Mammography Physics and Technology: For Effective Clinical Imaging

10/1/2019 The Physics and Technology of Mammography
How to Use This Resource

Table of Contents and List of
Topics
Mammography Physics and Technology

for effective clinical imaging
Perry Sprawls, Ph.D.
Outline Mind Map Learning Objectives Visuals for Discussion Text Reference
To step through module, CLICK HERE.

To go to a specific topic click on it below
Imaging Objectives Rhodium Anode Blurring and Visibility of Detail
Visibility of Pathology KV Values for Mammography Focal Spot Blurring
Image Quality Characteristics Scattered Radiation and Contrast Receptor Blurring
Not a Perfect Image Image Exposure Histogram Composite Blurring
Mammography Technology Receptor & Display Systems Magnification Mammography
Imaging Technique Factors Film Contrast Transfer Mean Glandular Dose
Contrast Sensitivity Film Contrast Factors
Physical Contrast Compared Film Design for Mammography
Factors Affecting Contrast Sensitivity Controlling Receptor (Film) Exposure
X-Ray Penetration and Contrast Film Processing
Optimum X-Ray Spectrum Variations in Receptor Sensitivity
Effect of Breast Size Film Viewing Conditions
Controlling the X-Ray Spectrum Digital Mammography Contrast
The Molybdenum Spectrum
Moly and Rhodium Filters
1 TOP Imaging Objectives BACK NEXT

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Let's begin with a simple observation that will be a foundation

for a much more in-depth study of the mammography imaging
process. We can all agree on the objectives of the procedure.
The challenge is in achieving the desired results. It begins with
the fact that many pathologic conditions, especially cancer,
produce very small physical changes that are difficult to
visualize with x-ray imaging.
This is what makes mammography the examination that

requires the highest image quality of all of the x-ray procedures.
Maximum visibility, especially of the signs of pathology, is
achieved by using state-of-the -art equipment and imaging
protocols (technique factors, image processing, etc.) that
optimize the procedure and balance the quality requirements
with the radiation dose to the patient.
This requires an in-depth working knowledge of the applied physics and technology by the clinical staff.
2 TOP Visibility of Pathology BACK NEXT

Saying that visibility of pathologic conditions depends on image
quality sounds like a "no Deterrent." It is a simple point but the
complexity comes from the combined factors that the various
signs of pathology have very different physical characteristics and
that image quality is not one, but a combination of several
specific image characteristics.
Most signs of breast pathology are either in the form of soft-tissue

masses that are not very different from the surrounding tissue or
in the form of very small (micro) calcifications.
As we will see, the visualization of these very challenging

conditions requires imaging procedures with special
characteristics.
TOP
3 Image Quality Characteristics BACK NEXT
The quality of a mammogram (just like any other medical image)

is not one single characteristic. It is a composite of five very
specific characteristics as we see here.
Visibility of anatomy and pathology, the primary objective of

mammography, can be affected by each of these individual
characteristics, but in very different ways.
The design of equipment, imaging protocols and techniques, and

quality assurance procedures generally address each of these
characteristics on an individual basis.
When there is a suspected image quality problem a first step is to

identify which one of the five characteristics is the source and
then do an evaluation that will lead to an appropriate corrective
action.
We will consider each of these characteristics in detail as we work through the imaging process.
TOP
4 Not a Perfect Image BACK NEXT
Although a mammogram is overall probably the highest quality x-ray image we produce, it is still not perfect, and we
cannot assume that it will show all significant features within a

breast.
The goal in clinical imaging is to adjust the imaging factors and

protocol to extend the range of structures and objects in a breast
that will be visible. However, we must always be aware that there
is no perfect image that will show every possible pathologic
feature.
The limitation of visibility with mammography is routinely

evaluated by imaging the accreditation phantom illustrated here.
The phantom is a cube of material designed to simulate "average"

breast tissue compressed to a 4.5 cm thickness.
There are three (3) sets of objects within the phantom to simulate
structures and objects that might be within a breast. These are the "masses, fibers, and specks." We will take a closer
look at each of these a little later in the context of the characteristics that they are used to evaluate. What is common to
all three types of objects is that they cover a range of sizes. The large objects (masses, fibers, or specks) will always be
visible, even under inferior imaging conditions. A mammography system and a specific imaging protocol is evaluated by
imaging the phantom and then counting the number of objects of each type that are visible.
In this illustration (on the left) we see a diagram of the phantom interior showing the various objects that are included.
On the right we see an image of the phantom and note that all of the objects are not visible. NOTE: this is a very small
image and not typical of an actual mammogram but is used here to demonstrate an important point. Even in
mammography, there is generally not a perfect image providing visibility of all possible structures and objects within a
breast.
We will use the phantom again later to evaluate specific image characteristics.
5 TOP Mammography Technology BACK NEXT

Equipment for mammography has evolved over at least the last 40 years to the current state of the art. While there are
some differences from one manufacturer to another, there are also many characteristics and features that are common to
all. That is what we will introduce here and then cover in more detail later.
X-ray Tube Anode: Whereas most x-ray tubes use tungsten as the anode material, mammography equipment uses
molybdenum anodes or in some designs, a dual material anode with an additional rhodium track. These materials are
used because they produce a characteristic radiation spectrum that is close to optimum for breast imaging as described
later.
Filter: Whereas most x-ray machines use aluminum or

"aluminum equivalent" to filter the x-ray beam to reduce
unnecessary exposure to the patient, mammography uses
filters that work on a different principle and are used to
enhance contrast sensitivity. Molybdenum (same as in the
anode) is the standard filter material. Some systems allow
the operator (or automatic control function) to select either
the molybdenum or a rhodium filter to optimize the
spectrum for specific breast conditions.
Focal Spots: The typical x-ray tube for mammography has

two selectable focal spots. The spots are generally smaller
than for other x-ray procedures because of the requirements
for minimal blurring and good visibility of detail to see the
small calcifications. The smaller of the two spots is
generally used for the magnification technique.
Compression: Good compression of the breast is one of the essentials of effective mammography (and a common source
of patient discomfort and concern). Potential benefits derived from compression include:
1. A more uniform breast thickness resulting in a better fit of the exposure into the film latitude or dynamic range.
2. Reduced blurring from patient motion.
3. Reduced scattered radiation and improved contrast sensitivity.
4. Reduced radiation dose.
5. Better visualization of tissues near the chest wall.
Grid: A grid is used in mammography (as in other x-ray procedures) to absorb scattered radiation and improve contrast
sensitivity. Compared to grids for general x-ray imaging, grids for mammography have a lower ratio and the material
between the strips is selected for low x-ray absorption.
The grid is contained in a Bucky device that moves it during the x-ray exposure to blur and reduce the visibility of the
grid lines.
Receptor: Both film/screen and digital receptors are used for mammography. Each has special characteristics to enhance
image quality and will be considered later.
6 Imaging Technique Factors BACK NEXT

