T he British Journal of Radiology, 71 (1998), 646–653 © 1998 The British Institute of Radiology

Estimation of compressed breast thickness during

mammography
1R P HIGHNAM, MSc, DPhil, 1J M BRADY, MSc, PhD and 2B J SHEPSTONE, DPhil, MD
1Medical Vision Laboratory, Engineering Science, Oxford University, Parks Road, Oxford OX1 3PJ, and
2Breast Care Unit, Churchill Hospital, Headington, Oxford OX3 7LJ, UK

Abstract. To estimate radiation dose during mammography the breast thickness must be known.
We present a new method for estimating the thickness of a compressed breast using only the breast
image as projected onto a mammogram, calibration data such as the mAs value and image
processing techniques. The method proves to be of high accuracy (±0.2 cm for craniocaudal
mammograms) and has the advantage over other methods of allowing retrospective estimation of
thickness.

Within the National Health Service Breast
Screening Programme (NHSBSP), radiation dose
is estimated by calculating the mean glandular
dose to a standard breast from measurements on
phantoms [1]. To make this estimate specific to
each breast requires the compressed breast thick-
ness and composition of the breast to be known,
as well as the beam quality and the mAs value
[2]. This paper is concerned with estimating the
breast thickness.
Many recent mammography system designs
have built-in analogue or digital thickness indi-
cators but the accuracy and precision of these are
currently wanting [3]. In clinical practice, most
existing systems do not have such indicators. Burch
and Law [3] have reported putting lead markers
on the top compression plate and then using the
magnification of the separation between these mar-
kers to estimate breast thickness. Although their
results appear promising with an average accuracy
of the order of 0.2 cm or so, with a maximum error
of 0.49 cm, analysis of the projective equations
reveals that the method is far from stable. A change
in the projected measure of just 0.1 cm gives rise
to a change in breast thickness estimate of 0.24 cm
at best. In many cases the lead markers were
reported to be invisible on the film due to scatter
and sometimes being projected onto the breast or
other lead markers. Moreover, this technique does
not allow for retrospective estimation of breast
thicknesses.
In this paper we show how to estimate breast
thickness using the breast image as projected onto
a mammogram and calibration data such as the
tube voltage and mAs value. The estimate is based
upon determining the ‘‘breast edge’’ which is the
Received 6 October 1997 and in revised form 23 December
1997, accepted 4 February 1998.
R P Highnam is funded by the EPSRC.
area on the mammogram that lies beneath the
fatty tissue surrounding the breast. The paper
starts by illustrating what we mean by the breast
edge and how we use it. We then introduce the h
int
representation [4] which allocates a real number
to each pixel in the digitized mammogram to
quantify the type of breast tissue between the pixel
and the X-ray source. The initial breast edge
arguments will be rephrased in terms of h A
int.
crucial part in delineating the breast edge is to find
a smooth curve in the image where the breast
tissue is all fat. To do this requires a measure of
smoothness and we explain the motivation for our
choice of a fractal measure. Our full algorithm is
outlined with implementation details before the
results and a discussion section.
Theory
W hat is the ‘‘breast edge’’?
During mammography, the breast is compressed
between two nominally parallel flat plates. The
compression causes the breast to spread out so
that over most of the plate the breast is of equal
thickness. However, towards the edge of the breast
it bulges like a balloon and there is not a straight
vertical edge. Figure 1 shows this schematically.
This bulge is what we term the ‘‘breast edge’’.
The breast tissue is enveloped in two layers of
fibrous tissue, the deep layer overlying the muscle
and the very thin superficial layer beneath the skin.
The superficial layer is separated from the skin by
0.5–2.5 cm of subcutaneous fat or areolar tissue.
Joining the layers to the skin are fine fibrous
ligaments (Cooper’s ligaments). From this, it is
reasonable to assume that the so-called breast edge
consists entirely of fat, although we recognize that
near the nipple and near the ligaments this will
not be the case.

