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: [email protected]@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)