Optimizing a mammography procedure for maximum
visualization of anatomy and signs of pathology without
unnecessary radiation to the patient is achieved by the selection of
the best combination of technique factors that make up the
imaging protocol.
Each of these factors generally has an effect on one of the specific

image quality characteristics and in many cases, an effect on
patient radiation dose. At this point we identify the principal
technique factors and their general functions. The detailed
applications will come later.
X-ray Beam Spectrum: The photon energy spectrum of the x-

ray beam is one of the most critical factors in optimizing a
procedure with respect to contrast sensitivity and radiation dose.
The spectrum depends on the combination of three factors:
1. The anode material (molybdenum or rhodium)
2. The selected filter (molybdenum or rhodium)
3. The KV (ranging from 24kV to 32kV)
These factors are either set manually by the technologist/radiographer after evaluating breast thickness and density or by
the automatic exposure control (AEC) function if it is available. The AEC typically makes a brief exposure to measure
penetration through the breast and from that calculates appropriate technique factors for the imaging.
When using the AEC to automatically set the spectrum the operator also has a role in optimizing the technique factors.
Most equipment with this feature allows the operator to select a "priority" for the procedure in the balance between
contrast sensitivity and radiation dose. When the "CONTRAST" mode is selected the spectrum controlling factors
(Anode, Filter, and KV) are automatically set to produce a spectrum that enhances contrast sensitivity. When the "DOSE"
mode is selected the factors are automatically set to produce a more penetrating spectrum that reduces the dose but at the
cost of reduced contrast sensitivity. The relationship between contrast sensitivity and dose is described later with an
emphasis on the need to optimize the imaging factors for specific breast conditions.
Receptor Exposure Control: Image quality depends on the appropriate exposure being delivered to the receptor. This
applies to both film/screen and digital receptors but for different reasons. With film/screen the objective is to expose the
receptor to a level that will produce the film density that gives maximum contrast. With digital receptors the contrast
generally does not depend on the level of receptor exposure but the exposure must still be carefully controlled to optimize
the procedure with respect to image noise and radiation dose to the breast.
The AEC system is useful in obtaining optimum exposure but does require involvement of the operator. First, the AEC
sensors must be selected and positioned in relation to the anatomy and breast conditions and the "Density" or exposure
control set to optimize for variable conditions.
The AEC system must be periodically evaluated by a medical physicist and set-up by the engineering staff to insure
proper performance.
7 Contrast Sensitivity BACK NEXT

A major requirement for effective mammography is high contrast sensitivity. As illustrated here, contrast sensitivity is
the characteristic of an imaging process that determines the visibility of objects in the body that have low physical
contrast. That is the challenge we have in mammography. The anatomical structures and pathologic signs are all soft
tissues with physical densities very similar to the adipose background of the breast. The visibility of small calcifications
is limited by blurring and will be discussed later, but they also require a high contrast sensitivity.
Contrast sensitivity is a fundamental characteristic of an imaging

system and the imaging procedures with each system.
The different imaging modalities (radiography, CT, MRI, etc.)

have different contrast sensitivities because of their design and
physical principles. Of the x-ray imaging modalities, CT has the
highest contrast sensitivity for visualizing soft tissues. For the
radiographic imaging methods, mammography is designed to
have a much higher contrast sensitivity than the other
radiographic procedures.
The
relative
contrast
sensitivity
is one of the characteristics that is tested using the accreditation
phantom shown here. That is done by counting the number of
simulated masses that are visible. The phantom contains a series
of five (5) simulated masses. We see them as decreasing in size
(diameter) from the largest (#12) to the smallest (#16) in the
lower right corner. However, it is not the diameter that is
important; it is the thickness of the masses which is also
decreasing as shown here.
The thickness of a mass determines its physical contrast and the

amount of x-ray attenuation it produces. Since we have a series
of objects (masses) with varying physical contrasts, it is a useful test device for evaluating contrast sensitivity.
It is expected to be able to see four (4) masses when the phantom is imaged with conventional mammography equipment
operating in a standard protocol. The fifth mass is generally not visible. This does not indicate that the equipment or
imaging procedure is defective. It does demonstrate to us that even with high-quality mammography, every thing within a
breast might not be visualize.
The one disk not in the numbered series (red arrow) is actually a small disk attached to the outside of the phantom and
used to measure overall contrast in the image using a densitometer. A numerical value for the contrast is the difference
between the film density values measured in the disk area and the background area near the disk.
As we will soon see, there are a number of technical factors within mammography that affect contrast sensitivity. These
need to be considered when setting up the procedure, processing, and viewing the image.
8 Physical Contrast Compared BACK NEXT

The level of contrast sensitivity that is needed in a specific
imaging procedure depends on the amount of physical contrast
that is present in the body section being imaged. That varies
considerably among the different anatomical locations.
It is interesting to consider the two extremes illustrated here. The

chest is a region with very high physical contrast because of the
large difference in density between the lungs partially filled with
air and the bones. The lungs form a low density background on
which most of the other anatomical structures and signs of
pathology can be imaged.
Chest radiography requires low contrast sensitivity because of the

high physical contrast that is present. The first step to achieve
low contrast sensitivity is by using high KV values (like 120kV)
that produce a very penetrating x-ray beam.
The breast is the complete opposite to the chest with respect to

contrast. It consist ofs soft tissues with relatively small
differences in density (or atomic number).
The adipose tissue does form a "low density" background on

which the glandular tissue and signs of pathology can be imaged.
However, the differences in density and the physical contrast is

very small and a procedure with high contrast sensitivity is
required for visualization.
We now move on to how high contrast sensitivity is achieved in

mammography.
9 Factors Affecting Contrast Sensitivity BACK NEXT

The breast imaging process consists of a sequence of actions and
events transferring the physical contrast in the breast to visible
contrast in the displayed image. There are factors associated with
each of these that have an effect on contrast sensitivity. We will
introduce them here and then go into more detail as we work
through the imaging process.
Anatomical Environment: This is where it all begins. As we