646 T he British Journal of Radiology, June 1998

Compressed breast thickness during mammography
Figure 1. We model the breast as having constant thick-
ness up until the so-called ‘‘breast edge’’. At this point
the breast thickness rapidly decreases to zero. We model
the breast edge as being homogeneous and to consist
mostly of fat.
Figure 2 shows a schematic picture of the breast
for a craniocaudal view mammogram. The arc
denoted by the letter E lies right on the very edge
of the breast as seen from the X-ray source, that
is, an X-ray from the source tangentially touches
the breast before reaching E. There is very little
attenuation of the X-ray beam anywhere along E.
Along the arc denoted by the letter D there is a
greater thickness of tissue than at E, but still
relatively little attenuation since this is the breast
edge and most of the breast tissue is fat. Along the
arc C there is H cm of fat so that the X-ray
attenuation is quite large but still uniform along
the arc. This all changes along arcs A and B, where
there is a heterogeneous mixture of tissues. The
X-ray attenuation along these arcs can vary from
between H cm of fat to H cm of fibroglandular
tissue.
Our method of determining breast thickness H
is based upon delimiting the breast edge from the
interior of the breast. That is, we seek to determine
the arcs C and E in Figure 2. It is easy to segment
the breast from the background and hence
Figure 2. This is a schematic of a craniocaudal mammogram being performed. The left picture shows the breast and
the right picture is the mammogram. The boxed area is meant to represent the interior breast region. Note that the
diagram is not to scale. It shows the reduction in X-ray attenuation and thickness of breast tissue as the nipple is
approached. See the text for a full description.
T he British Journal of Radiology, June 1998
determine the smooth arc E on the basis of the
film densities. If we then mark all the points which
are slightly less dark than those on E we get
another smooth curve since we are still in the
homogeneous breast edge, this is arc D say.
Eventually we reach arc C which is still smooth
since it is just within the homogeneous breast edge
region. If we continue to mark points which are
slightly less dark we start to mark points within
the interior of the breast and these could be
anywhere and numerous since the interior is a
heterogeneous mix of tissues. Thus we see that the
arc that delimits the interior of the breast (arc C)
is the last smooth isointensity curve. From this
model it is also clear that the breast tissue about
arc C is H cm of fat. Thus, if we can find C and if
we have a good model of the mammographic
imaging process we can use the film densities along
C to estimate the amount of fat which must have
been between the points along C and the X-ray
source and thus we have the breast thickness H.
T he h representation
int
We now assume the mammogram has been
digitized and we rephrase the preceding argument
in terms of the ‘‘h representation’’ [4] which
int
stores at each pixel a quantitative measure of the
tissue between that pixel and the X-ray source.
Ideally, one might hope for a quantitative three-
dimensional representation of the breast with each
voxel labelled with a tissue type. Unfortunately,
the nature of mammography projections and the
fact that the X-ray attenuation coefficients of most
of the non-fat breast tissues are practically
647

