Vol. 14 •Issue 18 • Page 8-9
patient positioning in mammography
Mammographers must work with, not against, the bodies that cross their path
The next time you’re at the mall or the beach, look around. Notice all the variations in body types. From short to tall, thin to fat, and everything in between, no body is created equal.
It’s only natural, then, to expect that taking a mammogram is never a standard procedure. From the kyphotic woman to the hairy-chested man, the best way to handle a difficult body habitus is to be prepared to think on your feet and to know a couple of tips that can help get you through the exam with your sanity intact.
Rita Heinlein, RT(R)(M), runs Mammography Consulting and Education Services, Clarksville, Md., and travels to various professional conferences teaching mammographers and radiologists how to better manage the patient aspects of their practices. She shared some of her recommendations with ADVANCE.
Heinlein said women who do not have a generous amount of breast tissue to place on the image receptor are challenging for mammographers. There is difficulty imaging the posterior aspect of the breast because, as the technologist moves her hand away to make room for the compression paddle, the posterior part of the breast often will slip out.
“For those women, I suggest they use a rubber spatula because it is much thinner than your hand and you can capture the posterior aspect of the breast and hold it on the image receptor while the compression is being applied,” Heinlein said, adding that she also suggests using the spatula for the craniocaudal view. For the mediolateral view, she suggests asking the patient to slouch to allow the breast tissue to fall forward, and again using the spatula while applying compression.
In these cases, “You tell the woman that you want to make sure we don’t miss any part of your breast and so you’re going to do several films,” Heinlein said. She advised doing a film for the front, medial and lateral views, followed by three films for the oblique view–lower, upper and front. That way, nothing will be missed. When doing multiple films, it’s important to overlap the tissue being imaged and include anatomical landmarks, she said.
Women who are very thick in the axilla–the upper part by their shoulders–can sometimes have axilla areas that are thicker than the breast itself. This anatomy precludes mammographer from compressing the entire breast in one image. “The only solution is to do two films–a film that would be for posterior and superior and a second for anterior,” Heinlein said.
Women with large tummies due to obesity are difficult to image because their abdomens actually stick out farther than their breasts. For both views, the craniocaudal and the mediolateral oblique, the best thing to do is to have the woman stand two hands’ width away from the image receptor and then to ask them to bend forward as if they are picking something up off the floor.
“As they bring their chest forward, it brings their derriere back and the abdomen leans back, and then you can bring the breast tissue onto the image receptor,” Heinlein said. “The biggest challenge here is to figure out how to get all of that out of the way without losing the back of the breast.”
This condition prevents a woman from lifting her arm. “The first thing I ask is if instead of bringing the arm up at 90 degrees, can she bring the arm forward and slide the arm back? If they can do that, then you can easily do a 90-degree lateral medial view and put the film against the sternum,” Heinlein said. She advised sliding the elbow back and turning the woman in toward the mammography unit; the edge of the compression paddle will help to hold the arm back. “I prefer a lateral medial to do this situation because then you can take advantage of the mobility of the breast and pull the tissue into the field of view.”
The breasts are wide from the sternum to the axilla, but they don’t necessarily protrude very far. “The problem is on the craniocaudal view. You are unable to visualize posterior lateral breast tissue because the breast is so wide,” Heinlein said. This means a mammographer can either use a 24-by-30 image receptor to help include the posterior tissue without losing medial posterior tissue, or, if that doesn’t work, do an exaggerated craniocaudal view where the patient is turned to include just the lateral posterior tissue. Thus, two views are done–the regular craniocaudal view and an exaggerated craniocaudal to be certain the posterior tissue is included.
“One thing that is important is that if their breasts are wide and they do not protrude far and they are also short-waisted, then you need to use the large image receptor on the craniocaudal view,” Heinlein said. “However, on the mediolateral oblique view, you will have to go to the 18-by-24 in order to maximize tissue visualization as well as compression.”
When a woman’s sternum caves, almost making her ribs protrude outward and then back toward her spine, it’s known as pectus excavatum. On the craniocaudal view, the mammographer is unable to visualize medial breast tissue because the ribs protrude. According to Heinlein, the best thing to do is a craniocaudal view that includes central and lateral aspects for both breasts and then to do a cleavage shot. But instead of elevating the intramammary fold as high as natural mobility will allow, place the image receptor at the neutral mammary fold. That way, the patient can lean over the image receptor and a spot compression paddle can be used to capture the medial aspects for both breasts on one view. “For the oblique, instead of doing a mediolateral oblique, if the sternum is so far inside the rib cage, then put the film in there, and do a reverse oblique,” she said.
The opposite of pectus excavatum, this condition causes the sternum to stick out from the rib cage. Heinlein advises mammographers to do a medial and central view followed by an exaggerated craniocaudal to get the lateral aspect. The reverse oblique (LMO) is also helpful.
Women with this condition have hunched backs and rounded shoulders, preventing mammographers from doing a regular craniocaudal view. Heinlein advises flipping the entire unit 180 degrees and putting the image receptor at the superior aspect of the breast, bringing the compression up from below. Also, do a reverse oblique instead of a regular oblique, or lateromedial oblique.
The best advice for this situation, said Heinlein, is to make sure the woman’s hips are situated against the back of the wheelchair and to use a pillow or a sponge to lean them forward. The idea is to prevent the woman from slouching. “Once that’s done, you just proceed and do a regular craniocaudal view,” Heinlein said.
Woman on a Stretcher
Turn the woman on her side. “Rotate the C-arm to 90 degrees and then do either a craniocaudal view or a from below view,” Heinlein said. Because the woman is recumbent, an oblique view is impossible. Instead, rotate the C-arm back to 0 degrees and rotate the woman forward into a left anterior oblique position, as if she is lying slightly on her stomach. Then, place the image receptor in line with the sternum so that when the woman rolls forward onto her stomach, the breast falls onto the image receptor and a lateromedial view results. Repeat this for the other side.
If the man has gynecomastia, it’s not a problem to image his breast. This is not usually the case, however. Heinlein said this situation should be handled the same as that of the small-breasted woman: Introduce the spatula. Nevertheless, the compression paddle may slide off a hairy chest. You may need to shave the chest in extremely hairy cases.
When an atypical patient arrives and there’s already a time crunch and the head radiologist is pushing to get as many patients through as possible, stress levels are bound to go up for mammographers. Heinlein advises technologists to remain calm and to give themselves permission to do more than four films to get the best possible views and also to ask for help from a colleague, if necessary.
“We can’t change the patient,” she said. “The only thing you can change is your perspective.”
Kelley Devereaux is an assistant editor at ADVANCE. She can be reached at email@example.com.