Survey of mammography practice in Croatia: equipment performance, image quality and dose

Patient radiation doses during coronary interventions in four Croatian hospitals: 4-y comparison

The number of coronary interventions increased substantially in the recent years. Although of great benefit to patients, these procedures can subject patients to considerable radiation doses. There is a legal framework for patient dose measurements in Croatia during radiological procedures, but in practice, it applies only occasionally. A quality control manual, established at the University Hospital Osijek, was accepted by other major cardiology centres in Croatia; besides checking the technical characteristics of the device, it provides constant measurement and analysis of patient doses in interventional cardiology. It also includes patient examination for radiation skin injuries in case of dose of >2 Gy. The aim of the study was to determine and compare patient radiation doses during cardiological interventions measured within 4 y in four major cardiology centres with the values proposed by the European Commission and other professional bodies. The local reference dose levels were also set.

Mammography equipment performance, image quality and mean glandular dose in Malta

In this first Maltese national mammography survey, the effectiveness of direct digital (DR) mammography in breast cancer screening has been confirmed. Patient data were made available from three clinics out of the participating nine. A dose survey of mean glandular dose (MGD) calculated for 759 patients examined in the state-owned mammography facilities was performed. An MGD national diagnostic reference level was set at 1.87 mGy for patients with breast compression thicknesses (BCT) between 5.0 and 7.0 cm. This range was selected since patient data were retrieved from three clinics only and the results showed that other international BCT reference levels may be unsuitable for the Maltese population. In fact, the overall average BCT was 5.75 ± 1.4 cm. The survey results have shown that the technical standard of mammographic equipment in the Malta National Breast Screening Programme is on a par with other countries, including its Western European counterparts.

Image quality of mammography in Croatian nationwide screening program: comparison between various types of facilities

PURPOSE

The study was aimed to provide objective evidence about the mammographic image quality in Croatia, to compare it between different types of MG facilities and to identify the most common deficiencies and possible reasons as well as the steps needed to improve image quality.

MATERIALS AND METHODS

A total of 420 mammographic examinations collected from 84 mammographic units participating in the Croatian nationwide breast cancer screening program were reviewed in terms of four image quality categories: identification of patient and examination, breast positioning and compression, exposure and contrast, and artifacts. Those were rated using image evaluating system based on American College of Radiology and European Commission proposals. The results were compared among different types of mammographic units, and common image quality deficiencies were identified.

RESULTS

Total image quality scores of 12.8, 16.1, 13.0 and 13.7 were found for general hospitals, university hospitals, private clinics and public healthcare centres, respectively. Average score for all mammographic units was 13.5 (out of 25 points). University hospitals were significantly better than all other mammography units in overall image quality, which was mostly contributed by better breast positioning practices. Private clinics showed the worst results in identification, exposure, contrast and artifacts.

CONCLUSIONS

Serious deficiencies in identification and breast positioning, which might compromise breast cancer screening outcome, were detected in our material. They occur mainly due to subjective reasons and could be corrected through additional staff training and improvement of working discipline.

Image quality and dose in mammography in 17 countries in Africa, Asia and Eastern Europe: results from IAEA projects

PURPOSE

The objective is to study mammography practice from an optimisation point of view by assessing the impact of simple and immediately implementable corrective actions on image quality.

MATERIALS AND METHODS

This prospective multinational study included 54 mammography units in 17 countries. More than 21,000 mammography images were evaluated using a three-level image quality scoring system. Following initial assessment, appropriate corrective actions were implemented and image quality was re-assessed in 24 units.

RESULTS

The fraction of images that were considered acceptable without any remark in the first phase (before the implementation of corrective actions) was 70% and 75% for cranio-caudal and medio-lateral oblique projections, respectively. The main causes for poor image quality before corrective actions were related to film processing, damaged or scratched image receptors, or film-screen combinations that are not spectrally matched, inappropriate radiographic techniques and lack of training. Average glandular dose to a standard breast was 1.5 mGy (mean and range 0.59-3.2 mGy). After optimisation the frequency of poor quality images decreased, but the relative contributions of the various causes remained similar. Image quality improvements following appropriate corrective actions were up to 50 percentage points in some facilities.

CONCLUSIONS

Poor image quality is a major source of unnecessary radiation dose to the breast. An increased awareness of good quality mammograms is of particular importance for countries that are moving towards introduction of population-based screening programmes. The study demonstrated how simple and low-cost measures can be a valuable tool in improving of image quality in mammography.

Mammography radiation dose: initial results from Serbia based on mean glandular dose assessment for phantoms and patients

The primary objective of this study is to investigate the actual mammography dose levels in Serbia and establish a baseline dose database for the future screening programme. The mean glandular dose (MGD) was assessed for standard size breast substituted by 45 mm polymethyl methacrylate (PMMA) phantom and imaged under typical clinical conditions at 30 screen-film mammography facilities. Average MGD was (1.9 +/- 1.0) mGy, with a range of 0.12-5.2 mGy. These results were used for the calculation of the initial diagnostic reference levels in mammography in Serbia, which was set to 2.1 mGy for a standard breast. At some facilities, high doses were observed and the assessed MGD was supplemented by a patient dose survey. MGD was measured for 53 women having a diagnostic mammography in cranio-caudal (CC) and mediolateral oblique (MLO) projections at the largest mammography facilities in Serbia. The parameters recorded were: age, compressed breast thickness, tube potential (in kV), tube loading (in mAs) and the MLO projection angle. The average MGD per image was 2.8 mGy for the CC projection and 4.3 mGy for the MLO projection. Dose to breast was compared with dose for PMMA phantoms of various sizes, assessed at the same facilities. The results have indicated that phantom dose values can assist in setting optimisation activities in mammography. Both phantom and patient dose values indicated unnecessary high doses in facilities with an extremely high mammography workload. For these facilities, urgent dose-reduction measures and follow-up actions were recommended.

