Caracterização tecnológica da mamografia digital em Portugal: progresso de um projeto em implementação

Introdução – A mamografia é o principal método de diagnóstico por imagem utilizado no rastreio e diagnóstico do cancro da mama, sendo a modalidade de imagem recomendada em vários países da Europa e Estados Unidos para utilização em programas de rastreio. A implementação da tecnologia digital causou alterações na prática da mamografia, nomeadamente a necessidade de adaptar os programas de controlo de qualidade. Objetivos – Caracterizar a tecnologia instalada para mamografia em Portugal e as práticas adotadas na sua utilização pelos profissionais de saúde envolvidos. Concluir sobre o nível de harmonização das práticas em mamografia em Portugal e a conformidade com as recomendações internacionais. Identificar oportunidades para otimização que permitam assegurar a utilização eficaz e segura da tecnologia. Metodologia – Pesquisa e recolha de dados sobre a tecnologia instalada, fornecidos por fontes governamentais, prestadores de serviços de mamografia e indústria. Construção de três questionários, orientados ao perfil do médico radiologista, técnico de radiologia com atividade em mamografia digital e técnico de radiologia coordenador. Os questionários foram aplicados em 65 prestadores de serviços de mamografia selecionados com base em critérios de localização geográfica, tipo de tecnologia instalada e perfil da instituição. Resultados – Foram identificados 441 sistemas para mamografia em Portugal. A tecnologia mais frequente (62%) e vulgarmente conhecida por radiografia computorizada (computed radiography) é constituída por um detector (image plate) de material fotoestimulável inserido numa cassete de suporte e por um sistema de processamento ótico. A maioria destes sistemas (78%) está instalada em prestadores privados. Aproximadamente 12% dos equipamentos instalados são sistemas para radiografia digital direta (Direct Digital Radiography – DDR). Os critérios para seleção dos parâmetros técnicos de exposição variam, observando-se que em 65% das instituições são adotadas as recomendações dos fabricantes do equipamento. As ferramentas de pós-processamento mais usadas pelos médicos radiologistas são o ajuste do contraste e brilho e magnificação total e/ou localizada da imagem. Quinze instituições (em 19) têm implementado um programa de controlo de qualidade. Conclusões – Portugal apresenta um parque de equipamentos heterogéneo que inclui tecnologia obsoleta e tecnologia “topo de gama”. As recomendações/guidelines (europeias ou americanas) não são adotadas formalmente na maioria das instituições como guia para fundamentação das práticas em mamografia, dominando as recomendações dos fabricantes do equipamento. Foram identificadas, pelos técnicos de radiologia e médicos radiologistas, carências de formação especializada, nomeadamente nas temáticas da intervenção mamária, otimização da dose e controlo da qualidade. A maioria dos inquiridos concorda com a necessidade de certificação da prática da mamografia em Portugal e participaria num programa voluntário. ABSTRACT - Introduction – Mammography is the gold standard for screening and imaging diagnosis of breast disease. It is the imaging modality recommended by screening programs in various countries in Europe and the United States. The implementation of the digital technology promoted changes in mammography practice and triggered the need to adjust quality control programs. Aims –Characterize the technology for mammography installed in Portugal. Assess practice in use in mammography and its harmonization and compliance to international guidelines. Identify optimization needs to promote an effective and efficient use of digital mammography to full potential. Methodology – Literature review was performed. Data was collected from official sources (governmental bodies, mammography healthcare providers and medical imaging industry) regarding the number and specifications of mammography equipment installed in Portugal. Three questionnaires targeted at radiologists, breast radiographers and the chief-radiographer were designed for data collection on the technical and clinical practices in mammography. The questionnaires were delivered in a sample of 65 mammography providers selected according to geographical criteria, type of technology and institution profile. Results – Results revealed 441 mammography systems installed in Portugal. The most frequent (62%) technology type are computerized systems (CR) mostly installed in the private sector (78%). 12% are direct radiography systems (DDR). The criteria for selection of the exposure parameters differ between the institutions with the majority (65%) following the recommendations from the manufacturers. The use of available tools for post-processing is limited being the most frequently reported tools used the contrast/ brightness and Zoom or Pan Magnification tools. Fifteen participant institutions (out of 19) have implemented a quality control programme. Conclusions – The technology for mammography in Portugal is heterogeneous and includes both obsolete and state of the art equipment. International guidelines (European or American) are not formally implemented and the manufacturer recommendations are the most frequently used guidance. Education and training needs were identified amongst the healthcare professionals (radiologists and radiographers) with focus in the areas of mammography intervention, patient dose optimization and quality control. The majority of the participants agree with the certification of mammography in Portugal.

