History of mammography:

Mammography is a radiographic examination that is designed for detecting breast pathology,

particularly breast cancer. Breast cancer screening with mammography assists in detecting
cancers at an earlier, more treatable stage, and is an important clinical procedure because
approximately one in eight women will develop breast cancer over their lifetimes.
Technologic advances over the last several decades have greatly improved the diagnostic
sensitivity of mammography. Early x-ray mammography was performed with direct exposure
film (intensifying screens were not used), required high radiation doses, and produced images
of low contrast and poor diagnostic quality. Mammography using the xeroradiographic
process was very popular in the 1970s and early 1980s, spurred by high spatial resolution and
edge-enhanced images; however, its relatively poor sensitivity for breast masses and higher
radiation dose compared to screen-film mammography led to its demise in the late 1980s.
Continuing refinements in screen-film technology and digital mammography, which entered
the clinical arena in the early 2000s, further improved mammography.

The American College of Radiology (ACR) mammography accreditation program changed

the practice of mammography in the mid-1980s, with recommendations for minimum
standards of practice and quality control (QC) that spurred improvements in technology and
ensured quality of service. The federal Mammography Quality Standards Act (MQSA) was
enacted in 1992. The law, and associated federal regulations (Title 21 of the Code of Federal
Regulations, Part 900) issued by the US Food and Drug Administration (FDA), made many
of the standards of the accreditation program mandatory. For digital mammography systems,
many of the regulatory requirements entail following the manufacturer’s recommended QC
procedures.

Breast cancer screening programs depend on x-ray mammography because it is a low-cost,

low–radiation dose procedure that has the sensitivity to detect early stage breast cancer.
Mammographic features characteristic of breast cancer are masses, particularly ones with
irregular or “spiculated” margins; clusters of microcalcifications; and architectural distortions
of breast structures. In screening mammography as practiced in the United States, two x-ray
images of each breast, in the mediolateral oblique and craniocaudal views, are acquired.
Whereas screening mammography attempts to identify breast cancer in the asymptomatic
population, diagnostic mammography procedures are performed to assess palpable lesions or
evaluate suspicious findings identified by screening mammography. The diagnostic
mammographic examination may include additional x-ray projections, magnification views,
spot compression views, ultrasound, magnetic resonance imaging (MRI), or -
mammoscintigraphy. Ultrasound is often used to differentiate cysts (typically benign) from
solid masses (often cancerous) and is also used when possible for biopsy needle guidance.
MRI has excellent tissue contrast sensitivity and with contrast enhancement can differentiate
benign from malignant tumors; it is used for diagnosis, staging, biopsy guidance, and, in
some cases, screening. The clinical utility of mammoscintigraphy utilizing Tc-99m sestamibi
is in the evaluation
FIGURE 8-1 Improvements in mammography.

The morphological differences between normal and cancerous tissues in the breast and the
presence of microcalcifications require the use of x-ray equipment designed specifically to
optimize breast cancer detection. the attenuation differences between normal and cancerous
tissue are extremely small. Subject contrast is highest at low x-ray energies (10 to 15 keV)
and reduced at higher energies (e.g., greater than 30 keV). Low x-ray Energy (keV) energies
provide the best differential attenuation between the tissues; however, the high absorption
results in higher radiation doses and long exposure times. Detection of small calcifications in
the breast is also important because microcalcifications are in some cases early markers of
breast cancer. Thus, mammography requires x-ray detectors with high spatial resolution that
function best at higher doses. Enhancing contrast sensitivity, reducing dose, and providing
the spatial resolution necessary to depict microcalcifications impose extreme requirements on
mammographic equipment and detectors. Therefore, dedicated x-ray equipment, specialized
x-ray tubes, breast compression devices, antiscatter grids, x-ray detectors (screen-film or
digital), and phototimer detector systems are essential for mammography. Strict QC
procedures and cooperation among the Radiographer, radiologist, and medical physicist are
necessary to ensure that high-quality mammograms are achieved at the lowest possible
radiation doses.

X-RAY TUBE AND BEAM FILTRATION

A dedicated mammography x-ray tube has more similarities than differences when compared
to a conventional x-ray tube.
A dedicated mammography system has many unique attributes. Major components of a
typical system, excluding the generator and user console, are shown.

