Surveying and QC of Surveying and QC of StereotacticStereotactic Breast Breast Biopsy Units for ACR AccreditationBiopsy Units for ACR Accreditation

ACMP 25th Annual MeetingACMP 25th Annual Meeting

Seattle, WA May 3, 2008Seattle, WA May 3, 2008

Melissa C. Martin, M.S., FACRMelissa C. Martin, M.S., FACRTherapy Physics, Inc.Therapy Physics, Inc.

879 West 190th St., Ste 419, Gardena, CA 90248879 West 190th St., Ste 419, Gardena, CA 90248

Office: 310Office: 310--217217--4114 Cell: 3104114 Cell: 310--612612--81278127

ee--mail: mail: Melissa@TherapyPhysics.comMelissa@TherapyPhysics.com

Learning ObjectiveLearning Objective

Become familiar with the recommendations and Become familiar with the recommendations and requirements of the ACR requirements of the ACR StereotacticStereotactic Breast Breast Biopsy Accreditation Program (SBBAP) Biopsy Accreditation Program (SBBAP) --1999 Quality Control Manual Information1999 Quality Control Manual Information

By product of conducting Quality Control tests for By product of conducting Quality Control tests for StereotacticStereotactic Breast Biopsy units is greater Breast Biopsy units is greater familiarity with the operation and performance of familiarity with the operation and performance of your SBB system, particularly image quality and the your SBB system, particularly image quality and the accuracy of needle placement during SBB.accuracy of needle placement during SBB.

LORAD LORAD StereotacticStereotactic Breast Biopsy SystemBreast Biopsy System

LORAD LORAD StereotacticStereotactic Breast Biopsy SystemBreast Biopsy System

LORAD LORAD StereotacticStereotacticBreast Biopsy Breast Biopsy System Control System Control Pendant Pendant

Geometry isreset for eachpatient

xz

Cartesiancoordinate system

x

yDon Jacobson 2/07

Siemens (Fischer) Siemens (Fischer) MammoVisionMammoVision Biopsy SystemBiopsy System

Siemens (Fischer) Siemens (Fischer) MammoVisionMammoVision Biopsy Biopsy SystemSystem

Fixed relationshipbetween Autoguideand breast support

DistanceVertical angleHorizontal angle

Sphericalcoordinatesystem

Don Jacobson 2/07

Don Jacobson 2/07

Don Jacobson 2/07

Goals of QC for Goals of QC for StereotacticStereotactic Breast BiopsyBreast Biopsy

To ensure that image quality in To ensure that image quality in StereotacticStereotactic Breast Breast Biopsy equals or exceeds that of screening and Biopsy equals or exceeds that of screening and diagnostic mammographydiagnostic mammography

To ensure that equipment designed specifically for To ensure that equipment designed specifically for Stereo Breast Biopsy performs properlyStereo Breast Biopsy performs properly

To ensure that needle localizations are accurateTo ensure that needle localizations are accurate

General Requirements for SBBAPGeneral Requirements for SBBAP

Qualified TEAM: Physicians, Technologist, and Qualified TEAM: Physicians, Technologist, and Medical PhysicistMedical Physicist

Equipment: Table or Equipment: Table or ““addadd--onon””; film or digital; film or digital

QA Program, Manual, and CommitteeQA Program, Manual, and Committee

TechnologistTechnologist’’s QC Testings QC Testing-- daily, weekly, monthly, semidaily, weekly, monthly, semi--annual annual -- 6 tests6 tests

Medical PhysicistMedical Physicist’’s QC Testings QC Testing-- acceptance and annual acceptance and annual -- 11 tests11 tests

The Quality Assurance Team: The Quality Assurance Team:

PhysicianPhysician

QC TechnologistQC Technologist

Medical PhysicistMedical Physicist

Medical PhysicistMedical Physicist’’s Qualifications for s Qualifications for SBBAP: InitialSBBAP: Initial

Certification by ABR, ABMP in Diagnostic Medical Certification by ABR, ABMP in Diagnostic Medical Physics ORPhysics OR

Alternate Education, Training and Experience ANDAlternate Education, Training and Experience AND

