8th Baltic Congress of Radiology

Breast Radiology

oral abstract

The goal is to exchange with experience of the newest technologies and their implementation in daily practice in breast imaging from a radiographer’s point of view in Riga East University Hospital (REUH), such as contrast-enhanced mammography (CEDM), digital breast tomosynthesis-guided vacuum assisted breast biopsy (DBT-VAB) and additional mammographic views that are used. The aim is to demonstrate the necessity and the process of CEDM, to be familiar with the various CEDM artefacts and to understand their causes to minimize or eliminate potential negative effects on image interpretation. CEDM in REUH is used mostly for histologically confirmed cancer cases to evaluate extent of the disease. Radiographers have to maintain competent positioning skills and patient care. Radiographers play a large role in preparing for, performing and avoiding of artefacts of CEDM. During CEDM examination it is important to follow timing of contrast-agent delay to avoid suboptimal image quality and false-negative examination. The aim is to exchange with experience of DBT-VAB at hospital’s practice and emphasize the role of radiographer’s skills, and knowledge about use of additional mammographic views in special cases. DBT-VAB is a method for localizing and sampling breast lesions discovered on mammography that are considered to be suspicious for malignancy. Radiographers assist radiologists during the DBT-VAB procedure and maintain operation of tehnical system. In addition to competent positioning skills and anatomical knowledge, radiographers need to know various of additional mammographic views and skills to modify any projection, needs of individual patients and each clinical case. The quality of the mammographic examination is of vital importance and focus must be placed on achieving high quality standards regarding positioning and technical criteria.

Analysis of daily practice of CEDM examinations from a radiographer’s points of view, review of literature about artefacts of CEDM and its elimination in clinical practice in REUH were proceed. CEDM exam consists of three different images per breast and per view: low-energy, high-energy and recombined. Both breasts should be imaged in two standard views. Providing optimal timing and sufficient contrast-agent flow rate of bolus injector is basic principle to maintain optimal examination. Mammogram has to be complied with the highest standards regarding positioning and technical criteria in perfect timing. Analysis of literature, clinical cases and statistics about DBT-VAB procedures in REUH were proceed. The patient must be able to get on the table and lie prone with the targeted breast pendant through an aperture in the table. A non angle scout view or tomosynthesis of the targeted lesion is first obtained with the patient’s breast in compression. The lesion’s x,y and z axes are determined through measurement of the parallax shift of the targeted area from defined angles of view. Prefire stereotactic images are obtained to confirm the expected needle trajectory. The needle is then fired and postfire stereotactic images are obtained to confirm optimal final needle aperture position. A localizing postbiopsy marker clip is placed at the biopsy site. This clip facilitates future mammographic monitoring of the area and serves to guide future surgical excision. Review of literature about additional mammographic views, analysis of clinical cases and implementation of views in daily practice in REUH were proceed. In addition to the standard mammographic views, the following methods are used: - Lateromedial view (LM) and mediolateral (ML) view; - Cleopatra view or exaggerated CC view; - Cleavage view (CV); - Rolled lateral view (RL) and rolled medial view (RM); - Spot compression and magnification views; - Lateromedial oblique view (LMO); - Eklund views;

There were total 210 examinations of CEDM made in 2020, and there were 339 examinations made in 2021 in REUH. The most common patient-related factors are motion artefacts, hair artefacts, antiperspirant artefacts and air artefacts. The radiographers play a large role in preparing for, performing and avoiding of artefacts of CEDM. 75 procedures of DBT-VAB have been taken in 2020, and 99 procedures have been taken in 2021 in REUH. DBT-VAB offers many advantages over a traditional 2D stereotactic biopsy system. The most used additional views in mammography in REUH are spot compression and magnification views, cleavage view, cleopatra view and Eklund views for breasts with implants.

Both patient and technical factors may lead to unwanted artefacts at CEDM, and as the use of CEDM in clinical practice is rapidly gaining popularity, there is a greater need for radiologists and radiographers to be aware of the artefacts associated with this relatively new technology. It is important to radiographers to maintain competent positioning skills and patient care and to be acquainted with the risks of iodinated contrast-agent. It is crucial for radiographers to be familiar with the various CEDM artefacts and to understand their causes to minimize or eliminate potential negative effects on image interpretation. Digital breast tomosynthesis guided vacuum assisted biopsy offers a number of benefits. Facilitates biopsy of noncalcified abnormalities, masses, architectural distortions. Blood vessels are better visualized, and their exact location can be confidently identified. Shorter duration of the procedure. Biopsy on the prone table is generally felt to be less anxiety provoking compared with biopsy with an attachable unit, as a result there is less patient motion to interfere with accurate targeting. Successful performance of this minimally invasive procedure spares women from undergoing potentially deforming and expensive procedures to diagnose breast disease. Percutaneous image-guided biopsy is an outpatient procedure that does not necessitate general anesthesia, is readily available, less invasive, and carries very low risks. The adequate use of supplementary mammographic views to characterize the findings on standard two-view studies may provide earlier detection of breast cancer, when the findings from routine mammographic views alone are not sufficient, reduction of unnecessary follow-up examinations and visualization of lesions which are not included in standard views.

REUH have introduced new breast imaging technologies, which improve diagnosing breast cancer in early stages. CEDM and DBT-VAB were implemented into daily practice. Also expanding roles for existing technologies, providing multimodality workflow for breast diagnostic imaging, improving of positioning technique for standard and additional mammographic views are being used. The radiographers play a large role in achieving high quality standards in all these breast imaging technologies.

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