Cathode and Filament Circuit

The mammography x-ray tube is configured with dual filaments in the focusing cup to
produce 0.3- and 0.1-mm focal spot sizes, with the latter used for magnification studies to
reduce geometric blurring. An important distinction between mammography and
conventional x-ray tube operation is the low operating voltage, below 40 kV, which requires
feedback circuits in the x-ray generator to adjust the filament current as a function of kV to
deliver the desired tube current because of the nonlinear relationship between filament
current and tube current. In addition, the filament current is restricted to limit the tube
current, typically to 100 mA for the large (0.3 mm) focal spot and 25 mA for the small (0.1
mm) focal spot so as to not overheat the Mo or Rh targets due to the small interaction areas.
Higher filament currents and thus tube currents, up to and beyond 200 mA for the large focal
spot and 50 mA for the small focal spot, are possible with tungsten anodes chiefly due to a
higher melting point compared to Mo and Rh anodes.

Anode

Molybdenum is the most common anode target material used in mammography x-ray tubes,
but Rh and increasingly tungsten (W) are also used as targets. Characteristic x-ray production
is the major reason for choosing Mo (K-shell x-ray energies of 17.5 and 19.6 keV) and Rh
(20.2 and 22.7 keV) targets, as the numbers of x-rays in the optimal energy range for breast
imaging are significantly increased by characteristic x-ray emission.

With digital detectors, Tungsten is becoming the target of choice. Increased x-ray production
efficiency, due to its higher atomic number, improved heat loading, and its higher
melting point, are major factors in favor of Tungsten. Digital detectors have extended
exposure latitude, and because post acquisition image processing can enhance contrast,
characteristic radiation from Mo or Rh is not as important in digital mammography as it is
with screen-film detectors.

Mammography x-ray tubes have rotating anodes, with anode angles ranging from 16 to 0
degrees, depending on the manufacturer. The tubes are typically positioned at a source-to-
image receptor distance (SID) of about 65 cm. In order to achieve adequate field coverage on
the anterior side of the field, the x-ray tube must be physically tilted so that the effective
anode angle (the actual anode angle plus the physical tube tilt) is at least 22 degrees for
coverage of the 24 X 30-cm field area. A tube with a 0-degree anode angle requires a tube tilt
of about 24 degrees to achieve an effective anode angle of 24 degrees. A 16-degree anode
angle requires a tube tilt of 6 degrees for an effective angle of 22 degrees. The intensity of the
x-rays emitted from the focal spot varies within the beam, with the greatest intensity on the
cathode side of the projected field and the lowest intensity on the anode side, a consequence
of the heel effect. Positioning the cathode over the chest wall of the patient and the anode
over the anterior portion (nipple) achieves better uniformity of the transmitted x-rays through
the breast. Orientation of the tube in this way also decreases the equipment bulk near the
patient’s head. The anode is kept at ground potential (0 voltage), and the cathode is set to the
highest negative voltage to reduce off-focal radiation.

Design of a dedicated mammography system. Reference axis

Focal Spot Considerations

Focal spot nominal sizes of 0.3 to 0.4 mm for contact mammography (breast compressed
against the grid and image receptor) and 0.10 to 0.15 mm for magnification imaging (breast
compressed against a magnification stand, which supports the breast at a distance from the
image receptor to provide geometric image magnification) reduce geometric blurring so that
microcalcifications can be resolved. A consequence of using small focal spots is reduced
maximal tube current (e.g., for a Mo target, 100 mA for the large focal spot and 25 mA for
the small focal spot) and correspondingly longer exposure times.

In order to avoid exposure of the patients’ torsos and to maximize the amount of breast tissue
near the chest wall that is imaged, all dedicated mammography systems utilize a “half-field”
x-ray beam geometry, which is achieved by fixed collimation at the x-ray tube head. As a
result, the central axis of the x-ray beam is directed at the chest wall edge of the receptor and
perpendicular to the plane of the image receptor. Furthermore, by convention, the nominal
focal spot size is measured at the reference axis, which bisects the x-ray field along the chest
wall—anterior direction of the x-ray field.

Tube Port, Tube Filtration, and Beam Quality

The tube port and added tube filters play an important role in shaping the mammography x-
ray energy spectrum. The tube port window is made of beryllium. The low atomic number
(Z=4) of beryllium and the small thickness of the window (0.5 to 1 mm) allow the
transmission of all but the lowest energy (less than 5 keV) bremsstrahlung x-rays. In addition,
Mo and Rh targets produce beneficial K-characteristic x-ray peaks at 17.5 and 19.6 keV (Mo)
and 20.2 and 22.7 keV (Rh), whereas tungsten targets produce a large fraction of unwanted
L-characteristic x-rays at 8 to 10 keV.