indistinguishable [5] means that the most we can
hope for is to estimate the thicknesses of fat, non-
fat (‘‘interesting’’) and calcification between any
pixel and the X-ray source. Calcification comprises
only a tiny percentage of the total area of any
breast image and is rarely seen within the breast
edge area so that for the purposes of this paper we
can ignore it. This leaves only two tissue classes to
consider, and we use h (x, y) to be the thickness
int
of non-fat or ‘‘interesting’’ tissue and h (x, y) to
fat
be the thickness of fat between the pixel (x, y) and
the X-ray source. At every pixel within the interior
of the breast, that is, where there is a constant
breast thickness H, the following equation holds:
H=h (x, y)+h (x, y)
fat int
To generate the h representation from a mam-
int
mogram basically involves mapping each film den-
sity on the mammogram to a value of h . We do
int
this by using a model of the imaging process which
we outline briefly here and which has been detailed
fully elsewhere [4, 6].
The first step is to map from film density to
energy imparted to the intensifying screen; we do
this by using the film–screen characteristic curve.
We then compensate the energies for the anode
heel effect which causes spatial variation of the
incident radiation across the mammogram; we do
this by using calibration data obtained by briefly
exposing a film (typically 4 mAs) without any
object present. Next, we compensate the energies
for the slant of the compression plate which typi-
cally drops about 0.5 cm from the chest wall out
towards the nipple. We assume that we know the
slant (measured by one of the radiographers under
typical compression) and we reduce the energies
by simulating the additional attenuation due to a
layer of fat of varying thickness so that the resulting
energies are as if the breast had been of a constant
thickness equivalent to the thickness at the chest
wall. The corrected energy (E imp) has compo-
pse
nents due to primary radiation (E imp), scattered
p than just using the pixel values in the original
radiation (E imp) and extrafocal radiation (E imp).
s e
We estimate the scattered and extrafocal radiation
components using the model described by
Highnam et al [6] and hence determine the pri-
mary component:
E imp=E imp−E imp−E imp
p pse s e
The primary component is directly related to the
tissue between the pixel and the X-ray source.
Using knowledge of the polyenergetic X-ray source,
anti-scatter grid, intensifying screen, tube
voltage, mAs value, breast thickness and attenu-
ation coefficients for fat and ‘‘interesting tissue’’
(from [5]) the primary component can be mapped
to a value of h .
int
648
R P Highnam, J M Brady and B J Shepstone
T he h representation and the breast edge
int
When the h values are generated using the
int
correct breast thickness we find that within the
breast edge there is so little attenuation that there
cannot even be H cm of fat above the pixels in
that area. For those pixels we set h =0 and then
int
determine what thickness of fat alone would give
the observed attenuation. Figure 3 shows some
examples of the breast edges found by marking
those pixels that have h =0.
int
Determining the breast edge
There are two potential approaches to the prob-
lem of finding the smooth curve which delimits the
breast interior and estimating the breast thickness.
One way is to find the smooth curve by using the
pixels values which are produced by the digitizer.
The imaging process is then simulated using differ-
ent breast thicknesses until the predicted pixel
value matches that which we find on the smooth
curve. The second approach, and the one we take,
is to take a rough initial estimate of the breast
thickness and then to generate the h represen-
int
tation. Analysis of the h representation allows
int
determination of how the estimate of the breast
thickness should be changed.
We start with an underestimate of the breast
thickness (H ) and then compute the h represen-
int
tation. We mark those pixels that have precisely
h =H, h =0 and work out how smooth the
fat int
curve is that those pixels represent (method
explained in the next section). Initially, the h
int
values will be too high and there will be no pixels
with h =0. As H rises we start to detect more
int
and more pixels with h =0 and these pixels will
int
represent a smooth curve until the internal breast
region is reached when the smoothness measure
ought to rise dramatically to indicate a jagged
curve. Performing the computation this way rather
image and looking for isointensity curves allows
us to be more accurate since we can use H to
predict scattered and extrafocal radiation. It also
allows us to check that the algorithm is working
properly using any one of a number of useful
metrics which can be computed using the h
int
values. One example is that if we start with many
points that have h >H then the value of H is far
int
too low and we should increase it dramatically
rather than increase in small steps. Another
example is that if we find that more than 20% of
the breast is within the breast edge, then H has
been increased too far. Figure 4 shows pictorially
how the computation progresses and Figure 5
shows real examples of the breast edge as H varies.
T he British Journal of Radiology, June 1998
Compressed breast thickness during mammography

Figure 3. The bright white areas represent the so-called breast edge. This is where the breast starts to decrease from
its constant thickness H and the attenuation is no longer enough even to be of H cm of fat. The inner edge of the
breast edge region is mathematically quite smooth.

Figure 4. One way of estimating the

breast thickness is to determine what
value of H gives a satisfactory h =
int
0 curve. This curve is meant to be
around the edge of the breast where
the breast thickness drops sharply
away, and the breast consists mostly
of fat. Consequently, we expect the
h =0 curve to be present, complete
int
and smooth. At low values of H the
values of h are too high, and there
int
is no h =0 curve. As H increases the
int
curves appear and are smooth but
then they become jagged. We measure
the smoothness using the covering
blanket concept which is shown on
the right of this picture and is
described fully in the text.

Figure 5. This shows images with luminance proportional to h except for the bright white ‘‘breast edge’’ which is
int
where h =0. The breast thicknesses tried were, from left to right: 3.4 cm, 5.4 cm, 6.0 cm and 6.4 cm. The first value,
int
3.4 cm, is far too low—there is no breast edge; the second value, 5.4 cm, is just about right—there is a substantial
breast edge and a smooth internal edge; the last two estimates are far too high—the breast edge has become ragged.