>6/1/97: Have Performed 1 SBB Survey Under the >6/1/97: Have Performed 1 SBB Survey Under the Guidance of a Medical Physicist Qualified to Guidance of a Medical Physicist Qualified to Perform SBB SurveysPerform SBB Surveys

<6/1/97: Have Performed 3 SBB Surveys<6/1/97: Have Performed 3 SBB Surveys

Medical Physicist Qualifications for SBBAP: Medical Physicist Qualifications for SBBAP: ReRe--Accreditation After 3 YearsAccreditation After 3 Years

At Least 1 SBB Physics Survey Per YearAt Least 1 SBB Physics Survey Per Year

At Least 3 Hours of Continuing Education in At Least 3 Hours of Continuing Education in SBB PhysicsSBB Physics

Documentation of AboveDocumentation of Above

Quality Control: Quality Control: Medical PhysicistMedical Physicist’’s Evaluations Evaluation

Acceptance Test Before Patient UseAcceptance Test Before Patient Use

Annually ThereafterAnnually Thereafter

Report Required as Part of ACR ApplicationReport Required as Part of ACR Application

Quality Control:Quality Control:Medical PhysicistMedical Physicist’’s Evaluations Evaluation

The 1999 ACR SBB Quality Control Manual The 1999 ACR SBB Quality Control Manual has a section for the Medical Physicisthas a section for the Medical Physicist

It has suggested Test Procedures, Forms, It has suggested Test Procedures, Forms, and Summary Report Formatand Summary Report Format

Detailed instructions on 11 Required Detailed instructions on 11 Required PhysicistPhysicist’’s tests s tests

ACR Quality Control ManualsACR Quality Control Manuals

• Mammography QC Manual(1990, 1992, 1994, 1999)

• Barium Enema QC Manual(1998)

• Stereotactic Breast BiopsyQC Manual (1999)

• MRI QC Manual (2001)• Sent free to all facilities

in program• To purchase, call ACR Pubs: (800) 227-7762• QC forms available to anyone on Web site

Rad Tech QC TestsRad Tech QC TestsMammo QC Tests Also Apply if ScreenMammo QC Tests Also Apply if Screen--Film UsedFilm Used

Localization Accuracy Localization Accuracy -- dailydaily

Phantom Image Phantom Image -- weeklyweekly

Hardcopy Output Quality Hardcopy Output Quality -- monthly, if appmonthly, if app

Visual Checklist Visual Checklist -- monthlymonthly

Compression Force Compression Force -- semisemi--annuallyannually

Repeat Analysis Repeat Analysis -- semisemi--annuallyannually

Zero Alignment Test Zero Alignment Test –– before ea patient, if appbefore ea patient, if app

Medical PhysicistMedical Physicist’’s Quality Control Testss Quality Control Tests

1. 1. StereotacticStereotactic Unit Assembly EvaluationUnit Assembly Evaluation

2. Collimation Assessment2. Collimation Assessment

3. Focal Spot Performance & Digital System 3. Focal Spot Performance & Digital System Limiting ResolutionLimiting Resolution

4. 4. kVpkVp Accuracy and ReproducibilityAccuracy and Reproducibility

5. Beam Quality Assessment (HVL)5. Beam Quality Assessment (HVL)

6. AEC or Manual Exposure Performance6. AEC or Manual Exposure Performance

Medical PhysicistMedical Physicist’’s Quality Control Testss Quality Control Tests

7A. Uniformity of Screen Speed7A. Uniformity of Screen Speed

7B. Digital Receptor Uniformity7B. Digital Receptor Uniformity

8. Breast Entrance Exposure, Average Glandular 8. Breast Entrance Exposure, Average Glandular Dose, and Exposure ReproducibilityDose, and Exposure Reproducibility

