http://www.r2tech.com/pti/index_b.

Mammografi, bersamaan dengan pemeriksaan jasmani, merupakan cara yang digunakan untuk mendeteksi keganasan di payudara.

Terdapat dua modalitas yang dikenal dalam melakukan mammografi, yakni xeroradiografi dan film-screen-grid mammography. Dari keduanya, teknik film-screen-grid adalah yang paling sering digunakan.

Teknik ini menggunakan target molybdenum dan filter molybdenum 0.03 mm dengan dosis 1.8-3.5 mGy, untuk mendapatkan hasil mammografi payudara yang ditekan sepanjang 5 cm. Metode film-screen ini dapat menunjukkan mikrokalsifikasi kurang dari 200 µ. Layar (screen) yang digunakan hanya satu, sebagai latar belakang untuk menghindari ‘perpindahan’, dan kontak film-screen diatur dalam jarak yang dekat, dipastikan dengan kaset yang dirancang khusus. Film harus memiliki nilai gamma yang tinggi untuk meningkatkan kontras, sehingga karena hal ini menyebabkan sempitnya paparan panjang maka pengawasan paparan otomatis adalah penting.

Xeroradiografi payudara menggunakan tube tungsten dengan fine-focus dengan filtrasi alumunium 2.5-3.0 mm dan modus pencitraan negative dosis 3.5mGy. Penetrasi radiografik pada payudara padat sangat baik, dengan hasil informasi yang lebih banyak dan detil dibandingkan mammografi film. Proses inherent edge-enhancement dari xeroradiografi memperlihatkan gambaran struktur payudara serta adanya abnormalitas lebih jelas dibandingkan teknik film, bahkan juga memperlihatkan mikrokalsifikasi yang lebih terang, khususnya di payudara yang padat.

Posisi Radiografi

Posisi yang tepat adalah penting sehingga didapatkan gambaran payudara seluas mungkin. Kolimasi cahaya, penekanan payudara, serta posisi pasien yang tepat adalah hal-hal yang esensial.

Terdapat dua posisi pandangan, yakni pandangan kranio-kaudal dan pandangan 45° medio-lateral oblique. Dua posisi ini harus dilaksanakan dalam pemeriksaan karena 10-20% keganasan dapat terlewatkan apabila hanya satu posisi pandangan saja yang dilakukan.

  Introduction to Breast Cancer and Mammography  

From the website of    http://www.r2tech.com/pti/index_b.html converted from their .pdf  

1. WHAT IS BREAST CANCER

Breast cancer is a “malignant neoplasm of the breast.” A cancer cell has characteristics that differentiates it from normal tissue cells with respect to: the cell outline, shape, structure of nucleus and most importantly, its ability to metastasize and infiltrate. When this happens in the breast, it is commonly termed as ‘Breast Cancer’. Cancer is confirmed after a biopsy (surgically extracting a tissue sample) and

pathological evaluation.

Microscopic cell differentiation

1.1. Demographics

Breast Cancer is second to Lung Cancer in the fatality rate due to cancer among women today. In the developed countries, one out of every nine women gets breast cancer during her lifetime.

Incidence Rate

Country (I) United States 94.2 Switzerland 73.5 Netherlands 72.7 Canada 71.1 Denmark 68.6 France 66.3 Italy 65.4 Sweden 62.5 Australia 61.7 Great Britain 56.1 Norway 54.8 Germany 46.3 Slovak 34.5 India 24.6 Japan 21.9

Mortality Rate M/I

(M) %

1. 25.2 2. 42.6

 

26.3 38.8

1. 35.6 2. 46.2

 

1. 36.7 2. 35.1

 

1. 32.6 2. 38.5

3. 59.0

 

18.7 37.8

1. 41.4 2. 56.2

3. 35.9

 

6.4 29.9

Incidence and Mortality rates; Cancer Incidence in Five Continents V6,’83-‘87

In1999, approximately 215,000 new cases of breast cancer are expected to be diagnosed in the United States and 43,000 women are expected to die from this disease.

1.2. Risk Factors

1.2.1. Age

The most important risk factor is age. The incidence of breast cancer increases with age. The majority of women diagnosed with breast cancer are over the age of 50.

Women under the age of 25 are least likely to develop breast cancer. However, younger women who do contract breast cancer, suffer from speedy and aggressive growth of cancer.