have just seen the challenge in mammography is to visualize the
very low physical contrast in the breast. The natural shape of the
breast with varying thickness from the nipple to the chest wall is a
general deterrent to achieving good contrast and visibility. Good
compression transforms the breast into a more uniform thickness
and a somewhat thinner environment for better imaging.
Dense breasts are more difficult to image because structures of
interest are contained in the more dense tissues rather than in an adipose background.
The X-ray Beam Spectrum: One of the most unique features of mammography compared to other radiographic
procedures is the x-ray beam spectrum that is used. A spectrum with relatively low photon energies is required to
produce the high contrast sensitivity and is adjusted to specific breast conditions to optimize contrast with respect to
radiation dose to the breast.
Scattered Radiation: Even though the breast is small, compared to other body sections, it is still a source of scattered
radiation that reduces contrast. Compression has some effect on reducing the scatter. The scatter reaching the receptor is
reduced with a grid designed specifically for mammography. The grid is generally not used with the magnification
technique and the air gap decreases the intensity of the scatter reaching the receptor.
Film: One of the functions of film is to transfer the contrast contained in the x-ray beam emerging from the breast into
visible contrast in the displayed image. There are three (3) major factors that affect this transfer. They are:
Design Characteristics of the Film
Level and Range of Exposure Delivered to the Film.
The Quality of the Chemical Processing
Each will be considered in detail later.
Film and Image Viewing Conditions: The display and viewing of the mammogram is the last step in the visualization of
the breast. Because of the requirements for high contrast sensitivity and the good visualization of detail (the small
calcifications) optimum viewing conditions are required.
10 X-Ray Penetration and Contrast BACK NEXT

An x-ray image is a shadow of the internal structures and objects
within the body. A shadow is produced when an object absorbs
or attenuates some of the x-ray beam as it passes through. The
contrast in the shadow image is reduced with increased
penetration through a specific object as illustrated here.
Using the light analogy, a clear piece of glass produces a low

contrast shadow because most of the light passes through or
penetrates it.
In x-ray imaging the contrast produced by a specific object is

increased by decreasing the penetration. For a specific object, the
degree of penetration and resulting contrast depends on the
photon-energy spectrum of the x-ray beam.
The penetration through soft tissues and fluids found in the body
(that have relatively low atomic numbers, Z values) generally increases with increasing photon energy. Therefore,
contrast is increased by using an x-ray spectrum consisting of low-energy photons.
However, there is another factor to consider...that is the penetration through the total body section, or breast in the case of
mammography.
Generally we want maximum penetration through the breast for two reasons. With good penetration less radiation is
required into the breast to produce the desired receptor exposure. This reduces the amount of radiation and heat that must
be produced by the x-ray tube for each exposure. The benefit is that the exposure times can be kept relatively short to
reduce motion blurring (a problem especially with large breasts) and less heat is produced in the focal spot area. This is a
potential limiting factor when using the small focal spot for the
magnification technique.
The major concern associated with penetration is the radiation

dose to the breast. The radiation energy, or dose, that must be
deposited in the breast is increased as the penetration is
decreased.
Therefore, in mammography we have two conflicting

requirements. W e need relatively low penetration to enhance
contrast but high penetration is needed to reduce the dose to the
breast.
The solution is to use an x-ray beam that has a spectrum that

produces an optimum balance between the requirements for high
contrast sensitivity and low radiation dose.
11 Optimum X-Ray Spectrum BACK NEXT

Let's do a quick review of the interactions of x-ray photons with tissue. At the relatively low photon energies used for
mammography many of the interactions are by the photoelectric process. The significance is that the rate of photoelectric
interactions depends on the energy of the individual photons, and generally decreases with increasing energy. This means
that both dose and contrast decrease with increasing photon energy as shown here. If they should both decrease at
exactly the same rate we would be out of luck! Fortunately because of some variation in composition of the breast and
some effect of thickness, the dose and contrast do not decrease at the same rate and that is what makes it possible to adjust
the x-ray beam spectrum for optimized imaging.
If we could measure the contrast and dose and determine the contrast to dose relationship for a specific breast size and
density it would look somewhat like the curve shown here. There is a "peak" at some specific photon energy. This is the
x-ray photon energy that would produce an optimized image with respect to contrast and dose.
The ideal
or
"perfect"
x-ray
spectrum
for
mammography would be made up of photons all having the same energy (mono-energetic) and with the ability to adjust
the energy for different breast conditions. That is represented by the vertical line shown here positioned at the optimum
energy for this particular breast.
If the spectrum (photon energy) is decreased below the optimum energy there will be an increase in the dose because of
the decreased penetration through the breast.
If the spectrum (photon energy) is increased above the optimum energy there will be a decrease in the contrast because
of the increased penetration through the glandular and pathologic tissues.
For every breast condition there should be a photon energy that is optimum for producing the best contrast to dose
relationship.
12 Effect of Breast Size BACK NEXT

The optimum photon energy (spectrum) for mammography

depends on the size and density of the breast.
With a thin compressed breast that is relatively easy to penetrate

the optimum energy for the best contrast to dose relationship is
relatively low as shown here.
For thicker and more dense breast there are two differences
compared to the thin.
1.A higher photon energy is required for the optimum contrast to

dose relationship.
2. The contrast to dose "ratio" will be less, primarily because of

the increased dose caused by the decreased breast penetration.
This general concept of an optimum x-ray spectrum for

various breast sizes was published in the 1970s in the
form shown here. The contrast to dose ratio was
expressed as a Quality Number and is plotted for the
range of photon energies.
The three important points to be observed are:
1. There is an optimum photon energy that depends on

breast size.
2. The optimum photon energy increases with breast
size.
3. The image quality (contrast) to dose relationship is
significantly less with the larger breast.
If we had the ideal mammography equipment this is what it would

be. It would produce a mono-energetic (one energy) spectrum and
the energy could be adjusted to achieve the optimum balance
between contrast and dose.
At this time we do not have the ideal machine so must use

equipment with a combination of factors to produce a spectrum
that is "close" to the optimum spectrum for the range of breast
conditions.
That is what we will do now.
13 Controlling the X-Ray Spectrum BACK NEXT