Technical considerations concerning digital technologies

This chapter addresses technical issues concerning digital technologies. Radiological equipment and technique are briefly introduced together with a discussion about requirements and advantages of digital technologies. Digital technologies offer several advantages when compared to conventional analogical systems, or screen–film (SF) systems. While in clinical practice the practitioners should be aware of technical factors such as image acquisition, management of patient dose, and diagnostic image quality. Thus, digital technologies require an up-to-date scientific knowledge concerning their use in projection radiography. In this chapter, technical considerations concerning digital technologies are provided.

Assessment of patient dose in digital systems

The assessment of patient dose has gained increased attention, still being an issue of concern that arises from the use of digital systems. The development of digital technology offers the possibility for a reduction of radiation dose around 50% without loss in image quality when compared to a conventional screen–film system. Digital systems give an equivalent or superior diagnostic performance and also several other advantages, but the risk of overexposure with no adverse effect on image quality could be present. This chapter refers to the management of patient dose and provides an explanation of dose-related concepts. In this chapter, exposure influence in dose and image representation and the effects of radiation exposure are also discussed.

Image quality in diagnostic radiology

This chapter provides a theoretical background about image quality in diagnostic radiology. Digital image representation and also image quality evaluation methods are here discussed. An overview of methods for quality evaluation of diagnostic imaging procedures is provided. Digital image representation and primary physical image quality parameters are also discussed, including objective image quality measurements and observer performance methods.

Practical insights into digital radiology

Digital radiography detectors—based on different technological solutions—are currently available for clinical applications and widespread in clinical practice. Computed radiography (CR) and digital radiology systems have been available for clinical applications and the trend over the last few years has become digital. Radiology departments have been changing from traditional screen–film technology to digital technology. This chapter is intended to give the reader a practical understanding about the key aspects concerning digital systems, related to the performance of different technologies, image quality, and dose and patient safety/protection. The discussion around an optimization framework for digital systems is provided.

Digital radiology and Picture Archiving and Communication System (PACS)

Plain radiography still accounts for the vast majority of imaging studies that are performed at multiple clinical instances. Digital detectors are now prominent in many imaging facilities and they are the main driving force towards filmless environments. There has been a working paradigm shift due to the functional separation of acquisition, visualization, and storage with deep impact in the imaging workflows. Moreover with direct digital detectors images are made available almost immediately. Digital radiology is now completely integrated in Picture Archiving and Communication System (PACS) environments governed by the Digital Imaging and Communications in Medicine (DICOM) standard. In this chapter a brief overview of PACS architectures and components is presented together with a necessarily brief account of the DICOM standard. Special focus is given to the DICOM digital radiology objects and how specific attributes may now be used to improve and increase the metadata repository associated with image data. Regular scrutiny of the metadata repository may serve as a valuable tool for improved, cost-effective, and multidimensional quality control procedures.

Quantificação da eficiência da proteção da tiróide no exame de ortopantomografia

Mestrado em Radiações Aplicadas às Tecnologias da Saúde - Área de especialização: Proteção Contra Radiações

Avaliação da margem do PTV em tumores ginecológicos com irradiação dos gânglios lomboaórticos, que realizaram IMRT

Mestrado em Radioterapia.

Results of radiation protection programmes on mammography

In this paper, we present the results of mammography quality control tests related to the work with Portuguese mammography equipment, either in conventional or in digital mammography computed radiography, showing the main differences in the tested equipments. Quality control in mammography is a very special area of quality control in radiology, which demands relatively high knowledge on physics. Digital imaging is changing the standards of the radiographic imaging. Regarding mammography, this is yet a controversial issue owing to some limitations of the digital detectors, like the resolution for instance. A complete set of results regarding radiation protection of the patients submitted to mammography diagnosis is presented. A discussion of the quality image parameters and its interpretation in conventional and digital mammography is presented. In conclusion, we present a sample of results that can be considered as characteristics of mammography equipment in Portugal.