1.2.2. Gender

Women are the main victims of breast cancer, but male breast cancer accounts for less than 1% of the total breast cancer cases.

1.2.3. Family History of Breast Cancer

A family history of breast cancer increases the risk of getting breast cancer during a woman’s lifetime. Breast cancer can appear in multiple family members and can be carried down to up to three generations. The maternal side of the family contributes to the high risk category of breast cancer, meaning, if a woman’s grand-mother, mother, aunt or sister has breast cancer, then she is more likely to develop breast cancer. The indirect commonalties are: lifestyles, hormonal and menstrual patterns and dietary habits.

1.2.4. Hormonal Factors

Breast cancer is directly related to the spurts of hormonal changes through a woman’s lifetime. Starting menstruation at an early age, no childbirth and late age of menopause contribute to the high risk category of breast cancer. A direct co-relation is found between the age of first pregnancy and breast cancer. It is believed relative risk of breast cancer increases by 1.4 if the first pregnancy occurred after the age of 30. On the other hand, women who experienced their first childbirth before the age of 20, had decreased relative risk of breast cancer (0.8). Some studies have shown that the use of oral contraceptives and long-term estrogen therapy increase the risk of breast cancer.

1.2.5. Lifestyle

Lifestyle contributes towards the probability factor of breast cancer. High fat content in the diet increases the risk of breast cancer. Some studies indicate that high meat consumption, high caffeine intake, smoking, environmental pollution also increases the risk of breast cancer, but these results are still unconfirmed.

1.3. Signs and Symptoms

1.3.1. Clinical Signs

The most common clinical sign of breast cancer is a painless, hard and fixed lump in the breast. This is one of the reason that makes clinical detection of breast cancer very difficult, as painlessness gives the woman a false sense of security. If the lump is movable, it is less likely to be cancer, and more likely to be benign cysts. Approximately, one-tenth of the patients have breast pain with no detectable lump.

Other symptoms are categorized under breast distortion. Dimpling of the skin surface, swelling, skin irritation, skin edema with ‘peau d’orange appearance’ (looks like orange peel), nipple inversion, tenderness and nipple discharge. At times, a rapidly growing tumor may cause dilated superficial veins forming a prominent vascular patters, visual on the breast surface.

1.4. Staging of cancer

Staging of breast cancer means the categorization of the type and extent of metastases of cancer. This determines the path of treatment and long-term follow-up. (Addendum 1)

1.5. Survival Rate

The survival rate has increased significantly over the past five years. One of the main reasons for this is: early diagnosis. Women’s awareness of the importance of breast self exam and mammograms, as well as the technological progress, leads to early detection. Survival rate is expressed in two ways : First, by the stage of detection and secondly, over time. If the cancer is detected in its initial stages, chance of recovery are very high. As per the American Cancer Society, based on the time issue, the relative survival rate for women diagnosed with breast cancer is 83% five years after diagnosis, 65% after ten years and 56% after fifteen years.

Survival by stage of diagnosis; American Cancer Society

1.6. Economic Justification

In 1994, out of 183,000 new cases of breast cancer diagnosed, 25% were at the late stage (National Cancer Institute, USA). The Treatment cost for early stage breast cancer is approximately $ 11,000, whereas at a late stage diagnosis, the treatment cost is about $ 140,000 per case. Hence, the difference between early and late stage cancer treatment is between $ 130,000 to $ 230,000 per case. Recent studies show that a second reading of mammograms increases the number of cancers detected by 5% to 15%. We know that very early detection of breast cancer through well structured screening programs, availability of a second reader and patient education, is highly cost-effective.

1.7. Importance of Early Diagnosis

As we can see, early diagnosis is the key to a higher survival rate. There are three ways in which we can diagnose breast cancer at its early stage:

1. Breast Self Exam 2. Clinical Exam

3. Mammography findings

4.

1.7.1. Breast Self Exam (BSE)

BSE should be done monthly and is one basic way for a woman to familiarize herself with her breasts and keep a close watch on the visual appearance of her breasts and the changes she feels. The best time to do a BSE is 2 to 3 days after the end of menstruation, as the normal lumpiness of the breast is then minimized. There are various ways of performing BSE. One of the best method of BSE is performed in the supine position (i.e. lying down, as this spreads out the internal breast tissue and deeper lumps can be felt easily) with one arm raised over the head. Using the smooth surface of the fingers of the opposite hand, a woman checks the breast with small circular motion keying in to any lumps that can be felt. She works from around the nipple area to the outer edges of the breast in concentric circles.