Added x-ray tube filtration improves the energy distribution of the mammography output
spectrum by selectively removing the lowest and highest energy x-rays from the x-ray beam,
while largely transmitting desired x-ray energies. This is accomplished by using elements
with K-absorption edge energies between 20 and 27 keV. Elements that have these K-shell
binding energies include Mo, Rh, and Ag, and each can be shaped into thin, uniform sheets to
be used as added x-ray tube filters. At the lowest x-ray energies, the attenuation of added
filtration is very high. The attenuation decreases as the x-ray energy increases up to the K-
edge of the filter element. For x-ray energies just above this level, photoelectric absorption
interactions dramatically increase attenuation as a step or “edge” function. At higher x-ray
energies, the attenuation decreases.

With a Mo target, a 0.030-mm-thick Mo filter or a 0.025-mm Rh filter is typically used, and

for a Rh target, a 0.025-mm Rh filter is used. A variety of filters are used with targets,
including Rh (0.05 mm), Ag (0.05 mm), and Al (0.7 mm).

Screen-film detectors most often use a Mo target and 0.03-mm Mo filtration with a kV of 24
to 25 kV for thin, fatty breasts and up to 30 kV for thick, glandular breasts.

For thicker and denser breasts, a Mo target and Rh filter are selected with higher voltage,
from 28 to 32 kV, to achieve a higher effective energy and more penetrating beam. Some
systems have Rh targets, which produce Rh characteristic x-ray energies of 20.2 and
22.7keV, achieving an even higher effective energy x-ray beam for a set kV. A Mo filter
should never be used with a Rh target, because Rh characteristic x-rays are attenuated
significantly as their energies are above the Mo K-absorption edge.
Half-Value Layer

The half-value layer (HVL) of a mammography x-ray beam ranges from 0.3 to 0.7-mm Al for
the kV range and combinations of target material, filter material, and filter thickness used in
mammography. The HVL depends on the target material (Mo, Rh, W), kV, filter material,
and filter thickness. Measurement of the HVL is usually performed with the compression
paddle in the beam, using 99.9% pure Al sheets of 0.1-mm thickness. A Mo target, 0.03-mm
Mo filter, 28 kV, and a 1.5mm Lexan compression paddle produce a HVL of about 0.35-mm
Al, whereas a tungsten target, 0.05-mm Rh filter, and 30 kV produce a HVL of about 0.55-
mm Al.

X-ray Tube Alignment and Beam Collimation

Alignment of the x-ray tube and collimator are crucial to ensure that the x-ray beam central
axis is perpendicular to the plane of the image receptor and intercepts the center of the chest
wall edge of the image receptor. This will protect the patient from unnecessary radiation
exposure to the lungs and torso and include as much breast tissue as possible in the image.
Tube alignment with respect to the image receptor must be verified during acceptance testing
of the system and after x-ray tube replacements.

Collimation of the x-ray beam is achieved by the use of fixed-size metal apertures or
adjustable shutters. For most screen-film examinations, the field size is automatically set to
match the film cassette dimensions (e.g., 18 x 24 cm or 24 x 30 cm). For a large area digital
detector (24 x 30 cm), when operating with the smaller field area (18 X 24 cm), one of three
active acquisition areas is used: center, left shift, and right shift, which requires the collimator
assembly to restrict the x-ray field to the corresponding active detector area. Field shifts are
used for optimizing the oblique projections for subjects with smaller breasts to accommodate
positioning of the arm and shoulder at the top edge of the receptor. Collimation to the full
active detector area is the standard of practice. There is no disadvantage to full-field
collimation compared to collimation to the breast only, as the tissues are fully in the beam in
either case. However, for magnification and spot compression studies, manually adjusted
shutters allow the x-ray field to be more closely matched to the volume being imaged.