The x-ray spectrum is determined by a combination of three (3)
factors:
1. The x-ray tube anode material.
2. The material used for x-ray beam filtration.
3. The KV.
Anode: Most mammography equipment uses molybdenum

anodes. Some systems have a dual-track anode that permits the
operator or automatic exposure control system to select between
either the molybdenum or rhodium as discussed later.
Filter: Molybdenum is the usual filter material but some systems

also have an alternative rhodium filter that can be selected.
The molybdenum filter should be used only with the molybdenum anode as explained later. The rhodium filter can be
used in combination with both the molybdenum and rhodium anodes.
Tungsten anode x-ray tubes and aluminum filtration, the standard for all other types of radiography, is not used for
mammography.
Let's recall that there are two types of x-radiation produced when electrons hit the x-ray tube anode. Bremsstrahlung is
the most common and is in the form of a broad continuous photon energy spectrum with a maximum energy
determined by the selected KV value, that is 26kV as illustrated here. Characteristic radiation is produced under certain
conditions and is confined to just a few photon energies represented here by the two vertical lines.
The photon energies of the characteristic radiation is determined by the atomic characteristics of the anode material. It
varies with the atomic number (Z) of the material.
Molybdenum, and in some cases, rhodium, are materials that produce characteristic x-radiation that is near the optimum
energy for mammography. That is why they are used for the anodes.
In addition to the desired characteristic radiation near the

optimum imaging energy, a continuous spectrum is produced
extending up to the set KV value. This is generally an undesirable
part of the spectrum because it is more penetrating than the
radiation near the optimum energy and has the effect of reducing
contrast.
The filters used in mammography are based on the "k edge"

principle and attenuate or block the radiation above the k-edge
energy of the specific filter material, either molybdenum or
rhodium as illustrated in more detail later.
14 The Molybdenum Spectrum BACK NEXT

Here we see the molybdenum spectrum in more detail showing both the characteristic radiation and the bremsstrahlung.
Because of the size (atomic number, Z) of the molybdenum atom the characteristic radiation is produced at two energies,
17.9keV and 19.5keV as shown here. This is close to the optimum energy, especially for smaller breast without extensive
dense tissue.
As pointed out previously the bremsstrahlung spectrum extends on up to the selected KV value, 25kV in this example,
and generally reduces contrast and needs to be removed with a filter.
An interesting question.... why is the KV set to values ranging up to 30kV or 32kV if this produces undesirable
radiation?
Answer...in addition to controlling the high-energy part of the spectrum and the maximum energy, the KV also has an
effect on the efficiency of x-ray production. That is the amount of

exposure produced for a specific MAS value. This higher x-ray
tube output is needed for the thicker and more dense breast in
order to produce an image in a reasonably short exposure time.
Also, increasing the KV does shift the spectrum, even below the
filter cut-off energy as described below, so that it is somewhat
more penetrating and appropriate for larger breasts.
The next
step to
produce
an
optimized
spectrum
is to use a
filter to attenuate or block that part of the bremsstrahlung that is
above the desired energy range. That is achieved with filters
based on the "k edge" principle.
A quick physics review... Recall that photoelectric interactions

occur when the energy of the x-ray photons exceeds the binding
energy of the electrons in the material. This is the so-called k-
edge when we are considering the attenuation produced by the k-
shell electrons in the atoms. Think of the k-edge as a boundary between photon energies that are not attenuated (below
the k-edge energy) and the photon energies that will be attenuated (above the k-edge energy).
The highest rate (coefficient value) occurs for photons that have energies that are just above the k-edge energy of the filter
material. The k-edge energy is equivalent to the binding energy of the k-shell electrons which is determined by the size
(atomic number, Z) of the atom. In principle, a filter material can be selected to position the k-edge and filter cut-off at
any desired energy.
15 Molybdenum and Rhodium Filters BACK NEXT

Molybdenum, with an atomic number (Z) of 42 has a k-shell
binding energy and its k-edge at an energy of 20.0 keV.
Rhodium, with an atomic number (Z) of 45 has a k-shell binding

energy and its k-edge at an energy of 23.22 keV.
When the molybdenum filter is selected as shown here it

attenuates and blocks much of the bremsstrahlung spectrum above
the energy of 20 keV. This results in the spectrum that is most
often used in mammography, produced with the "moly/moly"
anode/filter combination.
Many mammography systems have an alternative rhodium filter

that can be selected by the operator or AEC.
With the rhodium filter the k edge boundary is shifted to a higher

energy (23.22 keV) so that the portion of the bremsstrahlung
between 20keV and 23,22keV is added to the x-ray beam.
This makes the beam more penetrating than when using the
molybdenum filter and provides some advantage when imaging
larger or more dense breast.
16 Rhodium Anode BACK NEXT
Rhodium is an alternative anode material that can be selected to

produce a more penetrating x-ray beam than the more
conventional molybdenum anode. It is available in some
mammography systems in the form of a dual-track (molybdenum
and rhodium) x-ray tube anode. The operator or AEC selects the
one that is optimum for a specific patient based on breast
characteristics, especially density.
Now for the physics....rhodium with an atomic number (Z) of 45

has its principal characteristic radiation at an energy of 20.3 keV
with a less intense emission at 22.7 keV. This is compared to
molybdenum with an atomic number of 42 and a principal
characteristic energy of 17.6 keV with the less intense peak at
19.7 keV.
The rhodium filter, with a k-edge cut-off at 23.22 keV, is always used with the rhodium anode. If the molybdenum filter
is used, its k-edge cut-off from 20.00 keV upward would attenuate the rhodium 20.3 keV and 22.7 keV radiation.
17 KV Values for Mammography BACK NEXT

The x-ray beam spectrum is one of the most critical factors that must be adjusted to optimize a procedure with respect to
contrast sensitivity and dose.
We can think of it as a three-step procedure:
1. Select the appropriate anode (moly or rhodium)
2. Select the appropriate filter (moly or rhodium)
3. Select the appropriate KV (In the range 24 kV to 32 kV)
Increasing the KV has two effects on the x-ray beam. It increases

the efficiency and output for a specific MAS value and it shifts
the photon energy spectrum upward so that the beam becomes
more penetrating.
While a more penetrating beam does reduce contrast sensitivity it

is necessary when imaging thicker and more dense breast.
Therefore compressed breast thickness is the principal factor that
determines the optimum KV.
Mammography systems have indicators that display the thickness

of the compressed breast. This along with a general assessment
of breast density is used to manually select an optimum KV either
from experience or an established technique chart.
The general goal is to increase the KV as necessary to keep the

exposure time, MAS, and dose to the breast within reasonable
limits as breast thickness increases.
The automatic selection of the KV is a design feature of some