1.7.2. Clinical Exam

A clinical exam is performed by a trained healthcare professional. The Clinician examines the woman in a sitting position, looking for signs such as nipple inversion, breast distortion, nipple discharge, dimpling, and skin irritation. She may then ask the woman to press the palms of her hands together over her head. This accentuates any physical abnormality that may be present. In conjunction, an exam, similar to the BSE may also be performed.

1.7.3. Mammography

This is a radiographic exam of the breast and the most important exam to detect early stages of breast cancer. The American Cancer Society recommends women to have a ‘Baseline Mammogram’ done between the age of 35 - 40 years, each year or every other year till the age of 50 years and each year after the age of 50. The National Health Service Breast Screening Programme of England, recommends women between the ages of 50 and 65 to have a mammogram once every three years.

Lately, there have been many conferences in USA and some scheduled to be held in Canada to discuss the need for mammograms before the age of 40. It is a wide spread opinion that mammograms of younger breasts are not very diagnostic. Of course, there are controversies and breast cancer survivors have come forward as living proof that early mammograms saved their lives.

Country Baseline Age/Frequency Views

Canada   40+ : annually Rcc,Lcc,Rmlo,Lmlo

Finland   40+ annually Rmlo, Lmlo

Great Britain   50-65: once every 3 years Rcc,Lcc,Rmlo,Lmlo

Netherlands   50-65: once every 2 years Rmlo, Lmlo

Sweden   40+ : annually Rmlo, Lmlo

USA35-40 years

40-50:once every 2 years Rcc,Lcc,Rmlo,Lmlo

50+ : annually

Other European countries, such as Germany, France, Italy, Spain, Norway are in the process of setting up guidelines for women to have a baseline mammogram at a certain age and every or every other year thereafter.

Regular mammograms can detect lumps as small as 0.2 cm, whereas regular BSE detects lumps of about 1.2 cm. An average size lump found by women untrained in BSE is about 3.75 cm.

  Search Method     Average size of lump detected  

Women untrained in BSE   3.75 cm

Women practicing occasional BSE   2.50 cm

Women practicing regular BSE   1.20 cm

Initial mammogram   0.60 cm

Regular mammograms   0.20 cm

Size of tumor found by search Method; Susan G. Komen Foundation

2. WHAT IS A MAMMOGRAM?A mammogram is a radiograph of the breast tissue (refer to the attached copy of a mammogram). It is an effective non-invasive means of examining the breast, commonly searching for breast cancer. Cancer is not preventable, but early detection leads to a much higher chance of recovery and lowers the mortality rate from this disease.

2.1. Breast Anatomy

CC View : Positioning, Film, & Anatomy

mammo educ-content2.doc

X-rays Compression arm Ribs

cutaneous

Lactiferou ducts

Lobules

Cassette containing film

Infra mammary fold

Compression paddle MLO View : Positioning, Film, & Anatomy

mammo educ-content2.doc

Generally,

A younger woman has denser or fibro-glandular breasts. Her mammogram will look very white or “cloudy” (Error! Reference source not found.-dense breast).

Middle-aged women have a mixture of fibrous and glandular tissues (Error! Reference source not found.-50-50 breast). Their mammograms look black and white.

In a mature breast, most of the fibrous tissue is replaced with fatty tissue. The mammograms tend to look black or gray (Error! Reference source not found.-Fatty Replaced breast)

 

Different breast tissue composition.

2.2. Film sizes

18 x 24 cm used for small to average sized breasts and 24 x 30 cm used for large sizes.

2.3. Mammography Procedure

Here is what happens, in brief :

The Woman1

The woman is escorted to the changing room, where she undresses from the waist up and changes into the screening center gowns

She is asked to wipe off any deodorants, perfumes or powders that she may have used that day, as these can mimic micro calcifications on the film

She is taken into the mammography room, where the mammographer or technologist reviews her history sheet. The history sheet has questions pertaining to the woman’s previous mammograms, prior surgeries (if any), if she felt any lumps, superficial marks (such as prominent moles, scars from an incision), family history of breast cancer, number of children, her age when the first child was born, and last date of menstruation or post-menopausal (Addendum 2). Then, the mammography procedure is

explained. This opens communication channels and the woman feels free to voice her concerns, thus increasing her comfort level.

