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Mammography and ACR Protocols

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George David Resident Physics Series ACR Mammography Protocols
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Page 1: Mammography and ACR Protocols

GeorgeDavid

Resident Physics SeriesResident Physics Series

ACR Mammography Protocols

Page 2: Mammography and ACR Protocols

GeorgeDavid

Mammography QC ManualMammography QC Manual

• Radiologist

• Clinical Image Quality

• Radiologic Technologist

• Medical Physicist

Revised Edition, 1999Revised Edition, 1999

SectionsSections

Page 3: Mammography and ACR Protocols

GeorgeDavid

Facility ResponsibilityFacility Responsibility

• Designate One Lead Interpreting Physician

Page 4: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• Designate one technologist responsible for QC

• QC tech can delegate responsibilities to others

Page 5: Mammography and ACR Protocols

Lead Physician’s Responsibilities

Lead Physician’s Responsibilities

• Ensure technologists have adequate orientation

» based on procedure manual

training continuing education

• Ensure effective QC program

Page 6: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• Ensure availability of appropriate test equipment

• Arrange staffing / scheduling to allow time for QC

Page 7: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• provide frequent consistent positive & negative feedback to technologists about film quality & QC

• Review technologist’s test results no less than every 3 months more often if inconsistent

results

Page 8: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• Select a medical physicist administers QC program performs physicist’s tests

• Review physicist’s test results

Page 9: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• Oversee or designate qualified individual to oversee radiation protection program for employees patients individuals in surrounding area

Page 10: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• Ensure proper maintenance of records in QC procedures manual employee qualifications mammography technique / procedures quality control / safety / protection infection control

Page 11: Mammography and ACR Protocols

GeorgeDavid

Radiologist’s ResponsibilitiesRadiologist’s Responsibilities

• “The radiologist is ultimately responsible for the quality of films produced under his or her direction and bears ultimate responsibility for both proper QC testing and QA procedures in mammography.”

• “The radiologist is ultimately responsible for the quality of films produced under his or her direction and bears ultimate responsibility for both proper QC testing and QA procedures in mammography.”

Page 12: Mammography and ACR Protocols

GeorgeDavid

Physicist’s ResponsibilitiesPhysicist’s Responsibilities

• Note: All physicist’s tests are to Note: All physicist’s tests are to be done be done annuallyannually or after tube or after tube replacement or major servicereplacement or major service

Page 13: Mammography and ACR Protocols

Physicist’s Responsibilities: Mammography Unit Assembly Evaluation

Physicist’s Responsibilities: Mammography Unit Assembly Evaluation

• mechanical stability / identification of sharp edges

• receptor stability

• locks / motions / detents

• operator shielding

• thickness scale accuracy

• indicator lights working

• technique chart posted (see next slide)

Page 14: Mammography and ACR Protocols

Physicist’s Responsibilities: Mammography Unit Assembly Evaluation

Physicist’s Responsibilities: Mammography Unit Assembly Evaluation

• Cassettes slide smoothly into/out of holder

• Override available for auto-decompression display must indicate when auto-decompression

turned off

• Manual release of compression if power lost

Page 15: Mammography and ACR Protocols

GeorgeDavid

Collimation AssessmentCollimation Assessment

• x-ray light field alignment• beam does not exceed receptor by >

2% SID• compression paddle / receptor

alignment at chest wall within 1% SID paddle not visible on image

• Image should fill film Many units by design will not do this

Page 16: Mammography and ACR Protocols

GeorgeDavid

Physicist’s ResponsibilitiesPhysicist’s Responsibilities

• Focal Spot Performance limiting resolution pattern

• kVp accuracy / reproducibility

• Beam quality (HVL) minimum & maximum

» minimum: patient dose» maximum: image contrast

Page 17: Mammography and ACR Protocols

Automatic Exposure Control (AEC / Phototiming)

Automatic Exposure Control (AEC / Phototiming)

• kVp tracking• Thickness tracking• image mode tracking (cassette sizes, w

w/o grid)

• automatic mode tracking unit selects kVp, target, filter

• density control even steps of ~ 15-20%

Density Step Changes

0

2

4

6

8

10

12

14

16

18

-5 -4 -3 -2 -1 0 1 2 3 4 5

Step

% C

han

ge

Series1

Page 18: Mammography and ACR Protocols

Physicist’s Responsibilities:Physicist’s Responsibilities:

• Screen Uniformity compare O.D. of each cassette using

phototimer

• AEC Reproducibility

Page 19: Mammography and ACR Protocols

Physicist’s ResponsibilitiesPhysicist’s Responsibilities

• Breast Entrance Exposure, Average Glandular Dose, RMI-156 “accreditation” phantom used for entrance

exposure / average glandular dose

Page 20: Mammography and ACR Protocols

Breast Average Glandular Dose Limits

Breast Average Glandular Dose Limits

• 0.3 rad (300 mrads, 3 mGy) maximum per view for screen-film receptors using a grid

• 0.1 rad (100 mrads, 1 mGy) maximum per view for non-grid screen-film receptors

• Radiation output rate > 800 mR/sec

Page 21: Mammography and ACR Protocols

Image Quality EvaluationImage Quality Evaluation• use RMI-156 “accreditation”

phantom

• record fibers speck groups masses optical densities technique

Page 22: Mammography and ACR Protocols

A Poor Phantom ImageA Poor Phantom Image

Page 23: Mammography and ACR Protocols

GeorgeDavid

Artifact IdentificationArtifact Identification

• Artifact evaluation / description determination of artifact source

» processor

» other equipment

• Done with phantomfilm

Page 24: Mammography and ACR Protocols

GeorgeDavid

Physicist’s ResponsibilitiesPhysicist’s Responsibilities

• Viewing conditions ambient light viewbox brightness

• My experience Ambient lighting

often ignored

Page 25: Mammography and ACR Protocols

Technologist’s ResponsibilitiesTechnologist’s Responsibilities

• Daily darkroom cleanliness processor quality control

» sensitometric data

• Weekly screen cleanliness viewboxes and viewing

conditions Phantom images

All QC must not only be performed All QC must not only be performed but must be but must be documenteddocumented!!