mammography systems. This is often based on a short, low-level,
"pre-exposure" that is used to measure the penetration
characteristics of the breast. From this, a KV value is calculated
and automatically set for the procedure. Note: this is combined
with the automatic selection of anode and filter combinations for
equipment that has that capability.
The automatic selection of technique factors is a valuable

function because it is based on actual measurements of breast
characteristics. However, it should be used by experienced
radiographers who monitor the selected protocols and image
quality.
Automatic systems provide an opportunity for the operator to

have some control by setting a "priority" that will shift the balance between contrast sensitivity and reduced dose. This
function is illustrated here using a 4 cm compressed breast. If the "contrast" priority or mode is selected the automatic
system would select a relatively low KV value (for example, 25 keV). If the "dose" mode is set a higher KV value will be
selected (for example, 29 keV).
A word of caution....there might be the temptation to select the "dose" mode with the expectation that it will reduce the
dose to the patient. It will, but at the cost of reducing contrast sensitivity which might have an adverse effect on the
visibility of some pathologic conditions.
The selection of technique factors (anode, filter, and KV) to optimize a procedure with respect to the balance
between contrast sensitivity (image quality) and dose requires an educated and experienced staff.
18 Scattered Radiation and Contrast BACK NEXT

Even though a breast is relatively small compared to most of the
body, it is still the source of significant scattered radiation that
reduces contrast as illustrated This must be considered because in
mammography we are attempting to see many low contrast
structures where any reduction in contrast can be detrimental.
Two methods are used to reduce the scattered radiation to the

receptor in mammography.
Grids are used for most procedures. They are especially designed
for mammography with relatively low grid ratios and material
between the strips that have low absorption characteristics
because of the low-energy x-ray spectrum.
The usual procedure when doing magnification mode is to

remove the grid and rely on the air gap to decrease the intensity of the scattered radiation.
19 Image Exposure Histogram BACK NEXT

As the x-ray beam exits the breast it contains an image in the
form of different levels of exposure produced by the variation in
penetration through the different densities that make up the
physical contrast.
The contrast that makes up the image is represented by these

different exposures reaching the receptor. A general knowledge
of the range and distribution of the exposure values is helpful in
optimizing the contrast of the breast imaging process.
The histogram, as shown here, shows the distribution of

exposures for an example mammogram. While the concept of the
exposure histogram can be applied to film imaging (as we will do
here) its real significance and use comes in digital mammography
where the digital processing to optimize the contrast is based on
modifying or selectively enhancing certain segments (as in windowing) of the histogram.
20 Receptor & Display Systems BACK NEXT

There are two very different methods for recording and displaying mammograms: film and digital.
Each method has distinct design features that determine the contrast characteristics of the imaging process and the
necessary steps to optimize the contrast sensitivity and visibility of the breast.
With film based mammography, film serves as the media for recording within the receptor, transporting and storing
images, and is the image display device. The significant characteristic is that the contrast of the image is "fixed" and
cannot be changed after the film is exposed and chemically processed. That is why a major effort must be made to
optimize the exposure and processing conditions.
Digital mammography offers many advantages over film with

respect to contrast as will be described later. In addition to being
a receptor with a wide dynamic range (latitude) it provides the
opportunity for using digital image processing to enhance the
contrast characteristics for visualizing specific features and also
the ability to control and optimize the display and viewing.
We will now first explore the contrast characteristics and issues of

film and then move on to digital.
21 Film Contrast Transfer BACK NEXT

Let us recall that the principle function of film is to convert x-ray exposure (after it is converted to light by the
intensifying screen) into a visible film density, or darkness. This is the process that converts the invisible x-ray image
into a visible image for viewing.
The contrast within an image is determined to a great extent by how a specific film transfers exposure values into density
values.
It is not a linear, straight-line, relationship but follows a "curved" relationship as we see here. It is the shape of this curve
that describes the contrast transfer of a specific film. This is the so-called characteristic or H & D curve. The rate at
which exposure contrast is transferred to visible contrast is determined by the slope or steepness of the curve at each point
along the way.
The
transfer of
contrast is
represented by the slope or steepness of the curve. The contrast curve is a plot of the slope of the characteristic curve
which shows the film contrast at each exposure value. If we follow the curves to the higher exposure values we see that
the characteristic curve begins to become less steep indicating reduced contrast. This places an upper limit on the
exposure range that can produce contrast and an acceptable image. The range of exposure that results in good image
contrast is the latitude of the film. In digital terminology we would refer to this as the dynamic range!
The requirement for maximum transfer of contrast in mammography is that the exposure histogram fit within the range of
the contrast curve, that is within the film latitude or dynamic range.
Three steps in achieving this are:
1. Designing film specific for mammography that has both a wide latitude and high contrast transfer as discussed later.
2. Reducing the range of the exposure histogram, primarily with breast compression.
3. Carefully controlling the exposure so that the histogram is properly positioned within the latitude.
22 Film Contrast Factors BACK NEXT
The overall contrast characteristics and contrast sensitivity of the

procedure are the combined effects of four very specific factors
shown here. They are:
1. Film Design Specific for Mammography
2. Level and Range of Exposure
3. Chemical Processing
4. Viewing Conditions
Each of these factors requires attention and inclusion in a Quality

Assurance and Control Program for each mammography facility.
The challenge is that there are many variables associated with

film. These variations and sub-standard conditions that might occur can significantly deteriorate the contrast sensitivity
and visibility.
We will now consider each factor with an emphasis on steps to achieving the necessary image quality.
23 Film Design for Mammography BACK NEXT
For mammography we need two film characteristics that generally are conflicting with each other. First, we need a steep
characteristic curve because that represents high contrast transfer and contrast sensitivity. However, for the usual range of
film densities that can be viewed on a conventional viewbox, a steep characteristic curve results in a reduced latitude. A
wide latitude is required to image the rather wide range of exposure coming through the breast. While compression is
useful in providing a more uniform breast thickness, and a smaller range of exposure, there is still a considerable range
because of other variations in thickness (near the nipple) and in

density.
The contrast characteristics for mammography film are different

from other radiographic films in order to have both high contrast
(that is a steep slope) and a wide latitude. This is achieved by
designing the film to record contrast over an exposure range that
extends to the higher film densities (darkness) compared to
general radiographic film.
To utilize
this
extended
contrast
characteristic to the full advantage requires two things.
The film must be exposed to a relatively high average density