It is important to prepare the woman for the compression that would be used for imaging. This device causes discomfort, but should not hurt the woman. A Compression Paddle, (see Error! Reference source not found. and Error! Reference source not found.) is a device used to compress the breast tissue. This helps to spread out and separate breast tissue, enabling the Radiologist to get an unobscured view of possible pathology. Compression also lowers patient radiation dose and prevents patient motion.

The required views are performed and the woman is dismissed with instructions that she might feel sore for a day or so from the compression.

 

The Machine

• Mammography equipment has progressed rapidly over the last 10 years. In developed countries, a dedicated mammography unit is used. A whole range of manufacturers make these machines, for example : GE, Bennett, Lorad, Siemens, Fischer, Phillips. They generally have a reciprocating grid to reduce scatter radiation thus avoiding fog and blurry image. The Filter (to make the beam hard and more penetrable) used, is 0.03 mm Molybdenum.

Most mammograms are routine mammograms. The woman is perfectly healthy. Hence, rather than refer to her as ‘patient’, she will typically be considered a ‘customer’ or ‘woman’. Using the word patient would imply that she is ill.

Film Processing is done under specific conditions. The two ways to develop an exposed film are (1) Standard Processing and (2) Extended Processing. The choice depends on the type of film used.

Picture of Mammography Equipment

Technique used for a mammogram is low Kilo-voltage Peak (KvP) about 24 to 30. The milli-Ampere-seconds (mAs) varies depending on breast tissue density. When the photo timer cells are used, it provides the optimum mAs for the tissue to be imaged. This technique results in mammograms with a high film contrast, making it easier for the Radiologist to read.

The Films used for mammography are single emulsion fast films to enhance image sharpness by eliminating geometric distortion. Films commonly used are : Kodak Min- RE, Agfa, Fuji, Dupont, Konica.

The screens consist of a rare earth phosphor called terbium activated gadolinium oxysulfide. Screens have to be compatible with the film. The newest film-screen combination is responsible for dose reduction by 30 - 50 % .

Markers are used to indicate the side and view demonstrated on that particular film. Markers are placed on the side of the axilla (armpit) of the patient. This acts as a reference point to understand the orientation of the breast, especially in the CC view.

 

2.4. Views

2.4.1. Screening Mammograms

These views are done as a regular screening process to get an overall picture of the breasts and ensure that all is well. The protocol depends on the specific facility. In America, four films are required of the breasts: two views for each breast. In Europe, most countries do one view (MLO) of each breast and if an area of suspicion is notice, then 15% of the times, additional CC views are taken.

Abbreviation Projection/Position Direction of the X-Ray

CC Cranio-Caudal Direction from head (cranium) to the feet

(caudal)

MLO Medio-Lateral Oblique X-ray direction is from medial(inner) to

    lateral (outer) aspect; and the orientation

of the breast is at an angle (Oblique)

2.4.2. Alternate Views

These are views done when the patient is unable to be positioned in certain views due to physical handicap or when the Radiologist wants to get a better look at possible pathology.

Abbreviation Projection/Position Direction of the X-Ray

LMO Lateral-Medial Oblique Direction of ray is from lateral(outer) to

    medial (inner), obliqued breast to

demonstrate lesions in medial area

90LAT-LM 90 degree Lateral Direction of ray from one side to the other

90LAT-ML and the breast is in the lateral position

2.4.3. Augmented Breast Views

Regular views done and additional “Implant Displaced” (ID) Views performed. Regular views comprise of the screening views with minimal compression (too much compression can damage the implants) and ID views are the screening views with the implants pushed back against the chest wall and focus is on breast tissue only.

2.4.4. Diagnostic Mammogram

These views are to be used in addition to the screening mammograms to localize the exact position of an abnormality or views to better define the nature of an abnormality. Some abbreviations for those

views are:

ABBREVIATION MEANING

M Magnification

XCCL Cranio Caudal view eXaggerated to axilLa

XCCM Cranio Caudal view eXaggerated Medially

CV CleaVage

AT Axillary Tail

RM Rolled Medially

RL Rolled Laterally

ID Implant Displaced

2.5. Interpreting Mammograms

Reading mammograms is a challenge for Radiologists. Diagnosis is truly subject to interpretation. Hence the concept of a ‘second reader’ is catching on in USA. In Europe, a second reading is routine procedure. A powerful magnifying glass is used to get a better look at suspected pathology. The ideal reading condition is in a dark room with no lights other than the ones from behind the mammogram films (on a film viewer or a motorized film viewer). Usually, in the reading area, there is a ‘hot light’ which is more powerful, enabling the Radiologist to get a sharper view of suspected area. If required, the Radiologist can turn this on and hold the film in front of it.

