocaudal; DBT = digital breast tomosynthesis; IR = imaging receptor; MLO = mediolateral oblique; MQSA = The Mammography
Quality Standards Act.

Data from Peart Radiol Technol. 2014; Dialani et al. Insights Imaging. 2015; Ogren. Back to the Basics. Allina Health Web site. Published February 2,
2019. Accessed July 2022; Hadley R. Derenburger D. Technologist’s Column: Most Commonly Used Additional Views, Part 2: Minimizing
Superimposition and Identifying Location. SBI News. Published 2020. Accessed July 22, 2022; Pacifici S, Murphy A. Tangential views. Radiopaedia.org.
Updated September 27, 2021. Accessed July 2022.11,108,135,143,150 For educational purposes only.
Common Positioning Deficiencies and Errors on CC and MLO Projections
Given patient and equipment variables, positioning continues to be a challenge in obtaining quality
mammograms and has been included as reason for failure to adhere to mammography
accreditation and quality standards (MQSA). In 2015, the FDA reported that during breast imaging
facilities’ first attempts at ACR/MQSA accreditation that 92% of all clinical images that were found
to be deficient were due to deficiencies in positioning. 44 Results from an examination of over 5300
images revealed the most common positioning errors in standard CC and MLO mammography
projections (Table 10).116

Table 10. Common Errors on CC and MLO Projections

Ideal Parameter Not

View Right Breast Left Breast Bilateral
Seen

CC View Nipple not in profile 30 (1.115%) 27 (1.003%) 23 (0.855%)

(2691
Mammograms) Nipple pointing lateral or 98 (3.642%) 105 (3.902%) 80 (2.973%)
medial

MLO View Nipple not in profile 29 (1.078%) 27 (1.003%) 22 (0.818%)

(2691
Mammograms) Pectoralis not seen 20 (0.743%) 17 (0.632%) 14 (0.520%)

Pectoralis margin not 11 (0.409%) 12 (0.446%) 19 (0.706%)

straight/convex

Lower edge of pectoralis 71 (2.638%) 61 (2.267%) 56 (2.081%)

muscle above PNL

Inadequate coverage of 83 (3.084%) 87 (3.232%) 75 (2.787%)

lower quadrant

Mismatch in pectoralis– _________ _________ 104 (3.865%)

nipple distance

Nonvisualization of IMF 71 (2.638%) 79 (2.936%) 32 (1.189%)

CC = craniocaudal; IMF = inframammary fold; MLO = mediolateral oblique; PNL = posterior

nipple line.

Popli et al. Breast Cancer (Auckl). 2014.116 For educational purposes only.
Imaging Special Populations
Although routine breast screening usually includes a 4-projection series, comprising the CC and
MLO projections of both breasts, not all patients are the same size and age, and some have varying
body habitus. Knowing how to modify the standard projections to account for the individual
patient's specific needs and situation requires expertise in breast anatomy and physiology, as well
as positioning skills that can yield accurate and reliable images. Special imaging circumstances
require mammographers to analyze the imaging situation and discuss with the radiologists
potential imaging solutions.59 Table 11 outlines some of the positioning problems that may be
encountered with special needs patients and how best to navigate each. 16,40-41,132-134
Table 11. Navigating Mammography and Special Population Patients

Imaging Deficiency/
Patient Type or Description Solution
Condition
Motion Artifacts Motion artifacts are usually the result of patient • Make sure that adequate compression is
movement and are most often visible on MLO being applied to the breast.
views. One of the most common reasons for • Communicate proper breathing instruction
motion in the lower-inner quadrant of the left to the patient prior to taking the exposure.
MLO view is due to heart motion in the axillary
region, which is involuntary and cannot be
controlled.

Patients with Kyphosis is defined as excessive curvature of the • The RT/mammographer may discuss with
Kyphosis thoracic spine, a condition leading to a the radiologist to perform the CC or “from
hunchbacked posture. The exaggerated thoracic below” (FB) projection instead of the
curvature and rounded shoulders, which are standard CC projection.
common in patients with moderate-to-severe • The FB CC projection may be taken by
kyphosis, cause a sunken chest that pulls breast flipping the entire gantry upside down.
tissue forward, presenting RTs and
mammographers with such imaging challenges as
how best to capture the breast, manage patient
artefacts (eg, chin, neck, and ears), and ensure
safety and comfort during the examination.
Patients with Implant Implanted medical devices such as pacemakers, The RT or mammographer may need to adjust
Devices defibrillators, and vascular access ports, raise the imaging of the affected breast by using
special considerations that RTs and alternative projections, taking care to prevent
mammographers must assess on a case-by-case the pacemaker or defibrillator from contacting
basis to identify the best imaging approach to the compression device as it moves across the
effectively capture and compress breast tissue. fixed tissue margins.

Patients with Imaging patients with small breasts can be • The MLO projection is usually easier to
Small Breasts complicated in several ways, especially if the visualize accurately, as the patient can
patient's breasts are also firm. RTs and slouch in place. This position causes the
mammographers must find a way to visualize the breast tissue to fall forward, thereby
extreme posterior tissue, minimize skin folds, and covering the AEC sensors.
ensure that the breast tissue covers the automatic • The MLO projection should be performed
exposure control sensors to obtain proper prior to the CC, which may require a manual
exposure. exposure technique, which can be adjusted
to accommodate variations in breast
thickness.
• For better control, the RT or
mammographer may want to use both
hands to grasp the posterior tissue at the
thorax, moving the upper body and breast
tissue to the IR.
Patients with The challenge with this population is choosing an • To make sure that the entire breast is
Large Breasts approach that ensures both adequate tissue included from the medial to the lateral
inclusion and appropriate compression. If the margin, and from the posterior to the
patient's breast is of a sufficiently large size, the anterior margin in the CC image, 2 or 3
active area of the digital IR may be too small to overlapping exposures may be
include all margins within the mammogram. necessary. These overlaps should contain
approximately 1ʺ of tissue between sections.