(darkness) so that it is centered within the film's extended
sensitive range (latitude).
This is achieved by calibrating and setting the AEC to produce a

relatively high density (a density of 1.7 is illustrated here) when
imaging a test device (phantom) of uniform thickness.
A point about optimization....If the average density is set to a

lower value ( 1.2 illustrated here) that is more like what is used in general radiography, the dose would be reduced.
However, the contrast would be reduced. This is an example where attention must be given to optimizing the contrast to
dose relationship. It also illustrates the point that there are times when a certain dose level is needed to achieve the
necessary image quality.
The second requirement is that the properly exposed mammography film is relatively dark (high density) and must be
viewed on a specially designed bright viewbox as discussed in more detail later.
This is a good time to revisit a major reason for using good

compression.
With the compressed breast and the resulting more uniform

thickness, the range of exposure (exposure histogram) is reduced
and hopefully will fit within the film latitude (dynamic range).
24 Controlling Receptor (Film) Exposure BACK NEXT

Most mammograms are made using Automatic Exposure Control
(AEC). The AEC system measures the exposure that reaches the
receptor after penetrating the breast and turns the exposure off
when the necessary exposure has been delivered to produce the
expected film density.
While AEC is a valuable function for producing optimum film

density and visibility, it does not always produce the "perfect"
exposure. There are several potential sources of error that must
be considered as illustrated here. Two are associated with the set-
up and calibration of the system by the engineers, and two are
under the control of the technologist/radiographer.
AEC Calibration (Physicist and Engineer Function)

The AEC must be calibrated by the engineering staff to produce
the desired film density. The calibration is verified by a medical physicist who specifies a density value that is optimum
for the specific clinical facility. The calibration is specified in terms of the film density (a value of 1.6 is illustrated here)
produced when imaging a test device (phantom) of uniform thickness.
AEC Tracking (Physicist and Engineer Function)

Tracking is the ability of the AEC to maintain correct calibration over the range of receptor types, KV values, and
exposure times used in a clinical facility. This is generally not a problem with modern mammography equipment but is
evaluated periodically by a medical physicist in the context of the QA program.
AEC Sensor Position (Radiographer Function)

Typical mammography systems have multiple radiation sensors, or at least multiple sensor positions, for measuring the
exposure reaching the receptor. The film will be exposed to the calibrated density in the anatomical area over the selected
sensor or sensor position.
The appropriate sensor position should be selected by the radiographer based on breast characteristics, especially the
presence of dense areas.
An incorrect sensor location can result in an exposure error (too light or too dark) to the film.
Density Control Setting (Radiographer Function)

The radiographer can adjust the "Density" control to change the film density from that produced by the AEC normal
setting. Typical settings of the Density control are: (N)ormal, +1, +2, +3, -1, -2, -3,etc. Although there is no standard
relationship, changing the Density control by one unit will generally increase or decrease the exposure about 15%.
The Density control is useful when it appears that the AEC (N)ormal setting does not produce the appropriate film density
(until it can be recalibrated by the engineer) and when certain breast conditions are better visualized with lighter or darker
films.
Associated with the Density control is a function for indicating which receptor (film/screen combination) is being used.
The AEC must have this information to make the correct exposure.
25 Film Processing BACK NEXT

We recall that the formation of a visible image on film is a two-step process. First, the film is exposed to form the
invisible latent image and then the film is chemically processed to
develop the visible image.
Processing is a critical step requiring special attention in

mammography because of the many sources of variability and
sub-standard processing. The details of film processing and the
necessary Quality Assurance procedures are covered in the
reference below. Our purpose here is to take a brief look at the
factors associated with variations in mammography film
processing.
Film processing is a four step process: development, fixing,

washing, and drying.
It is the development step that converts the exposed film to one

with density and contrast. Development is not an instantaneous process but occurs over a period of time (usually about
25 seconds) as the chemicals interact with the exposed silver halide crystals in the film emulsion.
The objective is for the development process to continue until the film is fully developed, but not overdeveloped which
produces one form of film fog.
The final level of development is determined by a combination of physical and chemical factors as shown here. These are
the factors and conditions that must be addressed when setting up the processing and monitoring (either directly or
indirectly through sensitometer ) of it in the context of a Quality Assurance Program.
There are two very specific processing goals:
1. An appropriate level of processing so that all (ideally) of the exposed silver halide crystals are converted to black
silver and film density.
This is necessary to get both maximum contrast and the optimum exposure sensitivity or "speed" (to reduce patient
exposure) from the film.
2. Consistent processing so that the film exposure sensitivity does not drift or change with time resulting in exposure
errors.
Reference: The Photographic Process and Film Sensitivity.

The Physical Principles of Medical Imaging, Online, http://www.sprawls.org/ppmi2/FILMSEN/
26 Variations in Receptor Sensitivity BACK NEXT

Maximum contrast and visibility is obtained when the receptor
exposure, represented by the histogram, is positioned under the
contrast curve (within the film latitude or dynamic range).
Errors in obtaining the optimum film exposure can occur if either

the exposure technique factors are not correct for reasons
discussed previously, or if there are variations in the receptor
sensitivity or "speed" over time or from one patient to another.
Some of the possible sources of unwanted changes and variations
in receptor sensitivity are shown here.
Variations in Intensifying Screens. Generally, all of the screens

in a facility should have the same sensitivity or "speed" so that
they will not introduce exposure errors as the various cassettes are
used. A potential source of variability is when some new screens
are acquired and mixed in with the older screens, There are simple QA tests that can be performed to verify that the
screens in a facility have approximately the same sensitivity.
Variations in Film Sensitivity. The major film manufacturers have extensive quality control procedures to reduce the
variations in the sensitivity of the films they provide. However, there can still be some variations in the film received by
the user that might result in exposure errors. There are simple QA procedures (using sensitometry) to check for film
consistency, especially when changing the types of film, etc.
Exposure Time Effects on Sensitivity. A characteristic of film is that its sensitivity might change with changes in
exposure time, even when the total exposure (MAS) is the same. This is the so-called law of reciprocity failure. The
significance is that various combinations of MA and exposure time that produce the same MAS (and total exposure to the
film) might not produce the same density and contrast in a film because of this shift in sensitivity over the range of
exposure times times used in mammography. This comes from how the light photons exposing the film interact with the
individual crystals in the film emulsion. When there is a high intensity exposure in a short time the effect (resulting film
density) might be different from a lower intensity exposure delivered over a longer time, even when the total exposure is
the same.
This problem is addressed in mammography by having the AEC system adjusted and calibrated to compensate for the
reciprocity failure of the film being used.
Variations in Processing. Variations in the chemical processing are generally a major source of exposure error because
the level of processing affects the film sensitivity. That is why mammography requires an active QA program to maintain
processing consistency.
27 Film Viewing Conditions BACK NEXT

