Contents

Preface iii

  1. Introduction 1
  2. 1 Usefulness of Mammography 1
  3. 2 Usefulness of Mammography for Breast

Cancer Screening 1

  1. 3 Purpose and Scope 4
  2. Clinical Mammography 6
  3. 1 Anatomy 6
  4. 2 Viewing a Mammogram 9
  5. 3 Image Identification 12
  6. 4 Breast Positioning 13
  7. 4.1 Craniocaudal View 16
  8. 4.2 Mediolateral-Oblique View 19
  9. 5 Clinical Considerations on Positioning 35
  10. 5.1 Grid 35
  11. 5.2 Magnification 35
  12. 5.3 Reliability of the Automatic Exposure Control . 39
  13. 5.4 Compression 42
  14. 5.5 Technical Decisions 45
  15. 6 Double Interpretation of Screening Mammograms . . . . 46
  16. Equipment 47
  17. 1 X-Ray Unit 47
  18. 1.1 Introduction 47
  19. 1.2 Mechanical Assembly and General Considerations 52
  20. 1.3 X-Ray Source Assembly 56
  21. 1.4 X-Ray Generator 66
  22. 1.5 X-Ray Beam Geometry 69
  23. 1.6 X-Ray Beam Energy and Intensity 71
  24. 1.7 Exposure Control 74
  25. 1.7.1 Automatic Exposure Control 74
  26. 1.7.2 Manual Exposure Controls 79
  27. 1.8 Compression Device 80
  28. 1.9 Grid 87
  29. 1.10 Magnification Mammography 93
  30. 2 Screens, Films, and Film-Processing Systems 96
  31. 2.1 Introduction 96
  32. 2.2 Screens 97
  33. 2.3 Films 98
  34. 2.4 Film-Processing System 99
  35. 2.4.1 Processing Cycle Time 100
  36. 2.4.2 Developer Temperature 101
  37. 2.4.3 Chemicals 103
  38. 2.4.4 Replenishment 105
  39. 2.4.5 Agitation 106
  40. 2.4.6 Drying 106
  41. 2.5 Maintaining the Darkroom and the Processor . 106
  42. 3 Digital X-Ray Mammography 109
  43. 3.1 Digital Imaging Detectors 110
  44. 3.2 Digital Mammography System Designs 113
  45. 3.2.1 Area Detectors—Full Field 113
  46. 3.2.2 Scanned-Beam Detectors 116
  47. 3.3 Digital Imaging Display Monitors 118
  48. 3.4 Exposure Techniques 119
  49. 3.5 Digital Mammography Applications 119
  50. 3.5.1 Real-Time Image Display 120
  51. 3.5.2 Post-Acquisition Image Enhancement 120
  52. 3.5.3 Image Archiving and Retrieval 121
  53. 3.5.4 Teleradiology Applications 121
  54. 3.5.5 Dual-Energy Subtraction Imaging . . . 122
  55. 3.5.6 Computer-Aided Image Analysis 122
  56. 3.5.7 Computer-Aided Instruction 124
  57. 3.6 Future Developments in Digital Mammography 125
  58. 4 Stereotactic Breast Biopsy 126
  59. Image Quality 131
  60. 1 Introduction 131
  61. 1.1 Mammographic Image Quality 131
  62. 1.2 Screen-Film and Digital Mammography 132
  63. 2 Factors Affecting Image Quality and Radiation Dose . 133 4.2.1 Contrast 133
  64. 2.1.1 Subject Contrast 133
  65. 2.1.1.1 Scattered Radiation 142
  66. 2.1.1.2 Grids for Mammography. . 144
  67. 2.1.1.3 Breast Compression 145
  68. 2.1.2 Receptor Contrast 145
  69. 2.2 Spatial Resolution 148
  70. 2.2.1 Motion Blurring 150
  71. 2.2.2 Geometric Blurring 150
  72. 2.2.3 Receptor Blurring 153
  73. 2.3 Noise 156
  74. 2.4 Artifacts 166
  75. 3 Summary 167
  76. Dose Evaluation 168
  77. 1 Introduction 168
  78. 1.1 Requirements of a Dosimetry Method 168
  79. 1.2 Coverage 169
  80. 2 Risk-Related Dose 169
  81. 2.1 Radiation Risk 169
  82. 2.2 Variables Affecting Dose 169
  83. 2.3 Why "Mean Glandular Dose?" 173
  84. 2.3.1 Absorbed Dose, X-Ray Exposure, and Air Kerma 173
  85. 2.3.2 Depth Dose Distributions 174
  86. 2.3.3 Mean Glandular Dose and Other