T he British Journal of Radiology, June 1998 649


An appropriate smoothness measure
We seek a smoothness measure for the h =0
int
curve that enables us to determine when that curve
has reached the interior of the breast. As we start
with an underestimate of H the smoothness meas-
ure should initially be low and should then rise as
the h =0 curve becomes more jagged (Figure 6).
int
There are several possibilities for a smoothness
measure. One approach is to use a mathematical
measure such as the average curvature, or variance
in curvature, or an estimate of the Lipschitz dimen-
sion. Although these are nice in theory, they are
complicated by the discrete nature of digital images.
A second approach is to use an estimate of a
fractal characteristic of the curve. Xie and Brady
[7] point out that a fractal curve has two param-
eters: fractal dimension and D-dimension, and
show that for estimating image textures the latter
is more reliable, stable and gives better discrimi-
nation. Image texture is closely related to the
concepts of roughness and smoothness so that this
observation is directly relevant to our work. Xie
and Brady also give an elegant technique to esti-
mate the D-dimension: ‘‘the covering blanket’’
which is based upon morphological operations [8,
9]. To compute the measure, two further curves
are created from the h =0 curve: one from ‘‘open-
int
ing’’ the h =0 curve and one from ‘‘closing’’ it
int
(see Figure 4). An ‘‘opening’’ operation creates a
small curve which is smoother than the original,
whilst a ‘‘closing’’ operation creates a larger curve
which is smoother than the original. The area
contained between the two curves is a measure of
smoothness/roughness: the smaller the area the
smoother the curve. We use as our morphological
operator a 5 pixel×5 pixel disk.
Although the area between the curves is related
to roughness, it is also directly related to the total
length of the curve so that we need to normalize
the measure and make it dimensionless by dividing
by the length of the curve. Note that the area is
650
R P Highnam, J M Brady and B J Shepstone
not related to any concept of radius of the curve
so that that does not need to be accounted for.
Number of pixels enclosed by closing and opening of h =0
Roughness=
Number of pixels on h =0 curve
int
int
(1)
When this measure increases above a threshold, H
is no longer increased. We use a value of 1.3 and
have found this to be sufficient for every image
that has been examined.
An initial estimate of breast thickness
There are several ways of getting an initial
estimate of breast thickness from the calibration
data and image. One way exploits the fact that
near the chest wall there is low scatter, since there
is no scatter coming from the chest wall [6, 10].
As the breast tends to be fatty we can assume
h =0, h =H. Assuming the energy at the chest
int fat
wall to be from primary radiation allows us to
compute the X-ray attenuation and hence the
necessary thickness of fat (H ). Another way is to
assume that near the breast edge we have pure fat
and some nominal, high scatter-to-primary ratio
where we use scatter to include extrafocal radiation
which has been reported to be up to 15% of the
total radiation [11, 12] and which is significant
near the breast edge. In the current work we
estimate an initial value for the breast thickness
using a film density that we know to be outside
the breast and the calibration data. Such an initial
estimate is always less than the actual breast
thickness and so is suitable for our work.
Bounds on the breast thickness can also be
attained. These can be used to check that the method
is not trying infeasible breast thicknesses. The lower
bound on H is related to the minimum attenuation
apparent within the breast image. To achieve such
low attenuation requires a certain minimum thick-
ness of breast tissue. The minimum possible H occurs
if the breast tissue has very low fat content so that
h =H (i.e. highly attenuating). An upper bound on
int
Figure 6. We desire a smoothness
measure that reflects the raggedness
or smoothness of a curve. As breast
thickness increases we expect to see a
large jump in the measure just after
the breast thickness that we require.
In this picture, the curves marked
A–E would ideally have the smooth-
ness measures as shown on the right.
T he British Journal of Radiology, June 1998
Compressed breast thickness during mammography
H can be determined in exactly the same way except
that we use the maximum attenuation and consider
the breast to be nearly all fat.
T he algorithm
This comprises the following steps.
(1) Segment the breast image from the film.
(2) Find an underestimate of H.
(3) Generate an approximate h representation.
int
(4) Find all h =H, h =0 pixels and make them