Patients with Pectus Patients with either pectus excavatum (a sunken • Two CC views may be required to visualize
Excavatum or Pectus chest) or pectus carinatum (where the chest both the medial and lateral breast tissue in
Carinatum appears to be pushed outward; also called “pigeon patients presented with pectus excavatum.
chest”), the latter of which features a prominent • Patients with pectus carinatum are difficult
sternum caused by bone protrusion and the to visualize on MLO, because the
narrow depression that forms either side of the compression plate may cause substantial
rib cage. discomfort when it strikes the sternum.59
• With these patients, LMO or LM views are
preferred. These views allow for
compression from the lateral side of the
breast with little pain placed on the
protruding bone.
Skin Folds, Fat Folds, • Artifacts from all of these may all occur on • Consult with a department team member or
and Wrinkles either CC or MLO views. the radiologist, who can help the RT or
• Folds and wrinkles may produce mammographer determine when the
architectural or negative-density distortions imaging study should be repeated.
that may obscure the surrounding breast • The RT or mammographer should be
tissue. cautious while attempting to reduce the
• The RT or mammographer needs to take number of skin and/or fat folds. These
care when handling skin folds, fat folds, and should never be smoothed out or pushed
wrinkles with postsurgical and/or elderly posteriorly away from the nipple to
patients, who may be fragile, and have eliminate a fold. Doing so will eliminate
sensitive thin skin that tears easily. posterior breast tissue from the
mammogram.
• Common techniques for reducing skin or fat
folds and wrinkles in the MLO view include:
o Lifting the breast upward and pulling
out breast tissue before placing the
breast on the IR.
o Maintaining the "up and out" position
until compression is applied.
o Instructing the patient to lift their
contralateral breast up and back
without pulling tissue from the breast
being imaged.
• Vertical folds in the IMF on the MLO view
usually occur on the lateral side of the
breast, which can be difficult for the RT or
mammographer to see when positioning the
patient. To avoid and/or correct folds, the
RT or mammographer should:
o Smooth lateral and inferior breast
tissue before lifting the breast up and
out from the chest wall.
o Check the position of the IMF; do not
pull too much lateral breast tissue in
front of the IR as this will cause
additional folds.

• Skin folds in the axilla on the MLO view of a

patient with large breasts are sometimes
unavoidable, however, folds can be
minimized by ensuring the IR is placed
under the pectoralis muscle, in front of the
posterior skin folds and latissimus dorsi
muscle.
• To remove or minimize skin folds, fat folds,
or wrinkles in the CC view, RTs or
mammographers can:
 o Use one or more fingers to smooth out
the breast tissue when compression is
being applied.
o Position the patient toward the
mammography unit.
o Pull the breast forward starting at the
chest wall.
o Elevate the IR to the height of the IMF.

Skin Lesions and The most common skin lesions include keratosis, • RTs or mammographers may be requested
Scars moles, skin tags, and epidermoid cysts. Scars are to mark all skin lesions and scars with
often the result of surgical intervention. radiopaque markers.
• Others may be asked for a detailed diagram
by the radiologist of the breast that indicate
where skin lesions or scars are located.

AEC = automatic exposure control; CC = craniocaudal; LM = lateromedial; LMO = lateromedial oblique; MLO = mediolateral oblique; IMF =
inframammary fold IR = imaging receptor; RT = radiologic technologist.

Data from Peart Radiol Technol. 2014; Johnson M. Improving Mammography Positioning: Common Errors and Overcoming Challenges. eRADIMAGING.
Published October 15, 2019. Accessed June 15, 2022; Marks S. Patient-Centered Breast Imaging and Patient Treatment. eRADIMAGING. Published
December 4, 2020; Accessed July 20, 2022; Radiology Key. The First Question. RadiologyKey.com. Published August 25, 2019. Accessed July
2022.11,41,59,151 For educational purposes only.
Conclusions
Early detection of breast cancer depends on high-quality breast imaging techniques. Understanding
breast anatomy and development and being able to identify key structures of the breast is essential
in also being able to successfully perform breast screenings and mammograms. RTs and
mammographers will likely be performing a wide variety of breast examinations, ranging from
first-time screenings, to in-depth examinations of potential malignancies. Understanding the
breadth and scope of the imaging study at hand, the patient’s history, and any conditions or
physical restrictions that patient may have should be taken into consideration at the onset of the
study.

It's important that RTs and mammographers maintain clear communication with the patient in
regards to describing how the mammogram will be taken and how the patient should be positioned.
During mammography, many patients are improperly positioned, and as a result, the
mammography study may be inconclusive. Improper positioning can also lead to various artifacts
and breast pathology can be missed. To avoid all these potential issues, the mammogram must be
tailored as per specific needs of the individual patient. This can only be accomplished by employing
a team approach; all imaging professionals, from the mammographer to the radiologist, and all the
support staff, should all be involved and work together in order to capture, review, and successfully
diagnose their patients.
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