The display and viewing of the film is the last step in the total process of visualizing the anatomy and pathology within
the breast.
It can be a "weak link" and reduce much of the contrast sensitivity developed in the other stages of the imaging process.
There are three (3) specific factors associated with the viewing that must be addressed.
Viewbox Luminance (Brightness). A characteristic of the human visual system is that maximum contrast sensitivity
requires a relatively bright or well illuminated image for viewing.
Film mammography presents a special challenge because the

films are exposed to a relatively high density, compared to other
radiographs, in order to obtain the maximum contrast from the
film, as described previously.
These darker or more dense films require illumination with an

especially bright illuminator or viewbox in order to enhance the
visual contrast sensitivity and visualization of low-contrast
objects in the breast.
Viewboxes designed for mammography have brightness values of

at least 3500 nits compared to around 1500 nits for conventional
radiography illuminators.
Masking. The advantage of a bright viewbox brings a problem. If there are uncovered areas around a film this creates a
bright light shining right into the eyes of the viewer. This is the bright headlights of oncoming traffic situation. Bright
light shining into the eye reduces contrast sensitivity and visibility of relatively low-contrast objects.
The solution is to cover or mask the areas around a film.
Room Illumination. Low-level illumination in the film reading room or viewing area increases visual contrast
sensitivity as the eyes adapt to the darker environment.
28 Digital Mammography Contrast BACK NEXT

Digital mammography provides several advantages over film for optimizing the contrast transfer from the breast to the
image display and the maximizing the overall contrast sensitivity.
Three (3) of the major features are shown here.
Digital Receptor Dynamic Range. A valuable characteristic of

most digital receptors is a constant sensitivity over a wide range
of exposures. This is very different from the relatively narrow
latitude or dynamic range of film as we have see earlier.
The advantage is that the full exposure histogram will be easily

covered by the wide dynamic range and that a considerable
variation in exposure to the receptor (exposure error) can be
tolerated without loss of contrast.
The transfer of exposure contrast into digital image contrast is

represented by a linear (straight-line) rather than the steep
characteristic curve of film with its limited latitude. The digital
image recorded by the typical digital receptor will have relatively
low contrast (it would look like a rather gray image) but it will be
uniform over the full exposure range. The next step is to select the exposure range representing the actual image, that is
the histogram, and to enhance the contrast by digital processing and windowing.
Digital Image Processing. One of the great advantages of digital imaging is the ability to apply a variety of processing
procedures to change the image characteristics, hopefully to improve quality and visibility in most cases. Here we a
focusing attention on the contrast. Contrast processing is common in most forms of digital radiography and is used to
make the digitally acquired radiographs "look like" more conventional film radiographs with respect to contrast. This
processing can be thought of as applying a film characteristic (H & D) curve as illustrated here. The advantage is that the
user can select from many different "film characteristics" to meet the needs of specific clinical procedures. For example,
in general radiography, one "characteristic curve" type would be appropriate for chest imaging while another would be
used for imaging the extremities.
In digital mammography the various contrast processing procedures are generally built into the system and might vary to
some extent from one manufacturer to another.
Windowing. Windowing, as used in the display and viewing of most digital images (including CT, MRI, etc) is the last
step in optimizing the contrast and visibility of specific objects and structures within an image.
In summary....the various contrast characteristics of digital imaging (wide dynamic range, processing, and windowing)
can be combined to produce maximum contrast sensitivity as required in mammography.
29 Blurring and Visibility of Detail BACK NEXT

Blurring is one of the five basic image characteristics that
determines overall image quality.
Some amount of blurring occurs in all imaging procedures and the

major clinical effect is that it reduces the visibility of detail (small
objects and structures). Blurring is especially significant in
mammography because of the need to image very small
calcifications.
Of all medical imaging procedures, mammography is the one

designed to produce images with the least amount of blurring and
the greatest visibility of small objects.
There are three (3) observable effects of blur that we will review
here.
Unsharpness. Blurring reduces the perceived "sharpness" of an

image or picture. The term "unsharpness" is often used as an
alternate name for blur. However, what we see as unsharpness is
an effect that is caused by the more fundamental process of
blurring that occurs during the formation of an image.
Spatial Resolution. Spatial resolution describes the ability of an

imaging procedure to produce images in which closely spaced
objects can be seen as separate objects or "resolved". This
resolving ability is reduced by the blurring that in effect, blurs the
objects together.
Resolution plays a role in medical imaging because it can be measured by imaging certain test objects or "line-pair
phantoms".
Measuring resolution is an indirect method of measuring the blurring in an imaging procedure and is useful for evaluating
the performance of imaging systems.
Visibility of Detail. The clinically significant effect of blurring is that it reduces the visibility of small objects or detail in
an image.
The visibility of detail (effect of blurring) is routinely measured in

mammography by imaging the accreditation phantom introduced
earlier and shown again here.
It contains clusters of simulated micro-calcifications varying in

size. These are the star-shaped clusters.
It is generally expected to see four of the clusters, including the

ones that are 0.24 mm in diameter.
This is a general illustration of the ability of mammography to

produce images of very small objects. This is not possible with
other x-ray procedures.
The blurring that limits visibility of detail comes from three (3) sources:
1. Motion (if it is present)
2. The Focal Spot
3. The Receptor and Display System.
Hopefully motion is eliminated by good compression and keeping exposure times as short as possible.
Let's now look at the other two and how they produce a combined effect.
30 Focal Spot Blurring BACK NEXT

The blurring produced by the focal spot depends on two factors:
1. The effective size of the focal spot.
2. The location of the object (think calcification) in the space

between the receptor and the focal spot.
The amount of blurring expressed at the location of the object