9. Image Quality Evaluation9. Image Quality Evaluation

10. Artifact Evaluation10. Artifact Evaluation

11. Localization Accuracy Test11. Localization Accuracy Test

StereotacticStereotactic Unit Assembly EvaluationUnit Assembly Evaluation

Collimation AssessmentCollimation Assessment

Collimation AssessmentCollimation Assessment

Collimation Assessment

Collimation AssessmentCollimation Assessment

SID = 84 cm

Digital Limiting Resolution/Focal SpotDigital Limiting Resolution/Focal Spot

Digital Limiting Resolution/Focal SpotDigital Limiting Resolution/Focal Spot

Digital Limiting Resolution/Focal SpotDigital Limiting Resolution/Focal Spot

kVpkVp Accuracy and ReproducibilityAccuracy and Reproducibility

kVpkVp Accuracy and ReproducibilityAccuracy and Reproducibility

Beam Quality AssessmentBeam Quality Assessment

Beam Quality Specifications for SBB UnitsBeam Quality Specifications for SBB Units

The minimum acceptable HalfThe minimum acceptable Half--Value Layer measurement on a Value Layer measurement on a digital or film/screen SBB unit isdigital or film/screen SBB unit is

then seek service correction.

where C = 0.12 for Mo/Mo, C = 0.19 for Mo/Rh, and C = 0.22 for Rh/Rh,

if measured HVL > (kVp/100) + C (in mm Al)

orIf measured HVL < (kVp/100) (in mm Al)

Action Limit:

Image Quality Evaluation (Phantom)Image Quality Evaluation (Phantom)

Objective: Ensure Image Quality for SBB meets or Objective: Ensure Image Quality for SBB meets or exceeds that of mammography, and to detect exceeds that of mammography, and to detect temporal changes in image qualitytemporal changes in image quality

Procedure: Same as for Mammography, except Procedure: Same as for Mammography, except ACR phantom must be imaged in 4 separate ACR phantom must be imaged in 4 separate quadrants for digital because of small field of viewquadrants for digital because of small field of view

Two Types of Approved PhantomsTwo Types of Approved Phantoms

“Mini” Stereotactic Breast Biopsy Accreditation Phantom

Nuclear Associates 18-250

Mammography Accreditation PhantomRMI 156

Nuclear Associates 18-220

““MiniMini”” Stereotactic BreastStereotactic BreastBiopsy Accreditation PhantomBiopsy Accreditation Phantom

Chest Wall Side

SBBAP Testing CriteriaSBBAP Testing CriteriaDose and PhantomDose and Phantom

2.52.52.02.03.53.53.03.0MassesMasses

3.03.02.02.04.04.03.03.0Speck Speck GroupsGroups

3.03.02.02.05.05.04.04.0FibersFibersDigitalDigitalF/SF/SDigitalDigitalF/SF/S

Mini PhantomMini PhantomMAP PhantomMAP Phantom

• Dose- Must be less than 300 mrads (3 mGy)

• Phantom image quality

Image Quality for SBB UnitsImage Quality for SBB Units

RMI 156 or NA 18-220 - MAP Phantom

Don Jacobson 2/07

NA 18-250 Mini-Phantom

RM

I 156A

ccreditationPhantom

Nuclear A

ssociates D

igital Mini Phantom

AEC or Manual Exposure PerformanceAEC or Manual Exposure Performance

2 cm Thickness

AEC or Manual Exposure PerformanceAEC or Manual Exposure Performance

4 cm Thickness -Also used for Uniformity and Artifacts

AEC or Manual Exposure PerformanceAEC or Manual Exposure Performance

6 cm Thickness 8 cm Thickness

AEC or Manual Exposure PerformanceAEC or Manual Exposure Performance

AEC or Manual Exposure Control AEC or Manual Exposure Control Performance RequirementPerformance Requirement

Action Limit (Digital): If the signal range Action Limit (Digital): If the signal range exceeds exceeds ±±20% of signal for 4 cm phantom, 20% of signal for 4 cm phantom, revise technique chart.revise technique chart.

signal

range

exceeds

±20%

of

signal

for

4

cm

Action Limit (Screen-Film): If the density range exceeds ±0.15 of mean, revise technique chart.

Digital Receptor Uniformity RequirementsDigital Receptor Uniformity Requirements

For Units with ROI statistics measurement For Units with ROI statistics measurement capability:capability:

Action Limit: If SNR(I) / Action Limit: If SNR(I) / SNR(CenterSNR(Center) is > 1.15 ) is > 1.15 or < 0.85, seek service correction.or < 0.85, seek service correction.

