X-Ray system

Principle of an X-ray system with image intensifier. X rays impinging on the image
intensifier are transformed into a distribution of electrons, which produces an amplified
light image on a smaller fluorescent screen after acceleration. The image is observed by a
television camera and a film camera and can be viewed on a computer screen and stored on
a CD-ROM or a PACS.
 X-Ray tube
Filament
Cathode

Rotor

Anode Vacuum envelope

 The X-rays are produced from electrons that have been accelerated from in vacuum
from the cathode to the anode.
 Emission occurs when filament is heated by passing current through it.
 When the filament is hot enough, the electrons obtain thermal energy sufficient t
overcome the energy binding the electron to the metal of the filament.
 After accelerated they will be stopped at a short distance. Most of the electron energy
will produce heat at the anode. Some percentage will be converted to X-ray by two
main methods.
 Deceleration of charged particle results in the emission of electromagnetic field
called Bremmstralung radiation.
 These rays will have wide, continuous distribution of energies with the maximum
being the total energy the electron had when reaching the anode.
 The number of X-rays will be small at higher energies and increased for lower energies.
 Example of digital subtraction angiography
(DSA) of the bifurcation of the aorta

An initial image mask is obtained digitized and stored

Contrast medium is injected
Number of images are obtained.
Mask is subtracted
The resulting image contains only the relevant information
The differences can be amplified so the eye will be able to perceive the the blood
vessels.
Quality of deteriorate due to movements of the body can be corrected to some extent.
 Mammography
Mammography is a specific type of breast imaging that uses low-dose x-rays to detect
cancer early – before women experience symptoms – when it is most treatable.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and
treat medical conditions. Imaging with x-rays involves exposing a part of the body to a
small dose of ionising radiation to produce pictures of the inside of the body. X-rays are
the oldest and most frequently used form of medical imaging.
Three recent advances in mammography include
 digital mammography,
 computer-aided detection &
 breast tomosynthesis.

Digital mammography, also called full-field digital mammography (FFDM), is a

mammography system in which the x-ray film is replaced by electronics that convert x-
rays into mammographic pictures of the breast.
These systems are similar to those found in digital cameras and their efficiency enables
better pictures with a lower radiation dose.
These images of the breast are transferred to a computer for review by the radiologist and
for long term storage. The patient’s experience during a digital mammogram is similar to
having a conventional film mammogram.
Computer-aided detection (CAD): gives digitized mammographic images for
abnormal areas of densit, mass or calcification that may indicate the presence
of cancer. The CAD system highlights these areas on the images, alerting
the radiologist to carefully assess this area.

Breast Tomosynthesis: also called three-dimensional (3-D) mammography and

digital breast tomosynthesis (DBT), is an advanced form of breast imaging where
multiple images of the breast from different angles are captured and reconstructed
("synthesized") into a three-dimensional image set.
In this way, 3-D breast imaging is similar to computed tomography (CT) imaging in
which a series of thin "slices" are assembled together to create a 3-D reconstruction
of the body.
Although the radiation dose for some breast tomosynthesis systems is slightly higher
than the dosage used in standard mammography, it remains within the FDA-
approved safe levels for radiation from mammograms.
Some systems have doses very similar to conventional mammography.
Breast tomosynthesis may also result in:
Earlier detection of small breast cancers that may be hidden on a conventional
mammogram
Greater accuracy in pinpointing the size, shape and location of breast abnormalities fewer
unnecessary biopsies or additional tests
Greater likelihood of detecting multiple breast tumors clearer images of abnormalities
within dense breast tissue

Some common uses of the procedure:

Mammograms are used as a screening tool to detect early breast cancer in women
experiencing no symptoms. They can also be used to detect and diagnose breast disease in
women experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge.
Screening Mammography:
Mammography plays a central part in early detection of breast cancers because it can show
changes in the breast up to two years before a patient or physician can feel them.
Current guidelines from the U.S. Department of Health and Human Services (HHS) and
the American College of Radiology (ACR) recommend screening mammography every
year for women, beginning at age 40.
Research has shown that annual mammograms lead to early detection of breast cancers,
when they are most curable and breast-conservation therapies are available.
The National Cancer Institute (NCI) adds that women who have had breast
cancer, and those who are at increased risk due to a family history of breast or
ovarian cancer, should seek expert medical advice about whether they should
begin screening before age 40 and the need for other types of screening.

If you are at high risk for breast cancer, you may need to obtain a breast MRI
in addition to your annual mammogram.