The projected x-ray field must extend to the chest wall edge of the image receptor without cut
off, but not beyond the receptor by more than 2% of the SID. If the image shows evidence of
collimation of the x-ray field on the chest wall side or if the chest wall edge of the
compression paddle is visible in the image, service must be requested. A collimator light and
mirror assembly visibly display the x-ray beam area. Between the tube port and the
collimator is a low-attenuation mirror that directs light from the collimator lamp through the
collimator opening to emulate the x-ray field area. Similar to conventional x-ray tube
collimator assemblies, the light field must be congruent with the actual x-ray field to within
2% overall, which is achieved by adjustment of the light and mirror positions. x-ray
 Generator and Phototimer System

x-ray Generator

A dedicated mammography x-ray generator is similar to a conventional x-ray generator in

design and function. Differences include the lower voltages supplied to the x-ray tube, space
charge compensation, and automatic exposure control (AEC). In most cases, AEC is
employed for mammography screening and diagnostic examinations, although there are
instances when the technologist will use manual controls to set the tube current exposure
duration product (mAs). Like most contemporary x-ray imaging systems, high-frequency
generators are used for mammography due to low voltage ripple, fast response, easy
calibration, long-term stability, and compact size. There are circuits that prohibit x-ray
exposures if the setup is incomplete (e.g., insufficient compression, cassette not in the tunnel,
or digital detector not ready to capture an image).

Automatic Exposure Control

The AEC employs a radiation sensor or sensors, a charge amplifier, and a voltage comparator
to control the exposure. For cassette-based image receptors (screen-film and computed
radiography [CR]), the phototimer sensor is located underneath the cassette, and consists of a
single ionization chamber or an array of three or more semi-conductor diodes. x-rays
transmitted through the breast, anti scatter grid (if present), and the image receptor generate a
signal in the detector. The signal is accumulated (integrated) and, when the accumulated
signal reaches a preset value, the exposure is terminated. The preset value corresponds to a
specified signal-to-noise ratio (SNR) in a digital mammography unit or an acceptable optical
density (OD) if a film-screen system is used.

For an active matrix flat-panel imager, the detector array itself can be used to measure the x-
rays transmitted through the breast and the antiscatter grid. Phototimer algorithms use several
inputs to determine the radiographic technique, including compressed breast thickness,
phototimer adjustment settings on the generator console, the kV, the tube anode selection (if
available), and the tube filter to achieve the desired film OD or digital SNR in the acquired
image.

The operator typically has two or three options for AEC:

1. a fully automatic AEC mode that sets the optimal kV and filtration (and target
material on some systems) from a short test exposure of approximately 100 ms to
determine the penetrability of the breast;

2. automatic kV with a short test exposure, with user-selected target and filter values;

3. automatic time of exposure using manually set target, filter, and kV values. For most
patient imaging, the fully automatic mode is used, but, for QC procedures, the
automatic exposure time adjustment mode with other parameters manually selected by
the user is often employed.
An x-ray exposure that is not stopped by the AEC circuit and exceeds a preset time (e.g.,
greater than 5 s) is terminated by a backup timer. This can occur if there is a malfunction of
the AEC system or if the kV is set too low with insufficient x-ray transmission. In the latter
situation, the operator must select a higher kV to achieve greater beam penetrability and
shorter exposure time to correct the problem.

Inaccurate phototimer response, resulting in an under- or overexposed film or digital image,

can be caused by breast tissue composition (adipose versus glandular) heterogeneity,
compressed thickness beyond the calibration range (too thin or too thick), a defective
cassette, a faulty phototimer detector, or an inappropriate kV setting. Screen-film response to
very long exposure times, chiefly in magnification studies caused by the low mA capacity of
the small focal spot, results in reciprocity law failure, whereby the resultant OD is less than
would be predicted by the amount of radiation delivered to the screen-film cassette;
consequently, insufficient film OD results, and extension of the exposure time is added to
compensate. For extremely thin or fatty breasts, the phototimer circuit and x-ray generator
can be too slow in terminating the exposure, causing film overexposure. In situations where
the exposure is terminated too quickly, grid-line artifacts will commonly appear in the image
due to lack of complete grid motion during the short exposure.

The position of the phototimer detector (e.g., under dense or fatty breast tissue) can have a
significant effect on film density but has much less of an impact on digital images because of
postprocessing capabilities, even though the SNR will vary. Previous mammograms can aid
the technologist in selecting the proper position for the phototimer detector to achieve
optimal film density or optimal SNR for glandular areas of the breast. Most systems allow
phototimer positioning in the chest wall to anterior direction, while some newer systems also
allow side-to-side positioning to provide flexibility for unusual circumstances.

Compression, Scattered Radiation, and Magnification

Compression

Breast compression is an important part of the mammography examination, whether using

screen-film or digital detectors.

