The art of mammographic positioning.

The discovery of clinically occult breast cancer creates an exciting opportunity to alter the natural history of one of the major killers of women in our society. The skills required for this endeavor depend on high-quality images that provide the mammographer with sufficient information to construct three-dimensional perceptions recognizable as departures from normal architecture. Altering the natural course of breast cancer depends on early detection. Early detection of breast cancer depends on high-quality imaging techniques. Paramount among the imaging techniques for breast cancer detection is mammographic positioning. Optimal mammographic positioning is achieved by understanding the capabilities of available dedicated mammographic equipment and applying this understanding to take full advantage of natural breast mobility in overcoming various anatomic limitations. Compression of breast tissue, essential for proper parenchymal imaging, is achieved by moving one surface of the breast toward the other. The concept of moving the mobile surface of the breast toward the more fixed and immobile surface has been stressed as an important principle in optimizing the amount of tissue that can be imaged on standard mammographic views. Visualizing the fine details of a lesion or the margins of an area of clinical or perceived radiographic concern may be crucial to determining the need for biopsy. Visualization of such details is best achieved by projecting the suspected lesion into interface with adjacent radiolucent fat through separation of overlapping parenchyma by using spot compression or by tangential imaging against subcutaneous fat. Unique problems require creative, tailored solutions. Such tailoring is made less difficult by understanding and using equipment capability with breast anatomy and mobility. The very small, very large, or very dense breast can be imaged properly with modified techniques. Likewise, the augmented breast, mastectomy site, or axilla can be imaged with specialized techniques. Artistic application of these mammographic positioning principles will be rewarded with high-quality images, fewer missed breast cancers, and more lives saved.