fied to visualize findings in specific hard-to-see locations that are commonly missed by standard CC, MLO, and lateral views. It is not uncommon to see a suspicious lesion on one view and not see it on the orthogonal projection. This can be because of the patient’s body configuration or because the location of the find- ing makes it hard to see on the mammogram.
Some lesions are located in the extreme outer part of the breast not included on the standard CC view. A view that sees more of the outer breast is the CC view exaggerated laterally (XCCL; Figs. 2.43 and 2.44 and Figs. e2.1 and e2.2). The tech- nologist obtains an XCCL by modifying a standard CC view. The patient’s body is rotated to display more outer breast tissue than is seen on a standard CC view and excludes the medial portion of the breast. This projection sees more outer breast but does not see the inner breast.
The Cleopatra view also includes more outer breast tissue. In this view, the patient rotates laterally, as in the XCCL, but also leans obliquely like Cleopatra reclining on a bed of pillows (Fig.
2.45). The Cleopatra view includes much more of the outer part of the breast while excluding inner breast tissue, but unlike the XCCL, which is taken with the patient standing straight up, the Cleopatra view is taken with the patient leaning slightly back- ward and obliquely.
For inner breast lesions, CC views exaggerated medially (XCCM) image the medial portion of the breast while excluding the outer breast tissue (see Fig. 2.43, Fig. 2.46, and Fig. e2.3).
Another view that visualizes the inner breast is the CV (see Fig.
2.43), or valley view, which includes the medial portions of both breasts on the image receptor in a modified CC projection. Such views allow visualization of even more of the inner part of the breast than is seen on standard CC views, but also images some of the opposite inner breast (Fig. 2.47).
Some lesions are so close to the chest wall they are hard to image with normal-sized compression paddles. The small spot compression paddles can get closer to the chest wall. The tech- nologist can use the small spot compression paddles to image extremely inner or deep lesions because they are smaller than the bulky normal compression paddles (see Fig. 2.43).
Some lesions in the upper part of the breast are so far back against the chest wall that they can be pushed out of the field of view by the compression paddle (Fig. 2.48A–B). This problem can be solved by the from-below (FB) or CC view (Fig. 2.48C). For this view, the image receptor is placed on the
CC RL
Lateral Medial Lateral Medial
FIG. 2.33 Schematic of a rolled lateral (RL) view separating sum- mation artifacts into their fibroglandular components. The initial craniocaudal (CC) view of the right breast on the lower left shows a “mass” composed of overlapping glandular tissue. The rolled CC lateral (RL) view on the lower right shows the fibroglandular com- ponents separated into normal structures. In contradistinction, a mass should retain shape, form, and density, as seen on the origi- nal mammogram. (Modified from Sickles EA: Practical solutions to common mammographic problems: tailoring the examination, AJR Am J Roentgenol 151:31–39, 1988.)
B A
MLO
Spot Mag
CC XCCL
C
D
FIG. E2.1 Craniocaudal view exaggerated laterally (XCCL). (A and B) Mediolateral oblique (MLO; A) and craniocaudal (CC; B) screening mammograms. A round density suggestive of a mass (arrow) is seen in the outer portion of the left breast on the CC view under the scar marker but is not seen on the MLO view. (C) An XCCL shows the mass (circle with arrow) better. (D) The mass is also shown on a spot magnification view.
Note the scar marker in B–D.
A B
XCCM MLO
FIG. E2.3 Craniocaudal view exaggerated medially (XCCM). (A) A mediolateral oblique (MLO) view shows a round mass near the high chest wall that is excluded on the standard craniocaudal view. (B) An XCCM shows the round inner breast mass, which was diagnosed as invasive ductal cancer.
A B
CC XCCL
FIG. E2.2 Craniocaudal view exaggerated laterally (XCCL). The standard craniocaudal (CC) view shows no mass in the outer breast (A), but the XCCL view clearly visualizes the mass (arrow; B).
upper part of the breast. The breast is then compressed from below, excluding the lower part of the breast but including tissue high on the chest wall. In another approach for imaging lesions high on the chest wall, the image receptor is placed on the midportion of the breast with the lower portion excluded;
this approach, first described by Sickles et al. (1988), incor- porates more of the upper portion of the breast because the compression paddle does not have to include lower breast tis- sue in the field of view.
Another area that is hard to see is the region immediately behind the nipple, which can be hidden by adjacent blood ves- sels and ducts. Spot compression compresses normal ducts, blood vessels, and tissue while pulling the nipple into profile (Fig. 2.49). The nipple should be in profile on at least one view to see the retroareolar region; otherwise, the nipple may hide a cancer.
Lesions in the lower inner part of the breast are very hard to see. A superior–inferior oblique (SIO), or reverse oblique, view visualizes the lower inner breast. In this view, the technologist
places the imaging receptor on the medial part of the breast and the compression plate on the superior breast while the patient leans over the imaging receptor (Fig. 2.50). The compression pad- dle approaches the breast from the superior axillary side, allow- ing more of the inner breast tissue to be visualized.
Palpable findings imaged near the periphery of the breast are seen better with spot compression. This type of spot compression tangential to the palpable finding can push the mass against sub- cutaneous fat, allowing it to be seen. Spot compression directly over the palpable mass, previously known as a lumpogram, also can show masses by compressing the surrounding glandular tis- sue away from the suspicious finding (Fig. 2.51).