Firm compression reduces overlapping anatomy, decreases tissue thickness, and reduces
inadvertent motion of the breast. It results in fewer scattered x-rays, less geometric blurring
of anatomic structures, and lower radiation dose to the breast tissues. Achieving a uniform
breast thickness lessens exposure dynamic range and allows the use of higher contrast film,
or allows more flexibility in image processing enhancement of the digital image.

Compression is achieved with a compression paddle, a Lexan plate attached to a mechanical

assembly. The full area compression paddle matches the size of the image receptor (18 x 24
cm or 24 x 30 cm) and is flat and parallel to the breast support table. An alternative to the flat
compression paddle is the “flex” paddle that is spring loaded on the anterior side to tilt and
accommodate variations in breast thickness from the chest wall to the nipple, providing more
uniform compression of the breast. A compression paddle has a right-angle edge at the chest
wall to produce a flat, uniform breast thickness when an adequate force of 111 to 200
newtons (25 to 44 lb) is applied.

A smaller “spot” compression paddle (~5-cm diameter) reduces the breast thickness further
over a specific region and redistributes the tissue for improved contrast and reduced anatomic
overlap.

Typically, a hands-free (e.g., foot-pedal operated), motor-driven compression paddle is used,

which is operable from both sides of the patient. In addition, a mechanical adjustment knob
near the paddle holder allows fine manual adjustments of compression. While firm
compression is not comfortable for the patient, it is often necessary for a clinically acceptable
image.

A. Compression is essential for mammographic studies to reduce breast thickness. Suspicious

areas often require “spot” compression to eliminate superimposed anatomy by further
spreading the breast tissues over a localized area.

Scattered Radiation and Antiscatter Grids

x-rays transmitted through the breast contain primary and scattered radiation. Primary
radiation carries information regarding the attenuation characteristics of the breast and
delivers the maximum possible subject contrast to the detector. Scattered radiation is an
additive, gradually varying radiation distribution that degrades subject contrast and adds
random noise. x-ray scatter increases with increasing breast thickness and breast area.

Without some form of scatter rejection, therefore, only a fraction of the inherent subject
contrast can be detected.

In digital mammography, unlike screen-film mammography, the main adverse effect of

scattered x-rays is not a reduction of contrast. Contrast can be improved by any desired
amount by post-acquisition processing, such as windowing. The main adverse effect of
scatter in digital mammography is that scattered photons add random noise, degrading the
signal to noise ratio. Scattered radiation reaching the image receptor can be greatly reduced
by the use of an antiscatter grid or air gap. For contact mammography, an antiscatter grid is
located between the breast and the detector. Mammography grids transmit about 60% to 70%
of primary x-rays and absorb 75% to 85% of the scattered radiation. Linear focused grids
with grid ratios (height of the lead septa divided by the interspace distance) of 4:1 to 5:1 are
common (e.g., 1.5 mm height, 0.30-mm distance between septa, 0.016-mm septa thickness),
with carbon fiber interspace materials. Grid frequencies (number of lead septa per cm) of
30/cm to 45/cm are typical. To avoid grid-line artifacts, the grid must oscillate over a distance
of approximately 20 lines during the exposure. Excessively short exposures are the cause of
most grid-line artifacts because of insufficient grid motion.

A cellular grid, made of thin copper septa, provides scatter rejection in two dimensions.
Specifications of this design include a septal height of 2.4 mm, 0.64-mm distance between
septa (3.8 ratio), a septal thickness of 0.03 mm, and 15 cells/cm. During image acquisition, a
specific grid motion is necessary for complete blurring, so specific exposure time increments
are necessary and are determined by AEC logic evaluation of the first 100 ms of the
exposure. Because of two dimensional scatter rejection and air interspaces, the cellular grid
provides a better contrast improvement factor than the linear grid. For mammography grids,
the Bucky factor is 2 to 3, so the breast dose is doubled or tripled, but the benefit is
improvement of image contrast by up to 40%. An air gap reduces scatter by increasing the
distance of the breast from the detector, so that a large fraction of scattered radiation misses
the detector. The consequences of using an air gap, however, are that the field of view (FOV)
is reduced, the magnification of the breast is increased, and the dose to the breast is increased.
However, use of a sufficiently large air gap can render the antiscatter grid unnecessary, thus
reducing dose to the breast by approximately the same factor.