Radiologists read films as per certain criteria :

They do a comparative study of current films and prior films. They look for tissue, structure and calcification changes. If for example, they see that the current films have more microcalcifications than the previous, the woman would be subject to additional views in order to visualize the suspicious areas.

The Radiologists also do a comparative study of both the breasts. This is termed as an ‘ asymmetric study’. Generally, pathology does not occur in the both the breasts asymmetrically.

Viewing the parenchymal pattern is another method used by many Radiologists to find some signs leading to the detection of small invasive tumors. Both the CC views are placed against each other and they look for asymmetry, which is indicative of tumors. Similarly, both the MLOs are compared. Other features they look for are: architectural distortion,

comparison of the nipples and retroareolar areas.

 

2.6. Work-up process

If the Radiologist detects an area of suspicion, a series of work-up procedure is recommended. The criteria for their decision is based on what they see and the location.

For example, in the course of ‘asymmetric study’ the Radiologist discovers a density, then he/she has to decipher if the pathologic abnormality is obvious (stellate lesion, typical/linear cancerous microcalcifications). If the answer is ‘Yes’, various procedure and modalities could be used (core biopsy or ultrasound), if it is ‘No’, then additional views such as spot compression can be performed to see if see if the density is an architectural distortion, fibrosis or normal parenchyma.

Here is a table of ‘Protocol for Breast Cancer Screening Path’ :

3. PATHOLOGY IDENTIFICATION OFF MAMMOGRAMS

For location and identification of pathology, the breast is divided into segments in the following ways:

Breast Segmentation

‘BB’s are metallic markers that is used in the United States to mark the nipple or palpable mass for the Radiologist to locate and detect pathology. This shows up as white dots/circles on the mammograms as a reference point.

3.1. Frequency and Location of Breast Cancer

Maximum cases are in Upper Outer Quadrant and in the TDLUs (Terminal Duct Lobular Unit).

Areolar Area 25%

Frequency of Breast Cancer by quadrants

3.2. Morphologic Presentations

As you can see from the mammograms and diagrams, the breast tissue comprises of small intricate structures so pathology can easily be overlooked, especially if the film quality is not good. Not all structures are cancers. Many structures or macro (big) calcifications are often benign. Some basic forms of pathology and morphology presentations are (Addendum 3):

3.2.1. Masses and Densities

‘Masses’ differ from ‘Densities’ because ‘masses’ are seen on two views whereas ‘densities’ are seen on one view only. Hence, two views of each breast to identify this abnormality. Masses with smooth rounded edge is generally a fluid-filled cyst that can be confirmed by an ultrasound and aspirated to relieve pain for the woman. Hard lesions with uneven edges might be reason for follow-up procedures. A mass could be palpable (can feel it during a physical breast exam) depending on the size and proximity to the skin surface. A fat containing mass looks radiolucent on the mammogram. Sometimes, it is very difficult for radiologists to differentiate between a benign and a malignant mass off mammograms (as in Fig. below), so additional imaging modalities and/or biopsy may be required.

Examples of benign mass and a malignant mass

3.2.2. Micro calcifications

Calcifications are small calcium deposits that can be detected on a mammogram. Minute calcifications are called micro calcifications and bigger ones are called macro calcificiations. The latter is generally benign and does not need additional follow-up. Sometimes, other structures mimic micro calcifications such as calcified arteries that appear like ‘train tracks’. This is normal. Artifacts on mammograms due to specs of dust may look like micro calcifications, but the difference is that these specs are bright

and shiny whilst a micro calcification looks ‘milky white’. Radiologists categorize the calcifications as malignant or benign based on (1) the location of calcifications, (2) the arrangement (linear or scattered or clusters) (3) the total number of micro calcifications

(4) the changes with respect to the previous mammograms.

Examples of benign and malignant calcification.

3.2.3. Spiculated lesions

This is by far the most definitive way to detect cancer. As a cancer cell proliferates, it shows up as a ‘star-shaped’ or ‘stellate’ lesion, with spiky lines radiating in all directions from a central region. A white star shape is characteristic of a malignant stellate lesion whereas the black star indicates a radial scar and post-traumatic fat necrosis. In advanced cases, spicules that approach the skin or muscle, cause retraction and localized breast distortion.