If

measured

HVL

<

(kVp/100)

(in

mm

Al)

If

measured

HVL

<

(kVp/100)

(in

mm

Al)

Digital Receptor Uniformity RequirementsDigital Receptor Uniformity Requirements

For Units without ROI statistics For Units without ROI statistics measurement capability:measurement capability:

If

measured

HVL

<

(kVp/100)

(in

mm

Al)

If

measured

HVL

<

(kVp/100)

(in

mm

Al)

If line w/o black dots > 1/4 length of image, seek service correction

If non-uniform areas (w/o black dots) > 10% of image or

Action Limits: If geometric pincushioning > 1 cmfrom edge of image or

Digital Receptor UniformityDigital Receptor Uniformity

Digital Receptor Uniformity Digital Receptor Uniformity -- Image StatisticsImage Statistics

Breast Entrance Exposure, Average Glandular Breast Entrance Exposure, Average Glandular Dose, and Exposure ReproducibilityDose, and Exposure Reproducibility

Same Procedure as for MammographySame Procedure as for Mammography

Recommended Signal Level for DigitalRecommended Signal Level for Digital

Digital Matrix SizesDigital Matrix Sizes

Performance Criteria: Performance Criteria: a) Coefficient of Variation < 0.05a) Coefficient of Variation < 0.05b) Av. Glandular Dose < 3 b) Av. Glandular Dose < 3 mGymGy for Screen/Film for Screen/Film

and for Digital Image Receptorsand for Digital Image Receptors

Entrance Exposure/MidEntrance Exposure/Mid--Glandular DosesGlandular Doses

Entrance Exposure/MidEntrance Exposure/Mid--Glandular DosesGlandular Doses

Entrance Exposure/MidEntrance Exposure/Mid--Glandular DosesGlandular Doses

Artifact EvaluationArtifact Evaluation

11. Localization Accuracy: 11. Localization Accuracy: Gelatin PhantomGelatin Phantom

Objective: To assure that the biopsy needle is Objective: To assure that the biopsy needle is accurately placed for sampling as directed from the accurately placed for sampling as directed from the stereotacticstereotactic scout imagesscout images

Technologist to perform testTechnologist to perform test

Physicist to observe and analyze resultsPhysicist to observe and analyze results

EndEnd--toto--End test which supplements the daily inEnd test which supplements the daily in--air air positioning accuracy testpositioning accuracy test

Localization Accuracy: Gelatin Phantom Localization Accuracy: Gelatin Phantom MethodMethod

1. Position Needle: 1. Position Needle: -- Target Lesion Using Stereo ViewsTarget Lesion Using Stereo Views-- Position Core Needle to Proper X, Y, and Z Position Core Needle to Proper X, Y, and Z

CoordinatesCoordinates

2. Verify Needle Position:2. Verify Needle Position:-- Acquire Stereo PreAcquire Stereo Pre--fire Imagesfire Images-- Needle Tip should be within LesionNeedle Tip should be within Lesion

3. Fire Gun3. Fire Gun

Localization Accuracy:Localization Accuracy: Gelatin Phantom Gelatin Phantom MethodMethod

4. Verify Post4. Verify Post--Fire PositionFire Position-- Acquire PostAcquire Post--Fire Stereo ImagesFire Stereo Images-- Needle Tip should be beyond Center of LesionNeedle Tip should be beyond Center of Lesion

5. Verify Sampling of Lesion5. Verify Sampling of Lesion-- Examine Contents of Core SampleExamine Contents of Core Sample

Gelatin Phantom BiopsyGelatin Phantom Biopsy

Gelatin Biopsy ImagesGelatin Biopsy Images

Localization AccuracyLocalization Accuracy

SAMS Questions

The maximum allowable patient midThe maximum allowable patient mid--glandular glandular dose for a 4.5 cm breast equivalent phantom dose for a 4.5 cm breast equivalent phantom under MQSA is under MQSA is

0%

0%

0%

0%

0%

10

1.1. 1 1 mGymGy

2.2. 2 2 mGymGy

3.3. 3 3 mGymGy

4.4. 5 5 mGymGy

5.5. 10 10 mGymGy

Answer: C Answer: C -- 3 3 mGymGy

Ref: Ref: ““StereotacticStereotactic Breast Biopsy Breast Biopsy Accreditation ManualAccreditation Manual””