Magnification Techniques

Geometric magnification is used to improve system resolution, typically for better

visualization of microcalcifications. In magnification studies, geometric magnification is
achieved by placing a breast support platform (a magnification stand) at a fixed distance
above the detector, selecting the small (0.1 mm) focal spot, removing the antiscatter grid, and
using a compression paddle.

Most dedicated mammographic units offer magnifications of 1.5, 1.8, or 2.0.

Advantages of magnification include

1. increased effective resolution of the image receptor by the magnification factor;

2. reduction of image noise relative to the objects being rendered; and

3. reduction of scattered radiation.

Geometric magnification of the x-ray distribution pattern relative to the inherent unsharpness
of the image receptor improves effective resolution, as long as the loss of resolution by
geometric blurring is mitigated with the small 0.1-mm nominal focal spot. Since there are
more x-rays per object area in a magnified image, the effective quantum noise is reduced,
compared to the standard contact image. The distance between the breast support surface of
the magnification stand and the image receptor reduces scattered radiation reaching the image
receptor, thereby improving image contrast and reducing random noise and making an
antiscatter grid unnecessary.

Magnification has several limitations, the most significant being geometric blurring caused
by the finite focal spot area. Even with a small 0.1-mm focal spot, spatial resolution will be
less on the cathode side of the x-ray field (toward the chest wall), where the effective focal
spot length is largest. In addition, the small focal spot has a tube current limit of about 25 mA
for a Mo target, so a 100-mAs technique requires 4 s exposure time. Even slight breast
motion will result in image blurring, which is exacerbated by the magnification. For screen-
film detectors and long exposure times, reciprocity law failure requires additional radiation
exposure to achieve the desired film OD.

Regarding breast dose, the elimination of the grid reduces dose by a factor of 2 to 3, but the
shorter distance between the x-ray focal spot and the breast increases dose by about the same
factor due to the inverse square law. Therefore, in general, the average glandular dose
delivered to the breast with magnification is similar to that from contact mammography.
However, the smaller irradiated FOV justifies collimating the x-ray beam to only the volume
of interest, which reduces radiation scatter and breast dose.

Geometric magnification. A support platform positions the breast closer to the source focal
spot, resulting in 1.5x to 2.0x image magnification. A small focal spot (0.1-mm nominal size)
reduces geometric blurring.
Screen-Film Cassettes and Film Processing

Screen-film detectors in mammography have been a proven technology over the last 30
years; in fact, the 2001–2005 study comparing screen-film and digital mammography
detectors showed that screen-film detectors are comparable to digital detectors in terms of
diagnostic accuracy as a means of screening for breast cancer. Digital mammography has
been shown to be more accurate for women under the age of 50 years, women with
radiographically dense breasts, and premenopausal or perimenopausal women compared to
screen-film mammography (Pisano et al. 2005 ).

While digital mammography has reduced the use of screen-film mammography, for some
low-volume mammography clinics and those clinics not yet able to transition to digital -
technology, screen-film detectors remain a reasonable and cost-effective technology.

Design of Mammographic Screen-Film Systems

A mammographic screen-film detector is comprised of a cassette, intensifying screen or

screens, and a light-sensitive film. Most cassettes are made of low-attenuation carbon fiber
and have a single high-definition phosphor screen used in conjunction with a single emulsion
film. Terbium-activated gadolinium oxysulfide (Gd2O2S:Tb) is the most commonly used
screen phosphor. This scintillator emits green light, requiring a green-sensitive film emulsion.
Intensifying screen-film speeds and spatial resolution are determined by screen phosphor
particle size, number of phosphor particles per volume, light-absorbing dyes in the phosphor
matrix, and phosphor layer thickness.

Mammography screen-film systems have their own speed ratings and are classified as regular
(100 or par speed) and medium (150 to 190 speed), whereby the 100-speed screen-film
system requires 120 to 150 μGy incident air kerma to achieve the desired film OD. For
comparison, a conventional “400-speed” screen-film cassette for general diagnostic imaging
requires about 5-μGy air kerma. The intensifying screen is positioned in the back of the
cassette so that x-rays travel through the cassette cover and the film before interacting with
the phosphor. Exponential attenuation in the phosphor results in a greater fraction of x-ray
interactions near the phosphor surface closest to the film emulsion. At shallow depths in the
phosphor, absorbed x-rays produce light distributions that have minimal light spread prior to
interacting with the film, thus preserving spatial resolution. x-ray absorption occurring at
greater depth in the screen produces a broader light distribution and reduces spatial
resolution, but the number of interactions decreases exponentially with depth. For a “100-
speed” mammography screen-film cassette, the limiting spatial resolution is 15 to 20

Nearly all screen-film systems used in mammography employ a single phosphor screen with
a single emulsion film and are “front-loaded” (x-rays pass through the film to the screen).