DiagnosticMammography

Diagnostic mammography is used to evaluate a patient with abnormal clinical

findings—such as a breast lump or nipple discharge—that have been found by
the woman or her doctor.
Diagnostic mammography may also be done after an abnormal screening
mammogram in order to evaluate the area of concern on the screening exam.
  ’

Grid T t

Image
receptor
Scatter Breast Lesion

&Attenuation coefficients of breast tissue and lesion

T&t:thickness of breat and lesion
Simplified computer model of the mammographic image acquisition process:
For the simplified case of monoenergetic x-rays of energy E, the number of x-rays
recorded in a fixed area of the image is proportional to:

 T
 
N B  N 0 ( E )e
No(E) no.of x-rays that would be recorded in the absence of tissue in the beam
In the “background”
and:
[  ( T  t )   , t ]
N  N ( E )e
L 0

The difference in x-ray transmission gives rise to subject contrast which can be
defined as:

NB  NL
C0 
NB  NL
 For monoenergetic x-rays and temporarily ignoring scattered radiation ,contrast
depends on the thickeness of the lesion and difference the attenuation coefficient
and background material. ,
 (    )t
1 e
C0  (  ,   )t
1 e
For a given image recording system (image receptor) a proper exposure requires a
specific value of x-ray energy transmitted by the breast and incident on the receptor,
i.e. a specific value of NB. The breast entrance skin exposure required to produce an
image is therefore proportional to:

 t
N 0  N B ( E )e
 What Can Diagnostic Mammography
Show?
Diagnostic mammography may show that an abnormality (lesion) has a high likelihood
of being benign (not cancer). For these, it is common to ask the woman to return earlier
than usual for a recheck, usually in 6 months.

A diagnostic mammogram may show that the abnormality is not worrisome at all and
the woman can then return to routine yearly screening mammography.

In some cases, patients with a cyst (fluid filled pocket) or other abnormality will also
receive ultrasound imaging to obtain further diagnostic information.

Finally,the diagnostic work-up may suggest that biopsy (tissue sampling) is needed to
tell whether or not the abnormality is cancerous.

A recommendation for biopsy does not necessarily mean that the abnormality is cancer.

About 65% of all breast lesions that are evaluated with biopsy are found to be benign
(non-cancerous) when evaluated under the microscope.
What Abnormalities Does Mammography Detect and Diagnose?

Mammography is used to detect a number of abnormalities, the two

main ones being calcifications and masses.
Calcifications are tiny mineral deposits within the breast tissue that appear as
small white spots on the films.
Calcifications are divided into two categories, macrocalcifications and
microcalcifications.
A mass is any group of cells clustered together more densely than the
surrounding tissue.
 A cyst or fluid collection may also appear as a mass on mammography.
The difference between a solid mass and a cyst can often be shown
with ultrasound.
Calcifications:
Macrocalcifications are coarse (larger) calcium deposits that are often associated
with benign fibrocystic change or with degenerative changes in the breasts, such as
aging of the breast arteries, old injuries, or inflammation.
Macrocalcification deposits are associated with benign (noncancerous) conditions and do
not require a biopsy. Macrocalcifications are found in about 50 % of women over the age of
50.
 Microcalcifications are tiny (less than 1/50 of an inch) specks of calcium in the
breast.
When many microcalcifications are seen in one area, they are referred to as a cluster and may
indicate a small cancer.
About half of the cancers detected by mammography appear as a cluster of
microcalcifications.
Microcalcifications are the most common mammographic sign of ductal carcinoma in
situ (meaning the cancer has not spread or invade neighboring tissue).
Almost 90% of cases of ductal carcinoma in situ are associated with
microcalcifications.
An area of microcalcifications seen on a mammogram does not always mean that
cancer is present.
The shape and arrangement of microcalcifications help the radiologist judge
the likelihood of cancer being present.
In some cases, the microcalcifications do not indicate a need for a biopsy. Instead, a doctor
may advise a follow-up mammogram within 6 months.
In other cases, the microcalcifications are more suspicious and a stereotactic biopsy
is recommended. Only 17% of calcifications requiring biopsy are cancerous.

Masses:
Another important change seen on a mammogram is the presence of a mass, which may
occur with or without associated calcifications.
A mass is any group of cells clustered together more densely than the surrounding tissue.
Masses can be due to many things, including cysts, which are non-cancerous collections of
fluid in the breast.
A cyst cannot be diagnosed by physical exam alone nor can it be diagnosed by
mammography alone, although certain signs can suggest the presence of a cyst or cysts.
To confirm that a mass is a cyst, either breast ultrasound or aspiration with a needle is
required. If a mass is not a cyst, then further imaging may be obtained.
As with calcifications, a mass can be caused by benign breast conditions or by breast
cancer. Some masses can be monitored with periodic mammography while others may
require biopsy.
The size, shape, and margins (edges) of the mass help the radiologist in evaluating the
likelihood of cancer.
Breast ultrasound is often helpful. Prior mammograms may help show that a mass is
unchanged for many years, indicating a benign condition and helping to avoid unnecessary
biopsy.
Having prior mammograms available to the radiologist, as discussed above, is very
important.