10 kVp rule – An anthropomorphic pelvis phantom imaging study using a CR system: impact on image quality and effective dose using AEC and manual mode

Purpose - This study aims to investigate the influence of tube potential (kVp) variation in relation to perceptual image quality and effective dose (E) for pelvis using automatic exposure control (AEC) and non-AEC in a Computed Radiography (CR) system. Methods and materials - To determine the effects of using AEC and non-AEC by applying the 10 kVp rule in two experiments using an anthropomorphic pelvis phantom. Images were acquired using 10 kVp increments (60–120 kVp) for both experiments. The first experiment, based on seven AEC combinations, produced 49 images. The mean mAs from each kVp increment were used as a baseline for the second experiment producing 35 images. A total of 84 images were produced and a panel of 5 experienced observers participated for the image scoring using the two alternative forced choice (2AFC) visual grading software. PCXMC software was used to estimate E. Results - A decrease in perceptual image quality as the kVp increases was observed both in non-AEC and AEC experiments, however no significant statistical differences (p > 0.05) were found. Image quality scores from all observers at 10 kVp increments for all mAs values using non-AEC mode demonstrates a better score up to 90 kVp. E results show a statistically significant decrease (p = 0.000) on the 75th quartile from 0.37 mSv at 60 kVp to 0.13 mSv at 120 kVp when applying the 10 kVp rule in non-AEC mode. Conclusion - Using the 10 kVp rule, no significant reduction in perceptual image quality is observed when increasing kVp whilst a marked and significant E reduction is observed.

Development and validation of a psychometric scale for assessing PA chest image quality: a pilot study

Purpose - To develop and validate a psychometric scale for assessing image quality perception for chest X-ray images. Methods - Bandura's theory was used to guide scale development. A review of the literature was undertaken to identify items/factors which could be used to evaluate image quality using a perceptual approach. A draft scale was then created (22 items) and presented to a focus group (student and qualified radiographers). Within the focus group the draft scale was discussed and modified. A series of seven postero-anterior chest images were generated using a phantom with a range of image qualities. Image quality perception was confirmed for the seven images using signal-to-noise ratio (SNR 17.2–36.5). Participants (student and qualified radiographers and radiology trainees) were then invited to independently score each of the seven images using the draft image quality perception scale. Cronbach alpha was used to test interval reliability. Results - Fifty three participants used the scale to grade image quality perception on each of the seven images. Aggregated mean scale score increased with increasing SNR from 42.1 to 87.7 (r = 0.98, P < 0.001). For each of the 22 individual scale items there was clear differentiation of low, mid and high quality images. A Cronbach alpha coefficient of >0.7 was obtained across each of the seven images. Conclusion - This study represents the first development of a chest image quality perception scale based on Bandura's theory. There was excellent correlation between the image quality perception scores derived using the scale and the SNR. Further research will involve a more detailed item and factor analysis.

Image quality and dose analysis for a PA chest X-ray: comparison between AEC mode acquisition and manual mode using the 10 kVp ‘rule’

Purpose - To compare the image quality and effective dose applying the 10 kVp rule with manual mode acquisition and AEC mode in PA chest X-ray. Method - 68 images (with and without lesions) were acquired using an anthropomorphic chest phantom using a Wolverson Arcoma X-ray unit. These images were compared against a reference image using the 2 alternative forced choice (2AFC) method. The effective dose (E) was calculated using PCXMC software using the exposure parameters and the DAP. The exposure index (lgM provided by Agfa systems) was recorded. Results - Exposure time decreases more when applying the 10 kVp rule with manual mode (50%–28%) when compared with automatic mode (36%–23%). Statistical differences for E between several ionization chambers' combinations for AEC mode were found (p = 0.002). E is lower when using only the right AEC ionization chamber. Considering the image quality there are no statistical differences (p = 0.348) between the different ionization chambers' combinations for AEC mode for images with no lesions. Considering lgM values, it was demonstrated that they were higher when the AEC mode was used compared to the manual mode. It was also observed that lgM values obtained with AEC mode increased as kVp value went up. The image quality scores did not demonstrate statistical significant differences (p = 0.343) for the images with lesions comparing manual with AEC mode. Conclusion - In general the E is lower when manual mode is used. By using the right AEC ionising chamber under the lung the E will be the lowest in comparison to other ionising chambers. The use of the 10 kVp rule did not affect the visibility of the lesions or image quality.