(and therefore relative to its size) is the product of these two
factors when the location is expressed on the S scale as shown.
Focal spot blurring is reduced by using small focal spots and

keeping the breast as close to the receptor as possible.
31 Receptor Blurring BACK NEXT
All mammography receptors, both film/screen and digital,

introduce some blurring into the imaging process and are
designed to keep it to an acceptable level.
The major source of blurring is the spreading of light (or

electrons) within the thickness of the x-ray absorbing layer in the
receptor.
The film/screen combination used in mammography consists of a

single thin screen used with only one film as shown here.
The dimensions of the blur produced within a receptor is

generally related to thickness and is a tradeoff with x-ray
absorption and patient exposure.
The relatively thin screens used in mammography produce

significantly less blur than the receptors for other radiographic
procedures.
Receptors for digital mammography are designed for

approximately the same amount of blurring by using a
combination of thin x-ray absorbers and small pixel.
We recall that small pixels are produced by using a large image

matrix size.
The significance of blurring, and its effect on visibility, depends on the amount of blurring at the location of the object
(think calcification again) within the space between the receptor and focal spot as shown here.
Important point...receptor blurring is reduced (relative to the size

of an object) by moving the object away from the receptor.
In other words, introducing magnification reduces receptor

blurring.
The same geometry applies to receptor blurring as to focal spot

blurring, except that the direction is reversed.
32 Composite Blurring BACK NEXT

Some amount of blurring from both the focal spot and the receptor is present in all mammograms.
The contribution from each of these sources depends on the location of the breast along the S scale in the space between
the receptor and focal spot.
Now for "mathematical magic" (we will not go into the

equations), for every combination of focal spot size and receptor
blur value, there is an object location where the combined or
composite blur has a minimum value.
The location of that point of minimum blur depends on the size of

the focal spot compared to the receptor blur value.
Let's now see how it works.
In conventional mammography the larger of the two

focal spots in the tube is used.
The example shown here is an effective focal spot size

of 0.45 mm. While this is a relatively small size
compared to what is used for other x-ray procedures, it is
large enough to provide the heat capacity.
Because the focal spot is significantly larger than the

receptor blur value, the region of minimum blurring and
best visibility of detail (calcifications) is very near the
receptor.
If magnification were to be introduced with this size

focal spot, the image would become more blurry and the
calcifications would probably become invisible.
33 Magnification Mammography BACK NEXT

Geometric magnification is the technique that produces the least
amount of blurring and the very best visibility of calcifications.
The requirement for effective magnification is the use of the small

focal spot as shown here.
Magnification mammography, as illustrated here, is the medical

imaging procedure that has the least amount of blurring and
provides the very best visibility of small objects.
Question for thought...if a small focal spot reduces blurring, why

don't we use it for all of the mammograms? Answer: it does not
have the heat capacity to be appropriate for routine imaging.
34 Mean Glandular Dose BACK NEXT

It is difficult to make a precise determination of the radiation dose
to a breast during mammography because of the variations in
breast anatomy that are encountered and not being able to insert
measuring devices, dosimeters, into the breast.
The usual procedure is to make measurements of the exposure to

the surface of the breast (a value of 1200mR is shown here) and
then use published tables of dose factors to calculate a quantity
that is defined as the Mean Glandular Dose (MGD).
The determination of MGD values for a standard reference breast

is part of the a general quality assurance and procedure evaluation
program.
The objective in mammography is not to adjust the equipment and

imaging techniques to produce the lowest possible dose (MGD).
It is to use imaging conditions that produce the necessary image
quality (primarily contrast sensitivity and visibility of detail)
without the use of unnecessary exposure to the patient.
35 Conclusion BACK NEXT
This is the Conclusion of this module.

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Mammography Physics and Technology: For Effective Clinical Imaging

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10/1/2019 The Physics and Technology of Mammography

How to Use This Resource

Mammography Physics and Technology

To step through module, CLICK HERE.

1 TOP Imaging Objectives BACK NEXT

Let's begin with a simple observation that will be a foundation

This is what makes mammography the examination that

2 TOP Visibility of Pathology BACK NEXT

Most signs of breast pathology are either in the form of soft-tissue

As we will see, the visualization of these very challenging

The quality of a mammogram (just like any other medical image)

Visibility of anatomy and pathology, the primary objective of

The design of equipment, imaging protocols and techniques, and

When there is a suspected image quality problem a first step is to

cannot assume that it will show all significant features within a

The goal in clinical imaging is to adjust the imaging factors and

The limitation of visibility with mammography is routinely

The phantom is a cube of material designed to simulate "average"

5 TOP Mammography Technology BACK NEXT

Filter: Whereas most x-ray machines use aluminum or

Focal Spots: The typical x-ray tube for mammography has

2. Reduced blurring from patient motion.

3. Reduced scattered radiation and improved contrast sensitivity.

4. Reduced radiation dose.

5. Better visualization of tissues near the chest wall.

6 Imaging Technique Factors BACK NEXT

Each of these factors generally has an effect on one of the specific

X-ray Beam Spectrum: The photon energy spectrum of the x-

1. The anode material (molybdenum or rhodium)

2. The selected filter (molybdenum or rhodium)

3. The KV (ranging from 24kV to 32kV)

7 Contrast Sensitivity BACK NEXT

Contrast sensitivity is a fundamental characteristic of an imaging

The different imaging modalities (radiography, CT, MRI, etc.)

The thickness of a mass determines its physical contrast and the

8 Physical Contrast Compared BACK NEXT

It is interesting to consider the two extremes illustrated here. The

Chest radiography requires low contrast sensitivity because of the

The breast is the complete opposite to the chest with respect to

The adipose tissue does form a "low density" background on

However, the differences in density and the physical contrast is

We now move on to how high contrast sensitivity is achieved in

9 Factors Affecting Contrast Sensitivity BACK NEXT

Anatomical Environment: This is where it all begins. As we

Design Characteristics of the Film

Level and Range of Exposure Delivered to the Film.

The Quality of the Chemical Processing

Each will be considered in detail later.

10 X-Ray Penetration and Contrast BACK NEXT

Using the light analogy, a clear piece of glass produces a low

In x-ray imaging the contrast produced by a specific object is

The major concern associated with penetration is the radiation

Therefore, in mammography we have two conflicting

The solution is to use an x-ray beam that has a spectrum that

11 Optimum X-Ray Spectrum BACK NEXT

12 Effect of Breast Size BACK NEXT

The optimum photon energy (spectrum) for mammography

With a thin compressed breast that is relatively easy to penetrate

1.A higher photon energy is required for the optimum contrast to

2. The contrast to dose "ratio" will be less, primarily because of

This general concept of an optimum x-ray spectrum for

The three important points to be observed are:

1. There is an optimum photon energy that depends on