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Efficacy of Step-Oblique Mammography for Confirmation and Localization of Densities Seen on Only One Standard Mammographic View

¹ All authors: Department of Radiology, University of California at San Francisco, Box 1667, San Francisco, CA 94143.

View larger version (23K): [in a new window]   Fig. 1. —Drawing shows how to mount step-oblique mammograms on viewbox and perform triangulation. Progressive step-oblique images from 90° mediolateral (ML) projection to 0° craniocaudal (CC) projection, performed in 15° mediolateral oblique (MLO) increments, are mounted on viewbox with projection markers at top. Nipples point in same direction and are aligned horizontally. Note that straight line can connect lesion on all sequential step-oblique images, which permits triangulation as follows. Using subset of full complement of step-oblique images (i.e., lesion not yet identified on either 90° or 0° projection, or both), draw imaginary line through lesion on available images and extend line to left, right, or both to indicate expected location of lesion on orthogonal projections. In this case, lesion is in upper inner left breast.

View larger version (69K): [in a new window]   Fig. 2A Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. Screening mammograms at 60° MLO projection (A)

View larger version (63K): [in a new window]   Fig. 2B Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 0° CC projection (B).

View larger version (75K): [in a new window]   Fig. 2C Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. Step-oblique mammograms at 0° CC projection (C)

View larger version (80K): [in a new window]   Fig. 2D Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 15° MLO projection (D)

View larger version (84K): [in a new window]   Fig. 2E Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 30° MLO projection (E)

View larger version (113K): [in a new window]   Fig. 2F Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 45° MLO projection (F)

View larger version (110K): [in a new window]   Fig. 2G Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 60° MLO projection (G)

View larger version (117K): [in a new window]   Fig. 2H Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. Step-oblique mammograms at 75° MLO projection (H)

View larger version (116K): [in a new window]   Fig. 2I Step-oblique mammography obtained for poorly defined noncalcified density (arrows) in inner left breast not clearly seen at first on mediolateral oblique (MLO) projection. Progressive 15° incremental step-oblique images show density represents true mass, localized to lower inner left breast. Note nipple (white dots). Imaging-guided tissue diagnosis (not shown) revealed infiltrating ductal carcinoma. ML = mediolateral, CC = craniocaudal projection. 90° ML projection (I).

View larger version (94K): [in a new window]   Fig. 3A. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detal technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. Screening mammograms at 60° MLO projection (A) and 0° CC projection (B).

View larger version (87K): [in a new window]   Fig. 3B. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. 0° CC projection (B).

View larger version (112K): [in a new window]   Fig. 3C. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. Screening mammogram at 0° CC projection with area of interest photographically enlarged.

View larger version (105K): [in a new window]   Fig. 3D. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. SCM mammogram at 0° CC projection with area of interest photographically enlarged.

View larger version (100K): [in a new window]   Fig. 3E. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. Step-oblique SCM mammograms with area of interest photographically enlarged at 15° MLO projection (E).

View larger version (111K): [in a new window]   Fig. 3F. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. 45° MLO projection (F).

View larger version (88K): [in a new window]   Fig. 3G. —Step-oblique mammography requiring additional spot compression magnification (SCM) mammography for lesion seen well only with fine-detail technique. Poorly defined density (arrow, B), seen at first in inner right breast only on screening craniocaudal (CC) view, persists on craniocaudal spot compression magnification (CC SCM) image, in which margins appear spiculated. Density not seen on screening 60° mediolateral oblique (MLO) view. Step-oblique images obtained in 15° increments using SCM (over expected region of density) show spiculated density much more readily than on whole-breast step-oblique images (not shown), validating presence of mass and permitting precise localization. Imaging-guided tissue diagnosis (also not shown) revealed infiltrating ductal carcinoma. 90° mediolateral projection (G).

View larger version (96K): [in a new window]   Fig. 4A —Step-oblique mammography used to identify summation artifacts. Oval density (straight arrow, B-D) seen at first in inner right breast on screening craniocaudal (CC) view but not on screening mediolateral oblique (MLO) view. Note second poorly defined density (curved arrow, B) in central right breast seen only on screening CC view, confidently judged to represent summation artifact without need for further imaging evaluation. Oval density (straight arrow, C), persistent on 0° craniocaudal spotcompression magnification (SCM) view but not seen on 90° lateral SCM view (not shown), was subsequently shown on step-oblique images to represent summation artifact created by looping blood vessel (straight arrow, D). Screening mammograms at 60° MLO projection (A)

View larger version (95K): [in a new window]   Fig. 4B —Step-oblique mammography used to identify summation artifacts. Oval density (straight arrow, B-D) seen at first in inner right breast on screening craniocaudal (CC) view but not on screening mediolateral oblique (MLO) view. Note second poorly defined density (curved arrow, B) in central right breast seen only on screening CC view, confidently judged to represent summation artifact without need for further imaging evaluation. Oval density (straight arrow, C), persistent on 0° craniocaudal spotcompression magnification (SCM) view but not seen on 90° lateral SCM view (not shown), was subsequently shown on step-oblique images to represent summation artifact created by looping blood vessel (straight arrow, D). 0° CC projection (B)

View larger version (112K): [in a new window]   Fig. 4C —Step-oblique mammography used to identify summation artifacts. Oval density (straight arrow, B-D) seen at first in inner right breast on screening craniocaudal (CC) view but not on screening mediolateral oblique (MLO) view. Note second poorly defined density (curved arrow, B) in central right breast seen only on screening CC view, confidently judged to represent summation artifact without need for further imaging evaluation. Oval density (straight arrow, C), persistent on 0° craniocaudal spotcompression magnification (SCM) view but not seen on 90° lateral SCM view (not shown), was subsequently shown on step-oblique images to represent summation artifact created by looping blood vessel (straight arrow, D). SCM mammogram at 0° CC projection with area of interest photographically enlarged.

View larger version (100K): [in a new window]   Fig. 4D —Step-oblique mammography used to identify summation artifacts. Oval density (straight arrow, B-D) seen at first in inner right breast on screening craniocaudal (CC) view but not on screening mediolateral oblique (MLO) view. Note second poorly defined density (curved arrow, B) in central right breast seen only on screening CC view, confidently judged to represent summation artifact without need for further imaging evaluation. Oval density (straight arrow, C), persistent on 0° craniocaudal spotcompression magnification (SCM) view but not seen on 90° lateral SCM view (not shown), was subsequently shown on step-oblique images to represent summation artifact created by looping blood vessel (straight arrow, D). Step-oblique mammograms at 15° MLO projection (D)

View larger version (106K): [in a new window]   Fig. 4E —Step-oblique mammography used to identify summation artifacts. Oval density (straight arrow, B-D) seen at first in inner right breast on screening craniocaudal (CC) view but not on screening mediolateral oblique (MLO) view. Note second poorly defined density (curved arrow, B) in central right breast seen only on screening CC view, confidently judged to represent summation artifact without need for further imaging evaluation. Oval density (straight arrow, C), persistent on 0° craniocaudal spotcompression magnification (SCM) view but not seen on 90° lateral SCM view (not shown), was subsequently shown on step-oblique images to represent summation artifact created by looping blood vessel (straight arrow, D). 30° MLO projection (E).

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