Increasing source to image distance for AP pelvis imaging: impact on radiation dose and image quality

Aim - A quantative primary study to determine whether increasing source to image distance (SID), with and without the use of automatic exposure control (AEC) for antero-posterior (AP) pelvis imaging, reduces dose whilst still producing an image of diagnostic quality. Methods - Using a computed radiography (CR) system, an anthropomorphic pelvic phantom was positioned for an AP examination using the table bucky. SID was initially set at 110 cm, with tube potential set at a constant 75 kVp, with two outer chambers selected and a fine focal spot of 0.6 mm. SID was then varied from 90 cm to 140 cm with two exposures made at each 5 cm interval, one using the AEC and another with a constant 16 mAs derived from the initial exposure. Effective dose (E) and entrance surface dose (ESD) were calculated for each acquisition. Seven experienced observers blindly graded image quality using a 5-point Likert scale and 2 Alternative Forced Choice software. Signal-to-Noise Ratio (SNR) was calculated for comparison. For each acquisition, femoral head diameter was also measured for magnification indication. Results - Results demonstrated that when increasing SID from 110 cm to 140 cm, both E and ESD reduced by 3.7% and 17.3% respectively when using AEC and 50.13% and 41.79% respectively, when the constant mAs was used. No significant statistical (T-test) difference (p = 0.967) between image quality was detected when increasing SID, with an intra-observer correlation of 0.77 (95% confidence level). SNR reduced slightly for both AEC (38%) and no AEC (36%) with increasing SID. Conclusion - For CR, increasing SID significantly reduces both E and ESD for AP pelvis imaging without adversely affecting image quality.

The influence of experience and training in a group of novice observers: a jackknife alternative free-response receiver operating characteristic analysis

Purpose - The study evaluates the pre- and post-training lesion localisation ability of a group of novice observers. Parallels are drawn with the performance of inexperienced radiographers taking part in preliminary clinical evaluation (PCE) and ‘red-dot’ systems, operating within radiography practice. Materials and methods - Thirty-four novice observers searched 92 images for simulated lesions. Pre-training and post-training evaluations were completed following the free-response the receiver operating characteristic (FROC) method. Training consisted of observer performance methodology, the characteristics of the simulated lesions and information on lesion frequency. Jackknife alternative FROC (JAFROC) and highest rating inferred ROC analyses were performed to evaluate performance difference on lesion-based and case-based decisions. The significance level of the test was set at 0.05 to control the probability of Type I error. Results - JAFROC analysis (F(3,33) = 26.34, p < 0.0001) and highest-rating inferred ROC analysis (F(3,33) = 10.65, p = 0.0026) revealed a statistically significant difference in lesion detection performance. The JAFROC figure-of-merit was 0.563 (95% CI 0.512,0.614) pre-training and 0.677 (95% CI 0.639,0.715) post-training. Highest rating inferred ROC figure-of-merit was 0.728 (95% CI 0.701,0.755) pre-training and 0.772 (95% CI 0.750,0.793) post-training. Conclusions - This study has demonstrated that novice observer performance can improve significantly. This study design may have relevance in the assessment of inexperienced radiographers taking part in PCE or commenting scheme for trauma.

Guest editorial: OPTIMAX 2013

In 2012 we were awarded an Erasmus Intensive Programme grant to facilitate OPTIMAX 2013, a three week duration residential summer school held within the UK during August 2013. The summer school helped to further develop student radiographer skills in optimising x-radiation dose and image quality. With a major emphasis on visual techniques to determine image quality, lesion visibility, lesion detection performance and physical measures of image quality (eg signal to noise ratio (SNR)) we conducted controlled laboratory experiments on phantoms using Computed Radiography, CT and Full Field Digital Mammography. Mathematical modelling was used for radiation dose estimation. Sixty seven people from 5 European countries participated. This included 49 PhD, MSc and BSc students. Discipline areas included radiography, physics, biomedical science and nuclear medicine.