fat int
into a curve.
(5) Compute the smoothness of the curve using
the covering blanket.
(6) If the smoothness is above a threshold: then
decrease H and stop; else increase H and
go to (3).
The segmentation in step (1) is performed on the
basis that that part of the image which lies outside
the breast area is the only part where we can be
certain of extremely low variation in film density.
The approximate h values are computed using
int
simple approximations to scatter and extrafocal at
the breast edge thus ensuring a fast estimate of H.
Once the breast thickness has been found, h at
int
each pixel is accurately estimated using the full
mathematical models [6]. The number of pixels
with h =0 is typically a wide band. We are only
int
interested in the internal edge of that band and
find it by tracking out from a central position of
the chest wall and collating the first pixels that we
meet with h =0. The increase or decrease in H
int
in step (6) is 0.1 cm. We need to decrease H before
stopping to get back to a smooth h =0 curve.
int
Currently, an unoptimized implementation of the
breast estimation algorithm takes only a few
minutes to run on a Sun Ultra 1 and does not
take up substantial amounts of memory above that
used for the image itself. It is likely that an
optimized version of the algorithm could provide
an estimate of breast thickness within 30 s or so.
Results
We have observed and measured the breast edge
on hundreds of different images from different sites
from around the world. Figures 3 and 7 show
typical breast edge extents. For both craniocaudal
and mediolateral oblique mammograms the breast
edge is consistently about 10% of the total area of
the projected breast. This is one of a number of
useful metrics which can be used to determine if
the algorithms are running properly.
To test our estimate of breast thickness we
performed a series of tests at the Breast Care Unit
within the Churchill Hospital in Oxford. The
T he British Journal of Radiology, June 1998
mammography machine that was used is an IGE
Senographe which has a foot-controlled com-
pression device. A volunteer measured by hand
during mammography the breast thicknesses near
the chest wall. She felt that her measurements were
accurate for craniocaudal images (within
±0.30 cm) but far less accurate for mediolateral
oblique images (within ±0.50 cm) since the posi-
tion of the woman’s arm on the machine severely
hampers the measurement. With every mammo-
gram used in our tests, calibration data were
collected to quantify the imaging process. These
data include film–screen characteristic curve, tube
voltage, mAs value etc. [4]. Mammograms were
digitized to 300 micron spatial resolution, 12-bit
grey scale resolution using a Lumisys 85. Figure 8
shows two examples of the smoothness measure
and its variation with breast thickness H.
Breast thickness measurements were taken for
craniocaudal mammograms at assessment clinics
at the Churchill Hospital in Oxford on three
different occasions over a period of 6 months. A
total of 32 craniocaudal mammograms with
measurements were collected and digitized, the 32
were 16 pairs of left and right breasts. The women
were aged 51–65 years. The measured thicknesses
ranged from 3.4 to 7.0 cm with an average of
5.55 cm. The average absolute difference between
the left and right measured breast thicknesses was
0.39 cm. Comparisons between measured and esti-
mated thicknesses revealed an average absolute
error of 0.22 cm including a single exceptional
error of 0.71 cm. Burch and Law’s [3] average
accuracy of 0.2 cm appears to be the average
relative accuracy rather than the average absolute
error and so our technique compares favourably.
There is no apparent relation between breast com-
position or breast thickness with the difference in
estimated and measured breast thicknesses with
the errors varying mostly between 0 and 5% with
a maximum error of 10%.
Mediolateral oblique mammograms were col-
lected at a screening clinic. A total of 22 mediolat-
eral oblique mammograms were collected. The
women were aged 51–71 years. The measured
thicknesses ranged from 3.0 to 7.0 cm with an
average size of 5.09 cm. The average absolute
difference between the left and right breasts was
0.25 cm. The average absolute error for mediolat-
eral images using our technique was much higher
than for craniocaudal images at 0.44 cm, but this
almost certainly reflects the dubious nature of the
thickness measurements for the mediolateral
oblique images rather than our technique. This is
supported by the fact that the breast edges were
again 10% of the total breast area and that 90%
of the estimates using our technique were under-
estimates suggesting a systematic problem such as
consistent overmeasurement.
651