Mammography practice in Serbia: evaluation and optimisation of image quality and the technical aspects of the mammographic imaging chain

The purpose of this work was to assess mammography practice in Serbia and its appropriateness for both diagnostic service and potential screening by implementing quality control (QC) protocol in three large teaching hospitals. Corrective actions were suggested, accordingly. In addition to technical aspects of QC, image quality was assessed using image grading before and after the introduction of corrective measures. The survey demonstrated considerable variations in technical parameters that affect image quality and patients doses. Average glandular doses ranged from 1.8 to 2.8 mGy, while reference optical density (OD) ranged from 1.0 to 2.6. Image grading resulted in a very high percentage of images with poor quality (12-70 % for cranio-caudal projection and 8-66 % for medio-lateral oblique projection). Main problems were associated with film processing, viewing conditions and OD control. Following introduction of corrective measures, the image grading results were improved in some hospitals, so the percentage of images without any remarks has been increased.

Patient radiation doses in the most common interventional cardiology procedures in Croatia: first results

Apart from its benefits, the interventional cardiology (IC) is known to generate high radiation doses to patients and medical staff involved. The European Union Medical Exposures Directive 97/43/Euroatom strongly recommend patient dosimetry in interventional radiology, including IC. IC patient radiation doses in four representative IC rooms in Croatia were investigated. Setting reference levels for these procedures have difficulties due to the large difference in procedure complexity. Nevertheless, it is important that some guideline values are available as a benchmark to guide the operators during these potentially high-dose procedures. Local and national diagnostic reference levels (DRLs) were proposed as a guidance. A total of 138 diagnostic (coronary angiography, CA) and 151 therapeutic (PTCA, stenting) procedures were included. Patient irradiation was measured in terms of kerma-area product (KAP), fluoroscopy time (FT) and number of cine-frames (F). KAP was recorded using calibrated KAP-meters. DRLs of KAP, FT and F were calculated as third quartile values rounded up to the integer. Skin doses were assessed on a selected sample of high skin dose procedures, using radiochromic films, and peak skin doses (PSD) were presented. A relative large range of doses in IC was detected. National DRLs were proposed as follows: 32 Gy cm(2), 6.6 min and 610 frames for CA and 72 Gy cm(2), 19 min and 1270 frames for PTCA. PSD <1 Gy were measured in 72 % and PSD >2 Gy in 8 % of selected patients. Measuring the patient doses in radiological procedures is required by law, but rarely implemented in Croatia. The doses recorded in the study are acceptable when compared with the literature, but optimisation is possible. The preliminary DRL values proposed may be used as a guideline for local departments, and should be a basis for radiation reduction measures and quality assurance programmes in IC in Croatia.

Technical aspects of quality assurance in mammography: Preliminary results from Serbia

Mammography is the method of choice for early detection of breast cancer. In Serbia, mammography is performed only clinically, although there is a plan to introduce mammography as a screening method. Currently, there are 60 mammographic units in practice, resulting in 70 000 mammographies annually. The survey was conducted in order to investigate mammographic practice in Serbia, identify weak points and suggest appropriate corrective measures. Basic technical parameters of the X-ray tube and generator, processing, image quality, and patient doses in 20 mammographic units were studied. The survey demonstrated considerable variations in technical parameters that affect image quality, and patients doses. Patient dose levels, in terms of the mean glandular dose, were fairly consistent with current European reference levels: 1.8 (0.40-4.3) mGy. However, due to inappropriate image receptors, image processing and viewing conditions and automatic exposure control adjustment, suboptimal image quality was a common finding. Simple improvements of the radiographic technique and maintenance procedure, along with the rigid implementation of the quality control procedure and training of the operating staff, would improve the performance levels of mammographic practice in Serbia, i. e. result in the production of high quality images with a reasonably low radiation risk to patients.

Good reasons to implement quality assurance in nationwide breast cancer screening programs in Croatia and Serbia: results from a pilot study

The purpose of this study is to investigate the need for and the possible achievements of a comprehensive QA programme and to look at effects of simple corrective actions on image quality in Croatia and in Serbia. The paper focuses on activities related to the technical and radiological aspects of QA. The methodology consisted of two phases. The aim of the first phase was the initial assessment of mammography practice in terms of image quality, patient dose and equipment performance in selected number of mammography units in Croatia and Serbia. Subsequently, corrective actions were suggested and implemented. Then the same parameters were re-assessed. Most of the suggested corrective actions were simple, low-cost and possible to implement immediately, as these were related to working habits in mammography units, such as film processing and darkroom conditions. It has been demonstrated how simple quantitative assessment of image quality can be used for optimisation purposes. Analysis of image quality parameters as OD, gradient and contrast demonstrated general similarities between mammography practices in Croatia and Serbia. The applied methodology should be expanded to larger number of hospitals and applied on a regular basis.