Mammography alone cannot prove that an abnormal area is cancer although some
abnormalities are very characteristic of malignancy.
If mammography raises a significant suspicion of cancer, tissue must be removed for
examination under the microscope to tell if it is cancer.
This can be done with one of several breast biopsy techniques.
Ductography, also know as a Galactogram, is special type of contrast enhanced
mammography used for imaging the breast ducts.
Ductography can aid in diagnosing the cause of an abnormal nipple discharge and is
valuable in diagnosing intraductal papillomas.
 Digital Mammography
One of the most recent advances in x-ray mammography is digital mammography.
Digital (computerized) mammography is similar to standard mammography in that x-rays
are used to produce detailed images of the breast.
Digital mammography uses essentially the same mammography system as conventional
mammography, but the system is equipped with a digital receptor and a computer instead
of a film cassette.
Several studies have demonstrated that digital Mammography is at least as accurate as
standard mammography.
Digital spot view mammography allows faster and
more accurate stereotactic biopsy.
This results in shorter examination times and
significantly improved patient comfort and
convenience since the time the patient must remain
still is much shorter.
With digital spot-view mammography, images are
acquired digitally and displayed immediately on the
system monitor.

Traditional stereotactic biopsy requires a mammogram film be exposed, developed

and then reviewed, greatly increasing the time before the breast biopsy can be completed.
How Does Digital Mammography Differ From Standard Mammography?

 In standard mammography, images are recorded on film using an x-ray cassette. The film
is viewed by the radiologist using a "light box" and then stored in a jacket in the facility’s
archives.
 With digital mammography, the breast image is captured using a special electronic x-ray
detector, which converts the image into a digital picture for review on a computer monitor.
 The digital mammogram is then stored on a computer.
 With digital mammography, the magnification, orientation, brightness, and contrast of the
image may be altered after the exam is completed to help the radiologist more clearly see
certain areas.
 Digital mammography provides many benefits over standard mammography equipment.
These benefits include:
• faster image acquisition
• shorter exam time
• easier image storage
• physician manipulation of breast images for more accurate
detection of breast cancer
• transmittal of images over phone lines or a computer network for remote consultation

with other physicians

 Digital mammography has the potential to significantly reduce the amount of
time required to acquire a mammogram from 10 to 15 minutes to less than a
minute.
 This will provide a shorter, more comfortable exam for the woman and possibly
allow mammography facilities to conduct more mammograms in a day.
 Digital images can also be manipulated to correct for under or over exposure.
 If under or over exposure occurs with a standard film-based mammography
system women have to undergo a repeat mammogram before leaving the facility.

Many radiologists support digital mammography as an effective tool

to screen for breast cancer. The contrast resolution of these devices
is inherently better, "In addition, the extra features that digital
mammography will ultimately provide, such as telemammography,
tomosynthesis, and computer-aided diagnosis will prove invaluable
to patients and their doctors,”
Advantages
Breast cancer screening every 2 years over a 20-year period:
Reduces the risk of dying from breast cancer
Of 1,000 women who have a mammogram every 2 years for
20 years, 7 deaths are prevented
Reduces the risk of having to undergo chemotherapy
Screening often allows for the detection of cancers at an early
stage of development. Treatment is then possible without
chemotherapy.
Allows women to know the health of their breasts 
The vast majority of women (nearly 98 %) will not have breast
cancer if their mammograms and additional examinations do not
reveal cancers.
Disadvantages
Breast cancer screening every 2 years for 20 years can lead to:
Periods of waiting and anxiety when additional examinations are
required: Almost half the women who participate in the screening
for 20 years (453 in 1,000) have at least one additional examination.
This represents 156 more women than in the 1,000 who do not
participate in the screening.
Possible overdiagnosis
Of 77 breast cancer diagnoses, 10 would be cases of overdiagnosis.
Overdiagnosis is the discovery of a cancer that would never have
been detected without screening. It can happen that a woman
receives a diagnosis for cancer that would never have had an effect
on her health or consequences on her life – like a cancer that
develops very slowly or a benign cancer. This could happen to
participants in the screening program because a mammogram detects
breast cancer in the early stages of development.
Limitations
Breast cancer screening every 2 years for 20 years does not
guarantee:
That all breast cancers will be detected 
Of 1,000 women who have a mammogram every 2 years for
20 years, 77 will be diagnosed with breast cancer. Of these, 21 will
be diagnosed with cancer even though their mammography results
were normal. Such a situation can occur if:
The cancer was not visible on the mammogram
The cancer was not yet developed at the time of the
mammography
That all participants with breast cancer will survive
Of 1,000 women who have a mammogram every 2 years for
20 years, it is estimated that 13 will die of breast cancer.