Examples of benign mass and a malignant spiculations

4. BREAST CANCER TREATMENT OPTIONSTreatment of breast cancer is determined by the patient’s age and preference, patient’s medical history, staging at the time of diagnosis, and type of cancer.

4.1. Surgery

Surgery is the most preferred method of removal of cancer infested sites. There are various types of surgery.

Lumpectomy -a ‘lump’ or localized area that contains cancer cells is removed. Partial Mastectomy - a wedge of breast tissue is removed

Quadrantectomy - a quadrant of the breast is removed

Modified or simple mastectomy -all breast tissue and some lymph nodes are removed

Radical Mastectomy- The whole breast, pectoral muscle and lymph nodes are removed. This procedure is often combined with a total breast reconstruction at the same time, as per the patient’s preference.

 

In most of the above surgical procedures, ideally, at least a few lymph nodes are removed to determine if the cancer is localized or spread. Based on this information, the oncologists work out follow-up therapeutic procedure.

4.2. Chemotherapy

Chemotherapy is the use of drugs or chemicals to treat and/or prevent the spread of cancer. This therapy is typically used in cases when the cancer becomes ‘systemic’ (infiltrating into the various systems in the body for example, the lymphatic system). Each cell goes through several steps of cell division. The cytotoxic chemicals used for this therapy interferes with the process of cell division thus containing the cancer cells and in due course, killing the cancer cells. The commonly used drugs are : cyclophosphamide, doxorubicin or Adriamycin, methotrexate, and 5-fluorouracil. To some extent, these drugs do affect the normal cells too, causing side effects, such as nausea, vomiting, and skin burn from leaky veins into which the drugs are injected.

4.3. Radiation Therapy

As the name says, this treatment involves the use of radiation to kill the cancer cells, primarily for preventive treatment, after surgery. Usually, this treatment is split into two parts. At first, the whole breast from the collarbone to the ribs and breastbone to the sides, including the lymph nodes are radiated over a period of 5 to 6 weeks. Second, a ‘Boost’ is given, which involves extra radiation in the spot where the cancer was found originally.

4.4. Endocrine Treatment

This treatment involves interference with patient’s hormones. Breast cancer patients test positive for estrogen or progesterone levels and may be given endocrine therapy to interfere with the estrogen’s aid in the growth of malignant cancer cells. Some hormones that are used are : tamoxifen, progestins, aminoglutethimide, estrogens and androgens. The choice of the hormone used for therapy depends on the patient’s age and pre or post menopausal status.

4.5. Adjuvant Therapy

‘Adjuvant’ implies that two or more therapeutic means are used towards the complete treatment of the patient. For example, radiation in combination with chemotherapy, or chemotherapy in combination with hormonal or hormonal in combination with radiation, or surgery with chemotherapy and/or radiation. Adjuvant therapy is of great value to treat metastatic cancers that become systemic.

4.6. Other New Methods of Treatment

Tamoxifen

Certain types of cancers such as lobular carcinoma in-situ (LCIS) are not effectively treated with radiation or chemotherapy. In this case, the patient is treated with an anti-estrogen hormone like tamoxifen. This is a breast conservation method, so drugs can be administered without having to go through a surgery. It is still too early to be sure if this works, however, studies are now being carried out in Europe.

Bone Marrow Transplant

The bone marrow is a center which produces red blood cells, white blood cells, and platelets on a continuous basis. Chemotherapy slows this process down, hence there are intervals of time in between chemotherapy to allow the bone marrow to recover and produce good blood cells for the body. A compatible donor bone marrow is matched with the patient’s bone marrow and then it is injected through the bone into the patients trabeculae (where bone marrow is produced). This is a painful procedure, but the big advantage is that the patient has a new production of healthy red blood cells, white blood cells and platelets.

References

Caring for breasts, Susan G. Komen Breast Cancer Foundation Breast Cancer Facts & Figures 1996, American Cancer Society Mammography Quality Control Manual, American Cancer Society Cancer Incidence in five Continents, Vol. VI, period 1983-87. Sickles breast Screening Process, E.A. Sickles, Rad. Clin. North. America, 1992 Rhone-Poulenc Rorer Oncology Slide Library