American College of Radiology (1997)American College of Radiology (1997)

Using the dedicated miniUsing the dedicated mini--phantom designed for SBB phantom designed for SBB units, the minimum acceptable phantom image units, the minimum acceptable phantom image quality scores on a unit with digital imaging are:quality scores on a unit with digital imaging are:

0%

0%

0%

0%

0%

10

1.1. 2 fibers, 3 speck groups, 2.5 masses2 fibers, 3 speck groups, 2.5 masses

2.2. 3 fibers, 3 speck groups, 2.5 masses3 fibers, 3 speck groups, 2.5 masses

3.3. 4 fibers, 3 speck groups, 3.0 masses4 fibers, 3 speck groups, 3.0 masses

4.4. 3 fibers, 2.5 speck groups, 2.5 masses3 fibers, 2.5 speck groups, 2.5 masses

5.5. 3 fibers, 4 speck groups, 3.0 masses3 fibers, 4 speck groups, 3.0 masses

Answer: b Answer: b -- 3 fibers, 3 speck groups,3 fibers, 3 speck groups,2.5 masses2.5 masses

Ref: Ref: ““StereotacticStereotactic Breast Biopsy Breast Biopsy Accreditation ManualAccreditation Manual””

American College of Radiology (1997)American College of Radiology (1997)

The minimum acceptable Half Value Layer The minimum acceptable Half Value Layer measurement on a digital SBB unit at 28 measurement on a digital SBB unit at 28 kVpkVp isis

0%

0%

0%

0%

0%

10

1.1. 0.48 mm Al0.48 mm Al

2.2. 0.38 mm Al0.38 mm Al

3.3. 0.42 mm Al0.42 mm Al

4.4. 0.24 mm Al0.24 mm Al

5.5. 0.28 mm Al0.28 mm Al

Answer: e Answer: e -- 0.28 mm Al0.28 mm Al

Ref: Ref: ““StereotacticStereotactic Breast Biopsy Breast Biopsy Accreditation ManualAccreditation Manual””

American College of Radiology (1997)American College of Radiology (1997)

Min. HVL = (kVp/100) mm AlMin. HVL = (kVp/100) mm Al

The minimal acceptable uniformity level for The minimal acceptable uniformity level for a digital receptor on a SBB unit isa digital receptor on a SBB unit is

0%

0%

0%

0%

0%

10

1.1. 0.500.50

2.2. 0.700.70

3.3. 0.750.75

4.4. 0.850.85

5.5. 0.900.90

Answer: d Answer: d -- 0.850.85

Ref: Ref: ““StereotacticStereotactic Breast Biopsy Breast Biopsy Accreditation ManualAccreditation Manual””

American College of Radiology (1997)American College of Radiology (1997)

Action Limit: If SNR(I) / Action Limit: If SNR(I) / SNR(CenterSNR(Center) is > ) is > 1.15 or < 0.85, seek service correction.1.15 or < 0.85, seek service correction.

The AEC or Manual Exposure Control Performance The AEC or Manual Exposure Control Performance requirement on a SBB unit with digital imaging isrequirement on a SBB unit with digital imaging is

0%

0%

0%

0%

0%

10

1.1. +/+/-- 0.15 of the average signal for thickness of 20.15 of the average signal for thickness of 2--6 cm6 cm

2.2. +/+/-- 0.15 of the average signal for 4 cm phantom0.15 of the average signal for 4 cm phantom

3.3. +/+/-- 0.20 of the average signal for thicknesses of 20.20 of the average signal for thicknesses of 2--6 cm6 cm

4.4. +/+/-- 0.20 of the average signal for 4 cm phantom0.20 of the average signal for 4 cm phantom

5.5. +/+/-- 0.30 of the average signal for thicknesses of 20.30 of the average signal for thicknesses of 2--6 cm6 cm

Answer: d: +/Answer: d: +/-- 20% of average signal for 20% of average signal for 4 cm phantom 4 cm phantom

Ref: Ref: ““StereotacticStereotactic Breast Biopsy Breast Biopsy Accreditation ManualAccreditation Manual””

American College of Radiology (1997)American College of Radiology (1997)