Figure 7. This picture shows further examples of breast edges, i.e. areas where h <0, these are shown in bright white.
These examples are from a different database to the images shown in Figure 3. In these cases the breast edges are
slightly curtailed since the digitizer used had a maximum density of 3.2, compared with 4.0 for the newer databases.
Figure 8. The horizontal axis shows the breast thickness
in centimetres. The vertical axis shows the smoothness
measure as described in the text. The higher the value,
the rougher is the curve. We set a threshold to stop
increasing the breast thickness at a smoothness value of
1.3. This graph shows the variation of the smoothness
parameter for left and right breasts of the same woman
in the craniocaudal view. In these cases the measured
thicknesses were 6.0 cm and the estimated thicknesses
5.9 and 6.1 cm.
We also estimated the breast thicknesses from
mammograms for which we had little calibration
data. In these cases we would typically have the
tube voltage and mAs value but not our usual
film–screen calibration (a 14 step wedge). Instead,
we used the standard calibration data collected by
the Breast Care Unit itself, film–screen gradient
and speed, to predict how our step wedge would
appear. Over a set of such uncalibrated craniocau-
dal mammograms we found an average of 5.3 cm
which is close to the average for the calibrated
mammograms. In the few cases we have where we
have calibrated mammograms and uncalibrated
ones from previous screenings the breast thick-
nesses were within 0.5 cm.
It is surprising that the average mediolateral
oblique compressed thickness (both estimated and
measured) is less than the average craniocaudal
thickness since, for any one woman, an 8% rise in
breast thickness with the mediolateral oblique view
[13] can be expected. However, the craniocaudal
mammograms were performed at an assessment
652
R P Highnam, J M Brady and B J Shepstone
int
clinic whereas the mediolateral obliques were per-
formed at a screening clinic, which might explain the
discrepancy. The average craniocaudal thickness at
5.55 cm corresponds well with the 5.50 cm average
that Burch and Law found [3], but exceeds the
4.4 cm average found by Helvie et al [13] in their
American-based study and the 5.2 cm average found
by Fife [14] in a UK-based study. Our average
mediolateral oblique thickness at 5.0 cm just exceeds
the 4.8 cm average found by Helvie et al [13].
Discussion
In our estimate of breast thickness we detect
the smooth curve which delimits the interior breast
region. The presence of Cooper’s ligaments on the
image, which is quite unusual, would affect only a
smooth section of the curve and not the overall
smoothness measure. The increased density of
tissue around the nipple just means that the curve
is not a semi-circle but a more irregular shape that
is still smooth. Indeed, we intend to use the fact
that the curve is less regular to detect the position
of the nipple.
When skin thickening occurs in a breast the
edge of the breast becomes denser and this results
in a bright area around the edge of the mammo-
gram. This could potentially be sensed as being
the smooth h =0 line for an erroneous breast
int
thickness. However, since it would be far more
dense than the fat in the breast edge it will have a
far higher h value and will not affect our finding
int
of the interior breast region.
An estimate of breast thickness is vital not only
for calculating radiation dose but also for making
automated image analysis routines more robust
[4]. Breast thickness is only one of a number of
parameters which can vary in mammography and
any knowledge of the values of the parameters can
only aid the computer if used appropriately.
Conclusion
We have presented a method for estimating
breast thickness that is accurate to within ±0.2 cm
T he British Journal of Radiology, June 1998
Compressed breast thickness during mammography
for craniocaudal mammograms and to at least
±0.44 cm for mediolateral oblique mammograms.
The method compares favourably with other
methods that have been seen to be adequate for
the purpose of estimating radiation dose [3] and
it has the advantage that retrospective estimation
of thickness can be made.
Acknowledgments
The authors thank the staff at the Churchill
Hospital, Oxford, for their continuing support and
encouragement. Particular thanks to Yvonne
Swainston, Maud Poissonnier and Donald Peach.
The Lumisys scanner and Ralph Highnam were
both funded by support from the Engineering and
Physical Sciences Research Council. The authors
thank the referees for their constructive comments.
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