Speed

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O.D

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Page 26: Mammography and ACR Protocols

Technologist’s ResponsibilitiesMonthly: Visual Checklist

Technologist’s ResponsibilitiesMonthly: Visual Checklist

• visual checklist• SID indicator• angle indicator• locks• field light• smooth motions

Page 27: Mammography and ACR Protocols

Technologist’s ResponsibilitiesMonthly: Visual Checklist

Technologist’s ResponsibilitiesMonthly: Visual Checklist

• cassette lock Is cassette held firmed in place when tubestand tilted

• Compression device & firm compression Smooth edges Holds pressure

• hand switch placement• visibility• switches/ lights/ meters• cones/ collimators

Page 28: Mammography and ACR Protocols

Technologist’s ResponsibilitiesQuarterly

Technologist’s ResponsibilitiesQuarterly

• Fixer retention analysis Fixer affects archivability of

films

• Repeat analysis breakdown by cause

» motion» positioning» technique» static» etc.

Page 29: Mammography and ACR Protocols

Semi-Annual Technologist’s Responsibilities: Darkroom Fog

Semi-Annual Technologist’s Responsibilities: Darkroom Fog

• must use sensitized film

» partially cover previously exposed phantom film in darkroom for 2 minutes

• up to .05 O.D. increase acceptable

Page 30: Mammography and ACR Protocols

Semi-annual Technologist’s Responsibilities

Semi-annual Technologist’s Responsibilities

Screen Film Contact

• 40 lines/inch Copper mesh

• subjective results

• poor contact can result if time (15 minutes) not provided for air to bleed out of cassette after closing NOTE: 15 minutes between cassette loading & exposure

must be provided for all clinical films to insure good contact

Page 31: Mammography and ACR Protocols

Semi-annual Technologist’s Responsibilities

Semi-annual Technologist’s ResponsibilitiesScreen Film Contact

Page 32: Mammography and ACR Protocols

Semi-Annual Technologist’s Responsibilities

Semi-Annual Technologist’s Responsibilities

Compression• can use bathroom scale covered

with towel

• 25 - 40 pounds for automatic systems

• at least 25 pounds for manual compression

Page 33: Mammography and ACR Protocols

GeorgeDavid

From the FDAFrom the FDA

Page 34: Mammography and ACR Protocols

FDA Facility & Procedure Count(as of November 1, 2007)

FDA Facility & Procedure Count(as of November 1, 2007)

• Total certified facilities: 8,837 Total accredited units: 13,590

• Certified facilities with FFDM units: 2,434 Accredited FFDM units: 3,644

• Total annual mammography procedures: 35,385,494

Page 35: Mammography and ACR Protocols

GeorgeDavid

MQSA Violation LevelsMQSA Violation Levels

• Level 1 (Most serious) Example: Unqualified personnel Requires written response within 15 days

• Level 2 May compromise quality of service provided Example: No physics survey within 14 months Requires written response within 30 days

• Level 3 Minor deviations from MQSA standards Example: missing QC records No written response required.

Page 36: Mammography and ACR Protocols

GeorgeDavid

FDA Inspection Violations (2007)FDA Inspection Violations (2007)

1%16%

7%

76%

Level 1 (most serious)Level 2Level 3No Violation

Page 37: Mammography and ACR Protocols

Why Sites Failed Accreditation2001 - 2003

Why Sites Failed Accreditation2001 - 2003

71.1%

23.1%

5.5%

0.3%

Clinical Images Only

Phantom Images Only

Clinical & PhantomImagesDose

Page 38: Mammography and ACR Protocols

Units Passing Accreditation2001-2003

Units Passing Accreditation2001-2003

86.4%

96.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

On 1st Attempt On 2nd Attempt

Page 39: Mammography and ACR Protocols

Units Passing Accreditation 2003

Units Passing Accreditation 2003

88.7% 88.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Initial Accreditation Renewel Accreditation

Page 40: Mammography and ACR Protocols

MQSA Inspections Without Adverse Observations

0102030405060708090

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

%

Page 41: Mammography and ACR Protocols

GeorgeDavid

What is FFDM?What is FFDM?

• Fly Fishing Democratic Mothers

• Far Field Dignified Marketing

• Fat Farm for Dumb Maniacs

Page 42: Mammography and ACR Protocols

GeorgeDavid

What is FFDM?What is FFDM?

• Full Field Digital Mammography

Page 43: Mammography and ACR Protocols

GeorgeDavid

How Popular is FFDMHow Popular is FFDM

Page 44: Mammography and ACR Protocols

Number of Accredited FFDM Units

Number of Accredited FFDM Units

0

500

1000

1500

2000

2500

3000

3500

4000

Nov 07Nov 03

Page 45: Mammography and ACR Protocols

Is the Overall # of Mammo Units Increasing

orAre these Replacement Units?

Is the Overall # of Mammo Units Increasing

orAre these Replacement Units?

Page 46: Mammography and ACR Protocols

Number of Accredited UnitsNumber of Accredited Units

0

2000

4000

6000

8000

10000

12000

14000

Nov 07Nov 03

Page 47: Mammography and ACR Protocols

GeorgeDavid

The EndThe End

Questions?


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