Name of the Procedure:

• Common Name(s): Diagnostic Mammogram
• Technical/Medical Terms: Diagnostic Mammography, including Computer-Aided Detection (CAD) when performed; Unilateral (HCPCS Code G0206)

Summary

Diagnostic mammography is an X-ray imaging procedure used to examine the breast tissue more closely, typically following an abnormal screening mammogram or physical exam finding. This procedure often includes computer-aided detection (CAD) to help radiologists spot potential abnormalities more effectively.

Purpose

• Medical Conditions Addressed: Investigates abnormalities such as lumps, pain, nipple discharge, or changes in breast size or shape.
• Goals/Outcomes: To diagnose or rule out breast cancer, assess any suspicious findings, and guide further treatment or intervention if needed.

Indications

• Presenting symptoms such as a palpable lump, breast pain, or nipple discharge.
• Abnormal results from a screening mammogram.
• Evaluation of changes in breast tissue, such as those detected by self-examination or during a clinical breast exam.

Preparation

• Pre-Procedure Instructions: Patients should avoid using deodorants, talcum powder, or lotions under their arms or on their breasts on the day of the exam as these substances can appear on the mammogram.
• Pre-Procedure Assessments: Patients may need to provide medical history details and may undergo a clinical breast exam.

Procedure Description

• Step-by-Step Explanation:
  1. The patient will be asked to undress from the waist up and wear a provided gown.
  2. The breast is positioned on a flat support plate, and a compression paddle is used to gently compress the breast tissue.
  3. X-ray images are taken from multiple angles, often with assistance from computer-aided detection (CAD) software, which highlights areas that might require closer examination.
• Tools and Equipment: Mammography machine, X-ray imaging system, and CAD software.
• Anesthesia/Sedation: Generally, no anesthesia or sedation is required.

Duration

• The procedure typically takes about 30 minutes, though it may vary based on specific circumstances.

Setting

• The procedure is usually performed in a hospital's radiology department, an outpatient imaging center, or a specialized breast health clinic.

Personnel

• Healthcare Professionals Involved: Radiologic technologist (performs the mammogram), radiologist (reviews the images), and possibly a referring physician.

Risks and Complications

• Common Risks: Mild discomfort or pain due to breast compression, skin irritation.
• Rare Risks: Exposure to low levels of radiation, although the risk is minimized and considered safe for routine diagnostic purposes.
• Possible Complications: Inconclusive or unclear images may necessitate additional imaging.

Benefits

• Expected Benefits: Accurate diagnosis or exclusion of breast abnormalities, early detection of breast cancer, which significantly improves treatment outcomes.
• Realization of Benefits: Typically immediate upon review of the images by a radiologist.

Recovery

• Post-Procedure Care: Normally no special care required; patients can resume normal activities immediately.
• Expected Recovery Time: No downtime is required.
• Follow-Up: Further imaging tests or biopsies may be scheduled depending on the results.

Alternatives

• Other Treatment Options: Breast ultrasound, MRI, biopsy.
• Pros and Cons:
  • Ultrasound: No radiation exposure, useful for fluid-filled vs. solid lumps, but not as detailed for certain abnormalities.
  • MRI: More detailed images, no radiation, more expensive, and time-consuming.
  • Biopsy: Definitive diagnosis, invasive, and requires tissue sampling.

Patient Experience

• During the Procedure: Some discomfort from breast compression but generally well-tolerated.
• After the Procedure: Minor soreness or tenderness in the breast, which typically resolves quickly.
• Pain Management and Comfort Measures: Technicians will try to make the patient as comfortable as possible, and discomfort usually subsides shortly after the procedure is completed.