Mammography remains the basic tool of Breast Diagnosis and the first examination to perform when a suspicious palpable finding is detected in the breast.

A small tumour detected by mammography and self-examination. Clinical examination however, was negative. Mammography revealed a small infiltrative lesion at the site of the finding of self-examination. Core biopsy diagnosed a small (7mm) ductal carcinoma that was successfully excised

Of great importance is routine annual Mammography as a preventive procedure (after the age of forty).

Breast cancer is a very common clinical problem (Approximately one in every nine women will get the disease in her lifetime). It has been demonstrated by controlled studies that preventive screening with Mammography can improve survival by diagnosing early subclinical breast cancers that carry a significantly better prognosis and can be treated successfully by surgery.

Early detection may obviate the necessity for chemotherapy treatment, resulting in great improvement of quality of life for a large number of patients. Imaging may detect lesions 1-2 years before they become detectable by clinical or self-examination.

A large time span is needed for breast cancer to develop. It may take up to 5 years to reach a size detectable by imaging (2-3 mm ) and from there on to reach a clinically detectable size (usually more than 1 cm depending on location and on the properties of surrounding breast tissue). It is evident that breast cancer is mammographically and sonographically detectable 1-2 years before it becomes evident at clinical examination or self-examination. Figure from: Harris et al: Breast Diseases, 2nd Edition 1991

Accordingly, screening of the breasts at regular intervals by Mammography should be promoted strongly by every health practitioner working with women.

Great attention must be paid to all aspects of the Imaging Chain of the Mammography procedure in order to obtain Mammograms of superior quality:

Mammography requires trained staff and modern high-quality low-dose equipment (Picture courtesy of Siemens Corp)

Adequate positioning of the breasts on the Mammography unit by trained, specialized personnel under constant supervision by a breast imaging specialist and use of a modern High Resolution - Low Dose Mammography Unit with an Automatic Exposure Control System (AEC) checked at regular Intervals by a Medical Physicist is required.

We must make use of the latest combinations of sensitive dedicated mammography films and film screens that can minimize patient dose and improve image quality.

Use of a dedicated film processor under constant Quality Control (QC) is recommended, as is interpretation of mammography films using a special film viewer with adequate lighting and ability to mask extraneous light by shades.

Viewing the mammograms requires special lighting conditions and a dedicated film viewer with adequate lighting and ability to mask extraneous light by shades

Regular use of magnification and spot lighting accessories is advised. Correlation with the clinical examination findings, with findings of self-examination, with patient medical history and with the findings of earlier Mammograms is of extreme importance to achieve the correct diagnosis of breast pathology.

A large part of our daily clinical routine involves problem solving in patients whose initial imaging evaluation of the breast has revealed a finding causing some concern. Problem solving with Mammography commonly involves complementary evaluation of the breast using special mammographic views and techniques (Magnification, Spot Compression) and Ultrasound evaluation.

	A 66 year old woman with large pendulous breasts reported a new palpable finding at the site of minor trauma. A special localized view was used in this case to clarify a new palpable finding. A metallic marker has been fixed on the skin over the palpable clinical finding. A true lateral projection is used making sure that the lesion is seen in profile to document its distance from the skin marker.
	Magnification view of the lesion revealed a circumscribed superficial lesion with welldefined borders
	Ultrasound revealed a cystic lesion with internal layered echoes, surrounded by hyperechoic change of the subcutaneous fat. The superficial location of the lesion and the ultrasound appearance correlated well with the history of minor trauma in the area. Our diagnosis of hematoma was proven by FNA when the lesion was evacuated producing a small amount of bloody fluid.

These are also used to clarify a clinical finding that may not have been adequately visualized in routine views and whose significance remains uncertain. Ultimately, guided needle biopsy may be required to solve a diagnostic dilemma.

Preoperative localization of nonpalpable breast lesions, especially of suspicious clusters of microcalcifications is a valuable technique allowing the breast surgeon to remove pathologic non-palpable areas in the breast with great accuracy.

Malignant microcalcifications detected by screening Mammography. Initial surgery without localization failed to remove the suspicious cluster. Repeated surgery after wire localization removed a focus of DCIS with an associated 4 mm invasive component. Lymph nodes sampled during surgery were negative. The prognosis is excellent