Dose Terms Compared 174

  1. 3 Dose-Evaluation Principles 176
  2. 3.1 Introduction 176
  3. 3.2 Determination of Mean Glandular Dose (in millirad) per 1 R Entrance Skin Exposure (free-in-air) 177
  4. 3.3 Needed Measurements 198
  5. 3.4 Application to Patient Dosimetry 199
  6. 3.4.1 Comparing Techniques 199
  7. 3.4.2 Monitoring Patient Dose 199
  8. 4 Published Dose Recommendations and Surveys 200
  9. 4.1 Recommendations 200
  10. 4.2 National Surveys 200
  11. 5 Summary 201
  12. Quality Assurance 202
  13. 1 The Current Status of Quality Assurance in the United States 202
  14. 2 Essential Elements of an Effective Quality-Control Program 204
  15. 2.1 Selection of Mammography Equipment 205
  16. 2.2 Selection of Screens and Films 206
  17. 2.3 Selection of Film-Processing Conditions 206
  18. 2.4 Quality-Control Procedures 207
  19. 2.5 Acceptance Testing Procedures 210
  20. 3 Quality Administration (Medical Audit) 210
  21. 3.1 How to Conduct an Audit 211
  22. 3.2 Medical Audit Results from an Expert Mammography Screening Practice 215
  23. 3.2.1 Patient Demographics 215
  24. 3.2.2 Radiologist Demographics 217
  25. 3.2.3 Disposition of Abnormal Interpretations 219
  26. 3.2.4 Biopsy Results 220
  27. 3.2.5 Characteristics of Breast Cancers. . . .221
  28. 3.3 How to Interpret Audit Results 224
  29. 3.4 How to Use Audit Results Effectively 230
  30. 4 Mammography Interpretive Skills Assessment 231
  31. 5 Legislative Issues Relating to Quality Assurance . . . . 233
  32. Benefits and Risks of Mammography 235
  33. 1 Benefits 235
  34. 1.1 Introduction 235
  35. 1.2 Comparative Detection Sensitivity of Mammography and Physical Examination. . . . 236
  36. 1.3 Breast Cancer Survival Rates 237
  37. 1.4 Limitations of Survival Rate Data 237
  38. 1.5 Randomized Controlled Trials 238
  39. 1.5.1 Advantages and Limitations 238
  40. 1.5.2 Results for Women of All Ages 240
  41. 1.5.3 Results for Women Ages 50 and Older at Entry 242
  42. 1.5.4 Results for Women Ages 40 to 49 y at Entry 243
  43. 1.5.5 Results for Screening Women Ages 75 and Older 248
  44. 1.5.6 Estimation of Currently Attainable

Benefit from Mammographie Screening 249

  1. 1.6 Recent Service Screening Results 250
  2. 1.7 Screening Guidelines 252
  3. 2 Radiation Risks of Mammography 252
  4. 2.1 Factors Defining Breast Cancer Risk 253
  5. 2.2 Quantitative Risk Estimates 255
  6. 3 Radiation Risk Versus Benefit of Mammographic Screening 258
  7. Other Breast Imaging Modalities 267
  8. 1 Ultrasound 268
  9. 1.1 Ultrasound for Cyst-Solid Differentiation . . . . 269
  10. 1.2 Ultrasound for Benign-Malignant Differentiation 269
  11. 1.3 Ultrasound for Breast Cancer Screening 271
  12. 1.4 Ultrasound to Evaluate Complications of Breast Implants 273
  13. 2 Thermography 274
  14. 3 Transillumination 276
  15. 4 Computed Tomography 277
  16. 5 Magnetic Resonance Imaging 279
  17. 6 Magnetic Resonance Spectroscopy 283
  18. 7 Nuclear Imaging 284
  19. 7.1 Sestamibi Scintimammography 285
  20. 7.2 Positron Emission Tomography 286
  21. Summary and Conclusions 287
  22. 1 Summary 287
  23. 2 Conclusions 290

Glossary 292

References 302

The NCRP 346

NCRP Publications 355

Index 366

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