Film Recording and Film Processing

Mammography films are sensitized by x-ray–induced light from the phosphor screen. Light
produces latent image centers on microscopic light-sensitive silver halide grains in the
emulsion layered on a film substrate. Intensity variations in the light produce corresponding
variations in the number of sensitized grains per area. Chemical processing in a bath of
developer solution renders the invisible latent image into a visible image by reducing the
sensitized grains to elemental silver.

Unsensitized grains in the film emulsion are not reduced and are dissolved and washed away
by the fixer solution. Subsequent rinsing and drying complete the film processing. Film is
thus a two-dimensional recording of the incident light patterns encoded by silver grains on
the substrate that produce an image with varying light intensities when the film is placed on a
lightbox.

Film processing is a critical step in the mammographic imaging chain for screen-film
detectors and is performed by automatic film processors. Film characteristics such as film
speed (an indication of the amount of incident radiation required to achieve a specified OD
on the film) and film contrast (the rate of change of OD for a known difference in incident
radiation) are consistently achieved by following the manufacturer’s recommendations for
developer formulation, development time, developer temperature, developer replenishment
rate, and processor maintenance. If the developer temperature is too low, the film speed and
film contrast will be reduced, requiring a compensatory increase in radiation dose. If the
developer temperature is too high or immersion time too long, an increase in film speed
occurs, permitting a lower dose; however, the film contrast is likely to be reduced because
film fog and quantum mottle are increased. Stability of the developer may also be
compromised at higher-than-recommended temperatures. The manufacturer’s guidelines for
optimal processor settings and chemistry specifications should be followed. Also, because
mammographic films must be retained for years, fixer retention on the film must be measured
when evaluating the processor. If film washing is incomplete and fixer is retained, the films
will oxidize and image quality will deteriorate over time.

Quality Control
Because of the high sensitivity of mammography film quality to slight changes in processor
performance, routine monitoring of film contrast, speed, and base plus fog OD is important.
A film-processor QC program is required by the MQSA regulations, and daily sensitometric
tests must be performed before the first clinical images to verify acceptable performance.
This requires the use of a sensitometer and a densitometer. A sensitometer is a device that
emulates a range of incident radiation exposures by using a constant light source and
calibrated optical attenuation steps to expose a mammographic film to known relative light
intensities.

Developing the film produces a range of numbered OD steps known as a film sensitometric
strip. A densitometer is a device that measures the light transmission through a small area of
the film and calculates the OD. Additionally, a thermometer is used to measure the
temperature of the developer solution in the processor and monitoring chart are tools used to
complete the processor evaluation. A chart is used to record and monitor the quality control
measurements.

Film Viewing Conditions

Viewing conditions are very important so that the information on the film is visualized well
by the radiologist. Subtle lesions on the mammographic film may be missed if viewing
conditions are suboptimal. Since mammography films are exposed to high optical densities to
achieve high contrast, view boxes in the mammography reading area must provide high
luminance. Mammography view boxes should have minimum luminances of at least 3,000
cd/m2, and luminances exceeding 6,000 cd/m 2 are common. In comparison, the luminance of
a view box in diagnostic radiology is typically about 1,500 cd/m2.

A high-intensity “bright” light should be available in the reading room to penetrate high OD
regions of the film, such as the skin line and the nipple area. Furthermore, the use of a
magnifying glass improves the visibility of fine detail in the image, such as
microcalcifications.

The ambient light intensity (as measured by the illuminance) in a mammography reading
room must be reduced to eliminate reflections from the film and to improve perceived
radiographic contrast. Illuminance is the luminous flux incident upon a surface per unit area,
measured in lux or lumens/m2. For example, the full moon in a clear night sky produces about
1 lux, whereas normal room lighting generates 100 to 1,000 lux. Subdued room lighting
providing an illuminance of about 20-40 lux is acceptable for the viewing and interpretation
of mammograms.

Digital Mammography

Digital acquisition devices became available in mammography in the early 1990s in the form
of small field-of-view digital biopsy systems. In early 2000, a full-field digital mammography
system was first approved by the FDA; it had a thin-film-transistor (TFT) indirect detection
flat panel array with an 18  23-cm active area. Since that time, several digital
mammography systems have been approved by the FDA in the United States and, in 2010,
70% of all clinical mammography machines in the United States were digital systems.

Full-Field Digital Mammography

There are compelling advantages to digital mammography, the most important of which is the
ability to overcome the exposure latitude limitations of screen-film detectors and produce
better image quality at lower doses. Other reasons include increased technologist productivity
through rapid acquisition and evaluation of digital images; reduced patient waiting time,
particularly for diagnostic studies; and improved image quality and conspicuity of lesions.

Screen-film detectors for mammography are excellent image capture devices, and the film
serves as both the display device and the storage media, but the major drawbacks are the
limited exposure dynamic range and narrow latitude, which are necessary to achieve high
radiographic contrast. A highly glandular breast can produce exposure latitude that exceeds
200:1, causing underexposed film areas corresponding to the glandular tissue, and
overexposed film areas corresponding to the skin line and thinner parts of the breast. Digital
flat panel and digital cassette (CR) detectors have exposure dynamic ranges greater than
1,000:1, which result in images showing little contrast when the entire ranges of pixel values
are displayed. With mammography-specific image postprocessing, high image contrast can
be rendered over all exposure levels (e.g., from the high detector exposure at the skin line to
the low detector exposure behind dense glandular areas of the breast), as shown in the
processed For Presentation image. Post processing image enhancement is a key element in
producing an optimized digital mammogram.

Flat panel detector arrays, which became clinically available in the mid to late 1990s for
general radiography, are the major detector technologies used in digital mammography. An
active matrix, thin film transistor (TFT) array collects the local signal (electric charge)
generated during the x-ray exposure, absorption, and conversion process; stores the charge in
a capacitor attached to each detector element; and actively reads the array immediately
afterward to produce the image. The digital image is then stored in computer memory. In
some “fast” flat panel designs, readout of the whole array is performed in hundreds of
milliseconds, allowing near real-time acquisition of data for applications such as digital
tomosynthesis.

Computer-Aided Detection and Computer-Assisted

Diagnosis Systems

A computer-aided detection (CADe) system is a computer-based set of algorithms that

incorporates pattern recognition and uses sophisticated matching and similarity rules to flag
possible findings on a digital mammographic image, which may be a digitized film
mammogram. The computer software searches for abnormal areas of density, mass,
calcifications, and/or structural patterns (e.g., spiculated masses, architectural distortion) that
may indicate the presence of cancer. The CADe system then marks these areas on the images,
alerting the radiologist for further analysis.
For Processing images

for analysis, as the algorithms are trained on these images and evaluation of processed images
would result in lower performance in terms of sensitivity and specificity. Computer-assisted
diagnosis (CADx) devices include software that provides information beyond identifying
suspicious findings; this additional information includes an assessment of identified features
in terms of the likelihood of the presence or absence of disease, or disease type. For instance,
a CADx system for mammography will not only identify clusters of microcalcifications and
masses on digital mammograms but also provide a probability score of the disease or
malignancy to the radiologist for each potential lesion. Currently, CADe and CADx systems
are widely used by radiologists who interpret mammography studies in addition to other
duties.

The fraction of False-positive marks (marks placed on image features that do not correspond
to malignancy) can be high and is one of the downsides of using these systems. Many expert
mammography radiologists avoid using CAD for this reason.

Breast Digital Tomosynthesis

Digital radiographic imaging offers post acquisition processing capabilities that are not
possible with conventional analog imaging systems. One of the major problems with
conventional projection imaging is that overlying and underlying anatomy are superimposed
on the pathology, often obscuring the visualization and detection of the cancer or other
abnormality. A method for reducing this super imposition is to acquire multiple low-dose
images at several angular positions as the x-ray tube moves in an arc about the breast. Each
image projects the content in the breast volume with different shifts depending on the
distance of the object from the detector. With high-speed digital readout, several projection
images can be acquired in under 10 s, and each image set is processed with a limited-angle
reconstruction algorithm to synthesize a tomogram (in-focus plane) at a given depth in the
breast. Many tomograms representing incremental depths within the volume are produced,
and in-focus planes throughout the breast can assist in enhanced detection of pathology (e.g.,
tumor) or elimination of superimposed anatomy that mimics pathology, digital tomosynthesis
technology can lead to a superior diagnosis that might save a patient an unneeded biopsy or
provide guidance for early treatment of a cancer.